DISLOCATIONS AND JOINT-FRACTURES BY FREDERIC J. COTTON, A.M., M.D., F.A.C.S. VISITING SURGEON TO THE BOSTON CITY HOSPITAL CONSULTING SURGEON TO THE N. E. HOSPITAL FOR WOMEN AND CHILDREN, AND TO THE BETH ISRAEL HOSPITAL AND TO THE PETERBOROUGH HOSPITAL; CONSULTANT IN SURGERY TO THE VETERANS BUREAU; ASSOCIATE IN SURGERY, HARVARD MEDICAL SCHOOL SECOND EDITION, RESETJ WITH 1393 ILLUSTRATIONS FROM DRAWINGS BY THE AUTHOR PHILADELPHIA AND LONDON,] W. B. SAUNDERS COMPANY 1924 Copyright. 1910, by W. B. Saunders Company. Reprinted April, 1911. Revised, entirely reset, reprinted, and recopyrighted, May, 1924 Copyright, 1924, by W. B. Saunders Company MADE IN U. S. A. REDEDICATED TO MY FATHER THE LATE JOSEPH POTTER COTTON, C.E. PREFACE TO SECOND EDITION The favorable reception of this book leads me to think that the plan was probably correct; that a book of this sort may well be made a personal document. In this second edition, I have used more largely the cases of my friends and colleagues; cases that have come to my notice, often through the pleasant comradeship in professional matters that has been my best reward for work done. Since this book first appeared, many cases have been sent me; many skiagraphs, and so much in the way of detailed data, that I can express further thanks only in recognizing my obligation to many colleagues in the profession in many places. Not all that was sent could be used, but thanks are herewith tendered to all who have shown their interest. But for all this, I have tried to keep the lines restricted, and for the most part, the data still remain as before; cases that I have seen or have some direct knowledge of. I dare not become a lexicographer, or stand for all that stands written: Since the above lines were written we have had thrust upon us the vast experience of the surgery of the great war. This has necessi- tated some re-writing of the revision already written-but not so much because of things novel or revolutionary in fracture handling, as because the feverish activity of the last few years has hastened the development and acceptance of methods and tendencies in practice already underway-as for example, the effective fixation of infected compound fractures by plates, etc., the active disinfection and closure of joints, the developed use of physiotherapy methods. New chapters will be found dealing with these as with other more recent develop- ments-but from a personal point of view-not a re-hashing of the bewildering printed and rumored war-time reports, but almost wholly based on my own military hospital experience. 520 Commonwealth Avenue, Boston, Mass., May, 1924 Frederic J. Cotton. 1 PREFACE TO FIRST EDITION A good deal of matter that might well be looked for in a preface finds its place in this book in the introduction. Two points, however, have not been dealt with: First, it has occurred to me in reading the completed text that refer- ences to the literature are not very full. As has been stated elsewhere, the first draft was written, as far as might be, without reference to authorities as such, and the voluminous "literature" notes, collected later, were used for the most part for verification of fact and perspec- tive, not for incorporation in the text. Perhaps this is not the right way to work, but a reaction from the benumbing German scholasticism in which I was trained has led me to adhere to the original plan in the main. The second point is in regard to illustrations. There is no index- list of these, but in the general index there will be found many refer- ences to illustrations (by number) as well as to pages of the text. This is part of an attempt to make the illustrations much more integrally a part of the text than has been the rule in medical bookmaking. Whether such a result has been accomplished, I do not know. At any rate, the attempt has been made-and made on the theory that no man can do more in book-making than to present with pen and brush what he knows from instruction, reading, and personal observation, in as direct a way as he can. F. J. Cotton. TABLE OF CONTENTS Page Introduction 17 CHAPTER I Generalities 21 Definitions 21 Forms of Fracture 23 Terms of Description 24 Spontaneous and Pathologic Luxations 24 Spontaneous Fractures 25 Congenital (and Paralytic) Luxations 26 Diagnosis (in general) 27 X-ray and Fractures 28 Repair 34 Non-union 35 Traumatic Arthritis 46 Myositis Ossificans 48 Treatment (in General) 50 Physiotherapy 52 Operative Treatment 57 Compound Fractures and Dislocations 61 Bullet-wound Fractures 62 Results 65 Embolism 65 Fat Embolism 66 CHAPTER II Luxation of the Lower Jaw 69 Dislocation Forward 69 Recurrent Luxation 75 Habitual Subluxation Forward 75 Dislocation Backward 75 Inward Dislocation 76 Upward 76 Outward 76 Jaw Fractures 78 At or Near Angle 78 Coronoid Process of Neck below Condyle 80 CHAPTER III 5 6 TABLE OF CONTENTS CHAPTER IV Page Injuries of the Cervical Spine 82 Landmarks 83 First and Second Cervical Vertebrae, Fractures and Luxations 85 Dislocations of Occiput on Atlas 85 Dislocations of Atlas on Axis 85 Diastasis 85 Diagnosis of Upper Cervical Lesions 88 Treatment of Lesions of the Upper Cervical Spine 90 Prognosis of Lesions of the Upper Cervical Vertebra? 95 Lesions below the Second Cervical Spine 99 Dislocations 100 Unilateral Incomplete 101 Unilateral Complete 102 Double Rotatory 105 Bilateral Forward 105 Unilateral Backward 105 Bilateral Backward 107 Fracture Luxations with Displacement 108 Differential Diagnosis 109 Deformity 110 Clinical Conclusions 112 Treatment of Luxations 112 Reduction of Rotatory Luxation 112 Treatment of Fractures and Luxations 115 Prognosis 117 CHAPTER V Dorsal Spine 119 Injuries of the Dorsal Spine 119 Dislocation 120 Fracture Dislocation 121 Fracture without Displacement of the Bodies 122 Fracture of a Spinous Process 122 Distraction 123 Diagnosis 123 Prognosis 129 Treatment 131 Cases without Paralyses 131 Paraplegic Cases 132 Laminectomy 132 Forcible Correction 133 Gravity Reduction 134 After-treatment 135 CHAPTER VI The Lumbar Vertebrae 137 Luxations and Fracture Luxations 137 Diagnosis 139 Prognosis 143 Treatment... 143 TABLE OF CONTENTS 7 CHAPTER VII Page The Sacrum and Coccyx 145 Injuries to Sacrum 145 Injuries of the Coccyx 145 CHAPTER VIII The Sternum 148 Luxation of Gladiolus on Manubrium 148 Fracture of the Sternum 150 Dislocation of the Ensiform Cartilage 150 CHAPTER IX The Ribs 152 Dislocation of the Ribs on the Vertebrae 152 Dislocation and Fracture of the Front End of the Rib 153 Cartilage Separation • . 153 Separation of the Ribs from the Sternum 154 Fracture of the Rib Cartilage 154 Dislocation of the Rib from the Cartilage 156 Subluxation, Costo-chondral 156 Treatment 156 CHAPTER X The Clavicle 159 Dislocations of the Clavicle 159 Dislocation of the Inner End 159 Subluxation 160 Reduction and Treatment 161 Dislocation of the Outer End 163 Fracture of Clavicle, Outer End 169 Separation of the Outer Epiphysis 172 CHAPTER XI The Scapula 174 Luxation Inward 174 Congenital Luxation 174 Fracture of the "Surgical Neck" 175 Fracture of the Coracoid Process 176 Fracture of the Glenoid Cavity 176 Fracture of the Acromion 177 Fracture of the Spine of the Scapula 178 Fracture of the Body of the Scapula 179 CHAPTER XII The Shoulder 181 Landmarks 181 Shoulder Luxation 183 Forward Luxation 184 8 TABLE OF CONTENTS Page Subclavicular Luxation 200 Subglenoid Luxation 201 Subluxation Downward 203 Luxatio Erecta 204 Supraglenoid Luxation 204 Intra-thoracic Luxation 205 Posterior Dislocations 205 Complications-Fractures 208 Fracture of the Glenoid 208 Fracture of Greater Tuberosity 209 Fracture of Lesser Tuberosity 210 Fracture of Anatomic Neck 211 Fracture of Surgical Neck 211 Nerve Lesions 213 Vessel Rupture 216 Compound Luxation at the Shoulder 217 Old Cases of Shoulder Luxation . i Obstacles to Reduction 217 Recurrent Luxations 221 Pathologic Luxations 221 Congenital Luxations 221 Rupture of the Biceps Tendon 222 Bursal Lesions 223 CHAPTER XIII Fractures of the Humerus: Upper End 224 Fracture of the Head 224 Fracture of the Anatomic Neck 224 Fracture of Greater and Lesser Tuberosities 227 Greater Tuberosity 228 Lesser Tuberosity 228 Separation of the Epiphysis 229 Fracture through or below the Tuberosities (Including "Surgical Neck" Fractures 234 CHAPTER XIV The Elbow 248 Landmarks 248 Elbow Dislocation 252 Lesions 252 Complications 253 General Diagnosis 254 Luxation Backward 255 Luxation Outward 261 Luxation Inward 266 Dislocation of Radius and Ulna Forward 267 Divergent Dislocation of Radius and Ulna 268 After-treatment of Elbow Luxations 269 Prognosis of Elbow Luxations 269 Luxation of Radius Backward 269 Luxation Outward 271 TABLE OF CONTENTS 9 Page Luxation Forward 271 Luxation of Radius with Ulnar Fracture 272 Dislocation of Ulna Alone 273 Luxation of Ulna Alone Backward 273 Luxation of Ulna Forward. 274 Subluxation of the Head of the Radius in Children (Malgaigne's Luxation) 274 Congenital Luxation of the Radius 278 CHAPTER XV Fractures of the Humerus at the Elbow 279 Elbow Fractures in Adults 280 Supracondylar Fractures 281 T-Fractures 284 Fracture of the External Condyle 285 Fracture of the External Epicondyle 287 Fracture of the Capitellum 287 Fracture of the Internal Condyle 287 Fracture of the Internal Epicondyle 288 Treatment 292 T-Fractures 297 Fractures of the External or Internal Condyle 298 Internal Epicondyle 300 Results 300 Fractures of the Humerus at the Elbow in Children 303 Classification 306 Supracondylar Fracture in Children 309 Separation of the Whole Epiphysis 310 Separation of the External Condyle 312 Separation of the Internal Epicondyle 313 T-Fractures 313 Diagnosis 314 Treatment 319 The Gunstock Deformity 331 Operations 331 Volkmann's Contracture 333 Fractures of the Forearm Just below the Elbow 333 Fracture of Both Bones (High) 334 Fracture of the Ulna Alone 336 Fracture of the Coronoid Process 338 Fracture of the Olecranon 340 Separation of the Epiphysis of the Olecranon 346 Fracture of the Radius near the Elbow 348 Separation of the Upper Radial Epiphysis 353 CHAPTER XVI The Wrist 354 Radio-carpal Luxation Backward 356 Forward Luxation at the Wrist 358 Fracture-luxations 361 Fracture-luxation with Outward Displacement 361 Barton's Fracture 361 10 TABLE OF CONTENTS Page "Reversed Barton's" 361 Colles' Fracture 362 Simple Transverse Fracture 368 Comminuted Transverse Fracture 368 Separation of the Radial Epiphysis 370 Fracture Oblique Upward and Backward 372 Fracture Oblique Upward and Forward 373 Fracture Oblique Upward and Outward 376 Fracture Luxation of the Radial Styloid 377 Fractures Oblique Downward and Outward 378 "Cracks" of the Radius, Not Penetrating the Width of the Bone. . . . 378 Transverse "Cracks" 378 Green-stick Fracture of Both Bones 379 Fracture of the Ulnar Styloid 381 Fracture of the Ulnar Styloid (Alone) 381 Lesions of Periosteum. . 384 Injuries to Vessels 384 Injuries to Nerves 384 Compound Fractures 384 Impaction 385 Symptoms 386 Treatment 388 After-treatment 400 Results 401 Deformity 403 Operative Treatment 404 Luxation of the Ulna at the Wrist 404 Luxation Backward 405 Chronic Luxation Backward of the Ulna 407 Madelung's Deformity 408 Luxation of the Ulna Inward 408 Luxation of the Ulna Forward 408 Recurrent Luxation of the Ulna 409 CHAPTER XVII The Carpus 411 Anatomy 411 Luxations 411 Dislocation of the Distal on the Proximal Row 411 Luxation of Single Bones 418 Fractures with Carpal Dislocations 421 Symptoms and Treatment 421 Fractures of the Carpus 422 Fracture of the Carpal Scaphoid 422 Fracture of Scaphoid with Semilunar Luxation 427 Fracture of Other Carpal Bones 427 Epiphyses of the Hand 428 CHAPTER XVIII The Metacarpus 429 Luxation of the Metacarpals 429 TABLE OF CONTENTS 11 Page Dislocation of the Thumb Metacarpal Backward 429 Other Metacarpal Luxations 431 Dislocations at the Knuckle 431 Dislocation of the Thumb Backward 431 Other Dislocations of the Thumb 434 Metacarpal Fracture 434 Fracture of the First Metacarpal 434 Fracture of the First Metacarpal at Its Base 434 Fracture of the Metacarpals 436 Knuckle Fractures 437 Fractures of the Metacarpal Shafts 441 Fractures of the Metacarpals at the Base 442 CHAPTER XIX The Phalanges 444 Dislocations 444 Subluxation 444 Fractures 446 Epiphyseal Separation 448 CHAPTER XX The Pelvis 449 Fractures of the Rami 450 Fracture of Rami, with other Fractures 453 Separation of the Symphysis 457 Fracture of the Acetabulum 460 Fracture through the Acetabulum 461 Fracture with Penetration of the Acetabulum ("Central Luxation of the Hip") 463 Fracture of the Tuber Ischii 466 Fracture of the Iliac Crest 466 Separation or Fracture of the Anterior-superior Spine 467 Sacro-iliac Joint 467 Sacro-iliac Luxation 469 Sacral Fracture 470 CHAPTER XXI Landmarks of Pelvis and Hip 471 CHAPTER XXII Hip Dislocation 474 Posterior Dislocations 476 Ischiatic Luxation 482 Anterior Dislocations 483 Pubic Luxations 485 Central Luxation 487 Reductions 488 For Posterior Luxations 490 Gravity Method 490 Direct Method (Allis) 490 12 TABLE OF CONTENTS Page Circumduction Method (Bigelow) 492 For Anterior Luxations 494 Allis's Reduction 495 Reduction by Inward Rotation 495 Reduction by Outward Rotation 496 Other Methods 497 Reduction of Suprapubic Luxation 498 Reversed Thyroid 498 Obturator 498 Perineal 498 Luxation with Fracture of the Femur 499 Compound Luxation at the Hip 499 Old Dislocation of the Hip 500 After-treatment of Hip Dislocations 500 Prognosis 500 Obstacles to Reduction 501 The Capsule as an Obstacle 501 Muscles 502 Sciatic Nerve 503 CHAPTER XXIII Fractures of the Hip 505 Fractures of the Head of the Femur 505 Fractures of the Neck of the Femur 506 Signs of Impacted Fractures 517 Signs in Unimpacted Fracture 518 Treatment 520 Treatment of Unimpacted Fracture of the Femoral Neck 523 Results of Fracture of the Femoral Neck 529 Separation of the Epiphysis at the Hip 533 Fracture at the Base of the Neck 535 Treatment of Fracture at the Base of the Neck of the Femur 538 Prognosis in Fracture of the Base of the Neck 541 Fractures through the Trochanters 542 Fracture below the Trochanters (Subtrochanteric Fracture) 543 Fracture of Greater Trochanter, or Separation of its Epiphysis 550 Fracture of the Lesser Trochanter 552 CHAPTER XXIV The Knee 553 Dislocations 553 Anterior Luxation of the Knee 553 Backward Luxation at the Knee 555 Inward Luxation 555 Outward Luxation 556 Prognosis of Knee Luxations 557 Congenital Luxation at the Knee 557 Dislocation of Semilunar Cartilages 557 Fractures of the Femur Near the Knee 561 Fractures Above the Condyles. 561 T-Fracture 563 TABLE OF CONTENTS 13 Page Separation of the Femoral Epiphysis 565 Backward Displacement of the Epiphysis 570 Fracture of Either Condyle 572 Fracture of the Epicondyles 572 Dislocation of the Patella 574 Outward Dislocation 574 Recurrent Outward Luxation 577 Incomplete Outward Luxation 577 Inward Luxation 577 Rotatory Luxations 578 Congenital or Hereditary Luxations 578 CHAPTER XXV CHAPTER XXVI Fracture of the Patella 579 Treatment of Patellar Fracture 584 Old Fractures of the Patella 590 Rupture of the Quadriceps Tendon 591 Rupture of the Ligamentum Patellae 592 Avulsion of the Tibial Tubercle 592 Injuries to the Tibia just below the Knee 595 Fractures 595 Separation of the Upper Epiphysis of the Tibia 598 CHAPTER XXVII CHAPTER XXVIII The Fibttla 599 Luxation of the Upper End of the Fibula 599 Posterior Luxation 599 Anterior Luxation 599 Upward Luxation 599 Fibula Fracture Near the Head 600 CHAPTER XXIX The Ankle 601 Landmarks of the Foot and Ankle 601 Injuries at and about the Ankle (in general) 603 Luxations of the Ankle-joint 604 Forward 605 Backward 605 Inward 606 Outward 606 Fibula: Luxation of the Lower End 609 Diastasis of Tibia and Fibula 609 Pott's Fracture 610 Cotton's Fracture 622 Inverted Pott's Fracture 626 14 TABLE OF CONTENTS Page Fracture Involving Both Bones just above the Joint 629 Diagnosis 631 Treatment 632 Separation of the Lower Epiphysis of Tibia and Fibula 636 Separation of the Epiphysis of the Fibula Alone 636 Fracture of the Fibula Alone, at or above the Joint 637 Fracture of the External Malleolus 640 Compound Fractures at or near the Ankle 640 Complications of Ankle Fractures 642 Sprains of the Ankle 642 Results of Fractures through and near the Ankle-joint 643 Displacement of Joint Surfaces 643 Widening of the Mortise 644 Weakening of the Ligaments 645 Deviation of Axis 647 Stiffening 651 Operative Treatment of Ankle Fractures 653 CHAPTER XXX Astragalus, Luxations and Fracture 656 Total Luxation of the Astragalus 656 Astragalus Fracture 661 Fracture of the Neck 663 Fracture of the Body of the Astragalus 664 CHAPTER XXXI Luxations below the Astragalus 665 Subastragaloid Luxation 665 Medio-tarsal Luxation 671 Subluxation 675 Fracture of the Os Calcis 676 Lesions 678 Symptoms 682 Diagnosis 683 Treatment 686 Treatment of Fracture of the Avulsion Type 695 Compound Fractures 695 Results 695 CHAPTER XXXII CHAPTER XXXIII Other Tarsal Lesions 698 Luxation of Scaphoid 698 Fracture of Scaphoid 698 Luxation of the Cuboid 698 Fracture of the Cuboid 698 Luxation of the Cuneiforms 699 Fracture of the Cuneiforms 700 Other (Unclassified) Tarsal Fractures 700 15 TABLE OF CONTENTS Page Metatarsals 701 Dislocation of Metatarsals 701 Isolated Metatarsal Luxation 706 Metatarsal Fracture 706 Fracture of the Fifth Metatarsal by Inversion 711 Fracture of Sesamoid 713 CHAPTER XXXIV The Phalanges 714 Luxation of the Toes 714 Fracture of the Toes 715 CHAPTER XXXV Technic: Splints, Plaster Works, Etc 717 CHAPTER XXXVI Index 727 DISLOCATIONS AND JOINT-FRACTURES INTRODUCTION This book was originally planned as a treatise on dislocations. On a careful survey of the subject this limitation was promptly abandoned. Dislocations do not present themselves to us as such, but rather as injuries to or near the joints. Dislocations, neatly and academically classified,-considered as of settled diagnosis and irrespective of complications,-could be consid- ered, with all the reduction schemes thrown in, in but few pages. Injuries to and about joints, on the other hand, constitute one of the most doubtful fields of surgery, a field strewn with wrecks,-the products of mistakes and of unavoidable difficulties, prolific in dis- content and in resultant actions at law-actions based only too often on unavoidable uncertainty or error. Curiously enough, this dangerous field has been rather inadequately surveyed. A century ago, more or less, a peculiarly acute group of observers, mainly English, with a few Germans and French, wrote on this subject most admirably. Since then we have largely copied old data, save for the excellent work of Gurlt, of Hamilton, and later of Stimson. Two decades ago the x-ray came to our aid-and to our confusion. It seems that the time is ripe for a summary of the subject, based on personal experience, fortified by the great mass of admirable x-ray pictures more lately produced, the data of museum specimens, and the great store of valuable operative observations placed on record in the more recent literature. Such a review must be modified by the clinical records of preceding generations, but is in no way concerned with their opinions. We are fortunate today not only in having the x-ray as an accessory method of diagnosis, but in having, as a result of this diagnostic method and of a vast array of observations made directly at operation, a mate- rial for deductions not accessible to a previous generation. Wisdom did not begin with this generation, but we have had an unusual oppor- tunity to learn. It is in this spirit, then, that this book has been conceived and attempted: it is not so much an effort to "revise to date" as an attempt to state what I believe we really do know of the subject today, freed, as far as may be, from the encumbering traditions of earlier 17 18 INTRODUCTION days-an attempt to make a fresh start, though in no ultraradical sense. Unavoidably such a book as is here outlined must be largely personal. In the present case the first edition was five years in the making, and the cases cited and the cuts shown are very largely drawn from my own experience during this time and the five years preceding, and from cases seen by me with my hospital colleagues. No doubt many single conclusions here expressed are assailable: some may be modified as time goes on, but the attempt has been made to present a doctrine of traumatic lesions brought somewhere near the developed knowledge of the day. Only a few of the conclusions as to treatment are personal, but many conclusions, already common or shared by many surgeons, must be acted on with caution so long as responsibility is fixed by the rela- tively uninformed 11 general practice of the profession." Our knowledge has, however, made greater strides than many realize. There is, I think, hardly a recommendation given in these pages that is not directly drawn from my own experience, or amply based on work done by my colleagues, observed by myself. Our opportunities in the last decade have put us in a position where the advance of the next decade must be largely in the diffusion of such knowledge as the profession already has at hand, in the adaptation to actual working conditions of data already available, and in training ourselves to a greater degree of personal skill in diagnosis and in both non-operative and operative treatment. There is bound to be a broadening recognition of the fact that each fracture is a mechanical problem in itself, so far, at least, as reduction is concerned. The more we study fractures and luxations, the more we see how definitely they fall into series of roughly constant types; but these types are not constant in detail, and the ancient custom of treat- ing a fracture with a given form of reduction, or putting it up in A.'s or B.'s splint is no longer adequate practice. Greater opportunity gives greater responsibility, and our opportunity today-or, at least, tomorrow-must involve us in the obligation of having our work tested by results, as well as by intentions. This does not mean that results must be anatomically perfect; functional results give a much better criterion, as a rule. No damage to any machinery, human or other, increases its effi- ciency, and in the human machinery we cannot replace parts. Many breaks and dislocations do damage absolutely irreparable; many do damage entirely unrecognizable at the time, and for such conditions we can not be held responsible in any way. Imperfect results must be common; mistakes must occur, and will occur in the practice of the best, but I conceive that the day is past when we may defend ourselves by abjectly falling back on what the eminent Dr. X. said in the last century. Our duty is to obtain in the given case the best result obtainable in this 19 INTRODUCTION case, by whatever means are at hand, often irrespective of traditional methods. For better or for worse, we must study our cases of trauma, must do the best we can, and must rest on the result. I believe that fracture results in general are better today than ever before, and that more men are competent today to treat fractures than ever before. The general practitioner should be able, will be able, to treat most fractures. His work today is good; his work tomorrow will be better if he recognizes those fractures that can not be treated by routine methods, if he studies such cases carefully, and puts them in the line of modern, not ancient, methods. This means that doubtful results after reduction of luxations or luxation-fractures must be tested by the x-ray, as a rule, and that we must not be satisfied with poor results without further attempts at betterment, by means either operative or non-operative, as may be indicated. An x-ray plate two weeks after the injury would obviate most instances of disaffection or of legal process in cases of fracture or luxation. Obviously, if the point of view here given is accepted, no book can make any man a fracture expert .'-certainly no book ever has done this, whatever the point of view. What should be possible is to acquaint the practitioner with the types of luxation and fracture that commonly occur; to familiarize him with the points of diagnosis; to illustrate the characteristic x-ray appearances; to show, by description and illustration, just how to carry out the methods of reduction and of the application of apparatus that have proved of real value; to warn him of failures in reduction that are common, and of complications that are to be watched for; to instruct him in methods of detecting them and of remedying them, if that is possible; to outline after-treatment and prognosis, and the possibilities. Beyond this, experience, common sense, capable and trained fingers, and, perhaps most important of all, what we call mechanical sense or ability, must help him out. I have tried to supply as best I might such information of the sort as may be given in a book. For this purpose it has been of advantage to have had a good deal of experience at the work, to have been able to utilize a large material of this kind of surgical cases, operative and non-operative, partly my own cases, partly cases seen with my colleagues at the Boston City Hospital, and in consultation in private practice, and to have had pre- vious training in draftsmanship and in illustration. So far as concerns both text and illustrations, I hold myself directly responsible. No one has even assisted in the preparation of the text. The drawings are my own; most of them were drawn for this book, and are, in the strict sense, original; a very few were sketched from 20 INTRODUCTION drawings in articles by others. Some drawings for my articles in the journals, etc., are here used again. All retouching of photographs I have done. There is, therefore, nothing in the plates that was not meant to be there; the direct correspondence of text and illustrations may help toward clearness. I wish to acknowledge my great indebtedness to my colleagues of the Boston City Hospital surgical staff, one and all, for the generosity with which they have allowed me to see and use their cases, and to the x-ray department of the City Hospital for the patience with which they have taken skiagraphs and furnished prints. With few excep- tions, noted in the ulegends," the x-rays used in illustration are by the City Hospital x-ray department. All prints checked by numbers on the plate are by this department. Dr. Wm. F. Whitney, Curator of the Warren Museum (Harvard Medical School), has greatly helped me by placing the material of the Museum at my disposal for study, and it is through his permission that I am enabled to utilize many drawings from specimens in the Museum collection. No one has formally assisted in the work, but I feel my great obligation to the interest and cooperation of Drs. J. B. Blake and E. H. Nichols, of the late Dr. L. T. Wilson, and Drs. L. R. G. Crandon, W. C. Howe, D. Scanned, H. Binney, and many others of my colleagues, as well as to successive house-surgeons who have been most efficient and painstaking in helping me. The Boston City Hospital is in no way committed to what is here set down, but, save for the opportunity offered by service in this institution and for the courtesy of my colleagues of the staff, this book could not have been written. CHAPTER I GENERALITIES DEFINITIONS A dislocation is a total displacement of one articular surface from its fellow on the opposite side of the joint. Usually such a separation involves a tearing of the capsule, and often an extrusion of the end of a bone through the tear. Damage to ligaments is almost always present, but only rarely are all ligaments torn: as a rule at least the strongest ligament (as the "Y ligament" at the hip) remains intact and determines the constant fixed position that characterizes typical luxations of each of the various types. Subluxation is the term applied to displacements of such grade that the opposed joint surfaces are still partly in contact. The terms are not precisely used, and by long custom some lesions are classed as luxations that we know to be, in the strictest sense, only subluxations. A distraction injury is one in which joint surfaces have been forcibly separated from one another (with tearing of ligaments) with out other change of relation. The term is rarely used save in the description of certain vertebral injuries. A distortion is a result of wrenching of a joint that has damaged ligaments, but has produced no luxation. In practice we cannot sepa- rate distortions from luxations in which the bones have snapped back into place, as occurs, for example, with "sprung" finger-joints. Sprains are injuries that have damaged ligaments by stretching, very likely with minute areas of tearing of fibers, without actual liga- ment rupture. Very commonly the important lesions in sprains consist of damage to tendons and their sheaths, rather than any considerable damage to ligaments. Not rarely, however, damage to the bones (splinters torn off) as well as tearing of ligaments, may occur. Though many fractures are falsely called sprains, it is not true that sprains are all fractures, or even that true sprains are rare. The term sprain-fracture, apparently recent, was used long ago by Callender, according to Dr. W. W. Keen (Annals of Surgery, xl, 1904, p. 285). See "Sprains and Allied Injuries of Joints"; R. H. A. Whitelock, Oxford University Press, 1909. "Spontaneous" luxations are those occurring from an apparently inadequate cause. Often they result from deformity or disease of the joint-structures. They may come from incoordinated, though vigor- ous, muscle contraction in cases where the joint is normal in structure. 21 22 GENERALITIES "Congenital" luxations are those occurring without trauma in early life from original defect or from paralyses. The class is also used to cover those cases occurring from trauma at birth. Many of the "congenital" luxations are not congenital at all, but the classifica- tion is adhered to because it is impossible, in many cases, to be sure of the actual origin of the trouble. Recurrent luxations are those in which reluxation persistently recurs from slight cause. Defective and lax healing of ligament or capsule is the usual cause: bone damage (chipping off of the edge of a joint-surface) may give rise to this trouble, as at the shoulder. In the commonest form, recurr- ing luxation of the ulna at the wrist, tear- ing of the ulnar ligaments and deformity of the articulating radius are the control- ling factors. A reluxation occurring before healing is complete is not a recurrent luxation, nor does the fact that the same joint gives way in a second severe accident constitute a chronic recurrent dislocation. A compound luxation is one in which there is a wound, however caused, running from the outer air to the joint-cavity. A fracture is a "solution of continuity" of a bone-a break. It may be incomplete. Incomplete fractures may be simple cracks, running only part way through the bone. Subperiosteal fractures* may be com- plete, but usually are not. The periosteum in either case is not torn or appreciably stripped up. Displacement is absent or very trifling. This form of fracture is rather common in children. A greenstick fracture is an incomplete fracture of unusual form, produced by relatively slow bending of a bone; the bone gives way on the convex side by tearing. Often the line of fracture is a Y, open- ing toward the convex side of the bent bone, with one arm of the Y complete; the other arm and the stem of the Y are ragged cracks, running only part of the way to the surface; the bone may, however, give way transversely. In either case the cortical layer on the concave side is intact-merely bent. The deformity of a greenstick fracture persists, maintained by the "frazzled-out," irregular projections of the break that do not readily fit back into the corresponding depres- Fig. 1.- "Greenstick" fracture of radius-more exactly an infraction type. In this case the fracture was reduced without completing it, to a very exactly normal position. * Cotton: Subperiosteal Fractures: Boston Med. and Surg. Journal, Nov. 29, 1900, p. 553. FORMS OF FRACTURE 23 sions. They may, however, be forced back approximately where they belong, and it is almost always possible to straighten out a greenstick fracture (with a good deal of force), without breaking the cortical layer of the concave side. The old practice of completing the break deliber- ately must be condemned without reservation. An infraction is a fracture that differs from a greenstick in that the convex side is bent, the concave side crushed. They occur in children (rarely in adults) in circumstances in which one would rather expect a "greenstick" type of fracture. They occur typically in the frac- tures of rachitics, but also not very rarely in apparently healthy bones. Greenstick fractures are common in children, but occur also in adults. Subperiosteal complete fractures, even in children, are not greenstick fractures, nor are the "infractions," though they all call for much the same handling. FORMS OF FRACTURE Fractures may be of many patterns. Transverse or approximately transverse fractures include most breaks from slow-acting forces. An osteoclast gives a transverse fracture line. Other forces may give transverse fractures, as in Colles' fracture, fractures of the femoral neck, etc. Avulsion frac- tures are apt to be transverse-e. g., fractures of the patella. Oblique fractures result from obliquely acting forces, as a rule; for instance, the common fractures of the lower leg from falls on the feet, in which the fall is not squarely taken, are usually oblique. Spiral fractures are the result of tor- sion. The type instance is that of the humerus fracture resulting from the old test of strength, in which the weaker man's hand and arm are suddenly twisted over; the resulting fracture is always a spiral* of perfect type. Comminuted, splintered fractures are apt to be the result of direct violence, though not necessarily so. Such frac- tures are apt to be compound. Compound or open fractures are those in which a wound, from within or with- out, establishes communication between the lesion and the outer surface of the body. Fig. 2.-Rickets. There was a frac- ture (see the arrow) of the ulnar shaft next the epiphysis-really an epiphyseal separation but the point of main inter- est is the broadening and irregularity of the epiphyseal end of the shaft. There is also mottling of the shaft bone and delay in ossification in the wrist. These extreme cases of rickets show something of the picture of scurvy. * G. H. Monks (Boston Med. and Surg. Journal, 1895, cxxxii, 281; and 1896, cxxxiv, 40) has reported cases of this sort with some excellent plates of mechan- ism and lesion. 24 GENERALITIES "Complex" and "Complicated" fractures are obsolete terms that should be forgotten. Spontaneous fractures are those in which, from vice of develop- ment from malnutrition, from constitutional disease, from general bone degeneration, or from local bone disease (osteomyelitis, fragilitas ossium, rickets, gummatous syphilis, tuberculosis, myeloma, sarcoma, carcinoma, bone-cyst, etc.) the bone gives way under an apparently trifling stress. Fractures from abnormal muscle contraction-in tabes dorsalis, for instance-belong on the edge of this class. Frac- tures from extreme, but not pathologic, muscle action are often listed as "spontaneous," but do not really belong in this class. Fig. 3.-Strain fracture of corner of phalanx at X. The "chip" fracture of the phalanx is a break across at about the line YY. TERMS OF DESCRIPTION Broadly speaking, dislocations are classified under the name of the distal bone (i. e., a dislocation at the ankle is a dislocation of the foot, not of the tibia), and it is the displacement of the distal fragment that is described in a fracture (e. g., a Colles' fracture with backward dis- placement means displacement of the distal fragment backward). Rare exceptions to this rule are made only in favor of a long-established custom in certain special lesions. All relations and all descriptions of displacement are, as far as possible, reduced to terms of in and out, anterior, posterior, etc., with the body conceived in the anatomist's position, erect, with the palms facing forward. Spontaneous luxations belong to either the congenital or paralytic types (q. v.f or depend on local disease. SPONTANEOUS AND PATHOLOGIC LUXATIONS SPONTANEOUS FRACTURES 25 Subluxations, slowly or rapidly developed, occur commonly in tuberculosis, especially at the knee; they may, however, occur with any form of arthritis. Total luxation may occur from tuberculosis (not uncommon in hip disease), with syphilitic joints, and not very rarely in the "Charcot joints" of tabes. Acute infective arthritis, septic or gonorrheal, may lead to luxation, not by bone-destruction, but by softening and relaxing the ligaments to such a point that the joint is displaced by muscle-pull of ordinary force. SPONTANEOUS FRACTURES Spontaneous fractures, strictly so defined, would be limited to ero- sive diseases of bone. What we actually mean by the term are frac- tures occurring from apparently insufficient trauma. The frac- tures so common in tabetics, for instance, are hardly "spon- taneous": they depend on in- coordinate but powerful muscle action, for, contrary to the com- mon statement, the bones of tabetics are apt to be heavy and hard, rather than atrophic. The fractures of the insane, common enough, may perhaps be due to defective bone- strength, but are often the result of severe enough violence in- flicted by the patient himself or by others. There are, however, certain conditions involving weaken- ing of bone structure. Com- monest is the wasting of age, an absorption of bony tissue in both the shaft and the spongy bone-ends, with substitution by fat. A like condition may occur as a result of long disuse or from trophic lesions-e. g., in paralytic condi tions. The condition called osteogenesis imperfecta presents bone tissue of strength, as well as size, below the normal. " Osteopsathyrosis," also a congenital condition, is characterized by the liability to fracture, the patient sometimes having fractures one after the other to a total of dozens. In both these conditions repair is substantially normal. Osteopsathyrosis is sometimes recovered Fig. 4.-Pathologic luxation of the hip. In this case it was a septic joint. Note the new bone for- mation starting at the torn-up muscle insertions on the femur--bone formation really of the myositis ossificans type. 26 GENERALITIES from, in part at least, as the child grows up. There is no constant sign of abnormality in the bones. All the conditions of congenital lack of strength in the bones are usually 'Tumped" in the one class of "fragilitas ossium"-a good classification, on the whole, until the pathologic study of these cases is gone into more fully. Of general diseases favoring fracture we may mention osteomalacia (usually giving distortion rather than fracture), scurvy, and rickets. Rickets of severe grade very often gives "infractions"-incomplete fractures.* Diabetes is said to predispose to fracture and to delay repair. Other diseases act to favor fracture only by malnutrition. Of local causes that weaken bone come first the neoplasms, metas- tatic carcinomas, sarcomas, primary or secondary, the rare myelomata, etc. Local tubercular, syphilitic, or osteomyelitic processes may favor breakage under slight force, as may a bone cyst. Spontaneous fractures or fractures from slight violence deserve especially careful x-ray study, for early recognition of a local cause may illuminate the problem of treatment and, at worst, saves the possible necessity of humiliating explanations later on. CONGENITAL (AND PARALYTIC) LUXATIONS These luxations have been treated very fully in orthopedic works. In this book they are described in the text with other lesions of the particular joint affected, but a word applying to the class as a whole may not be amiss. True congenital luxations depend on defective formation of articular ends of bone or on faulty intra-uterine positions. The types of the latter class are the knee luxation known as genu recurvatum, and the subluxations of club-foot; taken early, these cases are remediable by correction of position. Defective formation of articular structures is not accompanied by malposition at first, and may only show itself, as so often with con- genital hip luxations, after active use of the limb has begun. Here the lesion is one of defective growth: the defect tends to increase with time, and the luxation increases. Reposition of the dis- location helps, but does not necessarily cure the condition at any age. Dislocations of the hip, some congenital shoulder lesions, and the rare type of ankle lesion known as Volkmann'st-all these lesions have some tendency to run in family lines. Another class of luxations depend on defects of one or another of the bones composing a joint, as in the defects of the fibula,f now inter- preted as results of amniotic pressure or adhesion. * Infractions are breaks on the concave side. I have seen "infraction" in one case in a tubercular patient, in two cases in normal bone in boys of twelve and fourteen. t Volkmann: Deutsche Ztschr. f. Chirurgie, 1872-73, ii, 538. + Cotton and Chute: Trans. Amer. Orthopedic Assoc., xi, p. 316. DIAGNOSIS 27 Other luxations depending on defective growth of a single bone are sometimes congenital in origin, but differ in no way from those deter- mined by defective growth from other causes. Such a luxation of the ulna at the wrist, due to defective growth of the radius, probably con- genital, is shown in Fig. 679. Checked growth at the epiphyseal line from early trauma may give a like picture. Some luxations, like the backward luxations of the shoulder appearing very early in life, are assumed to be the result of trauma in delivery, a trauma resulting in a splitting-off of the edge of the glenoid, for instance. Shoulder luxations again give an instance of the paralytic type: in some, at least, of the congenital backward luxations at the shoulder the displacement is due to unbalanced muscle pull in infancy, the result of paralysis, usually of obstetric origin.* It is the same sort of condition that gives subluxation, or even total luxations, of joints not actually diseased, under the unbalanced muscle pull of infantile paralysis or syringomyelia in later life. Practically all congenital luxations should be operated on, either to produce a restoration of the joint, or for arthrodesis, but space is here lacking to go into the operative details, for which the orthopedic text- books must be consulted. DIAGNOSIS So far as the general diagnosis of luxations goes, I am inclined to quote the words of my colleague, Dr. J. B. Blake, in a recent class lecture, to the effect that the important thing, trite as it may seem, is that "in a dislocation the head of a bone is dis-located"-that it is out of its place-not in the place which it normally occupies, where it may usually be found. This is the first sign. Next to this dislocation of a given bone-head the best general sign is the loss of motion; fractures, as a rule, give increased mobility; in dislocation the bone-head is displaced, while the ligaments are only partly torn; therefore the ligaments form a passive fulcrum, the new bed of the displaced head gives a passive resistance, and motion is restricted. In luxations in which ligaments are widely torn this rule does not hold. In relation to shoulder luxations, for instance, I have seen several cases in which grave results followed the overlooking of a luxation in which there was unusually free motion immediately after the injury. In regard to general fracture diagnosis, we must keep in mind that the cardinal signs of fracture are displacement and mobility. Either or both may be present; rarely there are fractures in which a simple crack across the bone gives, except for the skiagraph, no sign except local tenderness. Often enough the skiagraph helps us little, or we * R. W. Smith (Dublin Jour. Med. Soc., 1839, xv, 239), Phelps (Trans. Am. Orth. Assoc., 1896, viii. 23), Scudder (Am. Jour. Med. Sci., 1898), and Stone (Bos- ton Nied, and Surg. Journal, 1900, cxlii, 265) give a sufficient resume of the various forms of congenital luxation at this joint. 28 GENERALITIES cannot get an x-ray. Then diagnosis becomes a question mainly of skill in palpation. To deal with fractures and luxations we must first educate ourselves to recognize displacements. This means, apart from a scholastic knowledge of landmarks, that we must educate hand and eye to detect obscure variations from the normal. Obviously, this implies a very thorough knowledge of the landmarks, of bony outlines, and of rela- tions in the normal body-a point often neglected. The recognition of mobility, too, is not always easy, and calls for careful education of touch. As to crepitus, it may be said that bony crepitus proves fracture, whereas soft crepitus indicates injury to epiphyseal or other cartilage. Crepitus is not always easily obtainable, however, even in loose frac- tures, and when gotten, it tells us little or nothing in regard to location of the fracture,* though it proves its presence. THE X-RAY AND FRACTURES f Before the era of the x-ray we seemed to have reached about the limit of our information about fractures, and our fracture lore, based in the main on the wonderful observation of men like Astley Cooper, Dupuytren, Nelaton, Malgaigne, R. W. Smith, and Hamilton, had reached that stage of dogma where knowledge is too largely a matter of weighing the opinions of others. Then came the x-ray, and for two decades a great many observers have had opportunity to study fractures with the aid of a new and wonderful aid to diagnosis. The total number of cases so studied has been enormous, and the results of study have in large measure been made available, by publica- tion, for comparison and study. As a natural result we have learned much; our whole knowledge of fractures seems transformed, viewed, as it were, in a new illumination, and a new generation is growing up who can hardly think of fractures except in terms of the skiagraph, and are impatient with, if not neglectful of, the older means of diagnosis. For many years we have had good x-rays to work with-the method is no longer new. We should be able to judge now rather accurately the additions to our knowledge and skill due to the data accumulated, and to judge in what way the skiagraph may be of most use to us in our routine work. The addition to our fund of knowledge is probably the most impor- tant service of the x-ray. Increase of Knowledge.-Fractures occur in types-nearly con- stant types at that. We have, of late, been able to determine in how * Crepitus may often be transmitted a long way. Crepitus in a loose hip fracture may be felt nearly as well with the hand on the ankle as with it on the hip. The transmission is in the line of continuity of bone, not, for any distance, through soft parts. t This is reproduced from a paper by the author read before the annual meeting of the Massachusetts Medical Society, and published in the Boston Med. and Surg. Jour, of September 3, 1908, clix, 327. THE X-RAY AXD FRACTURES 29 far these types are constant, what minor variations they show, how fre- quently they occur. Previously, we had only museum specimens and unconfirmed clinical diagnoses to study. Now we may have for each case a tolerably accurate diagnosis of detailed lesions. Many types supposed to be rare prove common, as, for instance, comminuted Colles' fracture, fracture of the ulnar styloid, fractures and luxations of the carpus. On the other hand, lesions once commonly diagnosed are now hardly heard of, as, for example, fracture of the acromion, intracap- sular fracture of the neck of the humerus, fracture of the coronoid process at the elbow, uncomplicated dislocation of the radius at the elbow. 11 Stellate fracture into the joint" has gone out of business; not that fractures of this type may not be met with, but because this diagnosis (as the waste basket of the incompetent diagnostician) has been so shown up that we avoid the use of the phrase. We have learned also the frequency with which joint fractures are found as complications of apparently typical dislocations. What we now call sprain /radure-fractures produced by the tearing off of bone by ligament strain (an important class)-was never heard of in pre- Roentgen times. There is also a whole series of joint fractures about which we knew almost nothing in the old days. Most important in this list are the elbow fractures so common in children. They used to be classified, like those of adults, on a geometric basis. Work with skiagraphs has demonstrated clearly that this class really ought to be looked on as epiphyseal injuries. T-fractures and fractures of the internal condyle occur in adults, and we used to diagnose them glibly in children as well. We have learned that they do not happen. The lesions of the humerus at the elbow in children are the supracondylar fractures, the separation of the whole epiphyseal end of the bone, separation of the epiphysis of the external condyle, forming a distinct outer half of the whole epiphy- seal end, and separation of the little epiphysis of the internal epicon- dyle, usually entirely outside the joint. These comprise the lesions which, in fact, occur. Moreover, we have found that the dreaded gun-stock deformity is a result of supracondylar lesions only, and has nothing to do-though this was long taught-with fracture of either condyle. Fractures and luxations in the carpus and tarsus, particularly the very serious os calcis fractures, so common in industrial communities, have only become comprehensible in these later years, and, becoming comprehensible, are for the first time amenable to real and effective treatment. These have been among the most notable, though by no means the only, instances where our knowledge has been broadened. Our knowledge of types seems now pretty complete. We have learned what to expect and look for. But this is not all, or even the best of it, because in learning what to look for we have also learned how to look. 30 GENERALITIES Personal Training.-Those who have used the x-ray as it should be used,-merely as one means of examination,-have vastly increased their own diagnostic powers. We have learned new signs, have come to associate certain displacements, certain limitations of motion, cer- tain points of localized tenderness, and so on, with the lesions to which they are appropriate: have, in short, by means of the x-ray, greatly bettered our capacity to do without the x-ray. So it is in cases of carpal fracture-once they were utterly unrecognized, then admitted and studied; today we know that after a fall on the palm localized tenderness over the scaphoid usually means scaphoid fracture; that localized thickening added to this, with loss of extension and radial abduction, means displacement of the broken pieces: we hardly need the x-ray at all. So with fractures of the radial head: formerly they were not to be diagnosed at all; now, as a result of x-ray study, we may diagnose them without needing more than the results of palpation and the testing of the loss of pronation and supination (with flexion and extension intact) to justify diagnosis. In this way it has been possible for men favorably situated to train themselves to a personal efficiency in fracture work a good deal beyond what was attainable even a few years ago. Every case in which the diagnosis, once made, is checked and proved or disproved definitely is worth many not so checked for purposes of education, and it is in furnishing such a "check" that the x-ray serves its second purpose- that of aiding in personal education. So much for the extension of the world's fund of knowledge and our own education in skill. Routine Use.-The question of more direct bearing perhaps is what use we are to make of the x-ray in individual cases in practice- in what cases we need it, and when and how it is to be used. Much nonsense has been written about the necessity of a skiagraph as a preliminary to treatment of any fracture-of "criminal neglect" in failing so to use it. This is the sheerest nonsense, and I wish to be clear in disclaiming it. Very commonly such use is unnecessary and it is often impracticable. Exceptional Fractures.-There are a few classes of cases in which skiagraphy does necessarily precede any real treatment. Let us see what they are in fact. In a fracture of metatarsals, by direct crushing, for example, we may perhaps be able to guess at the lesions, but can be sure of nothing; until we get the plate all we can do is to put the greatly swollen foot at rest in a comfortable position. Fractures of the scapula, some injuries about the shoulder-joint, crushing injuries of the hand and wrist, fractures of the pelvis, a few hip fractures, some injuries to ankle and tarsus, often depend on the x-ray for diagnosis, in some cases because of swelling, in some because of the essential diffi- culty of getting at any serviceable landmarks. In all these cases, however, simple retentive apparatus till we can get an x-ray is adequate treatment for the first one or two or few days. THE X-RAY AND FRACTURES 31 The same may be said of the more obscure and atypical fractures into and about joints; until we can make our diagnosis we can rest with palliative treatment. Where we are dealing with obscure luxations, luxations complicated with fracture, or joint fractures with much displacement, the problem is different, for these we cannot let alone. The thing to do here is to make our diagnosis as closely as may be, then reduce the dislocation or correct the displacement as best we can, and wait for the plate, recog- nizing (and telling the patient) that we may have to have a second reduction later. In point of fact, the first reduction so made is often adequate, and no second trial is needed. The cases where an accurate diagnosis is essential to reduction of gross displacement are, fortunately, limited, so far as I have seen, to a few luxations with or without fracture in the tarsus and foot-a very trifling percentage of cases. Other threatening conditions, like separation of the femoral epiphy- sis at the knee, Pott's fracture by inversion with great displacement, etc., can be reduced at least accurately enough to avoid the dangers of delay, even without knowledge of exact details. From this it will appear that I am no thoroughgoing believer in the necessity of an early x-ray, even in the classes just cited. It is well that such early x-rays are not necessary, for they are often unobtain- able under conditions of practice as they exist. Routine Fractures -Now, as to the run of fractures and luxations -the routine cases coming into our charge. As we have said, the great majority fall into perfectly well-recognized classes. Aided by the skiagraph, we have evolved more precise methods of differentiating types than we used to have. I maintain firmly that in the great majority of cases a properly trained surgeon can make his diagnosis, so far as practical details go, about as well without the x-ray. If he has not the skill so to make a diagnosis, he is unlikely to be greatly helped by x-rays. Those of us who have used the x-rays most know best how easily one may be misled by this as by any special diagnostic method. Today we have, most properly, skiagraphers-specialists-who cannot only take plates, but can interpret them. Personally, I doubt if a man who has to have plates interpreted by specially trained men had not better leave fractures to men of special training, for one of the services of the x-ray has been to raise the standard of skill that may reasonably be expected. I do not mean to decry early taking of x-rays, if convenient, but wish merely to emphasize my belief that they are not a necessary rou- tine. Nor do I mean that every Colles' fracture, for instance, is a specialist's job; only, if the practitioner understands how to recognize direction and grade of displacement, can reduce and can gage the per- fection of his reduction, he is competent enough to do without both 32 GENERALITIES specialist and x-ray in routine cases, though he will usually want an x-ray for purposes of record. Not all men are so competent, and the practical danger is that men who know neither diagnosis nor treatment will, with a diagnosis fur- nished, undertake treatment they cannot handle properly. Moreover, leaning back on the x-ray makes for neglect of training in manipulation and for a progressive loss of competence in this work. This we see in house-officers in the hospitals, and it is the reason, some of us believe, why fracture work in the big hospitals hardly averages as good as ten years or more ago. A man who does not manipulate frac- tures for diagnosis is not apt to manipulate well for reduction, or to be a first-rate judge of the results of his manoeuvers. And, after all, the preservation of the general line, the reduction of palpable displacements of fragments, is what concerns us; fracture treatment is and will be far from attaining exact repositions of broken surfaces. My belief, then, is that the routine treatment of ordinary frac- tures should consist of the most searching examination immediately, or, if great swelling is already present, then within a day or two-an examination best conducted under ether in most cases; that we should thus establish with all possible certainty and detail just what we are dealing with, perform any necessary reduction, and "put up" the fracture.* Importance of x-rays after Reduction.-Then, in a day or two if the patient can walk, but within two weeks in any case, save sometimes in femur fractures, we should get an x-ray. An x-ray at this time tells us not only all there is to tell as to what the lesion is, but tells us also how successfully we have dealt with it. And, best of all, it tells us this at a time when we can still remedy any defects, whether due to wrong diagnosis or to faulty treatment. In routine hospital work I find it necessary to interfere later in three cases of bad results of treatment to one where the diagnosis was essentially at fault. This is mainly because so few fractures, relatively, fall outside the recognizable types. Malposition recognized within a fortnight may almost always be reduced by handling-rougher handling, of course, than is needful in a fresh case. If, through misfortune or fault, the skiagraph is not taken till three weeks or more have gone by, open operation may be necessary for any needful corrections. Of this, more later. If we do interfere as a result of the x-ray review, we are in duty bound to review our amended result in the same way a little later. My contention that the time for the x-ray is after, not before, reduction is based on the following considerations: (a) Immediate x-rays are hard to get, even in hospitals; any con- siderable delay in reduction means poorer reduction, as a rule. * Fractures that cannot be reduced usually fall in the operative class. Before open operation, we should always have a skiagraph if we can. In this connection may be mentioned the great convenience of stereoscopic .r-rays for information as to relations. THE X-RAY AND FRACTURES 33 (b) x-ray examination does not take the place of the time-honored examination in anesthesia, and this examination, properly done, with immediate replacement of fragments, usually fulfils the immediate indications. (c) Considerations of difficulty in transportation, expense, and procrastination make it unlikely that more than one x-ray will be taken in a given routine case. This one may best be taken when it will check both diagnosis and corrected position and will help in prognosis. Late x-rays.-Now as to late x-rays, taken to inform ourselves as to end-results. I believe they should be taken only for definite reasons. Nearly all cases of fracture call for an x-ray at some time, but this is not the time. In the best cases the x-ray shows abnormal positions of bone-ends; in less good cases things always appear far worse than they are. Accurate reposition is almost never attained, except by open operation, but it will be years before the laity, including the courts, will appreciate this. What is important is the obtaining of good functional results-an entirely different matter. The only possible service, except that of record, to be rendered by the x-ray in late cases is the explanation of defective functional results already observed with a view to bettering the results by operation or otherwise.* Where this is called for, well and good! Otherwise I confess I have no interest in having end-result skiagraphs: ordinarily they will tell nothing except what, clinically, are misstatements or half-truths. Remember that the x-ray does not tell anything except the relation of the original fractured bone-ends and surfaces. It shows callus little, if at all, and give no credit for any repair for months after such repair seems complete by other tests. In the usual run of fractures, I believe, we will be wise to use the x-ray in practically all cases, at least for record, repeating it, if we may, but certainly using it at such period as will enable us to establish or confirm the diagnosis and to "check" our treatment. It should not be used in place of skilled manipulation for diagnosis or as the arbiter of end-results, t * Since this was written a new point has come up. Today we can get valuable information as to the progress of union from good x-rays-not to be sure an accu- rate picture of the callus formation, but a differentiation of slow normal union from the failure of internal repair, even in the presence of callus, that often presages "non-union." t Since this chapter was written for the first edition many things have changed. The essential facts have not, and I have chosen to let the text stand. Today, however, x-rays are easier to get and are more used. The portable machine devised for army use helps out in many cases: stereoscopic plates are to be had-- of great value: immediate plates are often to be had and when possible it is very desirable to follow many fractures through their course with repeated plates. Moreover one may in many places today use the fluoroscopic screen as a direct check after reduction, or may view the manoeuvers of his reduction directly on the screen. The last method is of limited application because proper protection of the operator's hands and the screen in the way makes one rather clumsy. 34 GENERALITIES Repair of injuries of the skeleton differs in one respect from the repair of other tissues: in other tissues, save for the peripheral nerves, healing is essentially dependent on the formation of fibrous tissue-in the skeleton we may have, under favorable conditions, an absolute restitutio ad integrum; bone reproduces bone, capsular tissue reproduces itself in fibrous new-growth, and even the endothelial joint layer is reproduced. Ideally,we may have perfect repair. In fact, such repair occurs in dislocations not uncommonly, and in fractures when there has been no malposition. In practice there is apt to be either laxness or else re- striction of motion from over-repair in dislocations, and overgrowth of bone in the callus that welds together the separated fragments in fractures. Some temporary overgrowth of callus is almost always present, and extreme excess is not rare. The conditions favoring callus formation and bone-growth are im- perfectly understood,* but we may formulate the following rough rules: The primary callus is dependent for its mass on the primary blood- clot and the cellular infiltration of the surrounding tissues. The ossification of the primary callus proceeds in the main from the inner side of the periosteum, which is stripped up, more or less exten- sively, as a rule. The outer side of the periosteum seems to take no part as a starting- point of ossification-i. e., it furnishes no osteoblastic cells. Callus may enwrap muscles or tendons, but they are not a part of the bone-forming mass. Irritation, mechanical or other, usually increases the size of the primary callus: infection leads to its destruction. Callus formation between bone-ends and the internal callus arising from the marrow have a part to play later, but have little to do with bone formation in the provisional consolidation which is what we know clinically as firm union. The merging of tissues into real bony union is a long process, and occurs usually long after the case has been discharged as cured, surgic- ally speaking. The "restitutio ad integrum," with restoration of the marrow cavity, etc., takes many months, or even years, and is a process that we do not ordinarily concern ourselves with. In most cases all that concerns the practitioner in dislocations is such healing as permits joint motion without pain and without tend- ency to recurrence of the luxation: in fractures we seek a union suffi- ciently firm to permit use of the limb without danger of damage. It is surprising to learn how early in the process of repair this end is reached. In operating on certain cases, even three or four weeks after the injury, one is surprised to find it very difficult indeed to break up the fracture, REPAIR * For factors producing defect of bony growth see under the caption Non-union. 35 NON-UNION and yet when the bone-ends are once exposed, the original fracture sur- face seems practically unchanged. It is for this reason that the x-ray is so poor a guide as to union. Many a fracture that is united solidly enough for use will show on the x-ray plate only a trace of callus, with apparently unchanged ends of fragments. NON-UNION Non-union usually means delayed union. I can recall but few cases of my own in which union actually failed, but very many cases in which it was abnormally delayed. We all know that there are rare cases in which resorption of bone takes the place of callus formation, in which union is hardly to be expected, even after repeated operative interference.* But these are not the cases met with in ordinary practice. What we do see are the cases in which there is little or no callus formation; in which the skiagraph, or open operation, demon- strates the utter lack of change in the broken ends of bone, for better or for worse, after weeks or months-cases in which union does at length occur, but only after six months or a year, or even two years, after the receipt of the injury. Less common but not rare, are the cases of this class that never unite save as a result of operative treatment. The importance of these cases lies not only in the loss of time, but also in the fact that such late union almost inevitably involves shortening and other deformity from imperfect fixation. Even the greatest care will not wholly obviate this. Moreover, the necessary fixation tends to end in loss of joint motion, despite such massage as we can safely employ. In joint frac- tures or breaks near the joint there is often further limitation from excessive thickening of the capsule during the long repair process. Even cases where non-union is success- fully dealt with give, therefore, very imperfect results, as a rule. Fig. 5.--This plate shows the manner of union when union does follow after fibrous healing. The amount of bone is con- siderable-the external callus unites enough to give support and at last the opposed ends of bone join, bone apparently follow- ing along narrow bridges w here there is least fibrous scar. Such union is uncertain and takes many months at best. Today these cases are usually grafted early. Interest- ing in this plate is the atrophy of the shaft below the fracture. * These cases show in the skiagraph conical apposed bone-ends, curiously like the eroded ends of the carbon sticks in an arc-light. 36 GENERALITIES The causes alleged for non-union are legion, but our knowledge of them is really very imperfect. We know that in multiple fractures we may often get delayed union of one fracture. We know that certain bones tend to be slow in uniting (radius in the shaft, humerus, femur, etc.). We know that fractures within the capsule of joints give a large proportion of cases of delayed union or non-union, probably from the presence of synovial fluid.* Obviously, interposition of muscle or of tendon structures between the broken bone-ends is a bar to union. But this is not common.f In a good many cases operated on I have found it but rarely. Commoner is the interposition of intact periosteum. It seems that callus formation between the bone and the outer (not the osteoblastic) surface of the periosteum is almost nil. In case after case I have found this to be so, and the results of denudation of bone (stripping away such periosteum, bringing bone to bone with periosteal fragments as a cover") have seemed to justify my notion. Commonly enough it is hard to be sure whether the delay in union is due to this interposition of periosteum or to the very poor position usually present in such cases. Poor position is itself a cause of delayed union, for the bridging across of a wide gap takes much tissue and much time, even if there is no muscle in the way. Certain cases of slow union in femur fractures are undoubtedly due to this cause. Sepsis delays union very notably, even if there be no dead bone. Compound fractures, even if clean, do not unite so promptly as simple fractures of like type. Constant slight motion delays union as in cases on board ship, cases in patients who ride in automobiles all the time. On the other hand over-complete fixation especially if with com- pression by splints that checks circulation tends, apparently, to delay callus formation. * "When a bone which forms part of a joint is fractured transversely, union seldom takes place between the fractured ends, as in the patella and olecranon, where the same effusion of blood takes place, but is lost in the cavity of the joint from which it receives vessels and becomes of a ligamentous substance. When the cervix of the os femoris is fractured, it becomes united to the capsular ligament by bands. The reason for this kind of union taking place is exactly the same as in a trephined skull. For the action of the muscles inserted into the upper part of the bone draws it upward, and those into the lower part draw it downward, and the space becomes too great for the vessels of the bone to shoot into the coagulated blood and form it into bone. This I think will hold good, though it is different frcm the opinion of many men." (From extracts from lectures of Sir Astley Cooper, delivered in 1793, taken from the notes of Mr. Charles Fiske, Saffron Walden, 1824, fourth edition.) Substantially this statement of Sir Astley Cooper's holds true, and the role played by the synovial fluid has often been lost sight of. In 1912 I brought out this point at the American Medical Association meeting. No one paid the slightest attention to it, but I think it is true. t In one fracture it is very common, namely, in fracture of the patella in which the expansion of tendon and the periosteum on the front of the patella are torn and drop in between the fragments. NON-UNION 37 Fractures in tabetics commonly unite well enough but sometimes there is delay.* Joint fractures in Charcot joints do not unite. The presence of local bone disease is a factor. Fractures due to osteomyelitis occur usually during operative interference for removal of sequestra: they do not give non-union or even delay in union. I have seen one case of fracture due to tubercular bone lesion that united promptly; obviously, severe local tuberculosis or syphilis must delay repair. The presence of a bone-cyst favors fracture, but does not retard repair. New-growths-carcinoma, sarcoma, etc.-may be the cause of the fracture and also the cause of failure of the fracture to unite. Spon- taneous sarcoma of callus is written about, but it is likely that in these cases the neoplasm precedes the fracture. As to general "constitutional" causes, it may be said, first, that age (apart from grave malnutrition) plays no considerable role. Delayed union is not so very rare, even in healthy children. The general health is not as important as it looks in this regard. Many cases occur in robust young men and women.f Even actual illness often does not interfere with bone union. Severe wasting diseases do slow up the process of union, but not very markedly. + Conditions involving lack or apparent lack of bone- forming material are rare, and are not always important, for fractures in patients with osteomalacia, fragilitas ossium, or with rickets unite readily, usually with excessive callus. Scurvy does certainly delay union and may prevent it or cause resorption of formed callus, but scurvy is a rarity today. We are told that syphilis plays a part in non-union; perhaps so, but I have not seen it, and have seen many fractures in syphilitics. § So far as the reference of the condition to any general causes goes, we have little to help us, nor is the general "constitutional" treatment of these cases convincingly successful. Naturally, we will do our best to maintain the patients general health; plentiful food, fresh outdoor air, etc., probably help. Thyroid medication, administration of lime salts, etc., have proved theoretically * Possibly connected with the increased density of bone sometimes associated with this disease. I have seen such density act as an apparent bar to union where there was no tabes. 11 have just now under treatment three such cases of "non-union" or delayed union: one in a healthy, vigorous, outdoor man of fifty; one in a normal woman of twenty-five; and one in a man of twenty-five, six feet tall, weighing 190 pounds, lean, muscular, a fine type of man in every way. Each of these cases has been operated; in none of them was there interposition of soft parts. All now show gradual progressing union, but only after two to five times the normal interval. Surely there is an individual predisposition in this matter, potent but unknown as to its character, serious enough to make definite prognosis as to the time of union of any fracture a bit uncertain. t Diabetes may give delay in union. § Data from Willard Bartlett of St. Louis suggest a more real connection than I had thought, between general (not local) syphilis and non-union. I cannot confirm his observation. 38 GENERALITIES interesting, but their practical importance has not been demonstrated. Surely they are unlikely to do any harm. The question of fixation is certainly one of the important items in prevention and cure of delayed union. The cases of delayed union almost always show a fibrous callus, with defect of bone formation, with broadening of the broken ends. In cases where both contact and fixation are adequate, this repair by fibrous callus seems not to be met with. Repair is more nearly by first intention, as with inset grafts in experimental work on animals. No one can doubt that constant, jarring motion may interfere with union. The often delayed results in fractures occurring in sailors aboard ship show this clearly. Fig. 6.-Union of fracture after spontaneous break (in bed) due to sarcoma. Later union was broken down as the growth increased. The patient steadily refused operation. Nor can we, on the other hand, deny that the results of fracture healed under partial use, without fixation (as in dogs and other animals, for instance), show efficient callus formation, though often enough this is accompanied with much deformity. Nor is there any doubt that irritation, accomplished through moderate attempted use or through the now-forgotten acupuncture, ivory pegs, and forced manipulation of earlier days, or the neater open operations of today, with or without wiring or suturing, do contribute toward the natural effort at union. On the whole, it seems wisest to use especial care in immobilizing fractures that show a tendency to delayed union. Weight-bearing, so far as is consistent with such immobilization, sometimes tends to promote union, sometimes does obvious harm. There seems no way to determine this, short of actual trial in the given case. NON-UNION 39 So, too, with massage. It should be tried for a time (removing apparatus temporarily to permit manipulation); its continuance must rest on results, according as it serves to tighten or to loosen the insuffi- cient union in the given case. Either result may follow. No one knows why either result may follow but I do know that persistence in obviously harmful massage is indefensible, whatever our theories may be. The Bier or von Schmieden operation-injection of the patient's own blood into the insufficient callus-has given me results that were good and seemed due to this procedure. My own method of scoring the languid callus with a tenotome (subcutaneously) to get a local Fig. 7.-Bone syphilis. The affection is almost entirely of the ulna. There is also a supracondylar fracture which brought him to me. The elbow had not troubled him before the injury. clot, must be considered sub-judice, though it has worked well in a few cases. Stimulation of bone production by lime-salts and with metallic magnesium I have used with apparent success, but both are still experimental. Recent experience has shown that diathermy treatment has in these cases a very real stimulant effect on repair, through with limi- tations of course. There is no subject related to fractures in which I am so ready to plead ignorance as in this matter of delayed union, but I believe we may safely formulate the following conclusions: Lack of immobilization is apt to lead to "non-union." At least twice I have made deliberate and successful use of this where a perma- nent false joint was desirable. Far oftener have I seen cases in which the like result occurred independently of any effort on my part. 40 GENERALITIES Fig. 8.-Bone cyst. Non-malignant-later cured by fracture-i. e., by curettage of the cavity and crushing in of the wall. Fig. 9. -Fracture, spontaneous, through bone cyst, in a girl of 12. NON-UNION 41 Fig. 10.-Same at 3 months with firm union-which usually occurs in these cases, and is often the means of cure of the cyst. Fig. 11.-Charcot knee. This woman entered for a fresh patellar fracture. Abnormal lateral motion without pain led to a provisional diagnosis of Charcot joint. The x-ray tells the story. She had been operated on twice for patella fracture (once she had it, evidently) and the broken wires and separated fragments are plain in the picture. In this case, while there were absent knee reflexes and small pupils, the tabes picture was so little obvious that only after a repeated consultation would the nerve department make a diagnosis. 42 GENERALITIES Immobilization, attempted but neutralized by jarring (as on board ship), may result in long-delayed union. Multiple fractures often show "non-union" in one or more of the breaks: whether this is due to an unhonored excessive draft on the body's stock of lime salts I do not know. Apparently, fractures occurring in connection with great shock- e. g., in railroad accidents-show an abnormal proportion of cases of delayed union. Sepsis delays union. Compound fractures unite slowly even if aseptic. Fractures through the site of malignant disease may not unite. Age, malnutrition, and constitutional diseases (tuberculosis, syph- ilis, rickets, scurvy, diabetes, etc.) may, no doubt, play a part in de- layed union, but are not commonly operative as causes, even when present. Fig. 11a.-Old non-union completed, process of bone repair with false joint Contrast with plates Fig. 5 and Fig. 17. Fig. life.-Same case as Fig. Ila. Not de- layed union, but completed non-union. Operative Treatment for Non-union The indications for operative treatment in non-union may be made pretty definite. After a reasonable period, if union is deficient-certainly after three or four months it is time for a review of conditions. Open operation must always come up for consideration, unless there is some factor, like a history of imperfect fixation, to indicate further treatment by rest. OPERATIVE TREATMENT FOR NON-UNION 43 As a broad rule, latterly, I follow not any rule of time elapsed but rather the condition as shown in the x-ray picture. If there is a fair amount of repair bone and if the broken edges are vague-soft-then one may wait. If there is, across the bone ends, a definite thin shell-a new cortical layer-then the repair process has reached a stop and we may as well operate. (See Figs. Ila and 11b.) In a general way it is better to operate in the border-line cases, Fig. 12.-Colles' fracture with secondary "traumatic" arthritis. Note not only the widespread porosis of bone, but also the conspicuous "pencilling" of shadow of bone left intact along the articu- lar faces and the cortex. This is the picture also of the spontaneous arthritis of "rheumatoid " type. for one often finds unsuspected conditions irremediable except by operation. At worst such operation properly done, does no harm and gives a fresh start. The determining factor in non-union as just stated is the formation of a finished layer, a limit to bone growth across the bone- ends,-and any operation corrects this, giving fresh nutrition by doing away with this obstruction, incidentally removing any obstruction of interposed muscle or tendon or periosteum, and often improving the position of fragments as well. Today one hears of nothing but bone grafting. I do the bone- grafting operation as a rule myself but it is my belief that refreshing 44 GENERALITIES Fig. 13.-Same case as Fig. 12 : side view. Fig. 14.-Traumatic arthritis following fracture and luxation of the astragalus, reduced by open operation. There was no infection. Eventually the arthritis improved. He had some tend- ency of the foot to roll and went back to work with a light inside upright and T-strap and worked without pain and with no disability traceable to the arthritis. These arthritic cases after fracture usually clear up after about a year. 45 OPERATIVE TREATMENT FOR NON-UNION operations so done as to give fixation of fragments not too widely apart give pretty much the same results. I have often obtained ideal results from proper fixation with a kangaroo-tendon suture, with a single strand of wire, with the Lane staple or Terry's modification of it; and from a purely practical point of view the intramedullary splint where it is needed does about as well if of ivory or cooked bone, as the live graft does. Fig. 15.-Fracture both bones of forearm without displacement ("subperiosteal"). The radius has healed promptly with but little callus: the ulna shows a line of interposed "fibrous callus," and is consolidating slowly and irregularly with much new bone. The use of Lane or Sherman plates, or Parham bands, I prefer to avoid if possible-the presence of a metal foreign body of such bulk seem to depress bone formation. The operation most used and perhaps on the whole most useful, is after all the bone-graft. This is not the place to discuss detail in technic. It is essential the bone graft 1. Be autogenous. 2. Be of bone not too dense, if we expect active growth. 3. Be without periosteum on its imbedded faces. 46 GENERALITIES 4. Be set in a bone-bed carrying sufficient nutrition. 5. Be set in this bed solidly at both ends. Beyond these desiderata the rest is not essential. It is handiest to cut them with a power saw,-well and good if the saw is not run too fast or dry (that kills the surface of the graft)-but a hand saw is as good and an expert can do it as well with a chisel. Whether the graft is inlaid at the surface and tied or pegged in, or put into the medullary cavity matters little so long as it fits tight. A B Fig. 16.-A, Myositis ossificans coming on after reduction of an elbow luxation. After mis- taken zeal in passive motion he was entirely crippled. After protection for two months motion returned. The case was not operated on but he is back at his work as an obstetrician and has no trouble. B, A like case of like history. After waiting for the quiescent stage (here shown) I removed the bone. The arm originally much crippled became practically normal in range of motion, and painless. There are failures at times, of course, but not many under proper technic. Do not expect too much. The graft acts only as a bridge and a starting point for the union at best. In all operated cases in which bone formation is originally defective the beginning of solid union is discouraging slow, and the attainment of solid union takes a lot of time. TRAUMATIC ARTHRITIS Under this rather vague title, we class those cases in which abnor- mal soreness, stiffness, pain and swelling follow after a definite skeletal lesion (often two to six weeks after) with an intervening period of normal convalescence. TRAUMATIC ARTHRITIS 47 Often enough they occur in patients of robust type, without history of previous "rheumatism." The x-ray shows osteoporosis, often extreme. This picture is that commonly seen in arthritis of the "rheumatoid " type. In other cases, the same picture (really a picture of bone atrophy, merely) is seen after fracture, without a symptom of arthritis. In a few cases, the picture is partly atrophic, partly hypertrophic, and sometimes we have a typical osteoarthritic x-ray. This last class sometimes represents the Fig. 16c.- (Venzie). Spiral fracture of femur in a boy. Fig. 16d.-Same. Banded with the Parham- Martin band. waking-up of a pre-existing osteoarthritis; sometimes the process seems to start de novo with the trauma. In any of these types, the changes are not definitely limited to the point of injury, or even to the injured bone or joint; rather does the whole hand or foot show the involvement. (See Figs. 12-14.) In patients showing evidence of general osteoarthritic changes this complication may fairly be anticipated (though it does not necessarily ensue), but in any case, we may have it to deal with, in adults at least. 48 GENERALITIES Sometimes there is a toxic predisposing cause, like apical tooth- abscess, to be dealt with-usually nothing: some cases suggest a purely trophic change. The therapy includes heat, gentle massage, support and only the gentlest "active assisted" motion. It is a comfort to know that most of these cases do well in the end. Even when there is definite arthritic change, the results at the end of a year are apt to be better (much better) than one would anticipate from the condition a few weeks after the injury. Fig. 16e.-I am glad not to know the story of this surgical misdemeanor. It tells its own story! The moral is, I think, as Dr. J. Bapst Blake used to put it, in his neat phrase,-that "no man ought to try to mend the leg of a man who couldn't mend the leg of a chair." Only rarely do we see this condition go on through the rapid progress of an acute osteoarthritis with the outcome of a permanent ruined joint. Not quite clearly separable, clinically, from the cases of arthritis just noted, are the cases of ossification in and about the joints. The best accredited recent work seems to show that the ossifying process starts from communication of the blood-clot in or about the muscles with the synovial cavity. Be this as it may, we have in no inconsiderable class of cases, calcifications in or about the capsule or in the muscles about the joint. (See Fig. 16.) Some of these cases come to operation. The results are good, if the bone deposit is localized and limited. In other cases, palliative treat- ment, as for the arthritis, and a reasonable patience, give us very fair results. There is a definite tendencv to self-limitation in this condition. MYOSITIS OSSIFICANS MYOSITIS OSSIFICANS 49 The time for operation is after growth has ceased; to remove mechan- ical hindrance to motion. Removal of the masses does not check the growth, if done early. The cases occur (as might be expected from the etiology) rather in connection with the luxations than in fractures. Nearly all the cases that I have chanced to see, have been at the elbow. They may occur at any age; one in a boy of nine; another at about ten years, but usually in adults. The important cases are apt to be about joints, but like growth Fig. 16/.--The strand of wire used has a loop (brazed) at one end. The wire is passed about the bone, and the ends passed, crosswise through the oval, smooth edged hole in the tip, then up on either side the cross-bar (a). The looped end then goes over the hook (b), the free end is clamped by a camlock under the wing-nut (c). The handles are then closed until the wire is fairly snug. The tension is held by the ratchet (d). Then the whole instrument is twisted: the smooth hole in the tip makes the spiral close and the cross-bar (a) crowds the turns down close. The wires are cut at the level of (e). The loop is flattened over onto the bone. How close the wire-band is drawn may be seen from the insert at (/). may be anywhere. My most recent case showed large masses in the adductor tendons adjacent to the point of break in the ram in the double fracture of the pelvis. The importance of the condition is purely mechanical in the end. The importance of recognizing it early is very great, for there can be no doubt that active motion tends to stimulate the growth, increase the final damage, and necessitate later operation. In every case of j oint f racture (particularly at the elbow) any tendency to unusual tenderness with spasm after two or three weeks out of splints should lead us to have the rc-ray answer as to the presence of this process. 50 GENERALITIES If it is present, it means immediate change of treatment, careful continued observation, and often operation in the end. As to treatment of dislocations, it is purely a matter, first, of reduction, with the least possible damage to soft parts, then of rest untifrepair is pretty well advanced, then of careful mobilization and use. Reduction is to be carried out so as to give complete restoration of position, by the methods that require least force-usually this means a form of reduction that utilizes as its fulcrum the part of the capsule left intact (as the Y-ligament in the hip), but we must also bear in GENERAL PRINCIPLES OF TREATMENT Fig. I63.-Femur banded ten months previously. Refractured exactly at point of banding by fresh but slight accident. The band is clearly shown to have been imbedded, but it nevertheless constituted a point of least resistance. mind that the possibility of damage to nerves (or vessels) may guide our choice of method quite as much as ease of reduction. As to fractures, we are here dealing with fractures near to the joints or involving them: our treatment concerns itself particularly with avoidance of mechanical interference with joint function and of joint stiffening. Accordingly, our aim is the most exact reposition obtainable, and the earliest possible return to motion at the joint. There has latterly been a great change in our attitude in this regard -we no longer keep a Colles fracture up in rigid splints for six weeks, and we no longer expect stiff fingers and wrists. In short, we have learned the danger of long fixation as applied to traumatic cases. The theory of the harmlessness of fixation, brought out by Sands in 1886, was accepted because it was approximately true in tubercular joints, but this theory, unthinkingly applied to fracture, has done vast GENERAL PRINCIPLES OF TREATMENT 51 harm. In children, even in fractures long fixation does little harm. As applied to adult fractures, unprejudiced observation in any hospital on any day will show the dangers of fixation. We have also learned, on the other hand, that the rough passive motion taught in still earlier days does only harm, and that any forced passive motion is a doubtful measure. We have not learned fully as yet the benefits of massage, or of early active motion done by the patient himself, the hands of doctor or nurse steadying the injured part. It is not necessary to follow the frenzied lead of some of the French too closely, but there is no doubt that the trend of intelligent fracture treatment is along the lines of less pro- longed and less absolute fixation, of more and earlier massage, of less passive motion, and more and earlier active motion. This is particu- larly true in joint fractures and those fractures occurring near joints. One point in favor of open operations on fractures is that, with the more accurate reposition and fixation made possible by this method, we may safely begin motion a good deal earlier in most cases, and thereby avoid stiffness from fixation and, in a measure, avoid that loss of motion which results from the filling up with callus of physiolog- ically important fossse long left empty (as, for instance, the coronoid and olecranon fossse at the elbow). There is a question if we are not learning to utilize the "brisement force" responsible for so much harm twenty-five years ago-long since practically abandoned. "Brisement force" combined with careful splinting, very early and very careful massage has a place but it is easy to miss out on it and this must be recognized as experts' work. Done as the "breaking up of adhesions" used to be done, it does only harm. Traction or Extension Treatment It may seem that I give little space to the so-called Bardenheuer system. Save for fractures of the femoral shaft, I do not use it. In most fractures, it is bad mechanics, and, as is shown in the chapter on humerus fractures, may do real harm. (See Figs. 216,234.) This is entirely apart from the practical difficulty in applying it in our clinics. Since the above paragraph was written we have had the war and the extensive advertising of the various splints modelled on the Thomas-Jones originals. These are, as is often forgotten, transporta- tion splints primarily, and admirable ones. I have used them all, and shall continue to, if I have occasion to transport fracture patients. Traction of all sorts for femur fractures, whether with Buck's extension done with adhesive plaster, or with flannelette strips and Heusner's or other glue, or with the Steinman nail, or the ice-tongs of the American Ambulance, represents a necessity. Traction in certain very much smashed limbs to avoid telescoping, if one may so phrase it, is of great value, though not commonly needed save in war wounds. If it is needed, any way it can be done is a good way. Other than in these classes of fracture I avoid traction when I can. 52 GENERALITIES PHYSIO-THERAPY Massage Massage, as applicable to fractures, consists of rubbing (effleurage), of pressure (pression methodique), of kneading (petrissage) movements and of vibration. The other forms of massage proper hardly come in question here; but passive motion and active motion, with or without resistance, are often wisely carried out after a seance of massage. Broadly speaking, active motion, without resistance and with the operator's fingers fixing fragments so as to guard against displacement, is most often advisable. Massage, as we apply it in this country, is most often a procedure for 'Timbering up" joints already stiffening. This is all wrong. In children such massage is usually unnecessary; in adults, it is begun too late for the best results. Certain French surgeons begin massage immediately: the results appear to be good, and there is certainly less stasis of the circulation. We are hardly educated to this yet, and, if we were, most of us have no masseurs to whom we are ready to intrust cases at this period. It is certain, however, that massage and guarded active and passive motion should be begun much earlier than has been the American custom. There is a chance of imperilling reposition by such measures, and, in doubtful cases, the progress of union may be checked and such irritation may be caused as to interfere with the recovery of joint motion. The extreme advocates of massage deny both dangers: I am posi- tive, for I have seen both results actually happen, not once, but repeatedly. I believe in massage and believe that it should be begun rather early in most cases where fixation is simple and exact, provided we can depend on a competent masseur; but I believe the continuation of massage should be dependent upon demonstrated results, for better or for worse, in the individual case, as treatment progresses. In fact it is but rarely that a case of fracture leaves my care without having had more or less massage, and year by year I call for it more and more, but am more and more fussy about who does it and how it is done, for results are dependent on personal skill, and unskilful work even if so carefully supervised as to avoid damage does not bring results. Those who are to treat fractures should known enough to control this work, and should see much of it done. The surgeon can not be a masseur but he should have his own masseuse, and she should work not on vague prescription but under his eye as far as possible. Latterly I have had much work done in my own office with this in mind. There is nothing complicated about it, but it does require skill supplemented with the judgment of experience-like everything else worth doing. HYDROTHERAPY AND THERMOTHERAPY 53 There is available today a corps of several hundred women lately physio-therapy aides in our army, carefully trained (many of them with previous experience) through graduate schooling, and vast carefully supervised experience during the war, who have come to a standardized excellence in just the sort of thing we need in our fracture work. To my mind the "P. T. aide" is one of the best things that has happened lately and should, if she gets a fair chance, do much to help all surgeons to better functional results than secured through the masseuse usually available a few years ago. Hydrotherapy and Thermotherapy Which is to say, baths and baking-for, save to limit effusion in very fresh cases, as for example in patellar fracture, cold has no interest in relation to this matter of injuries. Baths are important as an adjuvant to massage in limbering up the later cases,-warm or hot baths. Heat applied as hot air or better yet as radiant heat from an electric light baker is more convenient and for many cases is almost a necessary preliminary to massage, increasing circulation, lessening sensitiveness, and particularly lessening muscle and joint stiffness. In cases with effusion into and about joints I find that hot sand baking is even more effective. This method, not necessarily done at the time of massage, can readily be done at home. Just because it is an almost forgotten technic, a short precis will be given. Get a box, preferably of wood, big enough to hold the joint in question,-for a knee not less than 12 in. by 8 by 8,--cut out holes in either side down to a couple of inches from the bottom, shaped so that the limb can be laid in across the box. Get plenty of any clean sand. Heat the sand, as a preliminary, enough to char the countless tiny bits of wood so often present that otherwise make pin-point burns. For use, heat the sand in a big pan over gas or other stove, stirring it with a wooden paddle till it gets as hot as the hand, thrust in, can bear comfortably. Then pour a sand bed in the box, put the limb in, cover it 3-4 in. deep with the hot sand, and cover the whole with a "comforter." The heat is usually held fairly well for over a quarter hour. This, done once a day, helps a great deal in many cases, particularly in the joint cases. Perhaps because there is pressure as well as heat it seems better, in cases with effusion in a joint or with oedema, than other ways of applying heat. Eau-courant or whirlpool baths are going to be used for their effect on the circulation through repeated impact of the flowing water and the small repeated motions. They are now available in a few places. 54 GENERALITIES This method and that of manual massage of the floating limb, I have seen used in the army cases enough to know that they have a future. Electrotherapy Up to date electrotherapy has had nothing to offer bearing on fracture handling, but judging from observation of the war work I think we may look for serviceable help in several matters. 1. In exercising atrophied muscles with the Bristow coil or with the rhythmic interrupted sinusoidal current. 2. In lessening pain and sensitiveness to handling with the high frequency interrupted, or with the deep heating of the diathermy current, or by ionization. 3. In absorption of deep exudates about joints by ionizing currents. In no sense an electrotherapeutist, I am offering these suggestions as to lines we should be working on. Mechanotherapy I fear I am no friend of mechanotherapy in the usual sense, whether by this one means Zander apparatus or Tait McKenzie's most ingenious array of machinery. All this, with the very admirable work of Dr. S. I. Franz in Wash- ington and Captain Bott in Toronto, belongs, I think, rather to the reeducation of chronic nerve diseases and disorders than to the treat- ment of injuries. I have myself devised and used certain special machines, but at the end find them used so little that even their description is going to be omitted. The fact is that work of this sort requires, for success, an amount of skilled supervision that will bring like success more certainly without the machinery, if we rely on massage and exercises, as a rule. Exercises There is here no place to go into this matter fully. All resumption of function after injury is by exercise but there are certain exercises beside those in common use, some for limbering, others for muscle development, that I am constantly having used by patients, which should perhaps be mentioned. The more formal sort of thing to be done under the direction of the masseuse or trainer must be left to special treatises. Hand and Finger Exercises Hand Exercises.-In the masseuse's hands, slow, rhythmic stretching and active exercise against manual resistance are our main reliance but there are a few exercises for the patient himself that are worth remembering. 1. The rubber ball-any ball of no greater size than a tennis ball-- with a hole punched in it to let the air leave and enter-or a light HAND AND FINGER EXERCISES 55 syringe bulb, gives opportunity for the best of finger flexion exercise. This can be carried on at odd intervals, even in the side-pocket of one's coat. 2. Marbles, ordinary marbles carried in the pocket, three or four of them, may be shuffled between the thumb and one finger after another with good results disproportionate to the trouble. 3. " Caterpillar " exercise with one finger after another crawling on the table forward, back, and laterally do much to restore coordination. One may lay off checker-board squares on the table to lend interest and measure progress. Exercises for Forearm Rotation.-Active exercises do more here than the masseuse can. Voluntary free rotation, and rotation with the forearm on the arm of a chair or over a table corner, and a cane, held so as to balance heavy at the top, are the serviceable methods. Elbow Exercises. 1. For flexion. (а) With the upper arm on a table flex actively. (б) Standing, place both hands on a table and flex both elbows, letting the body weight act to help flexion. (c) Lying on back with upper arm vertical,-utilize the drag of weight held in the hand to increase rhythmic movements of flexion and extension. Shoulder Exercises.-See chapter on shoulder injuries for special exercises. Note that for both shoulder and elbow stiffness the best exercise after a certain point is the swinging of light pound) Indian clubs. Previous acquaintance with club swinging is, however, almost a requisite. Hip. Exercises. (1) For Abduction.-Stand with the feet about 15 in. apart with the back to a table, hands on the table, and swing the hips from side to side keeping the knees straight. 2. For Flexion.-Sit in a rocking chair with the foot against a wall, and then rock. Nothing does as well as this and it particularly suits old ladies who are not apt pupils at formal exercises. 3. For Extension.-Stand back to a table, rock the body back and forward, using the table edge as a fulcrum at the hips. Knee Exercises.-There are three things one wants to do to knees: first, to increase the range of flexion; second, to restore the moderate range of hyperextension needed for standing in the " rest position "; third, the restoration of power to the wasted quadriceps, for, so long as the quadriceps remains atrophied, the knee joint is weak and very subject to damage from slight twists or strains. For these purposes we have exercises. 1. For flexion. (а) The rocking chair used just as for hip exercise. (б) Flexion in the standing position, hand on table, both knees acting together, the body weight giving the flexion power. 56 GENERALITIES (c) Sitting on table, flexion and extension voluntary, the weight of the limb acting as the stretching weight. 2. For extension. (а) Pressure by the patient with his own hands on the knee, the leg lying flat on a table or bed. (б) Voluntary effort in walking, with or without crutches, to secure maximum extension with each step. (c) At a later stage, standing in the relaxed position, body weight acting to stretch. 3. For quadriceps development-just the same exercise as 1 (c) for flexion,-in this case the voluntary extension gives pure quadriceps exercise. Fig. 16/t.-The outward rolling exer- cise. Weight on feet, body steadied by support of chair or table. Roll outward 12-30 times, twice daily. Fig. 16/.-Second exercise-up and out rise on toes and pull heels in! Ankle Exercises. 1. For dorsal flexion. (а) Just as for knee flexion,-standing flexion, with special care that the feet be parallel and the heels held to the floor. (б) Slow running-a "crew jog"-is of great use in the later stage. (c) Exercises on mechanical appliances have a value for this; for this and other foot motions I sometimes use the only "exercise machine" I own. (d) Hardly an exercise, but most important of all is the Davis wrench which renders unnecessary in nearly all cases the fashionable tenotomies for contractures whether of traumatic origin or not. 2. For lateral motion. (a) Free circumduction, both ways. (&) Exercises for "flat foot." (Figs. 167z, 16?.) 57 OPERATIVE TREATMENT OPERATIVE TREATMENT I am not one of those who believe in indiscriminate operating on simple fractures--certainly it is not called for now, nor in the future do I expect that it will be. I do believe, however, that there is a large field of usefulness for those whose experience renders such operative work reasonably safe and certain, in order to remedy (or, still better, to prevent) most of those innumerable cases that have been a reproach to the profession-excused in the past because in the past no better results were obtainable, today no longer excusable. The question of operation is one of judgment, necessarily based on the published records of cases, as well as on personal experience. Throughout the text of this book references to the scope of special operative procedures will be found, with some general perspective as to the results to be obtained in the given class of cases. There are a few injuries (such as fracture of the patella, separation of the upper epiphysis of the humerus, fracture luxations of the carpus, etc.) that ordinarily will do better if operated on early in any case; other injuries call for operation only if the reposition ordinarily practic- able fails for some special reason; by far the most common operations, however, are those performed some time after an injury to avert or to remedy some condition perhaps remediable by gentler means at an earlier date. There are few faulty repositions or faulty results that can not be bettered by operation; on the other hand, most operations undertaken later are productive of improved rather than actually perfect results; perfect results belong to the earlier operations, hence an added impor- tance of close oversight and of early decision. As to the broad outlines of procedure, we need- 1. Accurate diagnosis, always aided by the x-ray (except in emergency-usually compound-cases). 2. A definite plan of action. 3. A clear knowledge of anatomy-operation in the vicinity of joints, in particular, calls for exact knowledge of vessels and nerves that may be injured. 4. Adequate skin preparation for at least forty hours, as a rule- shaving, scrubbing, green-soap poultices, sterile dressing, alcohol preparation, and a second like sterilization twenty- four hours later; a few hours later a coat of 2 per cent, tincture of iodin; again a sterile dressing; then the morning of the operation 2 per cent, iodin again and a final coat on the operating table. This makes a two day preparation. 5. Perfect operating-room technic. Few operations of this class are so urgent as to justify doing them under other than the best conditions. Methods of procedure vary endlessly with the lesion to be dealt with. 58 GENERALITIES A few broad outlines may be laid down: (a) A tourniquet is rarely needed and renders identifications of vessels difficult, while it carries some chance of tourniquet paralysis. Fig. 17.-Femur fracture. Plate improperly applied-only one screw in lower fragment, giving no real fixation. This one screw seems, in fact, to have lost its grip entirely (not my case). Fig. 17a.-Wired ulna! Neglected radius! Unidentified case, but I feel sure that manipulation and a traction splint without operation would have done better. One could hardly do worse. (6) MuZZzpZe incisions, if practicable in the given case without damage, are preferable to overmuch handling through one incision. OPERATIVE TREATMENT 59 _ Fig. 17&.-Fracture both bones of forearm in a boy. Radius very exactly approximated with a Parham band. But: see how the band sets in and interferes with the formation of the external calms all around-(just as a plate does on one side). This is the disadvantage of the Parham method-avoided if one removes the band within a few weeks, as one always should do. Fig. 17c.-Fracture both bones. Wiring of the tibia with new technic of tightening the wire effectively (see Cotton and Duff-A New Wire Banding Device, Surgery, Gyn. and Obst., Nov., 1917). The wire takes up little room, and should give no liability to refracture. This point has not yet been tested out, however, as the method has been little used. It has the merit of extreme convenience in application, and is mechanically very "pretty." 60 GENERALITIES (c) Tendons and capsules may be cut and sutured without damage; muscles cannot, though the damage from cutting them may sometimes be trivial. (d) Stripping up of periosteum to some extent is unavoidable; but we should keep it at a minimum. (e) Bone chips are foreign bodies; remove them. (/) Great force in manipulation is often necessary in cases where some union has taken place; it rarely does harm. (</) Bleeding into a joint may mean later adhesions; outside a joint it makes little difference. Fig. 17d.-Plate to tibia-improperly applied, with only one screw, and no grip, on the lower fragment. Plate to fibula, accurately set on, but without any excuse for its use. (Not my case.) (A) A dead space outside the joint fills with clot and makes bone; in the joint it remains a dead space, so far as bone formation is concerned. (f) Use the simplest means of fixation; a strand of kangaroo tendon is usually enough; sometimes a buried nail, or a drill driven through skin and bone (and removed later), will suffice. Often the Terry staple holds everything solid. Wire sutures require much mauling of the parts to insert them, have no advantage, are apt to irritate, and are rarely advisable. Lambotte's cerclage with wire, even with my own wire-twisting tool,* and Milne's and Parham's bands do * Cotton and Duff: Surgery, Gyn. and Obst., Nov., 1917, pp. 557-8. COMPOUND (OR OPEN) FRACTURES AND DISLOCATIONS 61 not particularly appeal to me, although I have used the first and last often, though they are rarely necessary. Plates I like to avoid when I can. If fixation by stitch- ing periosteum is enough, let it go at that. In very many cases, fragments may be so interlocked that a plaster bandage or a splint secures perfect fixation. (j) Suture periosteum over the gap if you can. (A;) Suture any cut capsule if you can. (Z) Lay muscle over bone surfaces to avoid adhesion of skin to bone. (m) Do not drain, save for unusual reasons. (n) Suture skin loosely. This will nearly always give drainage enough. (o) Fix the limb for a few days. (p) Do not be alarmed by serous leakage-it is normal, and in itself does not mean infection. (9) Begin passive and active motion, as a rule, much earlier than in non-operative cases. (r) Operations should, as a rule, be postponed for a week or ten days from the date of injury: at this time clot organiza- tion has begun, and the chance of sepsis is less. COMPOUND (OR OPEN) FRACTURES AND DISLOCATIONS A compound fracture or dislocation is one in which there is a tear in the skin and in the soft parts beneath it, leaving a communication between the bone lesion and the outer air. Whether such a communi- cation exists or not is of great importance with regard to the entry of infection. Infection of traumatic bone-lesions in any other way than from the outside is so rare as to be a negligible factor. Compound fractures are rather common, compound luxations rela- tively rare. The treatment of the two sorts of lesion is the same, save that in compound luxation one rarely feels justified in doing less than a thorough opening-up of the joint and free irrigation, while certain few compound fractures may be treated more conservatively. Open bone-lesions (fractures or luxations) are produced in three ways:* 1. By direct protrusion of the bone from within. 2. By tearing or crushing of tissues caught between the bone and the ground or some other external object. 3. By penetration of some object from without, whether it be a bullet, a sharp stone on which the patient falls, or what not. It is not always easy to be sure just which cause has acted. It is important sometimes to be certain, in the interest of clear judgment as to probable infection, for certain cases of class 1 may be treated by less radical methods. * Rarely the rupturing of an old scar over the bone or joint may suffice. This we see in refractures of the patella, for instance. Such cases are too rare to deserve a place as a separate class. 62 GENERALITIES Diagnosis.-Diagnosis is not always simple, for often the diagnosis of the fracture must be made by the usual methods, and we are handi- capped by our care lest we soil the wound. Probing for diagnosis is not allowable. Sometimes the fracture is obvious, and there is a wound-the question is whether the wound communicates with the fracture or not. Sometimes the issue of blood from the wound when the region of the fracture is pressed on will give the answer; sometimes we cannot tell until the wound is laid open. In case of doubt it is well to assume that the fracture is compound. Detailed diagnosis-direction of fracture lines, etc.-may often wisely be left until we open up the wound. Treatment.-Certain injuries of this sort are obviously hopeless. If a limb has been run over by the wheel of a car, it is, I think, never worth saving.* Not only bone and muscle are gone, but vessels and nerves have been crushed and there is little left but skin, and even that not really viable. Here our only resort is amputation at a point where tissues have not been crushed. In other cases of crushed limbs it is obvious that, though the bones be reduced and covered over, yet the skin covering them is so crushed that it must slough. Sometimes, in such cases, if the joint be covered over by sound tissues, the bone elsewhere will take care of itself (some- times exfoliating), and later plastic measures or grafting will give a useful limb.f Nevertheless, amputation is wise in some such cases, especially in case of severe ankle injuries in which the best conceivable result (at- tainable only after months) is no better than an artificial limb. To save a hand or arm it is justifiable to take a longer chance, and the experienced surgeon often takes what look like hopeless chances, with a fair proportion of useful limbs saved as a reward. If we try to save the limb in these cases, scrupulous after-care is most essential. Sepsis often ruins results in such cases. Fractures from bullet wounds must be treated according to the amount of comminution and the extent of damage to soft parts. The fractures produced by small bullets may usually be treated, like other gunshot wounds, by cleansing of the wound of entrance only. If there seems danger that particles of clothing, etc., have been carried into the wound, it is wiser to clean it out. Primary amputations for bullet injuries can seldom be justified today, and secondary amputations are but rarely called for. Such wounds if opened at all are to be left wide open. * I have seen cases when it seemed worth trying, but the trial failed. Even these cases were those in which the wheel seemed not to have passed squarely over the limb. "Car" here means R. R. or street-car: auto fractures are subject to no such rule. t In one such case, a compound Pott's fracture with great denudation, the skin sloughed over the joint, but left behind soft parts enough to protect the joint. The result was a useful joint. Under the subject of Pott's fracture will be found the story of a similar case in which the attempt failed. COMPOUND (OR OPEN) FRACTURES AND DISLOCATIONS 63 The question of debridement comes up today. I am strong for debridement only in obviously filthy wounds. Even in the war debridement while saving lives ruined limbs too often and in civil life we are usually justified in taking chances on the conservative side. In most communities tetanus is rare and can be guarded against by serum injection. Gas bacillus is rare and very rarely appears in wounds left open, while our staphylo and streptococcus infections can as a rule be cleaned up by proper Carrel-Dakin treatment in the open wound without precautionary sacrifice of large amounts of needed bones, nerves, etc. Of the commoner sorts of compound fractures, there is one class the treatment of which is still in dispute, namely, those fractures in which a bone (the tibia, usually) has barely pierced the skin and then rebound- ed, so to speak, into the tissues. The wound is very small, with slight chance for entrance of infective material. If such a case involves no comminution of bone, no large accumulation of clot, it will usually heal under a dry aseptic dressing, without other precaution than skin disinfection. But it will not always do so: some cases are infected and do very badly. Personally, I am apt to open up such fractures and can show better results as to sepsis than have been attained by certain house-surgeons who have been allowed to use the other method. This may be a per- sonal matter, not one of methods. Certainly under less than excellent aseptic conditions, and in the hands of inexperienced operators, the "closed" method will show the best figures in such cases. In most compound fractures and luxations, however, the wound is wide open, the tissues more or less soiled, and often the protruding end of a bone is ground full of dirt. Here we must operate. Operation is best done immediately-after twelve hours the best cleansing may well fail of results. Delay may be justified by shock -we must balance the danger of shock against that of later sepsis in the individual case.* Thorough work demands anesthesia. The skin is first cleansed with soap and with alcohol and corrosive sublimate, care being taken not to scrub toward the wound. The wound is then wiped (not washed at this stage) with antiseptics, the contused wound-edges excised, and the wound enlarged to give free access to the lesions. All soiled or contused soft parts are snipped away. The wound is scrubbed with gauze, the bone cleaned with gauze or with a brush, or the surface chipped away with rongeur forceps until a clean surface is left. Loose bone chips are removed.f Then the wound is washed with salt solution (preceded, in my own practice, with 1 : 15,000 corrosive sublimate, usually) in large amount. Then the * But do not reduce infected, protruding bone into the presumably clean wound, if this can be avoided. Dress the wound as it lies with antiseptics (iodin is certainly justifiable here) and get at it as soon as may be. t Large separate fragments may be cleansed and left in on the chance. They have power of bone production but not high resistance to septic infection. 64 GENERALITIES bones are reduced, and, if need be, held by kangaroo-tendon sutures.* The soft parts and the skin are loosely sutured to allow leakage without formal drainage. The limb is dressed in dry gauze and put up in splints or plaster, as the indications dictate. Following such procedure there is usually a moderate temperature, falling from day to day. Pain is apt to be slight. The wound may well be inspected after five days to a week. Much staining of dressings with old blood and a moderate continued serous ooze are to be expected. In joint cases and in fractures with much contusion this oozing may continue for a fortnight without sepsis, f Any rise of temperature after the next day, or any increase of dis- comfort, is an indication for inspection of the wound. Mild infection may be checked by wet corrosive or alcohol dressings: severer infection calls for drainage; large opening of the wound may or may not be necessary. Sepsis of a spreading type or dangerous general infection may justify amputation. Even very sharp local sepsis is not inconsistent with preservation of a useful limb. Even a septic joint may be healed usually, and sometimes with preservation of some motion. Gas-bacillus infection usually shows itself within two days; there are temperature, malaise, dirty-looking wound-edges exuding serum (often blood-stained), and a crackling under the skin that is character- istic. Prompt treatment is called for--either amputation or generous slashing, as the case demands or permits. Early recognized and ade- quately treated, such cases show a relatively small mortality. Today we may be held to better work and results in septic cases. War methods of very radical open treatment of wounds are not often called for in civil life, but we have learned in the war how to deal with sepsis already present. Wide opening today should mean not only drainage but Carrel-Dakin treatment. With this we may not always avoid limited bone necrosis but we can control most sepsis. We can clean up septic bone conditions to give (after a secondary bone clean- up, often) a better than fair chance of good results. This is something that every surgeon should know enough of to get it done for him, something every hospital worth talking about should be equipped to do-and do it properly. A little later I am sure that proper surgery, Dakin after treatment and such handling of the Wilms method of healing under mobilization as may result from wider experience-that these factors will enable us to get better results in septic joints as we are getting them in septic bones. * These sutures have great tensile strength, are non-irritating, and are absorbed. Wire has no advantage, and often makes trouble. At times a staple is indicated, but never anything more. The trend of opinion today is toward later interference after the wounds have healed if position is poor, rather than the application of com- plicated plates, etc., at a period when the risk of sepsis is grave. t That is, without sepsis, clinically considered: very likely there may be infection, but it does not affect the result. EMBOLISM 65 Not to be forgotten in this connection is the vaccine treatment of these cases-often in desperate cases apparently the deciding factor. Results.-Our notion of results in compound fractures is somewhat colored by the data of a less fortunate period, before the introduction of antisepsis. Today the mortality actually due to compound frac- tures* is not large. Primary amputations are very few, secondary amputations by no means common. Sepsis, alas! is not very rare, but usually not serious; it entails slower union and a slower recovery, with some operations for removal of small sequestra, but eventually sound healing results. The commonest permanent ill results are deformity due to the diffi- culty of prolonged fixation in the presence of inflamed septic wounds, f and stiffness due to the long fixation necessitated by slow union. Such delay of union need not depend on sepsis. It is generally recognized that clean compound fractures unite decidedly more slowly than like lesions not compound, though the cause of this delay is not clear. Sepsis is not the reason, usually. No doubt in the absence of blood clot (due to draining away of the blood) we lose a favoring factor in bone formation, as von Schmieden has pointed out. EMBOLISM Embolism, as the term is used, means pulmonary embolism-the sudden plugging of one or more pulmonary arteries with loosened clots swept through the heart into the pulmonary circulation. It is nearly always fatal, and death is usually either instantane- ous, or ushered in by only a few moments of faintness and distress. Embolism as a complication of fractures is vastly rare. Stimson cites one case, reported by Virchow, and eight others collected by Durodie. Of these 9 cases, 1 was a fracture of the femoral neck, 1 of the femur, 7 of the leg. They occurred in from sixteen to fifty-seven days after the injury. I have seen two cases. The causes of embolism are, first, thrombus formation; second, dislodgment of the thrombus or thrombi. Thrombus formation may come from vein trauma, from long- continued stasis with or without trauma to the vein, and from infection. Thrombi of the smaller veins must be very common. J Thrombi of the * Statistics, such as those of Mumford (Boston Med. and Surg. Jour., May 10, 1894), covering 300 compound fractures with 10 per cent, of deaths, necessarily include deaths from other causes than the actual fracture. t Some of this trouble is avoidable. After the wound has begun to clean and the patient's resistance is good, reduction and fixation (as by wire or staple band or plate, even in necrotic bone ends) will give better results than the laissez-faire method. In many other case traction in splints of the Thomas-Jones types with adhesive or with the Steinman nail traction will avert deformity. JThe assumption that thrombosis is the cause of the swelling so often seen in convalescence after leg fractures seem to be without proof. To me the old theory of degenerate veins, unsupported by the now wasted muscles, seems more plausible. 66 GENERALITIES iliac veins must certainly happen with a proportion of pelvic fractures. Almost never is there any actual sign of such thrombosis, however. I have seen typical iliac thrombosis in one case only, a fracture of the femoral neck; the thrombosis occurred about six weeks after the injury, obviously as a result of stasis. If thrombi occur with fractures, why do we not find embolism? Probably because sudden sitting up or other brusque movement is not permitted in the treatment of injuries of thigh, hip, or pelvis until long after the usual time needed for organization and fixation of the thrombus. FAT EMBOLISM* Fat embolism depends on the entrance into the circulation of free fat in globules too large to pass through the capillaries. This fat may come from anywhere: certainly liver fat,f and possibly even subcu- taneous fat, may enter the circulation as a result of trauma. In prac- tice, however, large enough quantities of fat to cause trouble come from the bone-marrow, and from there only. This is evidently because we have here a fluid fat, substantially free to follow the line of least resistance. Probably every fracture is followed by the escape of some fat into the tissues, which later finds its way into torn veins or through the lymphatics into the general blood-current. The old observation of fat in the urine of fracture cases confirms the absorption of a consider- able amount of fat in certain cases, without any symptoms. J The many animal experiments carried out by various observers show that small amounts of fat produce no results worth considering, and that, in order to bring about a fatal result, a very large amount indeed must be set free into the circulation. § Experimentally and clinically, it has been found that increase of pressure in the medullary cavity greatly accelerates absorption, and it seems that such absorp- tion, with a flooding of the circulation with fat, is a factor in the sudden appearance of early symptoms. Clinically, in order to get large amounts of fat set free, we must have fracture of a large bone, and this fracture must be at a point where the marrow is fatty. The red marrow of children's bones gives little * Fuchsig suggested "traumatische Lipamie" as a better name, but it has not been adopted by others. Embolism caused by fat was noted by Zenker and by Wagner in 1862. Fitz, of Boston, reported the first case in this country (1876), and the first verified case diagnosed during life was reported by Fenger, of Chicago, in 1880. Much pathologic and experimental work has been done. According to Connell, there were 246 clinical cases on record in 1905. Excellent articles of recent date (with excellent literature references) are: Von Aberle: Ztschr. f. orthopad. Chir., 1907, xix; F. G. Connell: Jour. Amer. Med. Assoc., 1905, 612. t Hamilton: Brit. Med. Jour., October, 1877. j Von Aberle goes so far as to consider all temperatures in aseptic fractures as due to fat embolism; this theory seems to have no particular facts behind it. § The amount has been stated, for animals, as three times that contained in the medulla of the femur, but this applies only as the amount necessary for lung obstruction. FAT EMBOLISM 67 fat, and von Aberle* has pointed out the rarity of fat embolism in chil- dren's fracturesf under the age of fourteen. A very large proportion of the cases reported and studied have been in orthopedic clinics, occurring in the course of corrective operations on the brittle, degenerate, and very fatty bones of old cases of paralysis. In ordinary traumatic fractures fatty embolism of any grade to amount to anything is really very rare. When it occurs, the onset of symptoms may be almost immediate, or it may be delayed for some hours or a day, or, less commonly, for several days, but it belongs to the early complications, not, like pulmon- ary embolism from clot, to those of convalescence. The first symptoms are most often pulmonary-disturbed rapid breathing, pallor, and then cyanosis, slowly or rapidly deepening. Auscultation reveals the presence of lung edema, with rales over all the chest-first, in the smaller branches; in the fatal cases, rales in the trachea and the expectoration of reddish-stained froth precede the end. There is marked restlessness. The pulse becomes small and thready. Before death, consciousness is usually clouded. J With this type of attack there is little or no rise of temperature. This is the type with purely pulmonary symptoms, not commonly met with, because, while the engorgement of lung capillaries necessarily happens first, yet it is followed by capillary infarctions of the brain, as well as of the viscera. Accordingly we usually have symptoms on the part of the brain complicating the picture of the pulmonary involvement, or wholly overshadowing it. Essentially these symptoms are on the order of coma, rapid or slow in onset; presently pupillary reactions fail.§ There is a definite rise of temperature, sometimes running to 102° or even 103° F. Sometimes there are convulsive movements, general or localized. Paralyses are rare. General convulsions with vomiting occur atypically, and usually only at the end. Cheyne-Stokes respira- tion is sometimes noted. The lesions that lie back of the various symptoms seem uniform, save for degree and location. In the small arterioles and capillaries of lungs, brain, kidneys, heart, liver, etc., are minute droplets of fat, too large to pass; these drops determine localized areas of infarct in "ter- minal" arterioles, areas of anemic disturbance only if there is a colla- * Von Aberle: Ztschr. f. orthopad. Chir., 1907, Bd. xix. t There are a number of cases on record in children, but all, I think, in children with fracture of the atrophic and fatty bones associated with old paralysis, such fractures being involved in operative measures for relief of paralytic deformities. t I have seen but two such cases (not quite typical): one a fatality following bone plating of the femur after about eighteen hours. There had been a good deal of trauma during the reduction of the bone-ends in an old fracture with much over- lapping. The case was called shock on the records. In the second, death occurred during ether recovery, after readjustment of fractures of both legs below the knee and application of a double spica. The death was due to sudden respiratory failure. §The immobile pupils may be either contracted or widely dilated. 68 GENERALITIES teral blood-supply. The clinical importance of the variously situated lesions is disputed. Many are disposed to consider even the lung symptoms as cerebral in origin. Certain it is, however, that fat emboli and infarcts are found in lungs, brain, kidneys, and heart, and that the lesions in all these organs are important. No one has explained why the emboli, which must enter the cir- culation early, give such late onset of symptoms as is usual. The ex- planation given, of gradual accumulation of emboli, can scarcely help us unless we accept a lymphatic route for the fat. It is a fact that signs of trouble appear only after an interval-very often an interval of distinct "well-being," of a number of hours, and may not show up even for a fortnight. We know that many cases recover-how they recover is unknown. No doubt, at times, the fat passes on and is eliminated by the kidneys; in other cases collateral circulation must be established and the fat absorbed in situ. Diagnosis.-In every fracture, particularly in fractures involving the marrow of the long bones in adults, there is some fat embolism. Ordinarily, it is unrecognizable clinically and is unimportant. Even serious cases are apt to be misinterpreted, as the picture is not clean-cut. In the earlier hours it may be confused with shock or bleed- ing; later with inhalation pneumonia or wound sepsis. There is no pathognomonic sign. Our best guide is perhaps that of time of onset. Dennis' rule; shock, three hours; fat embolism, three days; pulmon- ary embolism, three weeks, is apt, if not conclusive. Septic processes are not apt to give serious symptoms as early as fat embolism, and do not give lung and brain symptoms in the beginning. Pneumonia from inhalation may give a very similar picture to that of fat embolism, and the differentiation may be impossible. Prognosis.-The outcome is uncertain. We do not know how often embolism happens, and therefore figures are of no use;* nor can we predict the results in the given case, save on general grounds-some of the apparently severest cases get well. As a rule, the progress of the symptoms in fatal cases is pretty steady. Most of the fatal cases die within a few days. Treatment.-Prophylactic treatment consists of avoiding unneces- sary handling of the limb. Treatment of the condition, once it has developed, is confined to heart stimulation. * Figures of percentage of deaths from this cause, computed on the total number of fractures, vary from 1 to 2 per cent. There are no figures of the percentage of cases that have embolism and recover. CHAPTER II DISLOCATION OF THE LOWER JAW Dislocations may be forward, backward, outward, inward, upward, and either unilateral or bilateral. The backward and outward luxa- tions are possible only as accompaniments of fractures-the backward dislocation involves fracture of the skull structures behind the condyle.* The outward occurs only in association with fracture of the jaw itself. Inward and upward displacements are vastly rare complications of fractures, and occur only with skull-fractures. DISLOCATION FORWARD This is the common form, and is often met with. Bilateral are somewhat more common than unilateral luxations. The patients are usually adults in youth or middle life. Women are more liable to this displacement than men. The cause is either muscle action alone or a slight force applied to the already open jaw. External force acts usually through tooth ex- traction or through introduction of foreign bodies of large size into the mouth. Muscle action is effective in yawning, laughing, coughing, or vomiting. The external pterygoid muscle gives (with the temporal probably) the force acting to draw forward the condyle, which has already advanced (with the opening of the mouth) well up on to the eminentia articularis, and needs only a tear or even a relaxation of the anterior capsule to let it slip forward. Pathology.-Naturally, there are few data, as the lesion is neither a common part-result of severe accidents nor a frequent cause of opera- tion. There are data to show that the interarticular fibrocartilage may be torn across or torn loose and carried forward. Ordinarily, however, this cartilage is very mobile, and it does not seem likely that this tear- ing or any extensive tearing of the anterior capsule can be of constant occurrence, for the luxation often, once reduced, leaves very little sore- ness or trouble. Tearing in front, when it occurs, is said to be between the interarticular cartilage and the condyle. The point of particular interest in the pathology of this luxation is, however, as to the cause of the difficulty in reducing it. The old theory was that the coronoid process engaged the malar bone or the zygoma in such fashion as to resist reduction. This theory is definitely disproved, and there remain but two explanations: first, the resistance of the ligaments; second, the spasm of muscles. * I have seen one case, traumatic, with backward subluxation only partially relieved by manipulation under ether, in which there seems to have been no skull fracture. 69 70 DISLOCATION OF THE LOWER JAW According to the first, the ligaments (the external and the long inter- nal lateral and stylomaxillary ligaments) are relaxed when the jaw is open, and tighten as attempts to reduce the dislocation are made. The trouble with this explanation is that the jaw came out under very slight force over the same track by which it will not return, save with the exertion of much force, although the relations of the ligaments are unchanged. It seems much more likely that the muscles, which are in obvious spasm, offer a large part of the resistance. The external pterygoid acts only to pull forward anyway, and the other muscles which normally should act to close the jaws are stretched, and their pull is exerted at a new angle. A pull from a on b (Fig. 19), with a fulcrum at c, gives powerful closure; but a pull from a' to b' with a fulcrum at c'would have no closing force and would surely drive the condyle very hard against its new bed. It seems to me that no theory that does not admit the action of the muscles can adequately explain the difficulties of reduction.* No doubt the elastic resistance of ligaments also plays a part. Fig. 18.-Dislocation of the jaw forward (schematic). * Interesting confirmation of this is given by a case in which Samter reduced a case of double luxation a year old after cutting the insertions of the masseter and the internal pterygoid, which he thought were obstructing reduction by vertical pull. Reduction on the right was easy, after clearing adhesions, but on the left reduction could be accomplished only after more fully dividing these muscle insertions (quoted by Bazy et Senechai, Revue d'orthopedie, 1906, vii, p. 353). DISLOCATION FORWARD 71 It has also been shown that the interarticular cartilage may at times be so torn and so displaced as to constitute a real obstacle to reduction by filling the socket (Perier,* Stimsonf). Diagnosis.-There is, of course, the history of a sudden " catch," usually following on a slight force only; then there is persistent in- ability to close the mouth, usually with severe pain, and more or less disturbance in speaking and in swallowing, with some dribbling of saliva. The physical signs vary accord- ing to whether we have unilateral or bilateral luxation. In the bilateral displacement the jaw is thrust forward-not to the right or the left. The mouth is open, and none of the teeth can be brought in contact without force. The mouth can be opened a little farther than it stands open, but an attempt to lift the jaw, to close the mouth, meets very firm resistance and is painful. There is an increased prominence below the zygoma, and-this is the diagnostic point-there is a distinct abnormal hollow in front of the ear, where the resistance of the condyle (and its motion) can normally be felt (Fig. 21). If the luxation is unilateral, the chin is swung laterally away from the side of injury, and the hollow in front of the ear appears on one side only. At times this one-sidedness of the face in unilateral dis- placement is less obvious than would be expected (Fig. 21). In the unilateral cases the mouth is less wide open, and the lips may be brought together after a fashion. Absence of crepitus, of unevenness in tooth outline, of bleeding in the mouth, and of local tenderness, rule out most jaw fractures from the differential diagnosis. Fracture of the condyle may give a somewhat similar picture, but the hollow in front of the ear is less, if any; there may be crepitus; the jaw is less fixed, and either there is no condyle palpable anywhere, or, if felt, it does not follow the iaw in its motions. Fig. 19.-The muscle pull is on the line a b. With the fulcrum changed, from c to c', the pull in line a-'b' tends not to favor, but to resist closure, de and d'e' show the stretched inelastic ligament. Fig. 20.-a, Meatus; b, condyle; c, temporal muscle; d, mastoid; e, malar bone; f, zygoma; g, stylo maxillary ligament; x, meniscus; y, denuded articular surface (seen from below in the upper right-hand figure) (after Perier's plate). * Perier: Bull. Soc. de Chirurgie, 1878, p. 222 (see Fig. 20). f Fract. and Dislocations, L. A. Stimson, 3d. ed., p. 481. 72 DISLOCATION OF THE LOWER JAW Treatment.-Reduction follows two lines: (a) By leverage--depression of the angle of the jaw with raising of the chin. Fig. 21.-Unilateral (left) luxation. Drawn from a case of the author's. Reduction was easy. Fig. 22.-Reduction by opening the mouth, then shoving the jaw backward (method &). (6) By opening the jaw to the limit and then shoving it backward. This method, first devised to clear the supposed contact of the coronoid process on the malar bone, has been revived as a more scientific DISLOCATION FORWARD 73 manceuver. In theory it works by relaxing ligaments; in fact, it is. said to work at times when the other method fails. It is carried out by depressing the chin as far as it will go ; then, with the thumbs in or outside the mouth, thrusting the jaw backward with- out great force, pushing the condyle back along the way by which it came out (Fig. 22). The first method (a) is called violent. In fact, however, it seems to. have no ill results and is still the method of ordinary choice. Fig. 23.-The usual reduction by pressure down with the thumbs, pull up with the fingers (method a1). (a1) The best way of doing it is to put the two thumbs (protected with a twist of gauze or with heavy thumb-cots) in either side of the mouth, to the outer side of the last molar teeth. Then sharp pressure is thrown on these teeth,-down and backward,-and the operator's fingers lift the chin at the instant he slips his thumbs outward into the cheek. (See Fig. 23.) The jaw goes back with a snap. If the thumbs remain in place too long, the operator is likely to become a partisan of method b. (a2) The other mechanism of reduction by leverage is to place a bit of wood, or anything of firm texture, between the back teeth, and then shove the chin upward, or strike an upward blow on the chin. This seems to me crude, and, unlike (a1)? must carry with it some chance of damage to ligaments, etc. In the run of fresh cases either of the methods is efficient. I have had experience only with a1, and have not chanced to have it fail me. 74 DISLOCATION OF THE LOWER JAW In the description of reduction no differentiation has been made according to whether one side or both are involved. In fact, there is no difference except that the wedge in method (a) would, in a unilateral case, be inserted on one side only. In the other methods we may add a little extra backward shove on the injured side-that is all. It has been recommended, in case of bilateral displacement, to reduce first one side, then the other, but the advantage is doubtful, and records show frequent redislocation of the side already reduced on attempting to complete the job. This dislocation may be reduced a long time after the injury. The latest recorded case of reduction without incision seems to be that reported by Donovan* at ninety-eight days. Even older cases have been reduced by open operation. After-treatment consists merely in caution as to the use of the jaw- i. e., soft food for a few days, and care not to open the mouth widely for a week or so. A "four-tail" bandage under the chin may be a wise precaution to insure this; it is, in fact, very rarely used. Most patients dispense with any apparatus or remove it. There are cases apparently irreducible or incompletely reducible. An autopsy was performed on a case of Perier's dying of other causes with a chronic imperfect reduction of a jaw luxation. Here, as in a case operated by Stimson, tearing and displacement of the interarticu- lar cartilage acted as the cause of difficulty in reduction: the curled-up cartilage occupied the articular space into which the condyle should have slipped. (See Fig. 20.) Operative Treatment.-In irreducible cases, or cases so inveterate that ordinary reduction is out of the question, cutting down on the joint for open reduction has been successfully carried out. The joint may be reached by a direct incision just below the zygoma and parallel to it. This clears the facial nerve and all but the edge of the parotid gland, and may be carried inward to expose the joint and the interarticular cartilage. Open reduction may then be done. Samter (quoted by Bazy, loc. cit.') reduced a case by operation a year after the injury. Hildebrand, of Bale, reduced a luxation six months old by operation through a field opened by temporary resection of the zygomatic arch. Annandale, Berard, Bazy, and Senechai have all done resections in such cases and with reported good results. Prognosis.-It has often been stated that jaw luxations left unre- duced do not reduce themselves, but do well after a time, and the patients cease to suffer any of the characteristic inconveniences. This is true only to a degree. There is a case of R. W. Smith's on record in which, after a year, the teeth could be only "partly closed," and resection of the condyles has been done in several cases for old luxation, arguing some considerable previous distress. All that can be * Quoted in Amer. Jour. Med. Sei., October, 1842, p. 470. 75 RECURRENT DISLOCATION OF THE JAW said is that this luxation unreduced gives a better functional result than we should expect. This is true of all luxations anywhere. After reduction these cases give little trouble, and are usually all right in a few days. At times some soreness remains. There is a definite tendency to recurrence, which sometimes may become habit- ual; such recurrence seems independent of the treatment adopted, and is, after all, a rare exception. RECURRENT DISLOCATION OF THE JAW This is not infrequent, and may be very troublesome. Reduction offers little difficulty: frequently the patient learns to reduce the luxa- tion himself. Annandale has operated to relieve this condition by suturing the interarticular cartilage in place, sewing it to the capsule anteriorly, with good results. Resection of the condyle has been done in such cases with relief. HABITUAL SUBLUXATION FORWARD (WITHOUT TRAUMA) Certain persons develop, without any injury or other obvious cause, a subluxation in which the jaw slips farther forward than normal when the mouth is opened. This produces an unpleasant cracking during mastication. The condition is not painful, as a rule. There may be, for years, this habitual cracking in the joint, with an occasional catch that seems to be a subluxation. Lateral motion of the jaw may clear it, or manipulation with the hand may be necessary. Probably these subluxations simply mean a jamming of a somewhat laxly held interarticular cartilage. The complaint is very often annoying. It usually disappears after a time. No treatment is of avail, seemingly. Operation seems hardly justifiable.* BACKWARD DISLOCATION OF THE JAWf This is possible only when there has been extensive smashing of the bones about the external auditory canal. There is said to be immo- * Curiously enough, this condition occurs usually in obviously neurotic young women! t One case, probably unique, presented habitual recurrent subluxation back- ward, with a deficient development of the articular socket (a flat glenoid cavity) shown by the x-ray. An interdental splint, worn at night, gave moderate relief. The condition was not of traumatic origin. I know of one other like case cured by slanting tooth-crowns so as to shift the lower jaw forward on biting. A third case resulted from yawning with an apparently complete double backward luxation, reducible under ether, but recurring on cessation of forward traction. This, an accident room case, was lost sight of. 76 DISLOCATION OF THE LOWER JAW bility, with the mouth standing open, and a loss of the prominence of the condyle. Disturbance of the relation of the back teeth (the lower lying too far back) is, of course, present. There is bulging of the forward wall of the auditory canal, and there may be bleeding from the ear. Reduction is by direct traction. INWARD DISLOCATION Similar smashing to the inner side may allow corresponding dis- placement inward, but not without complicating fracture of the jaw at some point of its arch. UPWARD DISLOCATION This, like the last, belongs to the curiosities. There is at least one case on record in which the condyle has been driven through the glenoid Fig. 24.-Dislocation of the jaw outward (schematic), cavity, through the base of the skull. A fracture of the base from impact of the condyle without smashing in of the base has happened oftener. This gives no actual dislocation, of course. In either of these cases the jaw lesion is only an incident of fracture of the base of the skull. OUTWARD DISLOCATION This is, of necessity, rotary. The condyle comes to lie on the outer side of the zygoma, while the coronoid process is hooked under the zygoma. Such displacement is possible only if there is some fracture OUTWARD DISLOCATION 77 of the body of the jaw, as will be seen by a glance at the skull. (See Fig. 24.) Reduction is accomplished by pressing the jaw slightly farther inward to unhook the hammer-shaped head of the condyle, and then by pushing the jaw bodily down and swinging it outward. Both coronoid process and condyle come into their natural places, and only the accompanying fracture is left to treat. CHAPTER III JAW FRACTURES Fractures of the jaw through the tooth-bearing area do not concern us here, except in so far as they occur as complications. We have to do only with those fractures that counterfeit jaw luxations more or less closely-fractures at or near the angle, and those occurring behind and above this point. These are: Fracture at or behind the angle. Fracture of the coronoid process. Fracture of the neck of the condyle. Such fractures are caused by violence directly applied to the jaw, apparently differing in no way from the trauma usually resulting in fracture farther forward. Not uncommonly a fracture at or behind the angle occurs with a fracture further forward on the same or on the opposite side. Such associated fractures are diagnosed by their own local signs. The danger is that such an anterior fracture may lead to our overlooking an associated and a more important break behind the angle. FRACTURES AT OR NEAR THE ANGLE OF THE JAW These fractures are in no way constant as to exact site or exact obliquity. Lateral pressure gives signs of soreness, etc., and there is inability to move the jaw normally. Ordinarily, there is much thickening below the zygoma, well forward. There is usually definite, though not great, disturbance of the "bite." The angle of the jaw is apt to be obscured, so to speak. Ordinarily, careful palpation inside and out shows the characteristic displacements. (See Figs. 25 and 27.) In these cases the temporal, masseter, and pterygoid muscles all tend to produce and to perpetuate the deformity. The upper fragment is pulled up and forward alongside the body of the jaw, usually to the inner side. The fragment is short and embedded in muscles, and we cannot get hold of it. (See Fig. 25.) All the cases I have seen or known of that have been treated con- servatively have done badly. The loose fragment becomes fixed in flexion and cannot be moved; the mouth cannot be opened. More- 78 FRACTURES AT OR NEAR THE ANGLE OF THE JAW 79 over, owing to the bad apposition, non-union, or at least delayed union, is likely to happen and does in fact occur. I believe, therefore, that our only effective resource in such fractures Fig. 25.-Fracture behind the angle: the proximal fragment dragged up and inward (schematic). Fig. 26.-Fracture of the neck of the condyle. is open operation with wiring of the fragments. This operation can be done without opening the mouth cavity in some of the cases. In two cases of my own the results of operation were excellent, and I have heard of no ill results of such operation. 80 JAW FRACTURES FRACTURE OF THE CORONOID PROCESS ALONE In this lesion there is upward displacement of the fragment by the temporal muscle. Diagnosis is by palpation. This condition has been met by fixation only. I know no better method. The results are said to be good. FRACTURE OF THE NECK OF THE JAW BELOW THE CONDYLE This lesion is not rare, relatively speaking, and it presents some aspects suggesting luxation. Ordinarily there is no obvious displacement of the jaw on the side Fig. 27.-Palpation for fracture of the ramus of the jaw. of the injury, though the "bite" is disarranged. The condyle is not palpable directly in front of the ear, but may perhaps be felt farther forward. There is not the same degree of hollowing in front of the ear that luxation presents. There is, of course, a decrease of vertical height, and the back teeth close when the front ones do not, even if the lesion is unilateral. Symptoms.-The signs are: local tenderness; failure of the front teeth to close to what is apparently the old "bite" without application of force; possibility of adjusting the teeth to their normal relation by moderate force, with a recurrence of the deformity on letting go; palpa- tion of the condyle in front of its normal position-sometimes as a movable mass; failure of the condyle to move with the jaw; increase in mobility of the jaw anter op oster iorly. 81 FRACTURE OF THE NECK OF THE JAW BELOW THE CONDYLE Treatment.-Treatment consists in getting an approximate reduc- tion of the fragments and then getting a proper wiring together of the teeth. In one case I found it wise to have a wedge of rubber set in between the last molars on the side of the break to avoid shortening- in the vertical length from muscle-pull. This may well be worth doing oftener. The wiring is a dentist's job-no surgeon is equipped for this sort of work, so far as the mechanical execution goes. Bandages are useless and not to be used. Feeding with a catheter if need be does not offer a serious problem ordinarily. Results.-Results seem to be good if the displacement is corrected, though there may be some loss of mobility. Union is by bone, at least usually. Results of neglect give an entire disarrangement of the "bite" and great loss in the range of motion. Operation is possible, but is not encouraging; there would be little to do unless to excise the condylar fragment-a doubtful benefit. I saw with Dr. William Darrach, of New York, a case of this sort in which he removed the condyle; the result was fair. CHAPTER IV INJURIES OF THE CERVICAL SPINE injuries of the neck are common. They result, as a rule, from falls in which the occiput or the side of the head receives the force of the blow. Direct twisting of the neck may be a cause, or lateral flexion or extension. Even sudden muscular contraction may occasionally suffice for such injury.* Occasionally a blow directly on the back of the neck is the cause of injury. The results are luxation or fracture,' or the two combined, or a distortionf or " distraction," J which involves neither fracture nor true luxation. The results are serious, in so far as they involve- (а) Damage to the cord. (б) Lesion of nerves in the foramina by pressure, or damage to- nerve-roots by stretching. (c) Loss of normal motion, with or without deformity. (d) Loss of bony support of the head. No region of the cervical spine is free from the liability to damage.. The cases that present themselves for diagnosis are mainly those of the lower half of the cervical spine; this is, however, not because such lesions are commoner, but because lesions of the upper part of the neck are so often instantaneously fatal. When there is a crush of the cord above the fourth cervical segment, this cut-off, if complete, paralyzes the phrenic nerve, and death, if not actually instantaneous, is too prompt for surgical aid to come in question. What we have to deal with clinically, therefore, are the lesions of the upper neck that are incomplete, so far as cord damage goes, and those of damage below the fourth segment, which may be fatal but are at least not promptly fatal. The whole class of injuries here involved are of great seriousness; the majority of them yield little encouragement for surgical measures. But we must not lose sight of the rather large class of cases in wdiich the cord damage is slight or is absent. A broken neck is by no means * I have seen two cases in which this was certainly the cause of a rotary luxa- tion. One was in a boy who luxated one joint surface of the sixth cervical forward, by a sudden jerk in getting into his suspenders; the other a young woman who- produced the luxation by tossing back her head in the process of hair combing. f A "distortion" is a twist, rotation, or lateral abduction, often involving a pull on the nerves, not necessarily involving bone or ligament damage. Cf. Courtney: Distortion of the Spine: Boston Med. and Surg. Jour., 1900, cxlii, p. 345. J In "distraction" or "diastasis" component parts of the spine (bodies, inter- vertebral discs, articular processes, etc.) are pulled apart, with ligamentous damage- 82 LANDMARKS OF THE CERVICAL VERTEBRAS 83 always fatal. I have seen certainly not less than forty who recovered entirely, or had at worst a slight stiffness as the residue. Nor do I Fig. 28.-Lateral view, showing the lack of prominence of the spines of the third, fourth, and fifth vertebrae. As a rule, we can feel the second and the fifth, sixth, and seventh only. Fig. 29.-The cervical spine from above and behind, showing the irregularity of the bifid spines. The lower outline shows the contour of the third spine in this specimen. believe that these cases walk in danger all their lives; any more than we all do. Before going into description of lesions and cases it may be well to review the landmarks. Landmarks.-Most obvious are the spinous processes. The spinous processes of the cervical vertebrae may usually be felt pretty clearly. The "vertebra prominens," academically the seventh cervical, is, in fact, in- differently the seventh cervical or the first dorsal spine. From this point up there is a sharp loss of prominence of the spines, and in many normal necks there is, above the fifth or sixth, an interval corresponding to two or three spines in which nothing definite can be felt. (See Fig. 28.) Above this we have, so to speak, a sudden reappearance of the spines. The spine of the axis is nearly always palpable-that of the atlas often is. Very little dependence can be placed on an apparent Fig. 30.-Palpation of the transverse processes. 84 INJURIES OF THE CERVICAL SPINE anterior displacement in the region of the fourth to sixth cervical vertebrae as shown by palpation of the spines. Unfortunately, we are also subject to a very considerable margin of error in regard to lateral deviation. The cervical vertebrae down to about the fifth have bifid spinous processes, and of these bifid processes, no one may say which side, right or left, is likely to be more prominent and more palpable. (See Fig. 29.) On palpation of the sides of the neck we may feel the transverse processes in most individuals. These may be palpable in front or behind the sternocleidomastoid muscle; usually they are most readily Fig. 31.-Palpation of the anterior surfaces of the cervical vertebrae through the pharynx. felt behind it or through its substance, just behind the vessels* (Fig. 30). So far as concerns the front of the vertebral column,-the bodies themselves-pharyngeal examination with the finger may give very useful information. A finger inserted in the mouth may be made to reach up to the atlas, and, in the adult, down as far as the fourth intervertebral cartilage, but no further. (See Fig. 31.) In this region (first to fourth vertebrae) we must expect a certain amount of forward convexity and irregularity, and must remember that the ring of the atlas normally projects forward, f It is only the sharp deviations, * In relation to any extreme apparent projection of transverse processes in the lower part of the neck the question of cervical ribs must be borne in mind. Their occurrence is not extremely uncommon. t See Fig. 68. 85 FIRST AND SECOND CERVICAL VERTEBRAE: FRACTURES AND LUXATIONS caused by slipping forward of one vertebra on another, that are of any use in diagnosis. FIRST AND SECOND CERVICAL VERTEBRAE: FRACTURES AND LUXATIONS Because of anatomic as well as clinical reasons lesions of the upper part of the cervical spine will here be treated as a class apart, though, in consideration of the given clinical case, the distinction may not be easy. Dislocations of Occiput on Atlas.-These are so rare as to be almost a negligible injury. The connections of atlas and skull are so secured by tough ligaments that the tendency is toward transmission of force downward to more vulnerable portions of the neck. Lesion at this level is, however, possible, and has occurred. Dislocation of Occiput Backward on Atlas.-There are three cases fully recorded: one (that of Coste, given by Blasius*) showed forward luxation of the atlas beneath the occiput, complete on the right, in- complete on the left, and also a luxation of the atlas forward on the axis, the odontoid process being broken also. Strangely enough the paralysis present in this case was a motor paralysis only, and the patient survived the injury for five months. The other recorded cases were instantly fatal. The cause in two cases was direct violence-a blow from behind at the level of the atlas. Dislocations of the Atlas on the Axis.-Such dislocation is possible only when the odontoid process is slipped out from under the transverse ligament,! when it tears through this ligament, or when the odontoid itself is broken and displaced. There are a good many autopsy findings including all these possible conditions, the last being most common. In almost all these cases the luxation is of the atlas forward-in some cases forward and to one side. Often there is fracture of the arches as well as of the odontoid process. The dislocation backward may happen-has happened in several cases, all fatal. In one promptly fatal case (autopsied) there was also a fracture of the arch of the atlas and a fracture of the odontoid process. One would say this process must be broken to permit the luxation, were there not a case on record (Nichet) of a "spontaneous" luxation in which the atlas had been displaced back and to one side, jumping the intact odontoid. There is no record of such injury from trauma. The question of double rotary dislocation between atlas and axis must still be left open. There is at least one probable case. Diastasis occurs at this level with more or less displacement. I have seen one case, with obvious damage at this point, shown by tenderness and rigidity unmistakably spinal, and by a fixed forward * Blasius: Vrtljhrschr. f. prakt. Heilkunde, vol. ciii, p. 65. f Curiously enough, there is one postmortem record demonstrating the possi- bility of such a slipping of the odontoid out from its socket without complex tearing of the suspensory ligaments (Hirigoyen). 86 INJURIES OF THE CERVICAL SPINE position of the head, which showed on the x-ray plate not the expected luxation, but an apparent separation wider than normal between the first and second arches, with nothing else discoverable. There were no cord or nerve-root symptoms. The patient refused the proposed fixation and bed treatment and disappeared. The injury resulted from a fall downstairs in which the back of the head was struck. This is the mild grade of diastasis, with no more than a rocking forward of the atlas. The severer form is that described as Malgaigne's "inclinaison," where without true luxation there is such a tipping forward (with a minimal sliding motion, of course) of head and atlas on the axis that there is pressure on the medulla between the posterior arch of the atlas and the undamaged odontoid process. If a diastasis due to ligament rupture be combined with a fracture of the odontoid, the immediate risk of compression of the cord is, of course, lessened, as atlas and odontoid slide forward together. Cases are on record where the displacement and the con- sequent compression of the medulla have been slowly progressive. Dubreuil's case showed slow gradual lowering of the chin; finally, on the seventeenth day, sudden death followed an incautious movement. In other cases there may be no deformity, only soreness and stiffness, without cord or nerve symp- toms, and yet there may be fracture of the odontoid, even with other fractures of atlas or axis. Here the danger of sudden movement is equally present without any warning signs. The fractures at this level are various and without definite type; the symptoms are not characteristic, and the x-ray helps but little in many cases. Commonest is, perhaps the fracture of the axis, with forward dis- location of the atlas, moving with the anterior fragment of the axis. (See Fig. 18.) As Dr. A. W. George has shown,* one of the most important observations that can be made of the pathology of the osseous system is the loss of the normal curves by the formation of acute angles. Injuries, destructive bone diseases, etc., will be early recognized by the formation of these angles: this is particularly true of the vertebral column. In the interpretation of injuries and diseases, the value of the imaginary lines as mentioned above becomes of utmost importance, e. g.,-in one of the most frequent injuries of the atlas, forward disloca- tion of the head and atlas upon the axis, the following points are to be noted: first, that the line AB (Fig. 34) will be no longer parallel to the line CD, and if extended would very soon meet. The vertical line produced by the retro-pharyngeal structures anterior to the an- (aj'/'cr- Gur/v-A Fig. 32.-Fracture of axis. * A. W. George: A Method for More Accurate Study of Injuries of the Atlas and Axis: Boston Med. Surg. J., 1919, clxxxi, p. 395. FIRST AND SECOND CERVICAL VERTEBRAE ! FRACTURES AND LUXATIONS 87 terior tubercle of the atlas will be distorted. The lines EF and GH will remain parallel, and the normal distance apart, but occasionally Fig. 33.-Normal lateral view, showing lines drawn to show method (George). Fig. 34.-Forward dislocation of the skull, atlas, and axis, with lines drawn. (Compare with Fig. 33.) (George.) Fig. 35.-Luxation of skull and atlas on axis due to a destructive bone disease of body of axis (new growth). (See Fig. 36.) (George.) Fig. 36.-Same case as Fig. 35. Lines drawn to illustrate method (George). more of the lateral masses may be demonstrated on the plate. This observation must be kept in mind so that it is not confused with the production of new bony tissue in this region. The length of the pos- 88 INJURIES OF THE CERVICAL SPINE terior arch and tubercle behind the line CD is very much shortened. The anterior margin of the posterior tubercle will also be seen on a plane anterior to the anterior margin of the spinous process of the axis. Occasionally a fracture of the odontoid process can be recog- nized in the lateral position, but it is usually seen better in the antero- posterior view. In Fig. 34 will be noted that the vertical lines AB and CD do not continue along the anterior and posterior surfaces of the cervical bodies, being suddenly interrupted at the third cervical vertebra. The line formed by the retro-pharyngeal structures is also interrupted in the same area. Nothing can produce this change, except a forward dislocation of the skull, atlas, and axis of the third cervical vertebra. It will also be noticed that the anterior part of the posterior tubercle is on a more anterior plane than the anterior part of the spinous process of the axis, which is not normal. However, the relation of the remain- ing parts of the atlas and axis to each other is normal. Naturally one will wonder what condition can produce such a change. A careful examination of the laminae of the axis will reveal a break in continuity, -a positive diagnosis of a fracture. This readily accounts for the distorted relation of the posterior tubercle to the spinous process of this vertebra. In Figs. 35 and 36 will be noted that the vertical lines AB and CD do not continue along the cervical bodies, being interrupted, as is also the line produced by the retro-pharyngeal structures. A diagnosis of anterior dislocation of the skull and atlas on the axis can readily be made. However, the outline normally formed by the body of the axis is distorted, and shows considerable less density than normal, which is diagnostic of a pathologic change in this body, which in this case is metastatic carcinoma. In the original plates it can be seen that the odontoid process has separated from the body of the axis and is in contact with the anterior arch of the atlas. So few of these cases of injury to the first two cervical vertebrse survive the trauma that data for diagnosis are scanty.* This much may be said, however. Substantially all these injuries show forward displacement, if any. The deformity is in the direction of a movement of the head directly forward, or forward (with or without rotation) to one side, with the chin sometimes sunk toward or even actually resting on the chest, rotated away from the most damaged side. In contra- distinction to the luxations and fractures lower down, the luxations and fractures here sometimes show not a deformity with persistent rigidity, but a simple dropping forward of the head. There is no locking as in the other cases-simply a "slumping," and this seems to be true whether there is any great displacement or not. Diagnosis of Lesions of the Upper Cervical Vertebrae * The writer has seen but nine such cases, and has seen the data of four other unpublished cases: the available literature records are relatively few. DIAGNOSIS OF LESIONS OF THE UPPER CERVICAL VERTEBRAE 89 The feeling in one's hands of some of these high luxations or fracture luxations is unique. The head simply lies loose. There is apt to be much interference with respiration and with swal- Fig. 37.-Obscure fracture of the second cervical vertebra. Evidently there must have been[a fracture of the odontoid process to allow of the forward displacement of the head and of the atlas. Curiously enough there was no cord pressure. lowing, partly mechanical in origin, but due also to medullary pressure in some cases. This sort of loose lesion is certainly characteristic of atlo-axoid Fig. 38, 39.-Areas of nerve-supply: Occ. maj., Occipitalis major; O. M., occipitalis minor, not uncommonly affected in alto-axoid injury; A. T., auriculo-temporal; G. A., auricularis magnus; S. C., superficialis colli. lesions. An occipito-atloid luxation would presumably show like looseness, with the head back and extended, but not locked. 90 INJURIES OF THE CERVICAL SPINE There are, however, cases of damage between atlas and axis, including cases of odontoid fracture, where there is no laxness, no deformity, nothing at all that is characteristic; simply pain and tender- ness at this level following injury, or perhaps slight abnormality of attitude or some rigidity, but nothing on which diagnosis can be made. The most we can do is to make out the level of the injury from local tenderness, for in non-fatal cases cord damage is not usually present to help show the level of the injury. Projection of the spinous or of the transverse process of the lower vertebra backward, or on one side or the other, or projection of the body of either vertebra felt in the pharynx, are of avail, if positive, but the lack of such evidence proves nothing. A sudden unguarded move- ment has caused a slipping of a fractured but undisplaced odontoid, and instant death where, a moment before, there was no sign to point to such injury. There are several such cases. Skiagraphs may help in showing injuries in this region, but are quite as apt not to show much of anything. Good plates of the upper neck are very hard to get, and often hard to interpret if obtained. Anesthesia or paresthesia about the base of the skull behind (over parts not struck) suggests nerve injury by compression (occipital nerve, rising from the second segment), and is apt to result from vertebral fracture. This sign is relatively common. (See Figs. 38, 39.) The importance of palpation through the pharynx seems to me to have been greatly exaggerated. There are bony prominences enough in the central line shown in bone specimens to be confusing, and when we add to these the exaggeration of prominences due to soft parts intervening, the difficulties of examination, the possible intervention of osteo-arthritic changes, etc., it is obvious that data so obtained must be judged conservatively. Nor does palpation from outside help us much. What we have to go on in practice is the following: (а) Rigidity of the neck, or abnormal position, usually in flexion, or looseness of the relaxed neck. (б) Local tenderness. (c) Abnormal bony prominences. (d) Signs of damage to the cervical nerves.* (e) x-ray evidence.! The only safe way is to treat all doubtful cases as actual spine lesions. TREATMENT OF LESIONS OF UPPER CERVICAL SPINE The question of diagnosis is subordinate, for detailed diagnosis of the bone lesion is, fortunately, not essential. * Damage to the cord does not greatly help in locating the level of the injury n these cases, for they show only incomplete cord lesion, as noted above. t In many instances the x-rays particularly if not very good may be very hard to interpret. Lately Dr. Arial George has formulated landmark lines for x-rays of the i-iii cervical that make more exact work possible-a distinct step forward. (See Figs. 33-36, 40 and 41.) 91 TREATMENT OF LESIONS OF UPPER CERVICAL SPINE Most cases come to postmortem diagnosis only. Of the more for- tunate, we have two classes: those with and those without sufficient displacement to give compression of the cord. If there are any con- siderable cord symptoms, it is fair to assume that they are from exist- ing persistent pressure, and the problem is one of instant relief of this pressure.* As a rule, the direction of displacement will be obvious-if it is not, it is pretty safe to assume that we have a forward displace- ment. Reduction will, of course, be in the direction of reversing this displacement. Fig. 40.-Lateral view with lines drawn by Dr. George-normal spine. The lines running along front and back of the first three bodies, including the tubercle of the atlas in front and the spine of front of the axis run parallel. The third line, running on the front of the arches, within the bony canal is straight but not parallel to the others. Note the much greater space for the cord higher up (A. W. George). Fig. 41.-Atlas and axis, from in front (through the open mouth). Vertical lines drawn through outer and inner edges of the articular surfaces at either side of axis and at- las should be true verticals and yet touch at all points. The drawing of these lines will settle the question of a fracture of either front or back arch of the atlas with spreading. In this plate both arches of the atlas come out very clearly. It is in this view that one gets a real picture of the odontoid process (A. W. George). Delay for further diagnosis is almost certainly fatal in such cases. Reduction by extension and gentle backward traction, controlled, if practicable, by manipulation with a finger in the pharynx, is the only worthy surgical treatment. The patient may possibly die on our hands: this is the risk we take. Fortunately, the risk is small. So far as I know the much-quoted case of Petit-Radel, and one of Boyer's,! are the only ones recorded in which * At this level we do not have to reckon with the cases (common at lower levels) of total cord damage, done and irremediable, without any present pressure from bone. Such extensive damage of the upper segments means instant death; lesser damage calls for active treatment. f Quoted by Blasius, loc. tit. 92 INJURIES OF THE CERVICAL SPINE Fig. 41a.--Luxation of fourth cervical vertebra forward on fifth. Fig. 42. Figs. 42, 43.-Plaster cuirass. Fig. 43. Same case as Figs. 49 and 50. TREATMENT OF LESIONS OF UPPER CERVICAL SPINE 93 such correction of the lesion resulted in death. Where no risk is taken death in such cases is almost certain. Fig. 44.-Thomas collar of "press board" cardboard. Usual pattern Back Tron. ( Fig. 45.-Two-piece Thomas collar. Good pattern. ccci|>urx C'acK Fig. 46.-Common pattern of collar. Gives little support against flexion, but is a very com- fortable pattern. After reduction, the obvious treatment is firm fixation, and in these cases this should take the form of-first, sand-bag fixation, with the neck supported, the head slightly extended; then, if the patient passes 94 INJURIES OF THE CERVICAL SPINE by the stage of probable lung complications, a plaster-of-Paris jacket (including head, neck, and upper chest) is to be worn for long enough to insure against redisplacement. (See Figs. 42, 43.) Probably six weeks of such fixation will be enough.* The plaster-of-Paris appara- tus is followed by a "Thomas" collar that steadies and supports the head and limits motion. The classic "Thomas collar" may serve; better yet is the pasteboard collar, shown in Figs. 44 to 47, worn for many weeks or even months. Traction on the neck applied to the head is often a wise measure, helping fixation at least (Fig. 48). Where there has been no definite displacement and no cord damage, reduction does not come in question. Bed rest with sand-bag fixation Fig. 47.-Shows the collar (made after the pattern of Fig. 46) applied. is indicated for ten days at least; following this the collar, carefully fitted, should suffice in a tractable patient; it should be worn four weeks at least. In cases of this class we have no indication for any operative interference. Even the existence of slight bone displacement does not call for reduction unless there be damage to the cord, but any con- siderable displacement would indicate that the support had better be worn longer for safety. In cases where damage to the cord is present, but seems slight, the matter is debatable. On the whole, the recorded cases rather suggest a * There is a case on record (Parker, quoted by Hamilton, Fractures and Disloca- tions, third edition, p. 161) in which fatal displacement occurred five months after injury. There was here a tearing of the occipito-axoid ligaments, as well as odon- toid fracture. This case had had no cord symptoms, but had obvious bony displacement and had had much pain. It is true that the odontoid unites by fibrous tissue only, but I do not believe that there is ordinarily any grave risk of displacement if there is no lameness after a month or two of adequate fixation. TREATMENT OF LESIONS OF UPPER CERVICAL SPINE 95 leaning toward interference and reduction where the question is open, on account of the not infrequent occurrence of progressive meningeal and cord damage in this class of cases. Anything that is done should be done promptly. Each case must be judged by itself. Personally, I should hesitate to manipulate a case of lesion at this level, simply because of par- tial paralysis of limited extent, unless I could form a pretty clear idea of the bone lesion. The cases personally observed have shown definite improvement (usually total) under simple fixation. It is often good surgery to "let well enough alone." It is probably safe to formulate the following rough practical rules: 1. Cases with cutting of the cord are dead. 2. Cases with pressure on the cord will die presumably if not relieved; the treat- ment is to take chances on a reduction by traction, extension, and backward replacement; then fixation. If signs of cord pressure are slight, the question of replacement is debatable. 3. Cases without paralyses should be fixed; sand-bags should suffice at first; moderate extension without traction is desirable. Later, fixation is by plaster and the modified Thomas collar. Judging from all the recorded cases it is safe to say that prompt treatment by reduction along these lines will save some cases; delay for more accurate diagnosis will show a worse percentage, both as to early deaths and as to paralysis. Open operation-laminectomy-seems to show no encouraging results in this class of high lesions. Fig. 48.-Two methods of apply- ing traction to the head for neck ex- tension. The method shown below can only rarely be applied to the adult head. With either method the head of the bed must be raised. The prognosis in general is bad. Many cases die instantly. Many others die within thirty-six to seventy-two hours as a result of damage to the medulla. Hyperpyrexia occurs up to 110° F. or higher; the pulse is high, and respiratory failure is added to by the distinct tend- ency to (vasomotor) lung edema in this class of injuries, which is often the direct cause of death.* If there is extensive paralysis, with con- Prognosis in Lesions of the Upper Cervical Spine * J. L., aged fourteen, seen by the writer August 12, 1907. Had fallen from a train platform shortly previous. Was in shock, dazed, but rational enough. Showed marked cyanosis, rapid and labored respiration, lungs full of coarse bub- bling rales throughout. There was a wound over the occiput, but no signs of cerebral damage save for slight internal strabismus. The neck showed character- istic flaccidity, without great pain. The case was seen for me by Drs. Lund and Scanned, and by Dr. J. J. Thomas of the nerve department, who concurred in the diagnosis of high cervical lesion (loose) with medullary damage and vasomotor lung symptoms. For a time his color improved, and the labored respiration and the lung edema improved, but after three hours the edema increased, with the frothing-up of thin, bloody, mucoserous discharge. Temperature and pulse rose; he became unconscious, and died about four hours after the first examination. 96 INJURIES OF THE CERVICAL SPINE sequent loss of action of abdominal and thoracic muscles, the distention of the abdomen encroaching on the chest capacity, with a respiratory movement confined to the diaphragm, adds a grave complication. There is also a possibility in these cases of suppurative spinal menin- gitis, hard to explain, but apparently undebatable in the face of recorded cases. Other complications are rare.* The considerable chance of sudden displacement in certain cases, particularly in those of fracture of the odontoid, is to be remembered.f Prognosis must, therefore, be guarded always, and treatment must be conservative even in the mildest cases. On the other hand, not all of even the most unpromising cases are fatal. Local function in the cases that do recover is surprisingly good. There may be only moderate loss of rotatory motion and flex- ion, nothing else. Coste's case of survival for months with complete unreduced forward luxation; Flecken's case of fortunate reduction of a uni- lateral axis luxation (forward), reduced after one week; a case of Ehrlich's of onesided backward luxation; a case of the same lesion reported by Walton, unreduced ; Horn's case;t Phillip's case of for- ward luxation with broken arch complicating it, without cord damage, who lived to die from phthisis, and the author's cases- speak for the possibilities in luxa- tion with or without fracture. No doubt many cases of odontoid fracture and fractures of arch and body have recovered spontaneously. Interesting in this connection is a specimen in the Warren Museum in Boston, of unknown history (No. 970 of the old catalogue), in which there is a sharp lateral tilting of the atlas with a fracture of the articular Fig. 49.-Case I, showing the projection of the axis behind. * There is one case on record of tearing of both the vertebral artery and the vein (Blasius). f In a case seen by me in January, 1909, by courtesy of Dr. J. B. Blake (fracture of second cervical vertebra with forward displacement of atlas), there was repeated paraplegia, occurring with slight changes of position, disappearing within minutes or hours after fresh hyperextension, for ten days. The patient eventually made a perfectly good recovery, save for partial paralysis of one deltoid muscle. f Horn (Blasius, from Horn, in Kleinert's Repertor. der Med. Chir. Journalist, Jahrgang 1840, viii, 139) records the following case: He guessed in the case of a man who had fallen out of a tree, and who had motor and sensory paralysis of arms as well as legs, and could not raise his head, which had fallen forward, that there might likely be pressure from the odontoid. Accordingly, the atlas was reduced backward, or manipulation to this end carried out. There was a double click, and ten minutes later the paralysis disappeared, and in two weeks the patient recovered. 97 PROGNOSIS IN LESIONS OF THE UPPER CERVICAL SPINE surface of the atlas; there is no narrowing of the medullary space, and the injury was evidently an old one. Case I.-C. F. Fell down-stairs, striking back of head. No symp- toms at first save soreness. Later, a prominence was found just below Fig. 50.-Case I: a>ray. Shows only the forward displace- Fig. 51.-Sketch of a>ray in case II. ment of the atlas. (Sketch from a>ray plate.) occiput on left. Pain in area of right lesser occipital nerve, which was persistent. Was kept in bed with sandbag as support until the fourth week. Fig. 52.-Case III: a>ray and explanatory sketch. The crosses show the displacement of the body of the axis forward, and the break in the arch. Then put up in plaster. (See Fig. 42.) This was removed after eight weeks. Motion of neck was regained gradually. January 17, 1908, fourteen weeks after injury, he went back to his work as a compositor. (See Figs. 49 and 50.) 98 INJURIES OF THE CERVICAL SPINE Case II.-T. D., aged forty-eight, entered May 7, 1906. Fell down- stairs. Unconscious for a time, and then showed paralysis of right arm, pain in right side of head, and tenderness of the upper part of the neck, with great pain on any motion. Seen by the neurologist who made a diagnosis (as to the arm) of nerve-root lesion. There was total paralysis, but no sensory disturbance. After three weeks he could move his head without pain and the arm paralysis was nearly gone. The x-ray showed fracture of the axis with much displacement, as seen in Fig. 51. At four weeks he was up in a Thomas collar. Showed a very slight spastic condition of the right leg. This presently cleared up. Fig. 53.-Case IV: i-ray sketch. Shows the break in the arch of the axis. The displacement is slight. At seven weeks the collar was omitted. Three days later he insisted on going home. There was nothing abnormal about him apparently, save slight stiffness of the neck, with no pain. Case III.-J. C. Fell from a horizontal bar, striking his forehead. Immediate lameness of neck. A few days later came to the City Hospital Out-patient Department, where I sawT him at the request of Dr. L. T. Wilson. He was treated as a probable fracture high up. The x-ray showed an axis fracture with displacement. Clinically, he showed a neck held rigid, with the head slightly tilted to the left. The prominence in front could be felt in the pharynx, though not very clearly. He had pain in the neck and in the region supplied by the occipitalis minor nerve on the right. From the first he walked about in a well-fitted Thomas collar. December 9, 1908, he showed some stiffness, but had no pain. (See Fig. 52.) Case IV.-P. J., aged thirty-five. May 23, 1906: Fell over banis- ters, striking head and shoulders. Unconscious for two hours. Neck LESIONS BELOW THE SECOND CERVICAL VERTEBRA 99 rigid, inclined to right. Tenderness of upper neck, and great pain in this region. No paralyses. No bony deformity detected, x-ray shows fracture of axis. (See Fig. 53.) June 7: Insists on getting up. Head in supporting splint. June 29: No symptoms. Insists on having all apparatus taken off. Went home against advice, apparently well. Lesions below the Second Cervical Vertebra Below the axis we have five cervical vertebrae of substantially similar structure, subject to like lesions. Below the axis the physiologic movements of importance are rotation and flexion. The traumas affecting this region act, first, by exaggerated rotation; second, by exaggeration of the slight range Fig. 54.-Unilateral forward luxation; incomplete (schematic) of normal flexion. Exaggerated rotation gives unilateral luxations, incomplete or complete, or " double rotatory " luxations. Exaggerated flexion leads to double forward luxation or to fracture. Extreme extension acts rarely: it may give backward luxation of one or both sides, or it may produce fracture. In general, backward displacement without rotation (i. e., from blows on the forehead or on the back of the neck) is more apt to occur between skull and atlas or atlas and axis. Lesions of the lower five vertebrae, in fact, almost always show forward displacement. Dislocations and fractures seem to occur indifferently often; both are more common in the region from the fifth to the seventh vertebra- the region of maximum physiologic mobility. Fractures are associated 100 more often with fatal cord damage; distortion of attitude and damage, not to the cord, but to the nerve-roots, rather suggests simple luxation. Dislocation may often occur as the result of a force probably too slight to give fracture. INJURIES OF THE CERVICAL SPINE The absence of ribs in the cervical region, the mobility of vertebrae at this level, and the nearly horizon- tal articular surfaces, make possi- ble the occurrence of pure luxations, such as can rarely occur lower down. DISLOCATIONS Fig. 56.-Incomplete unilateral forward luxa- tion on the left side. Sketch of author's case. Fig. 55.-Shows the normal direction of rotatory motion-not a pure rotation, but rota- tion with a tilting in abduction. Fig. 57.-Unilateral (right) incomplete rotatory luxation. Of the dislocations pure and simple we have six types, substantially the same in detail at all heights from the atlo-axoid joint downward.* 1. Unilateral forward, incomplete. 2. Unilateral forward, complete. 3. "Double rotatory," complete. 4. Bilateral forward, complete. 5. Unilateral backward. 6. Bilateral backward. * The earliest exhaustive study of these luxations, considered clinically, is to be found in an article in Langenbeck's Archiv., xxx, 188.5, p. 192, by W. Wagner, of Konigshiitte, who has contributed so much to our knowledge of vertebral lesions. The article is illustrated by admirable plates. DISLOCATIONS 101 The incomplete bilateral form has not been demonstrated so far as forward luxation goes. Backward luxation shows no definite distinc- tion between complete and incomplete forms. Fig. 58.-Sketch of case of unilateral forward luxation on the right. Reduction was easy, recovery perfect. Fig. 59.-Unilateral (right) incomplete luxation. Even on rotation the tilting of the head per- sists. All these luxations are most often rotatory in type. Type 1. Unilateral incomplete forward, represents merely an exaggeration of the normal mobility; when the natural mobility is over- 102 INJURIES OF THE CERVICAL SPINE forced, we have "jamming," presumably with a pinching of capsular structures and with some tearing of ligaments. Where there is an incomplete luxation, the position is then not strictly abnormal. It is merely an abnormal persistence of the position of extreme rotation. The position assumed by the vertebrae is as shown in Figs. 54 and 57. The position of the head is shown in Figs. 56, 58, and 59.* If the luxation is on the right, we have a tilting of the head to the left, a rotation of the chin to the left, and a slight lifting of the chin to the left. In fresh cases there may be a good deal of spasm, and the neck may be held rigid. There is, as a rule, no considerable pain referable to the bony displacement. The tenderness is sometimes localized enough to be of definite aid in diagnosis. Fig. 60.-Sketch from .r-ray'of a case of unilateral (incomplete) rotatory luxation (courtesy of Dr. Paul Thorndike). Fig. 61.-Area of pain and partial anesthesia (prompt- ly relieved by re- duction) in Dr. Thorndike's case (see Fig. 60). Fig. 62.-Right u lateral rotatory luxat forward: complete. Even in fresh cases flexion and extension of the head are possible (in the joint between atlas and condyles) to some extent. When there is less spasm, there may be tolerable mobility, but whatever the mobility of the head, there is a definite "bony" resistance to rotation toward the damaged side, short of the normal limit, and the lateral tilting remains obvious in all positions. An important sign in diagnosis is that we have in these cases little or no tightening of the muscles, especially no sternocleidomastoid spasm. This sharply differentiates the condition from a traumatic sternocleido lesion with torticollis, which gives a like tilting, though with an opposite rotation of the chin, and shows obvious spasm of this muscle. Type 2. Unilateral Complete.-In this form we have a position essentially abnormal. In this form the upper vertebra has been so far * The obliquity of this motion is a necessary result of the oblique articulations. Cf. Fig. 55. DISLOCATIONS 103 rotated that the projecting posterior edge of the articular process has slipped into the intervertebral notch. So soon as this slipping takes place there is an instant change. Fig. 63.-Right unilateral luxation: complete. Fig. 64.-A case of complete right-sided unilateral luxation. Reduction refused. The lateral inclination of the head is reversed, without reversal of the rotation, and the position becomes that of Fig. 63. The head shows, in a right-sided lesion, slight lateral inclination to the right, with rotation of the chin to the left. 104 INJURIES OF THE CERVICAL SPINE Here again we miss the spasm of the sternomastoid which is almost inevitably present if other causes than luxation determine a like position of the head. The attitude of torticollis and that of the complete uni- lateral luxation are the same. There is loss of motion, of course, Fig. 65.-Bilateral forward luxation Fig. 66.-Forward luxation (after Blasius). and almost inevitably symptoms of nerve-root pressure on the side of the injury. Fig. 67.-Forward luxation (after Blasius). Question of fracture also This takes the form of radiating pain down the arm. Inasmuch as these luxations usually occur low down in the neck, it DISLOCATIONS 105 is the roots of the brachial plexus that are affected,* and as it is a root lesion we get pain, involving not the distribution of single nerves, but zones corresponding to the roots, as sketched in Fig. 76. f In a few cases there may be not only pain, but motor or sensory loss in some part of the arm. The pain in these cases varies with, and in some measure is dependent on, motion of the neck. Type 3. Double Rotatory Luxation.-The double rotatory cases are a combination of forward luxation on one side, with a slight back- ward displacement on the other. In one autopsy of a case of my own the luxation (between fifth and sixth cervical) showed the fifth vertebra luxated back in such fashion that the articular surface of the sixth rested in the lower intervertebral notch of the fifth. The displacement is that of the complete forward luxation, only slightly exaggerated by the complicat- ing backward displacement on the other side. Type 4. Bilateral Forward.-In the fourth class, the bilateral forward luxa- tion, we are dealing with the result, not of rotation, but of forward shove and of flexion-the same force that so often makes for fracture. The position of the vertebral bodies is as shown in Fig. 65. The attitude is shown in Figs. 66 and 67, sketched after the plates of Blasius. This form is relatively rare; the writer has seen two cases only .J Blasius, in his wonderfully complete monograph, gives 54 bilateral luxations, against 37 unilateral, but it must be noted that this paper is based mainly on a study of reported autopsies; bilateral luxation is apt to be fatal; unilateral luxation rarely, if ever, cause death. So far as sur- viving cases are concerned, it seems that the great majority are unilat- eral. Certainly this is true not only of my few cases, but in those of which I have knowledge in the practice of others. Type 5- Unilateral Backward.-Blasius gives but one good case- that of Ollivier, a luxation of the sixth-and one doubtful case. Ollivier's case showed no obvious deformity, but it was complicated with extensive fracture of the seventh vertebra, so it tells us noth- ing to the purpose. Fig. 68.-Bilateral forward luxa- tion (with cord symptoms) (courtesy of Dr. F. B. Lund). * Nerve lesion from pressure in the notch must be carefully distinguished from damage of the plexus in the neck from stretching. It is limited to nerves of one segment; stretching may damage the whole plexus. f For much of the information used in preparing all the drawings of zones and areas of sensory disturbance the writer acknowledges indebtedness to the admirable studies of Head and Sherren, Brain, vol. xxviii, p. 116, November, 1905. t There are several cases on record, however, of bilateral forward luxation where the attitude differed greatly, there being only a shortening of the neck, apparently, and an exaggeration of the normal concavity at the nape, and in some cases there has been actual backward extension of the head. In regard to rigidity and pain there is great variation. The neck may be pretty freely movable. 106 INJURIES OF THE CERVICAL SPINE Fig. 69.-Forward luxation of fifth on sixth; temporary signs of cord pressure. Fig. 69a.-Luxation sixth cervical forward on the seventh. Four months after auto accident. Not treated at all. Some tendency to tiring of the neck. Not a trace of cord pressure. DISLOCATIONS 107 Necessarily, there would be in such an injury a persistent rota- tion backward on the injured side; beyond this we can say nothing definite. Type 6. Bilateral Backward Luxa- tion.-The classic symptoms are back- ward and upward extension of the head, hollowing in of the back of the Fig. 70.-Dislocation forward of sixth cer- vical vertebra from fall on head. Total par- alysis below nipples. Temperature rose to 110° F. Died eighteen hours after accident. Illus- trates displacement of spinous processes (Warren Museum, specimen 4904). Fig. 71.-Unilateral dislocation backward neck with deep skin-folds,* prominence of the larynx and trachea, with difficulty in swallowing and talking, or even in breathing. Fig. 72.-Classic attitude for double backward luxation. The transverse processes below the luxation are prominent. The head is held immovable. The neck looks shortened. * There are exceptions, and cases amply attested by autopsy have shown a flexion of the head well forward, with backward luxation, but they are a few, not the rule. 108 INJURIES OF THE CERVICAL SPINE Fig. 72, based on the plates of Ayres' case, shows the attitude. Diastasis-tearing of ligaments without formal luxation and without fracture, save for chips torn loose by the ligaments-is common in this region and figures in a number of autopsy reports. These cases commonly show stiffness and localized tenderness, without abnormal attitude, and with a negative finding on x-ray examination. They are apt to be associated with traction damage to the plexus or to nerve-roots of at least one side. Such ligament tearing may of course complicate any fracture or luxation. In a recent case (1913) the gap felt between the fifth and sixth spines was the only sign of a flexion fracture of the body of the fifth cervical vertebra. Fracture Luxations with Displacement These involve various details of lesion, but this injury in the cervical region is usually fracture by flexion, with slipping of the upper verte- bral fragment forward on the lower. The diagnosis of these cases is Fig. 73.-Injury to segments V and VI (after Thorburn). Fig. 74.-Injury to segments VI-VII (after Thorburn). based, as a rule, on the diagnosis of the cord lesion or on the x-ray picture. The local signs are confirmatory, rather than diagnostic. Any considerable displacement here involves pressure on the cord, and the diagnosis as to the presence and height of the cord lesion, and, therefore, of the height of the fracture, is apt to be far more accurate than can be made from an examination based on objective signs in the neck. Cord lesion may occur without fracture, but fracture with displace- ment rarely occurs without damage to the cord that can be sharply localized. Luxation without cord lesion is common. Of the fracture cases that come up for diagnosis, we have usually only those below the fourth spinal segment, for fractures with cord damage above this point almost invariably involve the cord origins of the phrenic nerve, and are fatal long before the question of diagnosis comes up. Below the fourth segment we have, so far as the clinical signs of cord damage go, three types, almost instantly differentiated on sight according to the motor damage. 109 DIFFERENTIAL DIAGNOSIS OF INJURIES BELOW THE AXIS If the damage is above the fifth segment, the arms are entirely paralyzed. If the damage is a little lower, in- volving the fifth and sixth segment, we get the picture of Fig. 76. This means damage involving the cord up to the fifth segment. If the damage is only to the sixth, we get paralysis of the hands, not of the arms, and a position like Fig. 74 and Fig. 75. Fig. 75.--Sketch of a case of the writer's: total lesion at the sixth segment. Differential Diagnosis of Injuries below the Axis It we have a case of injury to the neck, our consideration of diagnosis starts, not from known pathologic data, but from ascertainable symp- Fig. 76.-Shows areas supplied by individual nerves on the left side-"root-zones" on the right. toms to be used for diagnosis-a very different matter. In examining such a case the first thing to be settled is whether or not the patient has paralysis. If he has, we must first make up our minds as to the probable height of the lesion. 110 INJURIES OF THE CERVICAL SPINE If the paralysis is total, we know it must be from an injury below the fourth segment. Injuries higher up with total damage are instantly fatal. Partial paralysis may come from injury at any level or from nerve- root lesions alone. Total paralysis of the type of Fig. 73 means fifth segment. Total paralysis except for upper arm action in flexion and rotation (see Fig. 74) means sixth segment. Partial paralysis below the level of the arms necessarily means cord injury. Partial or total paralysis of one or both arms means either lesion of the cord or injury to the brachial plexus or nerve-roots. Sensory disturbances are of value, as a rule, only in defin- ing the level of hopeless trans- verse lesions of the cord, or in defining injuries of the brachial plexus or of the nerve-roots. The levels of the sensory dis - tribution corresponding to the various segments of the cord are indicated in Fig. 76. Disturbance of the sympa- thetic nerve is shown particu- larly by unilateral contraction of the eyelid opening (" verkleinerte Lid-spalte"), and at times by unilateral sweating. It depends on damage to the anastomosis between sympathetic and cord at the level of the first dorsal segment. Priapism (simply a soft engorgement of the flaccid penis, as a rule) is pretty constant in the total lesions; it may help out in the diagnosis in unconscious or drunken subjects. A like condition occasionally occurs where there is only very slight cord compression. Deformity.-If the displacement is forward, it may be-(1) Double forward luxation. (See Figs. 65 to 68.) (2) Fracture with forward displacement. (3) Distraction. There is no accurate differentiation of the first two. On the whole, there is a possibility of greater displacement without serious cord damage in luxation than in fracture. Displacement of spinous processes and transverse processes is common to both, and of similar grade. Crepitus is not justifiably obtainable unless by accident. "Distraction " must be differentiated on negative evidence. There may be deformity (in the upper vertebrae it is asserted that there usually Fig. 77.-Attitude in right-sided torticollis. DIFFERENTIAL DIAGNOSIS OF INJURIES BELOW THE AXIS Ill is), but this is in the form of forward flexion only;-the relation of the landmarks one to another is not notably disturbed. There may be no such deformity at all-only rigidity and tenderness. Obvious backward displacement of the head means-(a) Double backward dislocation of any vertebra. (6) Double forward dislocation. Both these are rare. If the displacement be above the fourth vertebra, an examining finger in the pharynx will usually differentiate. Otherwise palpation of the spinous and of the transverse processes is our only help. In such case the skiagraph may give welcome evidence. Fracture with backward displacement seems to be even rarer than luxation. Here again we should have to depend on the x-ray for accurate differentiation. If the displacement is lateral and backward, we may have either luxation or fracture luxation. If the displacement is forward with rotation, more especially if there be no symptoms of cord pressure (whether with or without signs of root pressure), the probability is that we have to deal with a pure luxation. If the head is inclined away from the side that shows local tenderness and palpable disarrangement of transverse processes, and possibly nerve-root signs, then we probably have incomplete rotatory disloca- tion forward-the commonest type of pure luxation. If the lateral flexion is reversed,-toward the injured side, with rotation still away from the damaged side,-then the luxation is a complete rotatory forward. It is possible in these cases of rotatory luxations to make the diagno- sis with some degree of certainty without the x-ray. That the x-ray may be of service is obvious from Fig. 60. It will be obvious from the foregoing that the differentiation is at best only approximate in many cases; there are not only these type lesions, but a whole series of atypical fractures and fracture luxations that often show no appreciable displacement, to say nothing of the self-reduced luxations and of the "distractions" in which there is practically no displacement. Rigidity without deformity per se does not prove anything. * There may be distraction, self-reduced luxation, fracture with little or no displacement, or even muscle soreness alone. Signs of nerve-root lesion, or more especially of cord lesion, in com- bination with a rigid neck without deformity, point to "distraction." Fractures are not likely to produce such lesions without demonstrable displacement, and distractions are commoner than self-reduced luxations, f * Absolute rigidity, like that of meningitis, I have seen in one neck fracture and in three fractures of the skull base. Presumably, the irritation of meningeal hemorrhage may rarely give this as a reflex result, just as meningeal suppuration commonly gives it. f It must be borne in mind, however, that falls on the side of the head and on the shoulder not very uncommonly involve damage to roots or plexus without any injury to the vertebral column at all, so that nerve lesion is indicative of damage to the spine only in the presence of some direct sign of such damage. 112 injuries of the cervical spine A condition to be considered is torticollis-directly traumatic from muscle strain or of the "rheumatic" sort. As a rule, torticollis involves the sternomastoid muscle. The differentiation is by attitude (see Fig. 77), and more particularly through the fact that the sternomastoid or the posterior neck muscles are tense in torticollis on the injured side. In the rotatory luxations and with all displacements the tension is slight and almost invariably on the other side. It is even possible to have serious cord damage without vertebral damage. This may be from hemorrhage outside or within the cord.* The mechanism of production usually seems to be one of overflexion, with tension in the length of the cord. Serious compression of the cord is not common without displacement of vertebrae, however. Clinical Conclusions To sum up: about all that can be claimed is that it is usually easy to be sure that we have to deal with an injury to the spine in this region. Beyond this the surgeon who has a reasonable experience with this class of cases can, as a rule, distinguish without much question three impor- tant classes: (а) The rotatory luxations, readily and completely relievable. (б) The cases without displacement, with or without lesion of cord or serious damage to nerves, with or without definite fracture or "dis- traction" lesions-cases to be let alone except for support. (c) The fracture dislocations, with apparently irreparable cord lesion,f in which treatment is useless if the diagnosis be correct, but cases in which any immediate treatment may be justified on the chance of a lucky error in diagnosis. Beyond this range diagnosis in detail is uncertain, and, though helped by a good .r-ray, is often left uncertain. Rotatory Luxation Forward-Unilateral Incomplete.-These cases not uncommonly cure themselves. I have seen three undoubted cases, all in children, which reduced themselves while the children lay in bed-not very quietly-awaiting parental permission to operate. Cases are recorded where reduction occurred under ether, prior to any attempt at reduction. Reduction is ordinarily easy. Ether is advisable-not actually necessary. Treatment of Luxations * I have latterly seen two such cases of practically total quadriplegia with a good deal of sensory disturbance, from neck injury. Both recovered within a month; one completely and the other with some persisting paralysis in the ulnar supply on one side. In a case now in the wards there is paraplegia with partial arm involvement almost without sensory loss, obviously hematomyelia, which is already improving somewhat. f There is no absolute distinction of these cases, even total paralysis with total abolition of reflexes (patellar, Achilles, plantar, etc.) does not prove a total trans- verse lesion. The question of these lesions is considered in the following among many articles: Thomas: Boston City Hospital Med. and Surg. Reports for 1900; Walton: Jour. Nerv. and Mental Dis., January, 1902. TREATMENT OF LUXATIONS 113 The patient lies on his back, with the head and neck projecting over the head of the table. The operator takes one of the grips shown in Fig. 78.-Grip for reduction of neck luxation. Fig. 79.-Another grip for reduction. Figs. 78, 79, and 80, and with very slight traction swings the head away from the side of injury, first rotating this side forward to disengage 114 INJURIES OE THE CERVICAL SPINE any obstruction, then gradually rotating backward while the lateral abduction is maintained. (See Fig. 81.) In this way the articulation of the sound side is used as a fulcrum and a fixed point about which the reduction is made. Little force is needed. The bones slide into place (sometimes without any click), and normal position and motion are instantly restored. I have in this way reduced five cases. Fig. 80.-A third grip for reduction. This is the strongest and usually the best grip of those shown. In the complete forward luxation the reduction is the same, save that we abduct toward the uninjured side somewhat more vigorously, to make sure that the articular process clears the notch into which it has slipped. In the cases of bilateral luxation for- ward the reduction is the same, but one side is reduced at a time. The double rotatory luxation (on side forward, the other back) is probably indistinguishable clinically. If distin- guished, it could not be treated otherwise than by simple reduction as for unilateral forward luxation. As to the backward dislocation, single or double, there are practically no data. The reasonable procedure obviously would be traction up and away from the side injured, then flexion and rotation forward on the injured side, provided the lesion was unilateral. Fig. 81.-For the right-sided luxa- tions the head is abducted to the left (1) and rotated down and back on the right (2). TREATMENT OF FRACTURES AND FRACTURE LUXATIONS 115 In bilateral luxation backward the manoeuver to be carried out is traction up and slightly backward (z. e., extension of the neck) to disengage the entangled processes, then flexion to reduce them, carry- ing the vertebra forward to its proper place.* Treatment of Fractures and Fracture Luxations Fractures in this region that are not associated with cord injury do not ordinarily call for any reduction manoeuvers. The exception is in case of considerable deformity, as in the case shown in Fig. 82; in such a case it may be well to reduce, remembering that in these fractures, Fig. 82.-Fracture dislocation of the fourth cervical vertebra. Taken four months after acci- dent (Peckham and Hammond). unlike the luxations, we do not know the precise kind or amount of damage, or whether there is in the given case a risk of over reduction. Cases of damage to nerve-roots by pressure at the foramina are usually bettered by hyperextension-simply by keeping the neck hyperextended, not by reduction procedure. All these cases should be kept in bed with the head steadied by sand-bags for two to four weeks, then put up in a plaster helmet or Thomas collar. Support should be continued for at least a month longer to be on the safe side, and some caution in avoiding falls or jarring is indicated for some time thereafter. As to treatment of fractures or of fracture luxations with cord damage there is little to be said that is not open to dispute. * Hamilton: Fractures and Dislocations, third edition, p. 523, cites Ayres, who successfully reduced such a case by a manipulation similar to that described. 116 INJURIES OF THE CERVICAL SPINE In this region pressure on the cord that suffices to give paraplegia means usually a transverse total lesion of the cord, which is beyond the present resources of surgery. Such a lesion means permanent paralysis, with death resulting at an interval varying from twelve hours to many months. Here and there laminectomy, or forcible correction without incision, has seemed to be the determining cause of recovery, total or partial. In competent hands either operation is next to harmless, and is always justifiable, if not hopeful.* We can not remedy total transverse lesions occurring at the time of the trauma, but may relieve any trouble due to persistent pressure. Such persistent pressure may be due to displacement of one vertebra on another, or to smashing in of the laminae into the canal, or to hemorrhage between meninges and bone, or within the meninges, or inside the cord.f If we feel that there is even a small chance that paraplegia is due to such pressure, not to damage already done, it is our duty to act and to operate immediately, even if the detail diagnosis cannot be made before operation. After reduction, whether by forcible correction or by laminectomy, the problem is one of fixation. The tendency to recurrence of displace- ment in pure luxation is very In fractures, reduced or oper- ated, it is greater. In fractures, originally without displacement, and in distraction injuries in the lower neck, the tendency to displacement is slight, and patients often refuse or remove apparatus without damage. Our means of fixation are, here, as in the higher injuries, sand-bags while the patient is in bed; after he is ready to be up, a plaster helmet or a Thomas collar, or its pasteboard modification, may be used, accord- ing to the gravity of the case. Support is to be long continued.§ In one case some years ago I used a wire "back-stay" to secure support, and with success. (See Figs. 83-85.) This wire was laced about the spinous processes. Today one would consider a bone-graft in such a case. * A series of cases of forcible reduction recently collected by Steinmann (Arch, f. klin. Chir., 1906), of 20 cases with 12 successful reductions without laminectomy gives by far the most hopeful view of any recent paper. f If we could be sure of the hemorrhage cases, they might be let alone, as clot pressure diminishes pretty promptly. In two recent cases of the sort in which the neurologist, Dr. J. J. Thomas, and I felt that the trouble was due to clot pressure, no operation was done. Both cases showed paralysis, nearly complete, both of arms and legs. One removed entirely; the other recovered entirely except for ulnar atrophy and a slight spastic condition of the legs. t There is one case of reported recurrence after reduction-that of Wittfeld. § In a case reported by Drs. Burrell and Crandon (Jour. Amer. Surg. Assoc., 1905, xxiii, p. 80) the patient at first showed no cord symptoms. At four days he sat up against orders, and immediately complained of numbness of legs and body. Examination showed paresis from the neck down, with diminished sensation. Two days later paraplegia was complete from the muscles supplied by the sixth and seventh segment downward. Operation was refused. Death occurred after a month. Autopsy showed a fracture of the first dorsal vertebra. PROGNOSIS 117 Prognosis Dislocations without marked cord lesion when reduced do well. Associated motor nerve injury usually recovers either at once or later, within the two to six months needed for nerve regeneration. Sensory disturbance usually disappears promptly, though pain may persist longer. Any serious neck stiffness lasting beyond a few weeks is not to be expected. Fractures without cord injury do well, but repair is slow, and, in proportion to unreduced displacement, there is apt to be rigidity of the neck or an eccentric holding of the head. Fractures or luxations with severe cord injury in this region usually do badly, with or without surgical aid, even if the lesion is not com- plete. Many cases succumb promptly to ascending myelitis ("red Fig. 83.-Radiograph before operation. (Explanatory diagram in upper left corner.) There was a large opening out of the space between VI and VII. softening''), showing prompt hyperpyrexia, semicoma, and respiratory disturbance,* accentuated by abdominal distention and the resulting dyspnea. * Most marked at about the second day-as dyspnoea alone or with actual lung edema, not rarely giving pneumonia as the secondary result. The following cases of the writer's are significant: C. V., August 15, 1907, was struck on the back of the neck by a beam. Showed a "knuckle" at the seventh cervical spine. Total paraplegia with loss of sensa- tion below the fourth rib; knee-jerks absent. Apparently a lesion of the seventh segment. Showed loss of sensation of the extensor surface of both arms. At entrance he showed some disturbance (rapidity) of respiration. The paralysis extended, with eventual loss of all motor power at a level corresponding to the sixth segment. At two days he developed a right-sided pneumonia and died within a few hours. W. T., aged thirty-four. Seen by the writer August 10, 1907, forty-eight hours after falling down-stairs. Respiration rapid and shallow. Heart-apex outside the nipple. Abdomen distended. Hand grasp weak on both sides. Paresthesias of both arms on the ulnar side. Anesthetic from the nipples down. Paraplegic Tenderness at the seventh cervical. No deformity. Reflexes gone. Respiration got better; involvement of arms improved. In course of transfer to the ward was carelessly handled, apparently, promptly became cyanotic, and died of respiratory failure. 118 INJURIES OF THE CERVICAL SPINE Other cases survive only to succumb to sepsis from ascending vesical and pyelonephritic infection, or to sepsis and exhaustion from the "trophic" bed-sores which are hardly to be avoided in these cases, even with the best care. Fig. 84.-Photograph before operation. This was the best position in which the head could be held long enough to take a picture. He could raise it somewhat high- er for a few seconds. (Jan. 26, 1910.) Fig. 85.-After operation insertion of a wire "back-stay." There is a "cocoon" dressing over the wound. (Feb. 15, 1910.) Here and there improvement or actual recovery follows, with or without operation, as the case may be. Such improvement seems to occur most often in cases where there is compression not by bone, but by clot (see cases above noted). CHAPTER V DORSAL SPINE Landmarks.-We have to consider here only the spines and arches. The bodies and transverse processes are beyond reach. The line of the dorsal spines, seen from the rear, is substantially straight; there are here no bifid spines to confuse us, and any normal lateral deviations are usually so slight as not to count.* On flexion the spines stand out better and their line may be made out even in fat patients. There is some variation in the length and prominence of the spines, but, as a rule, they are pretty even, with two exceptions-the first and the twelfth dorsal. The first is prominent: very often it is this first dorsal and not the last cervical that is the "vertebra prominens." The second spine is less prominent, but the change in level beneath the first is not conspicuous. The last dorsal spine in most individuals projects no more than the rest, but not uncommonly it is of greater actual length, or the contrast between it and a much shorter first lumbar spine gives it a prominence which at times is very conspicuous and looks abnormal. The arches of the dorsal vertebrae are not ordinarily palpable under the great muscle masses. They may, however, be felt vaguely as a firm resistance under the muscle. The distance from the arches out to the skin is, in fact, far greater than would be estimated, even in non- muscular subjects. INJURIES OF THE DORSAL SPINE Here we are confronted with the same classes as in neck injuries; dislocations, fracture dislocations, fractures without much or any dis- placement of the bodies, and " distraction " lesions. The determining trauma may be a direct blow, but is usually a forced flexion. Hence it is that the lesion is commonly very low down (tenth to twelfth dorsal), where the spine is least resistant to flexion strain. Causes.-In some cases dorsal injury results from a fall on the back --from direct violence. Indirect violence acts rarely in case of falls in the sitting posture, the impetus of the falling head and trunk produc- ing a sudden forced flexion. Forced flexion acts in another way more commonly, namely, in cases where a driver is caught by a low door, or where in other fashion a very forcible though slow compression in * The "normal" lateral curvature described in the anatomies I have rarely been able to find clinically. 119 120 DORSAL SPINE flexion is exerted. Something in the back must give way-it may be that there will be a simple tearing of ligaments, a "distraction," or there may be fracture, the vertebral body giving way obliquely down and forward. Still more com- monly one meets with the "compression" type of fracture with conversion of one vertebra] body to a wedge narrower in front, without displacement. Such fracture is usually at or near the dorsolum- bar junction, the point of greatest mobility and least strength. Displacement of the upper fragment backward is rare-it seems to be due always to a fall in which the lower portion is checked against some firm object, while the momentum of the upper part of the body backward causes both fracture and displacement. Theoret- ically, pure hyperextension may also give this displacement. Fig. 86. - Mechan- sm of flexion fracture as it occurs when a driver is caught between his seat and the top of a doorway. Dislocation Dislocation absolutely without fracture may occur and is attested by various autopsies.* Dislocations without fracture are, however, incomparably less com- mon than in the neck, owing, in the main, to the supporting relation of the ribs to the spine; they are, in fact, so rare as to become clinically insignificant, f Of Blasius' list of dorsal luxations there are 22 in all. In five the displacement was forward, backward in five, double rotating in one, that is, forward on one side, back on the other.J One case was a unilateral backward displacement, two are recorded as directly to one side. This list, however, includes many cases with associated fractures, more or less extensive.§ Of these luxations 11, exactly one-half, were at the point most often damaged by fracture, namely, at the lower end of the dorsal spine. Granting the possibility of luxations of the dorsal vertebrae as proved * And also cord injuries from overflexion involving no bone lesion. t Hamilton (Zoc. cit., p. 515) quotes one case. j Such a double rotatory case in my own series is here given (but there was also a laminar fracture): M. F., aged thirty-three, August 16, 1906. A staging fell on him. There was a knuckle at the twelfth dorsal and a separation of the spinous process of the first lumbar. Total paraplegia; sensation gone below the pubes. Transferred from the Relief Station to my care. Laminectomy August 18, 1906, showed the twelfth dorsal vertebra twisted forward on the right, with subluxation backward of the articular process on the left. Save for a fracture of the lamina of the twelfth dorsal there was no break evident. There was no continuing pressure, and the dura was untorn, but on opening the dura a complete or nearly complete crush of the cord was found. The operation did no good and no harm. He was discharged unimproved October 5th. § Four seem free from doubt as to fracture. All these cases are of backward luxation. DISLOCATION 121 by postmortem, it is perfectly fair to say that such lesions can not be diagnosed, that in cause, site, symptoms, complications, prognosis, and in the indications and the possibilities of treatment they can not be Fig. 87.-Specimen in Warren Museum (4629). Fracture of twelfth dorsal from fall. Total paraly- sis, but lived two years. differentiated, and that it is of no importance that they should be differentiated from fractures in this region. Fracture Dislocation.-The le- sion is most often a displacement of the upper portion of a vertebra Fig. 89.-Specimen in Anat.-Path. Mus. zu Giessen, No. 35-168a. Sagittal section. Sketched after Gurlt's plate. Shows pressure on the cord by the displaced wedge fragments. Fig. 88.-Fracture of twelfth dorsal ver- tebra. Laceration of intervertebral disc above twelfth vertebra. Paralyzed from below navel. on the lower part of the same. The torn ligaments and displaced joints often present are unessential.* Pressure on the cord is be- * As a curiosity onlv, we may note a case reported by Jouon (Revue d'Ortho- pedie, vii, 1906, p. 39) in which there was a separation of the upper epiphysis of the dorsal vertebra forward. 122 DORSAL SPINE tween the displaced arch behind and the fixed portion of the body below the fracture. (See Figs. 87 to 89.) Flexion of the column, as a whole, at the point of break is a factor in pressure, as is also the shoving backward of a not infrequent wedge- shaped bone-fragment on the cord. (See Fig. 89.) Rarely pressure is from fragments set free by fracture of arch or lamina: such pressure is more apt to occur in cases of fracture by direct violence, than in the commoner type of fracture by flexion. Here, as in the neck, signs of severe cord damage may accompany pressure from clot without any bone damage at all. Fracture or dislocation, with like displacement, without cord pressure, is not common. The canal is here nar- row, and little slipping is needful to give pressure. The cord is usually severely and irremediably damaged at the time of accident. Here, as in the neck, there is no reliable sign of total cord lesion. Abolition of reflexes* is highly sugges- tive of total cord lesion, but not conclusive. The most common site for these in- juries, save those from a direct blow, is low down, about the tenth dorsal to the twelfth. Displacement, as a rule, is of the upper portion forward on the lower. Some degree of lateral deviation is common; a deviation predomi- nantly lateral is rare. Fig. 90.-Fracture by crushing (i. e., flexion) of the twelfth dorsal vertebra. Sketched after Gurlt's plate. Fracture of the Spine without Displacement of the Bodies Fracture of the body of a vertebra does not occur without some little displacement, though it may escape detection. Fractures of the lamina may occur without displacement of the bodies. Such fractures give cord pressure usually, and, discovered accidentally at operation, furnish the best cases of recovery after lam- inectomy. Unfortunately, they can not be diagnosed. If there is no general deviation of the spine, but a deformity in the line of spinous processes, and if crepitus is felt, we may suspect fracture of an arch or lamina. The x-ray may settle the question. Fracture of a spinous process not very infrequently results from direct violence, or may occur as a complication of fracture of body or arch. It may be diagnosed by the abnormal position of the spinous process, which is movable laterally. There may be crepitus. There is pain, and the region is tender. There are no cord or root symptoms. * Loss of patellar and tendo Achillis reflexes and of plantar reflex. DISTRACTION 123 The presence of such fracture does not argue against associated fracture of the body. The treatment of fracture of the spinous process is simply rest- fixation of the fragment is impracticable without operation, which is not called for. The result is union, apt to be fibrous rather than bony. The injury involves no permanent damage, save perhaps some slight loss of strength and flexibility. Distraction Distraction.-The only form of "distraction" of clinical interest, that is to say, the only form in which a diagnosis may be made, is that in which the interspinous ligament is torn. Here and there such cases turn up. They are characterized by local pain, by a kyphosis seem- ingly beyond the normal, and by the separation of two adjacent spinous processes that is beyond the normal variation. This separation tends to increase on flexion of the spine, is reducible by hyperextension, and is associated with more or less localized pain and tenderness and ecchymosis. Nerve-root symptoms are usually lacking. There is often no gross displacement.* In these cases of distraction in the dorsal region the kyphosis is a reducible one, localized definitely at one point, and not associated with any irregularity of spines, other than their separation.! There is a decided chance of overlooking a slight irreducible kyphosis from body fracture. It is to be remembered that torn ligaments in no way exclude fracture. DIAGNOSIS As a rule, utter helplessness is the immediate result, from local pain, even if not from paralysis. If the patient is unconscious, drunk, or in severe shock, or if there are other severe injuries associated, the lesion of the spine may not be obvious. In unconscious cases loss of reflexes, or oftener the reflex priapism, may give the necessary sugges- tion of cord lesion. This priapism is usually only a soft engorgement of the penis, but often of considerable size. If the patient is conscious, there is, as a rule, severe pain in the back, often radiating around the chest or belly. * C. F. Painter has reported some cases of interest in this connection, some of which involve probably fracture, as well as "distraction." Painter and Osgood: Boston Med. and Surg. Jour., 1902, cxlvi, p. 1. f O. P., woman of thirty-six. Caught under the fender of a car. Seen by me August 30, 1907, and October 14. Never showed cord symptoms. Showed at the twelfth dorsal vertebra a separation of the spines, with a kyphosis which, with the separation of spines, was reducible by moderate forced extension. She refused any treatment. When seen nearly two months later, she showed no signs of cord damage, unless we may so class slightly increased reflexes at knee and ankle, and complained mainly of inability to sit or stand for a long time. There was no longer any reducible kyphosis, but there was a slight permanent kyphos. This case I regard as a pure "distraction." 124 DORSAL SPINE There is often (important in differentiating actual associated vis- ceral lesions) a rigidity of belly muscles and a tenderness of the belly obviously due to the spinal lesion, but not adequately explained. Passive motion (or active motion, if that be possible) of legs or pelvis gives pain at the site of the injury, but there is apt to be rigidity from spasm, rather than increased mobility. Local examination shows, as a rule, a hematoma.* If there has been no direct violence there is none the less apt to be some swelling of the soft parts about the seat of injury, and later a marked ecchy- mosis. This is significant: practically it means spinal damage always. Tenderness locally is usually great. Deformity.-First we must regard deviations in the general line of the spine in two planes. Anteroposteriorly, we may have type (a) and type (6), where no exact point of projection can be made out. (See Fig. 91.) Seen from behind, we may have lateral deviation of types (c) or (d). On palpating the region of damage we usually find irregularity in the line of spinous processes, the upper forward, as in (e), or back, as in (/). It is, however, a change in the line as a whole, not failure of two spines next to one another to agree, that often gives diagnosis. (See Figs. 92 and 93.) Displacement may be considerable, but often in the worst cases it seems slight, for cord damage may occur even in simple over- flexion, with or without distraction, or even without any fracture; on the other hand, some displacements, having done their appointed damage, seem to reduce themselves in part-to snap back, so to speak. In making diagnoses we must bear in mind that the spinal column varies a good deal as to prominence of spines. Very frequently the last dorsal spine is normally so prominent as to suggest something pathologic. If there is total paralysis, the top of the area of disturbed sensation gives us a guide as to height of the cord lesion. If there are symptoms of nerve-root damage, radiating pain, local anesthesia, paresthesia, or motor disturbance, this gives an additional guide. The heights of sensory damage corresponding to given cord segments may be seen at a glance from Fig. 76. Damage to nerve-roots is more apt to be irregular in distribution, but does not show itself very differ- from behind Fig. 91.-a-f show the profile view; c and d, the view from behind. We may have in profile an angle (cf. Figs. 87-89, and Fig. 94), or what is apparently only a curve, as in b. On palpation we usually find definite displacement; this may be of either the upper (c), or more rarely the lower, frag- ment forward (/), though in either case the deformity is one of kyphosis. Seen from be- hind we may have an angle (c) or a "jog" (d).t§ * In cases due to glancing blow on the back by a heavy object, there is at times a loosening (what the Germans call a "Schindung," a "shelling off") of all struc- tures between skin and ligaments, and a colossal hematoma. This proves nothing as to damage to the spine, though it is suggestive of such damage. 125 DIAGNOSIS ently from that of the cord, save that cord pressure does not give pain of radiating type. Fig. 92.-Lateral deviation of the upper spine as a whole. Fig. 93.-Anteroposterior deviation of the spine as a whole. The left-hand figure shows deformity in kyphosis; the other, a deformity in lordosis at the middorsal region. Differential Diagnosis.-Given a case with cord damage, the site of injury may be determined accurately and some idea may be formed Fig. 94.-Compression fracture of the twelfth dorsal vertebra. Old case untreated-almost complete disability. Shows little in the x-ray save increased density and foggy outline. The increased density always shows. It is due to the jamming together of bone structure. of its extent. At or about the level of the damage there may be obvious deformity. In this region this may be fracture or dislocation: 126 DORSAL SPINE Fig. 95.-Compression fracture of the twelfth dorsal vertebra with probable damage to the eleventh. Luxation of head of eleventh rib. An overlooked untreated case. Disability not as extreme as usual in these cases, but severe. Fig. 96.-Compression fracture of the twelfth dorsal body. Lateral view. Clinically there was;'only a slight kyphos. The case had been overlooked and not treated. Disability was almost complete. 127 DIAGNOSIS Fig. 97.-Compression fracture of twelfth dorsal and first lumbar vertebrae. Shows a bridgelof bone spanning the crushed intervertebral disc (courtesy of Dr. A. J. A. Hamilton of Boston).* Fig. 98.-Fracture of lamina of first lumbar vertebra. There is also a split in the body with a bit ot spreading outward. 128 DORSAL SPINE the dislocation is not to be differentiated from fracture at this level. There may be damage to the cord with simple distraction or from flexion with no spine lesion. Hematoma and local tenderness speak for bony damage. Abnormal mobility of the spine may mean either fracture or only extensive ligamentous tearing. Crepitus, rarely present, usually means fracture of lamina or arch, with or without fracture of the body. Fracture of the body (the usual type) does not give crepitus on moderate handling. In default of cord damage nerve-root symptoms (z. e., pain, paresthesia, anesthesia) may guide us as to the exact location, or we may have only local tenderness and lameness, with or without dis- placement. Fracture of the body, as well as of the neural arch, may exist without any displacement that can be recognized. " Distraction " is recognizable only where mobility shows. Fracture of spinous proc- esses alone may be shown by mobility of the fragment and by crepitus. Recently we have learned how common is the fracture of the com- pression type with only a crush- ing together of the structures of one vertebral body into a wedge shaped profile. Such fractures most usually result from flexion of the type shown in Fig. 86, but may be caused by falls on the buttocks or on the feet or even on the head, rarely. Careful exami- nation usually shows local tenderness, sometimes slight swelling, and either a very slight kyphos or at least a flattening of the lum- bar curve below the point of injury. Almost always the break occurs in the eleventh or twelfth dorsal or the first lumbar. These cases are often overlooked. The review of cases coming before the State Industrial Accident Board in Massachusetts brought to my attention in 1919 a series of some ten undiagnosed cases and I have seen a number since then. The plates accompanying this text are from that series (Figs. 95-99). Sever has reported like cases from the same source.* Such a lesion'once suspected is readily verified by the x-ray. Fig 99.-Fracture transverse processes of second, third, fourth, lumbar vertebrse on right. X-ray by A. W. George, M. D. * J. W. Sever, Boston Med. & Surg. Journal, Apr. 27, 1916. PROGNOSIS 129 First.-There is nearly always increased density of the body. Second.-There is a change in the depth of the body. Fracture lines are rarely seen. Third.-In the last few years we have had good x-rays of the lateral view which make the matter obvious. There is therefore little trouble with diagnosis in fresh cases. Since these cases are so often overlooked, however, patients turn up months later in whom there may be doubt. There are wedge shaped vertebral bodies in middle-aged folk, especially working men, that beyond question are the result of posture and work, and it may be very hard to distinguish between these and the traumatic cases. There is no hard and fast rule-as yet. PROGNOSIS Total cord lesions at this level always cause death. Patients die early from shock, from associated injuries, from pneumonia, from ascending Fig. 100.-Fracture with mobility due to "distraction"-torn ligaments. Despite support, the deformity persisted. There were signs of root pressure for some weeks, and for some months weakness and abnormal mobility of the back persisted, but after a year he was apparently as good as new. This photograph was taken four months after the injury. Later, he was at work as "puddler" in a foundry, the heaviest sort of work. myelitis, or later from the inevitable bed-sores or from ascending infection traveling from the bladder to the pelvis and to the kidney. Exhaustion and sepsis are usually the proximate cause of death. The fatal result may be postponed at times for many months. (See data 130 DORSAL SPINE on Fig. 87.) Accurate prognosis seems impossible as to duration of life in a given case. Partial lesions of the cord may become total from inflammatory involvement of parts not directly injured. As a rule, such cases tend to improve slowly, and often to a limited extent. Nerve-root lesions usually recover entirely or almost entirely. As to the function of the spine itself, apart from paralysis, full recovery of strength and mobility does occur, but is not the rule.* The patient, if a laborer, is apt not to be able to perform heavy lifting, and there is some lack of normal suppleness, f Some cases show considerable permanent weakness, and there are cases on record where considerable uncorrected displacement has resulted in a persistent mobility at the point of injury, such as to prevent the upright position save at the expense of great pain. This I have seen but twice, and one of these cases after a year this mobility was gone and the spine solid as ever (Fig. 100). Today such a case would be treated with a bone-graft on the basis of the Albee Technic. There is apt to be some deformity in the direction of a kyphosis, with or without some little lateral tilting. This interferes with flexi- bility and with the normal standing posture. At times the tendency of this deformity is toward increase. In how far this increase represents the "spondylitis traumatica" of Kiimmell J it would be hard to say. Undoubtedly, bone absorption under pressure does occur, with or without inflammatory process. In other cases yielding of weakened ligaments obviously plays some part. Some of these unfortunate results are dependent on inadequate support of the spine after injury. It is certainly a fact that even in our best hospitals some cases of fracture without cord damage are overlooked, and that few of them are given adequate support or properly followed up. * Since the foregoing was written I have had three cases-two reductions of marked deformity by the gravity method (reported in Surg., Gyn. and Obst., May, 1911) and one reduced by open operation with full return of stability and strength and in one case full flexibility of the spine. The compression fractures and the fractures of spinous processes give much better prognosis. f I have had opportunity, by courtesy of Dr. F. B. Lund, to examine one case of almost complete recovery after dorsal laminectomy. He had some weakness, pre- venting heavy labor, but not more than in many unoperated cases. t The condition known as "spondylitis traumatica," first described by Kiimmell in 1891, is rather ill defined. It was supposed by him to be a progressive osteoporo- sis following trauma. In fact, the cases I have observed that might fall in this class seem to me to be flexion fractures-unrecognized and not properly supported. There is no doubt that such cases do show protracted and considerable disability, sometimes progressive. Kbnig held this to be the condition in spondylitis traumat- ica, and Wagner and Stolper (Die Deutsche Chirurgie, Lief xl, p. 244) recognize the occurrence of such lesions. Henle (Mittheil. aus den Grenzgeb. der Medizin u. der Chirurgie, 1895-96, H. 3), Kocher (ibid., 1895-96, p. 448), Heidenhain (Monatsschr. f. Unfallheilkunde, iv, 3, S. 65), Vulpius (ibid., iv, 7, S. 201), Kirsch (ibid., iv, 5, S. 140), Schneller (Munch, med. Wochenschr.), Hettemer (Beitrage z. klin. Chir., xx, p. 103), and Bonsdorff (ref. Cbl. f. Chirurgie, 1900, No. 23, 1086) have all discussed this matter and reported cases. Grisel: Revue d'Orthopedie, 1907, p. 167, gives a more recent discussion. TREATMENT 131 Cases shown in Figs. 95 to 99 were all overlooked in the first instance by competent men; mainly in the services of the larger metropolitan hospitals. This series, so far as it goes, tends to explain and to discredit "spondylitis traumatica." Note that these x-rays do not show arthritic changes. There is no doubt, of course, of the occurrence of " osteoarthritic " spines after trauma, but most of these, as we see, follow strains, rather than severer traumata, and negative x-rays tend to relegate most of them to the class of muscle lesions. Prognosis in these cases, as in those with more obvious deformity is a matter not of the lesion but of the care given. Recognized in time, properly supported, these cases do remarkably well after six months or a year. Neglected, they become, and remain, cripples. TREATMENT We may treat by simple fixation or fixation in extension, or we may precede these measures by forcible correction or laminectomy. For purposes of treatment cases are divided into the paraplegic cases and the others. Cases without Paralysis.-If there is no paraplegia, then forcible correction or open operation are only to be thought of to correct severe obvious deformity or to relieve severe pain from nerve-root pressure. In either case correction to approximately normal contour, with a minimum of force, is enough, with later fixation carried out in the way presently to be described. If there is no tendency to kyphosis, in the simpler cases, simple fixation is enough; that is, fixation in bed with sand-bags, with a jacket to be applied later. As a rule, however, we have to deal with flexion lesions, and, there- fore, with a bony kyphosis. Consequently, if we do not wish or dare to reduce this kyphosis, we must prevent its increase. This must be done by fixation in the extended position. The patient lies on a Brad- ford frame, flat on his back, with hips and shoulders strapped to the frame. Opposite the kyphosis pads are placed (see Fig. 103) so as to support the spine, pressure being applied on either side of the spinous processes opposite the 'prominent vertebrae-usually the vertebrae below the break. Not rarely full correction of displacement as well as of general outline may be secured in this way. Day by day the padding can be raised without discomfort until the desired correction is reached. Felt makes the best pads, but folded pillow-slips do fairly well (Fig. 103). The patient can be raised, frame and all, so that he can be cared for without danger of disturbing the injured spine. According to the apparent severity of the lesion, this treatment is kept up from three to six weeks. Then the patient is put up in a plaster jacket. In occasional cases the predominant symptom is extreme abdominal pain. This is sometimes accompanied by anesthesia or paresthesia 132 DORSAL SPINE at the level of the lower ribs or abdomen, and by abdominal muscle spasm* It occurs in some cases even where there is no obvious dis- placement. It is a sign of nerve-root pressure. Occurrence of such pain is an indication for hyper extension, irrespec- tive of apparent deformity. This is because hyperextension relieves nerve-root pressure by opening up the foramina. Most, if not all, of these cases are flexion fractures. (See Fig. 101.) All convalescent cases are to be put up in a plaster jacket.f This is to be worn at least six months. Repair of the spine is slow, and the normal strain on the dorsal spine is very great. Failure to support such convalescent cases has, in a number of cases within my observa- tion, resulted in great pain and unnecessary prolongation of disability. E. G. Brackett has lately done the "Albee" bone-graft operation to relieve this sort of disability in such cases with good results, in a few cases. This is worth bearing in mind, but save for cases with extensive ligament tearing I hardly think it called for often, unless in late neglected cases, certainly not until all other treatment has failed. Paraplegic Cases.-If there is partial para- plegia, we must make up our minds in each case whether the displacement present at the time is probably causing pressure on the cord. If we be- lieve that it is, we are justified in operation, and all data tend to the conclusion that it is wise to operate in cases of reasonable doubt. The operation of choice is laminectomy. J Laminectomy in expert hands is not risky, but it is difficult and is distinctly a surgeon's operation, not to be undertaken by the inexperi- enced operator, especially if his assistance be not of the best. Fig. 101.-Action of hyperextension in opening up foramina in flexion fracture (dorsal). * Differentiation between such cases and those other cases of trauma received in falls in which there is actual peritoneal damage is very difficult. I have seen four cases in which belly pain and abdominal spasm were enough to have led to exploratory laparotomy had it not been for knowledge of the occurrence of such pains due to spine fractures. These did well. (Since this note was written for the first edition, I have verified this observation repeatedly. In the cases just cited the belly spasm was present. In these cases, and in several others, severe distension with obstinate temporary constipation for several days was encoun- tered, so severe as to threaten life by pressure on the diaphragm. Cf. also foot note to p. 139.) If a case were to turn up with spinal and visceral damage, it is hard to say on what our diagnosis would be based. f The plaster jacket is best put on with the patient prone on a hammock frame so adjusted as to give proper lordosis, with felt pads incorporated in the jacket alongside the point of deformity to keep up the needed pressure (Fig. 104). In case a hammock-frame is not at hand, a very good jacket may be applied by putting it on two sections, as shown in Fig. 105. Where expense is not a bar, a leather jacket (stiffened) is more comfortable and equally efficient. Of late years I have found the ordinary orthopedic "spring back-brace" perfectly efficient if properly fitted. It has the advantage that it can be worn at many sorts of even hard work till the patient is really well. t Laminectomy dates back to H. Cline (Tyrrell reported cases in 1822), and those inclined to look at this as a triumph of modern surgery will do well to read Cooper's Lectures (3d Am. ed., 1831, vol. ii, p. 15 ff.), in which he gives indications and contraindications that cover nearlv all we can say today. TREATMENT 133 The object of laminectomy is four-fold: (а) Loose fragments from the laminse and arches may be removed. (б) The laminse of the vertebrae next above the point of injury may be removed. (c) The dura may be opened, relieving tension from clot or from increased intrameningeal tension. (d) With the operator's finger defining the position of the cord, forcible correction (by any desired means) may be more efficiently and more safely carried out than without incision. Object (d) has been the con- trolling indication in several recent laminectomies of my own. Except for certain neck cases, I am inclined to consider laminectomy and forcible correction the desirable combination. Forcible correction alone applied to these cases is as old as surgery. Burrell and others have more re- cently advocated it. The only argu- ment against it or against laminectomy is the lack of results. Rightly considered, we must look at spine injuries with paraplegia as or- dinarily hopeless without interfer- ence. Any interference seems justifiable. Neither laminectomy nor forcible correction forms a cheerful field of surgery, but even the small minority of good results represent a gain over the hopeless- ness of cases let alone. Traumatic cord lesions are usu- ally total-that we cannot help;* what we can help is the abandon- ment of an occasional case of paraplegia from simple pressure to a certain death, and neither surgeon nor neurologist can differentiate between these conditions in most cases. This is the justification of operative procedures. Whether forcible correction is preceded and made simpler by lam- inectomy or not, the general inanceuvers of reduction are the same; Fig. 102.-Case of low dorsal fracture with a properly applied plaster jacket, high on the chest, low on the pelvis. * Most surgeons accept cord damage already done as irremediable. The cases of apparent repair of cord structures given by Harte and Stewart (Trans. Amer. Surg. Assoc., 1902) and Fowler (Annals of Surg., October, 1905) have not yet received sufficient confirmation. 134 DORSAL SPINE strong traction with direct pressure, aided somewhat in the open wound by direct traction on fragments with "lion" forceps or with retractors; direct pressure applied on the bone; and the occasional use of leverage with the "blunt dissector." Forcible Reduction.- -In forcible reduction only two manoeuvers seem to have been tried for luxations or supposed luxations without fracture: (а) Traction upward upon head and axillae, and downward on the legs, with direct pressure forward at the prominent portion of the spine. The patient, etherized, lies face down on a table. (б) Traction as above, but with the patient prone over a barrel or the like, so as to bring about flexion. Combined with this, direct pressure is exerted on the prominent point. (a) should be useful in anterior or posterior luxations of the usual types or in fracture luxations, (&) is devised for anterior dislocations. The flexion manoeuvers should disengage the articular processes. Such luxations are rare. Reduction in fracture cases has been, probably wisely, confined to manoeuvers approximating those of (a). One of the earliest modern papers advocating forcible rectification is that of Burrell.* He has since in a measure receded from the posi- tion then taken, but in a recent paper has reviewed 24 cases of spine fractures at the City Hospital mainly treated by this method.f Laminectomy should be superior to forcible correction in case of fracture of the laminae or arches; unfortunately, this class of cases can not always be diagnosed with certainty. As stated above, forcible correction after opening the canal seems, on the whole, the wisest of the operative procedures. "Gravity Reduction."-Since the above statement was written, I have become somewhat more ardently an advocate of "gravity reduction," as I have called it (cf. note to p. 130). In all dorsal and lumbar fractures, at least, we have a very impor- tant factor in the reflex spasm of muscles that prevents reduction of displacement. This "lets-up" under ether, but it gives way equally well under the steady pull of gravity. If we place our pads (thick pads) in the proper place (see Fig. 103), and if we then watch the patient's back, we find that within 48 hours at the most, the deformity is gone! In a series of cases in the last few years I have done this (Cotton: Surg., Gyn. and Obs., May, 1911) and the result seems reasonably constant. In the very few dorsal laminectomies I have done in this period, the same placing of pads, and the same gradual "gravity reduction" has seemed to me of much greater utility than any direct manual reduction possible at the time of operation. * Med. Communications of Massachusetts Med. Society, 1887, xiv, p. 151. f Burrell and Crandon: Trans. Amer. Surg. Assoc., 1905, xxiii, p. 66. TREATMENT 135 For example, in a recent case of laminectomy (done for Dr. Ruppel in Lynn, Mass.) the operation relieved the obvious cord pressure from pinching by the arch of the upper vertebra; reduction of the real dis- placement was accomplished by pads (as described above) and a considerable return of function of sphincters and leg muscles resulted. r Fig. 103.-Diagram to show proper position of pads at either side of the spine, for dorsal or lumbar fractures. Fig. 104.-The Bradford frame for applying jackets in the prone position. The canvas sling is pulled taut, slits are cut along either side of the patient's body, the cloth tied back, and the apparatus is ready for use. In one lumbar fracture I did succeed in doing a perfect reduction in the open wound with a wonderfully, good result. After-treatment.-In paraplegic cases apparently hopeless the treatment is purely symptomatic, except for precautions to limit the almost inevitable bed-sores and bladder infection. Accurate fixa- tion is difficult and not of first importance. The Bradford frame is used, ordinarily, to facilitate handling in treatment, but the patient is not strapped down, and is rolled over as is needful to care for cleansing, for alcohol baths, and for any neces- sary dressings.* Such attempts as are made in such cases to prevent kyphosis are carried out with soft pillows or with shaped pads. Passive motion of the limbs to minimize the formation of joint contractures is worth while in the event of possible recovery, and should always be carried out. Fig. 105.--Hyperextension jacket applied in two sections. After the first section has set a pad is put behind it (a rolled sheet or the like) and the patient's trunk thrown back while the jacket is completed. This is a fair emer- gency method for dorsal injuries. * Dressings of a laminectomy wound are not very bothersome. The wound should not be drained. There is, for a day or two, a good deal of leakage of blood, serum, and some cerebrospinal fluid, but this soon ceases, and we get practically first-intention healing. The wound does not share with the parts further below the fracture the trophic effect that tends toward infection and sloughing. 136 DORSAL SPINE Cases without Paralysis.-In all other cases than paraplegics our care is directed to fixation in as nearly as may be the normal position and curve; at first, by pads; later, with the jacket. As noted above, support is to be long continued, for fear of late absorptive changes. The problem is one of fixation and support. At first we secure rest in bed with support by folded sheets placed on either side of the spine opposite the injury. After three or four weeks a plaster jacket may be applied. The best method is by use of the Bradford frame (Fig. 104), but Fig. 106.-Sling device for putting on jackets with the patient supine. Readily arranged and efficient. * the schemes shown in Figs. 105 and 106 are simpler and may be made equally efficient. Plaster jackets for dorsal cases should fit well into the axilla, should come up nearly to the clavicle in front, and should come well down on the pelvis. (See Fig. 102.) They should be carefully padded, not only as shown in Fig. 103, but also over the sacrum and in front over the anterior superior spines. Some cases require not only some months of jacket support, but also a steel back-brace (a spring-brace, as for round shoulders) to be worn during the latter part of convalescence. * Drawn by the writer for the second edition of Bradford and Lovett, "Ortho- pedic Surgery," and used through the courtesy of the authors. CHAPTER VI THE LUMBAR VERTEBRAE LUXATIONS AND FRACTURE LUXATIONS Pure luxation at this level is extremely rare: there is, in fact, some question about its occurrence. A glance at the almost interlocking- articular processes in this region shows how unlikely it is that any pure luxation, even the theoretically possible backward luxation, should ever occur. (See Fig. 107.) Cases are recorded, but even the much- quoted case of Cloquet was, in fact, complicated with fracture.* In one case of my own, operated on, there was obvious luxation, but there was enough deformity to make me sure there was also fracture,! though no fracture was visible in the wound. In practice it is even more true here than in the dorsal region that we should consider all cases clinically as fracture luxations. Fractures in the lumbar region differ from those in the dorsal mechanically, in that the lumbar spine lacks any lateral support from the ribs, hence displacement may be in any direc- tion, laterally as well as forward or back. In fact, however, the greater strength of ligaments pretty nearly counterbalances this lack of rib support. So far as etiology goes, we have a somewhat larger proportion of fractures from direct blows, or from twisting or crushing, simply because extreme flexion breaks the weakest point in the lower dorsal rather than the lumbar spine. Fig. 107.-Lumbar ver- tebra from above, showing the direction of the articu- lating facets, also the rela- tively small spinal canal. * This was the case of a roofer who fell off a house and was immediately para- plegic. Two years later, when examined, he had return of sensation and some motion. Postmortem examination, after death from unrelated causes, showed a backward displacement of the second lumbar vertebra on the right. There was flexion of the spine, as a whole, forward and to the left, and the right side of the second lumbar was, therefore, lifted as well as moved back. The total separation of the articular surfaces was inch. There was also a fracture of the arch and a little breaking of the left side of the body of the vertebra. t In this case laminectomy showed a clean forward luxation of the first on the second lumbar, with about % inch separation on the right, and a little more on the left. There was partial crushing of the cauda. Forcible reduction was carried out by traction, backward pull, and rocking lateral movement ; there was no crepitus. This patient is still improving, having recovered sphincter control in part, and is gradually regaining motion and sensation in the legs. The point is that, so far as I could demonstrate, this was a case of pure lumbar luxation. In my belief, however, there was in all probability an associated fracture. 137 138 THE LUMBAR VERTEBRAE The bone lesions differ only in that the simpler flexion fractures are less common, while irregular displacements are more usual. Frac- tures of spines and laminae alone are even rarer than in the dorsal region.* So far as the clinical picture and the prognosis are concerned, we must take into account the relation to the spinal cord. The cord proper ends at the first lumbar vertebra; below this the canal contains not cord, but nerves-the cauda equina. Central lesions here are, Fig. 108.-Normal lumbar spine in adult. therefore, nerve lesions, not cord lesions. In theory such lesions should be capable of repair, as cord lesions are not. In practice there is evidence of such readier repair in partial lesions, but not in complete crushing lesions. Whether laminectomy with nerve suture will give better repair has not been tried out. * A rare source of deformity in this region, sometimes apparently due to trauma, is the condition known as spondylolisthesis, a defective ossification of the laminae of the lumbar spine, allowing a slipping forward of the column, with signs of nerve pressure. A good consideration of this, with bibliography, is to be found in Ortho- pedic Surgery, Bradford and Lovett, second edition, pp. 156-160. DIAGNOSIS 139 Injuries in this region, if complete, give sensory and nervous dis- turbances, as shown in Fig. 76. DIAGNOSIS Diagnosis in only too many cases is indicated by the paraplegia, and made more precise by determining the level to which motor and sensory disturbance extends. Direct physical signs of displacement are: Deformity in the line of the spine, usually a kyphosis. Asymmetry of the spinous processes, Fig. 109.-Fracture of lumbar vertebra (Warren Museum). Fig. 110.-Crushing fracture of the twelfth dorsal and first lumbar bodies Paraplegia. Lived nine months (Warren Mus., Spec., 941). which are fairly regular in the normal spine in this region. Crepitus or mobile fragments (rare). Displacement palpable through the abdomen (alleged in one reported case). Indirect Signs.-Nerve-root symptoms, radiating pain, dependent on pressure not in the canal, but at the foramina.* Local tenderness or signs of direct trauma. * Here, as also in low dorsal lesions, the "girdle-pains" from root pressure, with the reflex spasm of abdominal muscles resulting, may give a picture curiously re- sembling that of rupture of a vise us or other belly damage, as in the following case: A. B., aged thirty-seven. August 8, 1907, fell two stories. No cord symptoms. Main complaint was of abdominal pain. The abdomen showed marked general rigidity and spasm. Considering the presence of an obvious though slight deform- ity at the first lumbar spine, the apparent abdominal symptoms were disregarded. The girdle-pains (for that is what they were) were relieved by a hyperextension jacket. He was discharged September 17, and reported a couple of months later without symptoms. 140 In total lesions reflexes as well as voluntary motion are lost, but this does not help us in localization, as they are lost in all total lesions. THE LUMBAR VERTEBRAS Fig. 112.-Case II, fracture L 2, transverse process. Fig. 111.-Case I, fracture L 1, 2, 3, 4, transverse processes. Fig. 113.-Case III, fracture L 1, transverse process. Fig. 114.-Case IV, probably fracture- probably old. Fig. 115.-Case V, no symptoms, probably old fracture from unnoticed in- jury in a pronounced alcoholic. Fig. 116.-Case VI, old fracture. Differential.-In the differential diagnosis we must consider, if paraplegia is present, only the question of cord damage by hyperfiexion DIAGNOSIS 141 with intraspinal hemorrhage, with or without bone damage. Lesions of this type are rarely complete. Local tenderness or other signs of trauma at the level of damage speak strongly in favor of bone damage. In the doubtful cases the far greater frequency of fracture luxation will Fig. 117.-Case VII, no trauma-proba- bly developmental not traumatic. Fig. 120.-Case X, no trauma at all Fig. 121.-Case XI, had a severe accident but this finding is accidental, not due to recent accident. Fig. 118.-Case VIII, strained back in lifting: certainly not a fresh fracture. Fig. 119.-Case IX, no symptoms: not traumatic. Fig. 122.-Case XII, separate lumbar rib. In this figure as well as in the pre- ceding all the plates were listed at the Boston City Hospital as fractures in the g-ray records. For interesting details of cases and plates see Cotton, Interstate Medical Journal, 1916, xxxiii, No. 10. determine the provisional diagnosis, even if we can not make out any displacement. If there is no paraplegia, we must reckon with the fractures of spines, arches, and laminae, with "distraction" injury, with the very common "sprains" and "contusions" met at this level, and with compression fractures like those found in the dorsal spine. Isolated fracture of spine or lamina is even rarer here than higher up. In fracture of the spinous process we have soreness, mobility, crepitus, 142 THE LUMBAR VERTEBRAS perhaps a little displacement, but no signs of damage to the column as a whole or to the cord. Fracture of the lamina rarely occurs alone. It is diagnosed by the x-ray, only. Fractures of the transverse processes have been much heard of in the last few years, particularly in the law courts in tort actions. They deserve a word and a plate or two. I have seen fifteen alleged cases of which I have notes-and some others-within a few years past. Not all of these were genuine. In this series (reported in the Interstate Medical Journal, vol. xxiii, No. 10, 1916) there were lumbar ribs (unrecognized), developmental peculiarities of the process-well-rounded off fragments of what prob- ably were old fractures without history, as well as actual fresh breaks. The injury seems to result from falls on the back or from muscle strain of extreme sorts. Oddly enough save for temporary local soreness the cases run just like muscle injuries of the back and in several cases I have seen absolutely perfect recovery. In one such case the man is back at heavy lifting. In other cases there is for some time, some persistent soreness. The process heals, usually at least, by fibrous union, so far as we have data. (See Figs. 115, 116.) "Distraction" injuries are pure ligamentous injuries, to be diag- nosed when there is localized abnormal mobility in flexion, as when the patient sits up. We may safely say that in such a case there is a torn ligament. It is, however, often impossible to exclude associated fracture. "Sprains" and "contusions" of the spine are very common from lifting, from falls, from blows. The signs are lameness and stiffness, with soreness to touch, usually over the erector spinse muscle, at the sides of the spinous processes, most commonly close to the lower origins of the muscle. Even in genuinely severe cases there are no strictly objective signs, simply tenderness and "voluntary" spasm on attempted flexion. The pain and protective spasm are often extreme for a time. These cases must represent some stretching or tearing of muscle-fibers. Even in cases where there is no suspicion of malingering, there is apt to be a rather slow subsidence of lameness, lasting several months at times, especially in elderly or rheumatic patients. In cases of tort, these injuries seem far commoner and worse than in hospital or private practice. I have never seen or known of permanent injury from such lesions in a case without a suit on hand, but there is no doubt that lameness may persist a long time. Tenderness along the line of spinous processes may mean ligamen- tous strain or may mean nothing. If it is as great at as between the spines, or greater over the spines themselves, it does not mean such strain, in my opinion, but belongs to the curious "stigmata" of hysteric psychoses, as a rule. 143 PROGNOSIS PROGNOSIS The prognosis of life in cases of lumbar injury with crushing of part of the cauda is good, on the whole. If there be a high injury involv- ing paraplegia, we may have all the sequelse of a cord injury except ascending myelitis. The lower the lesion, the less the damage, of course. Lesions of the "conus," the sacral portion of the cord, involve anesthesia of perineum and genitals, and some disturbance of urination and of sexual power, sometimes with a persistent toe-drop. It seems that the central part of the cauda and the conus are either more subject to trauma, or less able to repair damage, for persistence of the disturbance just described is not uncommon in cases damaged well above the conus, in which paralyses, extensive at first, have retrograded to this point. The general prognosis of repair in the cord and nerves in this lumbar region may fairly be called hopeful, if the cord is not actually crushed; but it is not reliable, not better than hopeful. So far as the repair of the supporting function of the spine goes, the results are fair in lumbar injury. There is, as a rule, some stiffness of the segment involved in the injury, and some weakness at least for a long time after. In some cases there may be kyphosis enough, due to actual bone displacement, to interfere with standing readily or continuously, and consequent inability to do various sorts of work. Disability is, however, rarely due to bony displacement as such. If there is even a question of relievable pressure, laminectomy is the procedure of choice-safer in this region, probably, than forcible correction and far better surgery. One of the chapters in surgery yet to be written is as to the results of nerve suture in the cauda. Theoretically, at least, it should be of value, and certainly it should be tried. Ordinarily relief of pressure is all that is attempted. As to treatment: beyond open incision, we can only fix the spine in approximately normal profile, exactly as we do in other segments. In the after-treatment we must bear in mind that this segment of spine has no support of ribs, etc.,-no support, in short, except such as we give it,-and that its normal position is in lordosis. It is, therefore, wise to give pretty definite support-that is, to place on either side of the spinous processes, opposite the more prominent segment (f. e., usually the part below the fracture), fairly heavy pads (folded sheets or felt pads) to maintain the proper position.* Symptoms showing pressure on nerve-roots in the foramina call for exaggerated lordosis, which gives marked relief by easing this pressure. Support is perhaps TREATMENT * Particularly in the lumbar region, slow reduction by gravity succeeds very well. At times counter-pressure by sand-bags or pads alongside the projecting spines gives astonishing results. 144 THE LUMBAR VERTEBRAE even more important in cases without than in those with paraplegia, and must be continued in the plaster jacket appropriate to convales- cence, which must be applied in lordosis and must be so padded as to maintain this lordosis without pressure on the spinous processes, and without pressure anywhere on that part of the spine which has been displaced forward. In the cases of distraction, etc., all we need concern ourselves with is the matter of position (z. e., lordosis), maintained until the ligaments have had full time to heal. In the lumbar region, perhaps even more than higher up in the spine, support should be continued for a long period-several months at least. Muscle Strain.-A word as to treatment of the simple muscle Fig. 123.-Plaster shell by Dr. Fleury, City Hospital. This patient with a high lumbar fracture and broken transverse processes on three vertebrse lay six weeks without bedsores, with- out serious discomfort, and is now up in a back-brace rapidly returning to near normal. strains in this region may be worth while. Firm strapping with adhesive plaster gives astonishingly efficient relief in the early stages. Later, massage, heat, and the treatment by electric high-frequency currents are most helpful. Fixation by strapping or otherwise should not be long continued. Bed-rest is rarely called for after a few days. Despite the best treatment a little lameness is apt to persist for a good while. At times the spring back-brace is worth while for a time. Muscle strains in the back, with or without bone or ligament lesions may give curious reflex spasms. Of late I have seen two cases one a fracture of the dorsal lamina with an astonishing flattening of the dorsal curve and lumbar lordosis that disappeared with rest in the supine position, another without bone lesion, a simple lumbar sprain that showed an elaborate lateral lumbar curve-rigid-that subsided promptly under brace treatment, recurred on removal of the brace for a time, then disappeared, leaving only slight weakness. Such spasm, following no rule, may be very confusing. CHAPTER VII THE SACRUM AND THE COCCYX SACRUM There are no luxations of the sacrum.* As a result of direct vio- lence there occurs, though very rarely, an approximately transverse fracture of the sacrum. The displacement is of the lower fragment forward. Other fractures are complications of damage to the pelvis, treated under the caption of Pelvic Fractures. Diagnosis is by mobility and crepitus elicited on bimanual examina- tion with a finger in the rectum. Pain on cough or on other muscle action is suggestive. There may be, of course, damage to sacral nerves emerging at the level of fracture, or crushing in the canal of those emerging lower down. There may be damage to the bladder or rectum. There seem to be no data that give any accurate idea of prognosis. Cases of lesion of the sacral cord, untreated, give a tolerable result, with some loss of urinary control and sexual power, with some anes- thesia, and sometimes with a paresis of the lowest segment group of the leg (i. e., with a toe-drop). The bony lesion as such appears to be of no importance. Treatment.-As to treatment, obviously reduction by the finger in the rectum is desirable and indicated. For prevention of redisplace- ment we have no facts bearing on the problem. Paulf has made the interesting suggestion that Malgaigne's hooks or a modification of them might be used. Packing of the rectum has been suggested and tried. In this region laminectomy, with relief of pressure or with perform- ance of nerve suture within the canal, seems to be proper surgery. I have had no chance to try suture of nerve-trunks, and do not know of its being done, but it is obviously justified where there is damage to the nerve-trunks of the conus. There is no possible reason why the sacrum should not be cut open to clear away pressure in its canal. COCCYX Lesions of the coccyx arc rather common. In part they represent actual fractures or luxations. In still larger part, unfortunately, they * Unless we count those occurring as part of general pelvic damage-with other fracture or luxation of the pelvic ring-or the "sacro-iliac " strain and subluxation cases + T. W. Paul: Ann. Surg., loc. cit. 145 146 THE SACRUM AND THE COCCYX represent hysteric disturbances not necessarily connected with even slight trauma in this region. The coccyx may be broken between joints, or one or another joint may be luxated. Such actual injuries result from direct violence only.* The case illustrated in Fig. 126 may be taken as illustrative of the genuine class. This was the case of a healthy woman of twenty-six, who fell from a step-ladder so as to strike her coccyx fairly on the back of a chair. She was laid up for a time, and never fully recovered during the two years before she was operated on. Excision of part of the coccyx (Fig. 126) entirely cured her. The importance of operation on such cases is twofold: first, the relief of pain; second, avoidance of the interfer- ence with the obstetric difficulties of a fixed coccyx in later child- births of the patient. Fig. 124.-Diagram of forward and backward displacement of the coccyx. The dotted line shows the normal position. Fig. 125.-Method of palpating for deformity or tenderness of the coccyx. Diagrammatic sagittal section. The patients seem to be, in the rule, young women. The case above quoted is the only case of the sort I have operated on for years, out of a considerable number seen. The coccygeal region is the center of a curiously sensitive nerve plexus. Most of the cases seen, even when there is a history of some injury, are essentially localized symptoms of a psychosis, "hysteric," as we name these localized psychoses. In such cases operation will not help the patient and will only discredit the operator. * Trauma to the coccyx does not necessarily involve a blow from a pointed object; a fall on stairs when the patient slides down in a half-reclining, half-sitting position may give direct trauma of the coccyx, and often does, though until one examines the skeleton it seems impossible. COCCYX 147 In the absence of definite physical signs it is well to be skeptical as to operative prospects, even in cases where the rectal, as well as the external, surface of the coccyx is tender to the touch. Diagnosis is made by physical examination, with but little regard to the given history. Physical examination is best made with the forefinger in the rectum, the thumb on the external surface. (See Fig. 125.) In this way the whole coccyx can be palpated, and any irregularity, any preternatural mo- bility or loss of mobility, may be appreciated. Some loss of mobility in the various joints in the adult, and some irregularity, are within nor- mal limits. Any possibly reducible displace- ment in a fresh case would, of course, be corrected immediately. These cases are apt to come to the physician for help long after the in- jury. Such injuries give little ecchy- mosis and little crepitus even when fresh, but if fresh, the tenderness is so much more extreme on motion involving one or another point, and deformity or increased mobility is so obvious, that diagnosis is pretty definite. In these fresh cases walk- ing or any motion that brings strain on the pelvic muscles* is very painful. Treatment.-Given a definite fresh case of injury, we should en- join absolute rest for a week or two and protection from pressure until the tenderness is all gone. Such protection is well cared for by one of the large inflated rubber-ring cushions to be used while the patient lies or sits down. Such rings are a very useful palliative in the chronic non-operable cases, including those in which old trauma probably plays no part at all, or at least a very subordinate part. Fig. 126.-Specimen of coccyx removed by the writer. Dotted lines show the normal out- line and relations. * It must be borne in mind that the coccyx is one of the attachments of the levator ani, a muscle that is constantly pulling and being pulled on. CHAPTER VIII THE STERNUM I his injury is not extremely rare. It occurs from direct violence to the front of the chest, from forced flexion of the trunk, from forced extension under muscular pull (hence occasionally from simple muscle strain, as in lifting, or in rare cases in childbirth). The manner of its causation usually explains the displacement in the given case. * As a rule, it is the upper portion that is more likely to be struck and driven in. (See Figs. 127 and 128.) The overlapping is necessarily slight, owing to the resistance of the attachment of the ribs. Pathology.-The anterior liga- ment is usually torn clean across. According to evidence from speci- mens, and according to the infer- ence from clinical data, the peri- osteum at the back seems to strip up rather than tear. Obviously, there may be greater displace- ment, with mediastinal damage, f but in the usual cases where the chest is not actually smashed in, this periosteal flap is seemingly an adequate protection for the structures behind it. (See Fig. 127.) The luxation may be a clean dislocation, or the separation may run in part through the joint, in part as a fracture. Diagnosis.-The diagnosis is ordinarily obvious, and to be made by direct palpation of the projecting bone. The joint is, of course, exactly opposite the second rib. There is ordinarily little hemorrhage or swelling within twenty-four hours. LUXATION OF GLADIOLUS ON MANUBRIUM Fig. 127.-Separa- tion of gladiolus for- ward from manu- brium. (Warren Mus.) Note intact perios- teum. Fig. 128.-Median section, specimen of sternal luxation. This is the usual direction of displacement (after Gurlt's plate). * In a case reported by me in conjunction with Dr. J. S. Stone (Boston Med. and Surg. Jour., 1897) there was a driving in of the gladiolus. The patient, a tall, long-necked, long-chinned gymnast, had slipped in doing the "giant swing" and had fallen on his head, with his neck extremely flexed, so that his long jaw struck the gladiolus and drove it in behind the manubrium. f Gurlt quotes two cases where mediastinal bleeding was perhaps the cause of death, and says that the pleura may be torn open. 148 LUXATION OF GLADIOLUS ON MANUBRIUM 149 The only chance of error is that we find in some individuals a con- siderable projection at this point, an exaggeration of the usual "angle of Louis," which might impress the unwary as abnormal. Prognosis.- The injury does little damage-even the soreness is not great. There is a perfectly definite tendency for the displacement to be reduced spontaneously by any sudden muscle action, as in coughing. Even if reduction does not occur, the resulting disability is slight.* Treatment.-Reduction depends mainly on favoring muscle action -therefore general anesthesia is not desirable for the ordeal. Fig. 129.-Reduction of sternal fracture or dislocation. Author's method. The ordinary method is to place the trunk in hyperextension, and then to let the patient cough repeatedly. The operator helps by pushing on the projecting fragment. My modification of this methodf depends on the fact that the origin of the pectoralis major is largely from the manubrium. If, therefore, the patient is hung over the end of a table with hips and loins supported, with the trunk sharply hyperextended; if, then, the arms be held raised * Since this paragraph was written I have had opportunity to examine such a case of typical unreduced luxation of the gladiolus forward, about a year after the accident. There was no disability at all referable to this injury. t First employed in 1895; published in the Boston Med. and Surg. Jour, in 1897, loc. cit. 150 THE STERNUM and abducted and the patient required to contract the pectorals strongly (Fig. 129), he is in better position to profit by his own efforts in coughing and by what the surgeon may effect through counterpressure. After-care need consist only of cross-strapping of the front of the chest with adhesive plaster. The tendency to recurrence is practically negligible. To guard against irritation and possible prolonged soreness, any heavy work should be avoided until the lameness has gone. FRACTURE OF THE STERNUM Fracture may occur, as has been said, close to or into the joint; fracture in various lines through the gladiolus at any level is not rare; the accompanying plate shows the lines of fractures illustrated in the collections of the Warren Museum. These fractures are rather rare, except as a part of a general and fatal crushing of the chest. They may occur, however, as a "contrecoup" in falls on the back or side. Their recognition depends on the presence of loca- lized tenderness and possible slight deformity from displacement. Later, ecchymosis is evident. Curi- ously enough, this fracture is practically never compound. The treatment is usually by fixation only. Displacement, if present, may call for reduction, as in true luxation. DISLOCATION OF THE ENSIFORM CARTILAGE This is a rare and curious accident. The disloca- tion seems always to have resulted from a direct blow. The displacement is of the ensiform-back- ward; the line of separation may be through the joint between the gladiolus and ensiform, or there may be fracture of the ensiform cartilage itself. All real knowledge in regard to these injuries dates back a generation to the German surgeon Gurlt. He described certain cases in which persistent, continuous, or recur- rent vomiting resulted from the backward displacement of the process. One of these cases was relieved by digital correction of the displacement, another by lifting the process forward with an inserted hook. Apparently there is no question that the vomiting in these cases was due to the displacement; it ceased with the correction of the dis- placement.* Probably not all such cases give these symptoms. Fig. 130.-Sternum fracture from speci- mens in the Warren Museum: a = Spec. 5149:6 =978 and 5151; c = 5150;d = 976; e = 977. * It is rather curious that the occurrence of such symptoms has not been repeat- edly and recently confirmed, but there seems no question of the fact. Gurlt's data were usually reliable and well sifted. There is a case recorded by F. H. Hamilton, Buffalo Medical Journal, Vol. XI, 282, and in his book on fractures and disloca- tions, in which vomiting persisted at five to six day intervals for two years. Twelve years later, the deformity persisted, but there were no symptoms. DISLOCATION OF THE ENSIFORM CARTILAGE 151 There seems to be no inconvenience from either fracture or disloca- tion, reduced or not, except when the vomiting above mentioned occurs.* It is said that fractures of the ensiform give fibrous, not bony, union. Diagnosis.-The recognition of this lesion should not be difficult, inasmuch as the process is almost subcutaneous, and any displacement should be easily palpable. Treatment.-Obviously, replacement of the fragment driven backward should be the ob- ject of treatment. If this can be done by manipulation,-and ordinarily the finger may readily be hooked under the end of the proc- ess,-this is enough. If this method does not work, and if the symptoms warrant it, open operation would be called for. It should be possible to get a grip on the process without enter- ing the peritoneal cavity, though in Guilt's case the peritoneum was opened. After-care.-Save for immobilization of the lower chest as a whole and for rest, it is hard to see how any treatment would help. Prognosis.-Save for the (reflex?) vomiting there seem to be no sequelae. Ordinarily, not even weakness is left behind after either fracture or luxation. I have lately seen a case with long persistent sensitiveness and sore- ness of the ensiform, following trauma (not direct, but by way of muscle violence in a heavy fall) though there was no luxation or frac- ture shown. In this and in one other similar case I removed the ensiform entire -a very simple procedure. The cartilage is not missed at all. Fig. 131.-Sternum dislo- cation and fracture (after Gurlt's plates). * Since this was written I have seen two cases with backward displacement of the ensiform and the type pressure of persistent vomiting. In one I operated, re- moving the ensiform, with entire relief. The other a recent case has so far refused operation, and, after a year, is still disabled with sharply localized pain on almost any body motion, and still has the vomiting, though this is less severe than at first. CHAPTER IX THE RIBS DISLOCATION OF THE RIBS ON THE VERTEBRAE This is a very rare accident, hardly occurring except in the case of the lowest ribs-the floating ribs; if it occurs higher up, it is in associa- tion with damage of the transverse processes of the vertebra. It seems to occur only as the result of direct violence. To produce this sort of dislocation there must be a tearing not only of the ligaments between the articular end of the rib and the vertebral body, but also a tearing of the strong ligaments that unite the rib to the transverse process. Cases are described presenting various dis- placements-there seems to be no definite rule. Diagnosis.-The diagnosis rests on a dis- appearance of the normal prominence of one of the series of ribs close to the vertebra. Just what has happened in the individual case is a matter of inference. There are no special symptoms, save the lack of crepitus, to help us make the diagnosis of dislocation as against fracture near the back end of the rib. In the one case of this sort of in- jury in my experience it proved that we were con- cerned with a fracture, and not a dislocation, but previous to the taking of the x-ray all that we knew of the matter was that there was a forward dis- placement of the rib on the vertebra, shown by the absence of the normal resistance at this point in the back. There are no pathognomonic or trustworthy symptoms. Complications.-Curiously enough, considering the proximity of the kidney, there seems to be no tendency to any associated injuries of the soft parts. This is probably because the vio- lence acting on the one rib is checked by the resistance of the other ribs. Treatment.-No treatment seems to have been carried out in any of these cases. From the very nature of things only two forms of treatment would be worth considering-operative interference, which is rarely called for, and attempts to reduce the dislocation by having the patient strain or cough. Direct manipulation is obviously impractica- ble, at least in case of forward displacement, unless through an incision. Fig 132.' Fig. 133. Fig. 132.-Luxation of rib from vertebra (schematic). Fig. 133.-Fracture of rib close to the ver- tebra (schematic). 152 CARTILAGE SEPARATION 153 I have lately seen one case operated on-a downward luxation of the tenth-reduced and held with wire to the next rib above. In this case there was severe and persistent pain before operation. In a second case there was a curious sort of rotary luxation. Results.-Apart from such natural lameness as would be associated with the violence, the injury seems to give no trouble. From a practi- cal point of view it may be called hardly more than diagnostic curiosity, whether the lesion be a luxation of the rib or a fracture near this point. The unreduced rib seems to give no permanent trouble. DISLOCATION AND FRACTURES OF THE FRONT END OF THE RIB Dislocation here may occur as a separation of the cartilage from the sternum, as a separation of one cartilage from another at a level below the sternum, or as a separation of the rib from its own cartilage at the cos- tochondral joint. Fractures may also occur across any of the cartilages themselves. The differential diagnosis as to the form of injury-whether separation of rib from cartilage, fracture of cartil- age, separation of cartilage from ster- num or of cartilage from cartilage-is purely one of anatomy. There is no fixed relation between the length of cartilage in front and the length of the rib. In general, we may say that the cartilage length increases from a mean of about 1J4 inches at the first rib to about inches at the level of the sixth, with a maximum of inches of cartilage at the level of the eighth. Below the sixth rib the cartilages are attached, not to the sternum directly, but to the cartilages of the ribs above. Ribs eleven and twelve have no such attachment, and are called, for this reason, "floating" ribs. (See Fig. 134.) Any lesion in this anterior region is localized by deformity, or in default of deformity, by local tenderness. The diagnosis in detail is then made purely on the exact position of our findings. Fig. 134.-Anatomy of ribs and cartilages; the cartilages are shown in white. The commonest of these injuries is a partial or complete separation of some cartilage between the sixth and the tenth from the one next above it of the cartilages which form the arch of the epigastrium. These injuries may result from direct violence, from crushing in of the chest, or from a simple blow or fall so received elsewhere on the rib as to be transmitted to this point. Cartilage Separation 154 THE RIBS Diagnosis depends on localized tenderness with considerable sore- ness on movement and with some pain on breathing. We may have some local deformity, and sometimes there are cases in which breathing or coughing or manipulation gives a soft click distinctly to be felt by the hand. Later there is thickening, irrespective of original displacement. Treatment.-Any displacement present should, of course, be cor- rected, and in this region it is ordinarily possible to get hold of the rib cartilage at the epigastric end. Further treatment consists of simple immobilization of the lower part of the chest. The lower ribs may be immobilized by a broad band of adhesive plaster encircling the chest below the nipples. A half swathe applied to the injured side and running across the whole front of the chest may be sufficient. The purpose to be followed is such immobilization as will render the injury practically painless on breath- ing, and limit any motion of the separated surfaces. Results, so far as deformity is concerned, are good. In some cases there is a little thickening persisting for a while, more rarely for a long time. In others the callus formation is almost nothing. Owing to the slow repair, the spot often remains sore on physical exertion for a good many weeks. There is no permanent damage, but the accident entails a period of partial disability apparently disproportionate to the original damage. Separation of the Ribs from the Sternum This is a relatively rare accident, usually the result of direct violence or of crushing of the chest. The displacement of the cartilage may be either forward or backward. The displacement may be considerable, but is seldom more than enough to allow simply a slight overlap one way or the other. Except for the local tenderness, the slight deformity, and the occasional soft crepitus on respiration or cough, there are no special symptoms. Practically, diagnosis rests on palpation; in the absence of displacement, on tenderness. Treatment consists of attempts, by way of forced respiration or cough, combined with direct pressure, to reduce the displacement. If this is successful, immobilization of the chest by cross strapping is all that is required. If replacement is not practicable, the displacement may persist with slight local deformity, but without permanent damage, at least in cases where the injury is of one rib-joint alone. Fracture of the Rib Cartilage Fracture of the rib cartilage itself is not very rare, and may occur with any rib, most often, of course, with one of the lower "true" ribs. The cartilage fracture is usually transverse or nearly so. There may be no displacement or displacement of either fragment in front of the other, sometimes with overlapping. Diagnosis rests on the site (anatomically), and not on the character of the signs. 155 FRACTURE OF THE RIB CARTILAGE Fig. 135.-Shows the bony collar surrounding the fractured rib-cartilage (R. 6, sixth rib; C. 6, C. 7, sixth and seventh cartilages). Wilm's specimen (from Gurlt's Fig. 20). Fig. 136.-Horizontal section of united frac- ture of rib-cartilage. X and Y show the masses of new bone (sketched after Gurlt's Fig. 24. Specimen in the Mus. Path, in Giessen). Fig. 137.--Union in fracture of rib-car- tilage. Horizontal section, drawn from Gurlt's Fig. 22. (Specimen in the Path. Mus. at Giessen-No. 35-114a.) Replacement is by manipulation, aided by sudden muscular movement (e. g., cough- ing) on the part of the patient. After-treatment differs in no way from that of the other injuries treated in this chapter, nor is there any essential difference in prognosis. Of some interest is the fact- admirably expounded with illustrations from museum specimens by Gurlt*-that the car- tilage ends unite, not by fibrous tissue or cartilage, but by a rather spongy bone which usually forms a bony collar about the ends of the broken cartilage, which are almost unchanged, even under the micro- scope. He lists 15 cases and specimens, and gives five very satisfactory plates to prove his point (Figs. 135-137). Fig. 138.-With a fracture or displacement at a, there will not only be pain on pressure at a, but pressure at one side or the other- at points noted by the arrows- will give pain at a. So, too, will compression exerted in the line b c. If there be only contusion or peri- ostitis, pain is excited only by di- rect pressure at a or by muscle action. * E. Gurlt: Handbuch der Lehre von den Knochenbruchen, 1865, Bd. ii, 1 Th., pp. 244 ff. 156 THE RIBS Dislocation of the Rib from the Cartilage Costochondral Dislocation. -This is a more common accident than either of the last two. Between rib and cartilage, up to middle life or later, there is a distinct joint possessing only a little play, but possess- ing also little strength of ligaments. Under the influence of direct or indirect violence these ligaments are torn, and according to the direction of the force the rib overlaps the cartilage, or the cartilage the rib, producing a distinct displacement. Not uncommonly several of these Fig. 139.-Separation of ribs 2, 3, and 4 from their cartilages with luxation backward. Injury received by being rolled between two cars. Operation: pinning; perfect result. joints on the same side are displaced together. The direction of dis- placement will then be the same in each. Diagnosis.-There is no difficulty in diagnosis, as the injury gives rise to distinct displacement, usually without any considerable swelling or ecchymosis to obscure the contours. (See Fig. 139.) Treatment.-In this form again the treatment consists primarily of an attempt at reduction by coughing. Hyperextension of the trunk may also help. If in this fashion reduction is accomplished, the tendency to displacement is slight, and the strapping will be sufficient protection. If this reduction fails, there is a possibility that after the relaxation of muscular spasm spontaneous reduction will take place. If it does not, we have no resource except the choice of open operation or of allowing the displacement to remain. DISLOCATION OF THE RIB FROM THE CARTILAGE 157 The results of this dislocation are comparatively good, even if it is unreduced. The deformity remains, but the permanent damage con- sists only of a slight weakness of the chest in heavy work. There is no tendency to visceral complications. If, as usually happens, the injury is the result of crushing, the viscera are either fatally squeezed at the time, or they are sufficiently protected by the elasticity of the ribs. We have here no sharp points, as with rib fractures, to injure the heart or pleura or lungs. Operation may be performed as in the subjoined case. Case.-Bell; freight conductor; "rolled" between cars; showed a good deal of shock, from which he recovered promptly. Examination showed fracture of the right clavicle, and the second, third, and fourth ribs loosened from their respective cartilages. (See Fig. 139.) Second rib not displaced; third and fourth displaced inward and backward behind the cartilages, from which they had been torn away. The third rib on the left was similarly displaced. The left acromioclavicu- lar joint was dislocated, with moderate displacement. Owing to the man's somewhat weakened general condition and to the existence of a chronic bronchitis, operation was postponed. In the meantime attempts were made to induce a reduction of the ribs, by hyperextension of the trunk, by getting the patient to cough, and by supplying suction traction to the ribs. These trials all failed. The man suffered little pain, showed no reaction on the part of the lungs, and no difficulty with breathing, but the second and third ribs on the right were pulled inward with every inspiration. As this mobility did not decrease and promised anything but a strong chest, operation was decided on, and was performed under ether nine days after the acci- dent. An incision was made from the middle of the sternum outward along the third rib. The articular end of the rib cartilage was found smooth and undamaged. About an inch outside the cartilage the peri- osteum was incised, and the rib encircled with the periosteal elevator and retractors, as if for a rib excision. A strong pull upward and outward was then applied, with counterpressure over the sternum. Reduction in this way proved impossible. The end of the rib was then cut down on and freed by blunt dissection, and lifted up in place by direct leverage, with a Spencer-Wells blunt dissector. It showed no tendency to remain in place, but slipped indifferently back or in front of the cartilage. The cartilage was then drilled in a line running from the sternal end to the middle of the articular surface, from which the rib had been dislocated. A strong needle about 3 inches long was then passed through this drill hole and driven about % inch into the rib, while the rib was held in its proper position. The skin incision was then sutured. A like incision was then made over the fourth rib, and it was similarly reduced. In this case, however, manipulation did not fully reduce the displacement, as the cartilage had been partly torn loose from the sternum and twisted out of place. An attempt was made to pin this cartilage in place, but abandoned on account of the mobility of the torn cartilage. The tendency to displacement here was less, apparently because of the nearness of the intact fifth rib. The second rib showed some mobility, but no displacement at the 158 joint, and was let alone. There was strikingly little hemorrhage dur- ing the operation, and almost no ecchymosis resulting from the opera- tion or from the original injury. A wiring of the acromion dislocation was done at the same operation. Recovery from ether was good, and following the operation there was not only no discomfort from the pain, but the man felt more comfortable than he had before. April 2d the dressing was taken down for the first time, the tempera- ture having been normal, and not only the third, but the fourth, rib was found to be in place. The second rib, curiously enough, seemed to have suffered some displacement of the rib backward. The needle had caused almost no irritation and was not removed. Patient sitting up and comfortable. The needle was removed on the tenth day; there was no recurrence of displacement, and on the twentieth day the patient left the hospital apparently cured. THE RIBS Subluxations of the Costochondral Joint These are far commoner than total dislocations, and their occur- rence is particularly associated with heavy muscular strain during adolescence. Not uncommonly they occur as a result of gymnasium work or games on the part of girls of only moderate physique. In other instances they occur from the same sort of violence as would pro- duce a total dislocation were the force greater. In either case we have tenderness and lameness referred to this point on one single rib, and associated with well-marked tenderness, and, ordinarily, with some thickening. It is fair to assume that, at least in the distinctly trau- matic cases, there has been a temporary displacement, but when we see the cases, this displacement is no longer present. Treatment consists, not of reduction-for there is nothing to reduce -but of fixation by strapping of this portion of the chest, and of rest of the corresponding arm for a considerable time, at least for a fortnight. Later, massage will assist the union and minimize symptoms. Here, again, the results often seem disproportionately great in pro- portion to the actual injury. The joint is apt to remain a little thick- ened, a little tender, and a little lame on the use of the arm, and this condition may persist through months, causing a comparatively slight but very troublesome disability. Apparently stubborn as this trouble is, there is never any permanent damage unless we reckon the thicken- ing, which is apt to persist. CHAPTER X THE CLAVICLE DISLOCATIONS OF THE CLAVICLE The function of the clavicle is essentially that of a "strut" which holds the arm and scapula away from the body. In this function it is unsupported, and must bear the force of any blow that tends to drive the shoulder inward or forward, and must to some extent withstand the strain of any blow from above, or of any strain tending to pull the arm downward. For this reason, as well as on account of the exposed posi- tion of the bone, it is frequently damaged. The usual lesion is, of course, a fracture. Blows on the shoulder from the front usually break the clavicle. Blows from above may break it, or, if they strike far out, they may dislocate the outer end. Blows from behind are apt to break the shaft or to dislocate the inner end. Extreme extension of the arm backward may dislocate the inner end by leverage across the first rib. Dislocations of the Inner End Total dislocations of the inner end are rare. They may occur in any direction, including the dislocation behind the sternal notch. This particular dislocation is important because of the fact that the displaced head may encroach upon the vessels as they enter the medias- tinum,* and may produce considerable disturbances of circulation and respiration, f Fresh dislocations are readily reducible, whatever their direction, by traction and manipulation. The difficulty is not in reduction, but in maintaining the reduction. The condition after reduction is not essentially different from that obtaining in those subluxations, in which the ligaments are sufficiently retained to prevent very great displacement. In either case we have the problem of a joint in which * Such encroachment may not occur or may have no practical bearing, A case recorded in the City Hospital under Dr. M. H. Gavin's care in 1891 showed back- ward dislocation not only of the clavicle, but of the first rib as well, without special symptoms of this sort. The only case I have examined must have had some such encroachment, but showed no trouble from it at all, and not even any prominence of the neck veins of that side. t Slaughter (Amer. Med., March 3, 1906, vol. xi, p. 30) records a case in which a steeple-chaser fell and sustained an upward and backward luxation of the inner end of the clavicle. Unless held down by the fingers, the head rode up and pressed on the trachea, giving a sensation of choking. An open operation was done, as it was found impossible to maintain reduction. At operation all ligaments were found torn. A suture of kangaroo tendon through the end of the clavicle and the sternal ligaments, with a drill pinning the clavicle to the sternum (removed at ten days), brought about a perfect result. 159 160 THE CLAVICLE the contact with the sternum is of small area, and in which the strains of ordinary use are more or less tangential to the joint surface. There is nothing to maintain the position of the joint save the ligaments, and it is just these ligaments which have been severely torn by the injury and can not be depended upon for retention. This luxation may be up, down, in, or in and backward into the upper strait of the chest, into the entrance to the mediastinum. In all forms save the last the diagnosis depends on palpation of the sternal end of the clavicle in other than its normal place. In disloca- tion behind the notch we have simply a disappearance of the inner head, ordinarily palpable, and some restriction of shoulder motion. The classic picture of interference with respiration, venous congestion about the head, etc., is not necessarily present. Either in fracture near this joint or in luxations the existence and direction of displacement are to be made out not only by examination of the sternal notch, but by following the subcutaneous upper surface of the clavicle. In case of persistent laxness operation is called for-obviously. I have done this but twice but with perfect results. Cf. also footnote to previous page. Subluxations The diagnosis of the subluxations is not difficult, and the fact that they are sometimes overlooked is usually due to the fact that injuries to this joint are very frequently combined with other more obvious injuries, such as fractured ribs, etc. In the subluxations we have local- ized pain on motion, localized tenderness, and some deformity of the sternal notch on the injured side as compared with the other. In the total luxations the diagnosis is ordinarily obvious, and even in the subluxations, it is comparatively easy. The only question is between the dislocation and fracture close to the sternal end. In the presence of swelling the differentiation presents some difficulty. It is by comparison of this side with the other side of the sternal notch that we must reach our conclusions. This comparison is made by touch, not sight. A fracture near the sternal end of the clavicle may give some tilting upward of the outward end of the inner fragment, and some deformity, but deformity to an extent trifling compared with that of the real dislocation. Shortening measured from the acromion to the middle line may give valuable evidence of injury, but is common to the dislocations and to the fracture, while an accurate determination of a point on the middle line to measure from is hardly possible. In a recent case, operated upon by the author, a splintered fracture into the joint was found, in what clinically and on the .T-ray evidence had been called a clean dislocation. Of course post-operative repair is simpler and surer in the fracture than with the luxation. Worth mentioning is the loose joint with subluxation and snapping on motion that one sees not very rarely in the convalescence after REDUCTION AND TREATMENT 161 fracture of the clavicle. Strapped down, the joint presently ceases to slip out. REDUCTION AND TREATMENT For upward dislocation we need do no more than press the clavicle down, the shoulder up, and immobilize the arm in a sling, while the Fig. 140.-Treatment of upward luxation (the usual form). Clavicle held down by a pad and a strap of adhesive. Arm and shoulder are held slung high up in a sling. Fig. 141.--Treatment of luxation downward after re- duction. Backward traction and a sling. Fig. 142.--Treatment for outward or forward luxation sling and circular with the whole arm adducted. inner end of the clavicle is strapped down, with a pad over the bone.* (See Fig. 140.) This strap and pad are common to all the forms. Downward luxation calls for backward traction on the shoulder and retention of the shoulder in this position by a sling and by adhesive strapping (see Fig. 141) or a figure-of-8 dressing.! Outward and forward luxations call for reduc- tion by adduction of the whole shoulder-girdle, which is thereafter to be retained in proper posi- tion by a sling and a circular bandage or swathe. (See Fig. 142.) Luxations into or behind the notch may yield to traction, or it may be necessary to use the first rib as a fulcrum over which the clavicle may be brought into place by leverage, dragging the shoulder downward. Once this luxation is reduced, recurrence is guarded against by carrying the shoulder back and downward and holding it there with a swathe, with adhesive straps, if need be; the arm is supported only by a wrist-sling. (See Fig. 143.) Fig. 143.-Reten- tion after reduction of backward (retrosternal) luxation. Arm held back with plaster, sup- ported by wrist-sling, confined by a swathe. * In a case recorded in the City Hospital Records of 1889 a luxation of the clavicle up and forward could be reduced and retained only by putting the hand on the opposite shoulder, and a pillow between the shoulders. The patient was kept in bed three days, then sent out with the dislocation held reduced with ordi- nary apparatus. Slaughter's case above mentioned (p. 159) belongs here. t The City Hospital Records give a case (service of the late Dr. C. D. Homans in 1886) in which a dislocation of the sternal end down and forward was successfully held by the figure-of-8 bandage, applied as it has more lately been used for ordinary clavicle fracture. 162 THE CLAVICLE Apparatus ordinarily used consists of a sling or strapping so applied as to take the weight of the arm and shoulder-girdle, holding the arm forward or back as may best serve in the given case to maintain the joint in its best position. In any or all of these forms there should be fixation for at least three weeks. Massage is not called for, and passive motion must be restricted to the hand and elbow. Any use of the joint that will throw any strain on it whatever in less than four weeks is unwarranted. Prognosis.-This dislocation necessarily leaves a considerable thickening, and usually a little deformity. Owing to the frequency of associated injuries, it is often somewhat difficult to estimate the result in practical disability resulting from this one lesion. There is no great tendency to recurrence, but there is a long period of weakness and of uncertainty in the use of the arm, apt to be aggra- vated by abandoning fixation too early. The end-result is func- tionally at least fair. With regard to the subluxations, we can be somewhat more definite, inasmuch as they are not infrequent in young athletes, particularly foot-ball players, in whom the injury to this joint is the sole result of a fall. In most cases, if not all, this apparently slight injury leaves a weakness which persists for the season, if not permanently. It is rated as a more disabling injury than the dislocation at the outer end of the clavicle occurring in these same men from like causes. Case-Preston. Examined by courtesy of Dr. E. H. Nichols, 1907. Healthy negro of about forty, crushed under a team. Shows caving in of the whole upper side of the right chest. The cartilages of the first, second, and third ribs are prominent. The ster- nal ends project, while the ribs are displaced backward. The fourth rib shows a sharp bend at the costochondral junction. There is a question whether some or all of these first four ribs have not also been fractured near the axillary line, as well as displaced. The clavicle shows at its inner end a displacement from the sternum backward, in- ward, and downward, but displaced not over % inch. This displace- ment seems to have caused no symptoms at all. The outer end of the clavicle is completely torn loose from the acromion, and displaced two fingerbreadths upward. Beneath it the whole shoulder and shoulder- blade have fallen inward and forward on the sunken-in chest. With considerable force it is possible to reduce this scapular dislocation, but not to hold it in place. There seems no question that the conoid and trapezoid ligaments must be ruptured in this case. There is no dis- turbance of sensation or motion in the arm. There is no unnatural mobility of any of the ribs. There has been no crepitus. This case has shown no interference with respiration, no great pain or lameness, and is now, ten days after the injury, sitting in a chair apparently perfectly comfortable. Can use the arm to some extent, but his control of it, although he has no pain, is distinctly poor. 163 DISLOCATION OF THE OUTER END OF THE CLAVICLE Dislocation of the Outer End of the Clavicle This is a common accident, and always results from one form of violence, namely, a blow on the shoulder, such as is received in a fall from a horse in which a man pitches on his shoulder, and either breaks the clavicle or, less commonly, tears its outer end loose. The opposing force that renders this possible is, of course, the attachment of sterno- mastoid and trapezius muscles to the clavicle.* Lesions.-The injury produced is a tearing across of the ligaments between the clavicle and the acromion on top. The extent of lesion beyond this probably varies with the case. Fig. 144.-Acromioclavicular luxation. The usual type. Here there is probably some ripping of the conoid and trapezoid ligaments, but not an entire tearing loose. Apart from this tearing of the upper portion of the capsule and the protrusion of the end of the clavicle from the stripped-up sleeve of liga- ment and periosteum, there is usually no lesion described. From observation of cases I am convinced that while this may be the sum of the damage in most cases, there must be much more damage in some of the severer ones. Certainly in two cases that have come under my observation the coronoid and trapezoid ligaments were wholly torn loose, and the clavicle had ascended upward and into the neck, produc- ing an astonishing deformity which, in one case at least, showed slight increase after the man began to use the hand for work (Fig. 145). In the cases shown in Figs. 147-150, on the other hand, I think it is very doubtful if any lesion existed beyond simple tearing of the * This is a common foot-ball injury. See Nichols and Smith, Boston Med. and Surg. Jour., cliv, 1906, p. 1; Nichols and Richardson, ibid., clx, 1909, p. 33. 164 acromioclavicular ligaments. Such separation as here occurs may be, in part, allowed by the slack of the coracoid ligaments, and may be, in THE CLAVICLE Fig. 145.-Luxation of the outer end of the clavicle upward, with great displace- ment. Result of a crushing accident. Operation refused. Considerable disability six months later, probably permanent. Fig. 146.-x-ray of the author's case shown in Fig. 145 (retouched). part, due to a slight rotation of the scapula around the coracoid process as an axis. (See Fig. 151.) Certainly in these cases the clavicle is not freely movable, and there is no tenderness at any time in the region of the coracoid process. There are, then, really two classes of lesion included under this dis- location-serious, according as the damage is confined to the region of Fig. 147.-Luxation of outer end of left clavicle (author's case). DISLOCATION OF THE OUTER END OF THE CLAVICLE 165 the joint itself or involves damage to other attachments of clavicle and scapula. Diagnosis.--Ordinarily, the diagnosis is obvious; the shoulder, as the patient stands up, drops below its normal level, and the outer end Fig. 148.-Luxation of outer end of lefFclavicle up- ward (author's case). Fig. 149.-Lateral view of same case as Fig. 148. of the clavicle, held by the neck muscles, rises above the acromion for an appreciable distance. The muscles, and especially the trapezius, are held tense in spasm. On examination it is easily seen that the acromion lies distinctly below the outer end of the clavicle. (The two shoulders must be compared, because many individuals have a high Fig. 150.-View of dislocation of outer end of right clavicle upward, seen from above (author's case). The spur seen is the outer end of the clavicle. spur on the outer end of the clavicle, which gives normally an apparent difference in level at the joint.) (Cf. Fig. 180.) As a rule, there is comparatively little pain or tenderness, and the swelling is inconsiderable. On lifting the arm upward with a hand under the elbow the deformity decreases, and in many instances dis- appears (Fig. 152), only to reappear when the arm is dropped. 166 THE CLAVICLE The condition can hardly be confused with anything save a fracture of the clavicle near its outer end. In three cases, I have seen a frac- ture running down and inward from the joint surface; a combination of luxation and fracture, not to be differentiated by external signs in any way. (See Fig. 159.) Treatment.-There is, in the simple cases, no difficulty in reducing the dislocation, and ordi- narily there is nothing to show the alleged Fig. 151.-Shows how, by rotation of the scapula (produced by the weight of the arm), a separation between acromion and clavicle occurs without tearing of trapezoid or conoid ligaments. Fig. 152.-Shows the method of reduction (and diagnosis). Press down on the clavicle with one hand, and lift the elbow with the other. entanglement of the torn capsule. Not uncommonly, however, the reduction happens without any click or sensation of contact of hard surfaces, and there is some question of the completeness of reduction. Fig. 153.-Dressing for acromioclavicular dislocation. Here, as in the rare cases of any actual difficulty in reduction, it would seem to be a question of interposition of capsule fibers between the joint surfaces. In such cases, owing to the other ligamentous connec- tions of the parts, manipulation seems to be of no avail, and we must be satisfied with a partial, not a perfect, reduction, unless we wish to operate by incision. DISLOCATION OF THE OUTER END OF THE CLAVICLE 167 In the cases of severer type with torn coronoid and trapezoid liga- ments, the displacement is exaggerated, and not only is the shoulder dropped, but the clavicle is actually dragged up into the neck. (See Figs. 145 and 146.) Here there would be no difficulty in reduction if the shoulder could be lifted high enough, but it cannot be so lifted and satisfactorily held, nor can the clavicle be held down, and in this class of cases operative measures alone seem to promise any chance of even reasonably good results. In the simpler cases, where an apparently complete reduction is easy, the problem of treatment is simply to sustain the weight of the arm and to make enough pressure on the outer end of the clavicle to counteract the spasm of the trapezius. Simple as this is in statement, it is almost impossible to accomplish exactly. I have never succeeded in getting a per- fect result. The trouble is essentially in the im- possibility of sustaining the weight of the arm for many days without making unbear- able pressure on the bent elbow. The apparatus which best approximates the re- sult seems to be one shown in Fig. 153, devised for the treatment both of this con- dition and of clavicle fracture. Its applica- tion is obvious from the figures appended.* Stout muslin, folded, is the material used. The only other apparatus from which I have had any decent result, is Stimson's " figure-of-8 " of adhesive plaster, running under the elbow, crossing above the clavicle on the same side, and carried in both front and back toward the opposite axilla. (See Fig. 154.) The "Sayre bandage," despite all care, makes too great pressure on the elbow. It is efficient, but rarely tolerated by the patient. (See Fig. 163.) Whatever apparatus is used should be retained at least three weeks. Any work involving strain must be avoided for at least six weeks. Operative Treatment.-Operation has often been proposed, and occasionally carried out, even in the less severe cases. The infre- quency with which it is performed is due to the fact that patients con- sider the injury trivial, because it is not very painful. There is no question that the operation is indicated in cases in which the coracoid ligaments are evidently torn. In the milder cases it will probably be wise to operate in all cases, even of milder grade, in which the shoulder is likely to be called on for heavy work. My attitude in this regard is based on the better results, the trifling operative risk, and particularly on the more rapid return to working strength. Fig. 154.-Stimson's adhesive dress- ing. * This excellent and simple bandage was originated (about 1905) at the Relief Station of the Boston City Hospital. I can not discover who invented it, but can recommend it highly, from experience with it. 168 THE CLAVICLE I would not, however, be understood as failing to recognize the fact that excellent functional results, even if with deformity, may follow the conservative method of treatment. Operative treatment consists of an incision over the joint, an exposure of the joint surfaces, including a proper removal, or lifting out, of such shreds of capsule, etc., as overlie the articular surface of the clavicle. Cross-cutting of the capsule may be necessary. Then the luxation is reduced, the bone-ends are drilled and fastened together with either silver wire or kangaroo tendon.* Then the capsule is sewed up with a stitch or two, and the skin sutured. A sling to take the weight of the arm is needed for two or three weeks. At three weeks things are solid enough to allow light use. Results.-It is the current belief that this injury does not cause disability. To this I can not subscribe. It is true that in the majority of cases no such disability results as to keep a man away from his work after a few weeks, but in a good many cases, where the work is heavy, there is complaint of some weakness in the arm, especially on lifting with the hand, and this weakness does not seem to improve with time. There remains a certain laxity of the joint, though with a displacement of not over inch. For ordinary use the joint is perfectly serviceable. Under the pressure of heavy lifting or strain the separation tends to increase gradually for some months, and there is apt to be decided loss of lifting strength with some tenderness. In case the coracoid ligaments are torn, the separation is great at the start and remains great, and the deformity is very considerable, as is also the loss of working power. In two such cases observed months after injury there was also marked limitation of motion. To some extent passive motion was limited, but more particularly there was inability to raise the arm much above the horizontal, due to loss of all effective muscle attachments. In one of these cases the disability for many months after the injury was such as to prevent any but very light work, and the patient stated that he was unable to do even light work with any handiness or comfort. The results obtained by operation should be good. I have several times advised operation, but have had no chance to operate on a case of this severer sort. Burton J. Lee (Annals of Surgery for March, 1914, p. 456) reports such an operation with division of the outer edge of the trapezius, suture of the clavicle to the acromion, to the coracoid and to the coraco-acromial ligament. In the less serious type I have repeatedly operated, with a perfect series of results, so far, using kangaroo tendon sutures through both bones and across through the joint, as well as capsular sutures. Prac- * With a view to preserving mobility in the joint, a scheme has been devised of carrying the suture in a figure-of-8 crossing in the joint. It is ingenious, but in view of the good result of the ordinary operation, is probably superfluous. I have found the simple suture perfectly satisfactory. (Hopkins, Ann. Surg., 1902, xxxv, 650.) FRACTURE OF CLAVICLE, OUTER END 169 tically, a normal shoulder results, with all the motion necessary to this joint.* There is no danger save the slight one of sepsis.f FRACTURE OF CLAVICLE, OUTER END Fracture of the outer part of the clavicle internal to the ligaments differs in no essential from a break at the usual point. (See Figs. 155 and 156.) When we come to breaks in the outer end among the ligaments, the matter is very different. (See Fig. Fig. 156. Figs. 155, 156.-Sketched after Mal- gaigne's plates. Fractures at the outer end, but inside the ligaments. Fig. 157.-Fracture at the outer end of clavicle among the ligaments. Left clavicle from above (Warren specimen 7900). Fig. 158.-Fracture of outer end of clavicle (after reduction). Fig. 159.-Fracture of outer end of clavicle unreduced, showingjjthe reverse of the usual origina displacement. * The normal range is very slight-the clavicle is very movable, but the scapula moves with it always. 11 have had the chance to keep track of one case operated on by a man not a surgeon, in which there was a lively sepsis, but even here the end-result was not ankylosis, but a good joint with sufficient movement. 170 THE CLAVICLE 157.) There can no longer be any free displacement of the inner fragment upward; the fractured ends necessarily remain pretty nearly in contact, and the deformity must be confined to a bending-a "hinge" displacement. As a rule, the fracture results from a fall or from a blow striking the outer end of the bone from above. Conse- quently, the displacement tends to be of the outer fragment downward. If there is no origi- nal displacement, the weight of the arm alone tends to displace it in this way. In one case alone have I seen the reverse direction of dis- placement before reduction.* It is doubt- ful if actual impaction is ever present, but Fig. 160.-Abduction test to obtain crepitus in fractures of the outer end of the clavicle. Only in this way can we get motion between fragments in this region. Fig. 161.--Reduction by leverage: the elbow is shoved inward; the operator's arm in the axilla is the fulcrum over which the shoulder is pried outward and upward. Fig. 162.-Adhesive to hold fragments, and cir- culars to steady the arm. Fig. 163.-Sayre's clavicle dressing of ad- hesive plaster, often useful in these fractures at the outer end. often there is no mobility or crepitus elicited by any reasonable handling. * See Fig. 159. This fracture resulted from a fall in which the blow was received -as shown by contusion and abrasion-at a point internal to the fracture. FRACTURE OF CLAVICLE, OUTER END 171 The displacement is limited-it involves, even for slight displace- ment, a considerable rotation of the scapula, which is limited by the strong muscles that hold the bone in place. (Cf. Fig. 151.) As a result of direct violence, or as a complication of the acromio- clavicular luxation, there may be a break or chipping into or close to Fig. 164.-Shows the application of the Velpeau bandage, largely used in all clavicle injuries, but really of little use save as a neat covering for the adhesive strips that do the work. the joint. Here the displacement either is that of the luxation, or it will closely resemble such luxation, distinguishable from it only by slight difference in position of the deformity and by the presence of crepitus on reduction. Diagnosis.-Diagnosis depends on local tenderness, on bone thick- Fig. 165.-Adhesive plaster to steady the fragments, and a strong sling, applied so as to lift and hold the entire weight of the arm. This makes a very efficient dressing in most cases if properly applied. ening, on swelling, with some, though not much, deformity at a point to 1 inch internal to the joint, and on the crepitus sometimes obtainable by rotating the scapula (by lifting the arm, etc.; see Fig. 160), or by shoving the arm up. Ordinarily, the local tenderness and ecchymosis are the basis of diagnosis. 172 THE CLAVICLE Treatment.-Reduction is by manipulation and by shoving the arm upward, or by leverage. (See Fig. 161.) After-treatment is as for ordinary acromioclavicular dislocation, or by support in the ordinary apparatus for fracture of the shaft of the clavicle, but retention in apparatus is easier than with luxation. Often simple firm strapping with adhesive plaster to steady the fragments and a firm sling will be enough. (See Fig. 165.) Retention in appara- tus is not necessary after two or three weeks. Use of the arm will, of course, be postponed a little longer. (In the exceptional case above noted, with upward displacement, the most comfortable and apparently efficient treatment was to drag the arm downward and supplement the weight of the arm by tight strapping over a pad on the top of the shoulder at the outer end. The result was functionally perfect, without visible deformity.) Results.-The results are good, even if deformity is not reduced perfectly. There is apt to be a good deal of stiffness for a time, but in ordinary normal patients this entirely wears off and free motion and strength return. The epiphysis of the inner end (a mere plate of cartilage) begins to ossify at about eighteen years, and unites at from twenty-two to SEPARATION OF THE EPIPHYSES OF THE CLAVICLE Fig. 166.-Old fracture of clavicle taken at an angle. Was a question of non-union. Sma girl, aged ten. Illustrates the great distortion almost unavoidable in x-rays of the clavicle. Clin- cally, the position was not bad. twenty-five. Poland cites seven cases of its alleged separation, some of them distinctly doubtful. The lesion is to be handled like a frac- ture of the inner end. SEPARATION OF THE EPIPHYSES OF THE CLAVICLE 173 At the outer end there is no point of ossification, but there is in children a cartilaginous end that may be torn loose. I have met with but one case, the result of quick delivery by podalic version in a case of eclampsia. The case when I first saw it, at two weeks, presented a condition curiously similar to that of the complete dislocations (see Figs. 145, 146), with the proximal end drawn high up into the neck, almost parallel to the tense sternomastoid muscle. Only the square, blunt end and the site of injury spoke for epiphyseal separation rather than fracture. Massage and persistent traction by an efficient nurse brought the fragment near where it belonged-to a point where pads and strapping could be born without a slough, and union took place with little de- formity. After six months there was no deformity. I have seen a number of cases in which the question came up, and some in which a faulty diagnosis was made, because of the curi- ously long cartilaginous end of the clavicle and because there seems to be a loss of the normal contour. A normal child's clavicle can look extraordinarily abnormal. CHAPTER XI THE SCAPULA Dislocation of the scapula must obviously be a change of relation between shoulder-blade and chest, with or without damage to the chest, for dislocations between scapula and clavicle are classified as dislocations of the clavicle. There are no ligamentous connections between chest and scapula; therefore any scapular luxation must be from a caving-in of the chest or from a change in relation between scapula and muscles. A slipping of the edge of the latissimus dorsi inward under the angle of the scapula, between it and the thorax has been described: I have not met it. INWARD LUXATION The only class of luxation cases besides that just noted is that of "inward" luxation, cases in which the scapula is displaced inward into a gap produced by rib fracture. I have seen two such cases only, and have not chanced on any literature that contributes to knowledge of lesions or treatment. In these cases there was an extensive rib smashl ing-a fracture of several ribs. In one case pos- terior luxation of the ribs at the costochondra- joints was combined with fractures of the same ribs near the "angle" of the ribs behind: the scapula was less prominent than normal at the side and back. That was all. The patient re- covered without symptoms referable to this lesion. The second case showed a scapula apparently driven into the chest through a space furnished by the caving-in of ribs between anterior and posterior fractures. There were no symptoms characterizing this injury. The patient died from alcoholism plus trauma, and neither skiagraph nor autopsy was obtained. Save for support of the arm, after outward traction on the whole shoulder-girdle, I see nothing that can be done in these cases. Fig. 167.-Congenital luxation of scapula on the right. CONGENITAL LUXATION OF SCAPULA There is a congenital "luxation" of the scapula (Hochstand der Scapula of the Germans), but it is not likely to be confused with any traumatic condition. The position of the scapula, its articulation with the (usually present) superfluous rib, etc., may be understood 174 FRACTURE OF THE "SURGICAL NECK" OF THE SCAPULA 175 from Fig. 167. Marked improvement in position and mobility is secured by operation on these cases. FRACTURE OF THE "SURGICAL NECK" OF THE SCAPULA This form is described in the older books with particularity;* in modern literature I have not met it, nor have I seen but four clinical cases. None of these showed any such diagnostic picture as described. In all the diagnosis was by the x-ray only. It is supposed to be char- acterized clinically by the usual pain and disability of injuries in this region, but especially by the presence of a downward dropping of the whole arm (plus the glenoid fragment), reducible with crepitus by Fig. 168.-Fracture of the "silrgical neck" of the scapula: i. e., separation of glenoid and cora- coid portions from the body. upward pressure at the elbow, but reproducing itself on withdrawal of such upward pressure. There would seem a chance of confusion with acromioclavicular luxation, or with the downward drop seen in old deltoid paralyses after reduction of luxations, but neither of these should give crepitus, save the soft crepitus of secondary arthritis. The x-ray should be decisive in case of doubt. None of my cases showed any clear clinical picture, but were simply badly smashed shoulders in which the diagnosis was made by the x-ray. Poland reports a unique case, due to crushing, of separation of the whole epiphysis in a child. The epiphysis of the articular head * Astley Cooper says, however (after he had dissected two cases in which he had made this diagnosis that proved to be fractures of the anatomic neck of the humerus), "I must confess that I now doubt the very frequent occurrence of frac- ture of the cervix scapulae." ("Lectures," third American ed., p. 236.) As he origi- nated the usually accepted description, I think we may accept this as a retraction. 176 THE SCAPULA includes more than the glenoid neck, but, according to most authorities, not so much as Poland figures. His data are from an autopsy speci- men, however, and no doubt in this case coracoid and acromial base did belong to the epiphysis, contrary to the rule. (See Fig. 169.) Treatment.-In two cases I have been able to get excellent reduction by leverage across my arm prying the humeral head, and the shoulder joint, up and outward. The problem of maintaining position was solved in one case by strapping the arm to the side over a heavy pad high in the axilla. The tendency to forward displacement was met by keeping the patient in bed for a fortnight with a hard pillow between the shoulders-a light sandbag on the front of the shoulder. The result was absolutely perfect in this case. FRACTURE OF THE CORACOID PROCESS The existence of this fracture is amply attested, but, save as it occurs as a complication of luxation (where it is unimpor- tant), we know almost nothing about it. Personally I know of only one uncomplicated case, well shown by an excellent x-ray, now lost, in which no definite signs could be elicited even di- rectly after the injury; the local sensitiveness was gone within a week, and soon after this the slight disability began to wear off. Pelty (Annals of Surgery, 1907, xlv 427) records a case of coracoid fracture by muscle violence. Pain and crepitus and disability present; result good; back at work at seven weeks. He gives a skiagraph, not very satisfactory. For diagnosis, apart from the x-ray we have only localized ten- derness, ecchymosis, and the possible palpation of a movable fragment to go on. Theoretically, we should get pain on resisted flexion at the elbow and on active supination, owing to the fact of the origin of the short head of the biceps from this process. The treatment is obviously one of simple fixation of shoulder and arm with the elbow at a right angle. Union seems to be by bone, at least as a rule. No permanent ill results are on record. Fig. 169.-Sepa- ration of the scapular epiphysis as a whole (sketch from Poland's figure), a, Acromion; b, coracoid epiphysis. Fig. 170.-Epiphyses of the coracoid, complex, but not important. (Sketched from Poland's Fig. 24 after Rambaud and Renault.) This is rare, except as an incident of shoulder luxation. The anterior edge is that most often chipped off. Such chipping is reputed a common reason for recurrence of anterior dislocations, and has been invoked as cause in the permanent luxations roughly classed as congenital.* FRACTURE OF THE GLENOID CAVITY * It may here be part cause, but some such cases are obviously due to primary defects of development, others to obstetric paralyses, etc. 177 FRACTURE OF THE ACROMION Save for the ready reluxation of the reduced head and occasional crepitus, we have no signs for diagnosis. Without luxation the only case of my own I was ever sure of was discovered by accident during an arthrotomy. I know only one other, discovered unexpectedly by the x-ray. The treatment is fixation, of course, with support of the arm. The results, save for the possible tendency to recurrence of disloca- tion, seem to be perfectly good, and such recurrence, due to this lesion, seems rare, at worst. Fracture of the acromion is often diagnosed, but the accident is, in fact, rather rare. The cause seems to be direct violence always, except where the fracture complicates luxation. The disability is not complete, but nearly so. The diagnosis rests on external marks and on localized tenderness, FRACTURE OF THE ACROMION Fig. 171.-Epiphysis of the acromion. Fig. 172.-Right scapula from above and The dotted lines show the varying site behind: a, Epiphysis of acromion; b, epiphysis of of the epiphyseal line. The dark shaded coracoid process; c, epiphysis of glenoid cavity (from area is the joint surface with which the specimen in the Warren Museum), clavicle articulates. hence there is great chance of error. Rarely we may find crepitus, mobility, or obvious deformity. Any deformity is in the direction of a dropping downward of the acromion. It apparently is rarely more than slight. The question has often been raised as to whether apparent injuries in this region, shown by mobility or by the x-ray, may not rest on separate ossification-centers rather than on trauma as the ultimate cause. There is, in fact, an epiphysis here, and it unites late.* (See Figs. 171 and 172.) All we can say is that the ordinary signs of trauma ordinarily mean trauma; if the x-ray shows apparent separation without these signs, it is of no consequence; if sharply localized soreness, ecchymosis, pain on motion, and crepitus are present, with apparent separation or loosening of the acromion, it is of very little consequence whether this separation be a fracture or a traumatic separation of an epiphysis. * Poland, Traum. Seps. of Epiphyses, p. 153, gives a cut of specimens showing such (permanent) separations. 178 THE SCAPULA In a series of cases diagnosed by house-surgeons and others as acromial fracture, I am bound to say I have found various other injuries, but never signs of either fracture or separation of the acro- mion. Most of them were clavicle fracture or acromioclavicular dislocation. Perhaps it is fair to say that soreness over the acromion following trauma proves nothing as to bone damage, unless supported by other signs of such damage, and that luxation and fracture of the outer end of the clavicle both give similar pictures and are both far commoner than the acromial injury. Treatment.-In case we have either acromial fracture or epiphyseal separation, the indications for treatment are the same, viz., immobili- zation and support of the elbow to relieve traction through the muscles, and consequent displacement due to the weight of the arm. In other words, we have here a problem of support and fixation exactly equiva- lent to that in acromioclavicular luxation. We are to use the same reduction and the same apparatus, applied for about the same length of time. Results.-I have so far not learned of any case of acromial fracture, or alleged acromial fracture, in which any permanent disability has resulted. It is alleged that the acromial fractures may unite by fibrous tissue only. Probably fibrous union in this region, given a close approximation, would be about as serviceable as union by bone. FRACTURE OF THE SPINE OF THE SCAPULA This is not a very rare accident. It may be merely a smashing of the edge, or may rarely run through, so as to separate the whole base from which the acromion springs. It occurs, usually, if not always, as a result of direct violence. Diagnosis presents difficulty only because of the usual presence of much swelling. The diagnosis depends on an interruption of the easily palpable line of the scapular spine, with occasionally a palpable mobility, on local tenderness and thickening, on crepitus, and on reflex spasm of the shoulder muscles. Treatment.-The treatment is one of fixation only. The deformity is slight; the healing is by bone callus, and the chance of later trouble is slight. Apparatus to be applied is only the usual firm sling and circular, for support of the weight of the arm and for immobilization. Results.-Save for one case of delayed, but eventually solid, union, I have seen no serious damage from this fracture. The local deform- ity which may remain is of no consequence and there is no permanent disability. Darrach (Annals of Surgery, March, 1914, p. 456) reports a case successfully sutured for non-union; a fracture at the junction of the spine and acromion. FRACTURE OF THE BODY OF THE SCAPULA 179 This lesion results always from a direct blow-usually from a heavy fall on the back. It is less rare than would be supposed from the account given in text-books. In a limited experience I have met with at least 15 cases, more than my cases of any other scapular fracture. The lesion is a break, more or less accurately transverse, across the scapular body below the spine. There may be some comminution of fragments. In one case observed there was a green-stick fracture convex forward, with the lower end of the scapula sharply projecting.* Diagnosis.-The diagnosis is not always easy, for there is, as a rule, FRACTURE OF THE BODY OF THE SCAPULA Fig. 173.-Multiple fractures of scapula. Railroad accident. Man, forty-three years of age. Lived one day (Warren Museum, specimen 6028). Fig. 174.-Fracture of the body of the scapula. Bony union with moderate displacement (Warren Museum, specimen 8111). much hematoma, more or less limited by fasciae, and, therefore, tense and hard. Every case of marked hematoma and tenderness limited to the region of the shoulder-blade is suspicious. The disability of the arm is nearly, if not quite, complete. Lifting or sharp abduction of the arm gives sharp pain. It is sometimes possible to feel the break in the line of the vertebral edge of the shoulder-blade, and, by grasping the bone as shown in Fig. 175, it is usually possible to appreciate the pres- ence of some lateral mobility, and sometimes crepitus is obtainable. There is shortening of the bone measured from the spine (point x Fig. 179, is usually palpable) to the angle, but, owing to swelling, this measurement is hard to get accurately. Treatment.-It would be desirable to prevent the overlapping of the fragments or reduce its extent, but I know of no way. Fortu- *In a boy of about ten years; he fell out of an apple tree on his back. In re- ducing the displacement the fracture was rendered complete. Recovery under usual treatment was, as is usual, complete and uneventful. 180 THE SCAPULA nately, the overlap is very slight. The actual treatment used is to strap the scapula down with adhesive plaster with the shoulder carried back to relax all muscles, and then to support the arm in a sling and Fig. 175.-Manipulation to test fracture of the body of the scapula. By shoving or pulling the upper and lower parts in opposite directions mobility and (sometimes) crepitus are observed. fonfine it with a swathe. Absolute immobilization will not be needed cor more than three weeks, as callus-formation is prompt. In all the cases I know of* the end-results has been excellent-prac- tically perfect, despite slight persistent shortening and overlap.! * Save in one case, where there was a medicolegal interest, with obviously fraudulent claims of pains here and elsewhere and a second in which there was long continued stiffness of shoulder action-apparently from muscle adhesions about the break. t The bone is here thin, and the overlap, therefore, interferes little with the conformation of the scapula to the chest, over which it slides. CHAPTER XII THE SHOULDER LANDMARKS The landmarks of the shoulder are five: 1. The acromion. 2. The spur of the clavicle. 3. The coracoid process. 4. The most prominent part of the spine of the scapula, the spur of the acromion. 5. The head of the humerus. The acromion as a landmark is obvious in the most muscular or Fig. 176.-Shows, on the left, the female, on the right, the male shoulder contours. There is a characteristic and reasonably constant difference. even in the fattest shoulder. Its relative prominence is dependent on its relation to the tuberosities of the humerus. Even in case there is much swelling or much deltoid wasting, there is little difficulty in palpating-and accurately-the relation of these two prominences. If the tuberosities are not in place on this test, we must discrimi- nate as to the direction of displacement. Displacement forward and inward means either luxation at the joint or fracture near the head. Great displacement means luxation, with or without fracture. 181 182 THE SHOULDER If, as rarely happens in thin subjects, we can palpate the glenoid cavity or its edge, there is no doubt as to the presence of luxation. Clavicle Spur.-The spur that exists on the clavicle in a certain proportion of persons is sometimes a valuable confirmatory landmark when there is any trouble finding the acromion or the scapular spine. Its situation is evident enough from Fig. 180. The coracoid process is definitely palpable in the normal individual by the method shown in Fig. 178. If it can not be felt in this way, the chances are there is serious disturbance of relations, though much fat or much swelling may rarely inter- Fig. 177.-Cross-section showing the obliquity of the scapula in relation to the trunk. The gleniod cavity faces as much forward as out- ward. Fig. 178.-Palpation of coracoid processes. Fig. 179.-Scapula from above. Shows the spur of the acromion or of the spine at X. fere. In dislocation forward it is usually impossible to feel the coracoid. If the humeral head lies so close that the coracoid can not be felt as a separate prominence, the presence of dis- location is almost certain. Fractures of the coracoid are vastly rare, and even when they occur, appreciable displacement of the coracoid is improbable. The spur of the acromion lies behinc the prominent external portion. It is an angle rather than a process; its relation to the bone is shown in Fig. 179; its exter- nal relations, in Fig. 181. It is constant, though varying, as do other such spurs, in its prominence. Being subcutaneous, it is readily found. The head of the humerus is readily palpable as a rounded mass. (See Fig. 182.) Usually the contrast between the prominence of Fig. 180.- X shows the project- ng spur of the clavicle next the gap representing the joint with the acrom- ion and the scapular spine. SHOULDER LUXATION 183 the greater tuberosity and the groove for the biceps may be made palpable by rotating the arm. Fig. 181.-1, End of clavicle; 2, acromion process; 3, "spur" of acromion. Fig. 182.-Palpation of the head of the hu- merus from behind; the thumb lies on the acro- mion process. This is the commonest of the major luxations-perhaps the com- monest of all luxations. It is rare in the first two decades of life; very Shoulder Luxation Fig. 183.-Old subcoraeoid luxation. Shows the new flat socket and the eroded head (Warren Museum, specimen 5173). Fig. 184.--New joint at right angle to the glenoid and just in front of it (after a plate by Malgaigne). Old subcoracoid luxation, unreduced. rare in small children. Much ingenuity has been spent (wasted, per- haps we may say) in the minute subdivision of possible types of 184 THE SHOULDER shoulder luxation. Not less than 15* types have been named, with much confusion of definition. It is for us to consider what types are clinically distinguishable, and, further, to consider how far this dis- crimination of types may affect intelligent treatment or prognosis. Considered from this extremely practical point of view we have: Anterior luxations; luxations downward; luxations backward; with the vastly infrequent cases of luxation up and forward, of luxations far downward (luxatio erecta), of luxations in which the humerus is driven through the chest-wall, and of the luxations complicated with, or per- haps possible only in connection with, fractures of various sorts.f Fig. 185.--Old subclavicular luxation. Shows the big loose new capsule communicating witlf the old (Warren Museum, specimen 1172). These include the subcoracoid and those forms variously called intracoracoid or subclavicular. Far and away the most common type is that called subcoracoid, and this will be described as the typical lesion. It consists of a displacement of the head of the humerus forward and inward, to a point below and just external to the coracoid process, from which process it is separated by the subscapularis muscle or its remnants. Etiology.-Subcoracoid dislocation results, so far as we may deter- mine, from forced abduction, from a blow on the rear and outer side of the shoulder, or from forced inward rotation. Muscular contraction undoubtedly plays a part, and may perhaps be the sole cause of dislocation. The academic theory has been that forced abduction, with leverage across the acromion as fulcrum, is the common cause. This I take the liberty to doubt, first, because the acromial region rarely shows even local tenderness; second, because all abduction subcoracoid luxations seem to occur under conditions of strong muscular contraction; tense FORWARD LUXATIONS * Subcoracoid, intracoracoid, subclavicular, supracoracoid, subglenoid, axillary, supraglenoid, luxatio erecta, retroglenoid superior and inferior, subacromial, retro- axillary, subspinous, intrathoracic, subtricipital. These are all descriptive names that have been used, several of them synonymous, several as to which no man may say exactly what they mean. fFor example, upward luxation with acromial fracture. FORWARD LUXATIONS 185 adductor muscles seem much more likely than the bone to be the usual fulcrum. With forced abduction we may have three points that may act as the fulcrum: (a) the acromion; (&) the coracohumeral liga- ment; (c) the tendons of the contracted pectoralis major and the latissi- mus dorsi. It would be folly to try to determine this matter exactly. It is perhaps fair to say that my experience of clinical histories as given leads me to infer that the fulcrum point furnished by the adductor muscles has not been given fair weight.* So, too, in the luxations occurring from sudden forcible inward rotation, inflicted, for instance, in foot-ball or in sparring, there can hardly be any other than a muscular fulcrum. Fig. 186.-Subcoracoid luxation, apparently, from the slight abduction angle, a case with extensive tearing of ligaments. Whatever view we take of the detailed mechanism, we find, in fact, that the case histories show the cause to be either forced abduction or a blow on the shoulder, occurring with about equal frequency; luxation by inward rotation, while it does occur, is rather rare. Lesions.-There have been a good many autopsies, and the joint lesions found are constant in the main. The rent in the capsule lies constantly on the anterior inner and lower aspect of the joint, between the tendon of the subscapularis and that of the triceps. As a rule, it seems to be a rather large tear. The capsule is torn from the humerus, or near the insertion on the humerus, as a rule, though tearing at the * For instance, one of my cases was that of a young, muscular fellow who jumped on a moving street-car, as he had done habitually. He had, however, underestimated the speed of the car, and threw his shoulder out, though he did not fall. There was abduction, but an abduction certainly not extreme enough to act by leverage over the acromion; we must assume a muscular fulcrum. 186 THE SHOULDER glenoid edge, chipping of the cartilage on this edge, or stripping up of cartilage and of the adherent periosteum near this point have been found. The capsule, strictly speaking, may not be torn at all in these cases. The tendon of the subscapularis may be partly torn with the capsule, or the muscle-fibers may be torn in the later upward displace- ment of the head caused by the falling of the arm. Rupture of other muscles is rather rare, but there may be tearing, more or less extensive, of supraspinatus, infraspinatus, teres minor, and, very rarely, of the teres major. Tearing of the coracohumeral ligaments is very rare, hardly occur- ring save in subclavicular luxation. It is T. Kocher's service to have pointed out that this ligament is not torn in any ordinary dislocation; that it usually determines the faulty position and the fixation of the limb; that it is the key to proper reduction manceuvers in most cases, and that its relation to shoulder luxations is something akin to that of the Y-ligament to hip disloca- tions.* This ligament rises from the base of the coracoid process in two diverging bands, one, the weaker, running to the greater tuberos- ity; the other, the important one, running to the lesser tuberosity, there to be inserted with the capsule. In the ordinary subcoracoid form of luxation this ligament is stretched taut, and it determines both the close contact of the head with the anterior scapular surface and the fixation of the humerus in abduction. The ordinary position of the head on the scapula is well indicated by the position of the false socket in old cases (see Figs. 183 and 184); this is confirmed by dissections of recent cases. The head in this form of dislocation lies close under the coracoid process, separated from it by the subscapularis, entire or torn on its lower edge. The head is not far from the joint edge, and in some cases it lies on the front edge of the glenoid cavity. In such cases the capsule is less torn than usual; in some cases not torn at all, but merely lifted off the edge of the glenoid, carrying the periosteum with it. The cartilaginous edge, or even the bony edge of the front of the glenoid, may be broken away. This gives little difficulty in reduction, but probably predisposes to recurrence of the dislocation. Fractures of the coracoid or acromion are extremely rare complica- tions of anterior luxation. Associated with the displacement we may have tearing not only of subscapular muscle-fibers, but of other muscles, as noted above. The long tendon of the biceps may be ruptured or it may be dis- placed inward. * This parallel in detail has been drawn by Kocher in a very illuminating article in Volkmann's "Sammlung klinischer Vortrage," published in 1873, No. 61, p. 667 Kocher's first article calling attention to this ligament and its role in reductions was three years earlier (Berlin, klin. Woch., 1870, No. 9). FORWARD LUXATIONS 187 Either tuberosity of the humerus may be torn off. The tearing off of the lesser tuberosity frees the biceps tendon from its groove and slackens the tension of the coracohumeral ligament. ; All these complications may have a bearing on future function of the arm, but have none on reduction, except in case of interposition of Fig. 187.-Attitudes in shoulder injuries: 1, Clavicle fracture; 2, neck of humerus; 3, humerus below the neck; 4, subcoracoid; 5, subglenoid. the biceps tendon between head and socket. Probably the adaptation of the form of reduction to the detail of these lesions will be worked out later, but at present this relation is not discovered, and our forms of procedure take no accurate notice of these details. Rarely, the axillary vessels may be torn by stretching over the humeral head. (See under Complications.') 188 THE SHOULDEK Damage to the nerves by direct pressure of the displaced head, by nerve-root traction, or by the trauma of reduction is by no means unusual. Symptoms of Subcoracoid Luxation.-The arm stands away from the side, and the elbow cannot be brought to the side. All motions are restricted and painful; the arm is practically useless. There is a flattening of the shoulder and a hollow to be felt below the acromion. A fulness is to be felt in front, just below the coracoid process. The head is not felt in the axilla. From behind, there is a hollow below the acromion opposite the Fig. 188.-Subcoracoid luxation (author's case) glenoid cavity (see Figs. 191, 192), but the edge of the glenoid is rarely to be felt. The axis of the humerus, seen from the front, obviously runs too far inward-toward the clavicle (Fig. 187, 3 and 4). The length of the arm, measured from acromion to external condyle, is slightly increased. There is sharp restriction of all motions, limited not only by pain, but by mechanical check. Most significant is the loss of adduction. The elbow cannot be brought to the side* In practice the diagnosis offers little difficulty to the practised eye. * To be absolutely conclusive, this test should be performed with the arm in moderate outward rotation. The classic test, known as Dugas's test, is as to the patient's ability to bring the elbow to the side, with the hand on the opposite shoulder. This test occasionally fails. FORWARD LUXATIONS 189 First, the attitude is almost diagnostic. (See Fig. 187 and Figs. 188 to 192.) The arm stands out from the side stiffly, and cannot be brought in. Motion is largely lost, save when all ligaments are widely torn. The axis of the bone points wrong. There is flattening of the shoulder. On palpation the humeral head is gone from its normal site, and there is a mass to be felt (rotating with the shaft) close to the coracoid process.* The inference is obvious. There can be confusion only with certain fractures of the neck or with fracture plus luxation. Treatment.-Today few will dispute the preeminence of Kocher's method of reduction for most cases of subcoracoid type. This method depends on the fact that the displaced head is pressed close to the scapula under the cora- cohumeral ligament,-so close that it cannot rotate freely,-and that it is pulled into inward rotation by tension of the subscapularis. Fig. 189.-Subcoracoid luxation (author's case). Figs. 190, 191.-Subcoracoid luxation (author's case) If we rotate the arm outward, the head rotates over the glenoid edge; if this rotation is done slowly, the subscapular muscle is stretched and gradually ceases its resistance. During such rotation the head moves outward visibly (see Fig. 194), and may slip into the socket. * Much has been written as to feeling " the head of the bone in the axilla." I have not yet been able to feel the head in the axilla in a subcoracoid case. This position of the head means a subglenoid luxation. 190 THE SHOULDER If it does not move outward at all with outward rotation, this first manceuver is to be continued, or repeated, before going further. The next manoeuver is to carry the arm, still rotated out, forward toward and across the body, using the arch of the ribs in a measure as a fulcrum * to lift the head of the humerus, already rotated onto the edge of the cavity, into its place. The third step is internal rota- tion, with the elbow in adduction, to throw the head into its usual normal position. As a rule, the head moves out ward during outward rotation, and slips in with adduction. The final movement only restores the head to normal position after reduction, and clears capsular entanglements. One point that I have found important, unpublished, I think, is the slow execution of the out- ward rotation. This wears out the resistance of the subscapularis and renders reduction easier and more certain. I am accustomed to devote from two to five minutes to this part of the manoeuver, and have con- vinced myself that it is time well spent. Kocher's reduction certainly is the best single routine. It is to be tried first, unless we wish to try direct backward pressure on the head, exerted by the thumbs, with the arm held in moderate abduction. The last manoeuver will suffice for some cases, but for many it does not; where it works it is, of course, the gentlest method. Kocher's method is not violent, not very painful, and may, in the rule, be carried through without anesthesia. Properly done, with a real understanding of what happens at one end of the bone while we work at the other, it almost invariably succeeds; I have not chanced to have it fail me but twice-in one case of exceptional muscle spasm, and in one case of displacement perhaps more nearly intracoracoid than subcoracoid. Fig. 192.-Subcoracoid luxation (author's case). This photo is interesting in that it was taken at night by the ordinary electric light of the accident room with a "Kodak." Fig. 193.-The uselessness of measurement for shortening in shoulder luxation: o is the nor- mal measure; a, subcoracoid; b, subglenoid, show next to no shortening. Only the sub- clavicular type, c, is short. * This is not exactly Kocher's reduction; in fact, he described a motion of pure flexion (motion of the arm up and forward, in the sagittal plane) as the second manoeuver. The sequence given above is, however, what is usually done as Kocher's reduction. FORWARD LUXATIONS 191 Fig. 194.-Effects of outward rotation alone. An instant after the right-hand picture was taken the head slipped in (author's case). Shows the outward movement produced by rotation. " Fig. 195. Fig. 196. Fig. 197. Figs. 195, 196, 197.-Kocher's reduction. Fig. 195 shows the outward rotation movement; in Fig. 196 the elbow is carried forward and to the side, and in Fig. 197 it is pressed across the chest; the arm is then rotated inward. 192 THE SHOULDER I have repeatedly had it succeed after vain trial of other methods. The method carries no especial risks. I have thrice seen the humerus broken during the outward rotation, but this was in cases of some weeks' standing;* the accident has, however, occurred in fresh cases, and it is well in old people with brittle bones to use some caution. Reduction with the Heel in the Axilla (Fig. 201).-This is the method known as Astley Cooper's, though it antedates his time. For its performance the patient is laid on his back; the operator presses his Fig."-198.-Subcoracoid luxationrproduced by abduction and inversion on the cadaver (author's sketch). heel (without a boot) into the axilla, while he pulls the arm outward at right angles to the body, and then swings it down toward the patient's flank, using his heel as a fulcrum. The operator's body-weight gives the pull; the swing of his body gives the force for leverage. The only trouble with this reduction is that a moderately powerful man may readily exert far too much force. The heel pins the soft parts against the bone, and Heaven knows what damage may be done to nerves and * There are many cases on record. I have myself produced one such fracture in a luxation of four weeks' standing, but the break was a completion of a fracture that had separated the greater tuberosity. The type fracture so produced is apparently a spiral fracture of the "surgical neck." FORWARD LUXATIONS 193 vessels and to the short muscles, to say nothing of the chance of break- ing the bone at the surgical neck. The damage is greatest, of course, if the attempt at reduction is unsuccessful. There is no doubt that the bone may be reduced by this method, as a rule, but it is a method to be used with caution and as a last resort, not as a routine (Fig. 201). Downward Traction with Leverage.-This is merely a modification of the last-more merciful in detail. The abducted arm is gradually pulled down on and adducted, while an outward pull is exerted in the Fig. 199.-Same cadaver as Fig. 198. a and c show the ends of the pectoralis major, cut to expose b, the subscapularis and teres, and d, the latissimus dorsi; e, e, is the biceps; f, the coraco- brachialis lying directly over the vessels and nerves. axilla, or while the assistant pushes his doubled fist into the axilla as a fulcrum. It is the same leverage that is often useful to correct displacement in fracture of the surgical neck. (See Fig. 202.) Reduction by Outward Traction.-This method belongs more particularly to the reduction of subclavicular displacement, but may be useful with the subcoracoid type. It consists simply of a traction outward on the arm, with countertraction exerted by a sling about the scapula, crossed under the back, with the ends held by the assistant (see Fig. 203), or the operator's unbooted heel in the arm-pit may be used to give countertraction without being used as a fulcrum. Rota- 194 THE SHOULDER tion of the arm in or out is here allowable and may be useful. Unless unnecessarily great force is used, there is no objection to this method, and it is rather apt to be serviceable. There are two other forms of application of this method-the first is the method by elastic traction; in this rubber bands, or springs are applied to the bent elbow in abduction; it is a method in some favor on the continent; the second is Stimson's method of putting the patient on a gas-pipe frame on a hammock, and letting the arm, weighted if need be, hang down through the hammock to reduce itself by gravity. Fig. 200.-Same specimen. Shows how the subseapularis is tightened and the head moves out ward under it on outward rotation. The same mechanism is readily secured by using two tables. (See Fig. 204.) Reduction by Upward Traction.-This method, belonging by right to the downward luxations, and particularly to the "luxatio erecta," is sometimes used for the subcoracoid cases with success. It consists simply of traction directly upward, with counterpressure from above on the scapula and the clavicle. (See Fig. 205.) It has the advantage of a maximum relaxation of the coracohumeral ligament. There is one method to be mentioned only for condemnation. This is what we may call the " wrestling-grip." It is an arm grip long known to wrestlers. The patient lies on his back on a table; the FORWARD LUXATIONS 195 Fig. 201.-Heel in the axilla. Fig. 202.-Traction downward over arm or hand in axilla as fulcrum. 196 operator, back to the patient, grips the arm as shown in Fig. 206, then rotates his whole body toward the feet of the patient. The force exerted is, in part, one of traction down and out; in part, of a leverage across the operator's pelvis, carrying the head of the humerus outward. In the hands of an expert this method may do very THE SHOULDER Fig. 203.-Reduction by traction outward with countertraction. Fig. 204.-Stimson's method of reduction by gravity. well; for average use there is so great a possibility of applying enormous force too easily that the method should not be countenanced. Discrimination of reduction methods according to the complica- tions present seems not to have been established in either anterior or posterior luxations. Such complications are, therefore, still to be regarded only as legitimate excuses for failure and reasons for later operative interference. 197 FORWARD LUXATIONS Probably in the future some one will study and give to the pro- fession the diagnostic points indicating such complications, and the modifications of methods of reduction adapted to their interference as applied to shoulder luxations-a service comparable to that rendered by Allis in relation to dislocations of the hip. Fig. 206.-The wrestler's grip. A bad method. After-treatment.-The after-treatment consists in fixation for two or more weeks; fixation must here involve support of the entire weight of the arm, else we get undesirable strain on the capsule and on the deltoid and other muscles. This purpose is best accomplished by the use of the " sling and circu- lar" bandage. I use adhesive for the circular. (See Figs. 207 and 198 THE SHOULDER 208.) The Velpeau bandage (see Fig. 164) has little more than a decorative value. Exceptionally, the adhesive sling advocated by Stimson for acromioclavicular luxation (Fig. 209) is here of service if the cloth sling will not hold. Fig. 207.-Circular adhesive to hold arm still. Fig. 208.-Sling applied outside the circular to carry the weight of the arm. It should carry all the weight. Massage and careful passive and active movements may be begun early with profit. Some motion as early as three weeks is almost essential to a good result. Results.-Uniformly we have for a time much tenderness and much pain on attempted motion. Swelling and ecchymosis vary- within wide limits. If we begin massage and motion early, we get, as a rule, a very satisfactory restoration of the range of motion, even in elderly patients. Long fixation j eopardizes this result. There is almost always a rather persistent soreness about the coracoid process, and just below the acromial spine, apparently due to tear- ing of ligaments. It always wears off with time. It is fair to say that, except in cases com- plicated with fracture or with nerve lesions, the restoration of function is usually excellent. After efficient early reduction of anterior luxations we may expect in the younger patients perfect restoration of function within a few weeks in most cases; there remains at most a certain sensitiveness of the joint-a little soreness on hard use which may persist for some months. Recurrence of the luxation, of which much has been written, seems in fact to be a distinctly rare occurrence in cases properly treated; Fig. 209.-Adhesive dressing to support arm. Circular band- age outside it. 199 FORWARD LUXATIONS where reluxation is permitted by inadequate protection in the first two or three weeks, or where there has been fracture of the glenoid edge, or fracture of the tuberosities with dislocation or rupture of the biceps tendon, we may, of course, face such a prospect. Such cases are, however, the rare exception. In case of nerve lesions, whether of the brachial plexus or of the various trunks, the prognosis depends on the power of regeneration of the stretched nerves and on the care used to prevent stiffening while Fig. 210.-Shows the range of motion in an old unreduced subcoracoid luxation. (Drawn from a case personally observed.) such regeneration goes on; this means massage, motion, and electric treatment. Fracture of the tuberosities may give some delay in return of func- tion, but does not seem to be a source of much trouble. Unfortunately, any of these lesions is likely to prolong the necessary period of immobilization, and such prolongation in itself is apt to be a cause of delayed return of mobility. In older patients this may leave some permanent loss of motion and function. In older patients, irrespective of complications, the return of motion after luxation may be slow and imperfect. Massage with passive motion, properly handled, does much to avoid this. The last motion to return is inward rotation-the power to put the arm behind the back. Next to this, the power to put the hand to the back of the head is latest in returning. Unfortunately, these motions are peculiarly important to women in dressing and in arranging the hair. They almost always return in time, but often only after a period of some months. 200 In the rare cases where anterior luxations are unrecognized, or from other causes must remain unreduced, what may we expect as to func- tion? The results are curiously good. Fig. 210 shows the range of motion in one such case-probably a fair case to take as an average. Full motion is, of course, impossible, but the range of motion and of use is surprisingly good. Also, where there has been fracture of the anatomic or the surgical neck, with the luxation, and no replacement of the fragments, or where such fracture has attended overzealous attempts at reduction, we have a similar condition, and, again, surprisingly good functional results. THE SHOULDER Fig. 211.-Subglenoid luxation. Less than the usual abduction: ligaments probably pretty well gone. Fig. 212.-Subglenoid luxation, with fracture of the anatomic neck (impacted) and of the greater tuberosity (z-ray by Dr. Van Allen). It has been said that there is in any unreduced case some liability of pain from stretching of nerve-roots over the permanently displaced head. As to this, I have no opinion: I know only that such results of stretching sometimes persist. This is merely an extreme type of the subcoracoid,* accompanied in some cases, if not in all, by some tearing of the coracohumeral ligament, SUBCLAVICULAR LUXATION * No account is taken of the form of luxation called "intracoracoid." It is purely a transition form between the subcoracoid and the subclavicular types. SUBGLENOID LUXATION 201 as well as a more general capsular tear than usually occurs in the sub- coracoid type. (See Fig. 185.) Clinically, the picture is that of an exaggerated subcoracoid luxation. The arm stands farther out from the side; the humeral head lies farther in, to the inner side of, or below and in front of, the coracoid process. The hollowing below the acromion is increased, and there is slight shortening on measurement. (See Fig. 193.) Limitation of motion is apparently not greater; liability to damage to the various soft parts seems not to be increased, except for increased hematoma and soreness. Treatment.-Reduction in this form of displacement must take account of the inward displacement. Whether the coracohumeral ligament be torn or not, we must first reduce the displacement to that Fig. 213.-Subglenoid luxation; attitude of minimum discomfort assumed by a case of the author's. of a subcoracoid, in the course of our reduction. The rent in the capsule is about the same as in the subcoracoid type; the intact ligaments may be the same or they may not be. In either case direct traction outward, with the arm at right angles to the trunk, must bring the humeral head under the coracoid process. With the head brought to this point we may reduce by continuation of the lateral traction, or we may resort to any of the procedures above described for reduction of a subcoracoid luxation. In fact, the usual procedure is a continuation of traction in abduc- tion. If this fails, we may have recourse to any of the methods for reducing subcoracoid luxation. SUBGLENOID LUXATION Whether this is a rare or a common type is purely a matter of defini- tion. The head of the humerus in this type simply lies nearer the lower edge of the glenoid. If we establish as a clinical distinction that a 202 THE SHOULDER proper subglenoid luxation should leave the head more readily palpable in the axilla behind the greater pectoral than in front of it, then sub- glenoids are rare. I know no better dividing line, and on this basis should call the subglenoid types rather uncommon. Fig. 214.--Attitudes in various shoulder injuries: 1, Normal; 2, fracture of anatomic neck; 3,'fracture of surgical neck; 4, separation of epiphysis; 5, subcoracoid; 6, subglenoid; 7, fracture of clavicle;[8, acromioclavicular luxation-usual form; 9, same, with much tearing and displacement. Fig. 215.-Fracture luxation. The cross shows the center of the head. This lesion was over- looked despite an z-ray picture in a large suburban hospital where also a practically total brachial plexus paralysis failed to impress anyone. An excision was done. After a year the patient, a vigorous young woman, had recovered power and had a literally perfect function of arm and shoulder. Etiology.-Etiologically, they result usually, perhaps always, from hyperabduction on a fulcrum either of the acromion or of the resisting adductor muscles. Probably this lesion does not occur from direct thrust on the elbow. Lesions^-Pathologically, they show no peculiar character except that the tear of the capsule lies a little lower than in the subcoracoid types. The subscapularis is ordinarily not involved. SUBLUXATION DOWNWARD 203 Symptoms.--Clinically, they show a sharper abduction than the subcoracoid type, a somewhat different attitude of minimum dis- comfort. (See Figs. 187 and 214.) Beyond this we have only the slight shortening (measured from acromion to external condyle) and the presence of the head (palpable in the arm-pit) as guides. Reduction.-Reduction is ordinarily possible by any method ap- plicable to the reduction of the subcoracoid type, but the form of proce- dure probably most advisable is that of lateral traction combined with upward pressure on the humeral head. If this fails, upward traction, with pressure on the head, should lead to success. Fig. 216.-Impacted fracture of the head of the humerus. This patient was far away from town and saw no doctor for three weeks. During this time the subluxation from gravity (by pull of the arm on weak or damaged muscle) shown in the picture. After proper treatment-mechanical support, massage and exercises-the downward drop entirely disappeared and she obtained a pretty good shoulder. SUBLUXATION DOWNWARD There is a class of cases (ordinarily confused with the traumatic luxation) due to drag; drag from the weight of a heavy, helpless arm! They are seen usually in association with humerus fracture at the surgi- cal neck, or lower down, in cases that have been subjected to the respectable treatment of traction to reduce shortening, whether by Bardenhauer's or by simpler methods. Figs. 216 and 234 show what happens. Years ago, Dr. J. W. Courtney, then of our staff, overhauled some of these cases for me; found that they did show a reaction of degeneration in the deltoid, but wisely assured me that this did not imply nerve damage; at least not necessarily. Since then, I have seen many cases in which it seemed to me clear that (as I had long suspected) the real element of weakness-the real cause of the luxation-was the paralysis of the deltoid, not from the 204 THE SHOULDER original trauma, but from the drag of the heavy helpless arm. Since I came to see this matter in this light, I have been very careful in using traction; often using traction for a few days only; then using actual support of the arm, and my cases have done far better. Figs. 234 and 235 show what happens to a heavy swollen arm under such conditions; under pull and at rest. Fig. 216 shows the sort of luxation that depends purely on loss of muscular support at the shoulder. Personally I believe that nearly all the downward subluxations are purely paralytic, and that the paralysis is due to unrelieved tension on the muscles; allowed because of our blind belief in traction as the treat- ment in routine humerus fractures. I have seen certainly a dozen or two cases in the last few years, in which temporary deltoid paralysis resulted from traction. Not all of these showed subluxation but a number of them did. I believe that the subglenoid luxation is traumatic directly! I believe that all other downward luxations or sublux- ations at this point are paralytic in origin and that many of them may be avoided by understanding the possibilities of carelessness in this regard. LUXATIO ERECTA This is the type in which the arm is directed up- ward, close to the head, the hand usually resting on the head.* The type is excessively rare. The cause is extreme abduction, accompanied sometimes with a blow on the humeral head from above. In one case, at least, on record in the literature there was an associated acromial fracture. The condition is one of a subglenoid or axillary dislocation, in which the head is driven down to an extreme extent, while the intact muscles and ligaments, acting as a lever of the second type, hold the arm in extreme abduction. Very extensive tearing of ligaments is probably the rule. The diagnosis is obvious. Reduction is by traction upward and by direct pressure on the head. Reduction seems to have presented no peculiar difficulty in the recorded cases. The prognosis differs from that of ordinary luxations only in the greater probability of injury to the circumflex nerve. SUPRAGLENOID LUXATION This lesion is so rare as to be almost negligible. Many of the recorded cases were observed so late as to be invalidated, so far as details go. There are, however, certain cases, such as that of Holmesf (an autopsy at five weeks after injury), which establish the type. * Montgomery, Ann. Surg., 1905, xli, 475, records one of the few recent cases, f Holmes: Med.-Chir. Trans., 1858, xli, p. 447. Fig. 217.-Lux- atio erecta (diagram- matic). POSTERIOR DISLOCATIONS 205 In this case there was a broken coracoid, the humeral head was plunged upward and forward through the deltoid muscle, the capsule was extensively torn at the upper and inner part, and the biceps tendon, untorn, had slipped outward. Other cases recorded show an associated fracture of the acromion. The total of alleged cases on record is considerable; many of them, however, were examined only long after the original injury. So far as we know, this lesion necessarily occurs from a direct thrust upward and forward, exerted through a blow on the elbow. The diagnosis must be obvious, even on inspection. The only question would be that of displacement of the humeral shaft up and in, with fracture of the surgical neck or with epiphyseal sepa- ration-a question readily solved. Obviously, the mode of reduction would be by traction down and backward. There seem to be no fresh cases on record, so that we may advance no argument for such plan of reduc- tion other than its reasonableness. Fig. 218.-Supra- glenoid dislocation, with fracture of the acromion (diagram) INWARD OR INTRATHORACIC LUXATION A very few cases are recorded in which the head of the humerus has been driven inward through the chest-wall. These correspond in a way to the luxations of the femur through the acetabulum. They must occur from direct inward thrust, exerted through the abducted arm by a blow on the elbow. The diagnosis depends on the marked abduction with fixation and shortening, on the presence of thoracic symptoms, and on the absence of the humeral head on the out- side of the thorax. Usually, one or more ribs are broken by the passage of the head. Cases are on record in which the ribs have been forced apart, not broken. Reduction and Treatment.-The treatment must be obviously by right-angled traction, with rotation and rocking to bring the humeral head out again from the thoracic cavity to a position external to the ribs. From the stage where the head emerges from the thorax we have to deal with what is practically a subglenoid luxation, to be handled in the usual way. Fig. 219.-Intrathor- acic luxation. Penetra- tion of the thorax by the head of the humerus. The ribs may or may not be broken (diagram). POSTERIOR DISLOCATIONS Of these, we have the types described as subacromial and subspin- ous, differing only in degree of displacement, showing essentially the same deformity, amenable to the same schemes of reduction. Both 206 THE SHOULDER are but rarely met with as actual results of trauma. 'Congenital" luxation backward is not rare. Etiology.-These luxations occur from backward thrust, favored by rotation inward, by elevation, or by adduction. They occur from falls, or, not very uncommonly, from muscle action suddenly, as in the extreme spasm of epileptic convulsions, or slowly, from the pro- longed unbalanced muscle pull in cases of ob- stetric or infantile paralysis.* Pathology.-The rd nt in the capsule lies posteriorly-across the back of the jo nt, below the insertion of the supraspinatus muscle. The tendons or the muscle bellies of the short external rotators may be torn. The subscapu- laris may be torn (Cooper). Sometimes the greater tuberosity, torn loose, remains in its relation to the glenoid cavity, not to the head; the biceps tendon may be torn out of its groove. (See Fig. 221.) Symptoms.-Clinically, we have the head of the bone palpable behind its normal position, and its normal prominence above and in front is replaced by a flattening or hollowing. The arm is, as a rule, raised up and forward and rotated inward, with more or less adduction; Fig. 220.-Subacromial luxa- tion (diagram). Fig. 221.-Thirty-foot fall; died, after reduction, of other lesions. Capsule destroyed above; greater tuberosity fractured split and displaced. Biceps tendon had torn out of groove (sketched from Malgaigne's pl. xxii, Fig. 5). there may even be adduction across the chest, so that the hand rests most comfortably on the head. We may, on the other hand, find the elbow closely appressed to the chest. * In these paralytic cases, the capsule is not torn, though the lesion, at first a subluxation, may have become complete. There may be in the end, considerable changes in bone shapes all about the shoulder. 207 POSTERIOR DISLOCATIONS In general, moderate adduction characterizes the subacromial type; the subspinous type involves rather an abduction and an increased separation of the elbow from the side. The case in Fig. 223 shows the subacromial type. There seems to be, judging from reported cases, a good deal of variation in the deformity with either type. With either type there is, of course, a sharp limitation of the range of motion. Reduction proceeds along obvious lines. Trac- tion on the arm in its long axis, combined with alternating outward and inward rotation and with rocking movements, seems to have sufficed to reduce the cases on record. Digital pressure forward on the protruding head is of some importance. Adduction of the arm helps to clear the humeral head, so that it may pass over the posterior glenoid edge. Raising the Fig. 222.-Subspinous luxa- tion (diagram). Fig. 223.-Posterior luxation. Subacromial type, unreduced for several months (author's case negro woman of fifty years, luxation due to epileptic convulsion). arm up and forward and inward rotation all tend to relax the taut liga ments and to aid reduction. 208 THE SHOULDER Recurrences are reported in some number in cases supposed to be traumatic. Obviously, in "congenital," paralytic, epileptic, or other spastic cases recurrence may be counted on unless we do an open operation, and perhaps then. That recurrence should occur in a case like that of Cooper's in which the subscapularis was wholly torn off need excite no remark. COMPLICATIONS-FRACTURES Fractures that may complicate shoulder dislocations are those of the glenoid, acromion, coracoid process, greater tuberosity of the humerus, lesser tuberosity of the humerus, anatomic neck of the humerus, surgical neck of the humerus. Fig, 224.-Fracture dislocation. The cross shows the center of the displaced head (hard to see even in the good negative). Excision done with good result. Fractures of the glenoid are not very rare; they involve only the anterior edge of the glenoid, as a rule.* Such fractures do not inter- pose any obstacle to reduction, but do predispose to recurrence. Fractures of the glenoid involving more than an edge of the glenoid cavity, fractures approaching the surgical neck of the scapula, are a rare complication of dislocation. I have seen but one case of this sort. It did not interfere with reduction, but shared with a deltoid paralysis that accompanied it in the causation of an extreme dropping downward and forward of the reduced head of the bone. Apart from the x-ray we have no means of diagnosis of glenoid fracture save for crepitus and the tendency to immediate reproduction of the deformity after reduction. * Some separation of part of the cartilaginous glenoid edge is probably even commoner than fracture. COMPLICATIONS FRACTURES 209 Fractures of acromion or coracoid occur rarely, but seem to offer no difficulty in reduction and no influence on prognosis. The interest centering in them is practically one of differential diagnosis of such fractures as against others in this region which are of greater clinical import. They may accompany practically any of the described types of luxations.* The diagnosis rests on local tenderness and ecchymosis, on crepitus, and on palpation of the loose fragments. Separation of the greater tuberosity, not uncommon, gives more or less crepitus, and may give a palpable loose fragment near the empty Fig. 225.-Bursa and joint exposed for operation on supraspinatus tendon. Left shoulder seen from above. 1, Torn supraspinatus tendon: distal portion (this was an accidental finding on the cadaver.) 2, Same: proximal portion. 3, Edge of opened subacromial bursa. 4, Other edge of same. 5, Floor of the bursa and infraspinatus tendon. 6, Deltoid muscle, cut edge. 7, Same. 8, Same: cut close to origin from clavicle. 9, Same. 10, 11, Acromion, chiselled across just outside the acromioclavicular joint. 12, Acromioclavicular joint. 13, Acromiothoracic artery. 14, Coracoid process. 15, Tendon of subscapularis. 16, Coracobrachialis muscle. 17, Biceps- short head. 18, Biceps-longhead--in its sheath. 19, Vein. 20, Pectoralis major. 21, Clavicle. 22, Head humerus. glenoid. It is relatively unimportant except in so far as imperfect (fibrous) union may give some weakness of the muscles that raise the arm and rotate it outward, and in so far as resultant thickening may impede motion. Apparently the separation between the adherent tuberosity and the wandering head has no especial bearing on the ease of reduction or on the method to be employed in reduction. These cases I have found by experience to do very well in abduction treat- ment. It is a safeguard against a separation of the tuberosity that * Malgaigne (Atlas, Plate XXII, Fig. 4) figures a specimen found in the dis- secting room with an unreduced subcoracoid luxation and an unrepaired coracoid fracture. The displacement was trifling so far as the coracoid was concerned. 210 THE SHOULDER might later give great limitation of abduction by its contact with the acromion on attempted motion. Moreover we have in these cases a chance of subdeltoid adhesions, an added reason for the abduction position. Fracture of the lesser tuberosity (rare) might be dismissed in the same phrase, were it not that such fracture liberates the biceps tendon from its groove, and may permit displacement of this tendon or possibly its interposition in the way of reduction.* Presumably any such displace- ment of the lesser tuberosity is likely to be rather out of than in the way of the dislocation f-and of Fig. 226.-Fracture of the anatomic neck, with chipping of the tuberosities, complicating luxation. fOld case. Head excised: after result. Fig. 227.-Subluxation with ;fracture of the tuberosities and surgical neck. its reduction; i. e., the muscles will probably pull it out of the way. Fractures of either tuberosity tend, on the whole, to slight displace- ment only, since the periosteal and ligamentous connections are close. * A couple of very interesting cases of displacement of the biceps tendon by muscle action, without dislocation or fracture, are reported by Hennequin and Loewy (Les Luxations des Grandes Articulations, Paris, 1908, pp. 60, 61). In one case reduction occurred on abduction and inward rotation. The diagnosis rested on pain on abduction and on outward rotation, and on direct palpation of the cord of the displaced tendon. t In a case of my own there was a subcoracoid luxation with a T-split running between the tuberosities. The biceps tendon had slipped into the split. It had to be divided to allow reduction: it was then sutured. COMPLICATIONS FRACTURES 211 Ordinarily these complications are important only in the differential diagnosis as against simple fractures of the anatomic or surgical neck, and in so far as they affect prognosis of the eventual usefulness of the arm. Fracture of the anatomic neck complicating luxation seems to occur very rarely (Fig. 226; see also Fig. 228);* the differential diagnosis between such fracture alone and luxation alone will be considered later. Fracture of the surgical neck complicating dislocation does occur, and is a most formidable complication. The cases recorded are nearly always of anterior luxation. Some few result from over- vigorous attempts to reduce luxations. Obviously, the breaking-off of the head of the bone throws out all diagnostic points usually indicating luxation. To all in- tents and purposes we have an apparent fracture of the neck. The important fact of a disloca- tion of the head is discoverable only by the absence of the head from its normal site and the actual presence of this head pal- pable outside the socket, and un- affected by motions of the shaft. Crepitus may be present or it may not.f Obviously, all our methods of reduction are of little use in this condition; it is possible that enough connection of fragments may be retained to permit of reduction by right-angled trac- tion, with outward pressure on the head. Successful issues of this manoeuver are recorded in some number. If this fails, the ancient and classic method advised is to wait for union of the fracture and then to reduce. Fig. 228.-(Same plate as Fig. 212.) Fracture of anatomic neck and of tuberosity, with luxation. * Since the above was written I have seen a second case with a displacement of the head under the coracoid process, with the tuberosities lying in the glenoid cavity. The case was not seen until seven weeks after injury. Owing to pressure on nerves, the head had to be removed. In two other cases, not fresh, the head was removed because reduction seemed mechanically impracticable. In still another case, the head was replaced and union took place; there was not, however, any real gain in function over the resected cases, and I think the saving of the head of debatable advantage. < f Not uncommonly we may find in the x-ray an apparent dislocation of the head with fracture of the surgical neck. In fact, these seem rather to be subluxations. Fig. 227 shows such a case. There was no real luxation disclosed at the operation. 212 THE SHOULDER This is hardly rational or encouraging; the more so as these cases, unreduced, may show not only the troubles of poor joint function, but pain from the direct pressure of the displaced head on the nerves as well. If such attempt at reduction does not succeed, as it usually does not, there is nothing for it but to operate. Operation has been done in a number of cases, and with gratifying success, by many others besides my- self. The problem is simply to cut down upon the bone at the point of the break, and to reduce the head of the bone to its normal position with the least possi- ble manipulation of the injured parts. Fig. 229.-Fracture of the shaft high up, following an attempt to reduce an old sub- glenoid luxation. This fracture was wired. Some months later I saw the case and reduced the luxation by open operation with partial resection of the head. Rather good result. Fig. 230.-Subcoracoid luxation, with avul- sion of the gerater tuberosity, before reduc- tion. McBurney, years ago, devised a simple but ingenious method, consis- ting of the use of a right-angled traction hook, inserted into a drill-hole at the lower end of the upper fragment. This manoeuver renders rotation and traction perfectly simple, with but little hand- ling of the parts. This procedure was used by McBurney with a perfect result in a case first seen two weeks after the injury. This was in 1894.* The method has been used several times since with excellent results if interference is undertaken early. The incision to be used is the anterior, reaching the joint through the interval between deltoid and pectoral, severing no muscle, and imperiling no vessels or nerves. There is no question but that this method should also be used in the cases where the humerus has been broken in attempts at reduction. * C; N. Dowd: Annals of Surgery, 1894, i, 399. NERVE LESIONS 213 Unfortunately, considerations other than the simple surgical ones often prevent its use where such an accident occurs. In cases where luxation coexists with fracture, whether from the original injury or following a break during attempted reduction (Fig. 229), the results are surprisingly good, even if nothing is done. The shoulder is necessarily a relatively stiff one, but the humerus becomes fixed at such an angle that the elbow no longer stands out from the side, and the scapula, as always with a stiff joint at the shoulder, gains so much mobility as to give a very fair range of motion to the arm- sufficient for many kinds of work. If there is non-union, the pseudar- throsis will give a very tolerable joint unless there is marked secondary arthritis. The practically important point in these graver shoulder lesions is not the mechanical restoration, so much as the presence or absence of pressure lesions of the brachial plexus, particularly those due to persistent tension of the nerves across the displaced head. Damage to nerves is lamentably common in luxations-commoner than is usually realized.* We may have tearing of the brachial plexus NERVE LESIONS Fig. 231.-Relation of the trunks of the brachial plexus to the head of the humerus. Note how closely the circumflex wraps around the neck, and how high up the musculospirai runs to the back surface. The damage with any displacement of the head may be from either push or pull. in the neck (Fig. 231), due to the same violence that causes the luxa- tion,-not to the luxation itself,-or we may have damage to any or all of the nerves, caused by their being stretched over the luxated head; * Holm (Schmidt's Jahrb., cxxi, p. 82) cites a series of 112 luxations with no less than 7 cases with general paralysis of the arm, and 10 with deltoid paralysis alone. Tubby and Jones (Surgery of Paralyses, 1903, p. 248) cite 38 cases of nerve and vessel injury. They attribute the injury to reduction by the "heel in the axilla" method in 29 of these cases. Muller (Centralbl. f. Chir., 1892, p. 611) notes a case of gradual paralysis from scar pressure, verified by operation. 214 THE SHOULDER or we may have injury to the circumflex nerve alone,* due to stretching of this nerve by the simple displacement of the humeral head, just below which it is so closely entwined about the shaft (Fig. 232). Fig. 232.-The course of the circumflex nerve around the neck of the humerus seen from behind. Fig. 233.-Sensory areas. On the left are shown the areas corresponding to the fifth to the eighth cervical segments of the cord; on the right, the areas of distribution of the nerves; c, circum- flex; ich, intercostohumeral; m.s, musculospiral; m.c., musculocutaneous; w, nerve of Wrisberg; e.c., external cutaneous; i.c., internal cutaneous; r, radial; m., median; u, ulnar. * Broadly, we may say that these plexus lesions result most often from pull on the plexus, just as the obstetrical paralyses result from like traction; luxation or fracture, common enough, may or may not accompany the lesion. In cases where anterior luxation results from a fall on the shoulder it is not easy, even for a neurologist, to discriminate between the direct results of deltoid contusion and the circumflex lesion. This is because of the difficulty of electric stimulation of the deeply situated nerve. Both lesions are serious; both ordinarily recover with time if no other paralyses are present. In general, I think the fre- quency of actual lesions of the circumflex nerve rather over-estimated. See note on subluxation and deltoid paresis from continuous traction (p. 203). NERVE LESIONS 215 Any of these injuries may result from overzealous attempts at reduction, as well as from the first trauma. The frequency with which even the more serious forms of nerve Figs. 234, 235.-Old subcoracoid luxation, with extensive motor paralysis of the left arm and shoulder (brachial plexus or root lesion). Note the atrophy and the downward drop- ping of the arm. Regained some power under treatment. Fig. 236.-Old subcoracoid luxation. Very nearly total nerve lesions as to motor power. Note the atrophy and the down and forward droop of the shoul- der away from the acromion. There was little if any improve- ment in this case from any treat- ment. damage are entirely overlooked at first is the only reason for the series of plates appended (Figs. 233 to 239). In regard to these nerve injuries, it is perhaps fair to say that our first interest may rightly be that of self- protection. They may result from the luxation or from the reduction, and the first thing we should attend to after establishing the diagnosis of any luxation is an investigation of the condition as regards the nerves, a testing of motor function and of sensation in the arm and hand. If this were more regularly done, there would be far less blame attached to the profession for alleged production of really inevitable nerve injuries, due to the trauma and not to the reduction. Given an injury of one or more nerves, we must face the question of treatment. If the brachial plexus has been torn, operation and suture of the torn ends are indicated. Unfortunately, the prognosis is bad either way, but it is better with than without operation. In lesser injuries no treatment beyond that of massage, electricity, etc., is ordinarily called for. Fig. 237.--Shows the sensory loss in the case shown in Fig. 236. It has been my fortune, or misfortune, to see in the last few years ten cases of serious injury of this sort, apparently clue not to efforts 216 THE SHOULDER at reduction, but to original trauma, in four of which the united efforts of my neurologic colleagues and myself have accomplished little.* One case resulted in practically perfect recovery; in three recovery was creditable-at least three are still improving, but by no means perfect; one I have lost track of. It may be said that a failure of the power to abduct the arm, a paralysis of the deltoid (whether due to nerve injury or muscle con- tusion) is not rare, and not necessarily very serious. Such a degree of paralysis of the deltoid, however, as results in an obvious dropping-away of the humerus from the glenoid socket, is serious. I believe such a "downward dislocation" occurs only as a result of such paralysis. Some of these cases of paralysis, even if severe, recover in time more or less completely, but we do meet with cases of permanent motor Figs. 238, 239.-Old dislocation of left shoulder (subcoracoid), with loss of motor power cor- responding to nearly all branches of the brachial plexus. Only moderate improvement after long and patient treatment. Note the great deltoid atrophy. impairment-cases in which we can do little more than establish our innocence as to any blame for the unfortunate result. In all these cases there is a stiffening at the joint, due to the inevi- table disuse, that affects prognosis even if muscle power is regained. COMPLICATIONS-VESSEL RUPTURE Axillary Artery.-Very, very rarely the axillary arteryf may be torn by the luxation or by forcible attempts at reduction, though such damage more commonly points to fracture. J The signs are failure of * Stimson's statement that "Injury to the nerves, except of a slight and transi- tory character, is rare, and in most of the cases reported as such the injury has been inflicted during reduction," is one with which I am reluctantly compelled to differ. No doubt in old cases reduction is the great danger,-and this is an argument for open reduction,-but I have seen cases repeatedly in which prompt paralysis pre- ceded reduction or was present after the most careful and simple reductions. I con- fess, however, that I personally saw none of these before reduction. t Stimson in 1885 found 47 cases on record of vessel rupture associated with shoulder luxation, and says he has known of at least two cases since then. t Loss of radial pulse alone in luxation or in fracture about the shoulder does not prove, though it suggests, vessel rupture. Pressure of displacement often lessens and may obliterate the radial pulse. 217 OLD CASES OF SHOULDER LUXATION'S the radial pulse and the prompt appearance of an enormous hematoma; sometimes this hematoma pulsates. The indications are obvious: immediate compression of the sub- clavian artery where it crosses the first rib behind the scalenus anticus, prompt incision and ligation of the torn artery, with subsequent reduc- tion of the luxation. Even asepsis must give way to the urgency of the operative relief of this condition. There may, or may not, be sufficiently prompt establishment of collateral circulation to save the arm or the hand from gangrene; either way the surgical indication is the same. Schmidt* records a case in which axillary aneurysm resulted from partial lesion of the vessel in luxation. Stimson states that both circumflex and subscapular arteries may be torn. Tearing of the Axillary Vein.-This may occur in the same way. The hematoma is less, and is less immediate in its appearance. The indication for interference is the same; the prognosis as to reestablish- ment of circulation is somewhat better. Cyanosis and swelling may persist for a long time. COMPOUND LUXATION AT THE SHOULDER This is an excessively rare accident. The penetration of the humeral head occurs most often in the axilla, but the head may be driven through the pectoral muscle, or even backward. Obviously, the complication is important only in regard to nerve injury, to excessive displacement, and to sepsis. So far as sepsis goes, there is no excuse today for such a prognosis as would appear from the cases recorded in the literature, so it is not worth while to discuss statistics. Active antisepsis is obviously in order. Whether the given case calls for drainage must rest with the surgeon's judgment. Here, as elsewhere, it is safe in doubtful cases to drain-to drain with gauze for twenty-four to forty-eight hours-not longer. OLD CASES OF SHOULDER LUXATIONS Not rarely old luxations-overlooked, in the rule-present them- selves to us. Reduction of such cases is not easy and presents definite obstacles. Obstacles.\-Strong adhesions may exist between the new cavity and the neck and head of the humerus. After a long time there may be bony changes, including the formation of an actual new glenoid cavity of bony tissue. (See Figs. 183 and 184.) There may be marked short- * Beit. z. klin. Chir., 1904. xliv, 497. t Souchon (Trans. Amer. Surg. Assoc., 1897, p. 311) collected 154 cases, admi- rably showing the obstacles to reduction in both fresh and old luxations at the shoulder. His monograph is a notable one. A more recent article, dealing exhaustively with the question of hindrances to reposition, is by Bach (Deut. Zeit. f. Chir., 1906, Bd. Ixxxiii, p. 27). 218 THE SHOULDER ening and rigidity of the muscles. There may be such entire healing of the rent in the capsule, through which the head escaped at the time of injury, as to make the reentry of the head impossible. There may be firm adhesions between the capsule and the glenoid cavity. This process may uncommonly have gone on to the point of entirely filling up the cavity, leaving no place into which the head may be returned. Of course, these difficulties may occur not singly, but combined.* The amount of actual difficulty that each of these complications, or all of them combined, will offer in attempts at late reduction must depend largely on the time elapsed since injury. These represent the mechanical difficulties that oppose themselves to late reduction. They do not, however, measure the difficulties of late reduction, for such procedure carries not only difficulties, but Fig. 240.-Old subcoracoid luxation of right shoulder. The photograph shows little; palpation left no doubt of the lesion; it was confirmed by the x-ray. Disability was extreme. actual dangers-the danger of fracture or of damage to vessels or nerves during manipulation. jWorst of all is, of course, the rupture of the axillary artery. This is not an extremely rare accident. It occurs from the traction on adhe- sions which have involved the vessel, which have so glued it down to the humerus as to expose it to a tearing strain on reduction. The presence of arteriosclerosis is, of course, a favoring factor in such rupture. Within ordinary limits of force used it is a question not so much of the manner of reduction as of the lesions previously present. Listonf cites a case in which there was a firm fibrous band uniting coracoid process and humerus with an intimate connection with the sheath of the axillary artery. This occurred after only eight weeks. The artery, which was somewhat atheromatous, was ruptured in reduction, and despite the prompt operation which was performed, the patient died. The operation was an excision of the head of the humerus after securing the artery at the point of rupture. The conditions found at autopsy * In one of my cases the x-ray showed fracture of the surgical neck and a split between the head and the tuberosities. Operation disclosed the biceps tendon dropped into this interval. Only by section of the tendon was reduction made possible. The tuberosities were held in place with a steel pin; the tendon was reunited in place. The result was excellent. t Edin. Med. Jour., March, 1873. 219 OLD CASES OF SHOULDER LUXATIONS in this case are of interest; a broad and strong band of fibrous tissue connected the humerus with the coracoid process, and also with the sheath of the axillary artery which lay above it. The vessel was, there- fore, necessarily subjected to traction, because it was no longer movable in its sheath. This case, which is by no means an isolated instance, must be placed over against the cases reported in which late reduction has succeeded. Reduction without incision is dangerous. I am inclined to favor opera- tive reduction of old luxations, as a routine, but from results published and from cases 1 have operated and have seen, it is impressed on me that we can expect, not perfect results, but at best a serviceable improve- ment in function. In cases where there is fail- function with the head out of the socket we may well pause and consider what operation has to offer. Here and in other old dis- locations our rules of procedure have still to be modified by the greater safety of modern aseptic work. It is probably safe to say that, in patients able to stand an anesthetic comfort- ably, few risks attend the open procedure. With this open procedure we avoid not only the vitally serious danger of rup- ture of vessels and nerve tra- uma, but also the unfortunate fractures of the humerus which have so commonly attended attempts at reduction long after injury. Moreover, in an open wound nerves, as well as vessels, may be retracted; without the inspection possible through the wound we do not know where they are, and whether or not they are stretched across the head or dragged on by adhesions. Nerve injuries associated with dislocation are not rarely the results of attempts at reduction, especially in these late cases. In case open operation is done, access to the joint is most readily obtained by the anterior incision between the deltoid and the pectoral muscles, an incision which exposes the neck of the bone and gives good Fig. 241.-Detail of operation on the case shown in Fig. 240: a, Greater tuberosity; b, front of acrom- ion; c, coracoid; d, d', deltoid (cut edges); e, biceps tendon; f, biceps and coraco-brachiales; g, vessels and brachial plexus. 220 THE SHOULDER access to the displaced head. Before reduction some division of the capsule or of the adhesions which bind the head below the coracoid will be necessary. In accounts of operations published it is often stated that the subscapularis tendon is divided. As a matter of fact, in these old cases the distinction between tissues is largely lost and the anatomic structures next the joint are hardly to be made out. What we do, in fact, is to cut fibrous tissue on the inner side of the head until the head is free. We cut the capsule, true or false, which covers the head, and enlarge a way by which the head may return between the glenoid cavity and the posterior part of the capsule which lies ovei' the cavity. To do very accurate work one must expose by the large sabre-cut incision of Codman, which I have found very useful and less formidable than it looks. I have had no trouble with it. Posterior displacements are most easily reached from behind, or best of all, through a horizontal incision dividing the deltoid at its acromial origin. This divides no important nerves, cuts no vessels, and I have found it to give an admirable expo- sure of the structures hereabouts. The muscles are, of course, sutured before clos- ing the wound. In old paralytic posterior luxations dating from childhood it is often necessary to section the deformed, down- ward-hooking acromion before reduction. The filling up of the glenoid cavity by anything firmer than light adhesions is a very late, not an early result, and such adhesions will not ordinarily interfere with reduction. In certain cases there may be serious difficulty in reducing the head or in securing a satisfactory bed to replace it in. In these cases, rather rare ones, it may be well to consider an excision of the head of the bone. (See Fig. 229.) So, too, in cases like that above noted, operated on for rupture of the artery, or in cases where the brachial plexus, already stretched, is likely to sustain serious injury dur- ing reduction, excision may also be called for (p. 211, footnote). In choosing excision rather than reduction we must, however, be prepared for a functionally imperfect result. Late results in the unoperated case may give a stiff joint, but exci- sion often gives one so weak as to be of no great use except for elbow and forearm work. Cases of excision in which there is any power of abduction that is practically useful are not the rule. This is because the head of the bone is a necessary fulcrum. It is interesting to note, however, that in the cases of operative reduction reported even an extensive removal of the tendons from the head of the bone, as in some cases that Lister has reported, seems not Fig. 242.-Burrell's operation for "reefing" the capsule in recurrent luxation: a, Deltoid; b, pectoral divided; c, cephalic vein; d, lat. dorsi; e, long biceps head; f, shaft; g, sub- scapularis and anterior caps.; h, bi- ceps, short head; i, pectoralis minor; j, coracoid. 221 CONGENITAL LUXATIONS to interfere with the good result, as attachments are reformed, and the muscles take up their work in better fashion than would be expected. RECURRENT LUXATIONS Recurrent luxation is rare compared with the great frequency of primary dislocation at the shoulder. It has been assumed that a chipping of the glenoid is the cause,* but this by no means is proved as the rule. There is an obvious connection between tearing of muscle attachments and reluxation, but it is hard to demonstrate clinically. Defects of the head of the bone (traumatic?) have been reported repeatedly. In the rule it is the anterior luxation that recurs, and the displace- ment happens in abduction. Replacement is easy. Avoidance of abduction may suffice to avert luxation. I know of one subject of this trouble who used an elbow-strap fastened to his belt to insure against abduction, and with success. If the displacement occurs often, operation is indicated. The operation is a "reefing" of the capsule reached through an anterior incision. (See Fig. 242.) Burrellf and others have had excellent success with this operation. So have I in my ten cases, with no recurrences. Such luxations are rare at the shoulder except as the result of paralyses or spastic conditions that disturb the muscle balance. The result of such disturbance, in "infantile" cases, is noted under con- genital luxations. A like result from syringomyelia is recorded in the Deutsche Zeitschrift fur Chirurgie, 1905, Ixxx, 165-179. The author has seen one case in which luxation was obviously determined by muscle atrophy about the shoulder in an epileptic, and several in which infantile paralysis in children was the apparent cause of a posterior luxation. Luxations in epileptics without record of such atrophy are recorded in some number in the literature. PATHOLOGIC LUXATION CONGENITAL LUXATIONS These are not excessively rare. Almost always they are posterior luxations. R. W. Smith ± recorded and figured certain cases of anterior luxa- tion, also, apparently congenital. * Southam (Brit. Med. Jour., 1892, ii, 1192) records a case of this sort. He did an excision-and a postmortem. t Burrell and Lovett (Trans. Amer. Surg. Assoc., 1897, p. 293). Legueu, Picque, and others have recorded more recent cases (Bull, et Mem. Soc. de Chir. de Paris, 1905, xxxi, p. 564). There are many others on record. t Fractures in the Vicinity of Joints, etc. Dublin, 1850, p. 256. 222 THE SHOULDER No doubt these, and certain of the backward luxations, are really congenital developmental deformities analogous to those seen in the hip. Certain other cases may result directly from damage in delivery at birth-damage involving chipping of the glenoid or damage to the nerves only. Some of these cases unquestionably result from disturbed muscle balance, congenital only in the sense that the obstetric paralysis causing them dates from birth. Beside these, some few cases seem to be dependent on the muscle paralyses of anterior poliomyel- itis occurring in early life, though in no sense congenital. In some of these paralytic cases reduction, with incident cutting of contracted pectoral and other muscles, has given im- proved function. In others, as in Phelps' series, excision has been called for, with good func- tion as the sequel. I have had five such cases: two were reduced on section of the contracted pec- toral and got fair function; one other was reduced only after par- tial resection of the humeral head, but the result was relatively good. The last two were ex- posed by the horizontal incision, the capsular structures all divided and resutured. In one of these the acromion was divided to allow room for easy reduction. Fig. 243.-Rupture of outer (long) head of biceps from trauma: A, Normal contour; C, sketched from the photograph B. Note how the mass of the muscle has moved inward toward the line of pull of the short head (1). Note the retraction of the muscle at (4), of the tendon at (6), and the depression between at (5.) Normally, there is a distinct resistance at point (3) in Fig. A. This rupture may accompany luxation, though but rarely. Not very commonly, however, such rupture-a rupture of the long head which runs over the head of the humerus-gives a condition which may be confused with subluxation. The condition is, in fact, a subluxation of minor grade. The biceps tendon is one of the forces making for the fixation of the humeral head in its place. If the tendon is ruptured, the head tends to slip forward. Rupture of the biceps occurs from all sorts of trauma that involve sharp contraction of this muscle. Usually it happens in middle-aged men, mechanics or others, who, by heavy work, have acquired an unrecognized " occupational " arthritis. Probably the tendon has RUPTURE OF THE BICEPS TENDON BURSAL LESIONS 223 already been abraded-at all events, it gives way under strain. On examining we find that voluntary resisted flexion of the elbow gives no tension at the site of the long tendon. The mass of the muscle shifts inward, and we have a contour such as is suggested in Fig. 243. The bulging of the muscle below the tear increases with time. We may have well-marked ecchymosis along the course of the tendon after a few days. With the rupture of this tendon the humeral head very distinctly tends to move forward with any muscular exertion; it moves not into a position of luxation, but of subluxation; the anterior prominence is, however, well marked. Operations for suture of the ruptured tendon have been done with success. As a rule, however, in the individuals in whom this accident occurs, no longer young and usually much worn, operation is not ad- visable. The halving of the power of the biceps is tolerable; the opera- tion presents some risk. BURSAL LESIONS The relation of lesions of the bursae to shoulder injuries has not been worked out adequately. Codman* has shown how adhesions in the subdeltoid bursa affect motion at the shoulder, and has also indicated the role played by partial tearing of the supraspinatus tendon in causing bursal lesions.f Stimson has noted the inevitable opening between joint and bursa when the supraspinatus tendon is torn. I have sutured the tendon twice for total permanent loss of power to abduct, one case after four months, one after two years. One excel- lent result, the other a recent and promising case. How often this tearing happens, and how large a role it plays in our poor results, we do not yet know. It must be a serious factor, but there are no data as yet to help us in estimating its importance. As to lesions of other bursse, I know nothing, and am correspond- ingly skeptical. * Boston Med. and Surg. Jour., May 31, 1906. t He has also shown the way for serviceable relief in these cases. His later open operative routine has not commended itself to me. My results from rupture of adhesions (fixation in over-correction from seven to ten days, then careful mobi- lization) have been so good that I have done the open operation but a few times,- though successfully enough. CHAPTER XIII FRACTURES OF THE HUMERUS: UPPER END Here and there are reported fractures of the humeral head. These may accompany luxation, or may come independently; there may be a splitting of the head (see Fig. 246), or simply a chip split oft the articular surface. Either condition is very unusual. In either case there is a fragment FRACTURE OF THE HEAD Fig. 244.-Head of humerus from the front. Fig. 245.-Head of humerus from behind that usually lies out of relation to the head, even after reduction of the luxation that may be present. The fragment may unite to the humeral head in time, or may lie free. If it unites, it may increase the size of the head, and so limit its range of motion. If it does not so unite, we have, of course, an obstacle to motion, severe or trifling, according to its size and location. The cases I have seen have been those in which the condition had been overlooked. These cases have shown poor results before open operation--good results or relatively good results after operation. As to the results of such fracture properly reduced with early motion and massage, I have no data.* FRACTURE OF THE ANATOMIC NECK This much-written-of fracture is, in fact, rare. It consists of a break between the articular head and the tuber- osities, analogous to the fractures that occur close to the head of the * In one case, seen with Dr. Horace Binney, there was a split running through the head and not breaking out until a point about 4 inches below. Union with some deformity was prompt. This represents a curiosity, not a type, I think. 224 FRACTURE OF THE ANATOMIC NECK 225 femur. Like them, it is a fracture of the elderly. It may not be im- pacted, and may or may not be strictly intracapsular. The anatomic neck lies within the capsule, but fractures do not often coincide with the limits of the neck exactly. Since these cases have been studied with the x-ray it appears that real fractures of the anatomic neck are very rare. A few cases of frac- ture of the neck with dislocation are reported. (See Figs. 226, 228.)* Fig. 246.--Splitting offlof part of the head at the anatomic neck. The fragment pressed on the axillary vein, causing enormous edema of the arm, necessitating open operation. The frag- ment removed is shown above (two views); the relations are shown in dotted line. The fragment was removed, the remainder of the head shaped and held (in abduction) against the glenoid. The result was a useful arm, though with small power of abduction. There are some few uncomplicated fractures at this point, mostly impacted, in which the data gained through operation or otherwise are beyond dispute. There are some few museum specimens showing this fracture. Clinically, one sees cases with a bruised and slightly flattened shoulder, and the x-ray shows an altered head sometimes without definite fracture lines. From the ordinary clinical point of view this break might almost be considered as a false conception, so rare is it. (What actually occur in this region are fractures separating the head, but running through the * Since the above was written I have operated on a third case-clean fracture through the neck with the broken head lying under the coracoid process with the brachial plexus stretched across it. 226 FRACTURES OF THE HUMERUS: UPPER END tuberosities or below the tuberosities.) I have only seen six unimpacted fractures of the anatomic neck without luxation. Where there is fracture of the anatomic neck without impaction, of course, there is a probability of non-union. It does not necessarily follow that a fragment loose in the joint undergoes necrosis.* It simply does not unite and may be the cause of an irritative arthritis. Any effort at repair is essentially on the side of the shaft, not of the head. Diagnosis.-Some cases are recorded in which the displaced head has been felt, movable, with crepitus. Crepitus alone may establish the diagnosis, if we can exclude frac- ture of clavicle or scapula, or a break of or through the tuber- osities. Failing this, we must depend on disability, on local pain and tenderness, on the slight flattening of the shoulder, on the slight shortening of the arm, and on such information as the x-ray can give. Short- ening is so slight, even if there is no impaction, that its mea- surement is hardly serviceable. The impacted fractures are often doubtful, depending on x-rays that show change in the shape of the head without definite fracture lines. Treatment.-In the impacted cases we need fixation only. A circular bandage or swathe, a shoulder-cap, and a sling will suffice (see Fig. 248) and need be kept on only two or three weeks before massage rnd motion are begun, and only a protective sling is needed. Fixa- tion is ordinarily maintained far too long in these cases. In unimpacted cases we must attempt to get the best possible posi- tion. This will be obtained, as a rule, by traction on the abducted arm, with pressure on the head if it is palpably displaced. No leverage on the head is possible, as it carries no tendons and few, if any, shreds of ligament. It may be, and may remain, rotated, or it may not. The reduction is almost a chance reduction at best. Fig. 247.-Impacted fracture of the anatomic neck of the humerus (a:-ray, outlines added). * Here, as elsewhere in intracapsular fractures, a factor somewhat neglected latterally undoubtedly plays a part, namely, the presence of synovial fluid. Blood does not coagulate normally within an intact joint, and without such coagulation efficient callus-formation is impossible. How far this fact determines the fate of intracapsular fractures is hard to say. I suspect it is quite as important as poor nutrition by vessels, etc.; certainly chips of bone bathed in synovial fluid do not die -and thev do not unite. FRACTURE OF GREATER AND LESSER TUBEROSITIES 227 Fixation is carried out in the way just noted. Probably in most such cases we shall not get union anyhow, so it is unwise to put off massage to wait for it too long.* Unless there is reasonably prompt union, the indicated treatment would be excision of the fragment, leaving a clean false joint, as in excision. Such treatment would not be wise in a feeble, elderly person, espe- cially if even tolerable function can be obtained in the case in hand, with the head still loose in the joint. Such operative treatment will be called for rarely in actual practice, for it is in such patients that such fractures oftenest occur. Results.-Cases classed as of this type have typically shown excellent results in the impacted cases. Of the unimpacted, most of them unite; failing this, mechanically a false joint is tolerably good; the actual amount of func- tion seems to depend inversely on the degree of associated arthritis excited. Re- sults in operated cases are good, but nor- mal power of abduction is not attained, f and the general range of motion is limited in some measure, as a rule. Fig. 248.-Circular swathe, felt shoulder-cap, and wrist-sling. FRACTURE OF GREATER AND LESSER TUBEROSITIES These lesions not very uncommonly accompany luxations (see Fig. 212), but may occur alone. The fracture of the greater tuberosity is not rare; that of the lesser is rare. The presence of crepitus, the presence of a palpable, movable frag- ment, give the diagnosis of this fracture as a luxation complication. Sometimes the loose fragment may be felt. The treatment is that of the luxation, with protection carried on a little longer than would otherwise be necessary. J Like fractures may accompany fracture of the surgical neck. (See Fig. 266.) Here their presence may be diagnosed if we can feel the loose fragment; it may be inferred, from the apparent thickening or crepitus on palpation, but the skiagraph is apt to be needed to make sure. *More recently I have grown less pessimistic. I have latterly had four cases of loose fracture of this type: one seen too late to reduce-result fair with solid union; two in which reduction by manipulation gave rather good results with firm union; the fourth a case in which excellent reduction was followed by delayed union, but with an almost perfect end-result. t This is true of all shoulder excisions from whatever cause, and is a necessary result of the mechanics of the joint. t For consideration of the tuberosity fracture as an impediment to reduction see under Shoulder Dislocations. 228 FRACTURES OF THE HUMERUS: UPPER END Greater Tuberosity Where either tuberosity alone is broken, without luxation, we are apt to find muscle action as the cause; the result is an avulsion of the tuberosity; the displacement is not apt to be great, as some connection of the fragment with its bed usually persists. Fracture of the greater tuberosity may, of course, occur from direct violence. Displacement of the greater tuberosity is apt to be upward, with some forward or backward displacement, and with an (inconstant) rotation of the fragment. Diagnosis.-The head rotates with the shaft. There is no short- ening. There is no flattening of the shoulder. There is thickening (bony) of the region involved. There may be a palpable loose fragment. Manipulation may give crepitus. In addition to the usual local tenderness and disability there is pain on attempts at volun- tary outward rotation. The arm may tend to rotate inward. Treatment.-Treatment con- sists of fixation and if there is any separation of the tuberosity from its bed it is advisable to treat the lesion with the arm on an abduction splint, especially in case of marked upward and out- ward rotation of the fragment of the tuberosity.* In cases where this fracture complicates luxation, it may cause some trouble in reduc- tion because it remains attached to the glenoid rim and may get in the way. In other cases the fibrous attachments to the humerus are preserved, and reduction is a simple matter. Union is usually bony. Necessarily, there is some thickening and deformity. If extreme, this thickening may limit motion by contact with the acromion. It may not affect the use of the muscles inserted on the tuberosity. Some cases call for operation, just as one must operate if the supraspinatus tendon gives wav instead of the bone. (See Fig. 225.) Fig. 249.-Fracture of the greater tuberosity and of the neck (case seen with Dr. W. E. Fay; x-ray by Dr. Percy Brown). Lesser Tuberosity This process is still less often torn away, with or without luxation. The lesser tuberosity displaces inward when it gives way. When it is broken, there is no longer an inner edge to the bicipital groove, and the tendon may slip inward. * If this does not give proper reduction, open operation will be indicated. SEPARATION OF THE EPIPHYSIS 229 Diagnosis of the fracture as such depends on local tenderness and on the presence, to the inner side of the humeral head, of a hard, movable mass not sharing in rotation movements. Inward rota- tion by active muscle action is lost. Attempts at such action give pain. According to Bardenheuer, the arm tends to lie in outward rotation. Treatment is by fixation with the arm flexed and adducted, to relax the biceps and the muscles directly attached to the tuberosity, with a shoulder-cap added for protection. Results.-Functional results would seem to be uniformly good, though not perfect. There must be some persistent thickening, owing to the necessarily imperfect replacement of the fragment. SEPARATION OF THE EPIPHYSIS lhe shape and limits of the epiphysis are shown in Figs. 250, 251, 252, 254. It may be separated at any time in childhood, beginning with the separations inflicted by the ob- stetrician in arm traction, but separation is rarely met except between four and thirteen years of age. During this period it is far commoner than luxa- tion-probably much commoner than fracture of the surgical neck. It results apparently from the same sorts of trauma. The lesion is a clean separation in the earlier years; later there is apt to be a chip of the diaphysis separated with the epiphysis. There is the usual tendency to extreme stripping up of untorn peri- osteum that occurs in most epiphyseal separations. Here this stripping occurs on the outer side, as a rule. (See Fig. 252.) Displace- ment, usually of the shaft for- ward and inward, is often great. Damage to nerves or vessels is rather rare. Diagnosis.-In childhood this is the first lesion to be thought of in this region. The presence of some grave damage is ordinarily obvious from swell- ing and disability. On palpa- tion, the characteristic displace- ment is made out and the upper end of the shaft is easily felt, dis- placed up and inward. Sometimes it gives an actually visible projection. (See Figs. 257 and 259.) There is some shortening- but not necessarily a great deal of shortening. Fig. 250 .-Epi- physes of humerus at eight years (Warren Museum, specimen 334). Fig. 251.-Relation of the capsule of the shoulder- joint to the upper epiphyses of the humerus (diagram). 230 FRACTURES OF THE HUMERUS I UPPER END Fig. 252.-Shows very clearly the stripping of periosteum (still attached to the epiphysis) from the shaft. Tracing of an x-ray taken after reduction. Fig. 253.--Separation of the j.epiphysis: epiphysis rotated, shaft displaced up, forward, and a little outward (author's case). Fig. 254.-The same case after (open) reduction 231 SEPARATION OF THE EPIPHYSIS The axis of the arm is obviously displaced, just as with luxation, up, inward, and forward. The anterior axillary fold is distorted (Fig. 275). Fig. 255.-Separation upper epiphysis humerus. Fig. 256.-Separation upper epiphysis humerus. Before and after operation. (The right hand plate happens to show the rather unusual picture of an ossification center in the epiphysis of the acromion.) The head is palpable only as the normal resistance to be felt under the acromion. 232 FRACTURES OF THE HUMERUS! UPPER END There may be crepitus, but only soft crepitus, often to be brought out only by vigorous manipulation under traction, for the shaft- is apt to slip clear by the head. The injury is a perfectly typical one; the deformity is almost always the same, the displacement varying only in degree.* The shaft is pulled inward and upward by the muscles, even if not originally so displaced. The head lies in the socket, but may rotate as it does in the fracture of the surgical neck. (See Fig. 253.) Treatment.-The problem of treatment is no different from that of a fracture across the tuberosi- ties, except that-and this is important-we have in these Fig. 257.-Separation of the epiphysis, shaft displaced up and forward. On operating I found the end of the shaft buried in the deltoid muscle. Reduction was easy. Position was maintained with a single suture of kangaroo tendon placed through drill-holes. An ideal result was obtained. Fig. 258.-»-ray print (outlines sketched in) of the case shown in Fig. 257. Note how little the deformity shows in the front view. epiphyseal cases a long strip of intact tough periosteum. This seems to act as an obstacletto the ordinary means of reduction. Certainly the average end-result of a separation of the epiphysis is far less satis- factory than that of a fracture at like height in the adult, so far! as position goes. I have seen case after case with a deformity like that of Fig. 259 or even Fig. 257, after treatment by surgeons of acknowl- edged skill and carefulness, and in my own cases the results have not been what I might wish. * Original backward or outward displacement I have seen but twice. t Allis has shown how such a periosteal strip may be a real obstacle in the re- duction of thigh fractures: probably it acts in a like manner here, though the humerus head shows no great deviation from the line of the shaft. In the main, however, the obstacle here is that the strap of periosteum is short, and a pull in the line of the shaft tends, not to reduce, but to drive the displaced fragments together See Fig. 262.) 233 SEPARATION OF THE EPIPHYSIS Accordingly, my belief as to the desirable routine is as follows-we should attempt reduction by abduction, traction, direct pressure, etc., Fig. 259.-Separation of the epiphysis with moderate displacement up and forw'ard. This represents the best result obtainable by reduction and splints in this case (c/. x-rays, Figs. 260- and 261). Such a result gives little permanent deformity and good function, but is far from ideal. Fig. 260.- x-ray of case shown in Fig. 259. This x-ray shows the original displacement. (Lines- reinforced.) as for fracture. If apparently successful, we should "check" our replacement by palpation and by fresh Roentgen plates. 234 FRACTURES OF THE HUMERUS'. UPPER END If the replacement is not good, we should cut down and reduce the displacement under the eye; then suture the bones with kangaroo tendon or with a reliable catgut to insure maintenance of reduction. In this way we can secure perfect reduction and results. This operative procedure has frequently been carried out with good results by myself and others. I have operated in four cases* after repeated attempts by myself and others to reduce displacement by ordinary methods. The ob- stacle in one case chanced to be not periosteum, but an embedding of the end of the shaft in the sub- stance of the deltoid. Reduction was made and secured by a stitch of kangaroo tendon, f Convales- cence was uneventful, and a perfect functional result was secured in a very short time. (See Figs. 257 and 258.) The fact that I have not operated oftener is due purely to the conservatism of my patients and of the average surgical opinion of this community. I believe this to be an operable lesion in the majority of cases. J Results.-Cases perfectly reduced get perfect functional results. Cases ill-reduced get surprisingly good function, but retain, as a rule, a limitation of forward elevation and of abduction, owing to the deformity and thickening, and show, for years at least, an obvious deformity. Later interference with growth in the length of the arm is recorded in a number of cases, but seems so rare compared with the total number that we may almost disregard it. FRACTURE THROUGH OR BELOW THE TUBEROSITIES (Including "Surgical Neck" Fractures) The usual fracture lines are shown in Figs. 263 and 264. Solid impaction may occur, or a light impaction, or oftenest none at all. In the last case the deformity may be considerable. Fig. 261.-x-ray of the same case after reduc- tion. This plate shows a spur of the shaft (on the inner side) torn away with the epiphysis-a not unusual complication. Fig. 262.-Sketch to show the periosteal obstacle to reduction. A pull in the direction of the arrow tends to jam the fracture, not to reduce it. * And in six others, since this was written. f I can see no excuse for plates, nails or staples in these cases. In most of my own operations, I have used not even a suture, and in only one case was there any slipping, and in this case it was of trifling extent, with a clinical result absolutely perfect. Anyone who will examine the epiphyses of the next boiled chicken, at his table, will get a clearer idea of the difficulty of reduction, and the ease of retention, after reduction, than from many pages of my text. t An added argument for open operation is the chance of interference with growth or distorted growth at the displaced epiphyseal junction, if apposition is too inexact. FRACTURE THROUGH OR BELOW THE TUBEROSITIES 235 Fig. 263.-Fracture of the "surgical neck," unimpaeted. The sketch to the left, above" shows the fracture line visible in the original plate. Fig. 264.--Fracture of the surgical neck, below the epiphyseal line. The sketch shows details visible in the plate, not in the print. Fig. 265.-Impacted fracture of the surgical neck and tuberosities in section (Warren Museum specimen 8539). Fig. 266.-Fracture of surgical neck of humerus, with splitting away of the greater tuberosity. Case seen with Dr. E. G. Brackett. 236 FRACTURES OF THE HUMERUS: UPPER END The injury results from a fall, usually on the outer side or on the front of the shoulder, from abduction (leverage across acromion?), from a force applied to the elbow driving the bone up and forward/or even from a fall on the back of the shoulder. Lesions.-Apart from the vary- Fig. 267.-Fracture of the surgical neck; shaft displaced up and inward. Fig. 268.-Impacted fracture of the surgica neck (sketch from x-ray plate). ing height of the fracture lines, there is a good deal of variation in extent and direction of displacement, and of reciprocal impaction if any impaction exists. There is no use in classifying these displacements too closely, for we do not yet know what they cor- respond to in cause, in indicated treatment, or in prognosis. Figs. 263 to 274 will suffice to show the variants of type. The eroded forms Fig. 269.-Fracture of the surgical neck of the humerus. Much displacement. Loose fibrous union only (WarrenMuseum, specimen 991). Fig. 270.-Surgical neck fracture impacted in slight abduction, though to a less degree than Fig. 268 (sketch from plate). 237 FRACTURE THROUGH OR BELOW THE TUBEROSITIES Fig. 271.-Impacted fracture of humerus, fracture line running through the tuberosities (tracing from x-ray plate). (Fig. 269) seen long after injury leave us with little information as to the original plane of lesion. Associated fracture of one or both tuberosities is not rare. (See Figs. 212 and 249.) Spiral or oblique lines are not very uncommon. It may be noted that in all the cases that one would think of putting Fig. 272.-Fracture of the surgical neck, un- impacted (outlines added to poor x-ray print). Fig. 273.-Fracture of the surgical neck just below the epiphyseal line, in a child. The pointers show the level of the epiphyseal line. 238 FRACTURES OF THE HUMERUS: UPPER END in this class the lower fragment carries the attachment of the great ad- ductors (the latissimus and pectoral), while' the head carries the Fig. 274.-Case operated by the writer August 20, 1903. Smashing of the surgical neck, compli- cated by glenoid fracture (rough sketch from an inadequate z-ray). Fig, 275.-Fracture of the surgical neck: displacement of the shaft up and in (shifting of the anterior axillary fold); loss of radial pulse. Sketch by author, just before operation. Operation showed thrombosis of the brachial artery, with tearing of all coats save the adventitia. The clot was cleared out, and arterial suture (end-to-end) was done; circulation in the brachial artery returned. Evidently clotting had occurred lower down. The radial pulse did not return, but collateral circulation was established after two days, and the final result was excellent. FRACTURE THROUGH OR BELOW THE TUBEROSITIES 239 insertions of the short rotators, and, what is more important, of the short abductors. It is for this reason that, in cases in which there is no impaction, the tendency to displacement is practically con- stant, namely, abduction and some outward rotation of the upper fragment: adduction- and usually forward and upward displace- ment-of the end of the shaft. There is usually an obvious shifting of the anterior axillary fold (Fig. 275). This fracture is not very liable to inter- position of periosteum or muscles or tendons between the fragments. Nerve or vessel injuries are rather rare.* Diagnosis.-Impacted.-The signs of loca- lized damage are obvious. Ecchymosis and swelling are usual. Tenderness, voluntary fixation due to pain, pain about the joint and down the arm, are nearly always present. The arm lies at the side, not abducted, but the general axis may be displaced in- ward, giving an appearance not unlike that of the displacement with luxation. The arm is held supported by the other hand. Motion is limited only as a result of pain and spasm, as a rule. There is flattening of the shoulder from the outside, slight promi- nence of the shoulder in front. Shortening is slight, often apparently absent. Unimpacted.-If the fracture is loose, there is usually little flattening on the outside, but an ob- vious prominence of the upper end of the shaft in front-a rough prominence very different from the smooth head of a luxation, and usually lying a bit lower down. There is shortening, varying from almost nothing to an inch or more. Failure of the head to move with the shaft, to rotate when the elbow is rotated, is the best single sign; it is of no use unless the fracture is loose; moreover, we must be careful not to loosen an impacted or firmly entangled fracture to test this point. Crepitus is often obtainable in loose (or loosened) fractures, but not alwavs easilv obtainable. Fig. 276.--Fracture of neck of humerus: 1, Head of bone, rotated and a little displaced downward; 2, tuberosities displaced far up be- yond the head; 3, new-formed peri- osteal bone (courtesy of L. R. G. Crandon). Fig. 277.-Line of mea- surement for shortening. Acromial spur to external condyle. * Cf. Fig. 275. In two recent cases of vessel lesion, in one no suture was attempted: in the other, attempted and abandoned because of tension. In both, a satisfactory collateral circulation was established. 240 FRACTURES OF THE HUMERUS: UPPER END Pain on upward pressure on the elbow, pain felt at the shoulder, is of some value as an indication of fracture. Treatment. -Impacted.-In case there is impaction, our first duty is to determine whether we should not leave this impaction alone. As a rule, we should leave it alone. It is justifiable to break up an im- paction here only if the position is bad enough to justify us in taking a definite, even if small, risk of non-union. It is wise not to decide until a skiagraph is taken. If we break up the impaction, the further treatment is that of any unimpacted case. If we decide to let the impaction remain, our treatment is one of fixation and protection only-sling, cir- cular, and shoulder-cap. This must be retained for about four weeks, but massage may be begun at one week, and passive motion, gently, as soon as two weeks at latest. Unimpacted Fracture. Reduction.- Here we have to deal with a head some- times displaced forward or back, almost always rotated up and outward by the supraspinatus and infraspinatus and teres minor muscles, and pretty firmly fixed. The shaft, adducted, usually lies to the inner side, either overlapping the head or entangled with it at an angle. In either case we must use traction with direct manipulation of the end of the shaft. If we abduct the arm and rotate it a little outward, it will better correspond to the position of the head, and reduction will go better. Abduct, then, apply strong traction in the line of the arm, rocking and rota- ting it the while, and have an assistant press on the displaced upper end of the shaft, pulling it toward the head, which is supported by counterpres- sure (Fig. 278). The success of reduction is indicated by crepitus, and in fortunate cases rewarded by an interlocking of fragments. The perfection of position is tested by palpation, by measurement of length, and by the fact of rotation of the interlocked upper fragment with the arm. Sometimes traction downward, or downward and backward, is more efficient. It is all a matter of the detail of displacement. Often a leverage over the fist or wrist as a fulcrum on the inner side of the displaced lower fragment helps reduction. Fig. 278.-Reduction; traction in the line of the arm; a direct outward pull on the shaft with one hand, while the other shoves the shoulder inward. FRACTURE THROUGH OR BELOW THE TUBEROSITIES 241 Apparatus.-I have usually found a carefully fitted axillary pad, co- Fig. 279.-Grip for traction combined with outward rotation. Fig. 280.-Traction combined with inward rotation; rarely used or needed. aptation splints, closely applied, running up the outer, front, and back sides of the upper arm, a wrist-sling, a wide swathe, and a shoulder-cap 242 FRACTURES OF THE HUMERUS: UPPER END Fig. 281.-Axillary pad applied too low. Direct tracing from a;-ray plate (author's case). Fig. 282.-Same case as Fig. 281. Axil- lary pad applied at the proper level; note the improved position. over all for protection, to be a perfectly satisfactory apparatus. An elbow splint is rarely indicated. As a rule, sufficiently good entangle- ment, if we may so call it, of the broken ends can be secured so as to make the tendency to displace- ment by the pull of the deltoid comparatively slight; all the other muscle pulls may be neutralized in the above apparatus by arranging padding. Many forms of dressing have been recommended. One class rests on the theory of necessary traction in the line of the arm. These are: a weight hung from the elbow by adhesive-plaster strips applied above the elbow,* the patient being up and about, or Bardenhauer's complicated pulley apparatus for traction in bed, and, finally,-best of all, if we want light traction,-a plaster-of-Paris bandage that both fixes the arm and weights it, while the arm is supported only by a sling at the wrist.f If we have a spiral or oblique fracture, or if we must work against spastic action of very powerful muscles, one or another of these methods may be of * An internal angular tin splint may be applied, and the weight hung from this. (See Fig. 285.) This is efficient and comfortable. 1 Or the Jones traction splint, popularized during the war. Fig. 283.-Coap- tation splint seen flat and in section. Made by laying thin wood on adhesive plaster and splitting the wood with a knife. FRACTURE THROUGH OR BELOW THE TUBEROSITIES 243 use; ordinarily, they are not needed, and we had better get good repost tion first-it is not so hard to hold it once it is attained. Fig. 284.-a, Application of axillary pad, fastened with an adhesive band, b, "Internal angu- lar" splint, padded and strapped on with adhesive, c, Coaptation splints strapped on. d, Wrist- sling and circular swathe. Moreover there is a distinct risk of muscle paralysis from such traction, as is not uncommonly applied; a paralysis which tends to recovery but lasts long enough to favor the downward subluxation of the head not uncommonly seen [in x- rays of these cases. (See Figs. 264, 272, 276.) Given such a dropping of the head, and an inactive stretched-out deltoid, Fig. 285.-Wrist-sling, "inter- nal angular" splint. Traction by a weight hung on this splint by means of adhesive plaster This method is efficient only when the patient is up and about. Fig. 286.-Modified form of Dr. Geo. H. Monk "Triangle," made of J4-inch iron wire. 1-2 runs along and under the forearm; 2-3, from elbow to scapula; 1-6 gives the hand-grip, 3-4-5-6 gives the support against the body. The wire is adequately padded; the space between 1 and 2 and 2 and 3 is bridged with cloth to hold the arm. The splint is slung from points 6 and 3 around the opposite side of the neck. It is efficient and comfortable. A larger space, 1-2-3, may be allowed to let the arm lie clear of the wire. and we need not a drag but an upward thrust through the sling, to give us the best result. I have noticed this sort of thing many times in the last half dozen years, and have grown to use traction very cautiously in shoulder fractures. 244 FRACTURES OF THE HUMERUS: UPPER END Fig. 287.-Plaster for extreme abduction of the shoulder with external rotation. Shows also the comfortable method of slinging the whole thing to the head of the bed. The so-called "never- again" plaster. Fig. 288.-The "caterpillar" exercise-crawling up a wall to stretch the shoulder. An excellent and not a strenuous manoeuver. 245 FRACTURE THROUGH OR BELOW THE TUBEROSITIES Another class of devices is intended to keep the arm in abduction to correspond with the displacement of the upper fragment. Mittel- dorpp's triangle is the most used type. It may be dismissed with the remark that it keeps the arm abducted, but abducted in internal rota- tion.* The Osgood and Penhallow splint (see Figs. 387 and 388) I have used and found better in this regard, but even this is not usually adapted to this particular fracture. If abduction is necessary-that is, if on reduction in abduction we can not so entangle the fracture surfaces that the head rotates down when the arm is lowered-then the triangle devised by Dr. George H. Monks f will serve best (this is shown in Fig. 286). When such a Fig. 289.-The "down-dropping" exercise. Place the hand flat on the wall, bend the knees so as to let the whole body down, producing an abduction or forward stretching of the shoulder that can be made very precise and effective without any jar. splint can not be made readily, the same position may be secured with plaster-of-Paris (Fig. 287). The "aviation" splints of the English army type, or the better modification of Cleary, are called for in fractures of the greater tuberosity. I have not found them comfortable or secure in the fractures below the head; the Monks triangle is firmer and more comfortable. I recognize the desirability of treatment in the abducted position-the earlier recovery of shoulder motion, etc., and * The same criticism holds in regard to Albee's abduction apparatus, f Monks, Boston Med. and Surg. Jour., 1890, cxxiii, p. 183. 246 FRACTURES OF THE HUMERUS: UPPER END use it when I can, even at the cost of some discomfort to the patient, but in the average fracture of the surgical neck, the tension on the pectoral, spastic from irritation, and the tendency of the whole apparatus to work down, give a chance of displacement that can not be disregarded. Therefore save in picked cases I find myself going back to the older routine, though often going over to the partial abduction of the Pen- hallow splint after three weeks when union is fairly solid. After-treatment.-Apparatus must be worn for three to five weeks, Fig. 290.-Tie a loop in a rope or bandage and carry it over a bar overhead. Grasp the loop with the hand of the injured side, the free end with the other hand, and pull on the free end. Often it is better to let the patient do this lying in bed-the rope then goes over one of the bars of the head of the bed. according to the promptness of apparent union (tested by elevation, abduction, and rotation). Early massage and passive motion at two or three weeks help much. Hand, wrist, and elbow motions (passive) are indicated within a week. Results.-Union usually occurs promptly. Permanent non-union does occur, but is a rarity. Delayed union is less rare, but not to be expected. There seems to be no tendency to progressive deformity. Return of function is slow; as with luxations, the ability to put the 247 FRACTURE THROUGH OR BELOW THE TUBEROSITIES arm behind the head and behind the back returns last of all, but unless the reposition has been unfortunate it does return. Bursitis may occur. Fig. 291.-The "dip" carried out at a table or desk. This exercise involves both shoulder and elbow motions. For late convalescence it is excellent. Fig. 292.-Author's method of applying adhesive to maintain acute flexion. This method gives a better support through the strap running over the cap of the shoulder and does not-can not-interfere with the circulation. Do not expect end-results before four to six months, and adapt the prognosis to something near this date. CHAPTER XIV THE ELBOW Injuries to this joint are very common, especially in children under twelve years of age. In children, falls are apt to be received on the elbow, because children do not save themselves by throwing out their hands. So it happens that elbow injuries in adults result, as a rule, from severe accidents, while in children the fall that gives such injuries may often enough be very slight. From this fact, and from the ana- tomic differences dependent on the very complicated form of epiphysis Fig. 293.-The relations of the three bony points at the elbow in extension and in flexion (from behind). The marks are placed upon the internal and external condyles and olecranonforocess (diagram). at the lower end of the humerus, the fracture forms in adults ano those in children are very unlike. The luxations are, of course, practically identical. LANDMARKS The landmarks of the elbow are the olecranon, the two condyles, the head of the radius, and the lower portion of the shaft of the humerus at the front. It is often stated that the two condyles are equally distant from the olecranon, that they lie at the same height when the arm hangs at the side, and that, with the arm at right angles, the olecranon and condyles are on the same vertical plane. 248 LANDMARKS 249 As a matter of fact, the olecranon is distinctly nearer to the internal than to the external condyle, and in some individuals this difference is considerable (Fig. 293). Fig. 294.-Normal humerus (lower end) from in front and from outer side. With the arm hanging straight, the olecranon is apt to lie a trifle higher than the line between the two condyles. Fig. 295.-Landmark-drawings from the model: 1, 3, External condyle; 2, head of radius; 4, ole- cranon; 5, internal epicondyle. In the lateral view, with the arm at a right angle, the olecranon tip, as is seen in the accompanying cut (Fig. 297), lies distinctly behind the plane of the condyles. In determining the landmarks of an injured elbow not only must these facts be borne in mind, but a comparison must be made with the 250 THE ELBOW elbow on the sound side, for normal variations are considerable. In feeling for the landmarks, the elbow is flexed. The olecranon is first identified, if possible, by its continuity with the subcutaneous surface of the ulna. Shortening is measured from the olecranon. (See Fig. 299.) By pressing in above the olecranon behind, it is Fig. 296.-Shows the increase in prominence of the ole- cranon on increase of flexion (from the model). Fig. 297.-The olecranon lies behind the condyles. The dots show the prominent, easily felt points of external condyle and olecranon respectively. often possible to feel the sigmoid surface of the ulna, if there is disloca- tion (Fig. 298). The internal epicondyle may be felt in most cases without difficulty, and may be recognized by its hook-like shape and by the presence of the ulnar nerve within the groove formed by this hook (Fig. 300). Fig. 298.-Palpation of the sigmoid cavity (in backward luxation) In many instances the ulnar nerve is more certainly to be identified than any other structure about the elbow, being the only structure on the inner side, running vertically, which can be rolled under the finger.* * "The Ulnar Nerve as a Landmark of the Elbow,' F. J. Cotton, Boston Med. and Snrg. Jour., 1906, civ, p. 37. LANDMARKS 251 The external condyle can best be identified by placing the first two fingers on the external condyle and on the radial head respectively, and rotating the forearm (Fig. 301). Any point which rotates freely is presumably the head of the radius. Fig. 299.-Measurement of shortening of arm, from acromial spur (see also Figs. 181 and 277) to the tip of the olecranon. The elbow must be held at a right angle. Fig. 300.-Relations of ulnar nerve at the elbow. Right and left humerus from below. Normally, the nerve lies behind the internal epicondyle. If this process is broken, the nerve lies exposed, as shown in the lower figure. There is normally a sufficient asymmetry of the radial head so that this rotation is readily perceived, even though there be some swelling. Any fixed point (felt in this test) is probably the external condyle. Except for this test by rotation there Fig. 301.-Palpation of the external con- dyle. One finger rests on the condyle, one on the radial head in front of it; when the forearm is rotated, the two are readily differentiated. Fig. 302.-Palpation of external condyle just above the radial articulation to identify and to test mobility. is likely to be considerable confusion in this matter, as the radial head may frequently be the most prominent structure at this side of the joint. Flexion and extension at the elbow in most cases help the distinc- tion, for the condyle does not move much with the forearm, even if there is a break above it. The position of the lower part of the humerus in front is best made 252 THE ELBOW out by pushing the thumb in behind the biceps on the outer side, as shown in the sketch (Fig. 303). In determining all these landmarks in a swollen elbow it may be necessary to reduce the edema by massage. In this massage the tips of the thumbs and fingers are used, first to press in slowly until a considerable pit is produced; then this pit is, by knead- ing in a divergent spiral, enlarged to the size that is needed to bring the Fig. 303.-Palpation of the front surface of the humerus close to the joint. Fig. 304.-Synovitis of the elbow-joint- The swelling lies on either side of the joint, bisected, so to speak, at the back by the de- pression made by the tight triceps tendon. The swelling is made more obvious by flexing the joint. given landmark within reach of the finger-tip. For any fracture or luxation within a week or ten days from the date of injury this method is perfectly efficient, and, if carried out slowly, it is practically painless. Sometimes temporary firm bandaging of the part with a rubber band- age or with an elastic woven bandage is a useful preliminary to this examination. Later, there occurs in many fractures a firm infiltration of the subcutaneous and deeper tissues, especially just outside the area covered by splints, that can not be mas- saged away satisfactorily. Elbow Dislocation Dislocations at the elbow are common iirboth children and adults. They do occur from falls on the elbow, but seem to come more often from falls on the hand so re- ceived that the arm is driven into hyper-extension, or is driven for- cibly up in a position of partial extension. (See Fig. 305.) LESIONS Obviously, there must be much tearing of ligaments in all forms of elbow luxation. Fig. 305.-Mechanism of luxa- tion backward. Either the bones of the forearm are driven backward (elbow flexed) or they are thrown out by leverage (elbow hyperextended). COMPLICATIONS 253 Backward Luxation.-In the usual backward luxation the internal lateral ligament is always torn; the external lateral is usually torn. The anterior ligaments and capsule are, and must be, ruptured; behind, the damage is sometimes only a ligament tear, but often it is, in the main, a stripping up of the periosteum* from the shaft of the humerus. Either epicondyle may be torn loose: the internal is often torn off by the strain on the internal lateral ligament. If torn loose, these condylar fragments are displaced with the forearm, usually backward. COMPLICATIONS In rotatory luxation, particularly, the displaced internal epicondyle may, on reduction, be driven into the joint. There may be damage to radius or ulna at the joint. There may rarely be an entanglement of the biceps tendon behind the external condyle (Michaux, autopsy); other than this, there seem to be no tendon or muscle complications worth considering. Tearing of the brachial artery belongs to the complications of the rare compound luxation, and is excessively rare at that. (Flaubert's case of brachial artery rupture resulted not from the dislocation, but from the reduction manoeuvers.) Nerve complications, save contusion or pinching of the ulnar, are also practically confined to cases of compound dislocation. Median and musculospiral lesions have occurred. Ulnar nerve injury, on the other hand, is not rare. The ulnar nerve is rather firmly bound down in the groove behind the internal epicondyle, and it may be hurt in any kind of luxation, and is apt to be hurt if there is a tearing off of this epicondyle. Four cases in point have lately come under my notice: in one the nerve was stretched over the displaced epicondyle; in the others, the epicondyle, dragged into the joint in reduction, compressed the nerve by holding taut a strip of fibrous tissue that crossed the nerve. In other cases the mechanism is one of mere contusion at the time of displacement or of a temporary stretching, fully relieved by reduction. In a good many cases of dislocation the patients complain of temporary pain or numbness in the ulnar side of the hand. In still other cases, after injury, dense scar formation in this region ties down the nerve so that it is in part strangulated and also pulled on in the motions of the joint. I have had ten such cases, one recovering spontaneously, nine operated on, freeing the nerve and swinging it forward of the condyle into a new bed free of scar. (Cf. Cotton: Boston Med. and Surg. Journal, 1914.) Compound luxations are rare. * This stripped-up periosteum is the source of the massive formation of new bone behind and to the outer side of the joint, regularly found at operation on old luxations. Also plaques of myositis ossificans are rather common. (See p. 47.), 254 THE ELBOW If there is penetration of the skin, it is due to the protrusion of the humerus through the soft parts in front of the joint. GENERAL DIAGNOSIS OF LUXATIONS OF THE ELBOW According to the direction of the force, and more particularly according to the damage done to the ligaments, the direction of dis- placement varies. Most often it is directly backward; not unusually more or less outward as well. Rotatory luxations also occur-i. e., luxations backward in which but one lateral ligament is torn and in which there is total luxation of one bone, partial luxation of the other. These seem to be commoner than one would suspect from the scanty literature. Inward luxation, and the forward displacement, though among the well-attested possibilities, are so rare as to be only curiosities. "Divergent luxations" are still rarer. There is in the backward luxation at this joint, as in other disloca- tions, a good deal of pain. Swelling is not always especially prompt or very severe. In the backward luxations the arm is held in semiflexion (at about 130 to 140 degrees, usually); flexion is painful, and is practicable only to perhaps 110 degrees. Extension is possible to a varying extent, but is never normal. All motion is painful. There is marked muscle spasm. On inspection the displacement is obvious to the practised eye. The only question is usually between the dislocation and the supra- condylar fracture which results from like mechanical causes, and shows a similar displacement. In dislocation (backward) the olecranon lies behind the humerus, behind its normal relation; there is a concavity above it, equally per- ceptible whether it appears as a, in Fig. 306, or as b. The prominence of the olecranon is increased by flexion of the arm (Fig. 296). On examination we first identify the various landmarks-the two epicondyles, the olecranon, and the radial head. At times it may be necessary to massage away the edema, but this is always practicable with patience, except in old cases. As a rule, it is possible to feel the hollow of the olecranon at the back of the elbow, as indicated in the sketch. If this is clearly felt, the question of diagnosis is settled. (C/. Fig. 298.) The head of the radius may be certainly identified by laying two fingers, one on the external condyle, the other on the radial head (see Fig. 301), and then rotating the forearm. The internal epicondyle is recognized by its hook-like shape, and, if there is any doubt, by its relation to the readily palpable ulnar nerve.* As to the external condyle, there may be some question, especially if the dislocation be out and back or rotatory; with direct luxation back- * Cf. "Ulnar Nerve as Landmark at the Elbow." Cotton: Boston Med. and Surg. Journal, civ, 1906, p. 37. LUXATION BACKWARD 255 ward there is no trouble. If the dislocation be directly outward, of course, the external condyle will be beyond reach of palpation. If it is within reach, it may be distinguished from the radial head, which usually lies in contact with it, by the rotation of the radius, and by the fact that the condyle does not move with the radius in flexion and ex- tension. Remember, however, that a fractured external condyle may so move, though very slightly. With the five landmarks-olecranon, head of radius, internal epi- condyle, external condyle, front of lower end of humeral shaft-all determined, there need be no doubt as to the question of displacement in any of the forms of luxation, and but rarely in the fractures. Whether in the presence of a dislocation there are or are not asso- ciated fractures is not so easily determined. Avulsion of the tip of the internal condyle very often complicates dislocation, and not very infrequently small portions of the external condyle are loosened, with the periosteum. Fractures of the coronoid complicating dislocation are less heard of since the x-ray has given more accurate data. The writer has seen but three cases, though he has tested a number of cases with the x-ray in which this diagnosis preceded the skiagraph. Fractures of the radial neck or head are rather rare complications. Cases in which dislocation seems to be complicated with fracture of the external condyle as a whole often prove to be backward and outward dislocations uncomplicated-at least this has proved to be so in the writer's cases. As a rule, it seems safe to generalize that the chances are heavily in favor of a dislocation being uncomplicated, unless the internal epicondyle is torn away. The common mistake is not the overlooking of these fracture com- plications, but that of diagnosing dislocation when, in fact, there is only a fracture, entirely above the joint. LUXATION BACKWARD Such luxations are very common and form the overwhelming ma- jority of elbow dislocations. They occur both in adults and in children. a b Fig. 306.-Luxation backward may give, in case there is no swelling, the diagnostic outline seen at the left (a); the sketch on the right (b) is the usual picture, with swelling, less readily diagnosed. The general appearance is obvious from the illustrations (Figs. 306, 307, etc.). Swelling and pain vary greatly. If there is little swelling, 256 THE ELBOW the diagnosis is often made almost on sight. The diagnostic points have been gone over under general diagnosis and hardly need more discussion. Careful identification of landmarks-very easy unless there is swelling-gives positive diagnosis. Complicating fractures are rare, and are usually diagnosed only during or after reduction. Fig. 307.-Sketched from Cooper's plate. A dissection of a backward dislocation at the elbow: A, Humerus; B, olecranon; C, radius; D, ulnar shaft; E, internal condyle, trochlear por- tion; F, coronoid process; G, inner surface of capsule; H, brachialis anticus; I, biceps tendon; J, triceps; K, brachialis; L, biceps muscle. Reduction.-The overwhelming majority of dislocations are back- ward, or back and slightly outward. They are usually easily reduced. There are several methods. The writer has almost always used Fig. 308.--Fresh luxation backward (outlines added to x-ray print). Fig. 309.-Backward luxation, over a fortnight old. one-moderate extension downward, traction on the forearm, with counterextension on the upper arm, then a sweeping motion down and into flexion, with some attempt at separation of the joint surfaces as flexion is begun (Fig. 320). This has never failed to work in recent cases.* * Save in one case, in which traction and hyperextension worked instantly., LUXATION BACKWARD 257 Another method, gentler and equally effective with the readily reducible dislocations in children, is as shown in Fig. 319. Here the weight of the arm gives most of the forward traction. Fig. 310.--Old unreduced backward luxation of left elbow, girl of eleven years The thumbs shove the olecranon down and forward, while the fingers steady the arm and give counterpressure. Fig. 311.-Backward dislocation, twenty- four hours old. Readily reduced under ether (plate poor, freely retouched). Fig. 312.-x-ray; same case as Fig. 310 A method much described and a good deal used is direct traction with hyperextension. (See Fig. 323.) This seems based on the theory that the tip of the coronoid process will catch, and will not pass over the humeral surface. In fact, it will so pass without trouble, and this 258 THE ELBOW method has always seemed to me unnecessary, though unquestionably effective; it is open to the objection that it must further strain the remainder of the anterior ligaments, etc., already seriously torn. The reduction over the operator's knee (Fig. 325) is open to the same objections. Fig. 313.-Front view of same case (outlines added). Fig. 314.-Old backward dislocation with avulsion of part of external condyle. Drawing from plaster cast in the author's collection. The bow-string prominence of the triceps ten- don is well shown. Another method, gentle, showy, and moderately efficient, is shown in Fig. 324. Fig. 315.-x-ray of original of cast shown in Fig. 257. Fig. 316.-Photograph of outward and backward luxation with fracture (loose) of the external condyle. Reduced without incision; good functional result, but only partial union; of condyle. Neither this last nor the second method described practically ever calls for anesthesia, while the others either may or may not, according LUXATION BACKWARD 259 Jig. 317.-x-ray of the case shown in Fig. 316. Fig. 318.-Bone sketch, showing conditions in same case as Figs. 316, 317. Fig. 319 Reduction by shoving with the thumbs on the olecranon, thrusting forward and down- ward. 260 THE ELBOW to the time elapsed, and according to the sensitiveness of the individual. With very muscular patients reduction without anesthesia may be Fig. 320.-Reduction by flexion, traction, and counterextension. Note that the operator's right hand shifts, thrusting first downward, to carry the forearm bones clear, then backward, to give counterextension. Fig. 321.-Elbow luxation, old (from Dr. S. A. Mahoney of Holyoke) injurious; under ether the muscles slacken and less force in manipulation suffices. OUTWARD LUXATION 261 Fig. 322.-Same after open operation by Dr. Mahoney. Fig. 323.---Reduction by hyperextension, downward traction, and flexion; diagrammatically represented. Fig. 324.-Reduction of posterior luxation by flexion and leverage, the operator's elbow being used as a fulcrum. This is a spectacu- lar, but fairly efficient, method. Fig. 325.--Reduction of posterior luxation by pulling and flexing the arm over the opera- tor's knee as a fulcrum. OUTWARD LUXATION Of the other forms, the outward displacement is least uncommon. Not infrequently a dislocation that must be classified with backward displacements lies also somewhat outward, but a real outward luxation is rare-that is, a displacement such that the coronoid is still in front of the humerus. (See Figs. 329-332.) 262 THE ELBOW Three varieties of such displacement have been described: 1. Complete (without pronation). 2. Complete (with pronation). 3. Incomplete. In the complete forms not only are the lateral ligaments gone, but necessarily the anterior ligament as well, and the destruction of the soft tissues is necessarily great. The distinction between the two forms is that in the first the forearm is displaced directly out and up, without rotation (Fig. 333); in the second there is such rotation and we have a position like Figs. 329 and 334.* In the incomplete form the ulnar sigmoid has not entirely left the articular surface, and assumes the position of Fig. 335, with more or less rota- tion. Hutchinsonf described an autopsy on a case of this incom- plete type-a case in which reduction was done during life, but postmortem the luxation was readily reproduced. The sigmoid notch embraced the ex- ternal condyle; the head of the radius projected. The annular ligament was intact, but both lateral ligaments were com- pletely torn, and rents appeared in the anterior capsule. No fracture of the epitrochlea was noted. Hueter, however, found epitrochlear fracture in resections done for this dislocation, as did Stimson. The displacement of the epitrochlea is apt to be over onto the trochlea itself; may lie in the way of reduc- tion. This particular form of outward luxation is probably the one least often found. Diagnosis.-Diagnosis of outward luxation in any of its forms differs decidedly from that of the backward displacement. There is broadening of the elbow laterally, which is very great in complete outward luxation-practically a doubling of the diameter of the elbow. In the lesser forms it is still, of course, a very obvious deformity. These luxations tend to show more flexion than the backward luxation. In the last two forms the elbow may be held nearly at a right angle. In the first form flexion is less. In the complete luxation of the first class pronation is impossible. In the second class the hand is already pro- Fig. 326.-Dislocation backward and slightly out- ward; it was readily reduced (author's case). * A further "supracondylar" form is simply an exaggerated form of the second type. t Hutchinson, Med. Times and Gazette, 1866, vol. i, p. 410. OUTWARD LUXATION 263 nated, and the front of the forearm looks down and inward. The arm is flexed, and there is adduction of the forearm. In the incomplete Fig. 327.--Outward luxation of elbow. type pronation and supination are not necessarily interfered with, and flexion and extension are only partially limited. In all forms there is a considerable range of motion com- pared with that of the backward dis- placement, because in these outward displacements there is absolutely no bony check to either extension or flex- ion. In the severest cases, with great tearing of ligaments, muscles, etc., an astonishing range of motion is reported. Diagnosis is in the end, of course, dependent on the exact recognition of landmarks, or on the x-ray. Most ser- viceable of these landmarks is one not to be felt under any normal condition- the lower inner edge of the trochlea. When the olecranon is out of the way, this may appear as a very sharp edge, tunning forward and back near the in- fernal condyle. (See Fig. 336.) It is, when apparent at all, the most promi- nentpoint on the front and lower surface of the flexed elbow, and the skin is stretched tightly over it in such fashion that its contour can readily be made out, and it is unmistakable. Fig. 329.-Outward luxation (sketch of case): a, Trochlea; b, internal epicon- dyle; c, olecranon; d, head of radius. 264 THE ELBOW Fig. 330.-x-ray of case shown in Fig. 32!), seen from above. Fig. 331.-Same case, view from the side. Fig. 332.-Luxation outward (photograph by Dr. Loring B. Packard, City Hospital Relief Station Note the sharp edge of the trochlea! OUTWARD LUXATION 265 Fractures complicating these somewhat unusual luxations are not particularly likely to be diagnosed until after reduction. The presence of crepitus may tell us that there is a fracture. Just what the fracture is it may be impossible to say until reduction has restored more com- prehensible relations. The external condyle is the only point likely to be broken in the complete cases. Curiously enough, in the incomplete -not often in the complete-cases, epitrochlear fractures are reported. There is no peculiar liability to nerve or vessel lesions with any of these outward luxations. Reduction of Outward Luxations.-The reduction of an outward dislocation is not essentially different from that of the backward except that an inward shove or swing must be substituted for the forward motion. Reduction is easy in proportion to the extent of laceration. The Fig. 333 .-Out- ward luxation with- out rotation of the forearm bones. Fig. 3'3 4 .-Cut- ward luxation with rotation of the fore- arm bones (seen from the outer side). Fig?. 3 3 5. -In- complete luxation. Luxation outward, with rotation in ab- duction. The olecra- non is still partly in contact with the artic- ular surface. manceuvers advised include hyperextension, with special precaution not to produce a posterior dislocation, combined with traction and with an inward shove on the forearm. If the radius has a point of bearing on bone, then abduction with the arm (extended) will help clear the joint for reduction by separating the ulna from the humerus. Then an inward shove is used to complete the reduction. Apart from the possible jamming of an epitrochlear fragment into the joint, there is no difficulty about the reduction. The epitrochlea may become displaced in reduction into the joint between the humerus and the sigmoid fossa. Jamming of this sort is evident from failure to restore full motion, and from an abduction deformity, to say nothing of the fact that the epitrochlea is missing. The x-ray may help. In the two cases I have seen the diagnosis was far from certain until operation.* * These cases, both in small boys, both first seen after reduction, the first a case of my own, the second seen with Drs. F. B. Lund and E. II. Nichols, are per- haps unique in that actual removal of the fragment from the joint was carried out on recent cases. Both operations were done for nerve-pressure. All things con- sidered, the original luxations probably were incomplete outward or rotatory luxa- tions. There are no exact data, but the extensive tearing of the inner part of the capsule and the position of the trochlea make this probable. The most surprising 266 THE ELBOW The method of getting the fragment out of the way, recommended by Albert, is as follows: Flex the arm to a right angle, and separate the joint surfaces by pulling down on the upper part of the bent forearm; then swing the forearm inward. This is supposed to give more room for the epitrochlea to slide out of the way. It has been used successfully. In view of the possibility of further damage to the ulnar nerve it seems utterly unjustifiable in cases in which the nerve has been pinched, very debatable in any case. Confirmation of the fact by skiagraph, then open operation seems the only wise rule. Conversion of the outward dislocation into a posterior dislocation, and then a reduction of this luxation in the usual way, has been suggested as a way of getting around this epitrochlear difficulty. If these manceuvers fail, the only thing to do is to cut down and remove the troublesome fragment. It cannot unite, and at best it would form a loose body in the joint, giving much trouble later. Prognosis.-Except for the difficulty with the epitrochlea, reduction in all the cases of this class seems uniformly easy, and permanent in recent cases. In the record of old cases the good function said to have been acquired where the dislocation remained unreduced is some- what surprising. A perfectly serviceable range of flexion and extension is renorted in several instances. Fig. 3 3 6.-Out- ward luxation, show- ing the projection of the edge of the troch- lea. Right elbow, seen from the inner side and from behind (schematic). Fig. 329 also shows this promi- nence of the trochlea. INWARD DISLOCATIONS These are always incomplete. In part, they really belong to the isolated luxations of the ulna. If we consider the matter strictly, the radius usually does not really leave the capitellum at all, but is simply shifted on it. However, in some cases these luxations do represent a lateral shifting inward of both bones together. The conditions are as follows: The sigmoid fossa is in contact with the epitrochlea. The radius lies on or below the trochlea, in front of it, or behind and below it. The olecranon fossa is empty. The lateral thing was the fact that the presence of the epitrochlea in the cavity of the joint could not be demonstrated clearly by position or motion until the fragment was actually found and extracted. Since this note was written, a third case came to me; was diagnosed on the knowledge gained from the first two; was operated on and showed even more prompt recovery of joint motion and nerve function. A fourth case, seen with Dr. H. A. Lothrop, showed the same conditions, as to the ulnar nerve, but with a more definite limitation of motion, at the joint. Operation carried out, as in the others, gave a like favorable result. In these later cases, the diagnosis was made in detail, before operation, from good x-ray plates. In a fifth case, operated on lately for Dr. Kittredge of Brookline, the results were as good, and even more prompt. In a sixth the ulnar nerve lesion recovered but only months after operation. 267 DISLOCATIONS OF RADIUS AND ULNA FORWARD ligaments have both been found torn in the cases examined anatomic- ally. The anterior ligament is not largely torn. Diagnosis.-The diagnosis rests purely on identification of land- marks, and on the presence of some inward deviation of the axis of the forearm. There is nothing characteristic as to position or limitation of motion. Reduction.-Reduction is accomplished by extension, traction in the axis of the arm, and a direct push outward. This reduction in the cases on record seems never to have presented any particular difficulty. Results.-There seems to be no especial tendency to recurrence; the results are good; even with the luxation unreduced the functional result may be fair, with considerable motion in the joint. DISLOCATIONS OF RADIUS AND ULNA FORWARD This is a rare form of dislocation, present perhaps sometimes as the end position of a dislocation originally of some other type, but also apparently possible as a primary position. In considering this type, certain cases really consisting of dislocation of the radius forward with ulnar fracture are sometimes classed here; they should be excluded. Not much is known about the mechanism. In some cases of this lesion on record there seems to have been a direct thrust forward, exerted on the much bent elbow by the force of a fall.* Lesions.-The lesions are, so far as the data go, rupture of both lateral ligaments and of both anterior and posterior ligaments of the joint, more or less damage to the triceps (completely torn loose in Canton's case), and more or less damage to the muscles arising from the condyles. Naturally, there is great probability of nerve injury. The olecranon is wholly dislocated and lies in front of the joint. Symptoms.-The limb may be extended, in which case the olecranon lies up in front of the joint, or it may be flexed, as in Staunton's case, in which case the end of the olecranon rests above the condyles in front. There may be considerable outward displacement combined with the displacement forward. Reduction.-Reduction is accomplished by bringing the joint into flexion and then doing a distraction of the joint surfaces over the opera- tor's knee and pushing the olecranon back into place (Fig. 337). The prognosis depends upon the nerve and muscle damage. Fig. 3 3 7.-For- ward luxation (sche- matic). The arrows show the direction of the force needed to reduce the displace- ment. Fig. 338 -For- ward dislocation with subsequent extension of the arm (sche- matic). Must be con- verted to type of Fig. 337 before it can be reduced. * Staunton (Brit. Med. Jour., 1905, vol. ii, p. 1520) reports a case so caused. Elbow held at 130°, permitting slight motion: radius and olecranon 2)4 inches up above the condyles. Refers to "about twelve" cases on record. 268 THE ELBOW The above applies to complete luxations. Incomplete displace- ments in this direction, with the olecranon lying on, not in front of, the trochlea, seem not to be so uncommon, and are, of course, less serious, and are reducible by pushing the flexed forearm downward and rotating it into place as extension is carried out. DIVERGENT DISLOCATION OF THE RADIUS AND ULNA This is an extremely rare accident, necessarily the result of extreme violence. To produce it, it is necessary not only that the strong orbicu- lar ligament should be ruptured, but also that the oblique ligament and some part of the interosseous membrane should be torn. Not only are these very resistant structures, but it rarely happens that a force can act in such direction as to tear them. The dislocation is divided into two forms, the first where the radius is dislocated forward, the ulna backward; the second where the radius goes outward, the ulna inward, the whole width of the humerus lying between them. The first type is the less uncommon, though but few cases have been reported. The appearance of the joint in the first type seems, from the descriptions, to be not very unlike that of ordi- nary backward dislocations. In fact, several of these cases have been reduced, so far as the ulna was concerned, before the displace- ment of the radius was recognized. Even if this displacement is recognized, probably the best reduction is to put the ulna back in place, as we handle backward luxation, and then to reduce the radius by extension and pressure, as with the simple forward luxation of this bone. There seem to be no data as to details of after-treatment and results. Probably the best position for treat- ment would be acute flexion, relying upon the traction of the triceps on the fascia about the elbow to maintain the position. How far repair of ligaments or the formation of a new annular ligament may be relied on can not be stated on the basis of published experience, but, judging from similar cases, probably such a ligament would be formed after sufficient fixation without too early use of the limb. The other type is so rare as to be a mere curiosity of surgery. The diagnosis would obviously be made from the extreme widening, without the presence of crepitus, with the olecranon presenting to the inner side of the internal condyle, the radius in corresponding position on the outer side, and the intact humerus between, recognizable by the pecu- liarly shaped surface of the trochlea. The extreme tearing of ligaments necessary to this luxation would make reduction easy. The best position for treatment would probably be acute flexion with due regard Fig. 339.-Diver- gent luxation, the ulna passing behind, the radius in front of the humerus (sche- matic). Fig. 340.-Diver- gent luxation. The ulna has passed to the inner, the radius to the outer side of the humerus (schematic). LUXATION OF RADIUS ALONE-BACKWARD 269 to avoiding overtension and pressure on the vessels, and with enough lateral pressure to avert any tendency to fresh lateral displacement. AFTER-TREATMENT OF ALL ELBOW LUXATIONS The after-treatment of these cases, as in all uncomplicated luxations, calls for a rest, but not necessarily for absolute fixation, for two or three weeks. There is a definite risk of recurrence of elbow luxations, but rcluxa- tion is possible, so far as the writer's knowledge goes, only when con- siderable extension has been permitted within a few days. Possibly two weeks would be a safe limit; at least as early as ten days some motion should be begun, as some loss of motion is, especially in adults, far more frequent than recurrence of displacement. After three weeks it has been the writer's custom to leave the patient to his own devices, with the caution not to use the arm for work, but not to keep the arm quiet. PROGNOSIS OF ELBOW LUXATION Not infrequently the recovery of full motion takes many weeks; exceptionally, there is permanent loss of part of the arc of motion. Anything like ankylosis I have not seen follow reduction, however late the reduction was accomplished. Nerve Complications.-Motor paralysis is the most serious of the sequelee. This most often is a result of the trauma, not of the re- duction, but because of possible doubt in this regard we should test in- nervation before and after manipulation, both in luxations and also in fractures about this joint. Any of the nerve-trunks may be involved, the ulnar oftenest, and the musculospiral more often than the median. How readily the ulnar nerve may be injured is instanced by a case in which I reduced an old luxation by open incision with sheer cutting of ligaments, not by traction. The reduction was followed by a very definite partial paralysis of the ulnar motor supply, and a partial anesthesia, which, however, improved within the week and was well within about six weeks. Similar mild nerve injury shows itself very commonly directly after dislocation. Severer lesions calling for operation on account of pain or paralysis, like the cases cited (page 266), are rather rare. On the whole, the proportion of nerve injuries in elbow luxation is small, and the eventual prognosis is usually good. Myositis Ossificans.-This complication is curiously common in the later course of elbow luxations, and its frequency should lead us to take later x-rays in all cases not progressing normally in the recovery of motion, after a few weeks. LUXATION OF THE RADIUS ALONE*-BACKWARD This is very rare. The mechanism is doubtful; the lesion may apparently occur from blows directly on the radius, or as the result of * All luxations of single bones of the forearm 11 alone" (except the forward luxation of the radius) are misnamed, I think. Accompanying the named lesion must always be a subluxation of the other bone; a rotary subluxation at least,-or a fracture. 270 THE ELBOW a force that drives upward from the hand, the elbow being flexed. Presumably, an upward drive during forced pronation would produce it. Lesions.-The lesions are not known from any dissection of fresh cases; presumably the posterior ligament is torn, and perhaps some- times the annular ligament as well. There is at least one case on record where there was also a splitting off of part of the inner side of the radial head. Diagnosis.-Clinically, the diagnostic feature is the presence of the radial head behind its normal site, just to the rear of the external con- dyle. According to Langenbeck, there is obvious deformity on the radial side, but the radius is not prominent. Its hollow end is, however, palpable. The olecranon is not displaced. The arm is held in extension or in slight flexion, and is pronated. No movement is considerably restricted except supi- nation, but there is some limitation of flexion and extension. Reduction is by direct pressure on the radial head, with or without traction. No especial difficulty is re- corded in the reduction, but there is said to be some tendency to recurrence. Treatment must guard against this by pad pressure, with the arm at a right angle on a splint or in acute flexion. Fixation must be continued long enough to allow repair of the orbicular ligament, or formation of a new ligament if the ligament has been completely ruptured. This will mean not less than three or four weeks of fixation. According to Stimson, in old unreduced cases the motion, even in supination, is very fair. Just how this can be so is a puzzle; Langen- beck says it was not so in his case. It would seem that the same forces must act to prevent supination in old traumatic cases that make supination impossible in the so-called "congenital" cases of this class. There are no data at hand to show how much overgrowth of the neck of the radius results in these luxations from relief of pressure exerted by the external condyle, but in youthful cases it probably would be considerable. In the "congenital" cases it is often enormous. If the disability warrants it, there is no reason why an old backward dislocation of the radius at the elbow may not be treated by resection of the radial head and by stitching the altered capsular ligament back nearer its normal place. I have done this operation twice for pathologic backward luxation, produced by overgrowth in late hereditary syphilis, with admirable results. The resection of the radial head not only does not cause ankylosis, but gives a joint not weaker than the normal. Fig. 341.-Back- ward luxation of the ra- dius, necessarily com- bined with a rotation of the ulna on the trochlear surface of the humerus (sche- matic). DISLOCATION OF RADIUS FORWARD 271 DISLOCATION OF THE RADIUS OUTWARD This differs only by slight variation of position from the backward dislocation of the radius. As to mechanism, there is no question but that direct pressure exerted upward along the radius, with the elbow flexed and fixed, may produce this dislocation. Wagner* reported three cases so produced, in two of which a part of the inner edge of the radial head was broken off, apparently driven off as the head passed under the condyle. Loebkerf reported two similar cases. Lesions.-Our knowledge of the lesions rests largely on the observations during excision of frag- ments by these operators. The previous specimens of this lesion, as with other luxations, were very old cases, showing changes that were probably in part secondary. Apparently in these cases of Wagner and Loebker the pressure on the hand with the elbow bent and supported (these were accidents in pushing miners' coal-cars, the arm being caught between cars) caused an ascent of the radius on the ulna. The orbicular and oblique ligaments must have been stretched, though not obviously torn. Reduction.-The reduction is the same as for the backward dislocation, only with a different direction for the pres- sure-that is, with inward pressure over the radial head. Prognosis.-Apart from the results of the associated fractures noted above, there is nothing out of ordinary as to the prognosis. Fig. 342.-Luxa- tion of the radius out- ward, with some outward displacement of the ulna, and with tearing of the orbicular ligament (after Cooper's plate). DISLOCATION OF THE RADIUS FORWARD (WITHOUT FRACTURE) This dislocation is relatively not uncommon. Certainly it is the commonest of the isolated radial dislocations. In a good many cases fracture of the ulna close to the joint is associated with some displacement of the radius forward, as noted below. Isolated dislocations of the radius forward, in the stricter sense, may result from direct blows, apparently also from the torsion of a fall on the hand, and probably also as a result of muscle action by the biceps. J The dislocations are, as a rule, incomplete, in the sense that the radius does not entirely leave the surface of the capitellum. Lesions.-It is not necessarily true that the orbicular ligament must be torn through in this dislocation, though no doubt it is so torn in some cases. Probably the anterior ligament of the elbow is necessarily * Beilage zum Centralbl. f. Chir., 1886, xiii, 93. t Ibid., p. 91. $ The biceps may rupture its tendon or tear it from its insertion, or it may luxate the radial head. 272 THE ELBOW torn, at least in part. The diagnosis of these cases rests on the follow- ing points: Diagnosis.-Flexion is limited at or about a right angle by definite bony resistance, from contact of the capitellum with the humerus above the condyle (Fig. 345). Extension is limited by the changed relation of the biceps (Fig. 346). The radial head can not be found in its normal position, and the front face of the external condyle is exposed below. The radial head is present, and rotates normally, at a point above, and a little in- ternal to, its normal position. Reduction.-Reduction presents no special difficulty in fresh cases. The tend- ency to recurrence is great on account of the pull of the biceps on the radius. Acute flexion necessarily assures re- duction, and makes any considerable pull on the radius impossible. After-treatment.-Acute flexion is the best position to keep the arm in during the time of repair. Old luxations of this type are serious because of the limitation of flexion. Open operation, reduction, and retention by means of a new orbicular ligament made of fascia or of kangaroo tendon should be con- sidered in such cases. I have done this in two cases of old forward luxation with ununited ulnar fracture. In one the result was near Fig. 343.--Luxation of the radius forward (after Cooper). Fig. 344.-Luxation of radius forward, with ulnar fracture (schematic). Fig. 345.-Limitation of motion with forward luxation of the radius (diagram). Fig. 346.-Limitation of extension (due to biceps ten- don) in forward luxation of the radius (diagram). perfect, in the other the radius staid in place, rotating freely, and showed no tendency to loosen, even though bony union of the ulna was never obtained, thus throwing exceptional strain on the radial fasten- ings (Figs. 515 to 519). De Witt Stetten (Annals of Surgery, 1908, xlviii, 275) reports musculo-spiral paralysis following radial dislocation at the elbow. It is strange that this, like the other nerve lesions at the elbow, so seldom occurs in the various luxations hereabout. Radial Luxation With Ulnar Fracture The radial head may be displaced in conjunction with fracture of the ulna high up. This means, of course, a deviation of the axis of the LUXATION OF ULNA ALONE, BACKWARD 273 ulna. The radius, as a whole, keeps its alinement with the line of the ulna below the fracture, held by the interosseous membrane. This may determine dislocation of the radius outward or backward or forward as the case may be. Whether there must necessarily be a tearing of ligaments at the time of accident or whether this luxation or subluxa- tion may be purely a secondary result of bad position of the fracture I do not know. Excepting that such a fracture is hard to hold in place because it lacks the support of the radius, this dislocation is of no great moment: once reduced in flexion, the luxation is not likely to occur except for the same cause that first produced it. (See Figs. 513 ff.) DISLOCATION OF THE ULNA ALONE (ON RADIAL HEAD AS A CENTER) There are two forms only: the backward type and the forward luxa- tion. The backward displacement is not very rare. Luxation of the Ulna Alone, Backward Whether it is called backward or outward is a matter of terms; the fact is that the lesion is a rotatory luxation of the ulna, up, back, and outward, swinging on the head of the radius as the center. The radius itself is practically undisturbed. There is necessarily a rupture of the internal lateral ligament. The ulna slips back and up until, as shown by Roberts in an autopsy on a recent case, the coronoid rests in the olecranon fossa. Symptoms.-Clinically, the symptoms are those of an arm held in extension, or very nearly extended, with no possibility of flexion, with an olecranon very prominent, though not very high, and with a very definite inward deviation of the axis of the forearm, in the position of a "gun-stock deformity." There must necessarily be some rotation, to allow the ulna to slip back without moving the radius; Roberts men- tions that the front of the humerus faces outward. This rotatory displacement is hardly appreciably clinicalle. The exact mechanism of production is not clear. Apparently, the lesion may be produced by force applied to the hand with the arm at or near full extension. Reduction is carried out by hyperextension alone, or by supination followed by active abduction of the arm. It presents no difficulty, and there is no special liability of recurrence. Worth mentioning here are the cases, often without epitrochlear fracture, in which the scar formation occurring in repair of such a luxation produces pressure, or tension on flexion, on the ulnar nerve. Not rarely such cases call for operation; for freeing of the nerve from its scar envelope and forward transplantation of it into a bed of muscle (or better into fat tissue). (See p. 266.) It seems probable that such cases are often self-reducing. At least three of the four cases cited on p. 267 of dislocation of a broken epitrochlea into the joint, seemed to me to have been self-reduced rotary luxations of the elbow. 274 THE ELBOW This has been well described by Stimson from observation of a fresh case. Lesions.-The lesion is essentially conditioned on a tearing of the internal lateral ligament; in Stimson's case there was also an extensive tearing of flexor muscles in front of the internal condyle. The displace- ment brought the tip of the olecranon below and a little in front of the trochlea, without any great disturbance of the relations of the radius. Luxation of the Ulna Alone, Forward Fig. 347.-Luxation "of the ulna back- ward," really a rotatory luxation. The dotted line shows the normal position of the radius in relation to the humerus (schematic). Fig. 348.-Anatomy of swfeluxation of the radial head. The lateral ligaments and the orbicular ligament shown in black. Fig. 349.-Dislocation of the ulna backward (rotating on the radial head) (after Cooper's drawing from a museum specimen). The arm was held at a right angle-some motion was possible. There was lateral mobility outward; there was an abnormal abduction, and further abnormal abduction was also possible. Reduction is simple-by rotation and adduction. SUBLUXATION OF THE HEAD OF THE RADIUS IN CHILDREN (MALGAIGNE'S LUXATION) This is a common injury, long known and much discussed as to details. The only thing, curiously enough, on which every one is agreed is its mode of production. It occurs only in small children, under four years of age, and results from the child being lifted, or helped along, by the mother or nurse, who grasps one hand near the wrist (Fig. 350). The sequence of events is perfectly typical. The child that has been so lifted makes some complaint of pain, and forthwith refuses to use the arm. So long as the arm is quiet there is no trouble, but the child will not use it and objects to having it handled. SUBLUXATION OF THE HEAD OF THE RADIUS IN CHILDREN 275 The arm is held in a position which is constant (see Fig. 351); this consists of a partial flexion of the elbow with pronation of the hand. Handling of either elbow or hand seems painful. Flexion and ex- tension of the elbow are not checked, but supination is limited, and usually it is very much limited. If no reduction is attempted, this lameness persists for a considerable time. There is at no time anything definite to be felt at the elbow. There is little or no swelling, and \it requires some imagination to feel the alleged increased distance between the radial head and the condyle. Two theories (among many) as to what actually occurs in these cases, may be mentioned: A folding of the capsule between the bones has been Fig. 350.-Shows how to lift a child in order to produce subluxation of the head of the radius. Fig. 351.-Attitude in subluxation of the radial head (drawn from photograph of a case of the author's). held to explain the lesion; this presupposes a forced pronation. The nature of the force producing the accident renders this impossible. The child's arm is in extension when the injury occurs, and a forced pronation of the elbow cannot be produced in a young child in this position, for pronation of the extended arm happens mainly in the shoulder-joint. This consideration seems to dispose of this theory. The other theory is unproved, but probable. That theory is, that the radial head, by direct traction on the wrist and hand, is pulled part way down through the orbicular ligament and jammed there. Exactly how it is held so as to allow some rotatory motion no one professes to say, but this theory seems to correspond closely with the clinical facts. It is the original theory advanced by Duverney many years ago. On examination of one of these cases, the history, the disinclination to use the arm, the characteristic attitude, and the sharp limitation of 276 THE ELBOW supination, without limitation of other motions, and without other obvious injury, is enough to establish a diagnosis.* Reduction.-Reduction is performed by taking the lower end of the humerus firmly in one hand so as to prevent rotation, then bringing the arm into partial extension with slight traction downward, then pronat- ing slightly, then supinating with a gentle shove upward from the wrist, then flexing the elbow. (See Fig. 352.) Then test the pro nation and supination (Fig. 353). If it is neces- sary, repeat the procedure. When all motions are normal, the reduc- tion is complete, and within a few hours the child is ready to use Fig. 352.-Reduction of subluxation: a, Extend and supinate under moderate traction; b, flex and pronate. the arm. There is really no necessity for any apparatus whatever, for the lesion is one of stretching, not of tearing of ligaments. Results.-There is no tendency to recurrence and no liability to sequelse. For the sake of the mother's peace of mind it is commonly well to pin the child's dress-cuff to the breast of the dress on the oppo- site side, forming a simple sling, and allowing the child to convince the mother that there is nothing wrong. This they always do within twenty-four or forty-eight hours. * It must not be forgotten in the differential diagnosis that simple slight con- tusion about the joint or slight strain may, in a small child, give an apparent disability so far as use is concerned that is out of all proportion to the severity of the injury. SUBLUXATION OF THE HEAD OF THE RADIUS IN CHILDREN 277 One point of some interest is as to what becomes of these cases untreated. Personally, I think they must in time reduce themselves. The accident is very common, and is treated usually by the family doctor, if treated at all. Cases must escape treatment with some fre- quency, but we never hear of cases or see. cases in which loss of motion is or can be traced back to this injury in infancy. It has been supposed that some cases of forward displacement of the radius met with later might have such an origin, but this is very doubtful. Chassaignac, who considered these cases as nerve injuries, treated a lot of them and Fig. 353.-Final movement; pronate and supinate the forearm to test reduction. treated them without attempts at reduction; even under such treat- ment he noted no bad end-results. The following is given as a typical case, one of many: E. D., male, two years old. Previously healthy. November 3, 1905: About twenty-four hours ago the mother lifted the child by one hand. The child struggled at the time. Nothing was noticed until shortly afterward, when the mother noticed that the child showed neither inclination nor power to use the arm. This condition did not improve. The child was not, however, in apparent pain. The child showed the characteristic attitude seen in the cut, and absolutely refused to use the arm or move the hand, but seemeb 278 THE ELBOW to have no pain. Movements of the elbow proper were not limited at all. Pronation was normal; supination only one-third the range of that of the other side. Resistance firm, but elastic. Reduction by slight traction, with moderate pronation, followed by sharp supination, and then an upward shove. There was a sharp but soft click, and on testing, all motions of the elbow were found to have become normal. Put up with the dress-sleeve as a sling. November 6: Reported today. Began to use the arm within five hours after reduction. No complaint since then, and examination shows nothing abnormal. CONGENITAL LUXATION OF THE RADIUS Such luxation may be forward, back, or outward, most commonly backward according to Blodgett's summary of 51 reported cases.* Congenital luxation of the radius involves loss of motion; if forward, the loss is in flexion; if backward, there is overgrowth of the radius, and extension is checked.f * Blodgett: Amer. Jour. Orthop. Surgery, January, 1906. f The treatment is operative: resection of the often overgrown head, or remodelling and a revised attachment of the distorted orbicular ligament, are to be done as indicated in the individual case. CHAPTER XV FRACTURES OF THE HUMERUS AT THE ELBOW These fractures are very common. In general, they are rated as serious lesions. A great deal of discussion has been wasted on the question of the method of treatment best adapted to produce the best angle for the stiff elbow likely to result. As a matter of fact, ankylosis is rare, and, excepting for certain extremely severe compound and com- plicated fractures in adults, the results are by no means as bad as the literature would lead us to suppose. The whole subject of elbow frac- tures from the point of view of actual practice has been vague, in my opinion, for the following reasons: (A) The fractures occurring in children and adults have been, un- wisely, considered together. For all practical purposes they are very distinct, indeed. (B) The exact lesions have not been well understood and dealt with, even since the use of the x-ray has become more general. (C) The supposed end-results have been judged as they appear soon after splints have been removed, at a time when they show up very badly, and do not represent end-results at all. Elbow fractures in adults are apt to be the result of extreme violence, occurring either as the result of direct crushing in machinery accidents, or from hard falls on the elbow. The adult elbow seems rarely to break as a result of falls on the hand. Being a result of direct violence in many cases, these fractures in adults are not rarely compound, and even when they are not compound, the separation of fragments and the damage to soft parts make them very hard to handle and very serious. Elbow fractures in children, on the other hand, not uncommonly result from slight blows or falls. They differ in lesion from those of the adult inasmuch as they tend to follow the epiphyseal lines and are apt to be accompanied with comparatively little damage to the soft parts. They are almost never compound, except in cases where there is a tear- ing away of the whole epiphysis of the lower end of the humerus from the shaft. Astonishingly bad results as to deformity may occur in children as the occasional result of bad reposition, but when cases are discharged at the end of six or eight weeks, even the good cases look discouraging. If these cases in children are followed up six months or a year after the injury, we find a very different condition. The average fracture in children is apt to result better (as far as function is concerned) than even the most favorable adult case, and out of a large experience of this 279 280 FRACTURES OF THE HUMERUS AT THE ELBOW sort of cases the writer has rarely found any ankylosis in a child or even any loss of motion of any serious moment.* The rule is practi- cally perfect function, with much or with little deformity according to the lesion and to the skill used in treatment. It is for the reasons given, then, that elbow fractures will here be separated arbitrarily into two classes-those of adults and those of children. ELBOW FRACTURES IN ADULTS The common lesions are: (а) Supracondylar fracture. (б) T-fracture. (c) Fracture of the external condyle. (d) Fracture of the external epicondyle. (e) Fracture of the capitellum. (/) Fracture of the internal condyle. (g) Fracture of the internal epicondyle. There are also certain fractures that cannot be classified, in which there is very severe comminution in all directions. Fig. 354.-Humerus from the front; shows the epiphysis of the internal epicondyle still un- united with the shaft. Fig. 355.-Right humerus from the outer side. Arrows show the limits of the articular surface and the attachments of the capsule. Of those above listed, (e), the fracture of the capitellum, is extremely rare, and (d), the fracture of the external epicondyle, is met with only as a result of penetrating wound or as a complication of luxation. The others occur not uncommonly, and are to be looked for. Symptoms.-Common to all fractures in this region are: pain, dis- ability, and swelling, severe in proportion to the trauma; not necessarily severe in fractures of a single condyle or epicondyle. * I recall but one such case of real (fibrous) ankylosis following trauma in a child. SUPRACONDYLAR FRACTURES 281 Very severe swelling is apt to be a sign of T-fracture or, at least, of a break above the joint. T-fractures are relatively apt to be compound. The formation of blebs has here the same significance as an indica- tion of grave damage that it has in fractures of the leg. It is com- monest with supracondylar and with T-fractures. The absence of swelling on one or the other side of the joint is apt to be of help in locating the lesion. The position of the arm, and the rotation of the forearm in prona- tion or supination, are not constant enough to be of any value in diagnosis. The detail diagnosis rests upon the recognition of land- marks and of their relations and on abnormal mobility. If the land- marks are not accurately recognized, accurate diagnosis is impossible, Supracondylar Fractures Supracondylar fractures are apt to occur at any height, but lie most often close above the condyles. Almost always the fracture-line is oblique up and backward. Lateral obliquity is more often upward and outward than in the reverse direction. Kocher sepa- rates an extension type, oblique up and backward and displaced backward, from a flexion type with opposite obliquity and displacement. It is perhaps too much to assume that these always result from flexion and extension respectively, but certainly in the common type, resulting from extension or back- ward thrust, the obliquity is upward and backward, and both displacement and rotation are backward, as would result if hyperextension were the cause. The cases of obli- quity up and forward that the writer has met with have been very few, and with three exceptions have shown only a rotation of the frag- ment forward, and not a displacement in toto. According to the height of the lesion, these fractures.may or may not involve some tearing of the joint-capsule. They are, however, above the joint proper, and do not involve the attachments of any essential ligaments. Ordinarily, the break is entirely loose except for the periosteum (which, in the backward dis- placement, is regularly stripped up from the back of the bone) and for the muscles. Impaction seems not to occur. Clinically, we have the following cardinal points to bear in mind in diagnosis: (а) There is free abnormal mobility, usually with crepitus, of the whole forearm and elbow on the shaft of the humerus in every direction except forward. The condyles move with the forearm (Fig. 356). (б) The condyles show no broadening; their relation to one another is normal, and they move together in all motions. (c) There is usually marked backward displacement, not unlike Fig. 356.-Koch- er's "extension" (left) and "flexion" (right) types of supracondylar fracture: latter variety very rare. (Diagram. 282 FRACTURES OF THE HUMERUS AT THE ELBOW backward dislocation, but this displacement involves condyles as well as forearm. The radius and the external condyle are not separated. There is no hollow immediately above the olecranon. Sometimes Fig. 357.-Backward luxation (at; Jeft); normal elbow: supracondylar fracture (at right) (schemati c). Fig. 358.-Supracondylar fracture at twelve years; plate taken thirty-six years later (court- esy of Dr. McKechnie). Still shows displace- ment of fragments, in the way of the ulna on attempting full flexion. Fig. 359.-Front view: same case as Fig. 358; shows the lateral "gun-stock" devia- tion. we see inward displacement as well as backward. This displacement, owing apparently to intact fibrous structures on the inner side, is curiously hard to reduce (Figs. 470, 471, 472). (d) Extension is free except as limited by pain; flexion is apt to be hindered by impact of the lower end of the shaft on the forearm bones. 283 SUPRACONDYLAR FRACTURES (e) The lower end of the shaft may be felt lying well forward of its normal relation (feel for it as in Fig. 303). (/) The deformity recurs after reduction. Fig. 360.-High "supracondylar" fracture, more strictly a low shaft fracture, not always easily differentiated (without the x-ray) from fracture close to the joint. These rules apply to the usual backward and the backward and outward forms: points a and c apply to all save the rare subperiosteal fractures at this point, which cannot usually be more than suspected until an x-ray plate is taken. Fig. 361.-Displacement (extreme) in supracondylar fracture (after C. Beck). The spur is the lower end of the shaft.* Fig. 362.-Test for mobility of the forearm, with the condyles, forward and back. The shaft of the humerus is held firm. If the displacement is forward, the end of the shaft will lie above the olecranon. The elbow will be in front of, not behind, the general direction of the shaft, and extension, not flexion, will be interfered with. * In the compound cases, it is this spur that penetrates the skin, and it is here (at the front) that it comes through. 284 FRACTURES OF THE HUMERUS AT THE ELBOW In no case of supracondylar fracture is motion in pronation and supination interfered with, and some motion may always be obtained in flexion and extension. In the nature of things there must be shortening of the arm in these cases, and this may be measured from the spur on the acromion (Figs. 179, 181, 277) to the external condyle, but this is a measurement pecu- liarly open to error, and this test alone is of little avail. T-Fractures T-fractures present a somewhat more complicated problem. They may be precisely like the supracondylar, save for a split into the joint, without appreciable displacement. It may be difficult to be sure of the widening at the joint or of the movement of one condyle on the other, or the displacement may be so great that the end of the shaft actually de- scends between the fragments. In these Fig. 363.-Old T-fracture in adult (sketch of the Warren Museum, specimen 8974). Fig. 364.-T-fracture in adult. Unusually high T-fracture (Warren Museum, specimen 1000). severer cases the diagnosis of the T-fracture is simple-the ques- tion is only whether other and more complicated breaks are pres- ent. In the ordinary case, however, the diagnosis is not easy, for the widening of the elbow is a matter it is easy to be mistaken about if there is swelling, and the mobility of one condyle on the other needs some expertness to determine, for the fragments are still bound by liga- ments to the forearm bones. It may be well to note that crepitus, gotten in testing this motion, is worthless; it usually occurs not between the condyles, but between the upper and the lower fragment. This fact leads to frequent error. The diagnosis of T-fracture is often made FRACTURES OF THE EXTERNAL CONDYLE 285 where the break is simply supracondylar, or where one condyle is sepa rated without anv cross break Fig. 365.-T-fracture of elbow. Man of forty-five,1' fell twenty feet and struck elbow, producing compound fracture. Arm amputated (Warren Museum, specimen 999). Fig. 366.-T-fracture in adult-low T-fracture (Warren Museum, specimen 1002). Fig. 367.-Test for mobility of the condyles on the shaft of the humerus and on one another. The .shaft of the humerus must be very firmly held. Best test for T-fracture. Fractures of The External Condyle Fractures of the external condyle run from the middle of the joint (or thereabouts) in a line upward and outward-a line of varying obliquity. The displacement is apt to be backward or outward, some- times with outward rotation. The fragment is still held by the liga- ments in nearly its normal relation to the radius. As noted above, actual joint luxation may rarely be combined with this fracture if the internal lateral ligament is torn. 286 FRACTURES OF THE HUMERUS AT THE ELBOW Clinically, we find: (a) Swelling of the outer side of the joint only. (6) Tenderness only about the outer condyle, (c) Crepitus in this same region, (d) Mobility of the condyle under the fingers, (e) Recogniz- able deformity of bone-this is hardly the rule. Fig. 368.-Fracture of external condyle alone, in adult; non-union: 1, External condyle; 2, radia head; 3, trochlea (after A. Cooper's plate). Fig. 369.-Test for mobility of the external condyle, the shaft of the humerus being fixedjby the operator's other hand. Fig. 370.-Kocher's "fractura rotuli humeri." The round front face of the capitellum is chipped away and lies loose or nearly loose in the joint--and in the way. It should always be removed but this patient declined operation against advice. Valuable negative evidence is furnished by the immobility of the ulna on the humerus forward or backward. There is apt to be some slight abnormal play laterally. There is no thickening or deformity about the internal epicondyle or condyle, or along the inner surface of the humerus. There is little or no ecchymosis or swelling on the inner side, and little tenderness. FRACTURES OF THE INTERNAL CONDLYE 287 Flexion and extension of the elbow are painful. Mouchet* says that pronation and supination are limited in this lesion, but in testing many cases I have found such limitation but once. Usually the freedom of this rotatory motion argues against high fracture of radius or ulna, not against condylar fracture. The joint is often appreciably broader than normal. Usually no changed relation of the landmarks is , appreciable except for this broadening. Fracture of the External Epicondyle Such fracture undoubtedly occurs, and may result from direct violence (e. g., gunshot wound) or from traction as with luxation. There is a plate of Gurlt's (much copied) showing bony union of an old fracture of the sort, that has dignified the lesion beyond its deserts, f Fracture of the Capitellum This is the "fractura rotuli humeri" described by Kocher. He cites several cases; the writer has met with it twice. J The lesion is simply a splitting off of the anterior articular face of the external con- dyle. How it occurs is not certainly known. The fracture is intra- articular, and the fragment lies free in the joint. The diagnosis rests simply on the presence of a foreign body of considerable size in the elbow-joint, found directly after an injury. It differs in no way clinically from the cases where a portion of the radial head is split off and becomes a foreign body. In two of Kocher's cases the fragment was displaced backward; in one, (as in the writer's case) it was forward. According to the position, either flexion or extension is seriously interfered with. The check to the movement of the joint feels exactly like that met with in a dislocation of a knee cartilage: it is a very definite checking, well described as like that of "a stone in a hinge." The amount of local reaction from this injury is very slight at first, but the disability is considerable. The fragment does not unite, § and would probably grow in size in time, as do other intra-articular bodies. The only treatment is an excision of the fragment. The results of such excisions as are reported were good. The fragment is easily accessible by an incision on the outer side of the joint, in front or behind, as the case may be, guided by the x-ray in each case. FRACTURES OF THE INTERNAL CONDYLE Internal Condyle (into the Joint); Fracture of the Trochlea This lesion occurs less often than fracture of the external condyle. It presents corresponding signs. There is, however, a greater increase * Mouchet: Paris; G. Steinheil: Monograph, and Bull. Soc. Anatom., 1898, Ixxiii, 811. 11 know nothing about the lesion except for two cases in which a chip in this region had been torn off. This was merely a complication of other fractures with partial luxation. t Cotton: Boston Med. and Surg. Jour., cxlix, No. 27, pp. 734-736, December 31, 1903. § That is, it does not unite, as a rule. Gurlt and Hahn each record fractures with union, apparently belonging to this class. 288 FRACTURES OF THE HUMERUS AT THE ELBOW of lateral mobility, and, the ulna no longer being firmly held, there may be some mobility anteroposteriorly as well. Here, again, except for the broadening, the relations of the various landmarks are not disturbed. Fractures of the Internal Epicondyle (Epitrochlear Fracture) These are not intra-articular fractures in adults, and do not per se affect the joints at all.* The epicondyle carries the origin of the superficial forearm flexors and of most of the lateral ligament, but the attachment of the latter is so close to the base of the epicondyle that it is not ordinarily involved in the fracture, and in few if any cases is it entirely torn loose. The epicondyle may be broken either by direct violence or by strain exerted through the muscles which have their origin from it.f This lesion usually occurs by fall on the hyperextended hand or from like violence. Clinically, the injury is characterized by little reaction and swelling, without great immediate disability. There is, however, an inability to use the hand somewhat disproportionate to the disa- bility at the elbow, and hyperextension of the wrist is painful. This, of course, is owing to the special relations of this process to the superficial flexor muscles. The sensitiveness, swelling, etc., are all limited to the inner side of the elbow. Direct examination shows no obvious change in the relation of the landmarks. A prominence is felt at the usual point for the internal epicondyle, but on more careful examination this prominence proves to be shorter and blunter than normal, and without the posterior projection normally present. The ulnar nerve, instead of lying comfortably behind this hook-like process, lies exposed on a flat surface behind or near the tip of the shortened projection. (See Fig. 300.) On careful examination a thickening is often to be made out below and in front of the normal place for the epicondyle. Very often, however, even in fresh cases, it is impossible to make out a definite fragment. The separation in very rare cases may be not forward, but backward and outward. This is said to be the case in some instances where this fracture complicates dislocation, and where the fragment, larger than usual, has carried some attachment of the Fig. 371.-Isolated fracture of the internal condyle (uni- ted) (Warren Museum, speci- men 3775). * Fracture of this epicondyle is, however, a not uncommon complication of luxation. The luxations here concerned are apt to be those of the outward "rotary" type. (See Fig. 335.) In these cases, the epicondylar lesion is of impor- tance because of the liability of damage to the ulnar nerve from displacement of this bony tip. (Cf. p. 265.) t Up to about twenty years the lesion is apt to be epiphyseal separation, rather than fracture. FRACTURES OF THE INTERNAL EPICONDYLE 289 lateral ligament by which it has been dragged back. I have seen it twice in cases where there was no dislocation, and where it was im- possible to establish any tearing of the flexor origin, which would seem a necessary condition for this displacement. A valuable point in diagnosis is the pain on active finger flexion or active prona- Fig. 372.-Luxation elbow: epitrochlear fracture with dis- placement into the joint, locking the joint: ulnar nerve symptoms. Fig. 373.-Same case as Fig. 372-lateral view. Operation, excision of fragment. Perfect functional result. Fig. 374.-Old epitrochlear fracture. Non-un- ion. No symptoms. Fig. 375.-Epitrochlear fracture in child- hood, thirty-five years ago. No bony un- ion. No symptoms. tion of the hand, due, of course, to involvement of the origins of the flexor and'pronator muscles. 290 FRACTURES OF THE HUMERUS AT THE ELBOW Later, there is a well-marked selective atrophy of all these muscles in such fractures, that recovers very slowly. Fig. 376.-Supracondylar fracture in a child. There is backward displacement but more par- ticularly there is a rotation of the humeral shaft that throws the inner side of the upper fragment forward. Compound Fractures Compound fractures have already been mentioned. Here and there_thejess severe fractures may be compound, but, as a rule/this complication attends the frac- tures in which there has also been great damage to the bone Fig. 377.-Compound fracture of humerus at elbow, with great displacement of ulna between frag- ments. The fragment shown to the right had to be removed (figure drawn from this fragment direct; the olecranon and the humeral shaft drawn from normal bones). Fig. 378.-Comminuted compound fracture of elbow. Shows the fragments removed in an excision for primary sepsis (courtesy of Dr. J. B. Blake). VESSEL INJURIES 291 and to the deeper soft parts. It is for this reason that the net results in these cases are not very satisfactory. Even with the most careful technic there is a liability to sepsis, greater even than with most com- pound fractures about joints. Owing to the comminution of the bone and the poor nutrition of the fragments, sepsis almost always entails necrosis, and the result is necessarily bad. If the wound can be kept clean, however, good opportunity is offered for accurate reposition and fixation by wire or absorbable suture, which procedures give better results than can possibly be reached in the "simple" fractures. Partial excisions give admirable results at times.* Vessel Injuries Injuries of the vessels are not usual complications of elbow frac- tures; they occur only where the displacement is extreme. The brachial artery is the only one the injury of which need be seriously considered. The rupture of this artery is signalized by great swelling and by loss of the radial and ulnar pulses. This condition calls for prompt operation and ligature, in order that the removal of the swelling and pressure may give a chance for an adequate collateral circulation to establish itself. Such lesion is not a reason for primary amputation. If gangrene has already set in, amputation is, of course, indicated.! Nerve Injuries.-Injuries to the nerves occur in fractures of the elbow as well as in dislocations, and may occur as a coincident result of the trauma, as the result of pressure of the fragments, or as a result of manipulation in reduction. It is because of this last possibility that we should make it an abso- lute rule to test the function of all nerves before attempting to treat an injury in this region. Median, musculospiral, and ulnar nerves are all subject to injury at this point. More especially the ulnar is liable to injury. Musculo- spiral injuries belong more particularly to fractures several inches above the joint, where the nerve winds about the humerus. Ulnar nerve injuries are not uncommon in connection either with fractures of the internal epicondyle or with supracondylar fractures; they are shown by pain and loss of sensation in the regions supplied by the ulnar nerve. There is also apt to be some loss of motor power, to be found by the familiar test of the function of the interossei and of the flexor ulnaris. * Case: C-. Machinery accident: Fracture of external condyle, compound; excision of condyle. Perfect result save for moderate gunstock deformity. Is working in an iron-foundry. Reported by the writer in Boston Med. and Surg. Jour., 1906, civ, p. 644. 11 have seen one case of obvious tearing of the brachial vein with a hematoma from the axilla to the mid-forearm. The lesion was a much displaced supracon- dylar fracture. Recovery was satisfactory with the establishment of marked increase in size of the subcutaneous veins from the clavicle to the elbow; an increase which has persisted for ten years. In another case loss of circulation depended on tension on the artery only. After reduction of the compound dislocation the circulation became normal (but only after an hour) and remained normal. 292 FRACTURES OF THE HUMERUS AT THE ELBOW As a rule, unless the disturbance is very severe, it is wise to wait in these cases. In all the instances in which the writer has waited there has been complete restoration of function within two to four months, showing that the nerve was only contused; in the one case of total musculospiral paralysis from elbow fracture* the same course was followed with the same result, though the period required for complete restoration of function was nearly two years. Fig. 379.-Internal angular splint, Bolles type. The lower figures show the pattern and the making of such a splint out of heavy tin. This splint shows an obliquity down and inward. (See Fig. 380.) Supracondylar fractures, if the displacement is backward, are reduced much as one reduces a backward displacement, and always, if possible, under an anesthetic. This one manoeuver reduces the back- ward displacement, but does not secure correct position as to lateral displacement or rotation. These lesions must be dealt with according to the case, and the fragment must be directly shoved into the best possible position. The Treatment! *Operation refused. t Cf. Coenen, Beitrage z. klin. Chir., 1909, Ixi, No. 3. TREATMENT 293 Fig. 380.-Cross-section of forearm below the elbow. The splints sketched (with the ar- rows showing the direction of pressure) show that there is a definite tendency to press the ulna up, the radius down. Only with an oblique splint, lying as shown by the dotted line, can we avoid this tendency. Fig. 381.-Internal angular splint. Shows the straps needed with the splint, to secure immobilization. Often it is well to add a strap around back of the olecranon and the condyles. Fig. 382.-Position of supination, showing the carrying angle. The attitude shown in black line shows the position of pronation, with physiological disappearance of the carrying angle. 294 FRACTURES OF THE HUMERUS AT THE ELBOW restoration of the landmarks (olecranon and condyles) to their proper relation to the line of the humeral shaft is our only guide. The ten- dency is to let the forearm and the lower fragment drop or roll too far inward-this must be borne in mind. Overcorrection outward is usually impossible, owing to periosteal resistance. Fig. 383.-Proper application of sling: first stage. Fig. 384.-Second stage: folded across in front over opposite side of neck. One factor relating to reduction is important, and curiously neg- lected. For some years I have noted and taught that the humeral shaft in these cases is rotated outward, the lower fragment swung inward with the forearm. The spur that appears in Fig. 427, sticking out for- ward, is not the front edge but the inner edge of the upper fragment (Figs. 423, 427, 429 and 430). Therefore I always Fig. 385.-Third stage, completed. Note how the end from behind the elbow is carried forward and pinned, to make a secure pocket for the elbow. Fio. 386.- Wrong way to apply a sling (though the usual way), letting the front corner go up on the same side instead of crossed. Gives a much less secure support. carry out the reduction manoeuvers, above sketched, with the whole arm in pronounced outward rotation. Over-rotation in this direction seems impossible; when reduction is complete, the fragments lock, in flexion or on the splint, and the more comfortable position of inward rotation can be reassumed. Since I have done this, my results have much improved and the manoeuver seems absolutely justified. (See Figs. 454, p. 317.) TREATMENT 295 After reduction seems complete it is well to grip the upper arm near the elbow in both hands with some force, so as to fix the fragments, then to mt an assistant partly extend the arm; this will show whether the long axis of the arm has been approximately restored. ' [The splint to be used is the "internal angular," preferably of the " Bolles " type (Fig. 379). This is padded and is set close into the bend Fig. 387.-Osgood-Penhallow splint for right arm, seen from in front and from the right side. of the elbow, and strapped with adhesive to the upper arm; then, while some traction is exerted on the forearm to overcome possible backward displacement of the fragment, the forearm straps are applied. If the position is satisfactory, this will suffice; if there is any tendency to inward' displacement, the addition of an internal coaptation splint is wise. (See Fig. 398.) Fig. 388.-Osgood-Penhallow splint "tried on." This shows the relations, but without padding Fractures lying well above the joint, and even those of the lower supracondylar type in adults, which show sharp forward displacement, are often best held on the Osgood-Penhallow splint,* in which the weight of the arm exerts traction and the splint gives counterpressure. (See Figs. 387-390.) * Described in the Jour. Amer. Med. Assoc., July 31, 1909, liii, p. 375. 296 FRACTURES OF THE HUMERUS AT THE ELBOW Very rarely weight traction may be called for. (See Fig. 285.) Acute flexion has been recommended for for other elbow fractures. It works well in some cases; in tends to produce Fig. 389.-Case of high supracondylar break position after treatment in acute flexion. Fig. 390.-Same case properly treated Note how, on this Osgood-Penhallow splint, both overlap and bend are corrected. forward rotation. In the cases shown (Figs. 395, 463) acute flexion was the only and obvious cause of displacement. One of these cases came to open operation for correction, one to simple forcible correction. Fig. 391.-Adhesive strap applied to secure acute flexion, properly applied. The strap is laid flat on the skin; the ends meet at an angle and are pinned as well as stuck together. Fig. 392.-The same strap wrongly applied as a circular band. Symmetry is attained, but at the expense of a sharp constriction ofjthe flesh by the upper edge of the strap. The treatment on a straight splint has been much advocated. No doubt this is the easiest way to preserve the straight long axis of the arm and to avoid "gunstock" deformity, but personally I have never found myself able to use it without jncreasnif/ the backward TREATMENT 297 which is a much more serious matter than a slight "gun stock." This consideration is entirely apart from the practical inconvenience of the position, and the awkwardness of a possible total or partial ankylosis at or near the useless position of full extension. Fig. 393. Fig. 394. Figs. 393, 394.-Front and back views of the "Lund swathe,'' author's modification. This is a figure-of-8, one loop going around the elbow (over the adhesive shown in Fig. 391), the other loop going over the neck and through the opposite axilla. From the meeting-point of the the back a loose end is carried over to the loop about the elbow and pinned. The swathe is made of folded muslin cloth. Fig. 395.-Supracondylar fracture treated in acute flexion. This fracture should not be treated in this position. Note the deformity both of angle and of overlapping. Fig. 396.-Same case properly put up on an internal angular splint. Position not good, but much mproved. T-fractures.-These are to be treated much as are the supracondy- lars, save that in case of much displacement of the shaft downward, traction downward on the forearm, held at a right angle, will help clear the upper fragment out of the way and permit approximation of the 298 FRACTURES OF THE HUMERUS AT THE ELBOW condyles_by manipulation. When the broken condyles are brought together, an effort may be made to impact them by lateral pressure. In putting up these cases the same splints are usually used as with Fig. 397.-A, Supracondylar fracture put up at a right angle; B, same case put up in acute flexion Courtesy of Dr. L. R. G. Crandon (outlines reinforced). supracondylar fractures, but the addition of pressure pads, held in by adhesive straps so placed as to press the condyles together, is of great service. Occasionally splints to hold these pads (Fig. 399) are useful. Fractures of the external or of the internal condyle present no problem of maintenance of relation between humerus and forearm, as Fig. 398.-Prevention of rotation of lower fragment inward (this rotation is the cause of "gun-stock" deformity). A special strip of splint-wood runs from axilla to below the elbow, and on the outside a solid pad presses in just above the fracture. a rule. It is simply a question of the reduction of a fragment to its proper place. To some extent manipulation and rotation of the fore- arm may help in reduction (the ligaments between fragment and fore- arm being intact). In the main, however, it is a question of direct manipulation to correct ascertained displacement. TREATMENT 299 The form of retentive apparatus of most use depends on the indi- vidual case. Once reduction is satisfactory, we can directly test to Fig. 399.-Lateral splints and pads held with straps to produce and maintain approxi- mation of fragments in T-frac- ture. See from behind. Fig. 400.-R. Jones's wrist- -sling; a crude but efficient method of maintaining acute flexion of the internal epicon- dyle. A pad of felt or cotton is strapped in place with adhe- sive to hold the fragment back in place. Fig. 401.-Acute flexion, with adhesive plaster as ap- plied to separation or fracture of the elbow. determine the position that permits least mobility of the fragment. It may be the right angle, or at times a somewhat more open angle; often acute flexion seems to work best.* It is for us to choose the position Fig. 402.-Splint (applied to the flexor side of the arm) with screw and bolt arrangement to vary the angle from day to day. Very useful in various elbow fractures, in the convalescent stage, even before full consolidation. for the individual case and to apply either the right-angled or an obtuse- angled splint, perhaps with special pads to drive the condyles home, or to apply acute flexion, according to the conditions found in the individual case. * H. L. Smith showed very clearly years ago that acute flexion tends to fix fragments at the elbow by increasing the tension of the triceps and of its tendinous expansions. The position of acute flexion is, for various reasons, less universally serviceable in elbow fractures than he thought, but it is often very useful. (Boston M. and S. Jour., 1894, cxxxi, 386.) R. Jones, of Liverpool, has also advocated acute flexion; his apparatus is decoyingly simple. It is shown in Fig. 400. (Provincial M. J., 1895; Arch. Pedi- atrics, 1892, ix, 435.) F. B. Lund, Boston City Hospital Reports, 1897, p. 389, has devised the best bandage for maintaining acute flexion, but it is best used modified as in Figs. 393, 394, with the adhesive band shown in Fig. 391. Fig. 392 shows the not unusual wrong way to apply this adhesive plaster band, a way calculated to cause stoppage of circulation as well as cutting of the skin by the edge of the plasters. Efficient use of acute flexion is possible only where great swelling has not yet taken place. 300 FRACTURES OF THE HUMERUS AT THE ELBOW Internal Epicondyle.-In these fractures we have no joint involve- ments, but we do have a muscle pull to deal with-we must relax the superficial flexors. The only position that will do this is full flexion, and I have no hesitation in recommending acute flexion for these cases. By means of pads below the fragment, pulled up by strapping, we can go'even further to secure the best practicable position of the displaced fragment. Up means toward the humeral shaft (Fig. 401). Results In adults the result of these as of other joint fractures depends in part on the accuracy of reposition, but more particularly on avoidance of the loss of motion due to the trauma plus the fixation enforced to Fig. 403.-Diagram to show the amount of the limitation of extension that may be caused by very moderate callus (a) in the olecranon fossa, without displacement of fragments (median section of dry bones). insure proper union. There must always be a compromise between the risk of deformity and the risk of loss of motion from overmuch and overlong fixation. In the past we have gone too far in the direction of long fixation in such cases. Lucas-Championniere and his followers have probably gone too far in early mobilization. Yet under favorable circumstances, with a "good" patient, very early mobilization shows excellent results. So soon as the first tenderness and swelling begin to subside, or even before this, say at fourteen days, in many cases even as early as ten days, and in all simple fractures within three weeks, careful massage is in order. Very gentle passive motion may be begun, at the same time, with manual fixation of the fragments. This is early to be TREATMENT 301 supplemented by active motion carried out by the patient at regular times daily. For these exercises, all dressings are removed. Forced passive motion is rarely to be recommended, for its tendency is to "stir up" the joint, and so to stiffen it, instead of limbering it. This does not mean, of course, that forcible rupture of adhesions under ether may not be necessary at a later stage. In fact, however, this measure is rarely called for. Active motion, even with courageous and persistent patients, is rarely pushed beyond the point of slight pain. It is as efficient as passive motion in limbering up muscles and joints, and is practically free from the chance of increasing joint irritation. After three, or at most four, weeks, splints may be laid aside and a simple rest-sling used for a fortnight. The older treatment (four to six weeks of absolute fixation) is disastrous, and may be avoided in all save perhaps in some severe compound fractures. Results in the adult are largely depend- ent on the possibility of carrying out this somewhat difficult routine of after-treatment. If this treatment has been carried out, we have only the deformity and limitation of motion due to displacement of bone, and the deformity from callus. This is an ideal con- dition, and by no means always attainable, whether on account of circumstances, or be- cause of lack of interest, courage, or persistency on the part of the patient. As to disability and deformity, due to dis- placement, we are apt to have the following conditions present in greater or less degree. In supracondylar fractures and in the T- fractures without great displacement we get a varying valgus or varus deformity (details considered later under the children's fractures), some limitation of flexion from displacement of the upper fragment forward, some limitation of extension from filling up of the olecranon fossa by callus. (See Fig. 403.) These are approximately permanent results; with careful work, however, the end-result is fair, as a rule. Bad results usually come from grossly bad position or from over-long fixation. Bad T-fractures may be impossible to hold in place, and the results may be almost necessarily bad; we may even have complete ankylosis. Many of these cases when compound, and even some of the simpler T-fractures, come to joint resection later, but enough of them do well to make early resection unjustifiable. Fractures of the external condyle do well, as a rule. Very rarely non-union results. There may be some broadening and thickening at the outer part of the bone. Other deformities do not occur. Some Fig. 404.-Fracture of con- dyles and fracture of shaft above condyles from two separate in- juries. Result poor: excessive callus formation. Elderly pa- tient with arthritis deformans. 302 FRACTURES OF THE HUMERUS AT THE ELBOW limitation of motion is apt to be present, due mainly to callus in the olecranon and coronoid fossae, but a useful arm may be expected. Fractures of the internal condyle are even more apt to have limita- tion of motion for the same reasons, but the functional result is usually good under adequate treatment. Internal epicondylar fractures often unite by fibrous tissue only, but the union is firm, and save for some slight loss of power in the fore- arm flexors, eventually recovered from, no ill results ensue.* Fig. 405.-Back view of a supracondylar fracture. This is a very useful view, though the x-ray men are always loath to take it. There is some distortion, of course, but it tells more than any other view as to the lateral alignment. Pathologic Fractures.-Under this caption may be classed certain refractures, including cases in which previous partial ankyloses have determined the fresh fracture. I have seen one case (apparently an osteogenesis imperfecta; he had had various other fractures from slight trauma) in which there had been a condylar followed by a supracon- dylar break. Fig. 404 shows a like unfortunate result, in this case a fracture near an arthritic joint. Such cases are important in that good results are hardly to be expected. I have seen two cases in which poor results from old supracondylar lesions apparently acted as determining causes of fresh olecranon fracture. * A priori one would expect some late trouble with the ulnar nerve resulting from the fibrous union with displacement of the bone fragment, but this does not seem to happen. FRACTURES OF THE HUMERUS AT THE ELBOW IN CHILDREN 303 Fig. 406.-Separation of epiphysis of external condyle of humerus, arm fully flexed viewed from behind. There has been a rotation of the epiphysis out and down through 90 degrees. 1 Internal condyle; 2, external condyle, corner of diaphysis; 3, olecranon, 4, epiphysis of radial head; 5, radial shaft; 6, epiphysis of capitellum-the numeral is near what was the articulating surface; 7, frag- ment of periosteal bone from the diaphysis, still attached to the epiphysis, rotated far from its original place. FRACTURES OF THE HUMERUS AT THE ELBOW IN CHILDREN Anatomy of the Epiphyses.-The differing shape and growth of the epiphyses must constantly be borne in mind in examining children's Fig. 407.-Epiphyses in the new-born. Displacement backward (experi mental). Fig. 408.-Epiphyses in the new-born. Displacement forward. Fig. 409.-Epiphyses at eight years (drawn from War- ren Museum, specimen 334). fractures. At birth, and up to two or three years of age, the whole lower end of the humerus is a cartilaginous mass in which an ossification center appears at the outer side at about one and one-half to two years of age. Injuries up to the age of three or four years must almost necessarily be a separation of the epiphysis as a whole. By four or five years of age the external condyle has become a definite structure, and a cleavage line in the cartilage has been formed. (See Figs. 409 and 410.) The internal epicondyle shows a bone center at about five years, and at about ten to twelve years it has been separated from the rest of the 304 FRACTURES OF THE HUMERUS AT THE ELBOW epiphysis by the growth of the shaft downward into the epiphysis, leaving only a shell of epiphysis over the trochlear surface, with a small ossification center. From this time onward growth occurs by progres- sive ossification of the external condyle and by growth of the diaphysis downward. The external condyle unites Fig. 410.-Epiphyses at eightyears. Fig. 411.-Epiphysis at ten and one-half years. Anteroposterior view: A, Capitellar epiphysis; C, epitrochlear epiphysis; D, radial epiphysis; G, trochlear epiphysis. to the shaft usually between sixteen and nineteen years of age, but may persist longer. From an early age the line of demarcation of the external condyle includes not only the capitellum, but also the outer edge of the trochlear articular surface. This demarcation persists, although after about fourteen years there is only a very thin layer of epiphyseal cartilage marking this line (Figs. 410-415). There is an ossification center of the exter- nal epicondyle appearing at twelve to fourteen years, fusing, as a rule, with the external con- dyle by the sixteenth year. It is never more than a scale, and is surgically unimportant. Growth on the inner side-growth of the trochlea-is by growth of the shaft down into the epiphysis, and the lower end of the ossi- fied shaft becomes very oblique as time goes on (Figs. 410, 411). There is sometimes, at about thirteen years of age, a small ossifica- tion point in the trochlear portion, visible in the skiagraph, but this separate epiphysis has long before this become very thin, and is fused with the shaft soon after this. Surgically, it is of little conse- quence. It is the exception for it to be visible in x-ray plates at'any age. Fig. 412.-Epiphyses at ten and one-half years (B. C. H., plate 880). FRACTURES OF THE HUMERUS AT THE ELBOW IN CHILDREN 305 The last epiphysis to unite is that of the internal epicondyle. It may join as early as sixteen to eighteen years, but often there is delay Fig. 413.---Epiphyses at ten years (Warren Museum specimen (no number), seen from front and from outer side). Fig. 414.-Same specimen as Fig. 413, seen from the back. and, according to Rambaud and Renault,* it may remain as an epiphy- sis through life. Fig. 415.-Epiphyses at fifteen years (Warren Museum, specimen 537). Fig. 416.-Epiphyses at eighteen years (Warren Museum, specimen 417). From be- hind. Shows only the internal epicondyle still separate. In regard to judging the relations of epiphyses in x-ray pictures (a very difficult matter in many cases), it may be well to bear in mind the following points: 1. That the capitellar epiphy- sis is, in the lateral view, projected Fig. 417.-Epiphyses at ten years. Lateral view. Note how far forward the epiphysis of thefexternal condyle lies in relation to the shaft, and also how much of the olecranon is still car- tilaginous. Fig. 418.-Epiphyses at eight years. Same case as Fig. 410. Lateral view, slightly distorted. against the lower inner end of the diaphysis, because it lies higher, and that it normally lies well forward of the axis of the shaft. * Developement des Os, 1864, quoted by Poland. 306 FRACTURES OF THE HUMERUS AT THE ELBOW 2. That there is normally a marked apparent gap representing the space actually filled by the articular cartilage of trochlea and ulna. 3. That the trochlear epiphysis is not always apparent, even when we might expect ossification to be present in it: it is, in fact, rarely seen. 4. That the center of ossification of the epitrochlea is thin and may not show even in the anteroposterior view. 5. That this same epiphysis may show in the lateral view and give rise to confusion if its identity is not suspected. 6. That the ossification-center of the epiphysis of the external epzcondyle is so small and so unconstant that it may prac- tically be disregarded.* 7. The obliquity down and inward of the lower end of the diaphysis, as seen in the x-ray, is constant, and increases with growth. Classification of Fractures of the Hum- erus at the Elbow in Children.-The frac- tures and separations which do, in fact, occur in children are: Supracondylar frac- tures; separations of the whole epiphysis; separations of the external condyle; sepa- ration of the internal epicondyle, f In all except the first type these separations follow more or less closely the epiphyseal lines. The sup- racondylar fractures are in all respects like those we have considered in the adult, save for the greater stripping-up of periosteum, and the diagnosis of this lesion is no way different in children. Fig. 419.-Tracing of a;-ray of normal elbow. Shows how confusing a slightly oblique x-ra,y view of a normal elbow may be. Fig. 420.-The commoner forms of lesion at the elbow in children, according to Judet (sketched from his published plate). Fig. 421.--Typical fracture lines according to the writer. The T-fractures, and the frac- ture along line 4-6, almost never occur in child- ren. The children's types are: (a) The supracon- dylar, 1-2, 3-4, or at the epiphyseal line; (b) the external condyle, 3-5; (c) the internal epi- condyle, 4-7. * The foregoing is quoted practically verbatim from Cotton, "Elbow Frac- tures in Children," Ann. Surg., February, 1902. t Judet (Arch, d'electr. Med. Bordeaux, 1906, xiv, 123-141) has a discrimi- nating article, primarily on supracondylar fractures in children, but dealing also with the classification. Not uncommonly lack of anatomic knowledge seems to lie at the back of some classification. For example, a recent article by Warbasse (Med. Record, January 30, 1909, p. 170) figures as epiphyseal lesions a number of cases that the x-rays seem to show clearly as supracondylar fractures FRACTURES OF THE HUMERUS AT THE ELBOW IN CHILDREN 307 Fig. 422.-z-rays (after one year) of a case of separation of the whole lower epiphysis of the humerus, with a chip of the shaft also torn away on the outer side. Boy of twelve years. The '•insert" below shows the fresh lesion. Fig. 423.-Boy of nine years, supracondylar fracture, backward displacement, rotation of shaft forward on the inner side. 308 FRACTURES OF THE HUMERUS AT THE ELBOW Fig. 424.-Supracondylar fracture with moderate backward displacement (tracing of x-ray plate) Fig. 425.-Supracondylar fracture: extreme stripping-up of periosteum from shaft. Fig. 426.-Girl of three years. Supracon- dylar fractures, acute flexion. Fig. 427.-Age nine years; supracondylar fracture with rotation. SUPRACONDYLAR FRACTURE IN CHILDREN 309 Supracondylar Fracture In Children No fracture at the elbow is more familiar; whether this or the exter- nal condylar fracture is more often met with is a question differently answered by different statistics. This lesion differs in no essential from the corresponding injury in the adult either in mechanism or in lesions. As a rule, we meet with fracture of the "extension " type, oblique up and backward, displaced up and backward. Forward displacement occurs, but is rare; forward rotation may be primary, but more often results from unwise treatment. As a rule, there is a rotatory displace- ment about the vertical axis. Probably this results from the action of the strong outward rotators at the shoulder, now unopposed by the inertia of the forearm; at all events we commonly find the upper fragment rotated forward and inward, a point of great importance, as we shall see later. In the supracondylar fractures in children there is apt to be exten- sive stripping-up of the periosteum at the back, but this does not commonly interfere with reduction, and with proper reduction it does not affect the results appreciably. Rarely, we may find incomplete (or greenstick) fracture at this point. Fig. 428.-Supracondylar fracture with displacement. Seen before and after attempted correction. Fig. 420.-Supracondylar fracture. Toler- ably good position, but there is likely to be loss of flexion from the coronoid hitting the spur seen above it. Fig. 430.-Supracondylar fracture in a child of six. The upper plate shows the spur (due to rotation of the shaft outward), which is apt to check flexion. The lower shows the displacement and rotation inward of the axis of the forearm, sure to give gunstock deformity. 310 FRACTURES OF THE HUMERUS AT THE ELBOW The usual site of the break is low, above the epiphyseal line but only just above it, running, as a rule, obliquely, but not very obliquely, up and backward. Fig. 431.-Supracondylar fracture. Marked displacement of lower fragment inward. Fig. 432.-Same case as Fig. 431. Shows extreme backward displacement. This was an old fracture, later operated on; good result. The displacement is dependent on the original trauma; the rotation of the fragment depends on later handling; in a general way the lower fragment of the humerus follows the movements of the forearm. Fig. 433.-Supracondylar frac- ture. Good reduction. Fig. 434.-Supra- condylar fracture with extreme backward dis- placement (before re- duction). Fig. 435 .-Supracon- dylar fracture with great backward displacement. Supracondylar fractures in children show, as a rule, a marked swell- ing, much ecchymosis, occasionally blebs-far more reaction than is usual in fractures of other types in this region in children. Separation of the Whole Epiphysis Separation of the whole epiphysis is possible up to four years of age. After this, separation of this sort at least does not involve the internal SEPARATION OF THE WHOLE EPIPHYSIS 311 epicondyle; in fact, it is rare after this age in any form. The mecha- nism of the lesion seems to be the same as in the supracondylar cases. Except in very young children, in whom there is occasionally a loosening of the epi- physis laterally, the displacement is just like that of fracture above the condyles, from which it is not always easily distinguished save with the aid of the x-ray. Neither in displacement nor in rotation does this lesion differ from the supracondylar fracture nor is it differently treated. There is a definite tendency for these epi- physeal separations to be compound-the wound (of emergence of the shaft) lying on the front of the elbow. Ordinarily, the epiphysis is separated with- out splitting, so far as we know, but the x-ray can hardly decide this point, and I have repeatedly seen cases where I was in doubt. The specimen shown in Fig. 456 shows that such splitting may occur. Such splitting of a separated epiphysis is the only form of T-fracture in childhood that seems established by actual evidence. Interference with growth from damage to the epiphyseal line in these cases is at worst rather rare. One still reads at times articles Fig. 436.-Supracondylar frac- ture; the lower fragment, with the forearm, is much displaced back and outward, and is rotated out- ward, as well, on the axis of the humerus. Fig. 437.-Supracondylar fracture. Fair reduction: 1, Shaft of humerus; 2, lower frag- ment of the shaft; 3, epiphysis continuous with 2; 4, new bone under the stripped-up perios- teum behind. Fig. 438.-Supracondylar fracture. Good position, but with slight forward displacement, from overreduction. 312 FRACTURES OF THE HUMERUS AT THE ELBOW by men who have no cases to record, but believe such interference with growth something usual and much to be dreaded.* Fig. 439.-Separation of external condylar epiphysis, with outward displacement. Fig. 440.-Separation external condyle. Separation of the external condyle is about as common an accident as the supracondylar lesion. Separation of the External Condyle * The most recent noted is by Warbasse, Med. Record, January 30, 1909, p. 170. There is, of course, no doubt that loss of growth or distorted growth may occur. The wonder is that it does not occur oftener; that any serious distortion is, in actual practice, extremely rare. T-fractures 313 In very young children the separation follows exactly the cleavage line of the external condyle cartilage (see Figs. 409 and 413), a line run- ning beyond the con- dyle in the joint, taking in the external edge of the trochlea as welk- in the older child- ren the line within the joint is the same, but at the upper outer corner we are apt to find a chip of the shaft torn loose with the epiphysis. (See Figs. 441, 446, 447.) The fragment separated is still united to the radius by ligaments. Its displace- ment is apt to be very slight, but rotation down, outward, and often forward, is apt to occur. The diagnosis is to be made, as in the adult, by the evident limita- tion of injury to the outer side of the joint, and by the mobility of the separate fragment. Crepitus is often not obtainable. Lateral mobility of the forearm as a whole does not occur, a point definitely distinguishing this lesion from the first two classes. Fig. 441.-To the left is shown the line of fracture, including the outer edge of the trochlear articular surface, running along the epiphy- seal line, then up and out above the external condyle, tearing away a bit of the diaphysis. In the figure to the right is shown the way in which the fragment often rotates, throwing the fragment of shaft out- ward. The resultant new-growth of bone is indicated in dotted line. This is what I have called the exter- nal condyle "spur." Fig. 442.-Sketch from negative show- ing fracture line; poor negative. Separation of the Internal Epicondyle This is an accident involving less severe trauma than the other lesions, a trauma evidently due, sometimes to a direct blow, rarely to the pull of the muscles which arise from this process. In the latter case, displacement must be down and forward (see Fig. 449); in the former it may be forward or rarely upward. (See Fig. 450.) As a rule, the separation is clean-through the epiphyseal line. At the age when it does, in fact, occur (i. e., after ten years) the joint is very rarely opened by avulsion of this process. Associated damage is apt to be slight; ecchymosis and tenderness are local. The above applies to the simple cases without other damage. The cases in which this lesion is but a detail (though an important one) of elbow luxation have already been considered. T-Fractures T-fractures occur so rarely in children as to be almost negligible. There are a few well-attested cases where the epiphysis is split through, substantially without separation of the fragments. (See Fig. 456.) 314 The elasticity of the cartilage, and the presence of a line of less re- sistance along the line of external condyle fractures, are the probable FRACTURES OF THE HUMERUS AT THE ELBOW Fig. 443.--Fracture of the external con- dyle] on the left side. Photographed directly after injury. Fig. 444.--Skiagraph of case of separation of external condylar epiphysis. explanation not only of the non-occurrence of T-fracture, but also of the fact that a fracture of the internal condyle into the joint occurs very rarely, indeed, in childhood-so rarely as hardly to deserve a place in our classification.* Diagnosis Supracondylar fractures give definite dis- placement (almost always backward), differing from other lesions in that the forearm and both condyles move back together, with their mutual relations undisturbed. There is often crepitus. There is free abnormal mobility laterally, present only in the supracondylar lesions. Flexion is apt to be limited. Extension is free, but extension gives increase in the deformity. Separation of the whole epiphysis, occurring in very young children, differs in no way, clinically, from the supracondylar lesions, except Fig. 445.--Epiphyses at three years: a, Capitellar epi- physis; b, fragment of perios- teum; case of (reduced) separa- tion of the external condyle. *It is only fair to say that, apart from Mouchet (loc. til.') and a more recent article by Judet (Arch, d'electr. med., Bordeaux, 1906, vol. xiv, pp. 123-141), my classification above given has not been generally agreed to. As I see more and more cases, however, I am more inclined to insist on it. DIAGNOSIS 315 that crepitus is "soft." The final decision may depend on the x-ray. Between these two forms of lesion exact diagnosis is of no real conse- quence. In external condyle fractures we have damage obviously mainly confined to the outer side of the joint. There is no deformity of the general axis of the arm. There is a movable external condyle, movable apart from the shaft of the humerus. False motion of the joint is little, and usually consists of a little abnormal motion in abduction. As to the position (rotation, etc.) of the fragment itself, we can tell nothing until we get the x-ray picture. Separation of the internal epicondyle is diagnosed by-(a) intact (passive) mechanism of the joint; (6) lack of lateral play in the joint; (c) local tenderness and swelling; (d) thickening at a point near, usually below, the proper site of the epicon- Fig. 446 -Separation of external condyle epiphysis with a chip of the shaft at the outer side (lateral view). Fig. 447.--Separation of external con- dyle (and probably of whole epiphysis) with a chip of the shaft at the outer side (child of four). dyle; (e) sometimes a loose fragment can be made out; (f) pain on active use or on passive stretching of the superficial flexors of the arm. As a rule, the diagnosis is actually based upon the change in shape of the portion of bone left behind, with the disappearance of the "hook," and the changed relation of the ulnar nerve. T-fracture and fracture of the internal condyle, if they occur, give something near the signs of like lesions in the adult. The best guide as to the success of reposition is palpation. Remember that the external condyle should lie a little higher than the internal epicondyle, and the olecranon only slightly behind the condyles. We may, while holding the fragments firmly, partly extend the arm to test the axis. In supracondylar fractures there is a tendency to outward rotation of the shaft (by the shoulder rotators) that leads to deformity like that shown in Fig. 455. I know no way to correct this except to carry the 316 FRACTURES OF THE HUMERUS AT THE ELBOW whole arm into outward rotation as we reduce, in this way entangling the fragments so that position is retained even after rotation inward.* Fractures of the external condyle are best reduced by pressure in- ward on the fragment, executed while various motions of the forearm Fig. 448.-Separation of external condyle with displace- ment out and up (sketched according to the findings in a clinical case). Fig. 449.-Typical dis- placement, downward, of the separated internal epicondyle. Fig. 450.-Displacement of the epicondyle upward. This is very rare-I have seen it but twice. are being carried out. In this way pressure combines with the pull on various ligaments to help slip the condyle in place. If there is evident widening, then forcible jamming of the condyle against the shaft is wise; it may give impaction, though not firm im- paction. Correction of rotation of the fragment down and outward is desir- able, but it is very diffi- cult to be sure of this rotation-to say nothing of its correction-until Fig. 451.-z-ray tracing of separation of the epiphy- sis of the internal condyle. Fig. 452.--Separation of internal epicondyle. Tracing of arm, some weeks after the injury. Fig. 453.-The muscles aris- ing from the internal epicondyle (pronator radii teres, flexor ulnar- is; flexor carpi radialis, palmaris longus). These show marked a- trophy if the epicondyle is broken. x-ray pictures are taken. These fractures usually repair satisfac- torily if put up either at right angles or in acute flexion. There seems no especial advantage in acute flexion. * Latterly, I have made it my custom to carry out reduction manoeuvers for these fractures with the whole arm in outward rotation-and have had much better results. DIAGNOSIS 317 Separation of the internal epicondyle is reduced by direct manipula- tion, by putting the arm up in acute flexion in a "Lund" swathe, and holding the fragment as near the shaft as possible by means of a pad and strap (Fig. 401). In fractures and separations of this class in children no stress is laid Fig. 454.-Reduction of supracondylar fracture with the whole arm held in outward rotation. Fig. 455.--Supracondylar fracture of the humerus in a child. The plate shows the "spur" formed by the rotated internal condylar edge of the upper fragment that so often interferes per- manently with proper flexion of the arm (Cleveland. Med. Jour.). on early mobilization. There is no tendency to permanent stiffness at this age, and fixation is the only important point after reduction has been done. Splints are not usually necessary more than about two and one-half weeks, or even less in very small children. 318 FRACTURES OF THE HUMERUS AT THE ELBOW In fractures of the external condyle the writer never hesitates, however, to leave splints on for five weeks or more if there is any ques- tion as to the union of the condyle. Passive motion is not necessary in these fractures, and forced passive motion, once so much advocated, seems productive only of harm from joint irritation. If the child, after union is firm, is allowed to use the arm gently at first, he will in time develop all the motions permitted by the position of the fragments. That is to say, the result depends in children not at all upon the time of fixation, but entirely upon the perfection of reduction and upon the absorption of callus. This does not mean that there is any prompt restoration of motion. Fig. 455a.--Results in children are surprisingly good in the end. This plate was taken in 1913, a fracture in a girl of nine. This was a year later. There was only about 10 degrees loss of flexion then. Today, after nine years this arm matches the other in shape and in range of motion. In a series of these cases, followed up many months later,* the writer found astonishingly good results as to motion, but found that full motion was not regained until three to eight months after the re- moval of the splint. Many of these cases showed only a very small arc of motion at the time of their original discharge from treatment. So far as displacement and deformity are concerned, there is a curious constancy about these cases. Supracondylar fractures and separations of the epiphyses usually show slight backward displace- ment in spite of good treatment, and they not uncommonly show a rotation of the lower fragment back under the broken internal condyle, or, more accurately, external rotation of the loosened shaft, in such fashion that flexion is checked by the coronoid process hitting the condyle (Figs. 459, 475, etc.). Extension is rarely interfered with, and is often possible beyond the normal limit. Deformity is often in the line of the so-called "gunstock" deformity. This may be very *Cotton: Ann. Surg., February, 1902. 319 extreme. It comes from the rotation in and upward of the lower fragment, changing the plane of the joint so that the forearm bones are extended sharply down and inward, as shown in Figs. 458, 470, etc. The existence of such deformity alone gives the diagnosis of a supra- condylar lesion. Fractures of the external condyle show, as a rule, no permanent loss of motion excepting that Ayperextension of the elbow may not be possible. They do not show any gunstock deformity. They uniformly show some alteration in outline of the outer side of the joint. (See tracings, Figs. 481 and 482.) At times there is a well-marked "spur" growth above the joint (Figs. 480, 481). This is a result of growth of the detached bone and of the periosteum, which is torn away with the epiphysis. It proves nothing as to position of the fragment, and is apparently unavoidable in many cases. There may be some widening (up to inch), ow- ing to displacement of the loosened condyle outward. There is nothing to do about this rotation unless we can operate. In five such cases of short duration I have made the oblique posterior incision, freed the broken surfaces, corrected the rotation, not without much difficulty, and with sutures or a drill used as a peg (later removed) have fastened the fragment in place. Later x-rays showed practically perfect position. I am sure no great spur-formation will take place. Dr. J. S. Stone has also done several such operations with success, I understand.* TREATMENT Fig. 456. -t- fracture in a child. This resulted from direct crushing, a compound fracture. So rare a form of frac- ture in childhood as to be negligible (Warren Museum). Treatment The supracondylar fractures in children are treated exactly as in adults, so far as reduction is concerned. The internal angular splint will usually be found most serviceable. Cases where there is marked tendency toward backward displacement of the lower fragment may best be treated in acute flexion. This is a matter of judgment, purely. Treatment in the extended position never seems to be called for. It gravely increases the chance of backward displacement of the condylar fragment, to say nothing of the inconvenience of the position and of the small chance of stiffening at this unhandy angle. The claim that it is a necessary procedure in order to preserve the long axis of the arm is fallacious. * The deformity of rotation, with non-union, comes up for consideration later. 320 FRACTURES OF THE HUMERUS AT THE ELBOW Fig. 457.-Supracondylar fracture (schematic) Fig. 458.--Inward displacement and rota- tion of lower fragment and forearm, the cause of gun-stock deformity. Fig. 459.-Supracondylar fracture: back- wardudisplacement. This backward [displace- ment.is usually combined with a rotation of the shaft outward that brings the broken end of the ridge that runs up from the internal condyle toward the, front, where it is very likely to meet the coronoid process (shown by the arrow) (compare Figs. 423, 427, 428, 430, 436, 477). Fig. 460.--Shows how extension may aggra- vate deformity; the fracture is a freer point of motion than the joint (especially if there is muscle spasm). Fig. 461.--Internal angular splint- application. There should be a special pad at the bend of the elbow, general padding (three or four thicknesses of "sheet-wad- ding") fastened to the splint with adhe- sive. The splint is then fastened to the arm with four strips of adhesive 1 to inches wide, placed as shown, two above, two below. Outside this comes a layer of sheet-wadding over all, then a bandage, and last of all the sling. Fig. 462.-Internal coaptation splint used with the "internal angular" to insure against "gunstock deformity " from inward displacement and rotation of the lower fragment. TREATMENT 321 Fig. 463.--Increase of deformity due to acute flexion. Acute flexion acts by a tightening of the triceps tendon and its expansions about the fragments at the joint. This action depends on an intact humerus for counterpressure. If the humerus is broken across, the counter- pressure fails, and flexion tends usually to produce shortening with displacement either forward or back. Fig. 464.-Acute flexion with consequent production of deformity. Fig. 465.-Acute flexion applied (properly) to a case of separation of the internal epicondyle The displaced epiphysis does not show in the print. 322 FRACTURES OF THE HUMERUS AT THE ELBOW Fig. 466.-Acute flexion by means of an ad- hesive strap. Fig. 467.'-Tracings of end-results in supra- condylar fracture (author's cases). XXV, XXIII, XIX, show gunstock deformity (slight); XXVIII shows a trace; the others are good results. Fig. 468.-Gunstock deformity, arm tracing. Fig. 469.-Arm tracings. TREATMENT 323 Fig. 470.-'Photograph of end-result in a case of supracondylar fracture. Marked" gun- stock deformity" of the right arm (this case was operated on later, with marked improve- ment resulting). Fig. 471.-Gunstock result, x-ray, anterior view. Fig. 473.-Backward displacement. End-result ..of supracondylar fracture (after Mouchet). Fig. 472.-Extreme gunstock deformity-old supracondylar fracture. Fig. 474.-Backward displacement, after supra- condylar fracture (after Mouchet). 324 FRACTURES OF THE HUMERUS AT THE ELBOW It is true that in treating this fracture there is likely to be a devia- tion in the axis of the arm, and that the greatest care must be taken to Fig. 475.-Backward displacement with check to flexion. Supracondylar fracture (same case as Fig. 470). Fig. 476.-Gunstock deformity after supar- condylar fracture (same case as Figs. 470 and 475). avoid any dropping inward of the fragment toward the body. Such inward deviation is the cause of the much-discussed gunstock defor- Fig. 477.-Check to flexion. Supracon- dylar fracture (compare a:-rays of same case, Fig. 422). Fig. 478.-Extension in the same case; note that the elbow is away from the side, and the arm rotated so that the olecranon looks outward. This curious and confusing spiral movement of extension is seen in all cases with "gunstock" deformity. mity.* Not infrequently, if this fact is borne in mind in reduction, the * "Gunstock" deformity is a result of supracondylar fracture, not of dis- placement of one or the other condyle. Allis, many years ago, and without precise data, alleged that it resulted from ascent or descent of one condyle, and his state- ment has been .accepted and copied by many. Stimson, in this country, and sev- eral of the best Frenchmen, have recognized the facts. I stand to my opinion, expressed in the Annals of Surgery, February, 1902, that Allis was in error, and that such deviation belongs, with the rarest exceptions, to the lesions involving the full width of the humerus. TREATMENT 325 Fig. 479.-Fracture of external condyle. Shows the "spur" growth of new bone arising from the rotated bone fragment. (Compare Figs. 441 and 481, 482.) Fig. 480.-Same case viewed from behind. Fig. 481.-Arm tracings-right arm: a, In supination; b, in pronation; c, with ulnar side'of hand down (on paper); g, upper arm laid on the table, elbow in full flexion. Left arm: d, supina- tion; e, pronation; f, ulnar side down; h, upper arm, elbow flexed. Fig. 482.-Arm tracings of external condyle fracture. 326 FRACTURES OF THE HUMERUS AT THE ELBOW arm may be so reduced and "locked" on the splint that the contact of the rough fragments will prevent any such deformity. In order to minimize any tendency of the splint to produce it, it is wise to use the oblique "Bolles" splint. (See Fig. 379.) The mechanism of this splint and the mech- anism of production of the deformity by the ordinary splint may be under- stood from Figs. 380 and 381. A serv- iceable method of preventing deformity when the fragments arc loose is the one Fig. 483.-Deformity after union in a fracture of the external epicondyle (after Mouchet). Fig. 484.-Ununited external condyle. (first orally suggested to me by C. A. Porter) * of the addition of a padded internal splint on the inside of the arm, supporting the lower fragment, Fig. 485.-Anteroposterior view-extreme "gunstock" deformity. Fig. 486.-Same case-lateral view. * Not published, as far as I know. 327 TREATMENT Fig. 487.-Skiagraph of case of Figs. 485, 486, anterior view after operation. Fig. 488.-Gunstock deformity in the adult, x-ray tracing (Stewart, B. C. H., 13492). Fig. 489.-Gunstock deformity of the left, elbow. Tracing of arms. Child of four years Supracondylar fracture. 328 FRACTURES OF THE HUMERUS AT THE ELBOW Fig. 490.-Skiagraph of case XXXVII, lateral view. Fig. 491.-Skiagraph of case XXXVIL anterior view. Fig. 492.--Details of operation on case shown in Figs. 47C>, 475, 476. Incision was1 made to the outer side, the prominent spur resected, and then a transver: se osteotomy was done to correct the gunstock deformity. TREATMENT 329 as shown in the sketch. This scheme has proved very serviceable in cer- tain cases. Here and there external condyle fracture, like other intra-articular fractures, fails to unite.* Fortunately, this complication is rare. It is to be guarded against only by efficient and long fixation. If union does fail, there is nothing for it but nailing or excision of the fragment, which operations, however, promise at least a useful joint.f Fig. 493.-Gunstock deformity. Fig. 494.-Same, corrected by operation. Since the above was written I have operated on six such cases with perfect union without sacrificing the condyle. The broken surface was refreshed, the condyle pegged in place with a drill, which was removed * Cases of such non-union are not excessively rare apparently. I reported two such cases in the Annals of Surgery, 1902, and have seen many more since. Cooper gives a cut of a specimen (see Fig. 368), and Poland (Traumatic Separation of Epiphyses, p. 428, Fig. 116) gives an additional case. 11 have done such excision only in one case of compound fracture of the external condyle. The result was a moderate gunstock deformity, but perfect motion and entire restoration of strength. Several such excisions I have seen done, but without approval. In all my recent cases (four or five in number), save once, I have put in a temporary nail, and have in no case failed to get union. It is no slight matter to remove an actively growing epiphysis! 330 FRACTURES OF THE HUMERUS AT THE ELBOW Fig. 495.-Separation of the external condylar epiphysis-non-union. Untreat- ed injury in girl aged twelve of five years' standing. Later operated on with much improvement of deformity and function and with solid union (Cleveland Med. Jour.). Fig. 496.-External condylar epiphysis separated, displaced and rotated outward with much local deformity. Delayed and fibrous union. Case operated on later (replacement of epiphysis, held by tem- porary spiking) with excellent result (Cleveland Med. Jour.). later; union was perfect, and motion excellent. This is evidently the method of choice. Internal epicondyle fractures amount to little in end-results, as a rule. For a time there is almost always a conspi- cuous atrophy of the forearm muscles that have their origin from this process (Fig. 453); this is only temporary. Rarely there is a slight permanent loss of ex- tension. Union is fibrous only,-always. I lately had a chance to verify this in a case of fracture in boyhood, that hap- pened forty years ago. Fig. 497.-Result of operation shown in Fig. 492 in removing the check to flexion. Fig. 498.-Result of the operation, seen from the front. Improvement, but not absolute correction of the lateral deviation. OTHER OPERATIONS ON HUMERUS AT ELBOW AFTER FRACTURE 331 The gunstock deformity is "cubitus varus." It is the loss or reversal of the "carrying angle." The carrying angle is the normal angle formed between the axis of the forearm and the axis of the hu- merus when the arm is supinated. It normally disappears in prona- tion, and does not exist, even in supination, when the arm is flexed. It is the result of a normal obliquity in the transverse axis of the joint at the lower end of the humerus, not of the forearm. Its loss or reversal results from a fracture which obliterates or reverses the obliquity of this joint. Such a fracture in practice is always a fracture above the condyles, or an epiphyseal separation; in short, a lesion traversing the whole width of the humerus. It does not result from fracture of either condyle alone. It has been maintained that the deformity depends on irregular growth from traumatic damage to the epiphysis. Riedel has reported one case in which this undoubtedly happened, but it must be very rare. « The reversed deformity, "cubitus valgus," and increase of the carrying angle, is far less usual, and, as a result of fracture, the writer has only seen it, save in cases of trifling deviation, in cases of non-union of the external condyle. Apart from trauma, cubitus valgus occurs with cases of congenitally short radius, and, like cubitus varus, it is a not infrequent sequel to rickets. I have one case in which such deviation was due to loss of growth at the radial head; rare if not unique. In some persons, apparently normal and with no trace of old rickets, the arm is straight and there is no carrying angle. The angle varies very greatly in different individuals. In any given individual it is nearly always the same on both sides. It is stated that the angle is greater in women than in men. If this is true, it is a rule with many exceptions. Operation for Gunstock Deformity.-Ordinarily, this deformity is of no consequence as to function. Consequently, few patients call for operation. Operation is indicated in some cases for extreme deformity or for secondary arthritis (from mechanical cause) interfering with function. Operation is very successful. The operation usually indicated is an osteotomy above the epiphyseal line, done from the outer side with a chisel. The technical difficulty is avoidance of nerves. The arm is put up in extension in plaster. The results are next to perfect where operation is done for this deformity alone (Figs. 492, 483). The Gunstock Deformity Other Operations on the Humerus at the Elbow After Fractures Generally speaking I am for conservatism in these fractures in children, having seen and had several cases with great bone prolifera- 332 FRACTURES OF THE HUMERUS AT THE ELBOW tion that seemed the result of operative interference and did more harm than the displacement the operation aimed to correct. More- over the non-operative results are apt to be surprisingly good, especially as to function, if one will only wait in patience. (C/. Fig. 455a). Interference with the ulnar nerve by the internal epicondyle calls for immediate operation (excision of the fragment), and in certain cases of luxation with epitrochlear fracture in which the fragment has slipped into the joint we have no resource but operation.* So, too, if the fracture of the capitellum has left a fragment loose in the joint, it should be removed. If, after union, we have a spur interfering with flexion (see Fig. 459), this may be chiseled away; the results may be classed as fair to good. Fig. 499.-Volkmann's ischemic paralysis following fracture of the humerus. With the fingers flexed the wrist can be extended. Fig. 500.--When the fingers are extended, the wrist is flexed. This is characteristic, and is a result of the shortening of the long flexor tendons always occurring in this process. Perfect function is rarely attained, but the operation may be called satisfactory, on the whole. Operations aiming at the reestablishment of a filled-up coronoid or olecranon fossa have not been very successful in my hands, despite repeated trial. Operations for simultaneous correction of gunstock deformity and removal of spurs seem hardly to be recommended. I have done three such, with improvement in all, but I think there would have been greater betterment if I had done either operation alone. The combined operation presents great difficulty in proper postoperative fixation. Certain cases of old backward or back and outward luxations (reduced or partly reduced) appear from time to time, in which there is great overgrowth of the external condyle, either following fracture of the condyle or resulting from periosteal overgrowth. All my operative cases of this sort (3) have shown improvement, but only one, in a child, * Not rarely, transplantation of the ulnar nerve forward into an artificial fat sheath may also be called for. FRACTURES OF THE FOREARM JUST BELOW THE BELOW 333 got improvement enough to make so severe an operation as is called for seem particularly worth while. Volkmann's Contracture.-Volkmann's contracture is a paralysis, not from nerve injury, but from muscle ischemia, often due to tight bandaging, apparently. A paralysis ensues, involving all muscles in the region of the constriction. Later the paralysis lessens, but there is already a fibrous infiltration and a shortening of the muscles. Tests show that it is muscles, not joint adhesions that limit motion (see Figs. 499, 500), and with a little care we may differentiate this from nerve lesions and from the common stiffening of muscles after fixation. The differentiation is important, for the prognosis of ischemic paralysis is very bad; the power of the muscles is poor, and any gain in motion from stretching or cutting is apt to be lost by fresh scar contraction. The matter is not entirely hopeless, however. In the case shown in Figs. 499, 500, forcible stretching, followed by massage and active and passive motion, brought about great improvement, which was perma- nent. Two years later this arm was practically normal. Lengthening of tendons has given results in some cases,* shortening the bones in others.f Latterly results are reported from simply strapping the hand flat and then stretching the wrist in extension. FRACTURES OF THE FOREARM JUST BELOW THE ELBOW Fractures in this region are somewhat rare. Such fractures are produced by direct violence or by violence transmitted from the hand alone, or as an associated lesion in various dislocations of the elbow. Direct violence is rarely received at the proper point. Ordinary falls on the elbow may break the ulna, but even if they strike the ulna, they are apt to damage the humerus, rather than the ulna itself. The head of the radius is pretty well buried in muscle masses, which protect it from direct blows. Falls on the hand damage the wrist oftener than the radial head. Fractures of the radial head complicating elbow luxation are not very rare; usually only a piece is driven off the radial head. In practice we meet with the following lesions: (1) Fractures of both bones at the level of the neck of the radius. (2) Fractures of the ulna alone, either just above or just below the * Froehlich, for instance, reports 8 cases treated orthopedically or by tendon lengthening. Reference: Jour. Amer. Med. Assoc., July 17, 1909, and I have latterly achieved one notable success by lengthening all the anterior tendons across the arm; one other by freeing a compressed ulnar nerve, and instituting a long course of passive and active exercises. In a more recent case, freeing of all the nerves about the elbow brought about a perfect restoration of function. I suspect many cases of "Volkmann's" are as much of neuritis as they are of ischemia, taking the cases as listed. f Rolland (Lancet, October, 1905) gives detailed report of such a case. 334 FRACTURES OF THE HUMERUS AT THE ELBOW coronoid process, with or without associated dislocation of the radius. (3) Fractures of the coronoid process alone. (4) Fractures of the olecranon. (5) Isolated fractures of the radial head or neck. Fractures of Both Bones (High) These are most commonly the result of a direct blow or of crushing, as by machinery. They are naturally very apt to be compound. The displacement varies, but it is apt to be of the forearm forward and upward. They are, of course, loose fractures, and so far as the writer's experience goes, are not likely to be comminuted, nor is there apt to be any serious damage to nerves or vessels. If they are compound, diag- nosis is easily made. Such fractures almost necessarily involve the joint, and call for a thorough cleansing and disinfection, during the course of which the diagnosis is easily made by direct inspection. If the fracture is not compound, it becomes simply a question of identifying landmarks and of mak- ing sure that the injury to the radius is a fracture, and not a dis- location. It may be somewhat difficult to be sure that there has been an injury of the radius of any sort. The existence of crepitus on rotation proves nothing, because rotation will give crepitus trans- mitted from the ulna. Mobility with the ulnar fracture is very considerable, even with the radius intact. With the radius also gone we have a flail-joint of an exaggerated sort. Diagnosis of the fracture of the ulna needs no discussion, because this bone is subcutaneous at this level, and may be palpated. Treatment.-If the fracture is compound, the ulnar fracture is to be wired or otherwise fixed. It may or may not be well to wire or suture the radius or to remove its head. If it is comminuted or so impacted as to impair motion, it is better out. The one thing which should not be done is to remove the radial head without making sure that enough of the neck has been left to insure against its slipping out of the orbicular ligament. The argument given against wiring or suturing fragments of the radius is that it is likely to interfere with rotation. This is not likely to happen, but, as a matter of fact, the radial head is so hard to get at that the conservative operation of sutur- ing is hardly practicable without doing more harm than good.* Fig. 504.-Compound fracture of olecranon. Split of radial head and neck. Crushing injury. Olecranon wired. Radius reduced and held in forced supination. Perfect recovery. The patient returned to his work as a bench machinist. * I have saved two split radial heads and necks with good results, and in two cases' here reimplanted entirely separated and displaced radial epiphysis successfully. FRACTURES OF BOTH BONES (HIGH) 335 These fractures often do better than would be expected, so it may be well not to do too much. With regard to the treatment of simple fractures, it comes down to Fig. 505.-Dislocation of both bones forward, with a break in the ulna just into the joint: 1, 2 Olecranon; 3, external condyle; 4, coronoid process; 5, radial head. a question of the best possible reposition and the application of an in- ternal angular splint and a posterior forearm splint. The tendency Fig. 506.-Double fracture of the ulna. Dislocation of the radius forward. The head of the radius was excised, the olecranon fracture sutured, the lower fracture wired. to deformity seems to be toward a downward bowing of the ulna (see right-hand cut, Fig. 515), due to gravity.* The pull of the biceps is *In cases of fracture a bit lower down (of the upper third of the forearm), this tendency is even more marked, and not very uncommonly a serious deformity develops, even under the physician's eye. 336 FRACTURES OF THE HUMERUS AT THE ELBOW supposed to be important; it is not vigorously operative after a few days. In case of poor result, late operation, particularly for excision of a deformed radial head, may come in question, but this does not concern us in the fresh treatment of simple fracture at this point. Fracture of the Ulna Alone Fracture of the ulna may occur just above the coronoid process- that is, through the joint, or just below it. In either case, but espe- Fig. 507.-Fracture of radius: fracture of ole- cranon-luxation. Fig. 508.-Fracture of ulna: outward luxation of radial head. cially in the latter, there may be an associated dislocation of the radius forward or outward, or there may be no damage to the radius at all. If the fracture is above the coronoid (f. e., an olecranon fracture), there is some tendency of the upper fragment to be pulled backward by the triceps (Fig. 514). At whichever point the break occurs there is a tendency to original displacement of the lower fragment forward in case the radius is displaced, probably due to the direction of the smash- ing force. Diagnosis.-There is no serious difficulty in diagnosing these frac- tures. There are both mobility and crepitus, and their site may readily be determined by manipulation. If the break is through the joint, we have a simple olecranon fragment; if it lies lower, there is abnormal mobility of the forearm as a whole, even if the radius is intact and not luxated. FRACTURE OF THE ULNA ALONE 337 Treatment.-If the ulna can be brought into good position on an ordinary internal angular splint, no more fixation than this is required. Fig. 509.-Backward dislocation of radius (with splintering of head); fracture of ulna with displacement backward. Fig. 510.-Condition when I first saw the case. There was no union in the fracture of the ulnar shaft; the radial head (partly reformed) was utterly loose; the arm was useless and painful If, however, the fracture is hard to hold, this is one of the cases that distinctly justifies open operation for wiring, stapling, or suturing of the fracture. The only perfect reposition I have obtained was by driving a bone peg through the ole- cranon down across the fracture into the ulnar shaft-in the long axis of the Fig. 511.--After operation. The radial neck was confined in a new orbicular ligament, made of fascia and of fibers of the supinator brevis and the fracture refreshed and wired. Fig. 512.-Side view of same case. The result of operation was a fixation of the radius with rotation preserved, but union of the ulnar fracture was not secured. Function improved, but not very good. If the fracture is complicated with radial dislocation, it would prob- ably be a mistake to treat it other than by open operation. With the 338 FRACTURES OF THE HUMERUS AT THE ELBOW ulna fixed, the radial dislocation calls only for the ordinary replacement and proper pads to maintain replacement at a right angle or in flexion. Without operation there is risk of malposition of the ulna and of unmanageable recurrence of the radial dislocation. With all the fractures below the elbow so far considered, the ill results to be guarded against are non-union of the ulna and interference with flexion and rotation. Interference with rotation may come from excessive callus of the radius, but is much more likely to come from deviation of the axis of the ulna or from imper_ Fig. 513.-Sketched from find- ings in a case of compound elbow fracture of the writer's. Luxa- tion of both bones forward, with smashing of the ulna below the joint, and with the breaking out of a piece of the radial head at a. This piece was removed and the ulna sutured with heavy silk. Re- covery of motion practically per- fect. Fig. 514.-Check to flexion in luxation of radius forward with ulnar fracture (dia- gram) . Fig. 515.-We may have merely ulnar fracture with the not very serious rocking back- ward of the upper fragment, or there may be a break in both bones, necessarily limiting exten- sion and destroying practically all pronation and supination of the forearm. The distinction between the two is not always easy. feet reduction of the radius, as seen in the accompanying sketch (Fig. 515). Interference with flexion must follow if the forward displace- ment of the radius persists (Figs. 506, 510, 514). Fracture of the Coronoid Process Fractures of the coronoid are accorded a place of apparent im- portance in all text-books, and the picture given of the symptoms and the directions for treatment would not lead one to suspect that this is one of the rarest lesions-almost one of the fictions of surgery.* * Ferguson said that, in a dislocation of the forearm backward, "the coronoid process will probably be broken. Malgaigne thought the fracture more prevalent than the reported examples would lead us to suppose, basing his opinion largely on experimental luxations on the cadaver. Liston wrote: "The coronoid process is occasionally pulled or pushed off from the shaft, more especially in young subjects. I saw a case of it lately in which the injury arose in consequence of the patient, a boy of eight years, having hung for a long time from the top of a wall by one hand, afraid to drop down." Hamilton cites these remarkable statements, and shows how all our supposed lore on coronoid fracture and its muscular causation originated from them. In fact, there are a few specimens without history, some of them doubtful, and no one knows anything about the fracture clinically. It must be very rare. Wainwright, Clin. Soc. Transactions, xix, p. 332, reports an apparently sound modern case of fracture of the coronoid and of the radial head, in which the coro- noid was resected after three months. Dr. L. R. G. Crandon in 1905 (verbal communication), in a case of fresh com- pound elbow luxation tending to recur, removed a broken coronoid and also a loose chip off the head of the radius. To him I am so indebted for the T-ray in Fig. 517. FRACTURE OF THE CORONOID PROCESS 339 There is no manner of doubt that fracture of the coronoid has occurred in a few cases, but in nearly all of these cases it was a mere complication of crushing fractures or of other extensive injuries. It does not occur often enough to be worth consideration, even with these cases or with dislocations. Fig. 516.--Fracture of coronoid process. I have seen the diagnosis made in a good many instances, and have repeatedly tried to verify it by skiagraph or otherwise, and, save in Crandon's* case (Fig. 517), in every instance have found that the diagnosis had no basis in fact. If this fracture is present, there should be pain on the front of the arm on active flexion, there should be local tenderness, and possibly a small palpable fragment. The fragment would not be drawn up by the brachialis internus, as is stated, simply because this muscle is inserted well below the tip of the process, and a fracture could hardly do more than split the area on which it is inserted. There would, no doubt, be some increased mobil- ity of the ulna forward and back when the arm is bent, but unless the lateral ligament on the inner side-and the anterior ligament as well-were torn, this mobility would have to be slight. If the liga- ments were so torn, such free mobility would not prove a coronoid fracture, as every one who has seen recurrence of an elbow luxation can testify. The writer is frank in saying that he probably could not recognize a coronoid fracture except by aid of the Fig. 517.-Fracture of the coronoid process, with reduced subluxation of the elbow backward (courtesy of Dr. L. R. G. Crandon). * In a recent case of my own (a recurring backward luxation) there was a chipping-off of the coronoid tip. 340 FRACTURES OF THE HUMERUS AT THE ELBOW skiagraph. Only very lately I have had a real coronoid fracture,-at last without luxation-also almost without symptoms. Treatment.-The classic description involves treatment in acute flexion. This scheme was apparently devised with regard to the brachialis muscle; there is, however, no question but that this would be the position best calculated to secure proper position and to avoid any interference with flexion by displacement of the fragments. Results.-In the specimens known, union was by fibrous tissue only. So far as our data go, the presence of this process of bone, united by fibrous tissue, would have little or no effect upon the joint or its use. Fractures of the Olecranon These are not unusual. They may occur either from direct violence or from muscular action of the triceps. The former is the more com- mon mode of origin. The importance of differentiat- ing, as far as may be, between these causes, lies in the matter of probable separation of fragments, as in the case of fracture of the patella. At the elbow, however, fractures unquestionably the result of a direct blow may show considerable separation. Whether from the one cause or the other these Fig. 518.-Sketch of normal ulna from above. This shows the narrow weak point in the olecranon opposite in trochlear surface of the humerus. Fig. 519.--Sagit- tal section of the bones of the elbow-joint. The olecranon is broken where it is of least thickness, opposite the bottom of the curve of the trochlear surface, as a rule. Fig. 520.-Relations of olecranon to elbow-joint; all olecranon fractures are neces- sarily intraarticular. fractures are very apt to occur across the narrowest part of the bone. If fracture is the result of a direct fall, this is the part of the ulna most readily split by the convex trochlear surface, and it is the part most readily broken by triceps action, as this trochlear surface acts as a fulcrum. Extensive splintering, even from direct violence, is the exception; the great majority of fractures show a clean cross-break. This may, especially in children, be a clean break across, substan- tially without displacement, and practically sudpmosteaZ (Fig. 525). Such fractures resulting, especially in children, from falls on the elbow, FRACTURES OF THE OLECRANON 341 have been described as a special fracture to which Quenu's name has been appended. When there has been somewhat more tearing, although the perios- teum is gone, there are lateral expansions running down from the tri- ceps tendon to the sides of the joint at the back, which are not likely to be torn across entirely. They limit separation of the fragments, and if unevenly torn, may cause a tilting to one or the other side, as the fragment separates. Even with little separation there is some rotation up and backward of the fragment (Fig. 526). Where there is no obstacle, separation be- comes very considerable, even in the fresh cases, as a result of effusion. Extreme separation comes later, apparently as a result of gradual giving way of the fibrous bands above noted under muscle pull. Fig. 521.-Appearance of olecranon frac- ture: (6) End of ulnar shaft; (c) displaced olecranon; (a) bulging distention of joint be- tween fragments (schematic). Fig. 522.--Upper left, olecranon fracture upper right, normal elbow; lower sketch, ole- cranon (bursitis schematic). Symptoms.-There is a prompt loss of power to extend the arm, which may be complete or may be only partial. Extension of the arm in the ordinary position is possible simply by gravity; there may even be enough left of the lateral expansion of the triceps tendon to give some actual power of extension. Roughly speaking, however, power to extend the arm is lost. The arm may be held in any position. There is nothing character- istic about it. Half-flexion is usual. There is a prompt swelling, of rather characteristic outline, best understood by reference to Fig. 521, differing decidedly from the other fractures, and only likely to be counterfeited by a hematoma or by bursal effusion. On grasping the end of the olecranon and fixing the forearm in extension there is no difficulty, in fresh cases, in obtaining mobility, or in bringing the fragment close enough to give crepitus (Fig. 527). The amount of separation is usually slight at first. Treatment.-The time-honored treatment of olecranon fractures is by the straight splint, with straps holding down the fragment. Lat- terly, the operative treatment has been more in vogue and much advocated. 342 FRACTURES OF THE HUMERUS AT THE ELBOW No treatment ought to be made the absolute routine; the old- fashioned splint, the somewhat neglected right-angle splint, and the operation all have their distinct indications. If there is no tendency at all to separation of the fragments-a not uncommon condition,-then there is nothing to be gained by operation, and there is no necessity of using the cumbersome straight splint (Fig. 528). The writer has repeatedly secured good results, as have others, with the ordinary right-angled "internal angular" splint, with straps and pads to secure approximation and to prevent rotation of the fragment. If there is moderate separation, let us say, under a finger's breadth, then the case be- comes debatable. With elderly patients, or with those in infirm health, splint treatment is, of course, indicated. Young athletic persons, or men who have to do manual labor, had better have wiring or suturing done, because under severe strain even a short fibrous union is likely to stretch. In the majority of patients, who do not definitely belong to either of these classes, it is a question for the patient to decide whether he is willing to run a small risk for the sake of a short convalescence and a practically per- fect arm, or whether he would rather wait longer without operation for an imperfect, but probably serviceable, result. Waiting with the notion of a possible later operation is not wise. Late operations are serviceable, but do not give perfect results, because the shortening of the triceps muscle is a bar to full flexion when the fragments are brought together and held. If there is already, at the time the case is first seen, a very considerable separation of the fragments, operation should be ad- vised unless in the face of some definite con- traindication, such as a bad heart or diabetes, for instance, that would contraindicate any .operation, for the results of palliative treatment in such cases are not good. Compound fractures will be operated on in all cases. In all instances where operation is not advised, or where it is refused, the straight or nearly straight splint is to be used if there is any tendency to separation. The most serviceable form is a long, straight, narrow piece of splint board, reaching from just below the wrist to the axilla, and a little wider than the arm (Fig. 528). This is padded so as to allow for about 15 degrees of flexion at the elbow. This is done Fig. 523.-Olecranon fracture Upper three sketches show the varying displacement; the fourth shows the form of subperiosteal fracture that sometimes results from a direct fall on the elbow; the olecranon is split by the im- pact of the humerus. The fifth sketch shows separation of the epi- physis. FRACTURES OF THE OLECRANON 343 because a position of full extension of the arm soon becomes intolerable. The arm is strapped to this splint with the hand in supination and with both upper arm and forearm firmly fixed. An adhesive strap is carried Fig. 524.-Separation of fragment of olecranon by the triceps in flexion of the elbow (schematic). just above the upper end of the loose fragment, and is so placed as to hold it in the best position it can be brought to; the strap is made fast to the splint low down. The arm is then bandaged, and is to be carried Fig. 525.-Fracture of olecranon without separation of head also damaged) at the side. This is at best a very uncomfortable apparatus and very unwieldy. The straps are to be changed every few days to make sure that we are getting the best possible position. At any time after three 344 FRACTURES OF THE HUMERUS AT THE ELBOW weeks, if there seems to be a beginning serviceable union, this apparatus is exchanged for a splint with a movable angle (Fig. 402), and the arm is brought to a position of greater flexion by slight changes in the angle two or three times a week. The strapping down of the fragment is still continued. This process is carried on until the arm comes near a right angle, not beyond. At about five weeks after the injury this should have been accomplished. At about six or seven weeks the arm may be put in a sling without splints. Active motion will not be at- tempted earlier than two months. Mas- sage and moderate passive motion may be begun earlier. Operative Treatment.-If operation is decided on, it becomes a question of date. Operations done immediately after the in- jury usually do well. If the operation can not be done within twelve hours, it had better be postponed for about ten days. The interval between has been Fig. 526.--Olecranon fracture with rotation of fragment but almost without separation. Fig. 527.--Palpation to deter- mine separation of olecranon. The ulna just below the joint is fixed by the thumb and fingers of the lefthand. shown to be a poor period to operate on any joint fracture. The clot has begun to organize, but seems for the time being to have lost bactericidal power. At the end of ten days there is a good deal of organization of the clot, and the tissue resistance seems to have returned. As to the mode of operation, the incision is of no especial conse- quence, except that a longitudinal incision, just to one side of the sub- cutaneous surface of the bone, will give the least troublesome scar. The broken bone-ends are exposed, and are cleaned with a sponge and the curet; all clots are removed; the joint is thoroughly washed out with salt solution, or with salt solution containing 1 to 10,000 or 15,000 FRACTURES OF THE OLECRANON 345 parts of corrosive sublimate, followed by simple salt solution. The fragments are drilled as in the sketch (Fig. 529). Either wire or kangaroo tendon may be used for suture; the latter is perfectly serviceable, and usually preferable. The fragments are brought to- gether, making sure that no fibrous tissues intervene, and the sutures are tied. Suturing of the triceps expansion is done, if practicable. The triceps layer is not always a very definite one, and the procedure does not seem to be really necessary. The wound is closed without drainage, and the limb is put on a splint or in plaster in partial extension, or, if there is no tension, on a right-angled splint. The time of absolute fixation should be about a month; after this, only protection and passive and active motion are called for. Unlike fractures treated conservatively, these cases give an arm which is fit to use for fairly vigorous work in three months, instead of six. Results.-Cases operated on and wired give, with few exceptions, union without separation, and usually union by bone. The result is an arm practically, if not absolutely, as good as new. The cases conservatively treated give, in case there is little or no separation, a result nearly as good, although the union is usually, if not always, fibrous. In case the separation can be kept down to a half-inch or less, there may be a little loss of full active extension, but the power of extension is sub- stantially normal. The writer knew one man with such an elbow who was a very fair performer at "shot-putting," the severest possible test of pure extensor power. If there is more separation than this, there begins to be loss of strength, because the projecting lever formed by the olecranon is partly lost, and the mechanism of the joint becomes a "strap-lever" only, like that producing extension of the fingers, for example, an essentially weak joint mechanism. With considerable separation the results may be, and often are, very poor. It must be remembered, however, that an arm may be very useful for ordinary purposes which has very little power of active extension. At the worst, olecranon fractures are likely to produce only loss of this power. Any considerable loss of range of motion is rather unusual. Anky- losis hardly results except from failure of asepsis in open operation, which is, fortunately, rare. I have seen fibrous ankylosis in two cases treated with a splint: later open operation and suture gave an excellent elbow. Fig. 528.-Ole- cranon splint. A straight board, padded to allow for an obtuse angle at the elbow- 180 degrees is an un- bearable position. The splint is strapped on, and then straps, run- ning obliquely, are drawn so as to drag down the loose upper fragment of the ole- cranon. Fig. 529.--Lines of drill-holes for wire or other suture. They must be so directed that the suture shall lie entirely outside the joint. 346 FRACTURES OF THE HUMERUS AT THE ELBOW There is an epiphysis at the end of the olecranon, orginally compris- ing most of it, gradually lessening until, at about thirteen or fourteen years of age, it is barely more than a scale at the tip end, not always represented by any osseous center shown by the x-ray, even at this age. * Separation of the Epiphysis of the Olecranon Fig. 530.-Olecranon epiphysis. No ossification center. Fig. 531.-Lateral view of epiphysis at twelve years. Definite, though small ossifica- tion center. Fig. 532.-Olecranon epiphysis; small ossi- fication center. Age, nine years (Warren Mus- eum, specimen not numbered). Fig. 533.-Olecranon epiphysis. Age, ten years (Warren Museum, specimen not num- bered). Fig. 534.--Olecranon epiphysis at twelve years (after Poland). Fig. 535.-Olecranon epiphysis at eighteen years (Warren Museum, specimen 417). Occasionally, it becomes separated. In the three cases of this sort I have seenf all were between thirteen and seventeen years of age, all were the result of indirect violence, and all presented the same clinical picture, namely, primary swelling and disability, followed by lameness and partial loss of motion. This loss of motion appeared on attempting active flexion or on active hyperextension. Two of the three cases * There may be two ossification centers. (See Figs. 536 and 537.) f Cotton: Boston Med. and Surg. Jour., June 28, 1900, and one case observed since that time. FRACTURES OF THE OLECRANON 347 seen had gone for some time without treatment. In all, the clinical picture was obscure until a small mass was found, just above and at the tip of the olecranon, and movable upon it. The triceps tendon inser- tion is evidently not seriously involved. The distance of separation of Fig. 536.-Double ossification center in ole- cranon epiphysis. Fig. 537.--Separation of olecranon epi- physis in boy of sixteen: a, Posterior line of olecranon epiphysis. the fragments is very slight. All recovered perfect function and motion after a few weeks' fixation, at first in partial extension; later, with some flexion. In all the union was apparently fibrous only, and Fig. 538.-Double ossification center in olecranon epiphysis (outlines retouched). Fig. 539.--Persistent olecranon epiphysis in adult (also shows fracture, impacted, of radial neck). some little lateral mobility of the fragment remained. Cases of this sort do not resemble ordinary olecranon fractures. The symptoms are far less severe, comparable to those produced, for instance, by the tearing loose of the epiphysis at the tubercle of the tibia. 348 FRACTURES OF THE HUMERUS AT THE ELBOW Fractures of the Radius Near Elbow (1) These fractures may occur at the neck, below or within the annu- lar ligament. (2) They may, more often, occur just behind the head, that is, between the annular ligament and the head. Commonly, there is also splintering of the head. Often there is impaction. Fig. 540.-Separation of olecranon epiphysis. Clinically, the epiphysis was freely movable from side to side, not upward. (3) There may be simply a splitting off of a part of the head. Fractures of the first group, not uncommon in combination with ulnar fracture, are rare as independent fractures. Those of the second group are common, relatively speaking, and may occur in children as well as in adults. The third sort may rarely be found as a complication of backward luxation, a part of the radial head being driven off by the external condyle as it passes beneath it. Direct violence may give fractures corresponding to any of these groups. Symptoms.-The classic symptoms given apply rather to the fractures at or below the neck or, at all events, do not cover the more common forms of damage to the head and neck alone. Crepitus on rotation is present usually only in fractures below the orbicular liga- ment, or in case one or more chips have been loosened from the head. There is, ordinarily, no displacement that can be felt, wherever the fracture is, unless the break be below the ligament. Most conclusive of the symptoms is the failure of the head of the radius to rotate with rotation of the wrist or limitation of the arc of such motion. This FRACTURES OF THE RADIUS NEAR ELBOW 349 failure may not necessarily be accompanied by crepitus. There is apt to be well-marked local tenderness. There is no characteristic attitude, Fig. 541.-Fracture of radial head. Minimal displacement. Not an operable case. Recovered with practically normal function even as to rota- tion. Fig. 542.-Fracture of radius with marked displacement of fractured head. This sort of case calls for operation--dis- tinctly. (Here also olecranon fracture.) unless there are other injuries, motion in flexion and extension is unim- peded, though sometimes painful. Motion in pronation and supination is, however, definitely interfered with, and supination is apt to be more limited than pronation. This is true of both impacted and unimpacted forms. In either case there is usually bone locking, either be- cause loose fragments are in the way, or because the shape and angle on the radial head are changed. There is also limita- tion of motion as a result of pain, also from involuntary spasm of muscles, even when the pain is not very great. It makes no difference where the exact site of the fracture is: spasm on rotation is characteristic of all fractures of the radial head and neck, and not present in cases of fracture of the lower end of the humerus. This gives a valuable point in differ- entiation; on this point alone the writer has several times diagnosed damage to the radial head which was confirmed by the x-ray, and on the absence of such spasm in the presence of some Fig. 543.--Fracture of radial neck, high up. Shows impaction (same case as Fig. 539, which shows the side view; there is also in this plate a separation of the internal epicondyle) (outlines rein- forced). 350 FRACTURES OF THE HUMERUS AT THE ELBOW interference with flexion and extension has felt free to correct diagnoses of fracture of the radius previously made, and has done this so far without mistake. Fig. 544.-Fracture of radial neck, high up, with impaction Fig. 545.-Fracture of radial head. Frag- ments all consolidated (after Hamilton's Fig. 76) (Mutter Museum, A 105). Fig. 546.-Fragments of splintered radia head. Chips 6, c, and d were loose. They were removed, as was also the portion a, that was not broken loose. Fig. 547.-Same case as Fig. 546. Range of voluntary flexion and supination after opera- tion. Fig. 548.-Range of voluntary pronation (same case). In cases where only the head of the radius is broken, or where the head as a whole is driven down and impacted on the shaft, we have as diagnostic signs only the spasm thus noted, some local tenderness, and occasionally a click (not true crepitus) in the joint on rotation, appar- FRACTURES OF THE RADIUS NEAR ELBOW 351 ently caused by the irregularity of motion of the deformed head. These cases are apt to show little reaction and little disability in the early stages. In case there has been a splitting of the radial head, we may have a widening which mechanically interferes with motion of the joint and so adds to the symptoms, or we may have an entire slipping loose of a fragment or fragments. With a fragment loose in the joint we have the picture of a foreign body Fig. 549.-Range of voluntary extension shortly after operation. Eventually the arm became as useful as ever (same case). Fig. 550.-'Splintered radial head (case of Dr. F. B. Lund). in the elbow-joint, and the symptoms referable to it depend simply on its location. It is pretty sure to interfere with rotation, and according to its position it may get in the way of either flexion or extension. Lesions of the radial head and neck occur in children as well as adults, though not common at any age. Fig. 551.-Fracture and displacement of radial head, with backward luxation of the elbow (sketched from Poland's plate). (This plate shows the double ossification center of the olecranon epiphysis not uncommonly seen.) Fig. 552.-Portion of radial head removed by . Dr. Lund from case shown in Fig. 550. Treatment.-Treatment must necessarily vary according to the position of the break above or below the orbicular ligament. With the break below this ligament our only concern is to restore the fragments to position, and our greatest obstacle is likely to be the pull of the biceps. It is not practicable in most of these cases to use any splint other than a right-angled one, but it seems that acute flexion with a pressure-pad over the outer side of the radius would be the ideal treat- ment. If we use a right-angled splint, special padding is to be used 352 FRACTURES OF THE HUMERUS AT THE ELBOW over the upper end of the lower fragment in front and to the outer side. In case of fracture across the neck of the radius within or just above the ligament we have an entirely different condition to deal with. Unless the orbicular ligament is torn, or unless the neck has slipped out of it, we can have no displacement of anything except of the head within the elbow-joint. Unless the fracture was origin- ally impacted, it is very improbable that any bony union will result.* Probably the most serviceable form of treatment, so far as results are concerned, is an excision of the loose head. The only danger in doing this is that manipulation dur- ing operation might pull the neck out of the annular ligament. This danger is largely theoretic. The mechanism of the joint precludes any conservative operation at- tempting reduction and fixation of fragments. In cases where the head of the radius is impacted in place no man- ipulation is called for. We must put the joint at rest, on a right-angled splint, for three or four weeks, beginning moderate active motion at two to three weeks. In these cases the result is often good, and the only things to guard against are breaking up of impaction, and stiffness Fig. 553.-Splintered radial head; fracture of external condyle also. Fig. 554.-Impacted fracture of radial head and neck (outlines have been rein- forced). Fig. 555.-Impacted fracture of radial head and neck. The explanatory sketch in the right- hand corner shows the relation of the fracture to the epiphysis. from too long fixation. Results may not be good, and excision may be called for later, but not primary excision in this type. On the other hand, in case of fractures involving such smashing of * Malgaigne gives an excellent plate of a fracture of this sort in which twenty- seven years of active use had given no union, and, curiously enough, had pro- duced very little absorption of the opposing surfaces. SEPARATION OF THE UPPER RADIAL EPIPHYSIS 353 the head as to interfere with free rotation, results are poor, and, as a rule, there is nothing to do but to resect the head or to resect such parts of it as are in the way of rotation. This is commonly to be done without waiting more than ten days. I have done this in about 15 cases with excellent results. Not rarely for no obvious reason there is some permanent limitation of extension at the elbow (20 degrees or so) after operation. Rotation is usually fully restored. There have been two painful joints in this series that took some months to clear up. When part of the radial head has been split off and the fragment is loose, no treatment is worth considering except resection of this frag- ment, unless there is some definite contraindication to any operation. Left alone, the results, like those in fracture of the capitellum, can hardly be good, and those the writer has seen have been distinctly bad, with much interference in motion and with some joint irritation. Operative treatment of injuries of the radial head may be the more readily undertaken because resec- tion of the radial head in the adult causes no loss of function whatever. There is, after such resection, some reformation of a new radial head by cartilagin- ous growth (case Largess, see Fig. 509), but this probably does not affect the motions of the elbow- joint one way or the other. Apparently, the interosse- ous membrane and the oblique ligament are sufficient to support the radius against any longitudinal strain, provided the upper end of the radius is held close by the annular ligament. In children, judging from the conditions seen in congenital shortening of the radius (see Figs. 564 to 567), excision of this portion, which necessarily includes an epiphyseal line, would probably leave some deformity of growth, but in adults this does not become a question. Fig. 556.- Dia- gram to show how a part of the radial head may be smashed off by the humerus in back- ward luxation of the elbow. Separation of the Upper Radial Epiphysis This is a rare accident, occurring only in small children: even in them it is less common, apparently, than fracture in this region. Possibly there may be later interference with growth-probably very rarely. In all other respects such separation is comparable to the fracture at like height. Have operated on a radial epiphysis so separated; displaced to a point behind the external condyle where it became adherent and produced grave limitation of motion, especially in extension. By open operation the epiphysis was removed and rein- serted in the normal place; in which place it grew and flourished, though perhaps with somewhat less than the normal flourish! CHAPTER XVI THE WRIST Injuries of the wrist are very common indeed; they occur usually as a result of trying to " break a fall," to save one's self in falling. In the young and vigorous, "sprains" of liga- ments, ensuing synovitis, strains of muscle or tendon, etc., occur not rarely. In older persons nearly all wrist injuries entail fracture. It used to be taught by Dr. G. W. Gay that "there is no such thing as a sprain of the wrist," a statement calcu- lated, by its intentional dogmatism, to rivet the student's attention on the over- whelming proportion of fractures in wrist injuries. In fact, "sprained" wrists prove even rarer than was thought when Dr. Gay so taught, for the x-ray now shows many bone "cracks" without displace- ment, previously unsuspected. Most wrist injuries are fractures, some are luxations and luxation fractures; a few are simple sprains. Injuries may be divided into- (а) Radiocarpal luxations. (б) Radiocarpal luxation with frac- ture of the radius (includ- ing Barton's and "reversed Barton's"). Fracture near the Wrist: (c) Colles' fracture. (d) Reversed Colles' ("Smith's fracture"). (e) Epiphyseal separation. (/) Fracture of both bones-low. (</) Greenstick fracture of both bones. (fi) Fracture of the radial styloid. (f) Luxation of the ulna (alone). Fig. 557.-Landmarks of the wrist: 1, Level of radial styloid; 2, level of head of ulna; 3, level of the styloid process of the ulna; 4, hollow between radius and metacarpal of thumb; 5, base of fifth metacarpal; 6, cuneiform; 7, scaphoid; 8, hollow over the necK of the os magnum. 354 INJURIES OF THE WRIST 355 (j) Fracture of the ulnar styloid (alone). Carpal Luxations: (&) Of one row on the other (with or without associated fracture). (Z) Luxations of single bones. (m) Subluxations of the carpal bones. Carpal Fractures: (n) Scaphoid fracture. (o) Scaphoid fracture, with semilunar luxation. (p) Fractures of other carpal bones. Anciently, all wrist injuries were classified as dislocations of the Fig 558.-1. Supination. 2. Pronation, a, Tip of radius; b, styloid process of ulna; c, ulnar head. To illustrate that, in comparing the level of the styloid of radius with lower end of ulna in supination, 1, the styloid of the ulna is felt, and that in pronation, 2, the head of the ulna is felt wrist. Pouteau,* and later Colles and Dupuytren, recognized the real nature of the common injury, but old ideas are hard to dislodge, and time wore on until near the middle of the last century before it was generally recognized that real dislocations of the wrist are really rare- so rare, in fact, that only a few surgeons have seen any such cases at all. Hamilton cited only 11 authors as having reported cases, and outfof his very large personal experience he could add but two more-and one of these was a case of compound luxation from direct violence. The majority of such rare dislocations of this joint as are reported are dislocations of the carpus backward. The writer has seen but two cases, both from direct violence. * Pouteau, Chirurgien en chef de I'Hotel Dieu, Lyon; Oeuvres Posthumes de M. Pouteau, Paris, 1783, in vol. ii, p. 251, describing fracture of lower end of radius, at least thirty years before Colles' famous description in 1814. 356 THE WHIST RADIOCARPAL LUXATION. SIMPLE LUXATIONS BACKWARD AT THE WRIST Etiology. There would seem to be evidence that falls either upon the front or the back of the hand may produce this lesion. Falls on the palm must act by driving the carpus backward. Such falls, however, usually give Colles' fracture; less often they result in fracture of the carpal scaphoid or in a "Barton's" fracture; least often of all is the pure dislocation met with. Figs. 559, 560.--Posterior dislocation of wrist with fracture of radial styloid and back edge of radius. The fracture has been allowed to unite, but without complete reduction of the luxation. There were no fractures of carpal bones. The carpus was excised later, with entire removal of deformity and restoration of motion (author's case). That falls on the back of the hand should cause this luxation is hard to understand, but Hamilton's case, at least, seems conclusive.* The mechanism must be one of overflexion and of leverage across the front edge of the radius, lifting the carpus from its socket. Such a fall 1 2 3 4 5 Fig. 561.-Differential diagnosis in outline: 1, Colles' fracture; 2, backward luxation of wrist; 3, mediocarpal luxation backward; 4, scaphoid fracture; 5, "Barton's" fracture. will more usually give a "reversed Colles" ("Smith's") fracture of the radius. * Hamilton, Fractures and Dislocations, third edition, 1866, p. 611 RADIOCARPAL LUXATION 357 Lesions in posterior luxation (on authority of Hamilton): (а) Rupture of posterior and lateral ligaments. (б) Rupture of the anterior ligaments-more or less extensive. (c) Stripping up of extensor tendons from the lack of the radius and ulna. Constant: Inconstant: (d) Tearing of the skin-giving compound luxation. (e) Injury to tendons. (J) Injury to nerves in front of wrist. Diagnosis.-There should be no serious difficulty in recognizing the luxation, but the question as to whether or not it is complicated by fracture may be more troublesome. The styloid processes of radius and ulna are always palpable in Fig. 562.---A, Dislocation of the whole carpus forward; B, dislocation ofjdie semilunar bone for- ward (diagram of outlines of deformity). wrist injuries, even if, owing to swelling, long-continued pressure is required to reach them. Once these points are located it is simply a question of the site of the prominence of the back of the wrist, as the accompanying diagrams show. (See Figs. 561 and 563.) Between the forms of displacement here met with there may be great difference in opinion and an actual difficulty in diagnosis, only to be solved by in- dividual expertness of touch or by the x-ray. All of them-radiocarpal luxation, dislocation between the carpal rows, scaphoid fracture, and Barton's fracture-depend for diagnosis, like Colles' fracture, upon the recognition and the correct placing of the level of the backward dis- placement at the wrist. But, hard as it may be to straighten out this series, the Colles' fractures and fractures of the radial styloid should be perfectly differen- tiated, simply by the mutual relation of the styloids of radius and ulna. In both this relation is changed; in no other lesions is it disturbed. Permanency of reduction, and the absence of crepitus when reduction is accomplished, as indicating pure luxation, is, of course, of definite assistance. 358 THE WRIST Luxation of the wrist, whether forward or back, must of necessity give a greater actual displacement than any of these injuries except Colles' fracture, and gives a more definite and abrupt projection, formed by the front or back edge of the concave radial joint surface. (See Fig. 560.) The position of the hand and arm is not constant or characteristic enough in luxation to differentiate this lesion from the carpal injuries, but the limitation of motion should help, at least as against Colles' fracture; the luxation gives, as always, a much more definite limi- tation of motion than the fracture, dependent on mechanical limitation as well as pain and spasm. Results are good with reduction. No cases of bad results following reduction are noted in the literature, and no disability from failure to reduce, or from entire lack of treatment, seems to be on record, if we except the case noted by Hamilton.* This was really a case of partial luxation. A year after reduction of a total backward dislocation of the carpus there was a constant recurrence of partial luxation on strain, with some disability. Reduction.-Direct traction, with or without a rocking motion, has usually sufficed. Failing in this, flexion with forward traction should here be in place, as well as direct-line traction. Hamil- ton also suggests extension and direct reducing force by pressure. No fresh cases seem to be on record where reduction has offered any serious difficulty. Treatment after reduction must consist of the usual period of about three weeks of rest for repairs, accompanied by any bandage or sling that secures rest and approximate fixation. Luxation of the wrist backward complicated with joint fracture is Barton's fracture (q. v.). Fig. 563.-Rela- tions of radial and ul- nar landmarks in-A, Backward luxation; B, Colles' fracture; C, fracture of the radial styloid with displace- ment of the hand. FORWARD LUXATION AT THE WRIST Forward luxation appears to be an extremely rare injury. An apparently sound case is related by Bransby Cooper, f Differential diagnosis of such a lesion will concern itself with dis- location of single carpal bones forward, with reversed Colles', and with reversed Barton's fractures. (See diagrams, Figs. 561, 562.) * Hamilton, third edition, p. 611. t Treatise on Dislocations and Fractures of the Joints, Sir Astley Cooper, edited by Bransby Cooper: American edition of 1844, published by the Massachusetts Medical Society, p. 420, Case ccxcvii. This case is curious in that the patient is said to have fallen on the palms of both hands and got a luxation of the wrist forward on the right, backward on the left. FORWARD LUXATION AT THE WRIST 359 From isolated luxations of the carpus, wrist luxations forward should be differentiated by direct palpation, and from reversed Colles' by determining the displacement of the radial styloid; the "reversed Barton's" should present some differences (crepitus, etc.) even without Fig. 564.-Congenital luxation of ulna (with short radius). Fig. 565.-The same case seen from the back. Fig. 566.-x-ray of the same case as Figs. 456, 565. Fig. 567.-Same case, lateral view. the x-ray. There are no real data at hand to give more than a theoretic differential diagnosis between these forms. Forward luxation with joint fracture is 11 Barton's reversed," q. v. Lateral luxations, uncomplicated, seem not to occur: are, at all events, nowhere described. 360 THE WRIST Fig. 568.-Congenital forward luxation of the wrists from congenital spastic condition. Note also the inward subluxation of the feet. (Courtesy of Dr. J. S. Stone.) I- ig. 569.-Madelung's deformity (sketched from Madelung's original plates) Fig. 570.--No transverse fracture, but sepa- ration of the fragments from the posterior edge of the joint surface. Result of direct violence. also fractured (Warren Museum, 3776). Fig. 571-Outlines of deformity in-A, Colles' with anterior displacement reversed Barton's fracture. REVERSED BARTON'S 361 Congenital luxation forward is best described by R. W. Smith.* Madelung's deformity gives a similar picturef (Fig. 569). FRACTURE LUXATIONS Fracture Luxations Displaced Outward Lateral fracture luxations occur with fractured radial styloid (q. v.) or with " abduction Colles." Barton's Fracture This is a fracture of the posterior superior surface of the radius, with backward displace- ment. Barton, in 1838, i described such a frac- ture, but his cases seem, in fact, to be probable cases of Colles' fracture, wrongly interpreted. The fracture he described does, however, occur. (See Fig. 570.) Etiology.-So far as known this is a variant of Colles' fracture, with like etiology, or is the result of direct crushing force. Diagnosis.-This lesion differs from Colles' by the fact that, with a like displacement of the wrist, it does not give displacement of the radial styloid in relation to the ulnar styloid. The break is of the back edge, and does not in- volve the styloid. Treatment.-Reduction and treatment are those of Colles' fracture. Theoretically, there may well be greater difficulty in maintaining reduction than with Colles' fracture. "Reversed Barton'S" This, a chipping off of the front articular edge, is also a variety (rarely, if ever, diagnosed save by the x-ray), and treated accordingly. Fig. 57 2.--Skiagraph: Madelung's deformity (au- thor's case). Note the changed shape of the radius and the abnormal obliquity of the joint surface shown in the corner sketch. * Smith's article is in his "Fractures in the Vicinity of Joints," Philadelphia, 1850, p. 238. These cases are not uncommon. They represent in some cases a defect in'bone formation and growth, in some, the result of spastic action of muscles. (See Figs. 564-567, and compare Fig. 568.) t Spontane Lux. der Hand. Madelung: Arch. d. klin. Chir., 1879, xxiii, 395. Madelung's deformity is the result of oversevere work at or just before the period of puberty, at a time when the bones are in a "plastic " state. Such over- work results in a gradual flexion of the lower end of the radius; the ulna projects up and back. The condition resulting is shown in Fig. 572. No remedy has been suggested. Osteotomy would, of course, remedy the deformity; the question is purely whether it is worth while. The relation of the lesion to late rickets has been considered by Gasne~(Rev. d'Orthopedie, 1906, vii, 1522, 241). Of late there has been a tendency to confuse what Madelung described with certain forms usually called congenital, and others probably rachitic; e. g., compare De Witt Stetten: Surgery, Gyn., and Obstetrics, January, 1909, p. 4. t Rhea Barton, Medical Examiner, Phila., 1838, p. 365. Barton's cases were probably, so far as one many judge, Colles' fractures only, but the lesion he de- scribed does, in fact, occur. 362 THE WRIST (See Fig. 573.) Clinically, it is to be considered merely a variant of "reversed Colles'" fracture.* This fracture was described by Colles, whose name it bears, in 1814,f COLLES' FRACTURE Fig. 573.-" Reversed Barton's" fracture. There is anterior wrist luxation, with a chip torn loose from the anterior edge of the articular surface of the radius (see explanatory sketch to the left). * Letenneur: Bull. Soc. Anatom., 1839, xiv, p. 162, described a case with ante- mortem and postmortem findings, as follows: Clinically: "Une luxation du poignet droit, en avant, compliquee d'une fracture de 1'apophyse styloide du radius." After death, he found: "Une fracture de 1'apophyse styloide du radius, du cote droit, et du rebord anterieur de 1'extremite articulaire de cet os." Whether we should limit the term "reversed Barton's fracture" to cases in which the radial styloid is not involved is, after all, an academic question, of no grave importance if we keep the lesions squarely in mind. t By the English-speaking peoples it is called Colles' fracture; by others, more often known as Dupuytren's. Knott, in the Med. Press and Circular, 1881, gives an excellent review of the literature on Colles' fracture, well worth reading from a historic point of view. Pouteau, 1783, first described the lesion. M. Pouteau, Chirurgien en chef de I'Hotel Dieu, Lyon. Oeuvres Posthumes de M. Pouteau, Paris, 1783; in vol. ii, p. 251, describes the fracture of the lower end of the radius. Colles in 1814 brought it into real prominence in England, but it was left for Dupuytren, 1820, to establish among the French the frequency of fracture of the carpal end of the radius, and to prove practically the rarity of luxation of wrist of which he never saw an example. R. W. Smith, at nearly the same time as Dupuy- tren, brought into prominence the same view. Amusing stories are related about the fierce clinical disputes at the Hotel Dieu between Dupuytren and his colleagues, Pelletan and Marjolin, until finally the point was settled by the accommodation of a patient in providing an autopsy. Many men tried to offer a single explanation which would cover the mechanism for all cases. Bouchut in 1834. called attention to the obliquity of the line of fracture from above and behind, downward and for- ward. Velpeau in 1842 called attention to the characteristic S-shaped deformity , which he likened to a dinner fork. Voillemier in 1842 wrote a most elaborate and exhaustive thesis on the subject. He believed the most frequent form of fracture to be what he described under the name "fracture from penetration," and to this class of cases he relegates all those in which the history would lead to sus- picion of fracture, yet the predominant symptoms indicate merely a sprain, when deformity and ctepitus are absent, and an obscure mobility is the only local sign justifying the idea of fracture. Nelaton in 1844 adopts this impaction theory, slightly modified. Jarjavay, in 1846 contested these views of impaction most strenuously. Malgaigne in his work on Fractures and Dislocations gives promi- nence to the theory of "arrachement," to which Voillemier and Verneuil had called attention. COLLES' FRACTURE 363 in a masterly essay, conspicuous for brevity as well as for clearness, which appeared in the Edinburgh Medical Journal. He pointed out not only what had been known before, that a fracture of the lower end of the radius might occur, but also that it is a Fig. 574.-Old fracture united with but little displacement; much excess of bone formation at seat of fracture. Fig 575.-Transverse fracture of the radius with little displacement; fracture of ulnar sty- loid, tracing from x-ray. common fracture-and the common fracture of the radius. Thirty years previous to this description Pouteau had clearly described the fracture, but his description and argu- ments availed nothing against the author- ity of the eminent French surgeons of that time. Colles' work met reasonably prompt Fig. 576.-Transverse fracture of the ra- dius, some backward displacement; much rota- tion backward. The ulna is shown in dotted line; a, b, lower end of radial shaft; c, back edge of lower fragment; d, styloid process of radius; e, f, articular surface of radius rotated backward (tracing from x-ray plate). Fig. 577.-" Amputated three inches above condyles for compound Colles' fracture, with rupture of radial artery and subsequent spread- ing gangrene." A projecting spur anteriorly caused arterial injury; the fracture transverse, with loss of substance and with considerable backward displacement; lower fragment com- minuted at back and ulnar side (specimen of Dr. J. C. Warren, Warren Museum, No. 8117). recognition, but it was a long time before the old diagnosis of "dis- location of the wrist" fell into disuse. Colles' original description was of a fracture occurring inches above the carpal extremity of the radius. In point of fact the break 364 THE WRIST lies somewhat lower than this, on the average, about to % inch above the articular surface. The name of Colles' fracture is rather loosely used to cover all fractures of the lower quarter of the radius; this is unfortunate, because fractures occurring at a height of two inches or more, or fractures of both bones, do not show the peculiar features of the typical Colles' fracture. Etiology.-A strife of many years was waged in the medical press as to the mechanism of this fracture-a strife between the advocates of the theory of "arrachement" (that is, of the theory of those who held that the fracture was produced by hyperextension, through the pull of the anterior ligament on the lower end of the radius), and of those Fig. 578.---Transverse fracture with apparent impaction; avulsion of ulnar styloid. Fig. 579.-Transverse fracture practically with- out displacement. who believed that the fracture was a result of a breaking strain, received somewhat obliquely upward and backward, transmitted from the hand through the carpus, without any particular stretching of ligaments, and without the ligaments or the muscles playing any particular part in the mechanism. Undoubted cases of fracture by arrachement have occurred, but it is now pretty well agreed that they are exceptional. In the vast majority of cases the second theory holds good, and the reason why the bone gives way at this particular place is, as was long ago pointed out, because the cortical layer at this level becomes very thin. The shaft structure changes into the cancellated bone of the expanded end. Roughly corresponding to the obliquity of the breaking force, the fracture is usually slightly oblique upward and backward. Falls in which the weight comes on the ulnar side of the hand, or otherwise in such fashion as to throw the hand into abduction as it strikes, tend to produce obliquity of the fracture line upward and outward, with a corresponding outward displacement. It is well to keep clearly in mind that Colles' fracture is ordinarily a fracture-luxation of radius and ulna about the ulnar head as the fixed point; a rotary displacement in which the hand and the lower radial COLLES' FRACTURE 365 fragment are driven backward to be sure, but are more particularly rotated backward about the ulnar head. Strangely enough, there are cases in which falls on the back of the closed hand have produced, not reversed Colles', but nearly typical Colles' fracture, oblique upward and backward. More usually, however, falls on the back of the hand seem to Fig. 580 .-Transverse fracture: marked rotation back- ward of hand and of lower fragment. Fig. 581.--Same case as Fig. 579 (side view). In the print this looks like a " Bar- ton's" fracture; in fact, it was not. Fig. 582. - Transverse fracture; displacement in toto and rotation backward. produce a transverse fracture, or a fracture oblique upward and forward. Fractures by li arrachement" tend, in fact, to produce more nearly Fig. 583.--Transverse fracture, practically without displacement. Fig. 584.-Irregularly transverse fracture with little displacement. transverse fractures, very close to the joint; fractures experimentally so produced on the cadaver are apt to be oblique upward and forward.* Latterly we see these " arrachement " cases not uncommonly as a result of "back-firing" in starting automobiles. Such cases show transverse fractures low down, or a very nearly horizontal splitting away of the radial styloid, as a rule. Not uncommonly the displace- * Experimental Colles' Fracture, F. J. Cotton, Jour. Boston Soc. Med. Sci., May, 1898, vol. ii, No. 10, p. 171. 366 THE WRIST ment is nil and these fractures by " arrachement " seem never to give " splintering-up " of bones, such as sometimes occurs in the fractures from falls especially in older patients. Fig. 585.-Fracture of radial styloid from a "back-firing" accident. This is one of the two regular types of Chauffeur's fracture. Fig. 586.-Splitting away of radius at ulnar side. Lesions.-There has been some tendency to speak of our knowledge of lesions in detail as if such knowledge were based entirely or mainly upon the x-ray plates. As a matter of fact, there have been fresh COLLES' FRACTURE 367 specimens enough from autopsies or from amputations in compound fractures, etc., to say nothing of old postmortem specimens, to give us definite data as to all the lesions that do, in fact, occur-more definite data, as to many of them, than can be obtained from even the best x-ray. Fig. 587.-Transverse comminuted Colles' frac- ture (z-ray tracing). Fig. 588.-Comminution of lower fragmen, at inner edge, result of direct violence. Lowe, sketch shows same specimen from below (joint surface) (Warren Museum, specimen 1038). Skiagraphs of the ordinary Colles' fracture are, moreover, apt to be very deceptive indeed, unless examined with expert care, and even then unless we have pictures taken in two planes. What we have really learned by the x-ray is the comparative frequency of comminution and of other of the severer lesions, which had previously been sup- posed to be limited, as a rule, to the cases of extreme trauma. We have, then, learned nothing new of the possi- bilities of this fracture, but something of the frequency with which given lesions occur. In a somewhat extended article* on these pathologic lesions, based upon specimens as well as x-rays, the writer employed the following classification, which is perhaps as serviceable as any. Fig. 589.-Fracture showing lines of comminution into joint; plane of fracture nearly tranverse; backward displacement; some crushing and loss of substance at the back (after McGraw and Walker). * Cotton; The Pathology of Fracture of the Lower Extremity of the Radius, Ann. Surg., August, 1900. Codman, in 1900, collected and analyzed the x-rays of 140 cases of wrist fracture (Boston Med. and Surg. Jour., 1900, cxliii, pp. 305 and 318). Morton (Lancet, March 16, 1907) analyzed 170 cases studied radiographically. The results of these studies do not differ essentially from those of the writer. 368 THE WRIST I. iSzmpZe Transverse Fracture.-A fracture across the full width of the bone, most often within an inch, or an inch and a quarter, above the joint surface. Not infrequently the fracture lies not over % of an inch from the joint surface. There may be impaction with this form or Fig. 590.-Transverse fracture, commin- uted, with little displacement showing (taken after reduction). Fig. 591.-Same case, seen laterally, after reduc- tion. Shows displacement not reduced. there may not. The transverse character of the fracture is, moreover, no argument against the presence of extreme backward displacement or extreme backward rotation. The transverse line seems to argue little as to the direction from which the fall is received, but the cases in which there was fracture by "arrachement " (including the cases of ''auto- mobile fracture") seem to belong in this transverse class, practically without exception. Fig. 592.-Epiphyseal separation; left radius showing external and anterior surfaces (Warren Museum, No. 6212). Fig. 593.--Separation of the epiphysis of the radius, not now displaced; comminution of the epiphysis; fracture of the ulnar styloid at its base without displacement (tracing from z-ray). II. Comminuted Transverse Fracture.-This fracture differs only in its comminution from the form just described. There is not neces- sarily any separation of the different pieces. This sort of comminution seems to be frequent, and often not detected; not uncommonly it may colles' fracture 369 be made out in the x-ray, but it is probably present in many cases where it does not appear even in the skiagraph. Certainly in a very large proportion of the transverse fractures studied as specimens comminu- tion is recorded. According to the figures of Bennett, Power, Hutchin- son, and the writer, such comminution seems to be present in well over half of the museum specimens. Not all of these represent unusually Fig. 594.-Epiphyses at wrist; not obviously abnormal. Fig. 595.--Epiphyses at wrist; about five years severe trauma. The failure of the fragments to separate to any great extent explains the reason why these splits are not consistently demon- trated by the x-ray. Fortunately, the presence of such comminution seems to be of comparatively slight importance unless the fragments are separated. The line of comminution shows no exact constancy, but Fig. 596.-ar-ray of separated epiphysis on the left-hand plate (no present displacement) it is rather apt to start from the ulnar facet, running along closer to the back than the front, and breaking out posteriorly either into the groove for the common extensors or the groove for the radial extensors. Here and there is a case in which a line branches off from this line and runs forward toward about the middle of the front of the bone. Cases where the line of splitting is directly anteroposterior are decidedly 370 THE WRIST infrequent. In a few cases the splitting is in on entirely atypical and irregular lines. III. Separation of the Ra- dial Epiphysis.-The lesion is most common between twelve Fig. 597.--Separation of epiphysis of radius (reduced). Figs. 598, 599.-Separation of the radial epiphysis. and eighteen years, but pure separation of the epiphyses is more apt to occur in younger children; in older ones the sepa- ration follows the epiphyseal line anteriorly, while posteriorly the fracture runs upward, split- ting away a bit of the shaft adherent to the epiphysis. There has been a rather large oppor- tunity to study these lesions, postmortem and in compound fracture, for this condition seems often to be a product of very severe trauma; it is often found in children dead from severe falls, and the proportion of compound injuries is far greater than with other wrist lesions. Bruns (Arch. f. klin. Chir., 1881, xxvii, p. 240) has recorded a series of these lesions; and Poland's book,* as usual, includes all known cases in admir- able detail. The lesions resemble those of Colles' fracture, save for the less extreme displacement of the ulna and the different relations of the periosteum. The periosteum is torn anteriorly, but is stripped up posteriorly as a sheet. The displacement of the epiphysis is backward, with a backward rota- tion. Forward displacement does rarely occur, whereas marked displacement towrard the radial side does not seem to be recorded in the epiphyseal separations. Here and there the radial epiphysis is split. Fig. 600. Fig. 601. Fig. 600.-Same case. Fig. 601.-Same case: from the side. * Loc. tit. COLLES* FRACTURE 371 I1G. 602.-Separation of radial epiphysis. Obvious loss of growth after only two months (courtesy of Dr. Howard Clute). Fig. 603.-Short radius with luxated ulna and lateral deviation of the hand, the result of injury to the radial epiphysis five-six years previously (successfully operated on by shortening of the ulnar shaft). 372 THE WRIST Apparently anteroposterior splitting is somewhat more frequent here than in Colles' fracture proper. Rarely is there separation to any extent at the split. Very commonly the whole epiphysis is barely more than started from its place-hardly displaced. In these epiphyseal separations we have no prob- lem of crushed, "pulped," bone to consider; all anatomic parts remain intact-divided, perhaps, but intact as to total mass. There is a problem as to results, for at this point interference with growth from epiphyseal lesion is not very rare. Goyrand, Hutchinson, Holmes, Poncet, and Bruns all reported such cases in their time, and E. Wyllys Andrews (Ann. Surg., 1902, xxxv, p. 663) reports a more modern case. The possibility of such result is an argument for accurate operative reduction. Such reduction the writer has twice carried out; it is easy and satisfactory. IV. Fracture Oblique Upward and Backward.- This is what we have in the past supposed to be the typical form of Colles' fracture. If we regard very slight grades of obliquity, it probably is typical, but sharp obliquity occurs less often than the approximately transverse line. The reason why a very considerable obliquity was always predi- cated of this fracture until lately is the same reason underlying the Fig. 604. - Obli- quity upward and backward is less usual than is supposed. Dis- placement backward with rotation back- ward is usual. Often the perios- teum is stripped up at the back, and when the space under it, and the triangle in front (also shown in black in this cut), become filled up with new bone, the ap- pearance suggests both obliquity of fracture and impaction. It is for this reason that so many museum speci- mens have been mis- interpreted. Fig. 605.--Fracture, ob- lique! up and back, with ex- tensive splintering of the cor- tical! layer on the back (see the tilted bone plates). Fig. 606.-Same case. The bone plates broken out at the back of the wrist are shown here, though faintly (both Figs. 605 and 606 were taken after reduction). Fig. 607. -Frac- ture, oblique up and backward, just above the epiphyseal line. Backward displace- ment with some rota- tion. dogma of constant impaction, viz because conclusions were drawn from examination of old specimens, long consolidated, in which the new bone formed in the triangle between shaft, lower fragment, and periosteum was reckoned as part of the lower fragment. (See Figs. 604, 609.) COLLES' FRACTURE 373 There is no rule, of course, as to the angle of obliquity. Any slope beyond 25 or 30 degrees is, however, extremely exceptional. These cases show comminution in just the same way and tending toward the same lines as in the transverse fractures. V. Oblique Upward and Forward.-The number of good specimens Fig. 608.-Fracture, oblique up and back- ward; irregular comminution (after Ruther- ford). Fig. 609.--United fracture; displaced back- ward; depression at back filled up with new bone (Warren Museum, No. 5194). or complete records of this form of fracture are too few on which to form a conclusion. Smith* first called attention to it, and Robertsf has written a wonderfully complete monograph on the fracture with forward displacement, collecting 24 cases and 31 specimens that may be Fig. 610.-Colles' frac- ture, oblique up and forward (see arrows), though with very little displacement. Fig. 611.-Fracture with displacement up and forward, seen from the ulnar side; the ulnar displacement is backward (after R. W. Smith's plate). so classed. Unfortunately, the records of many of these instances are incomplete. * R. W. Smith: A Treatise on Fractures in the Vicinity of Joints, etc., pub- lished in Dublin, Philadelphia, Lea and Blanchard, and in 1850, page 162 ff. May I venture to recommend the reading of this almost forgotten work? Nothing better, or so good, has been done in this branch of surgery since. t J. B. Roberts: A Clinical, Pathological, and Experimental Study of Fracture of the Lower End of the Radius, with Displacement of the Carpal Fragment Toward the Flexor or Anterior Surface of the Wrist, 1897. Bennett (Dublin Jour. Med. Sci., 1902, cxiii, 242-244) treats of this among other rare fractures. I suspect it is not so very rare, but how many cases owe the anterior displacement to original trauma, how many to reposition, is hard to say. 374 THE WRIST It may be said that obliquity upward and forward does not neces- sarily imply displacement forward, nor does it even necessarily mean violence applied to the back of the hand, though such violence may Fig. 612.--Photographs of case of the writer's with backward displacement of the ulnar head. The fracture of the radius was transverse, with slight forward displacement. Fig. 613.--Fracture, oblique up and for- ward, just above the epiphyseal line. Dis- placement forward. Fig. 614.--Same case. Shows only the site of fracture, and that but faintly (see the dots at the ends of the line of fracture). (Case under writer's care at the Children's Hospital). often be the cause and such displacement may often occur in these cases. Displacement backward may, however, occur with the forward obliquity. Forward displacement from overzealous reduction is usually prevented by untorn periosteum, etc. It occurred, however, 1 am sure, in the case shown in Fig. 612. COLLES* FRACTURE 375 Fig. 615.--Fracture of radius up and forward, with backward displacement of the ulna (shown in dotted line): a, Lower end of upper fragment, overlapping; b, upper end of lower fragment, over- apping (tracing from x-ray). Fig. 616.-Fresh fracture of radius, oblique up and outward; much outward, some upward, dis- placement; moderate rotation of lower fragment; fragment freely movable under ether. Fig. 617.-Combination of transverse and oblique fracture lines; anteroposterior split into joint; fracture of shaft of ulna (views from front and from below) (after Westbrook's plate). Fig. 618.-'Comminuted fracture running obliquely down and inward into the joint; fracture of the semilunar bone; partial fracture of ulnar styloid (after Hunt's plate) (anterior view and view of lower end). 376 THE WRIST VI. Fracture Oblique Upward and Outward.-These fractures are rather common. It does not neces- sarily follow, from the marked out- ward displacement of the hand, that there is any corresponding obliq- Fig. 619.-Fracture of the radius above the epiphyseal line, oblique upward and out- ward-after reduction; epiphyses of radius and ulna ununited (x-ray tracing, writer's case). Fig. 620.-United fracture; displacement upward and outward; shows the "impaction line" (Warren Museum, No. 1040). uity in the fracture line. Where there is such obliquity we may have- (A) Fracture upward and outward through the whole width of the bone (common). (B) Fracture trans- Fig. 621.-Fracture, oblique up and outward (see arrows) (x-ray after reduction). Fig. 622.--Fracture, oblique up and outward, just above epiphyseal line. Extreme displacement. Fig. 623.-Same case as Fig. 622. Note that the dis- placement is purely outward, not backward; the ulnar head is not driven forward. verse toward the inner side, but tending up and outward externally (rather common). COLLES' FRACTURE 377 (C) Oblique fracture penetrating the joint (rare). In connection with all these subclasses well-marked rotation upward and outward is more constant and characteristic than displacement Fig. 624.-Displacement outward may be from oblique fracture clear above the joint or from fracture running into the joint. Fig. 625.-Outward displacement with a rocking that carries the radial styloid (and the hand) strongly out and up. May rarely occur with an approximately transverse fracture. outward in toto. It is the rotation, not the outward displacement, that gives the characteristic abduction of the hand often seen clinically. Great displacement outward is necessarily limited by the ulnar liga- ments, which are not often entirely, though often extensively, torn. There is no rotation (corresponding to the supination which makes backward displacement possible without much tearing of these liga- ments) that can permit outward displacement without extensive ligament rupture. VII. Fracture Luxation of the Radial Styloid.- This is not a very uncommon accident; it seems to occur as the result of a fall on the palm with sharp abduction of the hand. Not infrequently it is associated with fracture of the carpal scaphoid. This fracture shows the same rupture of the ligaments as occurs in Colles' fracture, and the same displacement of the ulna, though of less degree. As a rule, there is no impaction. The lesion very much resem- bles in appearance the "abduc- tion Colles." As a rule, displacement of the hand is less. There is less abduction of the hand, and little if any shorten- ing. The clinical diagnosis de- pends upon localized tenderness and upon the determination of a difference in level between the radial and ulnar styloids, with mobility of a fragment which in- cludes the radial styloid. Unless this mobility can clearly be made out, di- agnosis is uncertain without the x-ray. There is not apt to be much dis- placement forward or backward. There is usually displacement upward, not obviously connected with any pull upward by the supinator longus.* Fig. 626.-'Fracture of radial styloid; separation of ulnar styloid at its base, from direct violence (War- ren Museum, No. 4631). Fig. 627.-Cracks running vertically (the famous Bigelow speci- men in the Warren Museum). * As noted on p. 365, a fracture of this type occurs not rarely from the back- firing of an automobile. (See Fig. 585.) Often there is little or no displacement, when we see the cases for treatment, but there may be great deformity. The lesion seems to be exactly that shown in Fig. 626. 378 THE WRIST VIII. Fractures Oblique Downward and Outward.-These may show as a fracture running obliquely through the whole bone, not showing except for this peculiarity, any difference from the ordinary transverse fracture, or they may show as a fracture downward and outward into the joint surface, splitting off a fragment attached to the ulna. This frac- ture shows nothing clinically characteristic except the absence of obvious displacement of the hand in any direction, with the presence of mobility, tenderness, and possibly crepitus. This is a very rare injury, resulting probably in nearly all cases from direct violence. IX. Cracks of the Radius Not Penetrating the Width of the Bone.- These are the famous "stellate fractures," fractures in which splits in various directions run from the articular surface for a varying distance up or up and back. So far as we know, they are the result of direct violence by crushing. They are very rare: three specimens constitute Fig. 628.-Skin outlines in fracture of the radial styloid rs. those of simple displacement outward in Colles' fracture (diagrammatic). the total of the evidence. The writer has not seen such a fracture shown in the x-ray: it would only exceptionally show if present. Such a fracture clinically amounts to nothing, comparatively speaking. The only importance of the lesion is that, owing to Dr. Bigelow's observation of one of these cases (he being then a widely accepted authority), the diagnosis came to be a popular one, especially in Boston, and, even at the time the writer was in the medical school, diagnoses of "stellate fractures" at the wrist or elsewhere were made in all sorts of cases, not one in twenty of which can have been such a fracture. As a matter of fact, apart from the rarity of these cases, the diagnosis is next to impossible, and the possibility of the occurrence of such fracture has undoubtedly been an excuse for neglecting proper examination of many minor cases of injury. (a) Transverse Cracks.-These are far more common than the vertical ones. They occur from falls, and represent simply an incom- plete form of the ordinary fracture. Whether they involve the whole thickness of the bone we can not always tell; certainly they often seem to, judging by tenderness, and sometimes the x-ray shows the crack COLLES' FRACTURE 379 in the cortical bone, both front and back. They show no displacement, and nothing more than a sharply localized tenderness. There is sometimes, not always, tenderness to pressure exerted in the direction of the long axis of the bone. X. Greenstick Fracture of Both Fig. 629.-Fissure of radius, transverse (x-ray tracing). Fig. 630.-Fissure across inner portion of the radius only; fracture of the ulnar styloid process. Bones.-Fracture of this "greenstick" variety is common in children. It usually occurs at like height in both radius and ulna, slightly higher than the ordinary Colles' fracture. Fig. 631.-Greenstick fracture of both bones at the wrist (just above the epiphyseal line). Displacement is typically backward; here also slightly outward. Fig. 632.-Greenstick fracture of both bones; displacement backward (side view of same case as Fig. 631. This is a definite type of fracture, occurring particularly in small children, as a result of falls upon the hand.* The fracture itself is a * Not uncommonly these "greenstick" fractures in children become complete with overlapping. Such cases are curiously hard to reduce and hold. Open operation, often called for, should restrict itself to operation on one bone (with kangaroo tendon or fine wire fixation, not a plate) and manipulative reduction of the other bone. (Cf. Figs. 633, 634.) 380 THE WRIST break across both radius and ulna at about the same height, anywhere in the lower quarter of the bone. Clinically, the wrist from the radial side looks exactly like a Colles' fracture excepting that the silver-fork deformity looks a little high. On palpation we find readily that the ulnar head is not displaced in relation to the radius, and that there is a curve in the ulnar shaft. This fracture is to be reduced like any greenstick fracture, but here, more than almost anywhere else in the body, it is important to break away from the academic teachings as to reduction. This fracture, like every greenstick fracture, must not be completed if we can avoid it, but the bones must be pressed back to their former position, or even a little overcorrected. Any bone that will fracture Fig. 633.-Greenstick fracture of both bones; fracture of radius had been completed before the case was seen. Fig. 634.-Sketch from x-ray plate of a case in which there had been a "greenstick" of both bones. The fracture of the radius had been com- pleted in attempts at reduction before the case was seen. There was deformity as shown. Traction under ether with direct force gave bet- ter position, without overlap; proper use of pads gave perfect position eventually. in this fashion is soft enough so that we can press it back into a straight line, or even beyond a straight line, and so interlock the torn surfaces by jamming as to maintain the desired position, without completing the fracture, save by rare accident, and in any event without tearing across the periosteum. Treated in this way those fractures have no displacement and are far different from the loose fracture produced by completing the break, as to both treatment and prognosis.* XI. Lesions of the Ulna.-Fracture of the shaft of the ulna in con- nection with Colles' fracture is unusual, f It is apt to occur higher * Occasionally we see here at the wrist, or a bit above it, an "infraction" (see Fig. 1), technically different from a "greenstick" in that the lesion is of the concave, not the convex surface. Clinically it is exactly equivalent to a green- stick and to be handled just like it. t The writer cannot agree with Beck, who considers fracture of the ulna at or near its head a common complication of the radial lesion. Except for Beck's plates, there are only five specimens or plates known to the writer showing this condition. The assumption that such lesion is the cause of loss of pronation and supination is inconclusive, considering the frequency of comminution of the radius through the facet with which the ulna articulates. Moreover, in cases skilfully handled, such limitation is excessively rare. Separation of the ulnar epiphysis is well recognized as a complication of the fracture or of the separation of the radial epiphysis. COLLES' FRACTURE 381 than the fracture of the radius, but there may be a breaking across just above the ulnar head. The displacement is in the direction of the radial displacement. When the ulna gives way, there is little or no damage to the radio- ulnar ligaments. XII. Fracture of the Ulnar Styloid.-This is the commonest of the fractures complicating the radial lesions. It has been long recognized as occurring, but its frequency was unsuspected until proved by the skiagraph. Percentages vary greatly. The writer found it in 18 out of 45 unselected cases in which the skiagraph was examined for the purpose. Other series run much higher percentages-up to nearly half Fig. 635.-Separation of radial epiphysis (successfully reduced); fracture of ulna success- fully reduced (later) by incision and suture. Fig. 636.--Photograph of same case as Fig. 635. Despite appearances, the deformity was of the ulna only; the radius had already been perfectly reduced (photographed before operation). the cases of Colles' fracture. The fracture is usually near the base, and is apt to be nearly transverse. The displacement is downward and outward, and may be considerable in extent. The separation is prob- ably due to the traction of the lateral ligament and not from direct violence or from pull on the triangular fibrocartilage. Union is usually by ligament only. The only importance of this dislocation lies in the fact, pointed out by Moore,* that the broken tip left behind may become entangled with the ligaments, so as to complicate reduction. The fracture per se can- not usually be diagnosed except by the x-ray, and, so far as results are concerned, the writer has never been able to convince himself that this lesion made the slightest difference. • XIII. Fracture of the Ulnar Styloid (Alone').-The ulnar styloid may be broken without other lesions of bone. This lesion apparently results purely from abduction strain. Clinically, it occurs from falls on the ulnar edge of the hand. I have seen two cases. The lesion is of * Moore, of Rochester, N. Y., N. Y. Med. Record, 1880, xlii, p. 305. 382 THE WRIST little importance clinically. The course of repair differs in no appreci- able way from that of simple "sprain" of the wrist. (See Fig. 641.) Lesions of Ligaments.-The internal lateral ligament, at- tached to the ulnar styloid, may Fig. 637.-Fracture of the radius; fracture of ulna near the joint; much crushing of bone in the radius; marked outward and upward displacement and rotation; fragments freely movable; delayed union. Fig. 638.--Comminuted Colles' frac- ture. Fracture of ulna across above the head; much displacement (x-ray before reduction). be torn away. The anterior radio-ulnar ligaments, as well as the Fig. 639.-Colles' fracture, with fracture of the ulnar shaft. Colles' fracture reduced; the ulnar fracture wired. Fig. 640.-Separation of the radia epiphy- sis (reduced); fracture of the shaft of„ the ulna. posterior, are frequently more or less torn. That this is so is clinic- COLLES' FRACTURE 383 ally obvious from the frequency of associated forward displacement of the ulna. The triangular fibrocartilage which runs from the base of the ulnar Fig. 641.-Avulsion of the ulnar styloid from a fall on the hand, without Colles' frac- ture, but with a broken scaphoid (author's case). Fig. 642.-Same case (view from the side) styloid to the edge of the radial articulating surface may be variously torn. This seems, from the dissections, to be a common lesion, and must necessarily occur if there is extreme ulnar displacement. Nothing Fig. 643.-Fracture with backward displacement and backward rotation. Shows the stripping up of the untorn periosteum posteriorly (after Westbrook's plate). Fig. 644.-Colles' fracture with compound luxation of the ulna and rupture of the ulnar nerve. Seen June 27, 1907, with Dr. O'Shea, house surgeon at the City Hospital (redrawn from sketch made at the time). more is known of its importance than that these cases with extreme ulnar displacement are apt to show some weakening in this region after bony union of the radius. 384 THE WRIST Lesions of Periosteum.-The stripping up of the periosteum, espe- cially on the posterior surface, occurs in Colles' fracture, as it does in epiphyseal separation, though probably less constantly and to a less extent (Fig. 643). Injuries to Vessels.-These are rare, and the classic specimen of which the plate is here given seems to be almost unique. (See Fig. 577.) Injuries to Nerves.-Injuries to nerves are uncommon, and are limited, substantially, to stretching of the ulnar nerve over the head of the ulna, which, in fact, rarely occurs, and seems not to be of importance Fig. 64.5.-"Traumatic arthritis." Transverse crack across radius without displacement, treated without fixation of the fingers; splints removed early. She rapidly developed total loss of power in the hand, extreme stiffness, and much pain. The x-ray shows the extreme bone absorp- tion (with "penciling" of the lines of the cortical layer everywhere) characteristic of rheumatoid arthritis. Under treatment recovery was practically complete in about a year. The patient was a healthy woman in the forties, who never had had any joint troubles (case seen with Dr. F. F. Pike, of Melrose, Mass.; x-ray by Dr. Percy E. Brown). when it does occur. Twice I have seen actual tearing of the ulnar nerve in compound Colles' fracture (Fig. 644).* Thrice I have seen damage to the radial nerve (here sensory only) in one case with a distressing sensory disturbance in the thumb lasting several months. All recovered entirely but in one there was for a time a question if the nerve had not been completely pinched off. Compound Fractures.-Compound Colles' fractures are rare, strictly speaking. That is, there is rarely any outward communication with the fracture itself. * See, however, p. 398 in regard to nerve damage from trauma in recurring ulnar luxation following Colles' fracture. colles' fracture 385 Not uncommonly there is some tearing of the skin where the dis- placed ulna strikes, and now and then the ulnar head is thrust into this rent, making an indirect communication with the radial fracture. I have seen perhaps a dozen such; all were cleaned out thoroughly and did well, except the one shown in Fig. 646. Here and there we meet with cases in which there is extensive tearing of soft parts communicating with the fracture, in which the prognosis is mainly dependent on repair of nerve and tendon, and the bone lesion, so long as it remains aseptic, is of secondary importance. In other cases-I recall two-the radius came through. In one the projecting end of the radial shaft (it came through alongside the flexor tendons to the thumb side) was ground full of cinders, and part of the sur- face had to be removed with rongeurs to get a clean wound. This case healed by first intention with a fair result. Impaction.-The frequency of impaction in these fractures has been, and must remain, a matter of estimate. The skiagraph does not help us, and clinically it is very hard to say, even after reduction, whether a fracture was really impacted, or whether the muscles simply held the broken bone-ends entangled by their rough surfaces. I have seen four loose Colles' fractures. An impaction firm enough to offer great resistance to reduction is not common. On the other hand, fractures so loose as to permit of obtaining crepitus without anes- thesia, without the use of much force, are very unusual indeed. This resume covers the lesions actually occurring in radius fractures at the wrist which are of any consequence. Apart from the alleged constancy of impaction, there is but one other common assumption as to the pathology which is wrong and which should be corrected; this is in regard to hemorrhage into and adhesions of, the tendon-sheaths. It would be unwise to deny that there may be hemorrhage into the sheaths, but so far as the records of exact obser- vations go, hemorrhage is far more constant outside the sheaths, and we have no right to assume that the common swelling (see Fig. 651) about or even into the sheaths represents hemorrhage. As to adhesions as a primary cause of stiffness and loss of motion, we have not a shadow of evidence. Personally, I believe such adhe- Fig. 646.-Compound Colles fracture with comminution and with a long spiral fracture line running upward.* * First seen by me as an old case, with a sinus. A bit of bone was extruded later, and in the end the result was a very useful wrist. One other case dragged on for some months before full recovery on account of contracture involving tendons in the healed wound. 386 THE WRIST sions to be clinically negligible if they do exist, and I believe that the loss of motion here, as with most other fractures, is due to a shortening of muscles from fixation and disuse (plus the trauma), and to a shorten- ing of fibrous structures about the joints, usually of later origin. The theory of tendon-sheath adhe- sions lies at the bottom of much of the advocacy of forcible breaking up and forced passive motion, which has done so much harm. Symptoms.-The typical Colles' fracture causes only partial disability of the wrist and hand.* There is displacement of the hand backward. There is a fullness in the front of the wrist over the radius, and a full- ness slightly lower down, on the back of the hand-the first produced by loss of the radial arch and by the push- ing forward of tendons, etc., by the lower end of the upper fragment; the latter produced mainly by the promi- nence of the lower fragment itself, partly by blood and serous effusion in the soft tissues, or serum in the sheaths of the extensor tendons. (See Fig. 651.) There is a loss of the normal promi- nence of the ulnar head on the back of the wrist, with a correspond- ing fullness on the front of the wrist, a prominence caused by the displacement of the ulnar head forward to a position near the pisi- form bone. This displacement is almost absolutely diagnostic of Colles' fracture. The hand is usually held in partial flexion. Seen from either side, the typical "silver-fork deformity" is easily recognized. This silver-fork deformity may rarely be counterfeited by swelling not due to fracture, but is almost pathognomonic of Colles' fracture (Fig. 648). On closer examination we find a change in the relation of the styloid processes. The tip of the radius, instead of being lower than the ulnar tip, is at the same level, or even higher up. On feeling along the front of the radius the normal arch is found to be flattened out, and some- times the lower end of the upper fragment can be felt. On feeling Fig. 647.-Sketch from rr-ray of a similar lesion, in this case not compound. Fig. 648.-Diagram of the so-called "silver-fork" deformity. * There is a firmly fixed lay belief that there can be no fracture if the hand can be used, a belief responsible for a good deal of trouble. COLLES' FRACTURE 387 down the posterior surface of the bone it is usually possible to make out a ridge, which is the projecting edge of the lower fragment. A similar ridge is often to be felt on the outer surface (Figs. 649, 650). Motion is relatively little interfered with, but the range of extension Fig. 649.-'Backward ro- tation (diagram). The dotted line shows the normal slope of the joint surface. Fig. 650.-Outward ro- tation from the front. The dotted line shows the norma] outline. Fig. 651.-Site of the rather common effusion seen in Colles' fracture into the tendon-sheath of the thumb muscles and the common ex- tensor sheath. of the wrist is better than that of flexion. There is usually some tendency to abduction of the hand, as well as to backward displacement. At times this is so pronounced as to give an entirely different clinica picture from the classic one. An outward displacement of the hand without silver-fork deformity may be present, with well-marked prominence of the ulna to the inner side, as well as forward. These are the cases of so-called " abduc- tion Colles." In neither this nor in the classic type is any crepitus to be made out, as a rule. The foregoing describes the typical clinical picture of well- pronounced cases. The amount of displacement and the amount of bone destruction vary a good deal: we have cases varying through all degrees, from such as those described down to those in which a slight lameness of the wrist and slight swelling are ac- companied with nothing more diagnostic than a line of tenderness running around the shaft of the bone. These minor cases may not even show any abnormal position of the ulna. In such cases as this absolute diagnosis is not always easy. Fig. 652.-Colles' fracture on the left. Note the loss of backward prominence of the ulnar head at the wrist. 388 THE WRIST In cases where there is any considerable displacement there ought to be no question as to the diagnosis. The type of lesion of importance that is most often overlooked is the fracture in which the total displacement is not very great, though the rotation of the lower fragment backward may be very marked (Fig. 649). These cases, if seen when there is swelling present, show very little deformity; they show little change in the level of the styloids, and they may not show the characteristic ridges on the back and outer side. They do show localized tenderness, and they show a flattening of the radial arch and a dislocation forward of the ulna, which should be sufficient for diagnosis. The question of the use of the x-ray in Colles' fracture deserves a Fig. 653.-Ulnar head shows only slight promi- nence in pronated position. Fig. 654.-Ulnar head is displaced sharply forward on supination. There was in this case an obvious entanglement of the sharp end of the broken ulnar styloid in the ligaments (note the visible dimple). Attempts to reduce this entanglement failed (same case as shown in Fig. 652, but photographs reversed in reproduction). word of notice. Save for cases apparently atypical there should be no necessity of waiting for an x-ray before reduction of the fracture. With moderate experience and skill a very fair estimate of the displace- ment and position may be arrived at-an estimate quite good enough to guide our efforts at reduction, particularly because reduction is carried on in pretty much the same way regardless of exact details. Neverthe- less in the general run of cases, delay of an hour or so is of no conse- quence, and we should get an x-ray if we can-before as well as after. There should be an x-ray in every case, I think, after reduction. There are too many cases of breaks called sprained wrists, too many cases of breaks "without any deformity," too many cases like Figs. 666, 669a, in which the deformity, supposed reduced, is still there. Treatment.-All cases should be treated under an anesthetic if possible. Full surgical anesthesia is unnecessary. Primary ether* is sufficient, and nitrous oxid is a perfectly satisfactory substitute. All * That is, etherization produced by rapid full respirations to a stage of anesthesia with some relaxation of muscles. In such anesthesia consciousness may not be lost at all; sensation of pain is, however, abolished for a long enough time to permit reduction. COLLES' FRACTURE 389 that we need is the opportunity of a half-minute for manipulation with- out pain to the patient and without severe muscular contraction. Even if the patient is willing to stand the pain, his muscular resis- Fig. 655.-Grip No. 1 for reduction of Colles' fracture. Fig. 656.-Grip No. 2. tance and the effort of the operator to avoid inflicting pain unnecessarily almost always result in inferior work. Anesthesia is, therefore, almost essential. 390 THE WRIST Before reduction we must get a clear notion of the following points: (a) The amount of total backward displacement of the lower fragment. (5) The amount of rotation of the fragment, (c) The amount of out- ward displacement or rotation, (d) The presence of such thickening or broadening as would suggest comminution, (e) The extent of dis- Fig. 657.-Grip No. 3. placement of the ulna and the probability-or the reverse-of an en- tangling of the stump of the ulnar styloid in the ligaments. Then we may proceed with the reduction. An assistant gives countertraction at the elbow or axilla. The Fig. 658.-Grip No. 4. surgeon may use any of the grips illustrated in Figs. 655-660. The choice depends somewhat upon the amount of swelling present and the ease with which the fragment can be clasped, somewhat upon the size of the patient's hand in proportion to the surgeon's. More than COLLES' FRACTURE 391 all it depends upon the habit and convenience of the surgeon. The writer's older routine was as follows: Fig. 659. --Grip No. 5-only to be used where a good deal of force proves necessary, never for the first trial. Fig. 660.-Grip No. 6, for carrying out Moore's cir- cumduction movement to disentangle an entangled broken end of the ulnar styloid. (1) Grip 1 is used, with strong traction to start the loosening of the fragments. (2) Then grip 3, until any impaction present is entirely loosened. (3) Then grip 6 is assumed, and circumduction of the hand in both directions is carried out (Fig. 660), in order to untangle the possibly entangled ulna, then the hand is brought over into sharp flexion, with 392 THE WRIST a shove on the back (grip 2), and, finally, the displacement as a whole having been reduced by these means, the hand is sharply flexed in order to make sure that the backward rotation has been overcome.* If these manoeuvers have been carried out properly, there should be little tendency to any recurrence of deformity. Other grips shown give more power in reduction when this is needed. The position should be verified by a careful reexamination of all landmarks. It happens not infrequently that some outward displace- ment is first recognized at this examination: this must be corrected by traction, adduction, and direct pressure. All this seems like a complicated procedure, and does, in fact, require some experience in the various grips and manipulations, but in actual practice it takes a very short time indeed. This routine gives good results but personally I no longer use this method, but one published by me in 1919 after some years of trialf -in an article from which the following is quoted. It has been my fortune of late years to have referred to me very many cases of unsatisfactory results in Colles' fracture, and in nearly every one the trouble has been failure to recognize and to handle this feature-the factor of backward rocking of the distal fragment, which, as long as it persists, makes proper reduction of the ulna impossible- and it is a fact, even a well-recognized fact-that it is the ulnar luxa- tion, rather than the fracture itself, which gives disability. I have called attention to this factor of backward rocking before, but perhaps without emphasis. Today I am emphasizing it because I now know how to handle it, and have a method to offer that has stood the test of half a dozen years of use in the hands of myself and my assistants. When one breaks his wrist, it is the radius that gives way, but the whole damage may best be expressed as a rotation backward of the hand about the ulnar head as a fixed point, a rotation which tears the ulnar ligaments loose (the ulnar styloid often giving way with the ligament strain), and also breaks the radius. The hand is displaced, with the radial f ragment, up and back Al toto, to a varying degree-often great; but, whatever the total displacement of broken fragments, always we find the hand displaced backward-always the associated tilting backward of the lower radial fragment. We may have a or b of Fig. 665, but always a tilting back, an altered angle, of the articular surface. (See also Fig. 666.) * We must always bear in mind the rotary, supinating character of the whole displacement. (Seepage 388.) Our final reduction should be into sharp pronation as well as flexion. And this pronation and flexion are to be carried out about the displaced ulna as a fixed center. In ordinary cases, I no longer circumduct, according to Moore, first one way and then another, but always in the direction of pronation, only with flexion (after freeing the fragments by traction, etc., as stated), always using the ulnar head as the fixed point about which rotation is carried out. t Adequate Reduction and Care in Colles' Fracture-New Methods. Frederic J. Cotton: Boston Med. & Surg. Journal, 1919, clxxxi, p. 651. COLLES' FRACTURE 393 After long observation of this fact, after considerable experience in trying to use the accepted manipulations so as to correct it, it finally occurred to me to reverse, in reducing, the mechanism of production of the deformity. In other words, if the ulna is the fixed point about which the hand is displaced, make it the fixed point about which one reduces; if the hand is displaced in extension, reduce it in flexion; if it is displaced in a rotation of supination about the ulnar head, reduce in pronation. There is no finality in such a reasoning, but on trial this worked out surprisingly. The older methods of reduction aimed almost entirely at a carrying forward of the lower fragment on the upper. For this they were good, and I use them still-for this. The new matter is-after the obvious displacement of the radius is corrected, then carry the hand about the ulnar head as a fixed point into pronation and flexion. It is simple enough. Figure 667 shows the grips and the motion. A good deal of force is directed up under the ulnar head, a strong drag flexes the hand, and a twist of the whole hand about the ulna finishes the work. This may all be done as one twisting sweep-and easily,-rarely needing repetition. As soon as the fracture is properly replaced anesthesia is stopped. The wrist is held by the operator until the patient recovers full conscious- ness, which, with proper primary ether anesthesia, should not be over two or three minutes, and then the application of splints is carried out, with the patient again conscious and suffering very little pain. A number of forms of splint have been used, but, in fact, the form of splint is relatively unimportant if the points of pressure to be secured by pads are properly borne in mind. * Pressure made on the fragments means, of course, not active pressure, but simply the securing of the fracture against accidental disturbance. The points to be so used for pressure are as follows: (a) The arch of the radius, opposite the lower end of the upper fragment in front; (6) the lower end of the ulna in front, just above the Fig. 661.-Pattern of splints, of light splint wood, as used for some ye,ars by the writer. * All the older forms of splint, from Nelaton down, which depend on extreme adduction of the hand for correction, have been discarded. Such splints insure discomfort, and often entail some disability from stretching. In fact, the whole story is one of proper reduction, and such splinting as will minimize the chance of accidental displacement. Muscle pull is ordinarily unimportant, and we could not work against it effectively if it were important. In case there is much bone-crush- ing, for instance, I have seen few cases where attempts to hold the uncrushed portions apart were in the least degree successful. (See Fig. 662.) 394 THE WRIST joint; (c) the back of the hand; pressure on the back of the hand is equivalent to pressure on the lower end of the lower fragment, to which the hand is firmly attached by ligaments. There are also points of pressure which must be carefully avoided, viz., the back of the radius at or above the fracture, the back of the ulna at any point, and the thenar eminence. In order to avoid pressure on these points, and in order to give support to the pads by which we obtain pressure where it is wanted, both anterior and pos- terior splints are needed. Only in fractures without displacement-or substantially without displace- ment-is it wise to sacrifice support and to depend simply upon the strapping or upon strapping with the short dorsal splint, though such simple splinting has often been advised. Rigid splints for the first few days do no harm and may avoid redisplacement. The form of splints used by the writer is shown in the accompanying illustrations. The majority of surgeons today use splints of something the same general type.* These splints are padded in the usual way, with sheet-wadding strapped in place, and with pads cut to correspond with the special areas of pressure. The best material for these pads is the loose yellow "saddler's felt," which may be cut readily, is elastic, and holds its shape much better than a cot- ton pad. These pads are best strapped on the splint with the sheet-wadding covering. Considerable thicknesses of felt can be used without discomfort and with almost no risk of trouble from pres- sure. The one point at which the danger of pressure is con- siderable is over the spur at the bases of the second and third metacarpals, on the back of the hand. Sloughs here are very easily produced, even with felt padding, and where this spur is prominent, it is well to cut a hole in the splint. (See Fig. 664.) Fig. 662. - Com- minution of a portion ofi the bone to small fragments leaves a gap (upper figure). In such case only the most skilful reduction and c'a r e can prevent approximation of frag- ments; the best result attainable may include a closing of this gap by rotation backward of the lower fragment (lower figure). Fig. 663.--Application of pads (felt or cotton "sheet-wadding"). There is a pad under the arch of the radius, one under the lower end of the ulna, and a pad which lies on the back of the hand or may extend onto the back surface of the lower fragment. * The Levis or other molded splints, while serviceable, are not much used by those expert in fracture work because of the difficulty in fitting (exactly) the, individual case. If one wants this sort of splint I have found it much better to use strip splints of sheet aluminum and hammer them into shape in the office-on the spot. Colles' fracture 395 When the splints are applied, they must be fastened in place by ad- hesive plaster, holding them in their relative position, and, for part of the circumference, adhering to the skin. This is the only way to prevent rotation and slipping of the splints. It is permissible to shave a hairy arm before applying the plaster, but not permissible to apply a sheet of cotton under it to avoid sticking. Adhesion to the skin is exactly what is wanted. These adhesive straps should not be the means used to produce pressure by the pads. This pressure is obtained by the succeeding layers of bandage. After the plaster straps are put on, a roller of sheet-wadding is wrapped around the arm (splint included), and then the bandage, not of gauze, but a muslin roller 1 or inches wide, is to be applied snugly enough to produce whatever pressure is desired. Excess of local pressure is indicated by persistent local pain; too much general constriction or local pres- sure on the veins is indicated by blueness of the hand and by swelling of the veins and a slowed return of the circulation.* For purposes of appearances it is well to wet the roll of bandage before applying it. This makes a smoother bandage and one which soils much less readily, but it has the disadvantage of some shrink- ing when it dries, which must make us a little cautious in using it. After the bandage is applied the hand should be put in a sling which supports the forearm and wrist, but not the hand. The hand should be in a position of semipronation. The sling should be so arranged that the wrist is as high as the elbow or a little higher. The bandage must be inspected after the hand is slung up to make sure that the upper edge, whether of plaster or bandage, does not cut into the arm or im- pede circulation. This is the usual method of doing up such a case and serves in nearly all instances. There are a few cases of simple crack of the radius or of simple cross-break with little or no displacement (like some of the "automo- bile" fractures of the wrist), which do not need so much apparatus and which may perfectly wisely be put up with a single splint. A short dorsal splint may be used-a splint no wider than the radius-and slightly cut out to avoid pressure on the head of the ulna, or an anterior splints may be used, of the Bond, Carr, Nelson, or Bolles type or the most recent and neatest, papier mache splint usually sold as "Walker's." These are excellent rest splints, more comfortable than Fig. 664.-The crosses indicate the point of projection of the bases of the second and third metacarpals. We must have no pres- sure in this region, even if it is necessary to cut out a hole in the posterior splint (as I have repeatedly done) to avoid it. If we are careless, sloughs are liable to develop at this point in certain cases. * This is tested by pressing on the finger-nail until it goes white, then suddenly removing the pressure. The rapidity of return of the pink color is a measure of the sufficiency of the circulation. Numbness is apt to be from poor circulation; nerve pressure is more apt to show itself as pain. 396 THE WRIST the posterior splint, though not very well adapted to accurate fixation of fragments. Certain good surgeons, notably Moore,* of Rochester, Roberts,! of Philadelphia, and a few others, have boldly advocated the routine treatment of Colles' fracture (after proper reduction) with a simple circular band of adhesive plaster or with such a band reinforced with a short (3 inches or so) dorsal splint, with or without accessory special pads. There is no doubt that in the hands of a thoroughly competent surgeon, with proper cooperation of the patient, this method is adequate, and guards against overimmobili- zation. But until damage suits become less popular as a means of blackmail, and until the courts acquire the habit of closer discrimi- nation as to contributory negligence, I am not ready to recommend the method. It is possible to do more than by the routine so far indicated, but what I am about to quote! is to be understood as a method not without possibilities of trouble in inexperienced hands. If one wishes first rate results, the average splints are very often inefficient. The muscle-tonus holds the fragments against redisplace- ment in toto, but not against rock- ing back of the distal fragment, the more so as there is often enough crushed and missing bone at the back edge of the fracture to leave a gap. How to hold position I learned from doing osteotomies on old frac- ture deformities in which one must of necessity keep a wedge-shaped gap open until it fills with bone. This can be done only in flexion, and flexion is best held in plaster, preferably applied as strip-splints of eight to ten layers of plaster-of-Paris bandage, one on the back, Fig. 665.-a, Displacement backward. 6, Rocking backward without total displacement, c, Correction of &, showing gap left where bone was crushed by the "impaction" (Boston Med. and Surg. Jour.). Fig. 666.-a, Same tilting of joint surface in an- other case (Boston Med. and Surg. Jour.). * Moore, loc. cit. f Roberts, in his Fracture of the Lower End of the Radius, etc., P. Blakiston Son & Co, 1897, p. 75 and elsewhere. $ From paper above noted, Boston Med. and Surg. Journal, 1919. COLLES* FRACTURE 397 from elbow to finger knuckles, one in front, from upper forearm to palm. These are caught with a few turns of plaster-of-Paris band- age. (See Figs. 670 and 671.) Fig. 667.-First traction and rocking, with the hand a little extended (backward) so as to free the displaced radial fragment and the dislocated ulna; then, with the thumb under the ulna, making it a fixed fulcrum, drag the hand down into flexion and pronation, keeping up traction combined with this flexion and rotation (Boston Med. and Surg. Jour.). The same thing may be done less efficiently, but often well enough, with splints and exaggerated pads, as shown in Fig. 668. So long as the wrist is in flexion, the posterior ligaments, always intact, give the pull Fig. 668.-Splints and pads, a, The radial pad is short and does not come under the lower fragment, b, The ulnar pad runs to the joint level. that keeps the distal radial fragment from rocking backward; and so long as the ulna is held to the back of the flexed wrist, the ligaments can heal to something near their normal length. This is important, for not only is there weakness in the ligaments, but their laxity often permits a subluxation of the ulna with each supination,-a common 398 THE WRIST factor of disability. This slipping ulna not very rarely leads to ulnar nerve irritation. I have previously called attention to it, but find it Fig. 669.-a, Before reduction, b, After reduction. In this case splints were used, not plaster (Boston Med. and Surg. Jour.). Fig. 670.-a, Epiphyseal separation in a boy of 15 years--after two attempted reductions (elsewhere), b, After reduction through small incision-reduction by leverage of osteotome between fragments-shown held in flexion plaster (Boston Med. and Surg. Jour.). not uncommonly, always undiagnosed, whether slight or considerable in degree. The flexion position need not be kept up over a fortnight, and it is usually wise, if plaster is used, to slit the plaster along one side after COLLES' FRACTURE 399 a day or two to ease the circulation. Always remember that the position a little impedes circulation, and watch carefully. In several Fig. 671.-a, Colles's fracture 10 weeks old. Extreme displacement of radial fragment. Ulnar head locked in front of carpus. Entire loss of flexion of wrist and of supination. Finger flexion interfered with to unusual degree, b, Same after open reduction-osteotomy, then reduction by the manipulations described in the text. Shown held in flexion plaster. Note the V-shaped gap between x and y, successfully held open (Boston Med. and Surg. Jour.). Fig. 672.-a, Three weeks after fracture and alleged reduction, b, After reduction with "Thomas" wrench. Shown asjield in flexion on splint (c/. Fig. 668) (Boston Med. and Surg. Jour.). cases reduced by internes, I have seen a dangerous interference with circulation from too tight a plaster. This is better avoided if one uses 400 THE WRIST the strip-splints of plaster as described, but even that is no security against lack of skill or care. This chance of trouble is the reason I have not until now published this method of fixation, long as I have used it. After the flexed position is abandoned, use straight splints with exaggerated pads at a and b (Fig. 668) for a third week-never longer, unless for special reasons-and then a supporting strap of adhesive with pad in front of the ulna (the ligaments are the last to heal) to be worn (changed every three to five days) until the hand is strong. It has been my experience that the hand recovers function more quickly after flexed fixation than after straight splints-I do not know why. AFTER -TREATMENT These fractures, like all fractures of the limbs, should be inspected the next day. In the absence of some special doubt it is not necessary to remove even the bandage, but in these wrist fractures we should make certain regarding the following points: (а) Swelling of the hand. (б) Numbness or paresthesia of hand or fingers. (c) Cyanosis. (d) Amount of pain (pain in reduced fracture should not ordinarily be very severe after a few hours). (e) Complaint of general discomfort from pressure. (/) Complaint of localized pain at or near any point of special pressure. This last complaint should be regarded as an absolute indication for cutting down the apparatus immediately. If this is done, the danger of sloughs of the back of the hand, over the base of the second and third metacarpal, such as the writer has seen follow neglect of such precaution, will be entirely avoided, or, at worst, minimized. Avery considerable pressure may be borne for twelve to twenty-four hours without permanent damage. So far as the presence of swelling and cyanosis is concerned, it is a question of degree. We must not expect in any fracture to be able to apply efficient apparatus without any interference with the circulation. In these wrist fractures, if we can keep them sufficiently free from swell- ing to avoid any interference with finger motion or any considerable discomfort, we do sufficiently well. After this first inspection the patient should begin, if he has not already begun, to keep the fingers limber by passive motion, and more particularly by persistent active motion (not use). At no time should we allow the fingers to stiffen in the least, even if motion is slightly painful. The splints should be removed entirely for inspection after three to five days more. In cases where the tendency toward recurrence is very slight, we may omit the anterior splint after four to six days. AFTER-TREATMENT 401 The same pads are reapplied, but they are made thicker, as they are now held with straps only for counterpressure. The majority of cases may wisely be put on the single splint at the third, if not at the second, dressing. That is between five and ten days after the accident. It is wise to do this as soon as possible, because even the best anterior splint does somewhat interfere with full flexion of the fingers. Within two weeks some mobility should be given, not only to the fingers, but to the wrist. We may discard the splint, or we may retain it merely as a protection, strapping it on loosely. Only in rare cases of delay in union, in cases with very great damage to bone and soft parts, can there ever be need of any- thing more than a protective splint after two weeks. When the splints are removed, a wrist strapping of adhesive plaster is substituted for them. This is put on for a width of two to three inches upward from the wrist- joint; under it are put pads corresponding to the arch of the radius and to the front surface of the lower end of the ulna. This strapping should be changed every few days and kept on until we are willing to begin actual use of the hand. This will be, according to the case, from three to five weeks after the receipt of the injury. When this adhesive plaster is discarded, it is well to support the wrist with a leather wrist-strap, fastening with one or two buckles, to be worn until the patient feels no further need of the support. Results.-The important thing to remember is that bad results, so far as function goes, are far more apt to be the result of bad treatment than a result of the injury. In few instances has sur- gery inflicted so much unnecessary damage as in the treatment of Colles' fracture and of the related lesions. If such a case is left unreduced and the patient is allowed to consider it a "sprained" wrist, most unsightly deformities may result, but function is often almost perfectly restored. There is, at most, some weakness, but not the stiffening of the fin- gers which so often resulted from the well-meant treatment so care- fully carried out a generation ago. Almost without exception it is possible, as we now know, to secure efficient reduction, to avoid recurrence of deformity, and at the same time to avoid stiffness. The avoidance of stiffening consists simply in never giving a chance for the fingers and wrist to stiffen. We should so treat these fractures that late massage, passive motion, and the "breaking-up" of so-called "adhesions in the tendon-sheaths" shall not be called for. If we avoid stiffening due to unwise fixation, Fig. 673.-Supporting dressing; circular bandaging with adhesive plaster. The arrow points to a felt pad under the arch of the radius. Fig. 674.-Leather wrist- band, worn during convales- cence, and often a comfort for some time after recovery. The band should have two straps. 402 THE WRIST the disabilities resulting from Colles' fracture, and the allied lesions, are almost entirely confined to a weakness of the ulnar side of the wrist, due to an imperfect replacement of the luxated ulnar head, and to an imperfect repair of the torn ligaments. So far as the radius is concerned, we may have some limitation of flexion of the wrist, with a corresponding abnormally free hyperexten- sion, or a limited adduction, with a tendency to abduct too far, all due simply to a change of plane of the articular surface;* none of these factors are productive of any special trouble. The great majority of broken wrists which do not stiffen are function- Fig. 675.-Bilateral Colles' fracture. Shows how poor an anatomic result may give excellent func- tion. Both these hands were normal as to function. ally as good as new within a year of the injury. Secondary arthritis (Fig. 645) is rare, though non-predicable, and to be reckoned, when it does occur, as one of the calamities of surgery. It may occur in any case I Fortunately nearly all cases show power of repair of this lesion, whatever it is, and recover full motion within 6 to 18 months. This optimistic statement does not apply, of course, to the proved "arthri- tics" who chance to suffer from this injury; only to the cases in which this lesion develops without previous arthritic signs. * Dr. J. C. Munro first appreciated the fact that rotation, rather than dis- placement, accounts for both widening and abduction. AFTER-TREATMENT 403 Deformity.-All this has nothing to do with the deformity. It has been said, on excellent authority, that no wrist which does not show at least some displacement of the ulnar head, as compared with the other side, has ever been broken. There are exceptions to this rule, but it is a fact that most fractures in this region in which there has been dis- placement, do show in some degree some of the following deformities, however well they have been reduced: 1. Backward displacement of the lower fragment. 2. Backward rotation of the lower fragment. 3. Outward rotation of the lower fragment, with consequent broadening of the wrist. 4. Shortening of the radius, with consequent change in the relation of the styloids. 5. Forward, or inward and forward, displacement of the ulna. In most instances these displace- ments are present in so slight a degree that the wrist shows no obvious defor- mity, but the displacement of the ulna, the backward rotation of the lower fragment, and the broadening due to the outward rotation (see Fig. 650) may almost invariably be made out with- out difficulty on careful examination. There are cases in which even un- sightly deformity is entirely unavoid- able. Most commonly, this is due to- (а) Extreme displacement of the ulna with weak ligamentous repair, allowing a forward displacement, progressive on use. (б) A crushing of the posterior or outer surface of the bone into fine fragments, leaving an unfilled gap between the bone-fragments after reduction, a gap which can not be kept open until healing is complete by any practicable form of splints. (c) Comminution of fragments, admitting of little actual fixation by splints. This condition has no necessary relation to delayed union. In all the above conditions, even in cases with no more than the usual primary displacement, we may get astonishingly poor results as to shape, in spite of the greatest care. Fortunately, these conditions are not common. Extreme displacement of the ulna is associated with extreme trauma or with poor reparative power.* Fig. 676.-Old Colles' fracture with outward displacement and shortenings enough to bring the radial articulation above the end of the ulnar head. Good function, (x-ray tracing.) * Such displacement may occur late. I have followed two such cases in which marked deformity came on well after union of the radial fracture and after removal of splints. 404 THE WRIST The crushing-up of bone is apt to be an obstacle only in very old patients or feeble ones, in whom the bone structure has been greatly changed and weakened. As a rule, adequately treated cases show, in the end, only a slight flattening of the radial arch and slight forward displacement of the ulna. Operative Treatment.-Nothing is simpler than to do an osteotomy of the radius from the back or from the outer side, and to correct dis- placement. Many such operations have been done. Some should be done. Certainly bad results from epiphyseal sepa- ration in children should be corrected. As to the general run of cases, I should say that unsightly deformi- ties should be corrected, unless in the aged. As to the rest, it should often be left for the patient to decide how much he cares about a little deformity that gives no disability. Also, cases in which there is mechanical limitation of motion, as from contact of ulna and cuneiform (not extremely rare) or recurrent slipping of the ulnar head, or lameness from overstrain of ulnar ligaments, all call for operation and are all correctible. An os- teotomy of the radius with full forcible correction of the radial displacement, with splinting in flex- ion sufficiently extreme to keep open the wedge shaped space at the point of osteotomy: such operation gives results surprisingly worth while. LUXATION OF THE ULNA AT THE WRIST There is a good deal of literature devoted to this luxation,* but much of it is valueless for our consideration now, for two reasons: first, because a great many dislocations of the ulna backward are of "congenital" origin, or are due to a short radius or to other unusual causes; and second, that a great many luxations of the ulna forward and inward are really simply complications of Colles' fracture. These last are truly luxations, and in many instances the luxation counts for more in results than the fracture, but it is distinctly a secondary result, and hardly to be classed with independent luxations, f Allowing, however, for these two sources of error, there is sufficient evidence to accept the existence of uncomplicated backward dislocations of the ulna due to trauma, and of certain rare forward luxations Fig. 677.-Backward luxation of ulna (alone) at wrist (sketch after Rog- netta's plate). * In the main, this literature is so old as to be a bit doubtful. Valias (Bull. Soo. de Chirurgie de Lyon, 1904, and Lyon med., 1904, ciii, p. 885) reports a modern case. f I have seen three cases (one operated on) in which this luxation, complicating Colles' fracture, was a complete luxation, forward and inward. LUXATION OF THE ULNA BACKWARD 405 without fracture. Since the foregoing was written, I have met with one such case of backward luxation, reported in 1912.* Of uncomplicated inward luxations, I have some doubt. LUXATION OF THE ULNA BACKWARD Our knowledge of this lesion comes from Desault, who gives the following cases, which seem conclusive. Case of a child of five years, whose arm was overpronated as the child was lifted from a couch by an adult. This case Desault saw, and reduced the bone by direct pressure forward on the ulna, with an attempt at separation between the two bones and with forced supination carried out by an assistant. Immediate reduction was followed by permanent recovery. Desault also records cases of a child of two years with a like condi- tion but without a history, and of a man of forty with a history of an injury by overpronation three months before. Reduction failed in this last case. His other cases strike me as doubtful, f Symptoms.-From the data at hand this luxation seems to be ac- companied by a good deal of disability, including a loss of power in the fingers, which is not altogether easy to understand. The wrist is held in pronation, supination is entirely impossible, and the fingers are usually held extended or semiflexed, with the wrist extended. * Luxation of the Ulna forward at the Wrist (without fracture.) Cotton & Brickley: Ann. of Surgery, March, 1912, p. 369. (See Fig. 678.) f Rognetta (Archive gen. de medecine, 1834, Series II, vol. v, p. 397) describes certain other clinical cases. One was in a man of sixty-eight whose hand was twisted from overpronation, and who showed a displacement of the ulna backward and outward so far that the tip of the ulna was opposite the semilunar bone. Supination was impossible, the fingers useless. Was first seen at two months, reduced according to Desault's method; during reduction supination and the finger motions became possible, but the displacement recurred; further treatment was not carried out on account of outward circumstances. The second case was apparently typical, following an injury of the bone some time previously. In this case also reduction was possible, but recurrence was immediate. Further treatment was not carried out. This case followed an acute rheumatism, and the question is as to whether this was not purely a pathologic dislocation. Rognetta also speaks of a case of a wood-sawyer, a negro, in whom there was marked enlargement of the bones of the forearm and a laxity of liga- ments that permitted ready luxation of the ulna backward, and an equally ready replacement. He regarded this as a matter of loosening of ligaments due to strain, but there is a question if this was not also a pathologic luxation. He records also the case of a washerwoman of thiry-four years of age who had suffered an injury six days previously by overpronation in wringing clothes. This was the result not of overaction of her own muscles, but because another woman with whom she was working twisted more strongly than she. The hand was adducted and flexed, and was held in pronation. There was obvious deformity, as in the other cases. Reduction was accomplished as previously described. There was no recurrence of the displacement, and at the end of two weeks all motions of the wrist and hand were normal. He cites one more case, of two months' duration, successfully reduced, but held only by forced supination and by special padding. This case, after a month of such fixation, is said to have staid reduced, and to have had good motion. 406 THE WRIST The hand is uniformly adducted. There is an obvious prominence of the head of the ulna at the back of the wrist, with not only a displace- ment backward, but a displacement outward as well, so that the head of the bone crosses over to some extent onto the back of the radius. This results in an obvious narrowing of the wrist (Fig. 677). In the old unreduced cases there would seem to be little improve- ment of function, in unbelievable contrast to the perfect function of the " congenital " cases showing like deformity. Diagnosis.-The diagnosis of these cases presents one difficulty, namely, the discrimination between injuries of a congenitally abnormal wrist and the results of the original trauma. As an illustration of this may be cited the following: Miss M., nurse, aged thirty, seen by the writer with Dr. E. H. Nichols February 10, 1907. Recent injury to the left wrist. Clinically, the wrist showed a good deal of disability, and objectively there was a well-marked backward dislocation of the ulna at the wrist. The wrist is said to have been Fig. 678.-Luxation of the ulna forward at the wrist without fracture. Sketches of the wrist before reduction--from the back and from the radial side. Note the narrowness of the wrist and the sharp edge of the radius next the hollow left by the ulna (Cotton and Brickley, Ann. Surgery, March, 1912). Fig. 679.-Backward luxation of ulna alone1 Fresh injury, but also history of old injury (court- esy of Dr. E. H. Nichols). Probably a congenital luxation. abnormal in shape since an injury in childhood. x-Ray plate shows a curve outward of the radius, with an obliquity inward of the lower articular face of the radius, with a subluxation of the wrist inward, with a change in the shape of the carpal bones, and with the ulna a half-inch shorter than on the other arm, with its lower head dislocated backward. There is no semilunar facet on the radius, as seen in the x-ray plate. Reduction under ether proved impossible (Fig. 679). This is a case in point, inasmuch as it is not only very improbable that the recent injury produced any displacement, but also rather improbable that any injury in childhood could have produced these changes-changes which agree entirely with those seen recently by the writer in two other cases known to be nontraumatic and probably CHRONIC BACKWARD LUXATION OF ULNA 407 congenital. See Fig. 602 also Fig. 603 for ulnar luxation from results of old trauma to the epiphyseal line of the radius. Treatment.-Desault* has outlined what is probably the most efficient reduction manceuver. The wrist is grasped by the two hands, one on the outer, one on the inner, side, in such fashion that the two thumbs press at the interval between radius and ulna behind, and the fingers are pressed in the corresponding interval in front. An effort is thus made to separate the radius and ulna laterally, while an assistant forces the hand into supination, f The operator at the same time aids in forcing the ulna forward and the radius back. If the case be recent, reduction is accomplished with a snap, and seems not to tend to recur. In older cases there is a tendency to recur- rence, and fixation in the supinated condition will be necessary for several weeks, with only gradual resumption of pronation. Results.-In recent cases results are re- corded as perfect. The results of the untreated dislocations seem to involve considerable permanent disability, particularly from inabil- ity to supinate. According to Desault, reduction of the old luxation, followed by long fixation, gives good results, including the ability to supinate. There seem to be no other cases than his to show this. Fig. 680.--Desault's reduc- tion of backward luxation of the ulna. The thumbs shove the bones apart. Chronic Backward Luxation of Ulna Chronic backward luxation to a slight extent is apparently not very uncommon as a result of overwork in childhood. The writer has seen Fig. 681.-Luxation of ulna backward, with anterior displacement of radial fracture (radius in black). Fig. 682.-Dislocation of the ulna inward can only come from separation of the ulna from the radius-divergent luxation. several cases, always accompanied by a good deal of hypertrophy of the lower end of the ulna, not always accompanied by the deformity to the radius to which Madelung's name is attached. These cases show disability only in loss of hyperextension and sometimes in slight overtiring at work. Here and there in cases of Colles' fracture with forward displace- ment, or even without very much forward displacement, we may find subluxation of the ulna backward. In two instances, as a result of old Colles'fracture, there are shorten- * Journ. de Chirurgie, vol. i, No. i, p. 78, in an excerpt of an address of his, never published in full. f In our case supination was the really important and efficient factor in reduction. 408 THE WRIST ing of the radius and a luxation of the ulnar head back and down over the carpus so far that extension of the wrist was interfered with. A resection of the head of the ulna was done, with good result. Madelung's Deformity Madelung's deformity is described by him as a distorsion of the radius at its lower end, with ulnar displacement backward, a result of the strain of overwork at a time when the bones are still soft. Fig. 569 gives the character of the deformity. LUXATION OF THE ULNA INWARD In case of this injury also there is some question whether it occurs apart from fracture. The following case may be accepted on the authority of Dupuytren and Rognetta. Woman of twenty-one, washerwoman, who had had a blow on the wrist recently, but had had a deformity of the wrist dating back some years. There was a broadening of five or six lines, and the ulna dis- placed inward, that is, away from the radius, and a little forward. Supination was impossible. There was loss of motion in flexion of the fingers, and the hand was slightly abducted. Reduction temporarily restored the motion of supination, which was again lost when pressure was taken off, and the luxation recurred. The possibility of forward luxations of the ulna, apart from Colles' fracture, is somewhat doubtful. There are two dissections on record, one by Palletta, one by Desault, which show beyond doubt the possibility of the luxation. In one case no mention is made of the search for an old fracture; in the other, its presence is denied, but no details are given. Both were dissecting-room specimens without history. Thon* gives a case that seems beyond question. The patient was a man of fifty; he had hold of a rope by which his hand was pulled over the branch of a tree and into sharp supination. Pronation was lost; he showed a very narrow wrist, with the ulna prominent in front. Reduction was by extension, traction, and pronation, after direct pressure failed. It is in the case with marked displacement of the ulna forward that we are apt to get "compound Colles' fracture," consisting, in fact, of a compound ulnar luxation accompanying the Colles' fracture. The cause given for the isolated ulnar luxation is oversupination; inability to pronate is alleged as a result. In the common cases where the luxation accompanies the fracture there is no trace of such loss of ability to pronate. Diagnosis.-Absence of the prominence of the ulna at the back of the hand and the presence of a rounded thickening, covered by the LUXATION OF THE ULNA FORWARD * Deutsche Zeit. f. Chir., Bd. Ixxxiv, 1906, 257. RECURRENT LUXATION OF THE ULNA 409 soft tissues of the ulnar and other flexors on the front of the wrist, just above the pisiform, are conclusive and sufficient evidence of this luxa- tion. The whole look of the wrist from the ulnar side is entirely changed, as may be seen by Fig. 652. Save in the rare cases where there is entanglement of a broken styloid process in the ligaments, there is no difficulty in reducing this luxation, but the tearing of ligaments is so great that redisplacement to some extent is almost inevitable. Even if the position be long main- tained in splints, there is a marked tendency for the strain of work to produce some recurrence of the displacement. Results.-Where there has been great tearing of ligaments and displacement, some weakness usually remains, most noticeable in motions involving forced pronation. There is no limitation of motion and no disability due to the deformity as such, in the ordinary run of cases. RECURRENT LUXATION OF THE ULNA A number of years ago there came into my care a young girl who had, as a result of trauma, a slipping of the ulna on the radius with Fig. 683.-Diagram of wrist in supination and in pronation. Shows the falling away of radius from ulna in supination in recurrent luxation of the ulna (diagram). Fig. 684.-Recurrent luxation of the ulna. Sketch from arrays. The dotted line shows the original condition, the continuous line the position (corrected by osteotomy) that by tightening the radio-ulnar ligaments prevented the recurrent luxation (courtesy of Dr. Geo. H. Monks). every movement of supination. She was suffering severely from ulnar neuritis, as a result of the constant irritation. Operative treatment was declined; mechanical treatment failed on account of the intoler- ance of the damaged nerve to pressure. In this case there had been a Colles' fracture. Recently I examined, with Dr. G. H. Monks, a case similar in all respects, except for the neuritis. This latter case was practically cured by him by an osteotomy that in effect tightened the radio-ulnar ligaments (for mechanism, see Fig. 684).* I do not know that the lesion has been described in the literature. Evidently there is an abnormal laxity of some or all of the radio-ulnar ligaments. I have seen many cases where there was a little looseness here after Colles' fracture, but ordinarily it is of no consequence as a cause of weakness, and gives no pain. * J. E. Goldthwait had a case and operated on it with at least fair success; I do not think the case was ever reported. 410 THE WRIST Since the above was written, I have seen reason to change my mind a bit. I find on more careful examination that some looseness at this joint is common after Colles' fracture; that the slipping may be painless, but that it is apt to be painful. A serious, crippling range of abnormal mobility, often with ulnar nerve irritation, seems not rare. Within eighteen months I have seen six such cases; all completely disabling. On four I have operated by osteotomy. In all, the result is perfect. My operation, unlike that of Goldthwait and of Monks, is an osteotomy to permit sharp forward (not outward) correction of the wrist, bringing the ulnar facet on the radius, where the ulna lies in contact again, bringing the ulna back, as the radius and hand move forward. CHAPTER XVII INJURIES OF THE CARPUS Anatomy.-No injuries in the body need more accurate knowledge of anatomy for their proper diagnosis than those of the carpus. With- out such knowledge the x-ray is more of a trap than a help. There are in this region various anomalies-in the carpal bones themselves and in the occurrence of inconstant sesamoids. Pfitzner, of Strassburg, has written of these in a monumental work (Beit, z. Kenntniss d. menschl. Extremitatenskeletts, Morpholog. Arbeiten, Fig. 685.-Landmarks of the carpus from the side. The outlines of the scaphoid and magnum and semilunar are seen; their relation is sh own in the small explanatory sketch; note the obliquity of the scaphoid down and forward (shown by the heavy line). The faint outlines of the trapezium (b) and the pisiform (a) have been accentuated. Fig. 686.-x-ray of normal carpus from the front. All the bones are to be made out; the pisiform partly overlaps the cuneiform; trapez- ium and trapezoid overlap, and scaphoid and semilunar partly cover the head of the os magnum. Schwalbe, 1895, vol., iv and in Zeit. f. morph. Arbeiten, Schwalbe, 1900, vol. ii, p. 365). Dr. T. Dwight's "Variations of the Bones of the Hand and Foot," Lippincott, 1907, covers much of the ground and is more accessible. LUXATIONS OF CARPUS We have: A. Dislocation of one row on the other, with or without scaphoid fracture. B. Luxation of single bones, with or without fracture. Dislocation of the Distal on the Proximal Row This may result from severe falls on the hand in extension (rarely in flexion) or from direct violence. Frequently the injury is associated with fracture of the scaphoid; in a very few cases it is compound. 411 412 The displacement seems pretty uniformly to be backward displace- ment of the distal on the proximal row.* In the compound cases such INJURIES OF THE CARPUS Fig. 687.-'Landmarks of carpus: 1, Ulnar head; 2, ulnar styloid; 3, radial styloid; 4, position of os magnum-a deep hollow; 5, bases of second and third metacarpals; 6, lower edge of cuneiform. injury, especially if associated with fracture, should commonly be easy to make out, and the bones may readily be replaced. In such cases as are not open to direct inspection the injury is marked by swelling. Fig. 688.-Fracture of scaphoid only (same case as Fig. 689, right hand). Fig. 689.-Left hand of same patient. Frac- ture of scaphoid, with dislocation of the distal row of carpal bones backward: 1, Scaphoid, prox- imal fragment; 2, scaphoid, distal fragment; 3, semilunar; 4, os magnum; 5, cuneiform; 6, unci- form; 7, pisiform. z-rays of these carpal injuries are often very confusing, even with the best a;-rays. The author has had no experience with these cases just at the time of accident, nor are there recorded data of such cases in the literature. DISLOCATION OF THE DISTAL ON THE PROXIMAL ROW 413 In only one case was there any question of reduction of a fresh luxation. This case was seen after a week. There was obvious, though not great, displacement of the hand backward. There was thickening and tenderness, especially about the scaphoid. The pro- jection of the lower row of carpal bones at the back could be felt, though not very clearly. There was loss of motion, particularly of extension and abduction. The diagnosis was made and confirmed by the skia- graph. (Fig. 705.) Under ether, strong traction, direct pressure, and rocking motions brought about a reduction, with restoration of nor- mal motion. The final result was admirable, with practically per- fect function, though the fractured scaphoid is presumably only united by fibrous tissue. There was no tend- ency to recurrence. Fig. 690.-Dislocation of distal row of carpus backward. Fracture of scaphoid with great displacement: (a) Proximal fragment; (&) distal fragment. There is also a partial separation of the ulnar styloid. Fig. 691.-Same case from the side: (a) Distal fragment of scaphoid; (a') distal frag- ment; (&) semilunar. This case was treated by excision of half the scaphoid (proximal half), of the semilunar, of the head of the magnum, and about half of the cuneiform. He recovered with a wrist fully useful for work, and not pain- ful, though with some loss of motion. All the cases seen at a later stage had been overlooked or misinter- preted at the time of the injury, though most of them had been seen by competent surgeons. The difficulty here is obviously one of diagnosis. The deformity to sight or touch is far less than would be expected. What may be seen is obvious from the illustrations here given. What may be felt is a projection on the back of the hand, not very obvious, and a thickening of the wrist. There is loss of extension and of abduction and tenderness to touch, but, with all our aids, diagnosis is not always easy. * In a measure this displacement is rotatory in that the displacement of the cuneiform seems usually incomplete. Codman (Ann. Surg., June, 1905) has described the fracture luxation cases as scaphoid fracture "with dislocation of the semilunar forward." So also Destot (Bull, med., 1905, xix, 1033) and J. A. Blake (Ann. Surg., 1901, xxxiv, 297). 414 INJURIES OF THE CARPUS Figs. 692-695.-Another case with the same lesions as the last--fracture of the scaphoid with dislocation of one carpal row backward on the other. The photographs in various views show the astonishingly small deformity produced by this serious lesion, and suggest an explanation of the fact that it is usually overlooked or treated as Colles' fracture (as this case was at first). The photo- graphs were taken when he came to me nearly a year after the injury. The wrist was painful and almost without motion. Fig. 696.-x-ray of case shown in pre- ceding photographs. The small drawing is an explanation of the confusing skiagraph. 1 and 2 are the fragments of the scaphoid; note the overlapping of one row of bones over the other. Fig. 697.-Same case, seen from the side: 1, Proximal fragment of scaphoid; 2, distal fragment of scaphoid; 3, os magnum; 4, semi- lunar. This wrist was operated on precisely as in the case shown in Figs. 690 and 691. Re- sult, perfect use and strength. Slight limita- tion of extension. DISLOCATION OF THE DISTAL ON THE PROXIMAL ROW 415 Fig. 698.-Luxation of the distal row of carpal bones backward with scaphoid fracture. Fig. 699.-Same: from the side. 416 INJURIES OF THE CARPUS Given the diagnosis, there should be no difficulty in reduction of a fresh case by traction with alternate flexion and extension, combined with direct pressure on the projecting row of bones, as in the case cited. Fig. 700.-Similar luxation and fracture. Fig. 701.-Same lesions as in last two cases (including in this case a fracture of the ulnar styloid). This cut shows well the difficulty of diagnosis. From this plate alone I doubt if any one would make the diagnosis of more than fracture of the scaphoid and of the ulnar styloid. The next plate, giving the side view, makes the matter clear. Fig. 702.-Lateral a>ray of same case: 1, Ulnar styloid; 2, proximal fragment of sca- phoid; 3, cuneiform; 4, distal scaphoid frag- ment; 5, semilunar; 6, os magnum. (See Fig. 705.) The restoration of motion to normal range, especially in extension, is the test of reduction and is conclusive. Even where there is some doubt of detailed diagnosis-and I believe no man can be quite sure of these cases by manipulation alone-the DISLOCATION OF THE DISTAL ON THE PROXIMAL ROW 417 reduction should be carried out in this way, to be confirmed by the x-ray.* The manceuvers given are efficient for all the various luxations in Fig. 703.-Same case (diagram). Upper left hand, drawing of normal scaphoid. The outline gives the displacements, but (drawn from the operation, not from the x-ray) gives the relations reversed, right and left. Fig. 704.-Fragments removed in above case (c/. Figs. 701, 702, 703) in excision. In this case the head of the os magnum was not removed. A good joint resulted, useful, with fair motion. this region; the coexistence of carpal fracture is no contraindication to such reduction. As a rule, there is associated scaphoid fracture. Where weeks have elapsed since the injury we may make the diag- nosis without the re-ray or with it, but any question of simple reduction is fool- ish. Injuries in this region show a very prompt formation of scar tissue. In these late cases we must inter- vene, but only with open incision. In my cases of the sort I have done excision (of the proximal row of the car- pus, at least, including the proximal fragment of the scaphoid), and have usually attained (in 8-10 cases) the tardyf but very satisfactory result to be expected in radical wrist excisions- a practically perfect hand for work. As to prognosis without operation, I can only say that I have seen no case that justified any expectation of a useful hand without surgical interference. In one case operated, for example, there were almost total loss of wrist motion and great pain on flexion of the fingers, apparently from the slipping past of one bone row on the other. The hand was useless for any work, Fig. 705.-Diagram of position (in a case in which the x-ray showed the same lesion as in the preceding three cases) before and after reduction. This was a fresh case. Reduction complete; recovery perfect. * A glance at the illustrations will show how easy it may be, even with the x- ray, to overlook this lesion unless we have x-rays also in lateral view. f Recovery of function in wrist excisions is slow because at least a couple of months are required before the muscles shorten enough to act efficiently on the shortened fulcrum of bone. This fact has usually been overlooked and the opera- tion of wrist excision (whether for traumatic or pathologic lesions) has not been given its due credit for restoration of use, because the cases have been reported too early. Save for extension the motions come back, and extension is often very fair. 418 INJURIES OF THE CARPUS though this patient was a gigantic Swede of huge muscles and no nerv- ous system.* Luxations Of Single Bones These may involve any bone and may be forward or back. Com- monest is luxation of the semilunar forwardf to a point where it forms an obvious protuberance and gravely inter- feres with the action of the flexor tendons. I have operated on many such cases with admirable results. Where the luxation is complete-where both ends of the bone have left their nor- mal relation-there is little left to do save excision, though I see no reason against all possible attempts to reduce. Necrosis of a dislocated bone in carpus (or tarsus) seems, in fact, to be a rare result,t much as it might be expected theoretically. Dislocations of nearly every carpal bone singly are on record. The diagnosis is essentially that of dis- placement of some bone out of its place. Which bone it is, is a matter of rough infer- ence only. Reduction can be attempted by traction on the hand with various rocking motions and pressure on the fragment we wish to push in place. The chance is small. Partial luxation of single bones of the car- pus is not very rare. In these subluxations the os magnum is apt to be the bone involved. Sometimes it is the semilunar, or others. The following cases may be cited from my records. The reason for such citation is that these lesions seem little understood. Case.-B., aged twenty-four. Large ath- letic young man, woke up one morning unable to extend his right wrist. Other motions nor- mal and painless. In the afternoon he was seen and examined and showed no swelling, no tenderness, but absolute bony locking that prevented extension of the wrist much beyond the straight line. Examination with the fluoroscope showed definite change of relation of the os magnum, with backward displacement of its proxi- Fig. 706.-Isolated luxation of semilunar (and a chip of the scaphoid, proximal end) forward. Sketch made before operation. Arrow shows the lump (courtesy of Dr. H. A. Lothrop). Fig. 707.--Backward dis- location of the semilunar bone, of unknown origin (perhaps con- genital) in a boy. Disability mainly from loss of extension. Semilunar excised by Dr. Bur- rell, with good result (courtesy of Dr. H. L. Burrell). *This case was operated on by excision. Today he has an unbearably power- ful grip, free wrist motion, and a perfectly useful hand, though hyperextension is less than normal. t Such semilunar luxation may be complicated with a split of the scaphoid (see Fig. 708) and also the skiagraph of Bolton's early case (which I should interpret in this way), published in Ann. Surg., 1901, xxxiv, p. 291. J In fact 1 know of no case in which it has occurred! LUXATIONS OF SINGLE BONES 419 mal end. With this information I proceeded to reduce by traction, direct pressure, and extension of the wrist. The bone slipped back only after much force had been used, but motions all became norma] and painless, and the patient resumed use of the hand without any trouble ensuing. This case seems to have been a displacement due to some muscular action during sleep, probably acting through overflexion. Case.-D., girl of twenty. As a result of an accident nearly a year ago has been unable to extend the wrist fully or to abduct it without Fig. 708.-Bones removed by operation in Dr. Lothrop's case. Semilunar and fragment of sca- phoid seen from below. Drawn (by courtesy of Dr. Lothrop) from his specimen. Fig. 709.-Dislocation of semilunar forward (also some damage to radius). Drawn from the plaster cast (Warren Museum, specimen 9566). pain. Since two weeks after the injury there is said to have been nothing abnormal to be seen about the wrist. Flexion and abduction normal. Skiagraph shows no fracture, but apparent partial displace- ment of the os magnum forward. Treatment refused. Case lost sight of. Case.-C., woman of twenty-seven years of age. Athletic young woman; injured the wrist by shoving against a swimming raft. Had disability for a few days; since then has had occasional periods of disability, lasting a few days only, during which she was unable to extend the hand and had some pain. During one of these periods she presented herself to me. Ob- jectively, there was nothing ex- cepting limitation, somewhat painful, of extension abduction of the hand, apparently centered at the os magnum. A skiagraph was taken to exclude possible fractured scaphoid. The day this was taken the limitation of motion suddenly disappeared, as it had on previous occasions, as suddenly as it came, and the wrist when next seen was entirely normal except for some general laxity of ligaments. Support and exercises advised and carried out; no recurrence in two years. This case seems to have been of the same type as the two preceding. Case.-G., woman of forty. Fell and had, as a consequence of trying to save herself, a partial backward dislocation of the proximal Fig. 710.-Range of motion between semilunar and magnum in flexion and extension. 420 INJURIES OF THE CARPUS end of the magnum. Reduced by traction and pressure and rocking from side to side. Perfect restoration of function. Case.-X., seen with Dr. J. B. Blake. Young professional pugilist. In a recent fight he hurt his wrist, and on resumption of training he found there was something wrong, about which he sought advice. Wrist on inspection seemed entirely normal, but when he clenched his hand there was a motion, easily felt, of the semilunar bone of the right hand forward. The range of motion was not over % to inch, but occurred each time that the fist was clenched, and was accompanied with a soft click. There was considerable professional disability. For ordinary use the wrist was normal. Case.-Girl of about twenty. In the course of scrubbing she slipped and in some way hurt her hand by striking it against the floor. Comes in on account of pain. Examination shows tenderness about the right pisiform bone and very marked mobility of this bone with a click upon motion. The bone of the opposite side more movable than usual, but distinctly less so than on the injured right side. Any motion calling the ulnar flexor into action is painful. Curiously enough, this injury, which was diagnosed as a partial luxation of the pisi- form, was accompanied by pain and some anesthetic disturbance in the ulnar nerve, evidently pressed on by the bone at the time of its first displacement. Several weeks of fixation failed to improve the symptoms in this case very much. She was then lost sight of. Fig. 711.--Subluxation of os magnum forward. Result of trauma, reduced by man- ipulation. Fig. 712.-Form of reduction successfully applied in two cases in which the x-ray showed a luxation or a subluxation backward of the os magnum on the semilunar. One case of upward luxation of the trapezium has come to my notice (see Fig. 713), but this was merely a complication of dislocation between proximal and distal rows of the carpus. These cases illustrate, what is not very infrequent, a partial displace- ment of one or another carpal bone, which may or may not be perma- nent or become habitual. It will readily be seen that, as these bones receive practically no muscular insertions, any displacement, however 421 FRACTURE WITH CARPAL DISLOCATIONS slight, that involved a folding-in of the capsule, might not tend to spontaneous reduction, and any such displacement accompanied by loosening or tearing of ligaments would tend to recur. The matter of diagnosis comes down to a question of exclusion of fracture or general ligamentous strain, and a localization of the trouble at one or the other Fig. 713.-Luxation of trapezium from scaphoid, up and outward. Partial luxation of one carpal row on the other, also. Considerable deformity. Not reduced because of other more serious injuries and poor condition of patient. point in the carpus. Except in case of backward dislocation of the magnum or forward dislocation of the semilunar, which may be helped by traction and direct pressure, the writer is at a loss in regard to special manipulations. Fracture with Carpal Dislocations Such injuries as give fractures of the carpus by direct violence are apt also to give separation of fragments or total disruption of the carpus. These injuries are sometimes compound, and if so, are to be treated by excision of the broken or isolated bones. There is only one form of fracture which seems particularly likely to be associated with dislocation, viz., the fracture of the scaphoid, which, in part, belongs to the distal and in part to the proximal row. In five cases that the writer has met with, and in two others of which he has personal knowledge, this combination was found. Symptoms and Treatment.-It would seem that an injury of such gravity and extent should be easy to diagnose. As a matter of fact, all the dislocations in the carpus, as with the tarsus, seem curiously deceptive, and, as will be seen from the case histories above appended, the only significant symptoms seem to be a little thickening of the wrist, some lameness and loss of motion, particularly in extension. Even the x-ray is not necessarily conclusive, and the appearances in 422 INJURIES OF THE CARPUS the front view-the one usually relied on-are so nearly natural that any one save an expert would probably pass them as normal unless for the scaphoid fracture. The moral is that we should always take two views in doubtful wrist injuries. No doubt if the diagnosis were made, reduction of the dislocation and replacement of the scaphoid fracture would be easy, though apparently it has not been done, save in the author's case above noted. In one other of the cases noted there was little difficulty in reducing the bones after cutting down on them, though it seemed unwise to trust the permanency of this reduction.* The manipula- tion for reduction is, as in dislocation of the os magnum alone, flexion to clear the way, then traction with pressure on the fragment and extension of the joint. In the late cases there is nothing to do but let them alone, or to operate as was done in the author's cases. FRACTURES OF THE CARPUS Until recently the statement has been accepted pretty generally that fractures of the carpus are almost always results of direct crushing violence. The possibility of fractures of the scaphoid in particular, produced by falls on the hand, was recognized nearly a century ago, but it is only recently, particularly since the study of x-rays, that we have come to realize that these fractures are not rare, relatively speaking; that they may cause considerable disability, and that this disability is entirely remedi- able under proper handling. In discussing these fractures it will be well to speak first of- Fig. 714.-Point of tenderness on pres- sure, and, in cases with displacement of thickening, in scaphoid fracture. These occur from falls on the hand or from like forms of violence of the sort that more usually give a Colles fracture.f The lesion is a Fractures of the Carpal Scaphoid * Excision was done. I now think this was bad surgery! f Wolff, of Sonnenburg's clinic, in an admirable article (Monatsschrift f. Unfallheilkunde, 1905, xii, S. 363-394), credits Immelmann with the demonstration of the possibility (which he accepts) of scaphoid fracture from simple forced supination. He gives two cases where this seemed to be the mechanism. He also gives cases of his own, and cites others of Blau's, of alleged impacted scaphoid fracture, but his data as to these cases seem hardly convincing. FRACTURES OF THE CARPAL SCAPHOID 423 break across the scaphoid at its "neck" (see Fig. 715), where it is comparatively narrow, and where it is subject to a critical cross-strain in any fall where there is pronation of the hand. Apparently, there is no considerable displacement in the majority of these cases immedi- ately following the accident. The clinical picture is one of a "sprained wrist," showing tenderness to all motions, but particularly to extension and radial flexion, and a tenderness to pressure more or less localized over the scaphoid, front and back- tenderness especially marked in the "anatomic snuff-box" when the hand is in (ulnar) adduction. Fig. 715.-Right wrist from the side. Note how the obliquity of the scaphoid down and forward and the relatively thin "neck" expose it to fracture in falls. Fig. 716.-Proximal frag- ment of broken scaphoid. X is the articular surface for the radius. Y is that for the head of the os magnum (Warren Museum, specimen 1178). Fig. 717.-Sketches of broken scaphoid from various z-rays (seen from the front). These sketches illustrate the varying amount of displace- ment. At this time no more than an inferential diagnosis may usually be made, and a considerable number of "sprains" presenting these symptoms in mild degree, at least, may well be fractures of the scaphoid. In these fresh cases the z-ray is often essential to diagnosis.* In the later Fig. 718.-x-rays of a case of double scaphoid fracture, cases, however, the picture becomes more typical if the trouble is serious, that is, if there is displacement of fragments, whether this displacement is primary or, as seems usual, only a displacement following on at- * Roughly, one-third to one-half of the fresh cases of injury in which I have found enough of these signs to be suspicious have shown no fracture in the x-ray, and have recovered promptly. 424 INJURIES OF THE CARPUS tempted use. With such displacement there is a thickening of the wrist antero-posteriorly opposite the scaphoid, some tenderness, and a limitation of motion in the direction of radial extension and radial abduction, while ulnar flexion, ulnar extension, and straight flexion are entirely unimpeded. Fig. 719.-A cracked scaphoid without displacement. Result of fall on the hand. Long- continued tenderness over scaphoid and impaired usefulness. x-ray (taken three weeks after injury) shows the line of break with a slight gap. (x-ray plate by Dr. Arial W. George.) Fig. 720.-Fracture of scaphoid on the left; line of fracture unusually high; displacement almost none. Right side shows normal carpus. This combination of symptoms, persisting long after an injury, definitely means some damage to the carpus; usually it means scaphoid fracture.* * Dr. T. Dwight, the anatomist, has dwelt much (most lately in his "Variations of the Bones of the Hand and Foot," Lippincott, 1907) on the probability of error between separate ossification centers and fracture. Obviously, there is something in this, but in cases showing clinical signs of fresh damage, and in those furnishing specimens and skiagraphs like those of Figs. 708 and 716, there can be no question that the lesion is traumatic. FRACTURES OF THE CARPAL SCAPHOID 425 The limitation of motion is due to a displacement of the fragment, as shown in the sketch (Fig. 717), rarely to the interference of a third fragment. Fig. 721.-Fracture of the scaphoid, considerable displacement. Good functional result without operation. (Case seen too late for closed reduction.) There are certain other cases of undoubted fracture of the scaphoid where the function becomes practically normal, and where there is never any dislocation, never any definite thickening, and no consequences unless, as the writer has thrice seen, there has been a fresh strain from a second fall, which gives more prolonged lameness than would happen Fig. 722.-Fracture of scaphoid several months after injury. Some deformity, severe disability. Not operated on because of alcoholism-usually an opera- ble type of case. Fig. 723.-Fracture of scaphoid (lateral view). Little displacement. Disability was only moderate. 426 INJURIES OF THE CARPUS with normal bones, with tenderness localized about the scaphoid. So far as we know, these scaphoid fractures never unite save by fibrous tissue, but such union may be very serviceable. If such serviceable union is present or promised, we have no call to interfere. In other cases, however, there is displacement (primary or late), loss of motion, and much lameness. Fig. 724.-Fracture of scaphoid with displacement. Fig. 725.-Fracture of scaphoid with displacement. Grave disability. Opera- tion (late) with removal of proximal frag- ment. Recovery with perfect motion and function. Fig. 726.--Scaphoid fracture with displace- ment in a man of fifty. Removal of projecting distal fragment. Fair result. (In this case there was subluxation of row on row, which was not treated.) Displacement is not strictly constant in range or direction; motion in abduction and extension are usually most interfered with. Treatment is by partial excision. The good results obtainable are dependent on successful removal of one of two mutually impeding and irritating fragments. The one usually removed is the proximal, because it is easiest to get. Once I removed a third fragment in between, as well as the proximal part. FRACTURE OF OTHER CARPAL BONES 427 There is no trouble from the loss of the bone. In the writer's cases (only five in all) in which such excisions have been done for fractured scaphoid uncomplicated, the results have been practically perfect, save in one case (immobilized too long in the out-patient department), in which there was some finger stiffness. Fracture of Scaphoid with Total Semilunar Luxation* The writer has seen but one case (Fig. 708), seen in the service of Dr. H. A. Lothrop. The semilunar bone was luxated forward. It was Fig. 727.-x-ray of normal hand. excised, and only at the operation was it recognized that the proximal part of the scaphoid had followed the semilunar in its forward displace- ment. The result of the operation was excellent. Fracture of Other Carpal Bones No bone of the carpus is exempt from the chance of fracture, but save for those noted, there are no types of fracture. * See also under Luxation of the One Row on the Other as to the type of rotary luxation of the semilunar with broken scaphoid-an entirely different matter. 428 INJURIES OF THE CARPUS Diagnosis of the atypical fractures is hardly practicable, save with the aid of the skiagraph. We have no rules for treatment as yet. ANATOMY OF THE EPIPHYSES OF THE HAND In injuries of the metacarpus and carpus the epiphyses play little part. Fig. 727 shows where they lie. Rarely, they may be displaced. More often, a knowledge of the normal epiphyses, like acquaintance with the sesamoids, is of service in avoiding the diagnosis of fracture here none is present. CHAPTER XVIII METACARPAL INJURIES LUXATIONS OF THE METACARPALS Luxations of the metacarpals are very rare except in case of the first. The luxation backward of the thumb metacarpal is a special accident caused by special violence. Corresponding dislocation of the other four is not produced in the same way, although similar violence some- times leads to partial luxation. Where the metacarpals of the fingers Fig. 728.--Mechanism of luxation of the base of the first metacarpal outward. How to hit the "Sullivan blow." The wrist is turned so that the knuckles meet a resistance coming in the line of the arrow. Fig. 729.-The way a "drunk" carries it out. The turning of the hand is incomplete or too long delayed, and the resistance is met by the distal end of the first metacarpal. are displaced backward, there is often a fracture of the base of the bone, owing to the direction in which the force is necessarily received. This is the common lesion, or the least uncommon. It appears as a dislocation backward by simple tearing of the posterior capsule of the joint. Owing to the comparatively flat surface of this joint, there is nothing except this capsule to hold the bone in place, and the disloca- tion is very apt to be one that reduces itself and reproduces itself according as the thumb is extended or flexed, according to the me- chanism presently to be explained. All these cases seen by the writer, now numbering certainly over a dozen, have been due to one cause- namely, the striking of a blow in such fashion as to "land" with the thumb knuckle on the other man's head. This is a technical error in the delivery of the so-called "round-arm blow" an error by which the wrist is not pronated and extended quickly enough, so that the knuckle Dislocation of the Thumb Metacarpal Backward 429 430 METACARPAL INJURIES shall be m front when the blow lands. It is, accordingly, an accident rarely occurring to the skilled boxer, and unlikely to occur to any man whose nerve processes have not been somewhat slowed up by drinking. This is why this injury is so constantly the result of a drunken fracas. The mechanism of production seems to be a tear- ing across of the capsule by a lifting outward and backward of the metacarpal base. The blow is struck on the opposite end of the metacarpal, and an efficient fulcrum for the lift is furnished by the flexed fingers and the contracted muscles of the thumb, which form a hard mass in the clenched fist. (See Fig. 730.) The accident involves relatively little tissue dam- age, and is not immediately painful to any great extent. The hand can be used, but on the following day the man notices that the thumb is weak, or that there is a slipping at this joint. When the fist is clenched, the action of the flexor tendons acts to reproduce the same leverage over the same fulcrum as before, and the base of the bone is slipped out. There is no difficulty whatever about putting it back accurately in position. There is, however, a great deal of diffi- culty in keeping it there. Treatment.-Extension of the thumb and direct pressure over the metacarpal base are to be secured. This may best be done by a tin splint with a ridged back, as shown in the cut (Fig. 731). With the hand firmly strapped to this splint, a pretty accurate retention of posi- tion is possible. In this position contraction of the flexor muscles has little tendency to reproduce the dis- location. Fixation must be con- tinued for a considerable time, certainly over three weeks, for the repair of this joint calls for a very strong new capsule, as this newly formed capsule is to be the only support of the joint.* Results.-With adequate protection and fixation there seems no reason why good results should not be secured. As a matter of fact, however, the writer has not been able in any case treated to secure Fig. 730. - The force acts on the "thumb-knuckle" (up- per arrow) and drives it inward. The mass of contracted muscle x, held firm by the clenched fingers, acts as a fulcrum, and the base of the metacarpal is pried outward (lower arrow). Fig. 731.-"Gutter splint" of tin. Lower cut shows the pattern. For details of making compare Fig. 379. * I know of no cases of operation for this condition, but have in the past seen cases of results so poor that operation for fixation would be, under modern condi- tions, the desirable course. Since this was written have operated on one case with very satisfactory results. DISLOCATION OF THUMB AT METACARPOPHALANGEAL JOINT 431 really satisfactory results, mainly because the patients insisted on early use of the hand. There has been always some weakness, and in several cases slight slipping of the joint upon vigorous use of the hand, which did not disappear with time. We have here the same condition, so far as the condition of the joint is concerned, that obtains in acromioclav- icular dislocation, in which, also, the resulting repair is often insufhcient to withstand heavy work. In the thumb injury, moreover, we have to deal usually with the sort of man who is not likely to pay very much attention to after-treatment. As to the results of this injury where there has been no attempt at treatment, the writer has seen but one case. Here the injury, received many years before, had apparently been a pure dislocation and had resulted in very considerable deformity, with some loss of extension due to the position of the bone, but with the thumb functionally about as good as has resulted in any of the cases treated. Other Luxations of the Metacarpal Bases Luxation of any one of the metacarpal bones may occur as a result of direct or indirect violence.* Such luxations are reduced by traction Fig. 732.-Luxation of fifth metacarpal inward and backward. Result of striking a blow. Readily reduced by traction and pressure (sketched from a case of the writer's). on the Anger corresponding and direct pressure applied to shove the bone back into place. There is no especial condition making for re- displacement, as in the last variety of injury, and the results are good, as they are with most other dislocations of the bones of the hand. Treatment after reduction consists of the application of a straight rest splint and gradual resumption of use after two or three weeks. Dislocations of the Knuckles (Phalangeo-Metacarpal) Here again we must distinguish between the thumb and the Angel's. For here again there is a special mechanism governing, in this case, not the dislocation, but the replacement after dislocation. Dislocation of the Thumb at the Metacarpophalangeal Joint This is one of the classic injuries, not, however, a common injury, and not always showing its classic features. The type dislocation is of the phalanx backward on the metacarpal, a dislocation produced by * The injury shown in Fig. 732 was the result of striking with this hand; the bone held, but was driven out of its joint at the base. 432 METACARPAL INJURIES hyperextension of the thumb. There is a tearing of the anterior part of the capsule and a displacement of the phalanx upward and backward behind the rounded head of the metacarpal. The displacement is divided, according to the classic writers, into two types, a first and a second degree. The first degree is that in which the phalanx remains Fig. 733.-Dislocation of the thumb back- ward. "First degree" (diagram). Fig. 734.-Thumb luxation, "second de- gree." The thumb has been straightened with- out reduction. Phalanx and metacarpal lie nearly parallel, but overlapping. hyperextended (Fig. 733); the second, that in which efforts of reduction have brought the phalanx down parallel to the metacarpal bone, without reducing the dislocation (Fig. 734). The obstacle to reduc- tion, particularly in the second type, is an interposition of the torn portion of the anterior capsule between the two bones. Every text- book also outlines the way in which the head of the metacarpal is caught between the tendon of the long flexor tendon and one head of the flexor brevis (Fig. 735). There is no doubt that this has occurred, but the writer is inclined to be skeptical about it as a routine feature of this dislocation, and is inclined to think the diffi- culty of reduction somewhat overestimated. The presence of the torn capsule is, however, commonly present, and is the reason for the special form of reduction generally agreed upon. Reduction.-The manipulations are as fol- lows : Hyperextension of the thumb, whether it be found in the so-called first or in the second position; hyperextension sufficient to relieve pressure on the front edge of the end of the phalanx. With the thumb still hyperextended the thumb is shoved, not pulled, down toward its normal position at the metacarpal head. With this motion is combined a rocking and rotating motion, tending to help in keeping the capsule ahead of the bone. The phalanx slips in place suddenly, and shows no definite tendency to become displaced again. The writer has seen no cases in Fig. 735.-The metacarpal head may become "buttonhol- ed" between tendons: 1, Met- acarpal head; 2, short flexor, inner head; 3, abductor pollicis; 4, short flexor, outer head; 2', 5, and 5, tendon of long flexor. DISLOCATION OF THUMB AT METACARPOPHALANGEAL JOINT 433 which this manceuver, a few times repeated, did not succeed. In case it does not succeed, however, the probability would be in favor of the supposition that the metacarpal head was really buttonholed between Fig. 736.-Extend thumb (reducing second to first degree); then carry thumb down the metacarpal, base first, so to speak, until it slips over the metacarpal head. Fig. 737.-Dislocation of thumb phalanx inward and forward under the metacarpal head. Old lesion in this case, successfully reduced by open operation. the flexor tendons. If this is the case, there is no recourse but open operation, and the reduction by means of enlargement of the button- hole so formed and by direct manipulation under the eye. 434 METACARPAL INJURIES The after-treatment of this dislocation is not different from that of most, and the only comment to be made is that a good deal of joint thickening results, with a limitation of motion persisting for a long time-sometimes permanent, so far as hyperextension is concerned. Other Dislocations of this Joint These belong to the rarities, and are apt to be only subluxations, most often lateral, due to ruptures of ligament, and requiring no espe- cial form of reduction or treatment. The writer has, however, seen two cases of luxation forward. (See Fig. 737.) Both were cases of many weeks' duration. In both the disability was great, consisting of inability to extend the joint, and in one case of loss of strength, entirely preventing work: this man was a bench machinist. Both cases were reduced by open incision, with a good result in the latter, a perfect result in the former case.* Fracture of the First Metacarpal METACARPAL FRACTURE Fractures of the thumb metacarpal at the distal end or through the shaft are uncommon. They are apt to be the result of direct trauma. Fig. 73S.-Fracture of first metacarpal, distal end. The bone is so isolated that diagnosis is rarely difficult. If there is doubt, measurement of shortening, carried out not with the tape, but as shown in Fig. 740, is of service. Fractures of the metacarpal bone of the thumb cannot well be treated on the straight splint. Either the gutter splint made of tin or the Goldthwait splint are more serviceable. These must be made for each case, and the method of making and fitting them is shown in the accompanying sketches (Figs. 731 and 739). Fracture of the Base of the Metacarpal of the Thumb Two forms of fracture of this special metacarpal are to be considered separately. The first is a true impacted fracture of the shaft of the first metacarpal into its own base. It is produced by a force acting in * One case was one of tabes, in which ataxic muscle action had aggravated the result of the original trauma, and interfered greatly with repair after reduction. FRACTURE OF THE BASE OF THE METACARPAL OF THE THUMB 435 the line of the long axis of the bone. The diagnosis rests on shortening of the thumb, on thickening about its base, on localized tenderness. This shortening is most important.* There is nothing to be done or, nothing that should be done, to reduce this fracture. It is impacted, Fig. 739.-Goldthwait's thumb splint. The lower sketch shows the pattern to be cut out of light tin; the folding and bending neces- sary will be understood from the upper sketch. Fig. 740.-Relation of tips of thumb to first interphalangeal skin-fold of first finger. Much better measure of.any shortening of the thumb than we can get with a tape. and should be allowed to remain impacted. Function is restored very satisfactorily after reasonable rest and fixation, and the deformity is limited to thickening and to a shortening which, while distinct, is not conspicuous or important. Traction in abduction, in a "banjo" splint, works still better, as Dr. Henry Marble has shown, in this or the following type. Fig. 741.-Bennett's "stave" fracture, old case, with not inconsiderable disability * Shortening of the thumb may best be measured by determining the relation of the end of the adducted thumb to the finger knuckle of the forefinger (Fig. 740). In the uninjured hand the tip of the thumb comes just about to the middle wrinkle overlying this joint. 436 METACARPAL INJURIES The other form of fracture to be considered is the fracture produced by similar violence, which runs upward and backward through the base of the bone.* This displacement is upward and backward, and the fracture is not uniformly impacted. In appearance it almost exactly resembles the dislocation of the joint, but is either not so freely movable as is the dislocation or, if movable, is mov- able with crepitus. It is to be treated by obtaining the best possible position and apply- ing either the gutter splint, with fixation by traction straps, with or without rub- Fig. 742.-Old impacted fracture of first meta- carpal near base. Fig. 743.-Bennett's fracture, the "stave of the thumb," a splitting off of part of the base of the bone, with displacement of the shaft up and back (author's case). ber strips, or the Goldthwait splint, with a firm pad over the head of the bone. Some thickening and some backward prominence remain after consolidation, but function is not interfered with. Functional results are far better than with the luxation. The metacarpal bones may be fractured at any point in their length. Fractures of the shaft are, however, almost entirely confined to the result of direct violence, while fractures of the bases and heads of the bones are often produced by blows received on the knuckles Fractures of the other Metacarpal Bones * This is Bennett's "stave of the thumb." Bennett, Brit. Med. Jour., 1885, ii, 200; Ibid., 1886, ii, p. 13; Dublin Jour. Med. Sci., 1882, Ixxiii, p. 72. Russ, Jour. Amer. Med. Assoc., June 16, 1906, p. 1824; and Robinson, Boston Med. and Surg. Jour., 1908, p. 275-have published more recent series of such cases. KNUCKLE FRACTURE 437 acting more or less accurately in the direction of the long axis of the bones. The commonest fracture is that of the head of the metacarpal just behind the knuckle. This fracture does not ordinarily involve the articular surface of the bone, but consists of a break, usually oblique, most often oblique Knuckle Fracture Fig. 744.-Test for tenderness, mobility, and crepitus by pressure in the axis of the suspected metacarpal. upward and forward, close behind the expanded head of the bone. There is, as a rule, more or less entanglement of the fractured surfaces; that is, apparent impaction; real impaction is not the rule. Symptoms.-There is swell- ing of the hand, pain, and some disability. The diagnostic symp- toms are as follows: Shortening of the bone. Dropping of the knuckle. Pain on pressure in the long axis of the bone. Limitation of active flexion. Crepitus. If there is any considerable swelling, these points are not easy to make out. Shortening of the bone is made out not by measurement, but by inspection of the knuckles with the fist closed. The last three knuckles are in this position in a straight line in nearly all hands. The relation of the first knuckle to the others is pretty constant, and should be the same in both hands. If this inspection is car- ried out in this way, there is really no difficulty in ascertaining the shortening. (Compare Figs. 746 and 749.) Fig. 745.-The normal fist, clenched. The stars show the normal relations of knuckles seen from behind; the last three are in a straight line. Seen "end on," the knuckles and "finger knuckles " show nearly straight lines; the finger knuckles, save that of the forefinger, lie flat on the table. 438 METACARPAL INJURIES The dropping of the knuckle is to be sought for in another view of the clenched hand, as shown in the lower sketch in Fig. 745. If present, it is usually obvi- ous when looked for in this view. If there is any ques- tion, it may be settled by the line of the finger knuckle, Fig. 746.--"Dropped knuckle." In this view, also, the broken knuckle is dropped down. If there is swelling the changed relation of the finger knuckle to its fellows tells the story just as clearly. Fig. 747.-In question of fractures anywhere in the hand note carefully the relations of length of thumb and fingers. The skin-folds on the back of the fingers are constant and while their relation, like the relative length of the fingers, does vary a bit-yet the variation is con- stant right and left alike. Therefore for example the tip of the thumb should fall just short of the fold of the finger knuckle of the index. If this is so on the right but not on left we have something broken or luxated. which necessarily is also altered if the dropping is present (Fig. 746). Pain on pressure in the axis of the bone is constant, and needs no explan- ation. It is not necessarily very severe. (See Fig. 744.) Limitation in flexion is apparently due partly to tenderness, partly to dis- turbance of the relations of the flexoi tendon. Crepitus is not present, as a rule. The greatest diagnostic difficulty presented by these fractures presents itself in case the patient is known to have had some previous fracture of some knuckle. Often we can no longer depend upon deformity, but must rely upon pain and crepitus and upon mobil- ity. The last two signs are usually demonstrated only with the use of a good deal of force. The majority of knuckle fractures are received in striking blows with the hand, and are the pugilist's fracture par excellence. The Fig. 748.-The arrow shows an extra epi- physis (not very rare) at the base of the sec- ond metacarpal. Ordinarily, the single epiphysis is at the proximal end of the first metacarpal, at the distal end in the other four. This plate shows also a crack (x to x) of the third metacarpal. KNUCKLE FRACTURE 439 knuckles most commonly fractured are those of the fourth and fifth metacarpals.* Treatment.-The deformity is to be reduced by strong traction on the corresponding finger and by direct pressure of the head backward. Sometimes a rocking motion added to the traction is of service. Reduction to a per- fect position is often not attainable, and mainte- nance of the position first obtained is difficult. There are two methods of treating this sort of fracture. The first is by flexion of the hand around a roller, the second by treatment in the straight position, with or without traction. In treating the hand in flexion a roller, most conveniently a roll of bandage, should be used. This should be about an inch in thickness and about three or four inches in length, correspond- ing to the width of the hand. It is placed in the palm of the hand, the fracture is pulled into place, and all the fingers flexed firmly about the bandage. In this position they are held by straps of adhesive plaster applied as shown in Fig. 753. This method is reasonably satisfactory as regards results. The only disadvantage is that it is often distinctly uncomfortable. Treatment in the extended position consists in the application of a Fig, 749.-Broken metacar- pal. The fourth metacarpal shows the knuckle pushed back out of the normally straight line from third to fifth (compare Fig. 745). Fig. 750.-Fracture of second metacarpal. Note how the knuckle end has dropped into the palm of the hand (outlines reinforced). splint anteriorly, cut to fit the hand as shown in Fig. 754. It should go out somewhat beyond the tips of the fingers, and well up the fore- * Not very rarely there is an extra epiphysis at the back end-remember this! 440 METACARPAL INJURIES arm. It is padded in the usual way, with the addition of a pad, preferably of thick felt, in the palm of the hand. The wrist and fore- arm are firmly fastened with plaster to this splint, and the finger corresponding to the broken knuckle is held in place by strips of adhesive carried over the end of the splint. Care must be taken to see that this Fig. 751.-Fracture of fifth metacarpal; old, united. Fig. 752.-Fracture of fifth metacar- pal, distal end. adhesive does not cut into the sides of the finger at the tip, and does not press upon the nail, or it will be unendurable to the patient. In certain cases it may be well to use a somewhat longer splint and to fasten this adhesive plaster to elastic strips, or, better still, to rubber tubing, which is carried over the end of the splint, stretch- ed, and fastened (Fig. 755). What- ever method of treatment is adopted, it is necessary to change apparatus every day or every other day, until union has begun to be pretty firm, partly because the discomfort of any efficient traction becomes considerable if the straps be left in one position, partly because any apparatus applied to the hand tends to slip and to be- come inefficient. So far as the choice of apparatus is concerned, it may be said that the flexed and the extended positions are about equally effective, pro- vided that in the extended position the pads be made large enough. The advantages of the elastic traction do not seem to be worth the additional discomfort involved, as a rule. Owing to the fact that muscle action greatly tends to reproduce the deformity, treatment in Fig. 753?-Bandage-roll in palm. Fingers fastened in flexion and under traction; a holds the roll in place. Straps x and 1, 2, 3, hold the fin- gers in place. This dressing prevents projection of the bones into the palm. It is not very com- fortable. FRACTURES OF THE SHAFT OF THE METACARPAL 441 apparatus must be long continued-a month at least-to insure good results. Results.-Some part of the deformity, both of shortening and of the "dropped knuckle," almost invariably remains. The function may be impaired to some extent by limitation of flexion, but is nearly Fig. 754.-Straight palmar splint, cut out for the thumb. A pad to fill the palm is placed as shown by the dotted line. always good. In fact, it is often astonishingly good with poor posi- tion, as will be seen from inspection of the hand of any old prize-fighter. Many of these men have had a number of such fractures without loss of strength or of usefulness of the hand for their purpose. Dr. H. L. Burrell had a case in his practice* in which a man had had in the right Fig. 755.--Elastic traction, applied for fracture of middle finger metacarpal. Splint of light board longer than the band: 1, Pad over fragments; 2, ends of adhesive that pulls on the fingers tied to a piece of rubber tubing (3), which is stretched and tied to adhesives (4) that fasten it to the splint The wrist is held to the splint by adhesives. The rubber exerts a pull, transmitted over the smooth notched end of the splint to the extension adhesives on the finger (the lower sketch shows the palmar side of splint). and left hands 16 such fractures without serious impairment of function save in one knuckle which had been carelessly treated and came to an open operation. Fractures of the Shaft of the Metacarpal These are usually the result of direct violence, and are apt to be approximately transverse, with the displacement in the direction of an * Personal communication. 442 METACARPAL INJURIES anterior or posterior bowing. They show little or no shortening of the bone, but on careful inspection deformity, mobility, and crepitus are all present. Owing to the swelling of the hand from an injury, such as produces these fractures, they are very readily overlooked, and if overlooked, may produce serious trouble. This trouble is owing to deformity which gives a projection on either the front or back of the hand, serious so far as the backward displace- ment is concerned only because such projections are constantly getting struck; far more serious if the displacement is forward, because such dis- placement causes painful pressure in the palm of the hand when the hand is used to grasp anything. They are to be treated on a straight ante- rior splint, with the pad in the palm of the hand. Because of the seriousness of a projection in the palm it is wise to err, if at all, in the direction of padding too heavily in the palm. These frac- tures unite readily, but must be protected for some time after union is apparently firm, because if the hand is used for work, the action of the flexor muscles tends to produce bowing of the bone. This protection, Fig. 756.-There is a strong tendency for the fragments, or one of them, to be displaced into the palm. Fig. 757.--Eracture of base of 2d and 3d metacarpals. so far, at least, as abstinence from heavy work is concerned, should con tinue for six weeks after the injury. Fractures of the Bases of the Metacarpals These are produced, in the majority of instances, by indirect violence. They are commonly either fractures within a half inch of the joint surface, roughly transverse, or oblique fractures involving the 443 FRACTURES OF THE BASES OF THE METACARPALS joint surfaces. The detection of such fractures is often difficult, because the deformity is little or none, and mobility or crepitus can hardly be made out. Localized tenderness and thickening and pain on pressure in the long axis of the bone may make us suspect them, but the actual diagnosis must of- ten be made by the x-ray. They are serious only because certain ones of them remain persistently 1 ■ I Fig. 759.-Spiral fractures of two metacarpals. Fig. 758.-Fracture of two metacarpals. tender after injury. The reason of this is, I think, unknown, nor is it dependent upon any defective treatment. Treatment can at most con- sist only of a reduction by traction and pressure if there is any deform- ity, and of subsequent rest in splints. I have sometimes found straight traction as above outlined of value in holding the reduction against recurrence. CHAPTER XIX THE PHALANGES DISLOCATIONS OF THE PHALANGES* lhese dislocations are oftenest produced, in the case of the back- ward dislocation, by hypcrextension; in the case of the forward disloca- tion, by direct violence. Lateral luxations are not rare. They offer no special peculiarities as to diagnosis; deformity is obvious. As to treatment, there is only to be said that the same difficulty with the capsule may be met with as in the thumb luxations, and must be treated similarly. Most of the luxations are reduci- ble by simple traction and pressure, and are treated by simple immobili- zation, best continued only for a few days, and followed by active and passive motion, with massage and the application of heat. Restoration of function is good, though full recovery of motion may be slow. Permanent functional damage is rare. The deformity remaining is one of thickening, and sometimes of lateral distortion, familiar to all of us in this country, as exemplified in the hands of the old- time base-ball catchers. The permanent thick- ening about the joint is the rule, but not always present. The statement has repeatedly been made that these luxations show under the x-ray a frac- ture luxation with a considerable bone fragment torn loose. I have found a small scale torn loose in two cases only out of many cases skiagi'aphed. Until further proof is forthcoming, it is fair to say that this possible lesion affects neither treatment nor prognosis. Fig. 760.- Anatomy of phalanges of thumb and index. The crosses show the sites of com- mon though not constant sesamoids, that are often confusing. Fig. 761.-Location of the joints, distinctly below the cor- responding skin-folds (dia- gram). Subluxation of Phalanges with Tendon Rupture This is so distinct in its seriousness that it deserves a separate head- ing. The seriousness of the injury is due to the fact that both on the * Dislocation of the thumb at the metacarpophalangeal joints is treated in Chapter XVIII. 444 445 SUBLUXATION OF PHALANGES WITH TENDON RUPTURE flexor and extensor sides the tendon insertion into the last phalanx is indistinguishable from the capsule, and they may give way as one structure. This not rarely happens on the extensor side. Fig. 762.-Lateral luxation of a phalanx. Sketched from a case of the author's. Luxation readily reduced by traction and rocking. The mechanism seems to be that of a sharp forced flexion of the last joint, with the next joint fully extended or hyperextended. Fig. 763.-Subluxation of terminal phalanx of middle finger, with rupture of the extensor tendon at the joint. Sketch from a case (courtesy of Dr. H. A. Lothrop). The clinical appearance is as shown in Fig. 763. There is no real luxation. The last joint can be straightened easily, but not by the patient's own muscular efforts. 446 THE PHALANGES There is little reaction of swelling or pain. As the gap lies open into the joint, there is little tendency to repair even under fixation. Operation is called for: not seldom the condition found is a tearing Fig. 764.-Luxation of distal phalanx of thumb backward. out of the tendon insertion, rather than a rupture of the tendon as such; this makes suturing difficult. I have known the operation to fail in the hands of competent men, but in fresh cases it is usually entirely successful. Since the preceding was written I have operated on three cases all successfully but have seen four cases treated by sharp extension held by splint and pad with one good result, and three cases with defi- nite deformity but not a very troublesome finger. I still think, operation preferable but not absolutely essential. FRACTURES OF THE PHALANGES These are almost always the result of direct violence. They are very largely the result of industrial accidents, and naturally are very often compound. Being the result of blows or crushing, they follow no definite types. Diagnosis is made by tenderness, mobility, crepitus (by inspection in the compound cases); as a rule, the x-ray is desirable. They call only for decent reposition and a splint. Fig. 765.-Fracture of phalanx. FRACTURES OF THE PHALANGES 447 Even the compound cases usually do well unless violently septic. Necrosis, even of chips of bone, is not the rule. The desirable splints are shown in Figs. 731 and 754. A straight "finger splint" may suffice. For the deft mechanic, the copper-wire spiral is an admir- able device, but it needs careful fitting. Union is usually prompt (three to four weeks); Fig. 766.--Fracture of phalanx. Fig. 767.-Fracture of phalanx. Fig. 768.-Pathologic fracture of phalanx; spontaneous fracture in a case of tubercular dactylitis. delay of union in clean cases I have seen only rarely and only in frac- tures of the last phalanx, where accurate fixation was hardly possible Fig. 769.-Fracture of proximal phalanx of the ring finger. Note the projection into the palm This is, as it stands, a crippling deformity. Delayed union, of course, accompanies sepsis. Non-union seems not to occur. 448 THE PHALANGES End-results are uniformly good unless we get projection of frag- ments on the palmar side. This, as with the metacarpal fractures, gives pain from gripping hard and interferes with manual labor. Phalangeal fractures usually do fairly well, even if compound and septic, but compound dislocations or fractures that involve the joint, Fig. 770.-Grip for reduction of phalanx fracture or luxation. that become septic, do badly. As a rule, convalescence is so slow in these cases and the results are so poor that amputation is preferable to long waiting. Of late, since our State Employers' Liability law has been in force, Fig. 771.-Separation (and backward displacement) of the epiphysis of the first phalanx of the index-finger. the writer has had an exceptional chance to review the results in many of these smashed fingers. They do not average well! Of course most of them were compound lesions, and tendon damage, and tendon adhesions play a large part. In fact the proportion of useless fingers seems very large. EPIPHYSEAL SEPARATION This is but a variant of fracture, practically. Such a case is shown in Fig. 771. The epiphyses play but a slight role in hand injuries, considered from a practical point of view. CHAPTER XX PELVIS: FRACTURES AND LUXATIONS Fractures of the pelvis are not very rare-by no means so rare as seems generally to be supposed, nor necessarily so serious. The obviously severe fractures are rather uncommon, though, as Paul* has pointed out, not even these are rare in certain mining towns, etc. In the big city hospitals such cases occur less commonly, but the less severe cases are by no means uncommon. At the City Hospital in Boston I see certainly ten or more a year, and this is only on one of four surgical services, during a part of the year. It seems likely that these fractures may readily be overlooked where no serious damage to soft parts results. The diagnosis is not always easy in such cases, f There are many forms of pelvic damage, differing so much in cause, in prognosis, and in treatment that they must be considered separately. J Fractures of the pelvis, with the exception of injuries to the iliac spine and crest, represent a smashing, at one or more points, of the irregular bony ring which surrounds and protects the pelvic viscera and transmits the weight of the body to the hip. With fracture of this protecting ring the liability of the viscera to damage is obvious. Such damage and associated injuries are the reason of the high mortality in these fractures. Fractures of this protecting ring may be from direct crushing force, or may result from force transmitted through the femur by a blow on the trochanter, or even in falls on the feet. Fractures and fracture luxations of the pelvis may be divided into- 1. Fractures through the rami. 2. Fracture through the rami with fracture near the sacro-iliac joint, or with diastasis of that joint. 3. Separation at, or fracture near, the symphysis (with or without sacro-iliac lesion). * Paul, Ann. Surg., 1901, xxxiii, p. 733. He reports 54 cases from the hospital at Hazelton, Pa., in the heart of the coal-mining district. It is interesting to note not only the frequency of pelvis fractures in the mines, but their severity. In his series the mortality was 50 per cent., and the series shows five ruptures of the blad- der, nine ruptures of the urethra, and one rupture of the rectum, with many other severe complications. t In examining industrial cases within the last year, I have happened on four overlooked pelvic fractures; and this in a rather small total of accident cases. t One article of the few that recognizes fully the great variety of pelvic fractures is an admirable study by Simon (of the Insurance Hospital in Neunkirchen) that appeared in Bruns' Beitrage, 1905, xlv, p. 555. 449 450 pelvis: fractures and luxations 4. Fracture of the acetabulum. 5. Fracture penetrating the acetabulum. 6. Fracture of the tuber ischii. 7. Fracture of the iliac crest. 8. Fracture of the anterior superior spine. 9. Sacro-iliac lesions alone. 10. Sacral fracture. Fig. 772.--Median section of male pelvis. Notice close relation of bladder and urethra to the symphysis pubis. Fracture of pubic bone may injure bladder or urethra (frozen section by Pro- fessor Thos. Dwight). FRACTURES THROUGH THE RAMI These occur either as a result of direct violence, from force applied to the pelvis from the front, or from lateral compression of the pelvis- i less degree of the force that causes the fracture of class 2. There may be fracture of the rami on both right and left. The more usual sites of fractures are indicated in Figs. 773, 778. There are apparently no typical lines of fracture, only a general approxi- mation to a cross-break through both rami. There may be simply fracture of the pubic ramus alone. Sometimes we have a double frac- ture in front, involving only the horizontal ramus. Displacement is not ordinarily great-in fact, it is very little at the time of our examination. It seems fair, however, to assume always that displacement has been greater at the time of the trauma, and that there has been some measure of elastic readjustment. It seems prob- FRACTURES THROUGH THE RAMI 451 able that such transient displacement explains the frequent associated tearing of bladder, urethra, etc. For it is not very rare to find in these cases an associated tear of the bladder, extraperitoneal or intraperitoneal; even oftener there is a tearing of the deep urethra. These tears are evidenced by the usual Fig. 773.-Fracture of rami of ischium and pubes on the right. Much displacement of the pubic fragment. Showed palpable fragment in the groin. Recovered practically without lameness. signs, but the presence of pelvic fracture should put us on the lookout for them. Diagnosis is made on- a. History. b. Local tenderness, especially diagnostic in the perineum and over the femoral vessels. Fig. 774.-Lateral pressure on the pelvis just above the trochanter develops pain in most cases of pelvic damage. c. Ecchymosis in front (in absence of signs or history of direct blow). There is often fulness in front, with or without ecchymosis. 452 pelvis: fractures and luxations d. Mobility e. Crepitus both rather uncommon. f. Pain on pressure on the sides of the pelvis (Fig. 774). g. Pain on push or pull on the pelvis transmitted through the leg (Fig. 775). h. Pain on forced flexion or extension of the hip. i. Displacement shown by vaginal or rectal examination gives excellent information as to the ischial ramus and tuberosity. I have found signs /, b, and c most serviceable. Of course, deformity, mobility, and crepitus are absolutely conclu- sive when they can be obtained by direct or bimanual examination. The presence of damage to bladder or urethra points very strongly to pelvic fracture. As a rule, we will obtain confirmation of details by the x-ray, but the diagnosis may ordinarily be made without it. Reduction.-No reduction is ordinarily needed. In case of upward or downward dis- placement or of rotation of a loose fragment (in comminu- tion) we may attempt replace- ment by direct manipulation. I have tried it, often without any certainty that I had im- proved the existing position. Treatment.-Rest and im- mobilization by means of a snug swathe about the hips, prefer- ably a laced or strapped canvas swathe, is all we need in simple cases, or simple sand-bag support may be sufficient and more comfortable (Fig. 777). In cases of bladder rupture, torn urethra, vessel trauma, etc., the treatment is that of the complication-the fracture becomes secondary, and to be looked to later. At the time, the fracture in such cases is important only in that there is necessarily extraperitoneal blood-clot. Such cases do, in fact, give a mortality corresponding to the visceral lesion plus that of the frequent infection of the fracture made compound by the drainage of the bladder or urethra. Add to this the element of shock of the injury or associated lesions, and the high mortality needs no explanation.* Fig. 775.--Pressure upward in the line of the thigh shows localizing tenderness in nearly all pelvic cases. * Gerster lost a case from hemorrhage from the torn common iliac (Annals of Surgery, 1910, lii, 143). There are, however, many cases of recovery despite these complications; for instance, J. R. Eastman, of Indianapolis, in a recent paper (published in abstract in the St. Louis Med. Review, November 4, 1905), reports three cases of bladder rupture-extraperitoneal-with recovery, and discusses symptoms and treatment. FRACTURE OF THE RAMI WITH FRACTURE POSTERIORLY 453 In simple cases fixation should be kept up three weeks at least. What we accomplish by the swathe is simply immobilization and support: At times it is worth while to supplement this support with pillows or sand-bags at the sides, supporting trochanters and iliac crests from behind. Patients with pelvic fracture are apt to have a good deal of pain for the first part of the bed treatment. Results.-I have had the curiosity to look up end-results in some of these cases, and have been surprised at the recovery of function. Save for some slight and inconstant weakness and occasional pain, referred to the region of the fracture, there seem to be no sequelse* except in the older and infirm patients. I have seen two old cases with troublesome ossification spurs running from the break down the adductor tendons. One of these was cured by operation. Fig. 776.--Site of ecchymosis with frac- ture of the rami. Fig. 777.-View of the pelvis from below. The arrows show the points and direction of the sup- ports to the pelvis. The usual sites at which sand-bags are to be placed. Even where there remains much obvious thickening or even local deformity, we have no symptoms unless there has been nerve injury. The results of associated bladder or urethral rupture are noted above. FRACTURE OF THE RAMI WITH FRACTURE POSTERIORLY OR WITH SACRO-ILIAC SEPARATION This is the type described as the " double vertical fracture of Malgaigne," named after its first historian.! This injury consists of a breaking of the pelvic ring at at least two points, front and back. (See Figs. 779, 780, 781.) Hugh Cabot (Ann. Surg., January, 1909), reports a case of fracture of the rami on one side, in which G. W. W. Brewster did an immediate perineal section for urethral rupture. Cabot later did a plastic operation for urethral repair with success. Delore (Lyon med., 1905, cv, 964), in a like case, did retrograde catheterization and external urethrotomy with success. * Cohn (Bruns' Beitrage, 1905, xlv, p. 545) cites a case of a girl of sixteen who had had a fracture of the ramus (from being run over) at sixteen months of age. The right ramus was ligament with almost no bone; there was no disability. f What Malgaigne described was the break front and back on one side. Mal- gaigne: "Treatise on Fractures," American edition, 1859 (Packard), page 525. 454 pelvis: fractures and luxations The lesion at the back may be a break through the ilium or a dis- location or fracture-dislocation at the sacro-iliac joint. Fig. 778.-Fracture of both rami on the right. It will be noticed there is a shifting of the left pelvis as a whole upward and to the right, which could not be equalized by traction. Recovery only partial on account of apparent failure to recover strength at sacro-iliac joint. No trouble at point of fracture. The damage results from a crushing of the pelvis, as a whole, laterally or anteroposteriorly, or from rolling of the pelvis under heavy pressure. "Cave-ins " of dug banks, or of buildings, or car accidents, are the com- mon cause. Fig. 779.-Fractured pelvis; on the right, fracture across pubes and ischium; on the left, fracture involving acetabulum and sacrosciatic notch (Warren Museum, specimen 3857). Fig. 780.-Double vertical frac- ture of Malgaigne; fracture of the rami combined with fracture or joint- separation at sacro-iliac symphysis-■ on one or, as in this case, on both sides (sketched after Cooper's plate). If there be a double break, front and back, on the same side, all bony support of the pelvic ring is lost on this side, and considerable displacement is not infrequently found. There is also a greater pos- sibility of displacement inward than in class 1. FRACTURE OF THE RAMI WITH FRACTURE POSTERIORLY 455 If there is fracture in front with sacro-iliac separation behind, or if the lesion in front is a separation of the symphysis, there may be a similar upivard displacement.* With fracture on opposite sides, front and back, we get no such displacement, of course. New bone at seat of separation Scaro-iliac synchondrosis Fig. 781.-Fracture of rami of pubes; fracture and separation at sacro-iliac synchondrosis; much displacement; bony union (Warren Museum). Fracture, bilateral in front or behind, or both, is rarer. It occurs usually only with hopeless crushing and with associated visceral damage. With all cases where there is any combination of fracture in front with damage behind, ruptures of the bladder and tears of the urethra are rather common, and we have the added possibility of tearing of the rectum, in this class. Diagnosis.-All the points enumerated under class 1 (fracture of pubic rami) have their bearing also on class 2. In addition we may have: (а) Displacement, sometimes very obvious, of the whole of one side of the pelvis, upward. No measurement shows this. The x-ray is our only absolute proof. (б) Mobility of this side of the pelvis on the other on intermit- tent traction on the leg. (c) Local pain and tenderness, and sometimes ecchymosis, near the posterior spine of the ilium. Fig. 782.-Double ver- tical fracture of rami on both sides, with fracture of the sacrum instead of sacro-iliac separation (sketch after Stimson's plate.) * Creite (Deut. Zeit. f. Chir., 1906, Ixxxiii, S. 391) reports an autopsy case of this sort. There were no intrapelvic lesions. Death occurred from delirium tremens and sepsis at six days. The autopsy showed a separation of 3% cm. at the symphysis, and an entire loosening of the sacro-iliac joint on the right, with % cm. separation. The whole of this side of the pelvis was movable. The author also cites a number of like cases in the literature. 456 pelvis: fractub.es and luxations (d) Pain posteriorly, as well as in front, on bilateral pressure on the iliac crests. (e) Mobility of one part on another (crepitus rarely) on manipulation. There should ordinarily be no question of the gross diagnosis, even without the x-ray, which is, of course, desirable for purposes of detail and of record. Treatment.-Ordinarily, the treatment need be only that advocated for fractures of the pubic rami alone unless there are complications. Fig. 783.-Fracture of both rami on one side, with separation of the symphysis. In this case- there was some opening out of the pelvis as a whole, as well as marked rotation of the broken pubic portion. Except that the gap could be felt and there was some ecchymosis, there was very little to show for the lesion clinically. The patient died of delirium tremens before any question of repair could be considered (case seen by Dr. E. H. Nichols, to whom I am indebted for the plate). There is here, however, an added item, namely, vertical displacement. This is to be overcome only by traction. In three cases I have pre- ceded traction in apparatus by traction reduction under ether, with some success as to position of the sacro-iliac joint in two of them. Traction in such case (by the usual Buck's extension) I have used and found serviceable; weights of at least 20 pounds are required. Results.-Many cases die of shock or of complications. If the patient recovers, in case we are dealing with double fracture, consolidation becomes firm and the sequelae about as in class 1. Where 457 SEPARATION OF THE SYMPHYSIS there is fracture forward,-sacro-iliac diastasis aft,-we have a less solid healing. In two of my cases of this sort there was a complaint of pain in sleeping on either side-more from sleeping on the sound side -and moderate disability as to walking and lifting. Such part of the shortening as has not been overcome by traction ordinarily gives some little disability. To sum up, it is fair to say that these cases usually have some disability with a slight limp and local soreness after exertion, lasting for six to eighteen months; sometimes longer, etc., but, on the other hand, we do not find such disability as to interfere with moderate work and moderate use of the limbs and in most cases, the disability is entirely recovered from within a year from the time of the accident, limp and all. SEPARATION OF THE SYMPHYSIS Separation or subluxation of the symphysis alone is a postobstetric condition, not a traumatic one, as a rule. Its diagnosis depends on local pain and mobility. The pain is Fig. 784.--Total displacement upward of entire one side of pelvis, with separation of symphysis and of sacro-iliac joints. No fracture (diagram). brought out by direct pressure, by alternate pull and push on the thighs, and particularly by forced abduction. There is obvious ec- chymosis in this region in some cases. There may be gross and palpable separation; this is rare. In one case seen the damage resulted from a fall in which the legs were widely spread. He had great sensitiveness in the region of the symphysis, and about the adductors, close to the bone. There was some ecchymosis. Mobility at the symphysis was so slight as to be doubtful, but attempts to bring it out were very painful. Rest in bed, with the wearing of a pelvic girdle, brought about prompt and entire recovery. 458 pelvis: fractures and luxations Most of the recorded cases have been of this type as to causation and symptoms.* A curiously large proportion have resulted from accidents of one sort or another in the saddle. Fig. 785.-Opening out of the front of the pelvis, with tearing at the symphysis and diastasis at the sacro-iliac joints (diagram). Fig. 786.-Separation of symphysis. Fracture through acetabulum. Separation and dis- placement of sacro-iliac joint. A year later this boy had no disability, no limp, and only a little visible lateral tilting. * A case reported by Le Gros Clark (quoted by Stimson), for example, had a four-inch separation at the symphysis, with gaping of sacro-iliac joints on both sides, with various fractures also. There were also ruptures of the rectum and of the bladder, and the urethra was torn loose from the prostate. Obviously, in such cases, the bone damage is a detail merely. Other like cases have shown laceration of the iliac artery or vein. 459 SEPARATION OF THE SYMPHYSIS Fig. 787.-Fracture of the acetabulum. "Central luxation" of the femur without penetration. Fig. 788.-Fracture of acetabulum with displacement. 460 pelvis: fractures and luxations Separation may be considerable, but is not usually great. The point of separation is said to be not through cartilage, but be- tween cartilage and bone. Fractures may occur very close to the symphysis. Separation of the symphysis may be combined with various fractures or with sacro-iliac separation of one or even of both sides. Such injuries are, however, very rare. A few cases are on record in which such lesions have been associated with a direct shifting upward of one side of the pelvis, as a whole,- an actual double luxation,-a lesion obviously to be diagnosed by pal- pation, a lesion, by the way, proved not so dangerous as it sounds. Treatment.-The treatment is by pel- vic girdle or jacket, or rarely by wiring together the two sides of the symphysis.* Reduction of any vertical displacement is obviously indicated. Reduction is by traction. Twice I have greatly reduced the gap by lateral pressure under ether, followed by firm strapping. Prognosis.-Symphysis separation per se is not ordinarily a serious injury. Sym- physis separation with complications obviously carries the risk of these compli- cations, hence the statistics show a consid- erable mortality.! Union of the symphysis in these traumatic cases is satisfactory and function is good, as a rule. FRACTURE OF THE ACETABULUM That fracture of the acetabulum, especially of the back edge, may occur, is beyond doubt. Such fracture is essentially a complication of pos- terior luxation of the hip. Its existence is inferred from: (a) Crepitus in reduction; (6) recur- rence after reduction. There are no signs beyond this, unless the skiagraph happens to tell us something. The diagnosis is largely a matter of inference. Reduction.-Effective reduction of a reluxated hip, and fixation in the reduced position for more than the average time, constitute our means of defense. Fig. 789.-Fracture of acetabulum; force transmitted through femur (War- ren Museum, specimen 1053). * Since the above was written I have wired one case of symphysis separation. The interval was originally to 2 inches. The tearing was between cartilage and bone, with great periosteal stripping. The denuded bladder was intact. f Cohn (Bruns' Beitrage, 1905, xlv, p. 589) cites one case of his own and 14 from the literature. Of these, there were 6 cases of bladder ruptures. In 1 there was clot suppuration with prompt recovery on incision; 8 cases recovered. In 4 the recovery was perfect; in 3 almost perfect; in 1 the result is not stated. Le Gros Clark has called attention to the frequency of clot suppuration in the pubic injuries (cited by Stimson). FRACTURES THROUGH THE ACETABULUM 461 So far as can be learned, these means are efficient. Reluxation of the hip or chronic luxation is, at the worst, excessively rare. FRACTURES THROUGH THE ACETABULUM Of this lesion we have two forms-a smashing of the acetabulum and a penetration of the joint by the femoral head ("central luxation"') .* JL'V Fig. 790.-Central dislocation of the head of the femur, with acetabular fracture (sketched after Simon's plate). Fig. 791.-Central luxation of femur into pelvis (sketched after Arregger's a>ray). The simple smashing apparently occurs from force exerted through the femur, not severe enough to drive the head through. As to lines of fracture, information given us by the x-ray in two cases of mine Fig. 792.-Head of the left femur has been driven into Fig. 793.-Fracture similar the pelvis, breaking the rami and carrying the floor of the to previous plate; whole floor of acetabulum in front of it. Case of the author's. There was acetabulum driven into pelvis, a little shortening, some limitation of hip motion, but sub- No complications. Clinical re- stantially perfect result. suit good. and two published plates seems enough to suggest, if not to prove, a general type-a fracture line oblique upward and forward. * Of recent reported cases, may be cited: Wilms: Deut. Zeit. f. Chir., 1904, Ixxi, Nos. 5, 6. Schroeder (49 collected cases): ref. in Jour. Amer. Med. Assoc., August 7, 1909. Arregger: Deut. Zeit. f. Chir., Ixxi, Nos. 5, 6, 1904, S. 487. A. E. Halstead: New York Med. Jour., Nov. 13, 1909, p. 953, and Tully Vaughan: Trans. Am. Surg. Assn., 1912. 462 pelvis: fractures and luxations In younger patients the lines of epiphyseal junction may be followed. If we have mere smashing without penetration, there are but a few signs, namely: (1) Lateral mobility in the joint, brought out by shoving on the trochanter and pulling out on a perineal sling, alternately. (2) Possible crepitus on this test or on flexion and extension, or on rotation of the leg as a whole. No landmarks seem to be of use. In only one case of mine the diag- nosis was made beforehand on the above signs (with sign No. 2 doubtful), and was confirmed by the x-ray. There is not necessarily any shortening The trochanter may be less than normally prominent. The lesson is likely to be confused not with other pelvis fractures, but with fractures at the hip. As dis- tinguishing signs, the following may be given: Fracture through the Acetabulum.- (a) No shortening-or next to none. (6) There is no disturbance of land- marks save for less prominence of the trochanter. (c) There is not apt to be any fixed inversion or eversion. (d) Mobility of the joint is pretty near the normal. Hip Fracture.- (а) Restriction of mobility charac- terizes impacted fracture of the femoral neck. (б) Loose mobility with outward rolling of the foot belongs to unimpacted fracture of the neck. (c) Crepitus tells nothing as between loose neck fracture and the acetabular lesion, but- (d) There is always up and down mobility in loose neck fracture, and it is easily demonstrated, as a rule, by inter- mittent traction downward. Sometimes, however, muscle spasm hinders this test unless ether is given. Reduction Treatment.-To be guided by the x-ray. Mostly there is nothing to reduce. If there is, strong traction down and out is indicated. Obviously, immobilization is called for. I have used moderate traction (Buck's extension) also, and in one case (see foot-note) lateral traction outward as well, to overcome the tendency to displacement inward. The tendency is to rapid healing. Fig. 794.-Central luxation; in- jury received 33 years previous to taking of rr-ray. Has been able to get about very well all this time and still walks fairly. Hip motion re- stricted. FRACTURE WITH PENETRATION OF THE ACETABULUM 463 Results.-I know nothing in detail except as to five cases of my own. Of these, one had some little stiffness. The others showed an absolutely perfect result,* after the usual rather long convalescence. Fracture with Penetration of the Acetabulum : "Central Luxation of the Hip" Rarely, cases are recorded in which the head of the femur has not only split the acetabulum, but has actually penetrated it, so that the head comes to lie inside the pelvis, f Great force is required, and there are very apt to be intrapelvic complications, often fatal. Despite certain classifications of recent years, ucentral luxation of the hip" is not to be separated definitely from acetabular fractures with fractures through the arch. Penetration of the pelvis by the femoral head may occur with very extensive associated fracture or without any;J when the acetabulum is smashed in, the pubic arch must give way almost necessarily. For the mechanism of this fracture we have little to guide us save an experiment by Virevaux, who succeeded experimentally in producing this lesion by force applied to the trochanter directly, without adduction or adduction of the limb. In three other like experiments he succeeded in producing acetabular fractures, but without penetration. It is certain that the force is necessarily applied through the femur, though not necessarily through a blow on the trochanter. For instance, in Kronlein's case,§ the only case on record of bilateral "central luxation," the injury, resulted from a fall in which the patient Fig. 795.-Area of dullness to percussion from extraperitoneal hemorrhage in pelvic fracture. * J. E.: Fall from a second-story balcony, April, 1908. Fracture left pelvis' Clinically, there was slight pain only, with questionable shortening, and, on lateral pressure on the trochanter, a displacement of M to M inch inward, with a distinct, soft click. Provisional diagnosis, fracture of rim of acetabulum. Very slight swelling and ecchymosis about the region of the femoral vessels. The x-ray shows a fracture of the pelvis just anterior to (possibly through) the acetabulum. As soon as this diagnosis was made and confirmed, the treatment was insti- tuted of longitudinal traction with outward traction exerted by a band across the adductors, to which a pulley-weight was hitched. An x-ray plate of May 11th showed an entire disappearance of the deformity shown in the first plate. On examination there is now no click or mobility. The apparatus was removed at the end of four weeks. May 16, 1908: Up in a chair. September, 1908: Walking about with no limp or shortening or limitation of motion. Is at work. A perfect hip. January, 1909: Is working as a teamster without any disability. All motions of the hip are normal. t One case seen was diagnosed thirty-three years ago, as the City Hospital records show, as a hip fracture; and so diagnosed by Dr. W. H. Thorndike, perhaps the best surgeon in town in his generation. The patient has been active all these years, though of course with a stiff hip. I There is a central luxation of the hip recorded in which the head is driven through the obturator foramen. § Krdnlein: "Die Lehre von den Luxationen," Deut. Chir. 1882, Lief 26, S. 25. 464 pelvis: fractures and luxations landed on both feet. In my own cases, both mechanisms appear, if one may accept the histories; falls on the trochanter and falls on the feet. The lesion varies, of course. Essentially it does not differ from that of the smashing of the acetabulum in which the force has not sufficed to produce penetration. As to lesions of soft parts, we may have none, for the pelvic fascia is strong. Rupture of the gut has been recorded as a complication of the penetrating lesion. There is a case on record (Morel-Lavallee) where the autopsy showed not only penetration of the pelvis, but also direct pressure on the obturator nerve, explaining the severe pain complained of. Diagnosis.-The signs given for acetabular smashing without pene- tration are equally cogent here. The loss of prominence of the trochanter, the slackening of the tense fascia lata, etc., are present in even greater degree. There may be outward rotation, with loss of movement at the hip, but, on the other hand, the position may not be abnormal at all, and motions may be very free. Rectal examination showing the prominence of the head (and possi- bly its rotation with the shaft) may be of assistance in diagnosis. There is apt to be, in these cases, a good deal of intrapelvic hemor- rhage, not necessarily involving large vessels. The only sign of this is dullness on percussion about and above the groins. The sketch shown in Fig. 795 shows the sort of pattern of dullness we are apt to find. This case was a fracture of both rami, not of the acetabulum, but the pattern will serve. Treatment.-Obviously, it is desirable to reduce the displacement of the femoral head and then treat the fracture of the pubic arch in the usual way. This does not seem to have been the treatment of record in the cases of which I have seen the reports, but this is mainly, no doubt, because the cases have not been seen early, or, if seen early, have been in no condition for active interference. Reduction must obviously be by traction down and out, with rota- tory movements to clear the way. A cushion between the legs to act Fig. 796.-Reduction of the central luxation by pulling out on the upper end of the femur by means of a sling in the groin, with counter- traction on the pelvis; at the same time moderate traction and rotation exerted downward in the axis of the thigh. FRACTURE WITH PENETRATION- OF THE ACETABULUM 465 as a fulcrum over which the head of the bone may be pried out, has been suggested. Murphy's scheme of a wide fulcrum bearing on the adductor surface of each thigh and permitting of downward traction across this fulcrum is at least logical, and deserves trial. I have reduced three cases with displacement of about an inch in each case, by using the intact portion of the pelvis as a fulcrum for the flexed thigh (see Fig. 797). Katz* has proposed reposition by pressure from the rectum. This seems probably impractical (there are no cases to support it), and it seems possibly apt to inflict further damage; force exerted through the femur seems more promising. Simon (Zoe. cz7.) says that only light traction in indicated, and that the therapy is that of pelvic frac- ture in general, and not directed to this particular lesion. I can recognize no treatment of pelvic fracture in general; it seems to me that we must individualize more. It seems that strong traction on the femur downward and out- ward renders after-treatment more effectual. It is certainly more comfortable. Prognosis.-The possibility of good functional results in such cases is illustrated by Lendrick's case,f in which a man no longer young was involved in the over- turning of a coach, but had so recovered as to be able to take long tramping trips in German fashion. He died of phthisis, and the autopsy showed the femoral head driven through into the pelvis, where a new bony cavity had been formed. Both pubes and ischium had been smashed. The case shown in Fig. 797 had been able to be very active and substantially free from pain for thirty odd years. The cases with but little penetration do very well. All of mine have been able to walk. Three recent cases seen long after injury had considerable disability from limitation of motion. In one, removal of a broad spur at the edge of the acetabulum restored full motion. In another adductor tenotomy brought full success. The third is now rapidly improving under simple stretching exercises. Fig. 797.-Reduction of "central" luxation of the femur by the author's method of leverage. The thigh is brought to extreme flexion then the knee pushed in and back. The intact ilium is the fulcrum, the femoral shaft the long, efficient lever. * Katz: Bruns' Beitrage, 1902, Bd. xxxiii. f Quoted by Hamilton: "Fract. and Dislocations," third edition, 1866, p. 341. 466 pelvis: fractures and luxations Fracture of the Tuber Ischii (alone) I have no doubt that this fracture may occur. I have seen a num- ber of cases in which this diagnosis had been made, but none in which it was justified; in each case the skiagraph proved a fracture of the pubic as well as the ischial ramus.* Obviously, a real fracture loosening the tuber ischii could be definitely detected by bimanual examination, i. e., with the forefinger in the rectum and the thumb (and the other hand) outside. Treatment could do nothing beyond immobilization, and for this purpose rest in bed with any apparatus securing the comfort of the patient would suffice. I know nothing of the results: there is no obvious reason why they should not be good. FRACTURE OF THE ILIAC CREST These fractures are rather common. They occur always, it seems, from direct violence exerted, as a blow or as pressure, from the side. The lesion is a separation of the iliac crest through any part of its length (see Fig. 798), and to a varying depth. I have seen one case in which there was at least a suspicion that the separation was of part of the narrow shell of epiphysis that runs along the crest. Displacement is always inward. Diagnosis rests on the local soreness and swelling, on the palpable displacement, on crepitus, and, for confirmation, on the x-ray. Mobility and crepitus are obtainable only very early; this fracture " glues down " very early (like breaks of the nose, of the ribs, etc.). Treatment.-Real reduction seems to be impracticable. The best thing to be done is to secure rest. A tight swathe must obviously increase displace- ment by pressure toward the middle line. The best thing that we can do, therefore, is to immobilize with a loose swathe and support the frag- ment with pillows and sand-bags. As noted above, fixation by callus occurs early. When it has occurred, a tight swathe can do no harm and is comfortable. Fixation must be continued until consolidation is firm enough to resist the pull of the abdominal muscles which are attached to this edge of the ilium. This means three to four weeks. Fig. 798.-Fracture of crest of ilium (Warren Museum, specimen 5938). *At last (November, 1922) have found a case, result of a "sitting fall" in a heavy woman. Save for local soreness, no definite symptoms. 467 SACRO-ILIAC JOINT Results.-Apparently, no disability occurs beyond temporary sore- ness. Some deformity may persist, but is usually slight, and seems to be of no consequence. Separation or Fracture of the Anterior-superior Spine A rare injury. The one case I have seen was, like all those re- ported,* from muscle action. The process gives origin to the powerful sartorius muscle. In this case the man-a young fellow of nineteen years-was sprint-racing, when "something gave way." He did not Fig. 799.-Fracture of iliac crest only. fall, but could not run the race out. When seen, he showed a*"slight thickening below the normal side of the iliac spine, and a movable fragment could be made out, displaced downward, but not displaced far. There was pain on active attempt to lift the thigh, as well as on pressure on the injured region. Fixation gave prompt union (perhaps fibrous, but solid), and he soon regained approximately normal use of the leg. The lesion seems not to be one of any gravity as to encl-results. This is a very strong articulation-one that, by its shape, permits little motion so long as any of its strong ligaments are intact. In * Whitelock, for instance, reported two cases of the sort in the 1893 Lancet. SACRO-ILIAC JOINT 468 serious fractures of the pelvis we may have diastasis of this joint as a complication. Actual uncomplicated luxation rarely occurs in cases that survive the original injury. Now and again we see cases of sprain of this joint. They show local tenderness, pain on weight-bearing, pain on flexion of the hip, and pain on pressing in from either side on the iliac crests. The lesion results from falls on or about the hip. The treatment is rest in bed, with sand-bag support to the pelvis at either side, a pad or pillow under the lumbar spine, and a snug swathe about the hips; after this, support by a belt carried below the crest of the ilium on either side and worn tight is efficient (Fig. 801). The prognosis is good, recovery ensuing after lameness of some weeks.* There is little tendency of definitely traumatic cases to go on to the chronic sacro-iliac relaxation we some- times see but not a few of these cases have an associated "sprain" of the lower back that is troublesome for a good while. Chronic sacro-iliac luxation, or really relaxation, is more frequent. This complaint, well attested in certain cases, has attained a promi- nence of late which is probably in part fictitious- this prominence represents the usual psychic reac- tion when a condition previously ignored comes to be recognized. In the clean-cut cases we have much local lameness and various radiating pains of hips and thighs, with much disability. Pain on pressure inward on the ilia, pain on flexion of the straight leg, tenderness over the joints on either side, and relief of discomfort on applying support beneath the upper part of the sacrum as the patient lies on a table are the diagnostic features. The dis- placement seems to be usually a rocking hackward of the sacrum in the iliac mortise, if there is displacement. The cases give at times a history of trauma, but the condition is one essentially dependent on the relaxation of the sacro-iliac ligaments, not uncommonly, perhaps not abnormally associated with pregnancy, or due to general laxity of tissues. Trauma is not the common cause. pelvis: fractures and luxations Fig. 800.-View from the inner side, showing the sacro- iliac joint; its comparatively small pear-shaped articular sur- face, and a much larger area behind it entirely devoted to igamentous insertions. Fig, 801.-The pelvic girdle. *In one case I have seen suppuration follow such a condition-suppuration in which no evidence of tubercle bacilli was found in pus, which was also sterile as to other organisms. This case is probably noteworthy only as a curiosity. SACRO-ILIAC LUXATION 469 The treatment is rest in bed with sacral support, then application of some form of pelvic girdle to be worn until recovery is practically complete. Sacro-iliac Luxation This, or oftener subluxation, occurs not uncommonly as a complica- tion of pelvic fractures, especially, it seems, in the cases of fracture of one or both rami, produced by anteroposterior pressure. Similar damage may attend disastasis at the symphysis caused by spreading of the legs. Such damage may be of one or of both sides. There is but one case (Dubreuil) of clean-cut diastasis of the symphysis and of both sacro-iliac joints. Even here there was associated fracture. Such diastasis, of one or both sides, calls for the application of a tight compressing swathe. All cases of double diastasis up to date seem to have been fatal from associated intrapelvic and intra-abdominal injury, or tearing of the iliac vessels. In case we have diastasis of the symphysis in front and of the sacro- iliac joint of the same side behind, we may have a displacement not unlike that met with in "double fracture," namely, a displacement upward of the whole side of the pelvis. This occurs apparently from a fall on one foot, usually.* A number of such cases are on record. They are not necessarily very serious, except through complications. Salleronf had two such cases which recovered after reduction. Reduction is by traction downward by hand, kept up by weight extension. A weight of 25 to 50 pounds is not too much. The cases are treated until union is relatively solid (z. e., for about a month). Results.-One has few experiences with this lesion, and the cases recorded give little detail as to results. It seems unlikely that so ex- tensive a lesion, even if well repaired, could ever fail to leave behind some sacro-iliac weakness at least, but the prognosis with tolerable reduction seems to be rather good. Latterly I have treated five cases of complete sacro-iliac luxation. Of my cases, one was from a fall; two others from being run over by an auto-truck; a third from the overturning of an automobile. These cases recovered with perfect function, though real reduction was not accomplished in any case. In one case there was originally wide separation of the symphysis with acetabular fracture and fracture of both rami as well on one side; he is now working as a painter. In the most recent one, exactly similar lesions plus a broken femur. In this case reduction was almost exact despite great original displacement. The result was excellent, not even a limp. *Eare: Med.-Chir. Trans., 1835, xix, 257. fSalleron: Arch. Gen. de Med., 1871, ii, p. 34. 470 pelvis: fractures and luxations SACRAL FRACTURE Sacral fracture is one variant in this general class of injuries of the pelvic ring. It occurs but rarely.* The fracture is in approxi- mately vertical line, close to the sacro-iliac joint. (See Fig. 782.) So far as published data go, it seems to have no direct signs by which we may distinguish it from fracture of the ilium just on the other side of the joint,* and it seems to differ in no way as regards prognosis. * There should be liability to damage of nerves of the sacral plexus, but I have met no account of such a lesion, with the vertical fracture. It does occur with the independent transverse sacral fracture. CHAPTER XXI LANDMARKS OF THE PELVIS AND HIP Landmarks.-Externally, we may readily distinguish- Anterior-superior spine.-Its position is obvious save in very stout persons, in whom it may be overlaid with pendulous abdominal fat, which must be lifted up before it can be found. (See Figs. 802, 803, 804.) The "spine" is not always sharp; sometimes it is not even definite enough to give an accurate point of measurement, but it is always palpable. The pubic spine: the outer termination of the rough superior border or crest of the symphysis pubis. Poupart's ligament, connecting the iliac and the pubic spines. Symphysis.-The symphysis is always pal- pable, but too vague in outline to be of much use as a landmark. Ramus of Ischium.-This is always pal- pable-externally in the perineum, internally per vaginam or by rectum. Tuber Ischii.-Always palpable but under heavy fat masses it is very apt not to be use- ful for measurements.* Posterior-superior spine, the back end of the iliac crest-not always palpable, but the most distinct prominence posteriorly. Trochanter Major.-Palpable always as a bony point of resistance; usually its outlines may be made out. Its normal relations are indicated in Fig. 805. Often the digital fossa may be made out. (See Fig. 910.) The fact that it is a definite hollow on the sound side, not on the injured one, is of value as showing damage, particularly in hip fractures. Front of Joint.-The anterior portion of the hip has no landmarks, properly speaking, but marked fullness over or near the joint (see Fig. 912) is of value as indicating probable fracture of the neck or, rarely, joint effusion. Fullness from these causes is lower down than that sometimes seen with fractures of the pubic ramus. Fig. 802.-Landmarks of the front of the pelvis, as seen in the moderately stout, mid- dle-aged man. The crosses show anterior-superior spines and pubic spine; the line is that of Poupart's. * The tuber ischii and the ramus of the ischium are always palpable by rectum or vagina-a point of no value in hip measurement, but often convenient in questions of pelvic fracture. 472 LANDMARKS OF THE PELVIS AND HIP bascza Lata.- I he fascia is hardly a landmark, but the disappear- ance of the resistance it furnishes, as felt above the trochanter or near the knee (see Fig. 911), is proof presumptive of dislocation or of fracture somewhere between the hip and the knee-joint. Reference to the diagrams will make description of these landmarks and their identification unnecessary. It may be noted that the anterior-superior spine may be, in obese elderly subjects, far above the fold that usually corresponds to Poupart's ligament (see Fig. 803), and that in such sub- jects the pubic spine may only be discover- able by running the hand under the pendulous fold of abdominal fat. In utilizing these landmarks we usually make the following routine examination in every case of suspected pelvic injury or hip damage. The patient is laid on the back, so that the hips lie square (a line between anterior-superior spines runs at right angles to the vertical line of the trunk and legs), and the pelvis lies flat on the table (b e., the lumbar region and the posterior spines nearly in contact with the table). Then the position of the thigh is noted, whether flexed, abducted or adducted, or rotated in either direction, and we note whether this position is one of comfortable choice merely, or one fixed by muscle spasm or ligamentous or bony restriction. Then we measure the length of leg, measuring from anterior-superior spine to internal malleolus (or sole of foot at the heel). (Fig. 806.) This measurement to be of value must be with the pelvis square and with the two legs in like relation of angle to the pelvis. Any abduction or adduction changes the measurement (see Fig. 808), and with legs parallel, but pelvis not "square," the doubled error may be considerable. Then we place the thumbs on the anterior spines right and left and palpate, first, the region above the trochanter, to determine the relative tension of the fascia lata, right and left; second, the trochanter itself, noting displace- ment upward or outward or backward, also general thickening and obliteration of the groove at the back (the digital fossa) which is ordinarily to be felt even in fat people if felt for in this way. The practised hand can almost instantly appreciate changes of relation in such examination. For the less practised hand and for Fig. 803.-The landmarks in stout persons are found much high- er than would be suspected-a common cause of confusion. In still stouter individuals the belly frequently reaches the level shown by the dotted line. It is not un- commonly necessary to lift the belly off the pubes to reach the landmarks. Fig. 804.--The relation of the anterior- superior spine to the fat-folds in a man of middle age (sketch from actual case on the table). LANDMARKS OF THE PELVIS AND HIP 473 purposes of record we have two artificial methods-the Roser-Nelaton line and Bryant's triangle. The Nelaton line, as it is usually called in this country, is a line drawn from the anterior-superior spine to the tuber ischii; during the drawing the hip is flexed 45 degrees. This line just strikes the top of the trochanter unless this trochanter is displaced. The trouble with the line is that the tuber ischii is not always readily defined, and that even with the ends fixed, the line so drawn, across a fat hip especially, may vary greatly with variations in the position of the opera- tor's head and eye. Anatomically, it is all right; clinically, it is nearly worthless, save in the hands of the expert who does not need it. (Fig. 807.) Bryant's "triangle," on the other hand, is of real use. This measurement is made by dropping a perpendicular from the anterior- superior spine, as the patient lies on his back, and marking it on the skin. At right angles to this line a line is drawn to it from the tro- chanter, and another line, completing the triangle, from trochanter to anterior-superior spine. (See Fig. 809.) The length of this last line varies with injuries, and the difference may be of use, but the second line, compared right and left, gives an absolute index of the amount of shortening. It measures only shortening between acetabulum and trochanter-i. e., it is negative except in fractures of head or neck or dislocation, or the rare acetabular fractures. (See under Hip Luxa- tions for illustrations.) Fig. 805.--Landmarks from behind. Fingers on greater trochanters; thumbs pressed in to reach the tuberosities of the ischium. The arrow shows the site of the posterior-superior spine. CHAPTER XXII HIP DISLOCATION Despite its prominence in the text-books and the literature, disloca- tion of the hip is an uncommon lesion. The fascination of the compli- cated problems of reduction has led to much painstaking research and Fig. 806.-Measurement from anterior-superior spine to tip of internal malleolus. to an emphasis which the lesion, from a practical point of view, hardly warrants. The catalogue of the Boston City Hospital (an institution showing a very large array of unselected accident cases) shows, in the last twenty-eight years, 62 cases of hip luxation to 869 cases of fracture of Fig. 807.-Nelaton's line. A line drawn from the anterior-superior spine to the tuberosity of the ischium, with the leg flexed at about 45 degrees, normally just strikes the top of the great trochanter (a measurement peculiarly liable to personal error as the line is drawn over curved planes). the femoral neck; the possible error, owing to uncorrected provisional diagnoses and to enthusiasm for "operable" cases, would, if corrected, show an even smaller proportion of actual luxations. Hip dislocations are characteristically a lesion of adult life, rare, though not unknown, in children. 474 475 HIP DISLOCATION As a consequence of their greater exposure to severe trauma, men, rather than women, are liable to the injury, and for the same reason young men and the middle-aged, rather than the more elderly. The hip lesion that usually occurs in advanced years is not luxation, but fracture of the femoral neck; in the earlier years there is more nearly an even proportion between the two lesions. Dislocations of the hip are safely divisible into posterior and anterior displacements. Beyond this the classifications diverge widely, and it is hard to be sure what is meant by the indivi- dual reporter, for some of the classes are based not only on the actual position of the femoral head, but also on assumptions as to how it reached this position. The wise classification seems to rest on the position of the head. That is about all we can make out. Theories of transit in rotation, etc., diverge too widely for consideration in practice. It is not even worth while to be over- precise in classification of position. In any individual case the position is to some extent liable to change with-or even without- gentle manipulation. Moreover, very exact determination of position, even if possible, is of no moment so far as the all-important matter of reduction is concerned. The type of displacement depends on the relation of the displaced head to the socket and to the ligaments. Bigelow has fixed for all time the very important role of the Y-ligament. The matter of first importance in luxation is whether the head has escaped so as to lie in front of or behind the plane of this ligament. The division into posterior and ante- rior forms includes all cases save those very rare " irregular " ones, where the strong ligaments are torn loose, in which any position may be assumed, and those, hardly less rare, of "central" luxation, in which fracture of the pelvis at the acetabulum permits the entrance of the femoral head into the cavity of the pelvis* or in which the head is driven through the obturator foramen. Posterior displacements include the dorsal (including everted dorsal) and the ischiatic type.f Fig. 808.-In measuring from the anterior-superior spine to the ankle there is a constant error, due to abduction or adduction. This is due to the fact that the anterior- superior spine does not lie in the line of the axis of measurement. A reference to the small diagram to the right will make it clear that for this reason the distance b-c in case the acetabulum a does happen to lie on the line of measurement will obviously be more than the distance b c' , which corresponds to the meas- ure obtained in abduction. Natur- ally, when the legs lie parallel, shortening occurs on the right and lengthening on the left (and vice versa), so that the error is doubled and may be very considerable in amount. * Described under Pelvic Fractures. f The classic forms of luxation usually described are-dorsal, ischiatic, obtura- tor, pubic, with various subclassifications, and with various forms classed as atypical. 476 HIP DISLOCATION Anterior luxations include the pubic, suprapubic, obturator, and perineal forms. Fig. 809.-Bryant's triangle. With the patient on the back a perpendicular line is drawn from the anterior-superior spine to the table; the perpendicular distance of the trochanter from this line (that is, the length of the short leg of the triangle in the figure) gives the measure of the shortening. This is ordinarily the best single test of shortening. Fig. 810.-Line dividing anterior from pos- terior dislocations. This line runs through centers of both acetabula. POSTERIOR DISLOCATIONS These are far the commoner class. They may occur as a result of falls, but most often as a result of crushing injuries, as in cases where a laborer is caught by a caving bank or is borne down from behind by a falling bale or cask. The exact mechanism is not always clear, and here, as usually, experiments on the cadaver help but little, for the resisting action of muscles has a definite bearing on the result. We do know, however, that sharp inward rotation of the partly flexed and adducted leg may be a sufficient cause alone, and that a direct backward thrust is often the apparent cause. Allis has ingeniously explained how backward thrust of necessity involves adduction and rotation inward.f Probably this scheme holds true for slow-acting forces. It seems probable, however, that a quick thrust backward, acting as a direct thrust only, may also produce a backward luxation. Ordinarily, the position in which the victim is caught will be found to have been substantially that of Fig. 811. Here adduction inward, rotation, and backward thrust all act together. The important factor in producing rupture of the capsule is inward rotation. In inward rotation the head is pried downward and back- ward against the stretched capsule. Rupture by such forced rotation alone may commonly be produced on the cadaver. It is probably because the tear in the capsule is constantly so pro- duced by rotation that the situation of the tear at the lower back part of the joint is relatively constant in its site. * Bigelow, H. J.: "The Mechanism of Dislocation and Fracture of the Hip, with the Reduction of the Dislocations by the Flexion Method," Philadelphia, Henry C. Lea & Co., 1869. t Allis, Oscar A.: "An Inquiry into the Difficulties Encountered in the Reduc- tion of Dislocations of the Hip " (Gross Prize Essay), Philadelphia, 1896 (pp. 85-87). 477 POSTERIOR DISLOCATION'S Obviously, according to a greater or a less degree of flexion at the time of rupture, the tear will lie a little further forward or a little farther back. When the capsule is once torn, inward rotation tends to displace the head down and backward, while the associated backward thrust in the line of the adducted femur tends to produce back- ward, or backward and upward, luxation, as the case may be. After the head of the bone is once out of the socket it may move in various direc- tions around the edge of the socket, according to the proportionate role played by the various forces acting. Moreover, with the head once started toward the dorsum, the mere weight of the leg gives force enough to carry the head (the end of the short arm of the lever, which has its fulcrum in the Y-ligament) farther upward. Any force used in pick- ing up and transporting the patients acts similarly to displace the head further upward. Therefore, any attempt at exact deter- mination of the forces acting to produce the given result is futile. The head, once out, may go in any direction. Certain checks and obstacles (to be considered later) limit the up- ward progress of the head. Autopsy findings make it pretty clear that in certain cases the head is driven through the capsule, or twisted through, in a different way from that described, since they show the site of escape of the head to have occurred above and behind. This is not, however, the usual route of escape of the head from the socket. Lesions.-Capsule.-The capsule is ordinarily torn through at the back part at or below the site of insertion of the obturator internus. The tear varies greatly in length, largely according to the forces acting after the head has left the socket. It varies also in site, being near either the femoral or the acetabular insertion, or run- ning irregularly between them. Muscles.-The tendons of the small rotators are in close relation to the capsule, and are very apt to be torn with it, as the head goes out or as the upward progress of the head enlarges the capsular tear. Obtura- tor externus, obturator internus, pyriformis, and quadratus muscles Fig. 811.-Diagram to show how a crushing load may cause flexion, adduction, and inward rotation on the right, with abduction on the left. Fig. 812.-Relations of Y ligament. 478 HIP DISLOCATION (or tendons) have all been found torn frequently; even the gluteus maximus is torn at times. In case of the short muscles they are evi- dently torn loose by direct pressure of the head, and according to the point of exit any one may be torn, or all may be torn, by the sweep of the femoral head upward, or they may all escape tearing, leaving the head lying behind and below the obturator tendons, or the head may push its way between the intact obturator internus and the intact pyriformis, or between the pyriformis and the gluteus minimus, without tearing either. Adductors, pectineus, gracilis, gluteus maxi- mus, etc., may also suffer, but these muscles are probably torn rather by stretching in their length than by direct violence. Lesions of nerves and vessels are noted later. Position of the Head.-Posterior disloca- tions are variously divided: perhaps the conser- vative classification is as follows: High dorsal-head up, behind; definitely on the dorsum ilii. Low dorsal-head about between the ischiatic notch and the joint. This is the common type.* Everted dorsal] (in which the external limb of the Y-ligament is torn); the head lies above the joint and well toward the anterior-superior spine. Ischiatic Luxation.-(Probably the same as Bigelow's "dorsal below the tendon.") This class takes in cases in which the head lies low and displaced backward in the direc- tion of the ischiatic notch, or further down toward the tuber ischii; these cases are uncommon. It is to the credit of Malgaigne to have shown that dislocations "on the dorsum ilii" hardly ever really reach the dorsum, and that the run of dislocations lie lower than we ordinarily think. It is indisputable that the head only rarely passes above a line drawn from the anterior-superior spine to the top of the greater sciatic Fig. 813. - Diagram sketch. Relation of muscles to hip-joint: 1-1', Origin and insertion of gluteus max- imus; 2, gluteus medius; 3, gluteus minimus; 4, obtura- tor externus; 5, obturator internus and gemelli; 6, sci- atic nerve; 7, pyriformis. Fig. 814.-Line a-c from the anterior-superior spine to the tip of the tuberosity practically bisects the acetabulum and divides ante- rior from posterior displacements; i. e., any displacement in which the head lies in front of this line must be called anterior and vice versa. The line from the anterior superior spine to the top of the notch (a-6) is the limit shown to be rarely passed by any of the posterior dis- placements, which lie, in fact, much lower than is usually supposed. * The type of luxation called "anterior oblique" is that in which the head lies as in an ordinary dorsal, but the femoral neck has been carried up across the acetabu- lum, and the thigh crosses its fellow in adduction. Bigelow produced this lesion experimentally only: there is no clinical evidence of its occurrence, in his time or since. t There is an especial interest attached to the "everted dorsal " luxation in that 479 POSTERIOR DISLOCATIONS notch. (See Fig. 814.) The misconception in this regard is perhaps in part due to the fact that the pelvis in standing or lying is tilted: Fig. 815.-Dorsal luxation, high (diagram). Fig. 816.-Dorsal luxa- tion, high; from the side (diagram). Fig. 817.-Dorsal luxa- tion, high; clinical attitude (diagram). a dislocation upward goes toward a part of the pelvis that the anatom- ists persistently call backward, which lies, in fact, upward and backward. Symptoms.-In the typical dorsal dislocations we have flexion and adduc- tion, with apparent shortening of the limb, a shortening in part actual, in Fig. 818.-Dorsal luxation, high. Pro- duced on the cadaver by the writer by adduc- tion and forced inversion. Fig. 819.--Old dorsal dislocation with false socket (Warren Museum, specimen No. 1180). the position of the head is about that of the "subspinous" variety of anterior luxation, though the route traversed by the head to reach this position is exactly reversed. 480 HIP DISLOCATION part due to the error of measurement in the presence of adduction. (See Fig. 808.) There is usually sharp inversion-commonly the toes rest on the dorsum of the sound foot. Inversion is greatest in the luxations of the ischiatic type, less in those high up on the dorsum, absent in everted dorsal luxation where part of the Y-ligament is torn. Fig. 820.-Dorsal luxation, median (diagram) Fig. 821.-Attitude in dorsal dislocation, me- dian. Flexion will obviously be more complete in cases where the head lies low down. The same is true of adduction. There is, however, much variation in position. Inversion and flexion, at least, do not seem to vary very exactly according to the position of the head. It must be remembered that the tension of the Y-ligament is the main factor in flexion and inversion; this tension is directly proportionate to the distance the head is dis- placed away from the joint cavity. Fig. 822.-Dorsal luxa- tion, low, extreme adduc- tion (diagram). Fig. 823.-Attitude in dorsal dislocation, median (from below). Fig. 824.-Clinical atti- tude; dorsal luxation, low (diagram). The varying obliquity of the planes of ilium and ischium on which the head rests have a bearing on the position of the head and leg, but there would always be inversion, even if the pelvis were flat-sided, because of the tension of ligaments. As to flexion, the lodgment of the head on the pelvis (with the tension of the Y-ligament) may be the only factor in maintaining flexion-or there may be a resistance of the external rotators, under which the head 481 POSTERIOR DISLOCATIONS is hooked. This relation varies not only with the position of the head, but with the point of exit, with the amount of tearing of these muscles, etc. In dorsal luxations the head is not often palpable; in thin persons it may often be felt vaguely; in fat people it is commonly buried out of reach. The acetabulum is so rarely palpable that it is hardly useful as a landmark. A patient with dorsal luxation is unable to walk or to stand on the leg. Shortening is usually obvious, but, in fact, the anatomic shortening is slight; most of what we see is the apparent shortening of adduction. The patient stands (if he can stand on the sound leg) with a more or less marked lordosis. If he lies down, this lordosis largely disappears, and the abnormal position of the leg becomes more obvious. On testing motion we find that extension, abduction, and outward rotation are sharply and definitely checked. Flexion, increase of adduc- tion, and rotation inward are usually practicable. If flexion is also limited, this should mean-and probably does mean-a luxation above one or more of the external rotator tendons. In dorsal displacements there is loss of the prominence of the tro- chanter and of the hollow behind it; the gluteal fold is higher than normal; the ligaments and the tense muscles prevent palpation of the acetabulum in front. The head may be palpable behind; as a rule, it is not. There is no filling up of the space just below the groin as there is in hip fractures. Measurements carefully made show little shortening. Real shorten- ing is not over % to 1 inch. Decrease of distance from the anterior-superior spine to the tro- chanter is not over 1 inch, and is usually distinctly less. There need be no question as to the presence of inversion or eversion, inasmuch as the foot necessarily moves with the leg. The relations are often made clearer by flexing the knee. Fig. 825.-Crayon sketch from the cad- aver. Dorsal dislocation produced by circum- duction (with very little force) from a thyroid dislocation. 482 hip dislocation The rule usually given is that the head points very nearly in the same direction as the internal condyle at the knee. This is true, but the way the foot points (at a right angle to the pointing of the condyle) gives a handier check, equally reliable. We have, then, a tolerably constant picture in almost all dorsal luxations, as shown in Figs. 816-825. The few exceptions are the "irregular" luxations known as everted dorsal. (See Figs. 826 and 827.) In everted dorsal luxation the femoral head is no longer in contact with the broad surface of the ilium, but has swung clear anteriorly, Fig. 826.-Everted dorsal luxation. Note how the Y- ligament, torn in its outer part, has become wrapped under the head of the femur. Fig. 827.-Everted dorsal luxation. Clinical picture (diagram). Fig. 828.-Ischiatic luxa- tion (diagram). Substantially on the border-ground between anterior and posterior luxa- tions, though here classified as posterior. and the restraint of extension and outward rotation no longer exists; the displacement of the axis of the limb is but slight, and there is a good deal of mobility. There is extreme ou/ward rotation. The attitude is very similar to that of everted pubic luxation, but the dorsal form will hardly show so much eversion. Allis says that in this form direct pressure on the head will cause it to sink, as a " shifted thyroid" will not. Ischiatic Luxations Dislocations known as ischiatic are perhaps a transition form between anterior and posterior, but may be described here. They are the rare cases when the head rests just below and behind the acetabu- lum, on the ramus of the ischium. (See Fig. 828.) The rarity of this form is no doubt due to its instability; obviously, only a little force is needed to shift the head either way-displacement posteriorly is almost certain if the patient lies on his back, owing to the weight of the leg. A few clean-cut cases are reported, however, of real ischiatic luxation. Clinically, this lesion differs from the low dorsal type only in the presence of greater flexion. ANTERIOR DISLOCATIONS 483 ANTERIOR DISLOCATIONS We have the following types- Pubic-including suprapubic (and infraspinous or subspinous); reversed thyroid; obturator; perineal. Broadly speaking, these are luxations resulting from abduction and extension, rather than from the adduction and flex- ion responsible for the dorsal types. The mechanism is not constant, of course, and the ease with which an anterior may be converted into a posterior displacement, and vice versa, should make us cautious in any statement as to the mechanism of production. The escape of the head in both types may be pretty low down; as a rule, it is definitely further downward and forward in the anterior forms. The capsule in anterior luxations is torn below and in front; the encircling rent stops in front at the Y-ligament. The rupture of the capsule in this form of luxation is a result of direct strain in abduction-usually in abduction in the 11 coronal" plane, without flexion. In this sort of trauma we have a bony fulcrum to deal with-that of the neck against the acetabular rim: Abduction of the leg, with this fulcrum, obviously gives ample pressure below to burst the capsule; and this is usually the mechanism of rupture. Simple hyper- extension of the hip may cause-and has caused in indisputable cases reported-a like luxation, with a tear well forward in the capsule. Here the hyperextension gives the force for leverage, while the back of the acetabulum and the Y-ligament give a combined fulcrum, so to speak. Such a mechanism of displacement is rare; the dislocation by abduction is the rule. Lesions.-The capsule is torn in front and below. The Y-ligament is usually intact. The ligamentum teres is torn across or is lifted out of its insertion. Muscle damage is exceptional, apparently. Of course, muscles in the direct path of the head may be damaged, though, as a rule, they are not. The sciatic nerve is not exposed to injury. The anterior crural nerve is so exposed in the pubic forms of luxation, and anesthesia, with some muscle atrophy in the area of its supply, temporary or permanent, results in some cases. Vessel injury is more likely in this form than in the posterior luxa- tions,* but is vastly uncommon. Fig. 829.-Shows how the edge of the acetabulum forms a fulcrum for the neck of the femur by which, in abduction, the head may be pried out of the socket. Fig. 830.-Luxation onto pubes. Clinical atti- tude. Extension, abduc- tion, external rotation, prominence of the head in the groin (diagram). * The only two cases of damage to the great vessels of which I find record (Deboue, and one case noted in a report of the fourteenth Prussian army corps, 1878) were both pubic luxations. 484 HIP DISLOCATION Obviously, luxation by hyperextension stretches the vessels across the displaced head in dangerous fashion; carried far enough, it must cause vessel rupture almost of necessity. In the common trauma by abduction there is but little chance of this complication, for the head lies on a deeper plane than the vessels. Compound luxation is far more apt to occur with anterior luxation than with the posterior, though it is always very rare. Position of the Head.-The head may lie over the obturator Fig. 831.-Crayon sketch from the cadaver on which a pubic dislocation was produced by manipu- lation (extension, abduction, outward rotation, and leverage). foramen, or, driven to the limit of the length of the ligament, it may go so far inward as to present in the perineum. Displaced forward, it not uncommonly lies on or just below the pubic ramus; rarely, it passes the ramus and may lie under the Y- ligament, which is stretched across the front of the femoral neck. (See Fig. 833.) Or, by outward rotation and adduction, the head may come to lie at a point close under the anterior spine; in this case the position is very like that of the everted dorsal form noted above. Symptoms.-In all cases of anterior luxation the limb is extended more or less fully, in contrast to the posterior forms: extended in more or less marked abduction. ANTERIOR DISLOCATIONS 485 Unlike the dorsal luxations, this anterior dislocation does not abso- lutely interfere with walking, though such walking must be clumsy and accompanied by much pain. There are no fixed lines or boundaries between classes and subclasses, clinically, in the anterior luxations. The head escapes under an abducting force at a point so far forward that it does not tend to slip up and backward, and we find a displace- ment forward that carries the head to any point between the ischial ramus and the pubes, or even to a point under the anterior-inferior spine. Fig. 832. -Suprapubic luxation showing bones (dia- gram). Fig. 833 .-Subspinous dislocation. By adduction of the leg, the head has been forced outward the Y-ligament lying closely applied to the front of the neck. Fig. 834.-Everted ante- rior (thyroid) luxation. Posi- tion of bones (diagram). Compare this and the next fig- ure with Figs. 826 and 827, the everted dorsal type, in which the position is nearly the same, reached by opposite routes of rotation. In the everted thyroid the Y-ligament is wrapped around behind the neck; in the everted dorsal it is wrapped around in front of the neck. All displacements of this sort-whatever they have been called by zealous lexicograph- ers-are in essence the same, and the treatment is the same, save for slight modifications. For convenience, we divide the displacements into pubic (with its variants) and obturator and perineal types. Pubic Luxations.-Here we have displacement of the head up and forward. Eversion is marked, and cannot be corrected. There is definite fixed abduction, though this is less than in the obturator and perineal cases. Adduction is impossible. The leg, seen from the side, is in nearly full extension. There is apparent lengthening. The prominence of the trochanter fails; the trochanter lies near to, sometimes actually in, the acetabulum. The acetabulum is not palpable, with rarest exceptions. The head lies beneath or even internal to the vessels, and is pal- pable-and usually visible-as a fullness in the groin, even if its outlines are not to be made out clearly. The actual position of the 486 HIP DISLOCATION head varies; it may-usually-lie below the ramus of the pubes, or it may ride up on it, in which case its presence there is very readily made out. Dislocation of the head over the brim of the pelvis implies very extensive capsular damage; it is rare. Fig. 835.- Everted anterior luxation. Clini- cal attitude (dia- gram). Fig. 836.-Obturator luxation (diagram). Fig. 837.-Obturator luxation. Clinical attitude (diagram). The farther the head rides upward, the less will be the permanent abduction, and the greater will be the rotation outward. Suprapubic Luxation.-If the head passes over the brim, we have Fig. 838.-Obturator luxa- tion. Clinical attitude from be- (diagram). Fig. 839.-Obturator luxation. Relation of head to ligaments. Internal branch of Y-ligament alone is taut. Outer branch of Y and pubo-femoral liga- ment (a) are both slack. Fig. 840.--Luxation into the perineum. Position of bones (diagram). the rare suprapubic form. In this case the prominence of the femoral head in the groin can hardly leave a doubt as to the diagnosis. In place of slight flexion of other anterior forms we have a position of full extension. Abduction is slight. Infraspinous or Subspinous Luxation.-This is a form in which adduction has forced the femoral head to a point close to the anterior- CENTRAL LUXATION 487 superior spine, where it is firmly held by the Y-ligament, under which the neck has been forced. (See Fig. 833.) There is no permanent abduction; no flexion; there must be definite outward rotation. Everted Anterior Luxation {Reversed or Everted Thyroid).-In the cases known as reversed thyroid, the head has come to a position where it is hooked over the Y-ligament; there is no longer any firm fulcrum, nor any ligamentous resistance to maintain abduction, but the exter- nal rotation is extreme. (See Fig. 834.) The position is like that of the everted dorsal, but the eversion is greater, and there is the possi- bility of abduction to a greater extent than in the dorsal form. The production of this form of displacement is by excessive outward rotation from the pubic or suprapubic form. (Com- pare Fig. 826, "everted dorsal.") Obturator Luxation.-In obturator luxations we have some flexion,* abduction, and rotation outward. Measurements show an apparent lengthening, but this is due, in the main, to the error of measurement, unavoidable where there is any ab- duction, rather than to real displacement. Flexion, properly speaking, is not present in any considerable degree; lateral flexion of the everted leg should be described not as flexion, but as abduction. The head of the femur is not ordinarily palpable, though some fulness may indicate its position. The empty acetabulum, as a rule, is so covered by muscles and by the tense fascia lata that it can not be made out. The prominence of the trochanter is lost; sometimes the trochanter is not palpable at all. Motion is practically nil. Adduction and inter- nal rotation are entirely impossible. Perineal Luxations.-Perineal luxations show like signs, save that abduction is more marked. The diagnostic sign is the presence of the head, clearly palpable or felt as a marked resistance, in the perineum. The position is that shown in Fig. 841. CENTRAL LUXATION This name is given to cases in which the femoral head is driven inward into the pelvis. In most cases the head goes through the smashed acetabulum, and penetra- tion is only partial. These cases show no constant deformity save Fig. 841.--Luxation into the perineum. Clinical atti- tude (diagram). F Fig. 842.-Cen- tral luxation of femur. The head is driven directly inward, sub- stantially, without ab- duction or adduction, flexion or abnormal rotation in the cases I have seen or found ac- counts of. Clinically, there is some loss of motion, and loss of prominence of tro- chanter; sometimes, a little shortening. * Allis explains this flexion by the impinging of the trochanter on the edge of the acetabulum. I have had but one case, a late case treated by open reduction- which showed exactly the classical picture. 488 HIP DISLOCATION loss of the prominence of the trochanter, and slight-and incon- stant-malposition of the limb. There is a little shortening. The detail of these cases is considered under Pelvic Fracture. A few cases are recorded in which the femur has penetrated through the obturator foramen, an exaggerated obturator form, so to speak. The deformity is approximately that of the obturator luxation. The head may be palpable by rectal examination. Reduction is by direct traction and leverage; in these cases the ligaments are gone, and need not be considered. REDUCTIONS Inasmuch as the reduction of all typical dislocations (whatever may be the precise position of the head) depends on certain broad principles, it will be well to consider, first of all, the general conditions underlying the reduction problem. The old-time methods of reduction all aimed at direct reduction. All luxations were reduced (or equally often not reduced) by traction carried out with the intention of dragging the head from its false posi- tion to and into the acetabulum in a direct line. In this laudable effort our predecessors seem to have used a degree of force, exerted through blocks and tackle, hardly paralleled except in the most modern "blood- less" surgery. Such methods succeeded either by accident or by rupture of liga- ments. The trouble with such methods is the excentric arrangement of the hip-joint. The joint has its point of rotation at a (Fig. 843), its line of weight-bearing or of traction, as the case may be, in the line b-c, and its strongest ligament running from d to e. If the hip is dislocated backward, the relations are about as shown in Fig. 844. If the dislocation is forward, Fig. 845 shows the conditions present. Obviously, traction in the line b-c is not going to give reduction in either case, unless something gives way. Obviously, it is worth while to modify reduction efforts so that the Y-ligament (d-e) need not be ruptured. The recognition of the necessity of considering this ligament far antedates Bigeiow, but it was Bigelow who first clearly brought out the dependence of all (empirically) successful methods of reduction by "circumduction" on the relations of this ligament, and he showed that by using the ligament as a fulcrum, reduction might be accom- plished with a minimum of force and damage. More recently, Allis, of Philadelphia,* has worked out fresh details and has devised curiously simple and effective manoeuvers of reduction, which have been amply proved in practice. Allis pointed out also that sweeping circumduction movements, even when effective enough in reduction, involve unnecessary damage to the soft parts, avoidable by more careful manipulations. * I have found his methods preferable in my few cases. Once, in a dorsal luxa- tion, I failed with the Allis, but succeeded by circumduction. Still I think Allis has the right of it. 489 REDUCTIONS For our consideration today the practical methods are first those of Aflis; if these fail, the circumduction methods of Bigelow are to be tried; the older methods, involving greater force, seem to us now far worse than reduction by open incision, which is the modern last resort in late or otherwise desperate cases. The key to reduction is the "Y-ligament"-the iliofemoral liga- ment. It is merely a stronger part of the capsule, but a part almost always intact after dislocation, and most important through its strength and its location. It runs from the anterior-inferior spine of Fig. 843.-Shows the excen- tric arrangement of the hip-joint in relation to the limb; a, Ace- tabulum; a', head of femur; b, upper end of shaft; c, shaft; d, origin of Y-ligament; e, inser- tion of Y-ligament. The line d-e-the Y-ligament-the main obstacle to the displacement of the head, is not in line with the axis of the neck of the femur or the limb, as shown in lower diagram. Fig. 844.-Shows the same points as Fig. 843, with relation to posterior luxa- tion. Here again the Y-liga- ment d-e is in no relation to either axis and a pull in the line of the shaft b-c has no tendency whatever to reduce the dislocation. Fig. 845.-Same cond tion as Fig. 844, with anteri luxation. Same remarks ho as to the uselessness of a pi in the direct line femr the ilium down to the anterior intertrochanteric line. (See Fig. 812.) Ordinarily, it may be considered in practice as a single band; anatomic- ally, its insertion is very broad, and may be considered perhaps as a bifid insertion. In normal conditions the ligament limits hyperextension and out- ward rotation. In luxations it becomes the shortest bond between pelvis and femur; it limits motion and determines the characteristic positions of abduction and adduction and of rotation in or outward. In the posterior luxations it is drawn tense before the head jumps out of the socket, and its tension determines the range of adduction, of flexion, and of inward rotation. 490 HIP DISLOCATION In the anterior cases this ligament plays little or no part in the mechanism of production of luxation, but the bony pelvis and the liga- ment are the fixed points of support afterward, and their relations determine the abduction and the rotation outward. (See diagram, Fig. 845.) Let us take first the posterior luxation-the head has slipped out below and behind; the head has moved backward; the Y-ligament, not to be stretched, holds the femoral neck close in; flexion, adduction, and inward rotation was necessary consequences. Extension is impossible because of the resistance of untorn muscles above in the path of the head. Abduction is impossible because the head is fixed at a point well behind that to which the restraining Y-liga- ment is attached; external rotation also would require stretching of the ligament, already drawn tense by the backward movement, and the ligament will not stretch. If the displacement is anterior, the ligament is also put on the stretch, but the firm support of the head is on the lower and front part of the pelvis; hence there is abduction, and adduction is impossible; the head usually lies forward of the line of pull of the ligament, hence there is little or no flexion; and as the head is carried forward and farther forward on the oblique plane of the obturator fascia, or even onto the pubes, the base of the neck can move but little, therefore external rotation must result. (See Fig. 836.) The manoeuvers for reductions based on these data* are, when reduced to simplest terms, about as follows: FOR POSTERIOR LUXATIONS (DORSAL, HIGH OR LOW) Gravity Method.-Reduction of dorsal dislocation may at times be accomplished by the simple weight of the limb. The patient is placed on a frame-face down-and the leg and thigh are left to hang down; there is to be no support except at the ankle. Favoring this reduction we may apply pressure to the leg just below the bent knee, and may help with rocking rotations of the leg. Reduction, if it occurs, is not immediate, but occurs after muscle relaxation. Obviously, if it suc- ceeds, this is the least forcible and most desirable method. "Direct" Method (Allis).-(1) Flex, using some traction down- ward and forward. (The head moves down to a point not far from its point of exit.) (2.) Lift; if this lift does not produce reduction, then rotate inward to relax the capsule. Now the head may be brought forward, but if it strikes any resistance, this resistance (hamstring tendons or sciatic nerve) may best be avoided by outward rotation. It is most important * Those interested in the history of the development of methods, particularly the neglected work of Physick, N. Smith, Reid of Rochester, and Gunn, of Chicago (all antedating Bigelow) are referred to the interesting chapter in Hamilton, "Frac- tures and Dislocations," third edition, pp. 634 ff. FOR POSTERIOR LUXATIONS (DORSAL, HIGH OR LOW) 491 not to use much force. After the movements of rotation to clear obstacles, we must lift again. (3) Extend. Extension may not be necessary. If necessary, it should be done gently, and not forced against definite resistance. If the head does not pass into place without great force, it is best to go through the reduction again from the beginning, rather than use great force. As a rule, the head passes suddenly to its place under manipulation No. 3, if not before. In case we have to deal with a dor- sal luxation of the uncommon type, where we have not only a high situation of the head, but a high tear in the capsule and a protrusion of the head high up, just above or below the pyriformis, we must modify the manipulation in so far as we must flex the leg less; the lifting is to be, not vertical, but more nearly in the line of the body. The especial advantage of Allis's method is that it is relatively free from danger if carefully applied. No great force is admissible, and the temptation to use too much force is far less than with the sweeping Fig. 846.-Reduction by gravity and slight downward thrust in pop- liteal space; the simplest method of reduction of the posterior type. Fig. 847.--Allis's reduction for dorsal dislocation. Flex, lift, rotate in and out, lift again. circumduction motions. There is no objection to fixation of the pelvis by the unshod heel of the operator or by strapping the pelvis to the table. (See Fig. 849.) Some fixation by the hands of assistants is indispensable unless straps are used. 492 HIP DISLOCATION Circumduction Method (Bigelow). (1)-Flex (relaxing the Y- ligament). (2) Rotate inward (starting the head downward behind the acetabulum, and clearing it of torn muscles, etc.). (3) Adduct (still further relaxing tissues). Fig. 848.-Lift; rotate inward; rotate outward strongly and lift The rotation manoeuvers in this reduction are varied to meet the exigencies of the case. Forced rotation in either direction is not usually necessary. (Allis's reduction.) (4) Abduct. (5) Rotate outward (bringing the head down close under the tear in the capsule, and to the edge of the acetabulum). (6) Extend (thus prying the head into place, using the Y-ligament as a fulcrum). (See Fig. 851.) With a bit of practice these motions can all be merged into one continuous rotatory sweep-a real circumduction. It is as pretty as the "tour de maitre" with the urethral sound, and open to the same objections of possibility of damage, not only to muscles, but particularly to the sciatic nerve. When it works smoothly, there is nothing to be said against it, but it must always be used with a good deal of caution. The three methods noted cover the procedures for dorsal luxations. Here and there there are cases of high luxation in which the head has originally escaped from the joint either above or just below the pyriformis. Such cases are rare. In very high dorsal luxations (with probable high point of exit) the direct method carried out with less than the usual flexion and more drag down and forward, is in order. In case of "everted dorsal" luxation we must convert the displace- ment to the inverted dorsal (high) and then must proceed in the usual way. This conversion is effected by flexion and adduction, combined with inversion. Fig. 849.-Bands to strap pelvis to table to facilitate reduction (according to Allis). FOR POSTERIOR LUXATIONS (DORSAL, HIGH OR LOW) 493 High luxation may become "everted dorsal" in type. In case of difficulty in the usual manoeuvers after conversion from everted to inverted luxation, this point must be borne in mind, and the reduction Fig. 850.-Rotation versus circumduction. The sketch on the left shows a rotation movement on the axis of the femur. Such a movement, carried out without moving the knee much from its place, will occur substantially on the head of the femur as an axis. A circumduction movement, on the other hand (see sketch to right), in which the knee is moved widely, occurs about the Y-liga- ment as a fulcrum, about which the head of the femur describes a smaller circle, corresponding to the motion at the knee. Fig. 851.-Bigelow's reduction of dorsal dislocation by circumduction. Beginning at lower left-hand corner; flexion, rotation inward, adduction (with increased flexion), abduction, sharp out- ward rotation, extension. Properly carried out, these motions form a single sweep; reduction occurs ordinarily just at the beginning of extension. may be modified as is outlined for the high luxations. In such cases downward traction is obviously essential to replacement. 494 HIP DISLOCATION In other cases, through extensive rupture of the external rotator muscles, an everted dorsal dislocation may be produced out of an ordinary dorsal displacement. In either case inward rotation, facilitated by moderate flexion and adduction, will produce a dorsal inverted. In the apparently similar anterior subspinous forms, such an inversion manoeuver meets impracticable resistance. In case of dorsal luxations present- ing difficulty of reduction it has been recommended that the tear in the capsule and the gap in the rotator muscle group be increased, in order to facilitate replacement through an enlarged opening. The method of procedure to enlarge the tear in the capsule is by flexion, adduction, and forced extension. This seems to have been a successful manoeuver in some cases, a manoeuver justified in rare instances, but not lightly to be undertaken without considering that muscles and capsule are to be torn, and that the sciatic nerve may be injured. Fig. 852.-Test of reduction-according to Allis, with the limb in the position shown if the foot is dropped it will go to the posi- tion of the heavy dotted line, but, owing to the elasticity of the hamstring muscles, will rebound for an instant to the light dotted line. This elasticity does not so act unless the head of the bone is in place. Reduction of Anterior Luxations In anterior displacements we have a problem essentially different, and this difference brings us back again to the Y-ligament. In dorsal luxations we have a relation roughly corresponding to Fig. 844, with the Y-ligament free as a "strap" fulcrum. In anterior luxations this ligament lies across the neck, and in pubic luxations it lies closely applied to the neck (see Figs. 832 and 833), and in the cases with extreme eversion, the ligament is wound about the neck. (See Fig. 834.) Moreover, we are here dealing with a class of luxations in which a bony fulcrum is decidedly an element in the act of luxation, but cannot be used in reduction. This fulcrum is the upper edge of the acetabulum, with which the neck comes in contact in extreme abduction. In luxation, head and neck move inward to a point where no bony fulcrum is available in reduction. Obviously, the simplest reduction is to bring the head opposite the tear in the capsule through which it has been pried out, and then to thrust or pull it back. Allis's scheme of reduction aims at just this. His manoeuver is as follows: 495 REDUCTION OF ANTERIOR LUXATIONS Allis's Reduction.-Abduct the leg sharply in slight flexion. Let an assistant fix the head with his fingers. Exert moderate traction in the line of the femur. Adduct. (Figs. 853, 854, 855.) This is really a reduction by leverage. The leg is the lever, the fingers the fulcrum, and the head, already brought opposite its place of exit, is pried gently into place. I have found this method efficient in my few cases, and have not used the circumduction plan. Allis' method has the advantage of being applicable to cases with both fracture and luxation. G. H. Monks has lately successfully treated such a complicated case in this way. If this scheme does not work, we may try the "indirect" method by circumduction, with rotation in or out, the method in which the Y-ligament is used as a fulcrum to "cram" the femoral head into place, methods associated with Bigelow. Reduction by Inward Rota- tion.-Flex the thigh, but not to a perpendicular. Abduct (with traction down- ward). Adduct. Rotate sharply inward. Carry down into extension. (See Figs. 857, 858.) In this method the Y-]igament is the fulcrum, and the head, car- ried down and outward in the abduction and adduction movements, is pried into place by rotation and extension. The great drawback to this method is that anterior are very apt to be converted into posterior luxations, with increased laceration of the capsule. This may, in a measure, be guarded against by a lift just prior to extending. If the reduction seems to require force, we should begin again with more flexion, and with rotation attempted only after adduction is Fig. 853.--Anterior luxation. Fig. 854.--Reduction of same; first manoeuver according to Allis. Traction in the line of the abducted femur; pressure outward and backward on the prominent head of the femur exerted by the two clenched hands. Fig. 855.--Second manoeuver of reduction; the leg is adducted, the pressure of the fists over the femoral head giving a fulcrum. The leverage so obtained, plus the direct thrust of the head to- ward the acetabulum, accomplishes the reduction. Fig. 853.--Anterior luxation. Fig. 854.--Reduction of same; first manoeuver according to Allis. Traction in the line of the abducted femur; pressure outward and backward on the prominent head of the femur exerted by the two clenched hands. Fig. 855.--Second manoeuver of reduction; the leg is adducted, the pressure of the fists over the femoral head giving a fulcrum. The leverage so obtained, plus the direct thrust of the head to- ward the acetabulum, accomplishes the reduction. 496 HIP DISLOCATION complete. In this, as with all the circumductions, the reduction goes better if all movements are combined in a given tempo in one sweep, but this is possible only with some little practice. This method, by rotation outward, seems to have a better record clinically than the appar- ently more rational method by rota- tion inward, and is free from the risk of converting an anterior into a pos- terior luxation. It is purely a question of whether the head, as it is swept around below the joint, finds an easier path back- ward into the joint or into the hol- low beneath; in other words, whether it jumps the lower acetabular edge or not. If it does, well and good; if not, we have a backward luxation, reducible enough, but already associated with a good deal of damage to the soft parts. Reduction by Outward Rotation.- (1) Flex the thigh, but not to a perpendicular. (2) Adduct. (3) Carry knee down and inward. (4) Rotate outward. (See Fig. 859.) Flexion relaxes the Y-ligament, especially the inner limb, and moves the head closer to its point of escape. Adduction brings, or should bring, the head close to the rent in the capsule. Rotation outward (the thigh still flexed) pries the head into place, the Y-ligament acting as a fulcrum. Slight traction forward (upward as the patient lies on his back) will help the head into place. It is very important in this, as in other methods, to avoid any pressure backward in the line of the axis of the bone. Hence the rule never to place the hand on the knee in front. In this and in the preceding method too much flexion drives the head toward the thyroid foramen. The obstacle to this reduction by out- ward rotation is the Y-ligament, or rather its internal limb. Either insufficient flexion combined with the adduction, or outward rotation begun before the head has moved under this ligamentous band, may bring the head up against the ligament, or up and over it in front. Fig. 856.-Upper figure shows anterior dislocation seen from above. The lower fig- ures show Allis's reduction. The figure to the left: Traction in the line of the abducted femur, with pressure outward and backward on the femoral head (see arrows). To the right is shown the adduction which, with continued pressure on the head in the same direction, accomplishes the reduction. Fig. 857.-Reduction of anterior dislocation by internal rotation (bone diagram). If the bone in the position shown is rotated inward and slightly extended, it is evident that it must do one of two things--either slip into the joint underneath the Y-ligament or slip around back of it behind the ligament. REDUCTION OF ANTERIOR LUXATIONS 497 Other Methods of Reduction.-Other methods seem hardly worth mention in regard to reduction of the usual forms of luxation forward, save that irregular rocking and slight rotatory motions under traction may materially assist the result in all the methods above described. Fig. 858.-Anterior dislocation; reduction by inward rotation (Bigelow): 1, Flex but not to a perpendicular; 2, abduct and flex; 3, adduct in flexion; 4, rotate sharply inward; 5, carry limb down- ward into extension. Something perhaps may be said for the old method of traction and adduction against countertraction, and across a fulcrum represented either by the operator's foot in the groin, or by a sling similarly placed held by an assistant. (See Fig. 860.) In both modes remember that traction in abduction must precede adduction. I know of no reason Fig. 859.-Anterior luxation; reduction by outward rotation: 1, Flex, not to perpendicular; 2, adduct; 3, carry knee slightly down and inward, and reverse rotation, rotating outward; 4, at the same time extending the leg. against the employment of this method where other methods chance not to work. The method has some record of successful employment. In case the head rests on the pubes, we must first fetch it clear of bony obstacles by downward traction and abduction, then proceed as above described. 498 HIP DISLOCATION Suprapubic Luxation.-If the head lies over the pubic brim, traction in moderate abduction without flexion will bring it down. Until it so comes down, flexion, abduction, direct traction, etc., are of no avail, and may do harm. Reversed Thyroid.-In case we have to deal with an extreme everted displacement, the head must be brought back, by careful internal rota- tion with very slight flexion and under traction, to the usual position of a suprapubic, then of a pubic luxation; the reduction is then completed as in an ordinary pubic luxation. Fig. 860.-In case a stronger lift is desired, the operator's bare foot may be put in the groin or over the pubes, thereby greatly increasing the force applied without changing the method of reduction. Obturator Luxation.-The reduction is essentially the same as with the pubic, save that in the direct method traction is to be employed in more marked abduction, and abduction is to be made more marked than already exists in order to clear the jammed head; some increase of existing external rotation is likely to help toward the same purpose. According to Allis, in all cases of anterior displacement at the instant the head left the socket the shaft was in abduction at right angles to the trunk; hence he recommends traction in this line, accom- panied by rocking motions, to retrace the last step in the displacement. Certainly in the thyroid cases this is wise advice. Perineal Luxation.-This is an exaggerated form of thyroid luxa- tion; for its reduction the first thing needful is to reduce it to the COMPOUND LUXATION AT THE HIP 499 thyroid form. This is to be done by traction outward with the leg at a right angle (or more) with the body. This traction in the axis of the leg may be combined with gentle rotatory and rocking movements. Once the head starts outward, we have only a thyroid luxation, to be dealt with as usual. LUXATION WITH FRACTURE OF THE FEMUR The difficulty in diagnosis is not to ascertain the presence of the fracture, but to be sure of the dislocation-unless the fracture occurred in attempted reduction. The only signs available will be those of the direct recognition of Fig. 861.-Compound anterior dislocation of the femur (drawn by the writer by the kind per- mission of Dr. David W. Cheever, from his original photograph). Note the extreme outward rota- tion shown by the position of the knee and lower leg, as well as by the position of the extruded head. The nipple-like projection on the head of the bone is the torn and retracted ligamentum teres. landmarks, the presence of mobility and crepitus, and the evidence of the skiagraph. I think it fair today to throw aside all the older procedures; I have not had to meet the condition, but should not hesitate to cut down on the upper fragment, to drill a hole in it, insert a hook, and try to reduce, as is done in fracture luxation at the shoulder. Failing in this, I should feel that an open arthrotomy was justifiable. It is true that some cases have been reduced by the routine methods without incision (in anterior luxations always, I think),* and one would perhaps be wise to try this first. Such cases are very rare. Cheeverf lists eight cases. Of these, four were of the pubic type, two obturator, one dorsal, one ischiatic. COMPOUND LUXATION AT THE HIP * Dr. G. H. Monks, of Boston, recently reduced a case of anterior luxation (suprapubic) with a fracture just below the trochanters, using traction and pres- sure, much as in Allis's reduction scheme. t Cheever: Boston Med. and Surg. Jour., 1891, cxxiv, 523. 500 HIP DISLOCATION Of these eight, six died either from associated injuries or from sepsis following reduction, or, more often, after excision of the head and replacement of the stump of the femoral neck. Many of these cases antedated any real understanding of asepsis. Probably today, in a period in which our methods should insure at least a relative asepsis, we should do less excisions and more reductions with disinfection and with all antiseptic precautions. Time alone can tell whether results will be different, but I trust the years to come will show a less melancholy total in these cases. OLD DISLOCATIONS OF THE HIP Reduction of old dislocation has been reported in several cases as late as six months after the injury, accomplished by usual methods of manipulation.* Today we would be apt to consider open opera- tion rather than to take the ever-present risk of breaking the femur or doing other serious damage in the forcible manipulations unavoidable in such reductions. AFTER -TREATMENT In the ordinary run of cases a reduced hip luxation is not apt to recur. Fixation by sand-bags or by tying the knees together is ordi- narily sufficient, and need be continued only for two or three weeks. In a very few cases there is a tendency to reluxation. These are supposed to be cases in which the acetabulum has been broken in such fashion that its rim no longer furnishes an obstacle to luxation. While this seems to be an assumption, it is probably correct in some cases. (See also Fracture of Head of Femur, p. 506.) Whether acetabular fracture is the cause or not, certainly any luxation that tends to recur calls for care, and particularly for long fixation for repair of bony and fibrous tissues. The ordinary luxation admits of weight-bearing, beginning at three weeks;! a luxation that tends to recur would hardly be safe to trust under eight weeks. It goes without saying that a luxation with fracture must be sub- jected to the fixation and other after-treatment suited to the fracture, usually much longer than any luxation would call for. PROGNOSIS Reduced hip luxations leave little disability usually. Any tendency to reluxation is very rare4 There seems to be little or no trouble from the muscle-tearing that often occurs. * Hamilton: "Fractures and Dislocations," third edition, p. 679. t After reduction, there is no mechanical reason why any hip that has been dislocated cannot bear weight. The period of rest prescribed is essentially pre- cautionary, a time given the capsule and other damaged structures for repair. J In "Surgical Observations with Cases and Operations" (J. Mason Warren, Tichnor & Fields, 1867, p. 365, case ccxv) is described an interesting case of the sort, cured by proper immobilization after frequent recurrences. 501 OBSTACLES TO REDUCTION Some weakness commonly persists for some time. Traumatic arthritis may result, especially if reduction has been long delayed. To this complication older patients are more liable than the younger. Even in unreduced dislocation the functional result is apt to be very tolerable. Some part of the restriction of movement disappears with time; a new hip-socket develops, and the patient is at least able to walk after a fashion, and obtains a better result than is seen, for instance, with ununited hip fracture. OBSTACLES TO REDUCTION There is no blinking the fact that reduction of a dislocation at the hip often presents difficulties. In the old days such failure was appar- Fig. 862.-Three types of rupture of the capsule: a, Close to the acetabulum; b, across the middle of the capsule; c, close to the insertion; this last may give at times a lax, sleeve-like capsule, into which reduction is very difficult. ently very common. Today, even under the best methods, in the hands of skilled operators, such failure is by no means unknown. What are the causes of failure? It is of no use for us to consider the causes of failure under obsolete methods of treatment; for us, the question is of the obstacles that present themselves to those practising modern methods. The Capsule as an Obstacle.-The capsule may be torn near its origin from the pelvis, or near its femoral insertion. It is not likely to offer any resistance, save in the cases where the tear is small and our efforts to bring the head to the point of exit are not very successful, or where much of the circumference of the capsule has been torn far away from the acetabulum, leaving a sort of cuff of some length. This condition has been reported in several autopsies. In case of failure by other methods, in the first case, we may try 11 carrying the head of the bone toward the opposite side of the socket, and thus enlarging the slit" (Bigelow). This will not help but rather 502 HIP DISLOCATION hinder in the case of an obstructing cuff. Allis has had good luck, experimentally, in this type of obstruction by rotating the leg and dragging it forward as it hangs over the edge of a table-the body being in the prone position. Unfortunately, there is no way to differentiate between the forms of capsular obstruction clinically. All we know is that there is an obstacle to reduction or to free motion after an apparently complete reduction; Fig. 863.-If the tear in the capsule in front is close to the acetabulum, a, the capsule will probably preserve its normal relations during reduction, b; if, on the other hand, the tear is some distance from the acetabular edge, c, a fold of the capsule is very likely to be carried in with the joint in reduction, d. there may be a tendency to recurrence of luxation. Looping up of the sciatic nerve may be definitely excluded, but there may be either muscle or capsule in the way, and we cannot tell which. If the obstacle is a direct obstacle to reduction, a resort to the reduc- tion in prone position may be wise, or we may have to enlarge the rent, risking any damage. If the head is in the joint, but does not move freely, we should try the method of "cleaning the socket" proposed by Allis. (See Fig. 864). Fig. 864.-Shows how fragments of the capsule caught in the joint can be cleared out by the action of the joint-head by repeated motions of abduction and adduction. As to the clinical success of these manceuvers, nothing definite can be said, for the diagnosis is never certain. On the cadaver, they work. Muscles.-The important relation of intact muscles to possible difficulty of reduction is in the high luxations. We may have the head emerging just below the pyriformis or just above it. Obviously, in such case we must depend rather on traction than on circumduction in the first motion of our attempts to reduce. Any forcible attempt at reduction on typical lines can result only in unnecessary tearing of muscles OBSTACLES TO REDUCTION 503 It is alleged that muscles-torn muscles-may constitute a direct obstacle to reduction, in that muscle fragments, especially of the obtura- tor externus, may fill up the acetabulum or obstruct the way into it. Probably this is true. In case of a reduction, apparently successful except that complete extension is not practicable, we may assume, if sure that the sciatic nerve is clear, that muscle or capsule interposition Fig. 865.-Shows how the sciatic nerve may be caught up over the head of the bone in a dorsal luxation. The head of the bone has been driven between the nerve, (a), and the biceps tendon, with which the nerve is in close contact at this level. is the cause. If this is so, no course is open to us save repeated move- ment of rotation directed toward destruction of such muscle portions,* and the manoeuver directed to cleaning out the socket of capsular fragments. I suspect this condition is rare, clinically, though common in cadaver experiment. Fig. 866.-Shows how the nerve may be caught up not in the luxation, but in the reduction. The nerve (a-&) is caught up over the front of the femoral neck. This condition may not only result in severe nerve damage, but prevents complete extension in reduction on account of the actual shortening of the nerve. Tearing of the longer muscles, adductors, gracilis, glutei, etc., offers no obstacle to reduction. Sciatic Nerve.-In posterior luxations we may have the sciatic nerve- (a) Merely bruised in luxation or in reduction. (&) Caught up in the luxation. (c) Caught up in reduction. * In itself muscle tearing seems not to be very important. So far as I know, no connection has been traced between such muscle-tearing and any later disa- bility. Muscle tears in general do, in fact, heal with some disability, and probably this rough rule works in muscle tears from hip luxation, as well as elsewhere. 504 HIP DISLOCATION If the nerve is involved in the luxation primarily, it is not an ob- stacle to reduction, but is a serious complication until reduction has relieved the nerve tension. The position is that of Fig. 865. Between this lesion and mere bruising of the nerve we have no reliable diagnostic points, though the continued stretching must in the end give more pain and more functional damage than simple contusion. The nerve may be caught up as the femur is displaced, either in direct backward luxation, or in cases where backward displacement is secondary to an escape originally forward. The mechanism is a picking up of the nerve by the head as it moves back and out. The nerve has been found ruptured; it may, however, lie across the back of the neck without having been very seriously damaged. No signs beyond those belonging to damage to the nerve itself would be present. Such an entanglement would almost necessarily be reduced by the flexion in- volved in any proper attempts at reduction. In the anterior luxation the nerve is not exposed to trauma. The sciatic nerve may be caught up in attempts at reduction of posterior dislocations. The nerve is most apt to be caught up in circumduction movements. It lies close to the origin of the hamstring tendons, and somewhat tied to them by areolar tissue, and is nearly in the path of the head as it is moved in circumduction. If the first trauma has separated its loose attachments, it may very readily be picked up by the moving head and carried in front of it. At the completion of reduction it will then lie stretched across the femoral neck in front (Fig. 866). If this accident happens, we have two signs of it: First: The tension of the nerve prevents complete extension; but this sign is also common, though in less degree, to the interposition of capsule or of muscle. Second: There will be a tendency to flexion of the knee, and on attempts at extension of both hip and knee the sciatic nerve may be felt as a tense cord in the popliteal space. This can mean nothing else but a looping-up of the nerve. Obviously, redislocation is indispensable. After the head is again out of the socket, inward rotation (carried to the extreme) will free the nerve, and flexing the knee will render it slack, but this does not replace it. We must try abduction and adduction and rotation (avoiding flexion), and then reduce the luxation without flexion. If, even so, we cannot reduce the luxation without catching the nerve, Allis's suggestion seems practicable and certainly justifiable-namely, to redislocate and then cut down on the nerve in the popliteal space, and draw it tense over the finger while the dislocation is again reduced. I do not know that this has been tested clinically. If it should fail, our only resource would be arthrotomy and open reduction,-a serious operation,-but far preferable to the prospect of permanent flexion with inevitable degeneration of the nerve and paralysis or paresis of the muscles it supplies. CHAPTER XXIII HIP FRACTURES Hip fractures are clinically divisible into- (1) Fractures of the head. (2) Fractures of the neck. (3) Separation of the epiphysis. (4) Fracture of the base of the neck. (5) Fractures through the trochanteric region. Fig. 867.-Grip devised by Dr. Gordon Morrill for exerting traction on the foot. The operator uses his weight to pull with, and considerable traction can be kept up in this way for a long time with very little fatigue. (6) Fractures just below both trochanters-(a) Transverse, or nearly transverse fractures; (6) "spiral" fractures. (7) Epiphyseal separation, or fracture, of the great trochanter alone. (8) Separation of the lesser trochanter alone. FRACTURES OF THE HEAD OF THE FEMUR So far as our data go, these occur rarely as independent fractures, but as complications of luxations, particularly of luxations by direct thrust. Save for the accidental determination of crepitus, for the ease 505 506 HIP FRACTURES of redislocation, and for the help of the skiagraph, we have no way by which these fractures may be diagnosed. I have met few cases clinically, and can gather nothing of clinical use from the literature about them further than that they may occur. The treatment obviously calls for the most exact reposition we can attain, and caution as to early use-beyond the caution appropriate to simple luxation. Tendency to redislocation while the patient is in bed may be combated by traction on the leg (Buck's extension with 5 to 10 pounds pull) and a long side-splint. I have seen three cases of impaction within the limits of the head; otherwise like the ordinary intracapsular fracture, differentiated by the x- ray only, and one unimpacted case, occurring in a Charcot joint. FRACTURES OF THE NECK OF THE FEMUR Fractures of the Neck Proper, or "Subcapital" Fracture Much of what I wrote for this chapter ten years ago has been reconsidered. A lot of work has been done on hip fractures in that time. I have done some of it, and have in this period changed my mind, as is my privilege, in a number of matters. Fractures at the hip through the femoral neck or close to it are common in the later decades of life, rare in the earlier periods; but no time of life, not even infancy, is exempt from the chance of damage in this region. Beyond fifty years of age the frequency of the lesion depends, in part, on the lessening of that quick movement, that "easing," of a fall which so often saves us from injury, but, in the main, these fractures occur because as the years go on our bones grow weaker and more brittle. The femoral neck, like the lower end of the radius, loses its actual structural strength.* Hence it is that in the elderly or aged a slip resulting in a slight fall on the side, or apparently on the buttock, often results in fracture of the neck of the femur. It is this type of fracture of the hip that belongs peculiarly to old age; fractures of the base of the neck or fractures in the region of the trochanters, or just below, may occur at any age, given a trauma acting in proper direction and of adequate force, f Fig. 868.-Diagram to show how the head of the bone may be dislocated, leav- ing a part of the head split off in the socket. Probably the only way in which pieces of the head are split off. * Some stress used to be laid on an alleged increase of angle between the shaft and the neck of the femur coincident with increasing years. The fact of this increase is open to some doubt; its significance is still more doubtful. f Fractures of the femoral neck proper, common in the aged, may occur even in children. Nor is it always the epiphyseal line that gives way. I have seen fracture of the neck (well outside the epiphysis) without impaction, in a girl of eight, fol- lowed, under adequate treatment, by bony union and a good result. Royal Whitman has usefully emphasized the frequency of damage in this region in children and its relation to the development of coxa vara. FRACTURES OF THE NECK OF THE FEMUR 507 Lesions.-We have two general types of hip fracture that are common. Neck-fractures-the subcapital-the "intracapsular" cases of the older terminology. These may be impacted or loose. These Fig. 869.-Old impacted fracture of the hip; penetration of the inner wall of the neck into the head of the bone; displacement and rotation of the head downward and inward (Warren Museum, specimen 1086). Fig. 870.-Loss of substance of the neck of the femur (Warren Museum, specimen 3651). Fibrous union only. are now to be considered. For later consideration come the trochanteric type-"fractures of the base of the neck" "extracapsiilar"•-in which the bone breaks at the base of the neck with cracking or splitting between the trochanters (for types see Fig. 907). These fractures, usually entangled, rarely show real impaction. Fig. 871.-Loss of substance of neck of femur (Warren Museum, specimen 8075). Loose fi- brous union only. Fig. 872.-Old unimpacted fracture of the neck of the femur, with much loss of substance. Sketch from x-ray. Latter operated on by tem- porary pegging with serviceable, though not bony, union. (Author's case). In the class of real fractures of the neck, the common condition is one of impaction; of impaction more or less firm; often less rather than more firm. In not a few cases, the impaction (seemingly rock-solid at first) disappears in bed, and one morning we find the foot rollecl- 508 HIP FRACTURES out in the loose attitude of the loose fracture. The normal absorption of bone tissue next to a break, that precedes normal repair, accounts for this in part. Fortunately most impactions stay impacted. But the liability to breaking-up of impaction a fortnight or more after the Fig. 873. Fig. 874. Fig. 873.-Impaction of the neck into the head. Fig. 874.-Reciprocal impaction; neck into head on the upper side; head into neck on the lower side (diagram). fracture, has not been sufficiently appreciated. In very many cases, the impaction is hardly more than a catching of the sharp corner of the lower fragment on the surface of the upper. (See Fig. 901.) Such Fig. 875.-Fracture of the hip. Outward rotation of the leg because of impaction of the posterior portion of the neck of the bone. Fig. 876.-Fracture of the hip. Inward rota" tion of the leg because of impaction of the ante- rior portion of the neck of the bone. impaction is of little value mechanically. I have come to believe that clean, even penetration of one fragment by the other is rare. Still such impaction as we get usually holds fairly well. Damage to the capsule seems apt to be inconsiderable-at all events, we have no sign of it, unless the rarity of occurrence of demon- 509 SYMPTOMS strable effusion in the joint may be taken as a sign that the capsule is usually torn and so left open. No nerves or considerable vessels are in direct relation to the parts or directly exposed to damage. Where there is fracture of the neck, even if it is impacted, we have interruption of the vascular supply of the head. Some part of the vessel supply through periosteum and ligament is apt to be preserved, and such supply as reaches the head through the ligamentum teres is undisturbed.* Symptoms According as fractures of the neck are, or are not, impacted, our clinical signs vary. Commonly, especially where the break is close to the head, the posterior wall gives way first, and correspondingly we have an eversion of the limb as a whole (Fig. 875). This occurs whether there be impaction or not. Uncommonly (probably owing to a difference in the direction of the fracturing force), we have giving way of the front wall first, and inversion (Fig. 876). There may rarely be a comminution of the main fragments. Not very uncommonly there seems to be not comminution, but pulveriza- Fig 877.--Rotation of the head downward and inward as it lies in the socket. Broken sur- faces in contact for short space only. This condi- tion may occur with or without impaction. Fig. 878.-The first case: before impaction; after impaction; the final result. The result was rather good, but bony union uncertain (Annals of Surgery, J. B. Lippincott Co.). tion, so to speak, of some considerable part of the neck, with consider- able loss of length of the neck. In most cases with much loss of tissue, however, the loss is from absorption, not pulverization; such absorption may be very rapid and may show up within a week or two. * It was anciently supposed that intracapsular fractures involved entire loss of nutrition to the head, and, therefore, inevitable bad results. It must be rare that all vessels are torn; at any rate, necrosis of an impacted fragment seems excessively rare. Probably the synovial fluid helps in nutrition, just as we know it does in nourishing the growth of bone-cartilage chips in the joints (this form of "joint mice ' shows actual growth very clearly, as Codman has demonstrated). Failure of union in unimpacted fractures in this region is probably partly attributable to the disturbing presence of synovial fluid, as well as to the lack of enough nutrition in the fragment to allow firm union. 510 HIP FRACTURES Fig. 879.-First plate: sent out as impacted; sent back as re-fractured. See second plate. At this time patient was seen and presently was re-impacted under ether. Third plate shows results of re-impaction about two months later. Clinical result excellent (Annals of Surgery, J. B. Lippin- cott Co.). Fig. 880.-Loose fracture with much dis- placement shown in an x-ray now lost; ether reduction: re-impaction. The plate shows the position after operation. The re-impaction held and all went well until six weeks later, when the patient "went bad" and presently died, apparently of myocardial degeneration and con- sequent heart failure (Annals of Surgery, J. B. Lippincott Co.). Fig. 881.-Woman, aged seventy-nine years; loose fracture. Seven years ago fracture of the other hip. Loose fibrous union with tolerable usefulness resulted. The second lesion is here shown; before and after treatment. Bony union was secured, but owing to her advanced age, to the defective function of the other hip and to some stiffness she walks poorly but can walk (Annals of Surgery, J. B. Lippincott Co.). Fig. 882.-Before and after treatment. This was a loose fracture. The re-impaction held up to the last note. I have not traced this case to an end-result (Annals of Surgery, J. B. Lippincott Co.). Those familiar with operations on old patellar fractures and other cases of non- union, as at the elbow-joint, know how the presence of synovial fluid inhibits the clotting necessary to the formation of a proper callus. This failure of callus-forma- tion in intra-articular fractures is, I think, extremely important, though apparently unnoted in relation to the question of non-union in most of the later literature. SYMPTOMS 511 Fig. 883.-The first plate shows the fracture, unimpacted or at best loosely impacted; there was crepitus. The second plate shows the result shortly after reduction and mallet impaction. The third picture shows the end-result, after a year; slight shortening of the neck, but firm bony union. She has practically perfect motion and walks without a limp, unless much fatigued (Annals of Surgery, J. B. Lippincott Co.). Fig. 884.-A loose fracture in a man of forty years. The first plate before and the second after mpaction. He has returned to active work with excellent function. Not traced as yet, as to details of the end-result (Annals of Surgery, J. B. Lippincott Co.). Fig. 885.-Before and after reduction and impaction. Left the hospital with a solid hip. End- result.to be traced (Annals of Surgery, J. B. Lippincott Co.). Fig. 886.-Before reduction; a loose hip fracture; second plate, after reduction; third, before discharge. What happened in this case I do not know. I operated on the case referred in consulta- tion and have no data as to after-care, save the plates. This I call one of the failures (Annals of Surgery, J. B. Lippincott Co.). 512 HIP FRACTURES Fig. 887.-An old case of tabes. Hip shown before and after treatment. The fracture was unimpacted in the beginning. The artificial impaction held and bony union was secured; but the clinical result is that conditioned by the original tabetic condition (Annals of Surgery, J. B. Lippin- cott Co.). Fig. 888.-Operated for Dr. J. B. Blake; loose fracture; second figure shows after impaction; third figure shows impaction preserved, though with some absorption; early result excellent; too soon for end-result (Annals of Surgery, J. B. Lippincott Co.). Fig. 889.-Before operation (Annals of Surgery, J. B. Lippincott Co.). Fig. 890.-After impac lion, n ab- duction plaster. Clinical result excellent. Bony union. (Annals of Surgery, J. B. Lippincott Co.). SYMPTOMS 513 Fig. 891.-- Four months after forcible reduction for extreme eversion and shortening and the usual mallet impaction and spica plaster. Bony union, and the patient now (six months) walks without pain and almost without a limp. When shown at the Clinical Surg. Congress in October, 1915 she had no limp remaining (Annals of Surgery, J. B. Lippincott Co.). Fig. 892.--Extracapsular frac- ture, old, united. Coxa vara deform- ity (Boston Med. and Surg. Jour.). Fig. 893.-A, Coxa vara. B, Abduction treatment. Angle of neck corrected (Boston Med. and Surg. Jour.). Fig. 894.--Typical loose fragments. Neck all absorbed. Pictures under push and pull of ± 50 lbs. (Boston Med. andJSurg. Jour.). Fig. 895.-A, Fresh neck fracture--hardly more than a crack. B, Same, forty-four days later Note absorption of length of femoral neck without loosening of bony contact (Boston Med. and Surg. Jour.). 514 HIP FRACTURES Fig. 896.-A, Accidental'impaction. This loosened without fresh accident. B, Pull; C, Push, taken five months later, showing what happened in the end. A wretched clinical result (Boston Med. and Surg. Jour.). Fig. 897.-Two end-results of artificial impaction. A is the .-r-ray taken 10 months. B was taken at 15 months. Both these patients walk without a limp. Both were shown in 'October, 1915, before the Clinical Congress (Boston Med. and Surg. Jour.). Fig. 898.-Artificial impaction. A, Before; B, After; C, Three months later. At six months has not over five-eighths inch shortening and promises an excellent result (Boston Med. and Surg. Jour.). SYMPTOMS 515 Fig. 899.--Case of loose neck fracture operated on at the Peter Bent Brigham Hospital. Cour- tesy of Dr. Harvey Cushing. A, Before impaction. Impacted with mallet in usual way. B, Shows result two weeks later. (From x-ray through plaster spica.) C, Taken four months later (Boston Med. and Surg. Jour.). Fig. 900.-Loose fracture. Mallet impaction. Figure to the right shows condition'six'weeks'later. Is now beginning to walk (Boston Med. and Surg. Jour.). Fig. 901.-Supposedly impacted fracture that "fell apart." The x-ray confirms the illusory sort of impaction present (Boston Med. and Surg. Jour.). Fig. 902.-Original "impaction" clinically solid. Two months later, loose fracture, though the hip was fixed in the routine fashion, with a special nurse in charge (Boston Med. and Surg. Jour.). Fig. 903.-Three different cases of "impaction" of the usual type; note the spur on the lower fragment--the only support (Boston Med. and Surg. Jour.). 516 HIP FRACTURES Fig. 904.-'"Impaction" that broke up in bed under very careful treatment (Boston Med. and Surg. Jour.). Fig. 904.-'"Impaction" that broke up in bed under very careful treatment (Boston Med. and Surg. Jour.). Fig. 905.-Same case as Fig. 904, "push and pull" five months later; close fibrous union; note that the displacement is hardly more than a rotation of the head of the femur (Boston Med. and (Surg. Jour.). Fig. 905.-Same case as Fig. 904, "push and pull" five months later; close fibrous union; note that the displacement is hardly more than a rotation of the head of the femur (Boston Med. and (Surg. Jour.). Fig. 906.-"Impacted" fracture, see lower outline Above, to the left is the "push" pic- ture, fifteen months later, to the right the "pull" outline. Obviously, there is only fibrous union. The clinical result is poor (Boston Med. and Surg. Jour.). Fig. 907.-Types of basal fracture (Boston Med. and Surg. Jour.). Fig. 908.-Other types of base fracture of not unusual occurrence (Boston Med. and Surg. Jour.). Fig. 909.-"Intertrochanteric" hip fractures (Boston Med. and Surg. Jour.). SYMPTOMS 517 Signs of impacted fracture of the neck: (а) Disability. (1) Uniformly there is inability to raise the leg from the bed.* (2) Usually] walking is impossible. (б) Flexion, extension, and rotation are limited and usually painful. (c) In cases showing eversion, further eversion is possible, but no inversion can be carried through without undue force. (d) In the rare cases with inversion, J eversion is impracticable. (e) There is shortening, but a shortening running only from to one inch. (/) There is abnormal prominence of the trochanter, as a rule, due largely to- (p) Loss of normal tension of the fascia lata. (See Figs. 911 and Fig. 910.-Palpation of trochanter by fingers, with the thumb on the anterior-superior spine. The digital fossa may often be palpated in this way. Fig. 911.-Palpation of fascia lata with the fingers, thumb on anterior-superior spine, little finger on the trochanter. 914.) (A) There is usually a distinct loss of the hollow corresponding to the digital fossa, behind the trochanter. (See Figs. 910 and 915.) (t) There is almost always a perceptible thickening over the front of the joint.§ (See Fig. 912.) (J) There is not apt to be much local pain, tenderness, swelling or other of the usual fracture signs. (k) Crepitus, of course, is absent unless impaction is broken up. * I have seen three exceptions to this rule. f I have seen two cases in which the patient, vigorous men, walked some distance without breaking up impaction. Both had slight eversion, Lj-inch short- ening, and the x-ray showed impaction of the neck into the head. t Fractures of the femoral neck with impaction, but without eversion, or with inversion, are by no means very rare, but not the type. Their occurrence depends probably on the direction of trauma; the diagnosis is not difficult; the treatment is the same save that reduction of impaction is peculiarly unjustifiable, because they promise better results from conservative treatment than do the everted cases. § Walker (Ann. Surg., 1908, xlvii, 84) calls especial attention to fulness in the outer part of Scarpa's triangle, due to the fact that in the most common variety of fracture the head and neck, with the trochanter, are bent backward and downward thus resulting in forming the apex of a fracture-angle upward and forward. 518 HIP FRACTURES There is no way, save with the x-ray, to discriminate between "intra- capsular and extracapsular " fractures, or between fractures near the head or near the trochanters. Signs in unimpacted fractures: (а) Shortening. (1) Usually greater than in im- pacted cases. (2) Tending to increase under the undisturbed pull of the irritated muscles. (3) Varying with even gentle manipulation, i. e., with inter- mittent traction. (б) Disability-more extreme than in impacted cases. (c) Eversion-more extreme, with- out any power to invert actively. (d) Lack of any check to passive inversion or eversion. (e) Rotation of the (palpable) trochanter takes place on a shorter rotation axis than in the normal leg or in an impacted fracture. (This sign is classic, but I think apt to be of little value, because the observation is hard to make out with certainty.) Fig. 912.---Palpation of the front of the joint with the thumbs; fingers on anterior-superior spine and crest. Fig. 913.--The error in measurement of length of the leg; if the pelvis is tilted, the length of the leg on the concave side, so to speak, i. e., the leg that is in abduction, will be less, that of the other leg is more, than if the pelvis were level. This results from the fact that the points a and a', c and c', have no fixed relation to the acetabulum b and b'. The line dia- gram shows obvious shortening of a' o' as compared with the other side; in fact, the error (in this figure) is shown by the length of the vertical line marked x in the lower left-hand corner-a very considerable error. Fig. 914.-Foss of tension of the fascia lata, due to hip fracture. The fascia lata is attached to the crest of the ilium above, to the head of the fibula and its vicinity below. Any break between these points with shortening necessarily slackens the tension of the fascia. This slackening can be felt between the trochanter and the iliac crest. (See Fig. 911.) SYMPTOMS 519 (/) Crepitus is not always obtainable, often not obtainable except by carrying out rotation, while strong traction is exerted on the leg to bring the fragments opposite one another, a procedure obviously unjustified except to confirm a diagnosis already made of a loose fracture. If we wish to demonstrate change in total length, crepitus, etc., a procedure devised by Dr. Gordon Morrill, one time house-surgeon Fig. 915.--Normal right pelvis and femur, seen from above. The arrow at the back shows the digital fossa-a much deeper groove than is ordinarily appreci- ated. Fig. 916.-Rotation on the long, versus the short, axis. In the normal femur there is a distance corresponding to the arrows in the figure; this is the radius on which the trochanter rotates. If there be an impacted fracture, the mechanism is the same, but the distance (the radius) is shorter. If the frac- ture be unimpacted, the shaft rotates on its own axis and the distance (or radius) is zero. on my service, is worth noting. The procedure is, I think, amply explained by Fig. 867. Its advantage lies in the fact that we may, in this way, exert a traction force of several hundreds of pounds if we wish, and any desired traction may be kept up for a long period with- out great fatigue to the assistant exerting traction, and without damage to the patient. One may, by this method, readily keep up the pull long enough, for instance, for the appli- cation and setting of a plaster spica. In regard to the broad question of diagnosis, irrespective of impaction: Dr. Gay* has long taught what I believe to be sound general doctrine, namely, that in practice there is no such thing as a "strain" of the hip. Certainly it is well within bounds to say that any injury to the hip in an old or elderly person that causes marked disability, that makes it impossible to raise the heel from the bed, that gives deformity in eversion, with loss of possible inversion-that such in- jury means hip fracture almost without exception. I have, in fact, seen no exceptions to the rule that I can recall. The reason for the greater liability of the old to this fracture lies, as noted above, in structural changes in the bone and less agility. Fig. 917.-Extreme outward rota- tion in unimpacted fracture of the femur shown on the right leg (lesion on left is fracture of the lower leg). * George W. Gay, Lecturer on Surgery to the Harvard Medical School; he has elaborated this and other valuable clinical points in a paper published in the Trans- actions of the New Hampshire Medical Society, May, 1903. 520 HIP FRACTURES One more point is perhaps worth noting, namely, that occasional cases that look like anterior luxations prove to be atypical cases of fracture of neck or trochanters, firmly held in abduction by muscle spasm. If there is any doubt, after palpation, it is better to wait even a day or so for an x-ray rather than do harm by ill-advised attempts at reduction. (See Fig. 965.) The reversed error-mistaking a luxation for a fracture, I have not feared, or seen. There are many cases that we class as impacted that the x-ray shows to be hardly more than what we may call entangled: the x-ray in these cases is apt to show considerable displacement with only a spur- like tip of the neck caught near the upper edge of the head (Fig. 904). Such " impaction " is worth little. Treatment If a hip fracture is impacted, the chance of better- ing the condition present is small. Intracapsular fractures go on to non-union unless they are impacted. Consequently, we should not be strenuous in diagnostic manipulation. It is far better to be vague and to do without too many facts in these cases than to be exact at the expense of breaking up a useful impaction. If we have the signs above noted, slight shorten- ing, loss of tension of the ilio-tibial band, slight prominence anteriorly, eversion, loss of the hollow at the digital fossa, prominence of the trochanter, etc., but with motion in rotation of the trochan- ter on a reasonably long axis, we have to deal with a case of impaction, a case we should let alone, as a rule. Always, if we wish to do proper work, we should have x-rays before outlining anything beyond preliminary treatment. In the younger patients, if we have impaction in excessive eversion or with great shortening, active measures may be considered. Breaking up of impaction may here result in greatly improved position, and such break- ing up, with subsequent impaction and abduc- tion, has led to excellent results in my hands. Such treatment is to be employed only with great conservatism, of course, and rarely without consultation to divide responsibility, for the mass of literature does not fully sanction this treatment. In the average case, where there is impaction, we have a peculiarly serious lesion that we are not likely to make better by active interference. Our first concern must be the patient, rather than the fracture. These old people not only bear shock badly, but they are peculiarly Fig. 918.-Unim- paectd, ununited frac- ture, with a good deal of loss of substance. Very little shortening. Sketch direct from x- ray plate. Fig. 919.-Long out- side T-splint; extends from the axilla to below the foot. Applied with a swathe to the chest. The leg, with or without a back splint is strapped to the splint to steady it and to limit rotation. 521 TREATMENT apt to die from mere confinement to the bed. The percentage of deaths in fractures at the hip is rather staggering; it is certainly above 16 per cent., even in non-alcoholic cases. The proximate causes of death seem to be heart failure and hypostatic pneumonia, as a rule; the real cause of death is usually confinement to bed and change of routine. Old people stand such confinement badly, as a rule.* Often it is wise to neglect the fracture entirely in the interest of preserving life, whether the fracture be impacted or not; often patients who are allowed to sit up without regard to the fracture will "perk up" and be restored to a few years of comfort (in a wheel-chair, perhaps) and possibly to some usefulness, a result which is certainly better than death from hypostatic pneumonia or from sheer inertia. Often, then, it is wise to treat the patient and not the fracture. Such treatment is not uncommonly rewarded by a fairly useful limb as well, for sitting up alone will not break up impaction, or even greatly hinder union in an unimpacted case, as a rule. In case we have an impacted fracture, we may let the fracture alone, and sit the patient-up, or we may rely on sand-bags to help inversion (see Fig. 920), or we may put him to bed and use a long outside splint alone (Fig. 919), or we may apply extension with both sand-bags and splint. If such extension is used, it is applied as for fracture of the thigh, but the weight used is only three to six pounds, and the pur- pose of the traction is not to pull fragments apart, but purely to steady the limb and to guard against sudden twitching of the muscles. It is rarely called for. In any case it is well to make sure that the leg lies in abdwdwn because adduction contracture is hard to overcome and is crippling. If the patient is reasonably tolerant, I like to put on a plaster spica in moderate abduction. In certain cases (nervously tolerant but liable to hypostatic pneumonia) I have used Dr. Moore's abduction in flexion, but using what my H. O's call the "frog plaster" with both legs flexed and abducted in a double spica. This is comfortable and efficient: the only drawback is the liability to stubborn flexion contrac- tion at the knee in old or arthritic patients. Fig. 920.-Position of sand-bags to prevent leg and foot from roll- ing outward. * Certain old people stand it perfectly well. Dr. H. L. Burrell, years ago, used to call attention to the types of old people, as shown in manner and face, who do and do not endure such confinement. Those who "fuss " and who show nervous tension in their faces are those, as a rule, who do badly under these conditions. I have (since this chapter was written) seen two old ladies of eighty-four with hip frac- ture who tolerated bed treatment with perfect equanimity and even cheerfulness. In both cases we obtained good results. It is largely a matter of nervous tempera- ment, rather than of physique. 522 HIP FRACTURES If a case is unfit to handle as above sketched, the whole scheme may well be abandoned. We should be able, if experienced, to judge of the patient, and what he or she will stand. If things look unfavorable to bed treatment at any time, I do not hesitate to sit patients up at once, relying only on sand-bags or pillows to help maintain position. As a rule one may do this without doing harm to the hip. Fig. 921.-Diagram of section of leg and splint to show how a strap carried from the back of the leg over the long side-splint can prevent eversion of the foot and leg. Fig. 922.-Form of stirrup to prevent the foot assuming an equinus position, needful in almost all fractures of the femur at any level. Fig. 923.-Cradle to keep clothes from leg. Made from two barrel-hoops with a little adhesive plaster. The question comes up (whatever the exact line of treatment pursued) as to when we may let up on fixation; when we may get the patient up; when we may allow weight-bearing. I think we have been all wrong about this in the past and base my opinion partly on study of x-rays and the slow repair (remember the head here is hardly better vitalized than a bone graft), but more par- 523 TREATMENT OF UNIMPACTED FRACTURE OF THE FEMORAL NECK ticularly on case after case, seen long after, in which a bony union was supposed present at discharge from hospital, after five to ten weeks, in which a loose hip resulted from early attempted use, without accident. This opinion applies only to those cases of impacted fractures of the neck proper. My routine in the last few years has called for not less than eight weeks of fixation in private cases, and in the hospital cases, as near this as circumstances permit. It is understood of course that this may have to be shortened if the patient's general condition is unsatis- factory. After this time of fixation is over, the patient gradually, aided by massage and gentle passive motion, recovers control of the Fig. 924.-Traction and countertraction to give great temporary force for reducing fragments or adjusting apparatus. limb. At four months he can not only begin to walk on crutches but bear more and more weight. It is slow business, but I find my- self content if full weight can be borne with fair control at six months. Let us not forget that a very large share of these cases, under ordinary treatment, never get so far. Under this routine my results have been better, usually good, and in a group of cases, almost perfect. The disadvantage of stiffness to be overcome, is to my mind more than counterbalanced by the risk of total failure of union; a very present risk. Treatment of Unimpacted Fracture of The Femoral Neck We have the choice of- (а) Traction and immobilization. (б) Longitudinal, with lateral traction. (c) Traction in abduction. (d) Abduction. (e) Traction in abduction, with trochanter pressure. (J) Traction with inversion. (g) Open operation, with or without nailing. (A) Artificial impaction. 524 HIP FRACTURES Manoeuver (a) is that ordinarily in use; I now believe it absolutely inefficient, and have found no case in which its use has resulted in bony union. Reasonably serviceable fibrous union results in part of the cases, as in those treated by any method; or lack of method. Method (6) seems to have been a good deal used in the west, and is reported as very efficient. The method consists simply of the usual traction downward in the line of the leg, with lateral traction outward by the pull of a weight on a band run- ning through the groin (Fig. 926). This is the Phillips-Maxwell-Ruth . method, of which so much has been heard. Dr. Ruth of Des Moines has a remarkable collection of seven post-mortem specimens (all with bony union) treated by this method. I have examined all these seven very carefully. In five the lesion is obviously an extracapsular, intertrochan- teric fracture; united, of course, as all these fractures unite. In two there is much hypertrophic change about the joint; of these two, one Fig. 925.-Ununited fracture of the neck, with aimost entire absorption of the neck. Fig. 926.-Traction in the line of the femur, with lateral traction in the groin. Theo- retically wrong, but used with some success. Fig. 927.--Bradford ham- mock frame, cut out to facili- tate the application of a (right- sided) plaster spica of the thigh. Fig. 928.-The position of a fracture through the head or neck may sometimes be secured by putting it up in ab- duction. The adductor mus- cles act as a strap fulcrum, and the broken surfaces are forced in contact. may definitely be classed as extracapsular; as to the other, there are no remaining data as to where the fracture, if any, was situated. So far as I know, there are no data to show bony union in any loose subcapital fracture under this method of treatment. TREATMENT OF UNIMPACTED FRACTURE OF THE FEMORAL NECK 525 Method (c),-traction in abduction,-that is, traction obliquely down and outward, is accomplished as shown in Fig. 928. Fig. 929.-;Table, modeled after Hoffa's original, for obtaining extension by adhesive-plaster traction and winches; counterpressure in the perineum by means of a 3-inch wooden spindle. Lsed for reduction, and more particularly for the proper application of the plaster "spica." Fig. 930.-Same seen from lower end. Theoretically, the pull of the adductors in abduction should help the short rotators in maintaining contact of the fragments. It is well 526 HIP FRACTURES not to abduct too far, and to control our treatment by careful measure- ment, for too much abduction may easily produce shortening, the adduc- tors acting as a lever. In applying a plaster spica, abduction of about 30 degrees is the rule -not so much for better position, but because it overcomes the usual Fig. 931.-"Hoffa" table with patient ready for application of plaster. limitation of abduction, that is troublesome when the patient first tries to walk. Whether this treatment ever produces bony union, I have no data, nor have met any, that constitute anything like proof. Method (d), abduction alone brought about by a plaster spica, is claimed by Whitman. He has stated a lot about what must happen Fig. 932.-Plaster spica for femur fracture. Put up in plaster about ten days after the accident (delay because of shock). About inch shortening: perfect alinement (photograph by Dr. F. L. Richardson). if this is done; this is amusing but not conclusive. The method I have found a good one is to avoid unnecessary coxa vara in the extra- articular fractures; to avoid the very undesirable adduction contracture in these, and in the impacted intraarticular cases. Whether it ever gives sufficiently good contact to determine bony union in loose subcapital fractures, I have not been able to find out. Whitman uses it for everything. Method (e), urged by Senn, but belonging by right of priority to Newton Shaffer, consists of the application of a plaster 11 spica" TREATMENT OF UNIMPACTED FRACTURE OF THE FEMORAL NECK 527 bandage in which a window is cut over the trochanter; through this window a pad presses on the trochanter, its pressure regulated by a surcingle band about it and about the pelvic part of the plaster bandage, or a steel splint with a screw-pad. I have no experience with the method; theoretically, at least, it is rational; whether it possesses any real advantage, I do not know. (/) Peckham of Providence, R. I. has lately reported a striking short series treating by traction with inversion to produce contract. Results are worth watching. Open operation (g) has been practised in many cases, mostly on cases in which there had been failure of union under ordinary routine. We have, broadly speaking, two methods: first, opening the joint in front and refreshing the fracture surfaces; then, with or without nailing, putting the leg up in the best attainable position (usually in abduction) in plaster, with or without traction under the plaster; second, external incision with temporary resection of the greater tro- chanter; the operation so approached is usually completed by nailing of the trochanter, often also of the broken neck. There are but two objections to nailing of the broken fragments: first, the difficulty of stopping the nail short of the acetabulum,-I have an x-ray of a case (not mine) in which the nail is shown by the x-ray at least of an inch beyond the pelvic wall; second, the tendency of the nail to erode a cavity for itself, and to become, after weight-bearing is begun, an irritation rather than a support. Our object in these cases is purely the approximation of fragments; I suspect the nail is not essential, and may, by the irritation of its pres- ence, hinder union.* In the cases I have operated on such a nail has always been in the "kit," but I have used it but rarely, and the results without nailing have uniformly been very satisfactory-union in all cases was firm enough for walking, though I feel sure of bony union in only three cases. Of late the substitution of a spike of bone (the patient's own bone, from the tibia), for the metal spike has been much talked of. The spike of live bone, whether it has much capacity for real growth or not, has at least no disadvantage as a foreign body, and may be left in. I have used it in a few cases, not always with real success, and I think the question still open; perhaps the removable spike is as good. Resection setting the trochanteric fragment into the acetabulum has been done. This is a last resort and good. All these operative measures, though useful, should be avoided by an adequate method of care in the first place; when the subject is better worked out, there will be less operable cases. If we are to use the nail, the rational method seems to be the approach by the anterior incision, denudation of surfaces, insertion of a long spike driven through the skin from the outer side through the * I have seen x-rays of such cases in the hands of colleagues that have somewhat discouraged me in the use of the nail. This objection may readily be met by driv- ing the nail in through a separate incision over the trochanter, and removing it after a few weeks. 528 HIP FRACTURES trochanter and neck into the head. Such a spike may be removed after three to six weeks leaving no foreign body to make trouble. Moreover, its insertion is controlled (as to depth) by a finger between the frag- ments. I have used this method with excellent results in a number of cases. The treatment of artificial impaction is my own; used for eight years. I believe it to have a very definite place. Those who have looked into end-results know that in these intra- capsular fractures, those that chance to have a solid impaction of fragments do rather well (given adequate after-care) and that those in which impaction is absent, or gives way, rarely attain bony union. My effort has been to furnish to those patients lacking impaction, the fixation by impaction, accidentally present in many cases. This can be done with a reasonable certainty. It has been done in many cases and bony union beyond question has been shown by the z-ray many months later. The clini- cal results have been demonstrated; at the Clinical Congress of 1915 particularly.* All that is claimed for this method is that it pro- duces an impaction as good as that one comes on by accident, and that prior to producing this impaction, a very excellent reduction of the fracture may be brought about, and this favorable position maintained through and after the impaction. I have had a few failures, of course; the general run of the results has however been so good that I think the method well worth while; particularly as it seems to have no dangers or drawbacks. I have used it on some cases with impaction in wretched position, with satisfactory results, but it belongs essentially to the loose frac- tures of the femoral neck proper; of the " intracapsular " "subcapital" type. The method has been used only under anesthesia. The patient is put on a Hoffa or Hawley table. The broken femur is dragged down (the operator's stocking-foot in the perineum) till the position seems good, and the length is within inch the same as on the sound side. This can be done. The foot is slightly inverted. A double layer of felt is put over the trochanter; a "husky" assistant braces the pelvis from the sound side; the operator with a heavy wooden "maul" or mallet drives the trochanter in, using a slow "following" stroke until he feels something "give." When this happens, it is found that the leg no longer flops out loosely; the picture becomes that of an impacted fracture. From this point on, it is an impacted fracture to be treated as such. My usual treatment has been a plaster spica in abduction; usually a double spica from heel to waist on the injured side, down to the knee on the sound side. Fig. 939.-Tempo- rary spike to hold head in proper relation. *Rep. Am. Surg. Assn., 1915. Ann. Surgery, March, 1916. Boston Med. Surg. J., Sept., 1916. 529 RESULTS OF FRACTURES OF THE FEMORAL NECK My after-care has been that given to the accidentally impacted case; long fixation and late weight-bearing. This method is perhaps not to be recommended to the tyro; there may be a chance of damage. I have seen no damage save a slight hematoma in one case; the case, by the way, which was shown in 1915; the patient has bony union, no visible limp, and full function. These cases are not common in any man's practice, but I believe the next few years will show an accumulation of real end-result data beyond criticism. Already I believe the results shown to be far better than by any other method, in this relatively small group of unfortunate cases. Results of Fractures of the Femoral Neck End-results in fracture of the femoral neck have not, to my knowl- edge at least, been adequately studied. As has been noted, the mortality is heavy, from causes we can not control. Fifteen per cent, at least in the aged. Beyond the list of those who die, we have many others in whom the feebleness and infirm- ity of age make useful recovery (even from injuries even much less grave than this one) quite out of the question. Apart from these cases, however, my im- pression is that the results are rather poor. These are not normal hips, nor is their func- tion normal. There is shortening; there is loss of power to abduct; there is thickening; usually there is eversion. As sequels, we have a limp, some loss of motion, and an added awkwardness of gait from eversion. But all these disabilities disappear, to some extent, with time and use. Particularly I have noted an accommodative inversion by muscle action that, in large part, counterbalances the displacement in eversion. In short, none of these cases in the elderly, perhaps none at any age regain a normal hip, but many patients get around fairly well. I have seen many such, even cases in whom the fracture occurred at eighty years or later. What the percentage of such results is can not now be stated. Certain few individuals show rheumatoid, or rather "osteoar- thritic," changes, with a good deal of lameness and " rainy-weather pain." Some develop a definite "malum coxae senile." The cases with non-union show markedly greater disability, more shortening, more eversion, more pain, more inability to handle or use the leg. Fig. 940.-Fracture of femoral neck on the right. Slight shortening and adduc- tion; solid union. Going to be a good result. 530 In fact, however, some of these cases get about tolerably well, though with a marked limp and with small endurance. The support of the body-weight is assumed to be the Y-ligament in front, the obturator muscles behind; the upper end of the outer fragment, still in part enveloped in capsule, forms a sort of false joint on the ilium that carries some part of the weight.: Some of these cases may be greatly benefited by a late operation that, with or without pegging or nailing, brings about a rigid union, but such an operation is a major operation in the case of old people, with some mortality attending. Those unoperated are al- ways cripples to an extent if there is no union, but it is not correct to suppose that they are always hopeless cripples, unable to walk. It has become my habit to treat such cases in the really infirm with a rigid belt about both hips at the trochanter level. This helps, often helps a lot. Briefly, it comes to this. Unimpacted fractures of the femoral neck proper rarely unite by bone; well-impacted frac- tures do so unite, almost always. Obviously the conversion of cases of the first into cases of the second class is extremely desirable. Can it be done? I assert that it can be done; that it can be done without damage and without great diffi- culty, and can be done at any time within a fortnight at least, whether we are dealing with a fracture thoroughly loose when we first see it, with one which has loosened up in the first fortnight, or with one in which we have deliberately sacrificed the original impac- tion to secure improved position. The breaking up of hip fractures is far from new. I saw it done when I was a house officer, but the attempt to establish or re-establish a condition of impaction I believe to be entirely new and its possibility rests, to date, entirely on the data I have here. There are 21 cases with one failure and one prospective failure. The first case was impacted on August 31, 1909. HIP FRACTURES Fig. 941.-Fracture with impaction of the neck of the right femur. Slight shortening, outward rotation, and abduction. All to be seen, but slight. The edema of the leg is the temporary edema almost always present in these cases on beginning use. 531 RESULTS OF FRACTURES OF THE FEMORAL NECK Fig. 942.-Loose fracture with much dis- placement shown in an a;-ray now lost; ether reduction; re-impaction. The plate shows the position after operation. The re-impaction held and all went well until six weeks later, when the patient "went bad" and presently died, appar- ently of myocardial degeneration and consequent heart failure. Fig. 943.-Woman, aged seventy-nine years; loose fracture. Seven years ago fracture of the other hip. Loose fibrous union with tolerable usefulness resulted. '1 he second lesion is here shown; before and after treatment. Bony union was secured, but owing to her advanced age, to the defective function of the other hip and to some stiffness she walks poorly but can walk. Fig. 944.---Before and after treatment. This was a loose fracture. The re-impaction held up to the last note. I have not traced this case to an end-result. Fig. 945.-An old case of tabes. Hip shown before and after treatment. The fracture was unimpacted in the beginning. The artificial impaction held and bony union was secured; but the clinical result is that conditioned by the original tabetic condition. Fig. 946.--Operated for Dr. J. B. Blake; loose fracture; second figure shows after impaction; third figure shows impaction preserved, though with some absorption; early result excellent; too soon for end-result. 532 HIP FRACTURES Of these cases treated by the same technic, four proved to be extra- capsular fractures. In fractures of this type, the impaction procedure can give at best merely an easier fixation, and is probably no better method than Whitman's simple abduction in these cases; probably not as good a method as the Phillips-Maxwell-Ruth method of longi- tudinal and lateral traction. Ruth has, or had recently, seven post- mortem specimens showing admirable results by this method. All, or at least all save one debatable specimen,* were definitely extracapsular. I think this method probably the best for this type of cases; it seems illogical and is certainly unproved as to fractures of the femoral neck proper. I do not wish to be taken as advocating forcible impaction in all cases, even of neck fracture proper. Not a few of such cases are simply cracks. Many show a sufficient accidental impaction, with deformity in adduction and eversion not great enough to warrant any interference. Some, of course, that show deformity enough to render correction desirable, are poor surgical risks. Here and there even loose fractures must be neglected because of the risks imposed by age, by heart lesions, by chronic pulmonary damage (usually bronchitic), by diabetes, etc., though the proportion of such non-surgical cases is apt to be over-estimated. What I do maintain is that in all cases of loose fracture, in all cases in which impaction gives way, in all cases in which adduction and eversion deformity promise definitely poor results, the procedure here- with given is indicated, and should be carried out unless there are definite contra-indications. The technic I have followed is this: First anaesthetize the patient-not deeply-and put him on the table; preferably a Hoffa table, though even an ordinary wooden table will do. After measuring the length, drag the leg down (with your stockinged foot in the perineum) till the length comes out even, and until rotation gives definite slight crepitus; then correct any eversion deformity present; give the leg to an assistant; have another assistant give counterpressure on the opposite side of the pelvis; pad the tro- chanter with two thicknesses of saddler's felt and pound on it with a very large wooden mallet, till there is a sensation of "giving." The blow should be a slow swinging "following" blow, and the "giving" is very definitely felt in most cases. Then one should test the fact of impaction by the loss of mobility in rotation when the leg is released. When the job is properly done, this loss of mobility is perfectly definite and rather striking. After impaction, the length of the two legs should come out very nearly even. After all this is done, I put the leg up in an abduction spica of plaster. Abduction prevents adductor contracture, often troublesome in the period of re-establishment of function. It neutralizes the tendency to coxa vara from muscle-pull, and is a more convenient posi- * Obscured by osteo-arthritic changes. SEPARATION OF THE EPIPHYSIS 533 tion in respect to the bed-care of the patient. In general, abduction is the optimum position for handling nearly all hip lesions of whatever sort, and I always use it when I can. This first plaster I leave on six to eight weeks or longer. Not until three months do I dare let the foot to the floor. Repair in these cases is slow at best. Always in hip fracture at the neck, there is a considerable absorption. Even with the x-ray, we can not always judge and it is best to be cautious. From three to six months one is busy with getting the joint mobilized and learning to walk with crutches, bearing little weight on the hurt leg. During this time, nearly all the motion should be regained. After six months the ques- tion is one of use, of regaining strength and losing the limp. Separation of the Epiphysis The epiphysis of the femoral head occupies the relation shown in Fig. 947. Its separation is relatively, but only relatively, rare. The trauma causing such separation is not apparently different from that causing fracture of the neck. We may have falls on the trochanter or the buttock or on the feet, as a cause. Whitman* has demonstrated conclusively that fracture of the neck, as W'ell as epiphyseal separation of the head, is not very rare in young children. The differential diagnosis is not easy. We can diagnose these cases only by the signs that help us in adult fractures. "Soft" crepitus may help in the diagnosis of epiphyseal lesions. A good x-ray will settle doubts. The peculiar interest of these cases rests on the curious similarity, which Whitman has shown, between the consequent coxa vara resulting from such trauma and that coxa vara familiar to orthopedists which results from lessened resistance of bone structure, expressing itself oftenest at about the age of puberty. Today there is a question about the relation of epiphyseal trauma to the disorder of epiphyseal nutrition at the hip in children, that results in a deformed flat-topped head, and in no little disability, the condition that is known as Perthes'-or more justly Legg's disease. Probably it is too early to be very positive as to this condition and its causes. The shortening is common to both forms, as is also the inability to abduct the leg-actively or passively; there is the same increased prominence of the trochanter, made more obvious by flexion; the x-ray shows the same change in angle between neck and shaft. Coxa vara of traumatic origin, after consolidation, is amenable to the same operative procedures as the coxa vara dependent on develop- mental failure, with the same results. * R. Whitman, Med. Record, July 25, 1893; Ann. Surg., June, 1897, ibid. February, 1900. 534 HIP FRACTURES But our effort should be rather to prevent than to repair these deformities. The moral is that we should be very careful to exclude fracture or epiphyseal separation in any doubtful case, at or before the age of puberty. If we are on the watch for such a lesion, the general diagnosis is not Fig. 946a.-Os calcis (and heel tissues) bitten off in an escalator--a very modern type of accident difficult, though differentiation between forms in detail may be difficult or perhaps even impossible without the x-ray. If we have an epiphyseal separation to deal with, the displacement must be reduced, and accurately reduced. A good x-ray is essential, for we can feel but little to guide or test our reduction. Displacement is of the shaft and neck upward; the epiphyseal head remains in place. Reduction is by traction down, with traction outward (applied inside the groin) to carry the broken outer end past obstructions into place. There is no chance of carrying it too far, for the ligaments are substantially intact. Abduction or adduction or rotatory motions may be called for before the frag- ments fit.* The leg is to be put up in sharp abduction in a plaster spica. The result is to be tested by the x-ray. If it is not satisfactory, we have no choice but open operation, replacement, and another plaster spica. Fig. 947.-Epiphy- sis of the head and of the great trochanter. (Warren Museum, specimen 417.) * And, after all, they may not fit with anything like accuracy. Should we be satisfied with moderate position? I think not, and though with experience of operative treatment on only 2 cases, suspect that this, like separation of the humeral epiphysis, belongs to the operable lesions. FRACTURES AT THE BASE OF THE NECK 535 Long protection-several months-in plaster or a Taylor or Thomas splint seems the wise precaution in these cases-and a follow-up for two to three years with the x-ray. If it is not an epiphyseal injury, but a fracture, the treatment must vary to fit the case. In these cases in children there is no impaction to deal with, nor is an absolute "fit" essential, as with the epiphysis. If we overcome shortening, the union of bone-ends will take care of itself. Shortening is to be overcome by a Buck's extension, loaded with a weight of 3 to 20 pounds according to age and size, and an out- side splint is employed for fixation. After three weeks a spica of plaster-of-Paris is enough. There is no harm done to children by bed confinement. There seems to be no chance of non-union. So far as we know, cases adequately treated do not develop coxa vara, but it is true that the early soft callus may yield to weight, and weight-bearing may well be postponed to three months. The x-ray should be used as a constant check, and any tendency to coxa vara promptly taken account of. Interference with growth does not occur in fracture, and seems vastly rare in the epiphyseal cases, at the hip. Fractures at the Base of the Neck Fractures of the neck near the trochanter are, in fact, common. Their occurrence has long been recognized; their frequency has been known to us only since the skiagraph became useful. Fig. 948.-Fracture at the base of the neck; impaction of the base into the shaft (diagram). Fig. 949.-z-ray of fracture of the base of the neck, with impaction of the base of the shaft. Explanatory diagram to the right. The trauma is essentially that of the neck fracture; the only differ- ence is that severer falls, and at times falls on the foot or knee, appear oftener as the cause. Perhaps this means only that this is less charac- teristically a fracture of the aged than is fracture of the neck proper. The lesion is commonly a break at the base of the neck, with more or less impaction of the neck into the trochanter and shaft. (See Figs. 948-956.) 536 HIP FRACTURES The line of break varies somewhat, and not rarely there is some splitting in the region of the trochanter (see Fig. 950), or an associated spiral fracture running downward. Very commonly the lesser trochanter is split away as a separate fragment. The degree of impaction varies much. The fracture is, however, very definitely ex- tracapsular, and the formation of callus is prompt and is usually efficient, even if there is no impaction. Fig. 950.-Fractures of base of neck and of trochan- ters of femur. View from behind and inner side (Warren Museum). Fig. 951.-Impacted frac- ture of base as well as head. Old case (sketch after plate of Cooper). Fig. 952.-Impaction of the neck of the femur into the shaft, with a splitting of the trochanter. Oui' concern in these cases is purely one of obtaining the best possible position; union may usually be left to take care of itself. Diagnosis of Impacted Fracture of the Base of the Neck.-We have disability; shortening, ordinarily not great; eversion, sometimes absent, sometimes replaced by in version; obliteration of the digital fossa. All these signs occur also in fracture of the neck with impaction. There may be not only filling up of Fig. 953.-Similar lesion to that in Fig. 952. Specimen from Oldknow's case (sketch after Cooper's plate). Fig. 954.--Fracture between neck and shaft and fracture of great trochanter; partial impaction. Union so imperfect that fragments separated in maceration (Warren Museum, specimen 1075). the digital fossa, but marked thickening of the whole region of the trochanters; this usually means fracture at the base of the neck. Beyond this, we must depend on the skiagraph to differentiate between the two lesions. If, by chance, such a fracture is wholly unimpacted, we are again confronted with the question of differential diagnosis as against unim- pacted fracture of the neck proper. FRACTURES AT THE BASE OF THE NECK 537 Diagnosis of Unimpacted Fracture of the Base of the Neck.- The signs are: total disability; shortening, varying with intermittent traction; loose eversion, with active inversion impossible, passive inversion unhindered; rotation of the trochanter on its own axis when Fig. 955.-Fracture of the neck of the femur and of the great trochanter, in section. Im- paction; union not firm (Warren Museum, specimen 5225). Fig. 956.-Fracture of femoral neck. Impaction of base into the shaft, with downward and inward rotation of upper fragment (Warren Museum, specimen 6303). Fig. 957.-Frac- ture well below trochanters, with a split running upward through great tro- chanter. Also frac- ture of neck of bone, with displacement of head up and out- ward. Recent case (Warren Museum, specimen 1074). the leg is rotated; prominence of the trochanter under an entirely relaxed fascia lata. In short, there is nothing that definitely distin- guishes these from like loose fractures higher up in the neck. Usually we are content with the approximate diagnosis and wait for the z-ray. _ Fig. 958.-Buck's extension apparatus. Adhesive-plaster straps for traction; posterior splint to the leg and thigh; weight traction over the pulley at the foot of the bed. The whole leg steadied by the long T-side-splint shown in Fig. 919. Foot of bed raised on blocks to give countertraction by body-weight. As we first see these cases, they are apt to lie in bed or on a stretcher in a position strongly suggesting a subpubic luxation, and not uncom- 538 HIP FRACTURES monly, if a little time has elapsed since the injury, muscle spasm is such as to fix the hip almost immovably in this position. In some cases Fig. 959.--Same apparatus applied to give traction in abduction. Traction made from one corner of bed, and this corner raised disproportionally high. To carry this out successfully the T-splint should not reach much above the hip, in order that the abduction position be not lost. of this sort in stout patients even the fracture diagnosis can hardly be made at all, save by the skiagraph. Treatment of Fractures of the Base of the Neck In impacted, cases, if the deformity is not great, we treat as with impaction of neck into head, merely to preserve impaction. The details of the treatment are the same. If the position, however, is bad; if shortening, adduction, or external rotation promise much deformity and disability, we may wisely consider breaking up the impaction to improve position, without fear of nonunion, because these fractures are definitely extracapsular. Before doing this we must have a good x-ray to make sure in detail just what we are deal- ing with. In etherizing cases for such breaking up I have often found them to show no firm impaction at all; so soon as the muscles relax we have a loose fracture. For the rest, the case is treated like the obvi- ously unimpacted ones. In the unimpacted cases we first reduce, as well as may be, with or without ether, according to the need and according to the fitness of the patient, and then attempt to hold Fig. 960.-Spiral fracture of femur through and below trochanters, with fracture of the base of the femoral neck, partly impacted into the shaft. TREATMENT OF FRACTURES OF THE BASE OF THE NECK 539 reduction by the methods used in unimpacted neck fractures of the usual type. Fig. 961.-Extracapsular hip fracture. Fig. 962.-Same case after eight weeks in abduction (double plaster spica). Result good as to function, but position not well held. Reduction is by a pull on the foot, with counterpull on a sling in the perineum, with appropriate rotation. 540 HIP FRACTURES Fig. 963.-Extrascapsular hip fracture. Fig. 964.-Same case treated by weight traction and Thomas splint with traction for eight weeks. Far better result than the case treated in abduction plaster. PROGNOSIS 541 To maintain position we usually apply extension straps and use weight traction (8 to 25 pounds). Lateral traction may be called for, but can be applied later if the position calls for it.* Sometimes position is best secured in sharp abduction. This may be attained by abduction-traction with weights, or, if abduction holds things without any pull, a plaster spica alone (without traction) may be enough, or traction straps may be put on underneath and covered with the plaster spica, and we get the fixation, combined with more or less efficient weight traction, during the time the patient is in bed. Fig. 965.-Unimpacted fracture through base of neck and through trochanters. Note extreme eversion and thickening in groin. As in anterior luxation, position was improved, and firm union resulted, with a useful leg. (From photo of case of the author's.) The choice of methods is purely one of judgment of the individual case. Some cases are very readily held; others are almost impossible to treat satisfactorily, f Traction may usually be omitted after three to four weeks. Fixa- tion, or at least non-use, may wisely be continued until six weeks have passed. During this period, however, massage and careful passive movements are in order. Resumption of weight-bearing must be cautiously begun. Prognosis Good in the main. If there has been undisturbed impaction, there is no question that union will take place. There is some shortening, * Lateral traction seems to me an undesirable and unnecessary routine. The objection to it is that it necessarily interferes with circulation somewhat, and ordinarily is not particularly comfortable and probably not very useful. t Frequent x-rays are almost essential to check on maintenance of position. 542 HIP FRACTURES usually some eversion, and a moderate limitation of motion, due in part to bone thickening, in part to fibrous changes during the immobili- zation necessary to insure repair. Union is solid, and we may expect eventually a serviceable result, with no worse damage than a slight limp and slight stiffness and moder- ate pain on use, decreasing with time. If there has been no impaction, prognosis depends largely on ade- quate treatment. With good reduction well maintained, the result is that of the impacted form. Disability is present in less successful cases about according to the displacement persisting after union. Secondary arthritis must be kept in mind as to the prognosis. Delay in union is not uncommon; weight-bearing, therefore, is to be delayed in such cases for eight weeks or more. Non-union is rare, even in neglected cases. In fact there is some doubt if it ever occurs. FRACTURES THROUGH THE TROCHANTERS These fractures-by no means uncommon-are usually the result of rather severe trauma. Commonly, they are met with in young or middle-aged patients in whom the structure of the femoral neck still retains its strength. The causes are: (a) Direct violence, (&) Torsion of the leg. The lesions in the torsion fractures often show a combination of a torsion fracture (with spiral lines) through the trochanters, combined with a fracture between the neck of the femur and the intertrochanteric line (Fig. 960). Breaks directly across, between the level of the greater and lesser trochanters, are rare. They are from direct violence usually. Such lesion may accompany a break at the base of the neck, perhaps from splitting of the trochanteric neck by this basal fragment. (See Fig. 954.) Torsion fractures may break the bone above or below the lesser trochanter; the iliopsoas is attached to this process, and the determina- tion of the site of fracture with reference to this insertion is not unim- portant, but these fractures clinically belong with those wholly below the trochanters (class 6, p. 544). Diagnosis of Fractures Through the Trochanters (1) Complete disability. (2) Much thickening at and behind the trochanters; obliteration of the digital fossa. (3) Eversion (permanent), usually present, though not constant. (4) Limitation of motion. (5) Shortening-not necessarily great. (6) Impaction, actual at times, often only apparent, but apparently very definite in nearly all cases examined without ether. 543 FRACTURE BELOW THE TROCHANTERS (7) Crepitus is rare. (8) Rotation shows, if there is any impaction, a greater trochanter rotating on the head as an axis, without obvious change from the normal radius: loose rotation does not belong to this type. Usually the greater thickening is our best diagnostic point. Posi- tive diagnosis is often dependent on the skiagraph. Treatment The treatment is substantially that outlined for fractures of the base of the neck. Results Non-union of fractures in this region I have not met. The fracture is distinctly extra-articular, and callus-formation is usually profuse. Given a reasonably good reposition, we get in these cases very good results indeed. There may be some shortening and consequent limp; there may be thickening enough to limit in some measure the move- ments at the hip, but, as a rule, such disabilities are not great and the results are usually good. FRACTURE BELOW THE TROCHANTERS* (CLASS 6) We have no insertion of any of the shorter hip muscles below the break, and therefore no apparent impaction from muscle spasm. Im- paction is extremely rare. Therefore we find: (1) Disability-total. (2) Shortening--often great. (3) Extreme outward rotation, from gravity, as in shaft fracture. (4) Flexion and outward rotationf of the upper fragment (by the iliopsoas muscle). (See Fig. 971.) (5) Abduction of the upper fragment by the gluteal muscles. (See Fig. 970.) (6) Free mobility of the leg in all directions, including inward rotation. (7) Crepitus (not always readily obtained). (8) Failure of the trochanter to rotate with the leg or to share its other motions. (9) Possibility of testing the varying length and the looseness of the leg by direct intermittent traction. In short, we have in these fractures below the lesser trochanter the picture of high fractures of the shaft. The diagnosis in detail is often difficult; swelling is apt to be con- * Many fractures do not anatomically fall either in this class or in class 5, but belong to both. Clinically considered, the important matter is whether the main fracture runs below and outside the insertions of the short hip muscles, and particu- larly of the iliopsoas. t Not as constant as the text-books declare it, but usual. 544 HIP FRACTURES siderable, and differential diagnosis is obstructed by the difficulty in reaching the various landmarks. According to our skill, we may approach accuracy in this matter, Fig. 966.-Spiral fracture of the upper part of the femur. View from in front and exter- nally (Warren Museum, specimen 1103). Fig. 967.-Spiral fracture of the upper half of femur. Viewed from behind (same speci- men as Fig. 966) (Warren Museum, specimen 1103). but for exact diagnosis a good skiagraph is apt to be essential. In no fracture is our ordinary hospital routine as to x-rays more unfortunate Fig. 968.-Fracture below trochanters, outward bowing. Fig. 969.-Fracture below trochanters; shaft firmly impacted into trochanters. Clini- cally like impacted neck, though with somewhat more thickening (writer's case). than in various hip fractures. We have too often permitted the diffi- culties in transportation of these cases to interfere with their proper FRACTURE BELOW THE TROCHANTERS 545 Fig. 971.-In fracture below the lesser tro- chanter, not only do the abductors act, but the iliopsoas (drawn in black) pulls the fragment into flexion. Fig. 970.-Spiral fracture just below tro- chanters. Abduction of upper fragment. No impaction, but firm entanglement of upper end of lower fragment (sketched from x-ray). Fig. 972.-Diagram of similar deformity in fracture above lesser trochanter. Here there is no flexion pull, but even more liability to ab- duction (better leverage for abductor muscles Fig. 973.-'Fracture of shaft of femur very high up; union with much displacement (War- ren Museum, specimen 5993). Fig. 974.-Fracture of shaft high up; typi- cal abduction of upper fragment, due to muscle pull (compare Figs. 968-970). 546 HIP FRACTURES diagnosis, though accurate diagnosis is here essential to proper treatment. Treatment of subtrochanteric breaks consists essentially of proper Fig. 975.-X-ray, fracture below lesser trochanter; flexion and great abduction by muscle action. Fig. 976.-Sketch of x-ray of case of unim- pacted fracture between trochanters, with no deformity from muscle pull. Fig. 977.-Pad inside the long side-splint, to limit abduction deformity. coaptation of fragments with traction. Fractures in this region are not impacted. According as we find the upper fragment abducted by the gluteal muscles, or flexed by the iliopsoas, we must endeavor to correct this displacement or to place the shaft in line with said upper fragment. 547 FRACTURE BELOW THE TROCHANTER This may call for abduction or for flexion; much may be made out by skilful manipulation as to what the displacement is, but we are aided Fig. 978.-Anterior suspension splint for cases of high femur fracture, with much flexion of upper fragment. The splint (see lower drawing) is of iron wire: it is padded, and the leg and thigh firmly bandaged to it (from behind and below); then pulley ropes are slung to the rings in front, and the weight traction arranged to give the pull in the desired line. This plate is a photograph of a case in which extreme flexion of the upper fragment could successfully be met only in this way The Balkan frame is the modern form of overhead, perhaps no better. by the skiagraph. If abduction is called for, we must employ either sharp abduction, maintained by a plaster spica, or traction in abduc- Fig. 979.--Double-inclined plane splint, padded and applied. Fracture at junction of middle and lower third. Very old man. Died. Today one uses a Thomas splint with flexion. (Courtesy of Dr. F. L. Richardson.) tion. Sancl-bag pressure on the upper fragment, or a pad between the long Liston side-splint and the leg, is often effective as an aid (Fig. 977). If flexion is called for,-and this measure is less often called for than we should suppose from reading the text-books,-then we must use 548 HIP FRACTURES the Smith or Hodgen splint,* or the much-vaunted, rarely used, double- inclined plane. Our endeavor in these cases is to overcome shortening and angular displacement; therefore we exert the necessary traction Fig. 980.-Double-inclined-plane splint, adjustable. in the line of the displaced upper fragment, the position of which we can not easily influence. This end is often more simply accomplished by traction in the direct line or in abduction without flexion, because the Fig. 981.-Vertical suspension for high femur fracture in a child. Adhesive-plaster traction bands as for usual "Buck's." Coaptation splints to thigh. There should be pull enough to bring one side of the pelvis slightly off the bed. This is the best apparatus to use to bring the lower fragment in line with a flexed upper fragment. By children it is well borne; for adults it is intoler- ably uncomfortable.t tendency to flexion is slight or readily reduced, and easily held in many cases. * Even better, the Thomas splint suspended, so much used in the war hospitals, t Latterly I have ceased to suspend, in any but very small children, getting better results by weight traction. FRACTURE BELOW THE TROCHANTER 549 It is only in fractures well below the lesser trochanter that such com- pensatory flexion is likely to be needed, and in these cases, even, it is often uncalled for. Often it is possible to bring the tilted upper frag- ment down by the steady pressure of a sand-bag applied direct y over it. Broadly speaking, we are apt to find it wise to treat fractures in this region by traction in abduction, followed by a plaster spica (in abduction). Each case must, however, be judged by itself, and or- Fig. 982.-Same apparatus with varying detail. High fracture of thigh in a child. Bradford frame. Vertical suspension of leg with weight and pulley. Coaptation splints to thigh, and fixa- tion of pelvis by towel swathe about frame. dinarily we have three checks as to the perfection of our reduction: (a) the measurement of shortening; (6) palpation of the end of the upper fragment; (c) the x-ray. Given a reasonably accurate reposition, we have little trouble as to the union of these fractures. Callus is usually profuse and solid. Fig. 983.-Cabot splint arranged as double-inclined plane: B, The part behind the knee- joint may be bent to a more acute angle; C, the body portion; to be molded to the trunk; A, the foot- piece. Care must be taken as to early mobilization, and particularly as to early weight-bearing, for these fractures are rather liable to late progressive deformity under too early use. There is some tendency to deformity in anterior bowing, but more particularly to outward bowing under weight, even with good position and apparently solid union. Such tendency is to be avoided by avoid- ance of early weight-bearing; if it already threatens, pads of felt, etc., with fixation in flexion or abduction in plaster, will tend to neutralize 550 HIP FRACTURES it. Fractures of this sort are rarely fit for weight-bearing under ten weeks.* Fig. 984.-'Fracture of greater trochanter alone. FRACTURE OF GREAT TROCHANTER ALONE, OR SEPARATION OF ITS EPIPHYSIS These lesions are uncommon. They may occur from direct violence, more often from muscle pull. Fig. 985.-Separation of the cartilaginous epiphysis of the great trochanter (Warren Museum, Specimen No. 1190). I can obtain no history of this specimen or of the cause of the epiphyseal separation, but there are signs in the dry specimen of obvious inflammatory process from the neck of the femur down to the point shown by the white arrow in the figure, involving at least the peri- osteum and the epiphyseal line (probably acute epiphysitis) (age about twelve years). * But the use of a Thomas or a Taylor splint of convalescent type may, without risk, shorten this time two or three weeks. FRACTURE OF THE GREAT TROCHANTER ALONE 551 The trochanter may, so long as it remains an epiphysis (up to eighteen years) be torn loose from its bed. In adults, the trochanter, no longer an epiphysis, may be torn out of place. Fig. 986.-Upper end of femur in a child: a, a, Line of junction of epiphysis of head and shaft; b. epiphysis of greater trochanter; c, epiphysis of lesser trochanter (Warren Museum, specimen 334). Diagnosis.-The diagnosis is by direct palpation. The damage to the trochanter is apt to be overlooked at first. Fig. 987.-Separation of epiphysis of lesser trochanter alone. Courtesy of Dr. C. Metcalf, Con- cord, N. H. There is tenderness about the trochanter, and on careful examina- tion, perhaps a movable fragment. There is, of course, no shortening, and disability is not complete. Active abduction is necessarily abolished; other motions are painful. 552 HIP FRACTURES Treatment.-The conservative treatment is that of fixation in abduction, with pad pressure dver the trochanter. Consolidation will take three to four weeks. Open operation and nailing have been proposed and carried out. There is little to say against it, but not much to say for it, except for the gain in time from solid contact as a start for union. So far as I know, no disability has been reported in these cases when conservatively treated. It would seem unlikely that even fibrous union would give any disability if position was good. In case of difficulty in retaining the fragment in place there would be every reason for immediate operation. FRACTURE OF LESSER TROCHANTER This lesion occurs often as a complication of spiral or splintering fractures. As an independent fracture it is recorded by Julliard.* He gives marked external rotation and absolute helplessness as the signs. The diagnosis was confirmed by autopsy. Dr. Metcalf of Concord, N. H., had a case, the x-ray of which is appended, in which there was apparently a separation of the lesser trochanter as an epiphy- sis, without other lesions. Clinically the case presented nothing characteristic, and did well under routine fixation. * Julliard: Arch. f. klin. Chir., 1903, Bd. Ixxii, p. 82. CHAPTER XXIV THE KNEE DISLOCATIONS Dislocation at the knee-separation of tibia and femur-is a very- rare accident, far rarer than one might expect, considering the great force under great leverage to which the joint is often subjected. Most commonly, knee luxations are fracture luxations in which splitting off of one or the other femoral condyles or of the tuberosities of the tibia has permitted lateral displacement.* Rupture of single ligaments alone-particularly of the internal lateral liga- ment-may commonly enough give sw&luxation. Anteroposterior displacements are not apt to involve bone damage, as lateral luxations do. Anterior Luxation of the Knee Displacement of the tibia forward at the knee results from great force acting by direct thrust or, probably, through hyperextension. The lesion occurs not through a fall, as a rule, but in some form of crushing or twisting accident, f Such displacement involves rupture of the lateral ligaments and either rupture of the strong posterior ligament or its separation (by stripping up of the periosteum) from the back} of the tibia. Vessel and nerve injuries are not unusual. The crucials are torn, of course. Diagnosis.-Displacement is obvious; the only question is as to associated fracture, a question to be answered by palpation of land- marks and by cautious manipulation of the lower leg by an assistant while the surgeon palpates the region of the knee. Lateral mobility is present, of course, since all ligaments are gone. Hyperextension is possible. Flexion is more or less hindered. Reduction.-The most efficient reduction is by hyperextension with downward traction, and direct manipulation to force backward the dis- Fig. 988.-Landmarks of knee from outer side: a, Tubercle of tibia (insertion of ligamentum patellae); b, edge of outer condyle; c, patella; d, top edge of tibia; e, head of fibula. * The name of "strain fractures" has lately been given to such knee lesions- not a bad term, for the luxation usually reduces itself. (Sidney Lange: Ann. Surgery, 1908, xlviii, p. 117.) f Eames (Brit. Med. Journ., 1900, i, 908) gives an instance in which a car in a mine dropped 60 yards down a shaft. Of the 18 men in it, 5 sustained forward luxation at the knee. 553 554 THE KNEE placed tibial head. This succeeds, but is open to the objection of pos- sible stretching of the nerves, especially of the external popliteal. Traction and direct pressure without hyperextension seem, from the recorded cases, to be efficient without this risk, and should be tried first. Fig. 989 Fig. 990 Fig. 991 Fig. 989.-Anterior luxation, occurring by hyperextension, may give the position shown at the left, or by later traction may come to lie as in the right-hand sketch. Fig. 990.-In the latter case the movements here shown (hyperextension, then traction with direct thrust) will be called for. Fig. 991.-If there is no overlapping, simple traction and countertraction with a direct reducing shove will suffice. Treatment is by fixation in plaster, aided by massage after a fort- night, with passive motion at about a month. Weight-bearing must be resumed cautiously and late, for the substitution of scar tissue for liga- Fig. 992.-Forward luxation of the knee (from a severe crushing accident); left leg, seen from the outer side (photographed for author, courtesy of Dr. H. A. Lothrop). ments so powerful as the posterior and laterals at the knee takes weeks, and is apt to be somewhat imperfect at best. Therefore a light split-plaster or a leather and steel support, worn while walking, is advisable for some months, mobility and the preven- INWARD LUXATION 555 tion of muscle wasting being assured by massage and by active motion with the apparatus off. Fig. 993.--x-ray of same case. No fracture. Reduced readily by Dr. Lothrop, by mechanism shown in Fig. 990. Did well. Backward Luxation This is less common. The diagnosis is again obvious from the pres- ence of the exposed condyles in front and the obvious backward dis- placement of the leg. The patella disappears into the intercondylar groove (Fig. 994). Reduction is to be accomplished under traction by direct pressure forward on the displaced tibia, with counterpressure on the femur in front. I have seen two old cases only. One came to me months later after reduction of the backward dislocation, for relief of false motion laterally, a knock-knee of at least 30 degrees being allowed by the loss of the internal lateral ligament. An artifi- cial ligament of silk solved the stability problem on this case. A recent case with almost exactly the same disa- bility has not yet submitted to operation. Operation for this condition today would consist (in my hands) of a reefing with a strip of the patient's own fascia lata, just as in the cases of simpler tear of crucial ligaments and the internal lateral ligament in which I have so reefed several times with success. Pathological luxation or subluxation backward is of course a familiar picture. Fig. 994.-Back- ward luxation at the knee, right knee, from the outer side (schem- atic). INWARD LUXATION This is excessively rare without fracture. The diagnosis calls merely for the exclusion of fracture of the condyle or of the tibial tuberosity (established by palpation when the knee is moved). Re- duction is by action and pressure. Inward subluxation is even rarer-it is to be dealt with similarly. 556 THE KNEE OUTWARD LUXATION This is a bit commoner; the displacement is usually in part rotatory in the direction of outward rotation. Not rarely there is concomitant outward displacement of the patella to the outer side of the external condyle. Of course, the direction may be outward and forward or, more often, out and backward. I have successfully reduced one old case by open operation and secured a stable joint with some motion by using ligaments of fascial strips. The diagnosis is obvious. The reduction in this form also is by traction and direct pressure, with or without rotation. Subluxation Outward.-This is not uncom- mon as the result of apparent rupture of the internal lateral ligament. There may be actual subluxation, or, more often, simply a mobility in the joint permitting free play in abduction. This motion commonly reaches 20 degrees or more. In these cases there may be tearing of the internal lateral ligament to some extent, Fig. 995.-Posterior and outward luxation (strictly subluxation) of the knee, with fracture of inner part of tibia into the joint. End-result here shown; much disability. (Case of the author's in 1893, before the days of z-ray confirmation and study.) Fig. 996.-Congenital luxation (genu recurvatum). Sketched from a plate by Barth (Arch. f. klin. Chir., 1884-85, pl. ix, Fig. 2). but apparently the tearing of the vastus internus and its enveloping fascia is a very important factor in permitting lateral motion.* Two cases I have seen operated (Crandon) showed this sort of tearing, but no obvious damage to the ligament itself. It is because "ruptures" of this ligament seem, in fact, not to involve any tearing of the ligament in mass that the prognosis of these cases is so good. * Lateral motion of a few degrees is of no consequence in diagnosis-it not uncommonly appears in knees that have shown synovitis for a few days. DISLOCATION OF SEMILUNAR CARTILAGES 557 Prognosis of Knee Luxations.-In all uncomplicated knee luxations the prognosis, if there be no complications, is better than would be ex- pected. The torn ligaments repair, and a mobile joint may result, with fair strength. There is a risk of progressive knock-knee from any of the complete luxations and in fracture-luxations, especially in the outward luxa- tions, owing to imperfect repair of the heavy internal lateral ligament on which, normally, a great strain is thrown. Congenital Luxation of Knee There is a luxation of the knee forward-"genu recurvatum," illustrated in Fig. 996-that should be mentioned. It is congenital, and is often associated with partial or total defect of the patella. The condition permits of effective reduction with good function if the knee is straightened early. Dislocation of Semilunar Cartilages ("Internal Derangement of the Knee" of Hey) There are in the knee two cartilages, an outer and an inner, attached at their ends to the tibia, and held at the peripheral edge by the so- called coronary ligament, which is really a part of the capsule. The inner edges are free. The cartilages move with the tibia in flexion and extension, but probably act as sliding "buffers" in the slight abduction and adduction movement of the joint, and certainly do so act in rota- tions of the tibia on the femur. Their normal range of motion, like that of other interarticular cartilages, is slight. Dislocation of one or the other cartilage may rarely occur without any tearing: the "coronary ligament" attachments may be lax. Or- dinarily, however, the cartilage, before displacement takes place, is torn loose at either end, or its peripheral attachment is loosened, or, perhaps the most common lesion of all, the cartilage is torn across. Such tearing may be associated with immediate displacement. This, however, is not the rule; usually the first trauma shows only a synovitis as the obvious result, and later some slight twist of the knee brings about a dislocation. What we meet with in practice is ordinarily the recurring dislocation -habitual dislocation of the cartilage. The tearing of the ligaments or of the cartilage, in the first place, is supposed to be caused by the cartilage becoming caught at one point between the bones, and then, by traction in the rotatory movement, torn loose or torn across. I have always suspected, however, that the transverse clean-cut break across the middle of the cartilage must be a fracture under extreme pressure. In the habitual cases there may be a thickening of the broken ends, or, more commonly, a thinning; one or the other end may be doubled over. There are not usually any concomitant joint changes unless recent luxation has left a synovitis. 558 THE KNEE Dislocation may be toward the center of the joint, or, less usually, toward the periphery. In case the cartilage itself is torn, only one fragment luxates. It is very doubtful if any factor other than trauma enters into these cases. Shaffer maintains that a long patellar ligament is the constant predisposing cause. It might well be, but the presence of such a lengthened ligament in the actual cases has not usually been confirmed by other observers. Falls or slips involving a twisting of the knee are commonly the cause of the original damage, as of the recurrent displacements. Once the displace- ment has become habitual, rotation of the knee in slight flexion under very light force may cause it, more particularly if the muscles are relaxed. For this reason a slight slip of the toe at the completion of a step or an unguarded movement in bed is, in inveterate cases, more likely to give displacement than is a more forcible twist. Symptoms.-Whichever cartilage is displaced, and in whichever direction the displacement may be, the main symptoms are the same-- a sudden "locking" of the knee in slight flexion. So long as the knee is kept flexed there is no great pain, and the sufferer can walk if he does not fully extend the leg. But so soon as extension comes to a point somewhere within 20 to 15 degrees of the straight line, motion is abso- lutely checked, and there is excruciating pain from pinching of the cartilage. Some one has aptly compared the mechanism to that of "a stone in a hinge." If reduction is not prompt, a sharp synovitis develops, and there is reflex muscle spasm. After reduction the synovitis is often not severe, and in the frequent inveterate cases where the patient has learned to do instant reduction himself, the reaction is trifling or none at all. In all cases, however, habitual dislocation leaves the patient justly fearful, whatever work or sport he engages in. Rarely, the tendency to luxation lessens with time; often tends to grow worse. In any given instance where the cartilage is out it stays out until reduced by some man- oeuver. There is only rarely any tendency to spontaneous reduction.* Diagnosis.-Similar symptoms may be given only by a "foreign body" in the knee, a loose cartilage of the "mouse" type, or by pinching of a fringe of ligament (the free edge of either of the liga- menta alaria, outer or inner). No other conditions give the locking Fig. 997.-Right tibia at knee-jo int (from above), showing size and relations of the two sem- ilunar cartilages. Fig. 998.-a, Region of tenderness in strain of inter- nal lateral ligament; b, upper edge oi tibia; c tibial tub- ercle; d, internal semilunar at point most often damaged. * In strict fact, in recurrent cases use and motion of the joint do sometimes throw a cartilage in, inasmuch as they involve the various rotations. DISLOCATION OF SEMILUNAR CARTILAGES 559 in extension with free function in flexion. Differential diagnosis be- tween a pinched fringe and a cartilage may be impossible; fortunately, the treatment is the same. A "mouse" may be suspected if other "mice" can be felt in the joint, or if the offending body can be felt as a rounded mass, or if there is a history of previous locking not caused by any 'particular motion of the knee. The locking caused by a foreign Fig. 999.--Reduction for dislocation of internal semilunar cartilage. Flex leg over bent wrist, at the same time abducting the leg and rotating it outward. This increases space to the inner side. Then extend; with a space to slip in, the cartilage is dragged into place by its lateral attachments. body is often very sudden and sharp: so far as I know, the sort of locking that throws a man off his feet never occurs from a jammed semilunar cartilage. Today one operates on nearly all these cases. Here and there such a condition is not intolerable and rarely the condition improves under bandaging, etc. With semilunar displacement we have the locking at a definite point, short of full extension, with exquisite pain on either the outer or the inner side. Usually there is nothing objective to be felt; occa- sionally the luxation is peripheral and the cartilage may be felt as a cylindric mass lying outside the joint. Such a displaced cartilage is tender to the touch; even when nothing is to be felt, there is tenderness over the site of the displaced cartilage. Diagnosis as between displaced inner and outer cartilages rests on the localization of pain and ten- derness. The history may also help; a twist of the foot outward typically leads to displacement of the inner meniscus; the outer is usually displaced by a twist inward. Displacement of the inner meniscus is far the commoner injury. Treatment.-Reduction of the displacement depends on the relief of the pressure on the cartilage between femur and tibia, giving it room; and then on pulling it back into place by utilizing its movement with the tibia in rotation. The exact mechanism of this has been interest- ingly worked over by Tenney,* though the rules for reduction have long been established. Fig. 1000.-Shows the origin of the gastro- cnemius from the back of the femur above the condyle, and the mechanism by which contraction of the gastrocnemius causes backward and down- ward rotation of the lower fragment of the femur. * Ann. Surgery, July, 1904, vol. xl, p. 1. 560 THE KNEE 1 or our present purpose it is enough to say that whether the carti- lage is displaced in or out, the pull of rotation tends to bring it into its own proper position. The motion needed for the right pull is that of rotation of the leg away from the injured side, e. g., outward rotation if it is the inner cartilage that is displaced. Reduction of displacement of the inner meniscus is best carried out as follows: The patient is placed on his back; the operator puts his forearm in the hollow of the partly flexed knee; then, grasping the ankle with the other hand, he flexes the leg forcibly over the forearm fulcrum so as to separate the joint surfaces; then, still keeping- up this separation, he rotates the leg outward, then brings it up into extension and inward rotation. There is no click-the test of reduction is the pos- sibility of full extension with pain. The manceuver may need several repetitions. At times pressure on a palpable cartilage edge will help. With a lean leg and a strong-handed assistant holding the thigh, it is possible to abduct the bent leg a little during rotation. This helps. Some cases, curiously enough, reduce with a rotation against the rule, i. e., inward rotation for displacement of the internal cartilage. Ether is not often necessary. Properly done, the reduction may be forcibly done with very little pain; there is no point in doing forcible extension. Reduction of the displacement of the outer men- iscus is the exact reverse in the rotation, otherwise the manoeuver is the same. After-treatment.-Fixation in extension until the synovitis subsides. If it is the first time the acci- dent has happened, longer fixation may cure it; in recurrent cases it is of no use to try it. You may as well bandage the knee and allow walking. Shafter has devised a rather complicated apparatus to con- trol rotation and so prevent the slipping of the car- tilage. With this, worn for a long time, he has had cures, but the method is too tedious to find many followers. Under proper aseptic conditions operation will give prompter and more certain results, and is to be advised in the troublesome chronic cases and in the rare cases where, after weeks of neglect, the cartilage has become irreducible. The stitching down of the cartilage is not always satisfactory-the modern operation is a removal of the cartilage, or of such part of it as becomes displaced, through a small oblique incision at the side of the joint. Fig. 1001.-The forms here shown, in which muscular action plays no part, are clini- cally about as com- mon as those in which the muscle does act. Fig. 1002.-Frac- ture, oblique, above the knee, united with- out other deformity than that of overlap- p i n g (sketch from Cooper's plate). FRACTURES ABOVE THE CONDYLES 561 The loss of the cartilage in no way interferes with perfect function of the joint, nor is the long axis of the leg perceptibly changed. FRACTURES OF THE FEMUR NEAR THE KNEE Fractures of the femur near the knee may be classified as follows: (1) Fractures above the condyles. (2) T -fractures. (3) Epiphyseal separations. (4) Fractures of either condyle alone. (5) Fractures of a small part of either condyle ("strain fractures"). Fractures Above the Condyles These are not very rare. The classic picture is that of a transverse fracture, displaced in backward rotation by the backward pull of the gastrocnemii. (See Fig. 1000.) Such fractures do occur, but, as a rule, the gastrocnemii play but a small role. The action of the powerful thigh muscles, tending to shortening of the limb, is much more important. Overlapping is the rule, but, ordinarily, it is overlapping as in Figs. 1001 and 1002, rather than the type of Fig. 1000. The problem is one of shortening rather than rotation, a problem to be met by vigorous traction. Treatment calls for active traction, and only rarely for the double inclined plane, etc. Traction by Buck's extension, with a supporting ham splint, applied after the best possible reduction under ether, is the treatment ordinarily most effective. There is massive thickening; non-union does not occur, apparently; the question is one essentially of motion at the knee. The question of function is, in a measure, dependent on the relation of the patella to the upper fragment, if the latter is displaced forward (Fig. 1003). Ordinarily, the massive callus thrown out in the repair of these cases, as much even as any rotation or displacement of fragments, is the cause of limited motion and disability. The prognosis, on the whole, is fair-not better than fair, though a useful leg may be looked for. These fractures seem not apt to cause vessel or nerve damage. To-day many of these cases fall in the operable class. They are not easy to reduce; very hard to hold. In the late cases, of which I have had several, the procedure has been to cut back the spur of the upper fragment in cases like Figs. 1002, 1004 and 1006; to cut out a socket to hold the upper fragment in cases like Fig. 1007. Results have been good. Fig. 1003.-Shows how the motions of the patella may be interfered with by the lower end of the upper frag- ment in various positions of fragments. Moderate rotation backward of the lower fragment is in this regard not a disadvantage. 562 THE KNEE Fig. 1004.--Oblique frac- ture of the shaft just above the knee, with splitting apart of the two condyles. Extreme dis- placement; necrosis of tip of upper fragment. Patient, a man of thirtyseven years, lived for five months (Warren museum, specimen 1118). Fig. 1005.-Pos- terior view, same speci- men as Fig. 1004, show- ing splitting apart of the two condyles. A high T-fracture. Fig. 1006.-Diagram showing the condition in a case of the writer's (very similar to case shown in Figs. 1004 and 1005) in which trac- tion was utterly ineffective, and operation was refused. There was eventually penetration of the spear- pointed fragment at the place marked 1 (2, external condyle). The patient finally came to thigh amputation after sloughing over the fragment. Fig. 1007.-Fracture of the femur just above the knee, produced by gunshot (see bullet near level of joint). The bullet wound healed by first intention, but the photo shows marked displacement (here again without much rotation) and a position such that the jower end of the shaft directly impinged on the patella. The patient declined operation, and as she was elderly and not vigorous, it was not urged. Fig. 1008.--Same case as Fig. 1007, with position modified only by con- tinued traction, and by the use of pads. Note the excellent position, and par- ticularly the changed relation of the lower end of the shaft and patella. The. leg united firmly in this position, with fair motion at the knee. 563 T-FRACTURES T-Fractures These are not very common lesions. Substantially they result from the same violence that oftener gives supra- condylar fractures-falls on the knee. The height of the cross-break varies greatly; the vertical split runs straight to the intercondyloid notch. Diagnosis depends, as differentiated from simple supracondylar fractures, on widening of the knee (in the bicondylai' width) and on separate mobility of the two condyles, with crepitus. This crepitus in itself is not reliable, for attempts to move the con- dyles separately will give crepitus between condyle and shaft that is very confusing. Fig. 1009.--Diagram of T-fracture of the femur. T- fractures may be lower; not rarely they are a good deal higher than this. Fig. 1010.-A common de- formity in fractures near the knee-joint is that shown above; a simple sagging back, due to gravity, having nothing to do with rotation of fragments due to gastrocnemius action. Fig. 1011.-Sketch from x-ray plate. High T-fracture. Recovered with some broaden- ing of the bones an consider- able limitation of knee motion, but with a pretty serviceable leg. Fig. 1012.--Drawing from a>ray plate. High T-fracture of the femur. Good position. Fig. 1013.--femoral 'epi- physes at fifteen years. Note relations of lower epiphyseal line to inferior articular sur- face (Warren Museum, speci- men not numbered). Treatment is by traction and manipulation, preferably under ether. It has been my experience that continued traction (Buck's extension) tends to produce marked improvement in the relation of one condyle to the other, as well as in the relation of both to the shaft. 564 THE KNEE Theoretically, mutual impaction of the condylar fragments with mallet and sand-bags, after the best practicable reduction, should be indicated, but the reduction in my more recent cases has been appar- ently too good to justify the measure, so I have no data to give. In the manipulation, however, strong pressure on the condyles from both sides is most useful. Prognosis in these cases must be carefully stated. Because of disturbance of relations of the Fig. 1014.--Diagram of double-inclined plane for fractures near the lower end of the femur. Secures good position through relaxation of gastrocnemius muscle and pads beneath lower fragment. Fig. 1015.-Traumatic sep- aration of epiphysis of femur. Note in this case the stripping up of the periosteum which has remained attached to the epi- physis (Warren Museum, speci- men No. 9771). joint planes of the femur, it is apt to be distinctly less good than in supracondylar fractures. If our reduction has been poor,' the result Fig. 1016.-Character of deformity in the more usual anterior displacement. Compare plates in Figs. 1018-1021. The displacement in these cases is much less obvious than would be expected from the degree of sepa- ration of the fragments. Fig. 1017."-Sketch of the deformity in a case of back and inward displacement seen 24 hours after injury. Injury resulted from twisting the knee in jumping off a wagon; there was back- ward and inward displacement of the whole epi- physis, with a projection of the end of the shaft of the bone to the outside of the patella, and a marked bow-leg deviation of the general axis of the leg. Reduction under ether required a good deal of traction and force, but presented no real difficulty. may be very poor indeed; on the other hand, we may get an almost perfect leg. 565 EPIPHYSEAL SEPARATIONS In the average case, handled with skill and fair luck, we may expect a strong leg, with perhaps 60 degrees of flexion. Such a result is to be called very good. I know nothing of the operative treatment of these cases; they involve the knee joint, of course, and necessarily imply much trauma from the accident, and would call for much trauma in attempts at replacement. One would rather not operate if operation could be avoided with fair prospects. Epiphyseal Separations The lower epiphysis of the femur is the largest epiphysis in the body. Its separation is important not only from its size, but also from its proximity to the vessels and nerves of the popliteal space. The epi- physis may be separated at vari- ous ages in various ways, but the type case (constituting a fair ma- jority of the cases occurring) is the Fig. 1018.-Separation of lower epiphysis of femur with forward displacement: a, lower end shaft of femur; b, lower epiphysis of femur displaced and rotated forward; c, front articu- lar surface of this lower epiphysis; d, chip of bone torn loose from shaft; e, epiphysis, upper end of tibia; f, patella (Warren Museum, specimen No. 8116-1; alcoholic specimen). Fig. 1019.-Separation of the epiphysis with forward displacement. Detail of displacement exactly as in Fig. 1018. separation by hyperextension in boys of ten to fourteen years of age. The mechanism is usually that of pure hyperextension. The knee is hyperextended, and the strong posterior ligament tears off the epiphysis. Causation.-The trauma is curiously constant; the hyperexten- sion is brought about by the rotation of a wagon-wheel-the boy has been caught in the wheel while "hanging on behind." Nearly all the cases I know of have been from this peculiar accident. 566 THE KNEE The epiphysis is torn loose, and as hyperextension continues, it is driven forward and upward between the end of the shaft and the patella.* Diagnosis.-The position assumed is that of Figs. 1016, 1018, and 1019. The lower end of the diaphysis obviously comes into such Fig. 1020.-Separation of the epiphysis with a chipping of the lower end of the shaft in front. In this case, there never was any more displacement than is here shdwn. Fig. 1021.-In this case the epiphysis was simply loosened and a little displaced, but pre- sented no difficulty in replacement and no ten- dency to come out of place. position that the popliteal vessels are exposed to compression. Rarely they are torn; usually they are compressed. Often also the popliteal nerves, particularly the external, are damaged. The history of such forward displacements is a melancholy one. There have been many cases of gangrene from vessel damage, and Fig. 1022--Reduction for anterior luxation of the epiphysis. Flexion of hip and knee; femur held firmly and traction made in the line of the lower leg, with constantly increasing flexion; pres- sure is made on the lower fragment with the thumbs. With variations in the angle at which the knee is held at the beginning of the movement, this is probably the best method of reduction. many deaths subsequent to such gangrene. Death, or amputation to avert such death, seems to be the usual sequel.f * Pathological luxation from congenital syphilis, "Parrot's Disease," and from infantile scurvy may be mentioned. f Of 22 cases referred to in the Cbl. fiir Chirurgie, 1898, xxv, p. 175, there were four deaths and 14 amputations. EPIPHYSEAL SEPARATIONS 567 Reduction.-The surgical indication in such cases would seem obvious. If there is displacement with loss of distal circulation, we must interfere-without incision if we succeed in adequate replace- ment, with open operation if this does not work. The one unjustifiable measure is delay. Open incision makes it possible to use direct traction (with hooks) to reduce the fragments. If this should fail at first, radical cutting of any periosteal or other obstructing bands is obviously called for. Resec- tion should never be necessary. Reduction without incision is by traction on the flexed lower leg (see Fig. 1023.--Old backward dislocation of the epiphysis of the femur, caused by fall backward in which the lower leg was immovably jammed. Photograph shows the case five months later. The arrow shows the point of projection of the lower end of the shaft of the femur. Union solid. Fig. 1024.--Same case as Fig. 1023. a: shows the prominence above referred to. This is the best extension possible because of the rotation of the joint and lower fragment backward (compare with Fig. 1025). Fig. 1022) and pressure downward on the site of the fragment. This is followed by flexion. The best procedure after this is treatment in flexion first proposed by Hutchinson and Barnard. In three cases lately, I have used this method. It is ideal. It is not uncomfortable, apparently it gives no compression of vessels, and there is not a chance of slipping (Figs. 1031, 1032). The only "out" is a certain difficulty in getting extension of the knee after union is solid. These cases are in boys of ten to fourteen; nearly always at this age mobilization is easy, and all my three cases have regained full motion. 568 The technic is evident from Figs. 1022, 1031, 1032. The only caution is to make sure by palpation of the dorsalis pedis, and the THE KNEE Fig. 1025.-x-ray of case shown in Figs. 1023 and 1024. Fig. 1026.-a:-ray of case shown in Figs. 1023-1025, after operation. This case was oper- ated on by chiseling the end of the shaft clear and making a new bed for it in the mass of epiphysis and callus. In this new socket the shaft was sutured into place after straighten- ing the leg into proper position. The result was a leg perfectly straight, with slight local deformity, ninety degrees of motion, and perfect function. Fig. 1027.-x-ray of case shown in Fig. 1017 after reduction. Perfect reduction. The boy was walking on this leg in six weeks; result perfect. Fig. 1028.--Fracture of external condyle (sketch from Cooper, Pl. xvi, Fig. 3). posterior titral artery (below and behind the internal malleolus that circulation is not unduly interfered with). With this method at hand, to my mind there is no other treatment for fresh, reducible cases. Open operative treatment seems to me to EPIPHYSEAL SEPARATIONS 569 belong to the irreducible and the neglected cases only. We have to consider the later growth defects. I have seen one case of increase of Fig. 1029.-Separation of femoral epiphysis at knee (by hyperextension) Fig. 1030.-Same case held after reduction by putting up in acute flexion. growth on the inner side mainly, with a total increase of this leg over the other of one inch in three years. 570 THE KNEE Displacement of the epiphysis laterally: we have no especial problem of vessel trauma to consider. Reposition is accomplished by Fig. 1031.-Separation lower femoral epiphysis. Reduced and held in acute flexion. Eig. 1032.-Same case as Fig. 1031 held in acute flexion by adhesive. No other dressing needed. traction and direct pressure. These cases are very rare. I have seen but one. Displacement of the epiphysis backward is less common than the forward displacement, but a number of cases are on record; two EPIPHYSEAL SEPARATIONS 571 occurring in my practice are noted. Forced flexion, with or without torsion, seems to be the determining force. (See Figs. 1023, 1026, and 1017 and 1027.) The displacement is directly back or back and to one side. The rotation is apt to be backward, as shown in Fig. 1025. There is no es- pecial liability to tears or tension of either vessels or nerves. Diagnosis, as distinct from supracondylar fracture, depends on the age of the patient, the height of the injury, the presence of soft, not bony, crepitus, and the skiagraph. Fig. 1033.-Reduction in backward displacement of the epiphysis; shows the grip by which traction downward in the line of the thigh and a lift forward (against counterpressure at the point shown by the arrow) may be so employed as to carry lower leg and epiphysis forward to the proper position. This was the reduction used in case shown in Figs. 1017, 1027. Reduction is by traction on the leg with the knee bent (see Fig. 1033), with direct pressure on the protruding fragment; rocking from side to side and varying the angle of flexion may assist the reduction. Here, as in the forward epiphyseal displacement, the success of reposition is measured by the loss of deformity and the loss of any ten- dency for it to recur. After-treatment in all these cases consists of two to four weeks' rest-then gradual use. Repair is far more prompt than in most fractures at this level, and there is no tendency toward any gradual increase of deformity later. Recovery of motion is better than in fracture, if reposition has been good. * J. Hutchinson and Barnard: Lancet, 1898, ii, 1630; Med. Chir. Trans., Ixxxii, p. 77. 572 THE KNEE Fractures of Either Condyle Fractures of the internal or external condyle alone occur by avul- sion as a result of forced abduction or adduction of the extended knee, more commonly than as a result of direct violence. The accident is not very rare. The line of fracture varies. (See Figs. 1028, 1034.) There is little tendency to displacement, except as controlled by the traction of ligaments running from the broken frag- ment to the tibia. With the leg straight at the knee a little displacement of the broken condyle away from its fellow is all we have. Diagnosis depends on lateral mobility of the joint, with motion of one condyle following the motion of the lower leg. Crepitus will usually be present. Synovitis is always present. Reduction is by restoring the axis of the leg and pressing the loose fragment into place and holding it there with pads. The leg is, of course, held on a ham-splint or in plaster. Early massage and motion are in order; weight-bearing is not to be hurried.* Prognosis is good according to the accuracy of the reduction. In the best cases we get admirable results;-not far from the normal function,-but in the run of cases there is considerable loss of flexion at the knee. The cases in which the condyle is crushed in do less well than those in which it is torn away. Fig. 1034.--Lines of fracture of the fe- mur at the knee (dia- gram of usual types); 1-3 and 2-3 represent the types of fracture of the external and the internal condyles; lines 4-6 and 5-7 are rather epicondylar fractures, and result from avulsion of these portions of bone by ligament, what Sid- ney Lange aptly calls "strain fractures." Fracture of the Epicondyles Here and there we find cases where the ligaments under strain have pulled off smaller fragments, little more than the areas of bone to which they are attached,! fragments that leave the bone-shaft practically intact. (C/. Fig. 1082, showing like lesion of the tibia.) Clinically, they give the picture of ruptured ligament. Sometimes a loose frag- ment is felt, rarely crepitus, or the x-ray first brings the fracture to light. Displacement is trifling; fixation gives a good result. Sometimes direct trauma acting at a single point on the flexed knee drives in a portion of the articular surface of the femoral condyle- usually the inner. There are no signs of such damage except local tenderness at one point; there is apt to be a sharp synovitis, but this proves nothing. Tenderness is apt to continue long, but eventually recovery is usually perfect. * Operation is rarely needed though I have done it with success. Mostly these cases do better than one anticipates without operation. f A very interesting lot of cases of this class are reported by Sidney Lange, "Strain Fractures," Ann. Surg., xlviii, 1908, p. 117. 573 FRACTURE OF THE EPICONDYLES The results of later loosening of such depressed fragments in rela- tion to the formation of "joint mice" have been interestingly discussed by Codman.* At the time of injury diagnosis is apparently not possible; treat- ment, therefore, is likely to be that of the accompanying synovitis only. These cases are apt to show a local tenderness and consequent long disability apparently out of proportion to the actual lesion. * E. A. Codman, in a paper presented to the Suffolk District Med. Soc., April 25, 1903, reported in the Boston Med. and Surg. Journal. CHAPTER XXV DISLOCATIONS OF THE PATELLA Only two classes of dislocations of the knee-pan fairly deserve consideration-the outward and the rotatory. All the others, up, down, back, and in, occur as accompaniments of other injuries, not independently (for instance, the upward luxation accompanies "genu recurvatum" or is the result of rupture of the patellar ligament, and the luxation is in itself unimportant). OUTWARD DISLOCATION This is the direct outward displacement of the patella onto or beyond the ridge of the external condyle. More commonly the knee- Synovial membrane cavity of joint Fig. 1035.-Horizontal frozen section of the knee-joint. pan is rotated, so that the articular surface lies next the bone (Fig. 0137), but it may rest on edge* (Fig. 1038) or be rotated further back and completely reversed, the articular surface being forward. The dislocation may be the result of violence acting directly on the knee-pan from the inner side, but fully as often it results from sudden muscle action. Where produced by muscle action only, the occurrence, and espe- cially the recurrence, of the displacement is apt to depend on knock- knee and on deficient development of the external condyle. * On either the outer or the inner edge, for rotation may be either way. 574 OUTWARD DISLOCATION 575 The case histories show that sudden muscle contraction with the leg extended or in moderate flexion, especially if the knee is turned in or the foot and leg sharply everted,* suffices to cause the displacement. A glance at Fig. 1041 will show how the quadriceps muscle, acting Fig. 1036.--Diagram drawn from the dry bones. Fig. 1037.-Diagram of the forms of the outward disloca- tion of the patella without rotation. Fig. 1038.-Outward luxa- tion of patella with rotation (diagram). on the insertion of the ligamentum patellae, must, on contracting, tend to straighten its length (Fig. 1041), including its sesamoid, the patella. There is nothing to resist this save moderate capsular resis- tance and the ridge of bone on the outer condyle, never as high as on the inner side, and sometimes very trifling indeed, f Fig. 1039.-Outward dislocation of patella without rotation. Old case unreduced. (Warren Museum, speci- men No. 1187; plaster-of-Paris cast.) Fig. 1040.-;Same case as Fig. 1039. It will be noted that in flexion in this case there is a sharp outward rota- tion and some subluxation backward of the lower leg on the femur. This subluxaton is not characteristic of the fresh traumatic case. (Warren Museum, specimen No. 1188, plaster cast.) Lesions.-In cases of direct examination (autopsies, etc.) the capsule has been found torn toward the inner side of the patella in a 576 DISLOCATIONS OF THE PATELLA majority of cases, but not in all. Tearing away of the vastus internus occurs not infrequently.* Symptoms.-The leg is useless. It may be found flexed or ex- tended-more often somewhat flexed, with sharp limitation of further flexion. Voluntary extension is lost, but passive extension is practi- cable. The patella is fixed firmly in its abnormal position. Diagnosis.-We have a hard body, attached to quadriceps and patella tendons, lying, firmly held, to one side of a joint in which the patella is missing, with all other landmarks in place. The rounded surfaces of the condyles are practically subcutaneous and readily identified. The position in regard to rotation of the patella may be made out by palpation. The external surface of the patella is smooth and flat, and suffi- ciently attached to the skin to give a dimpling that will help identify this surface. (See Fig. 1044.) Reduction.-Any motion in extension may reduce. The classic manoeuver is to flex the hip (to relax the rectus) while extending the knee, and then to shove the patella inward, so shoving as to correct any rotation present at the same time. Pressure and traction downward on the lower part of the quadriceps muscle are also advised. Ordinarily, reduction is easy. In case the manoeuver above described fails, like manoeuvers in flexion (moderate flexion, that is) have been reported successful. After reduction there is, of course, some syno- vitis, but the damage repairs in the usual way. A ham splint for a fortnight or three weeks and then a bandage and massage suffice. Prognosis.-In the cases due to direct violence without favoring bone-deformity, complete resti- tution is to be expected. In cases due to muscle action we must remem- ber the frequency of underlying anatomic causes; moreover, we have, besides the original causes, the laxity of the joint due to muscle atrophy, to capsule distention, and to possible defective repair of the tear in the capsule. Prognosis will, therefore, be given guardedly. Unreduced luxations of this type do not necessarily prevent walking, but do put normal active extension out of the question. Fig. 1041.--Shows the oblique pull of the quadri- ceps in cases of knock- knee, favored by excessive toeing out and consequent outward rotation of the tibia. If the quadriceps (1) with the insertion of its tendon on the tuberos- ity at (3) contracts, the ob- vious tendency is to pull the patella from its posi- tion at (2) to a point at (4) approximately in a line between the muscle belly and the insertion of its tendon-i. e., between 1 and 3. It is on account of this fact that the slipping of the patella is rather apt to happen in stout non-muscular women with some knock-knee and pro- nated feet. * Tenney: Ann. of Surgery, 1908, xlviii, p. 723, records an interesting operation on'a fresh lesion of this sort. There was a tear, to the inner side of the patella, of 5 inches in length with a gap of inches. The vastus internus was torn. INWARD LUXATION OF THE PATELLA 577 Recurrence of this luxation may occur only occasionally-usually unexpectedly in the course of flexion motions; or it may recur very frequently, the patient learning to put it back himself. It involves in time a relaxed and uncer- tain joint. The tendency to recurrent luxation may be relieved-sometimes cured-by a specially fitted knee-cap of steel and leather, or even by bandag- ing. Of more radical methods, we have a choice between reefing the inner side of the capsule (with or without opening the joint) and transplanting the insertion of the patellar liga- ment inward.* These operations I have found it feasible to combine, without opening the joint, and with good results. INCOMPLETE OUTWARD LUXATION This lesion does occur. It calls for no dis- cussion, except for mention of the possibility of overlooking or mistaking the condition present. Reduction is easier, but otherwise differs in no way from that for the complete form. INWARD LUXATION OF THE PATELLA This luxation, complete or incomplete, is extremely rare, if it ever occurs. Certainly the cases on the basis of which it is entered as a type seem unsatisfactory. RECURRENT OUTWARD LUXATION OF THE PATELLA Fig. 1042.-Transplanta- tion of the ligamentum patellae to cure habitual out- ward dislocation of the knee- pan: A, transplantation of whole tendon inward; B, Goldthwait's improvement on this, by which the tendon is split, the outer half sepa- rated, carried under inner half, and given a new attach- ment to the tibia, well to the inner side. I have gotten good results also by shifting the inner half of the tendon farther inward on the tibia. Fig. 1043.--Rota- tory dislocation of the patella without lateral displacement; rota- tion inward or out- ward through a right angle; rotation in either direction through 180 degrees. Fig. 1044.-Most impor- tant is the question of "dim- pling." The attachment of the patella to the subcuta- neous structures in front is close and tough. It must be an altogether exceptional case in which the "dimpling" of the skin will not give an indi- cation of the direction of rota- tion. Fig. 1045.-In rotations of the patella of 90 degrees or more it is said that the rolled-up, cord-like quadriceps tendon gives the guide as to which the direction of rotation has been-inward or outward. This is to be determined according to whether the anterior edge above the patella is continuous with the outer or the inner border of the quadriceps muscle. * Goldthwait (Boston Med. and Surg. Jour., 1904, cl, 169) has successfully treated several cases by splitting the tendon, cutting the outer half at its insertion, carrying it behind the intact half, and inserting it to the inner side of its old inser- tion. He claims improved results. 578 DISLOCATIONS OF THE PATELLA Incomplete displacement in this direction seems plausible. Reduc- tion would simply be the reverse of that used in outward luxations. The patella, as a result either of external violence or of muscle action, may be rotated on its vertical axis without moving out of its proper situation. This rotation may be of any degree and in either direction. The knee- pan may lie on edge, with the articular surface facing inward or outward, or it may come to lie so that the articular surface faces forward, having come to this position through either outward or inward rotation (Fig. 1043). Lesions.-Save for damage to the capsule, probably constant, there are no recorded lesions. Symptoms and Diagnosis.-There is pain, of course, and the leg is held in extension. If the patella lies on edge, it is firmly held by muscle tension. It may be possible to distinguish by touch between the articular surface and the flat front surface.* If this sign is not avail- able, the lifted edge of the quadriceps tendon serves to tell in which direction the rotation has occurred. Moreover, the relative ease of rotation in one or the other direction on gentle attempts to reduce rotation will be of assistance. If the rotation has been total or nearly so, the quadriceps is twisted to a cord, but may still show a guiding edge. This palpable edge may be of help, for rotation is oftener nearly complete than complete, and is apparently never beyond 180 degrees. Therefore, a quadriceps tendon prominent at (a) must mean that the patella has rotated out,- in the direction of the arrow,-not inward. (See Fig. 1045.) Reduction.-Reduction is attempted with the knee extended or hyperextended, the leg raised to a right angle with the body to relax the rectus femoris; the actual reduction is by forcible rotation applied with thumb and fingers to the patella. In some few cases slight flexion has proved a more favorable posi- tion than extension for such manipulation. The patella is very firmly held, and reduction may be very difficult. Hooks have been used, and tenotomy resorted to. Today, obviously, open operation would be the choice if simple attempts at reduction fail. ROTATORY LUXATIONS OF THE PATELLA Bogenf describes a series of cases that justify his assumption of a class of really hereditary outward luxations of the patella, some of them actually congenital, some associated, like the upward luxations with genu recurvatum, with failure of development of the patella. CONGENITAL OR HEREDITARY LUXATION * I have not seen this lesion, but it seems to me that there must be a dimpling of the skin corresponding to the front surface, owing to the close connections of patella, fascia, and skin. This is not usually given as a sign, however. (See Fig. 1044.) Since this note was written, a case of the sort was reduced at the City Hos- pital Relief Station. Drs. L. B. Packard and E. L. Drowne, who handled the case, both assure me on question that there was a distinct dragging inward of the skin attached to the front surface. f Zeit. f. Orthop. Chir., xvi, Hft. 3, 4. CHAPTER XXVI FRACTURE OF THE PATELLA Fracture of the patella is common, occurring predominantly in male adults in the vigorous years. It is not rare in women, but is a rare injury in children. Patella fractures are divisible into two classes: (1) Transverse; (2) vertical or irregu- lar or comminuted. Either variety may be compound-not very infrequently. TRANSVERSE FRACTURES The transverse fractures are nearly, if not quite, always the result of muscle action, most often of that sudden, very powerful muscle action exerted to save one's self from a fall. With the knee bent at say 60 to 90 degrees, the patella is held by the ligamentum patellae firmly down and against the condyles, while the full pull of the strongest muscle in the body is suddenly exerted at its insertion on the top of the patella, well out of line with the fulcrum (i. e., the convexity of the condyles) (Fig. 1046), and the result is a fracture, approximately transverse, at or about the part of the bone resting on the fulcrum. But this is not all, or the most important part: the force continues to act, and the lateral expansions of the quadriceps tendon-in which the breaking patella has started a rent-tear widely out to either side; the whole extensor apparatus is gone, and there is no hindrance left to oppose separation of the patellar fragments. The tears vary in extent, but it may be laid down as a rule that fractures by muscle violence (including nearly all transverse fractures) show this tearing and show separation of fragments. The importance of this as to treatment we shall come to later. Fig. 1046.-Mechanism of pa- tella fracture. The comparatively straight-surfaced patella, held rig- idly in place by the ligamentum patellse, is broken across the curved surface of the condyles by th6 con- traction of the powerful quadriceps pulling on the upper end of the patella. This is the usual mech- anism of patella fracture. Fig. 1047-Not less important than the break in the pa- tella is the tearing of the capsule at the lateral expansion of the tendon of the quadriceps on either side of the joint. 579 580 FRACTURE OF THE PATELLA IRREGULAR OR COMMINUTED FRACTURES The other class, the irregular fractures, result from direct trauma, usually in falls. Rarely, the impact of the fall, caused by the bone Fig. 1048.-Normal :r-ray profile of the knee, showing very well the straight- back surface of the patella and the curved surface of the condyles. Fig. 1049.--Direct violence, three fragments, no tear- ing of the capsule; no operation (writer's case). giving way transversely, may in turn result in comminution of frag- ments, but as a rule we have definitely one or the other type. Whatever the lines of the irregular fracture, we have substantially no separation of fragments. The shivering of the patella by a blow gives no cause or starting-point for a tear of the ligament at the sides. Fig. 1050.-Recent fracture of patella, with comminution. From direct violence (Warren Museum specimen 1130). Fig. 1051.-Periosteum and tendon-shreds in quantity fall in between the broken surfaces from the front. It is not uncommon to hear patients ascribe a broken patella to the fall as such; of course, there is a fall in either case, but I believe these stories to be due to error in observation; at all events, I have seen no cases in which there seemed to be any doubt in judging from the lesions as to the mechanism of their production. LESIONS 581 Lesions We have a clean-cut, pretty regular fracture-line in the first class of cases: it runs from cartilage to periosteum, without any considerable irregularities, almost exactly at right angles to the long axis of the bone, usually nearer the bottom than the top. The periosteal and fascial coverings of the bone in front are torn into ragged ends, which fall between the fragments, often largely covering the broken surfaces, and promptly adhering to them. The patellar fragments are apt to Fig. 1052.-Much tilting of fragments is not unusual, often without evident cause, and, as in this case, in spite of careful non-operative treatment. Fig. 1053.-Compound frac- ture of the patella from refracture through the old. adherent sub- cutaneous scar of the first frac- ture (drawn from the plate in Bell's Surgery, vol. ii, Plate III). rotate forward or back, often through 60 to or sometimes even through 90 degrees; they retain this position (as they take it) without obvious cause. Occasionally one sees a third fragment. The torn edges of the capsule lie separated only by blood-clots. Separation of both bone and capsule fragments is apt to be slight, until bleeding and serous effusion distend the joint. Bleeding into the joint, and outside the joint into the torn and bruised tissues, is usually con- siderable in amount. The fracture may be compound as a result of the secondary fall, or any adherent scar (e. g., from a previous operation for patellar suture) may determine a simple tearing open of the skin above the fracture, so that the joint lies open. (See Fig. 1053.) Any form of compound fracture is relatively rare. Lesions in class 2 from direct violence differ in that the fracture lines are irregular and may be ragged. There is no tearing of the capsule at the sides, and little tearing of the structures in front of the Fig. 1054.--Patellar frac- ture from indirect violence; slight separation of frag- ments. 582 FRACTURE OF THE PATELLA knee-pan. There is no dropping in of torn shreds between bone-frag- ments in this type of fracture. Separation of fragments is very slight at most-it is prevented by the strong intact tendon in which the patella still lies as a sesamoid. This form may also be compound, and is more often compound than the fracture by muscle-pull. Lesions beyond those described do not belong to the fracture of the patella as such. Injuries to vessels, nerves, etc., are conspicuous by their absence in all patellar fractures, for no great nerve-trunks lie near the front of the knee. Symptoms "Can a man with a fractured patella walk?" This is a favorite examiner's question. The answer is that he can. In the books he walks backward. The only patient I recall who walked after fracture with a complete transverse tear said he did not walk backward, but, as near as he could tell it, swung his leg forward and locked it in hyper- extension before putting his weight on it, as do so many cripples from old infantile paralysis. Of course, if a man has an intact tendon and a splintered patella within it, so to speak, there is no mechanical reason why he should not walk, even without resorting to hyperextension. As a matter of fact, he does not walk with any type of fracture, because it hurts. Nor does he lift the foot as he lies on his back because it hurts: if he has a torn capsule, he can not do it, not only because of pain, but also for mechanical reasons. He has also a good deal of pain, and when the effusion is fairly established, at twelve to twenty-four hours, he has much pain, and may even have a little temperature. Diagnosis Type 1 (Transverse).-Diagnosis depends on: (a) Loss of active extension: he can not raise the foot from the bed as he lies on his back, and can not voluntarily straighten the flexed knee. (6) A rounded swelling of the whole joint, differing from simple synovitis in that it is evenly rounded.* There is often much ecchy- mosis and swelling about the joint. (c) The fragments may be palpable-are palpable, as a rule, despite the swelling, and their mobility and the interval between them may usually be demonstrated. * The difference between such effusion and the common synovitis is sketched in Fig. 1055. It seems no exaggeration to say that such a rounded effusion must mean either patellar fracture with separation, or rupture of the quadriceps or of the patellar tendon. I have seen no exception in several years' observation of this particular sign, save for two cases in which rupture of the quadriceps tendon, instead of the patella, gave the same picture. DIAGNOSIS 583 (d) There may be crepitus, but often it is felt only after forcibly dragging the fragments together. If there is much effusion, crepitus is not obtainable. Fig. 1055.-In synovitis (A) there is moderate swelling, seen from the side; on flexion, this becomes a bulging, especially pronounced at the sides of the joint, between quadriceps tendon and ligamentum patellae and the iliotibial band, and at a corresponding point to the inside. The thigh, seen from above (knee flexed), shows lateral bulging, as in the lowest figure. Cross-section would show lateral bulging; in the center the extensor tendon and the patella hold down the bulging. If is broken, there is no such resistance. We have an even, globular swelling of the whole joint (B). Fluid in, or hemorrhage into, the prepatellar bursa gives the condition shown at C, an added lump in front of the patella, not modifying the shape of the knee. Fig. 1056.-Patellar fracture (fresh). Note the even, rounded swelling. Diagnosis of Type 2 (Irregular).-Diagnosis depends on: Pain and loss of function; tenderness-localized; mobility of fragments; interval (a line only) between fragments; crepitus. 584 FRACTURE OF THE PATELLA Synovitis in this type is almost constant, but the effusion rarely reaches such amount as with type 1. Moreover, the especial appear- ance above noted-the domelike rounded swelling-is absent; the outline is like that of any acute synovitis, for there is practically no separation of the fragments of the patella. Differential Diagnosis of Patella Fracture.-Differential diagnosis Fig. 1057.-Patellar fracture, with separation of fragments, after some days. Note even, globular swelling of whole joint. Fig. 1058.-Synovitis (subacute) of right knee. Note the bulging at the sides of the joint, limited by the quadriceps, patella, and ligamentum patella: in the middle line. concerns especially quadriceps rupture and rupture of the ligamentum patellee, or tearing out of its insertion. Both give loss of extensor power; both give, in a measure, the rounded swollen joint. The downward mobility, and the readily palpable gap above the patella dis- tinguish the one; upward mobility (and dislocation) of the patella and the signs of damage farther down, well below the knee-pan, characterize the other. In diagnosis it may be well to recall that irregu- larity counterfeiting a gap in the bone, and a crepitus of a sort, may both belong to a dry bursitis of the prepatellar bursa. Twice within the half year past have I seen such cases classed as patellar fracture. Treatment of Patella Fractures The many minds of many men have been cu- riously displayed in the literature on treatment of patellar fractures, particularly in regard to operative treatment. This literature is historically very interesting, but surgically all the dis- cussion is much out of date. The facts seem clear. Fig. 1059.-Direct violence; no displace- ment; no tearing; no operation. TREATMENT OF PATELLA FRACTURES 585 We have, on one side, the results of non-operative treatment, safe, but usually imperfect and unsatisfactory; on the other hand, the operative results, brilliant, but not without risk. The risk of operation is sepsis. Many years ago Lister advocated wiring, as did others after him. Wiring, as then done, was clever, but hardly safe enough. Today we have a better technic, and far less danger is involved. Conservative treatment offers the safe prospect of a knee that will be useful after six to twelve months, for light work at least. The chance of a perfect result under such treatment is prac- tically nil, though many serviceable knees have been obtained by such treatment. On the other hand, we have the results obtainable by operation: Fig. 1060.-Unless bony con- tact is perfect, the presence of joint fluid hinders callus forma- tion, and the fibrous bond is less in depth than the depth of the bone. Fig. 1061.-Fracture of patella; . fibrous union. Broadening of lower frag- ment (Warren Museum, specimen 3652). Fig. 1062.-Fracture of patella. Fibrous union with moderate separation; no en- largement of fragments. View from side: a, Fibrous union; b, extent of articular surface which is now concave (War- ren Museum, specimen 1129). the possibility of a perfect result, obtainable in half the time required for splint treatment. But this treatment calls for the opening of the largest joint in the body, a joint notoriously hard to deal with, and it carries a risk of sepsis that we can not honestly ignore. The risk is statistically very small in recent years, but we must all admit that cases of sepsis, even cases of death from sepsis, have resulted, even in the hands of competent surgeons, from such an operation. The question of operative treatment is one on which we must advise the patient according to his years, his condition, and the needs of the occupation by which he earns a living. We may tell the patient how long he must wait for a doubtful result without operation, and may tell him of the quick, clean results obtained by operation. Surgically, the question may be considered as follows: Fracture of the patella without separation of fragments (f. e., the cases from direct trauma) do well under any treatment (or no treatment). 586 FRACTURE OF THE PATELLA Fractures with separation under conservative treatment never unite by bone; never show obliteration of the gap between fragments. Conse- Fig. 1063.-Fracture of patella; union with long fibrous band (W'arren Museum, specimen 5253). Fig. 1064.-Ham-splint without strap, showing proper length and relation to thigh and leg posteriorly. Fig. 1065.-Fracture of patella; bony union; some elongation of bone as a whole. View from side (Warren Museum, specimen 6707). This bone is too long for good function as a sesamoid. Fig. 1066.-Splint treatment: A, Posterior wire splint; B, leg strapped to splint; patellar fragments strapped down with adhesive-plaster strips; C, coaptation splint to front of thigh; a bandage finishes the dressing. quently, there must be a bond of fibrous tissue-a bond, in all instances, of less thickness than that of the patella (Fig. 1060). If this bond be short and firm, and remain so, the knee may be practically as useful as TREATMENT OF PATELLA FRACTURES 587 ever. But if the fragments are widely separated before union com- mences, or if the bond of union stretches with use, we have, as an end- result, a lengthened tendon without a sesamoid (see Fig. 1063), and consequently a weak and unreliable joint, as a rule. A union giving a rigid but long patella often gives poor motion, as Chaput has noted, mainly because of limited motion. (See Fig. 1065.) Final union is very late in all these non-operated cases, and function is almost always imperfect. In operated cases, on the other hand, properly handled, we are sure of union, usually bony; at worst we get a short fibrous union, with early restoration of function. (See Fig. 1067.) The two methods of treatment, discarding unnecessary discussion and detail, may be described as follows: Non-operative Treatment.-Pad a "poste- rior wire" splint. (See Fig. 1066.) Strap the leg to it. Raise splint (and leg) on pillows. (This is to relax the rectus femoris.) Apply coaptation splints to the front of the thigh, over the quadriceps muscle, to insure its relaxa- tion. Strap the fragments as shown in Fig. 1066. Keep up the treatment for six to eight weeks; then get the patient up on crutches, with a protecting ham-splint or light plaster. Begin massage at about six to eight weeks, with very gentle passive motion. Do not begin weight- bearing under three to four months, and then without flexion. Active motion and use of the joint begin at six months. Operative Treatment.*-Aseptic preparation should be most scrup- ulous. Cut on the line shown in Fig. 1068, to avoid thickened skin, and to keep the scar away from the kneeling surface. Clean out all old blood-clot from the joint by picking and washing. Clear the fractured surfaces of periosteum, etc., that has dropped down between the frag- ments. Pick up the periosteal capsular layer at either side of the patella, and suture it snugly with kangaroo tendon, f (See Fig. 1069.) Suture the lateral tears of the capsule with catgut. Put the knee up in hyperextension in plaster, without drainage. Under proper conditions and technic, septic accidents are very rare. On the whole, the operative treatment has decidedly the best of the argument. It must be recognized that many of the results of opera- tion are close fibrous rather than bony unions. They are practically none the w'orse. (Fig. 1070.) Fig. 1067.-Old patella frac- ture. Sutured at time of accident. Close fibrous, not bony, union. Excellent,prac- tically perfect, result, clinically. * All operative procedures in this as in other fractures are safest at or after ten days. By this time organization of clot minimizes the chance of sepsis. t Absorbable sutures are as reliable as the old-fashioned wire, and on the whole, less likely to break. They last as long as we need them. 588 FRACTURE OF THE PATELLA One argument, of no small importance in urging us toward opera- tion, is that the earlier useful results in operated cases save many men to usefulness who would degenerate under conservative treatment.* After-T reatment In cases operated, as well as those treated without operation, the first chance to be guarded against is refracture. Fig. 1068.-Line of incision of choice: above the coarse skin of the friction surface in the region of the pa- tella, and above the fracture, with the least chance of tearing the joint open if there is refracture. Moreover, the scar of the wound here shown is subject to no pressure. Fig. 1069.-Best plan of suture. Mat- tress sutures of heavy kangaroo - tendon at either side of the pa- tella; accessory sutures for the lateral capsule tear (practically J. A. Blake's operation). Fig. 1070.-Fracture of patella: open operation: absolutely even recovery: abso- lutely perfect function. A year later the patient--a doctor-had this plate taken out of curiosity. Probably such results are not uncommon. This may occur in either case. It may best be guarded against by massage and careful passive motion. The chance of refracture is greatest in the relatively rigid knee. * Those of us who see and follow up many cases of trauma in the larger metro- politan hospitals come to realize that the average "workingman"-the man most subject to traumata-works more from habit and necessity than from conviction. The difference between a treatment that promises results within two to three months and one that calls for a year of idleness may often mean the difference between a useful citizen and a park-bench loafer. Such a difference may well justify the taking of some slight additional surgical risk. In the last analysis we may better subject a man to the chance of sepsis than to the influence of the 15-cent lodging-house. 589 AFTER-TREATMENT If treatment has already secured 40 to 60 degrees of flexion, the chance of refracture is slight, even if the patient makes a misstep or stumbles. As a rule, after six weeks, this stage should be reached and careful walking exercise is safe. Fig. 1071.-Old patella fracture, not operated. Note the great increase in the total mass of the patella. Refracture with giving way of the suture is more apt to happen with wire than with the more elastic kangaroo tendon.* Fig. 1072.-Old patella fracture, not oper- ated on. Great separation. Nodules of bone formed in the fibrous band of union. Fig. 1073.-Old patella fracture, not operated. If such "refracture" occurs, immobilization will minimize the dam- age and will give reasonably prompt results, comparable to the best results of non-operative treatment, without a fresh operation. * Wire cuts a groove for itself; then when the strain comes, it comes as a sudden tension on a slack wire, which snaps of course. 590 FRACTURE OF THE PATELLA Refracture after eight weeks is rare. If wire has been used and has broken away, even without appre- ciable separation of fragments, the removal of the wire is often called for later on account of irritation. Such removal through a small incision theoretically involves opening of the joint, but, in fact, is a simple procedure, almost devoid of risk. At times the wire causes irritation later, and calls for removal, even though it has not broken. The second thing we have to look out for is stiffness. In the cases operated on we can begin careful massage and active motion (tem- porarily removing apparatus) at three weeks. In unoperated cases we usually wait for six to eight weeks. In either case serious loss of motion is very rare indeed; even neglected cases, kept fixed for months, get good motion.* At times I have found it of use in operated cases to hurry things up by manipulation under ether at eight to ten weeks. This, however, is to be done with great caution, not to risk refracture, f OLD FRACTURES OF THE PATELLA Old fractures of the patella unoperated almost always show some separation of fragments. Separation of fragments is not an indication for operation. Operation is called for only to improve poor function. Fig. 1074.-In cases operated so long after injury that the mus- cles have shortened the quadriceps may be lengthened by alternate cuts, right and left, so as to per- mit suture of the patella. Fig. 1075.--If we must use direct wire or suture, it is passed as here shown; it must not lie in the joint at any point. Fig. 1076.-Patella fracture wired. Bony union. The main difference between these late operations and the early ones is that there is a shortening of the quadriceps muscle, as well as a separation of fragments. Often the separation may be overcome by simple traction and suture. At times we can not bring the fragments together without lengthening the quadriceps tendon. (See Fig. 1074.) In these old cases, and these alone, the inelastic rigidity of a wire suture is of advantage. * I have seen one case of adhesions in a fracture without separation, treated without operation, and know of two Boston cases that had adhesions after open operation; apparently dependent on over-long fixation. t One case has come to my notice in which there was such refracture from manipulation "to break up adhesion," after four weeks. RUPTURE OF THE QUADRICEPS TENDON 591 In such old cases, owing to muscle shortening, the return of motion in flexion is slower and less perfect than in cases operated shortly after injury. Useful results are the rule, perfect joints the exception. RUPTURE OF THE QUADRICEPS TENDON This rupture occurs only from muscle action, and is a sort of equiva- lent of fracture of the patella. The symptoms are the same, the physical signs the same, save that instead of an interval between frag- ments, we find an abnormal hollow-a gap-just above the patella. The extent of damage varies. There may be an incomplete tear, giving nearly entire loss of function and a palpable gap, but tending to Fig. 1077.-Rupture of tendon of quadriceps muscle just above the patella-photograph of recent case. prompt repair. I have seen two such cases that recovered entirely in a few weeks under simple splinting. The tear is usually a tearing out of the insertion from the patella, but may be a tear of the tendon proper. I have seen four cases, showing all the signs except that the gap was not quite "clean-cut;" undoubtedly these cases presented a "ragging-out" of the tendon; not a clean cross-tear. In one case this was demonstrated by operation: only a reefing was done. In all four cases, later function was perfectly good. Where the tear is complete and involves the capsule at the sides, the disability is as absolute as in patellar fracture, the tendency to spontaneous repair far less. I have seen two cases, not operated on, in which, after many months, there was absolutely no power of exten- sion. The gap that had developed in one case was about three inches. 592 FRACTURE OF THE PATELLA Operation, consisting of a simple suturing of torn ends or of the one torn end to the periosteum of the patella from which it was torn, gives entirely satisfactory results.* All the cases I have seen have been in men past 50! One patient had been operated on a year before for the same lesion on the other side. In but one of my cases have I been able to demonstrate tabes, but I suspect that some ataxia of some sort explains these cases. RUPTURE OF THE LIGAMENTUM PATELLA This is a rare accident-rarer than quadriceps rupture. It occurs as a result of muscle pull. The ligament is torn across or torn away from the patella, or torn away from its insertion, sometimes fetching with it a scale of bone. The symptoms are those of fracture of the patella, but the prognosis is graver. Examination shows a gap below the knee-pan. There may or may not be obvious upward luxation of the patella. Sometimes enough of the lateral expansion is left to hold the patella down. Displacement seems never very great. Diagnosis is based on: (1) Local pain and tenderness; (2) inability to extend the leg actively, in the absence of any hindrance to passive extension; (3) palpation of a gap, or, at all events, a loss of the firm out- line of the normal tendon. Treatment by splints and strapping is not satisfactory. Open suture gives practically perfect results in cases reported f AVULSION OF THE TIBIAL TUBERCLE Tearing off of this tubercle as a chip of bone may occur at any age as a result of muscle pull, but it is rare in adults. It is diagnosed by the presence of a loose chip of bone; it is treated by a splint and by strapping-by pegging the fragment down if there is a marked displace- ment to be dealt with. The lesion is a result of single trauma-an equivalent to rupture of the tendon. The results seem to have been very good in cases recorded. J * I have operated on several cases, with excellent result. The operation in the hands of others seems to have been uniformly successful, barring accidents. The suturing of tendon to patella is difficult, and calls for patience. If the periosteum is insufficient, we may pass the kangaroo-tendon suture through the top edge of the bone (two drill holes) and through the end of the tendon, as a mattress suture. This I had to do in all but one of the cases cited. 11 have operated on but three cases, with excellent result. In one there was a clean rupture; in the others no clean tear, but a lengthening of the tendon by pull- ing apart of fibers. In these cases the tendon was cut and shortened by overlapping. It may be noted that neither the trauma nor the operation necessarily involves opening of the knee-joint, though usually it is torn into. J Sendler, Deutsche Ztschr. f. Chir., 1893, xxxvi, 546. Godlee, Illust. Med. News, September 29, 1888, vol. i, p. 12. AVULSION OF THE TIBIAL TUBERCLE 593 In youths and children the equivalent of this accident is not un- common,* but the cases present themselves as the result, not often of a single trauma, but rather of a recurring lameness from overstrain, sometimes giving a history of the first trouble having been the result of football scrimmages or the like. To understand this lesion we must look into the anatomy. In childhood the tibial tubercle is cartilaginous. Sometimes it is a part of the main epiphysis, from which a long tongue runs down (see Figs. 1085 to 1087); sometimes there is a separate epiphysis, and sometimes this part is separate, but consists of cartilage without a demonstrable ossification center. This cartilaginous tubercle receives a part of the insertion of the ligamentum patellae-not all of it. Consequently it is not liable to be torn off bodily, but may be loosened from its bed by single or repeated violent contrac- tions of the quadriceps. So long as the leg is used it does not quiet down into its bed again. Symptoms consist of lameness in the knee on severe use, usually sharply localized, but sometimes with recur- ring synovitis as well. Diagnosis depends on lameness, slight thickening, local tenderness, and on the palpation of a slightly movable small fragment. The x-ray shows some widening of the epi- physeal line; sometimes it shows an obvious lifting-off of the tubercle; sometimes it shows nothing. Treatment.--Some cases quiet down with rest, and under simple adhesive strapping running across the leg over the loose fragment. The fragment presently becomes fixed in place. In other cases this does not work. The writer has had excellent success in cutting down on the frag- ment and removing both it and the "false bursa " that sometimes forms under it. In this operation the joint is not opened, the ligamentum patellee is not damaged,-merely split,-and use of the leg can be resumed in two or three weeks. Prognosis.--Untreated, these cases go on for a good while, giving much lameness. Properly treated, they do well and give a perfectly functioning knee. There is no interference with subsequent growth from trouble with this small epiphyseal fragment, whether the lesion is treated or not. Fig. 1078.-Traumatic separation of the end of the tongue of the tibial epiphysis at the tuberosity (compare Figs. 933-937) * Jacobsthal, Deutsche Zeit. f. Chir., 1906-07, vol. Ixxxvi, p. 493 (with full literature references); Osgood, Boston Med. and Surg. Jour., January 29, 1905; Makins, Lancet, 1905, ii, 213. 594 FRACTURE OF THE PATELLA I have twice seen (in both cases, in young robust adults) an ex- tensive overgrowth of bone; a veritable spur formation on both knees, of a sort that suggested a source in the sort of semi-chronic trouble in boyhood, above sketched. One case was entirely relieved by a bone plastic operation; the other was lost sight of. CHAPTER XXVII TIBIAL INJURIES JUST BELOW THE KNEE A variety of fractures occur in this region, both from direct smashing Fig. 1079.-Fracture external tuberosity of the tibia at the knee. Not much displacement. This is the usual type. Fig. 1080.-'Same as Fig. 1081, from the front. Shows how the external popliteal winds around the head of the fibula and becomes sepa- rated into peroneal and anterior tibial supply. Fig. 1081.-The relation of nerves to bone behind. The external popliteal nerve is particu- larly subject to violence or to moderate contin- ued pressure in its course behind the external condyle and the tibia to the point where it turns around the neck of the fibula. In this latter region it is pretty firmly bound down, and stretching injuries as well as pressure injuries are to be looked for. violence and from indirect trauma. There may be a cross-break, or a T-fracture, or a splitting-off of either tuberosity as a whole or in part. 595 596 TIBIAL INJURIES JUST BELOW THE KNEE Fig. 1082.-'Fracture of the internal tuberosity of the tibia by ligament strain. Fig. 1083.--With such an avulsion fracture, due to ligament strain, we shall find, on test, increased lateral immobility, but only in one direction-i. e.. if there be a tearing on the in- ner side, we will have abnormal motion only in the direction of abduction. Fig. 1084.-The skin supply corresponding to the various nerves of the leg and foot: int. s., int. s,. Internal saphenous; e. p., e. p., e. p., ex- ternal popliteal; p. t.; posterior tibial. The areas of anesthesia or par- esthesia in leg injuries give us definite information as to the nerves injured; unfortunately, however, many of the most obstinate injuries, particularly of the external popliteal nerve, are almost entirely motor in character, and may very readily be overlooked for a long time. Fig. 1085.-An- other view of same specimen as shown in Fig. 1087. 597 TIBIAL INJURIES JUST BELOW THE KNEE Displacement is apt to be by gravity. It there is a T-fracture, or if only one tuberosity is broken, there is usually widening just below the joint. In any case there is abnormal mobility laterally,-either Fig. 1086.-Usual type of epiphysis. The epiphysis of the upper end of the tibia has a tongue-like prolongation con- tinued down the front of the bone to the tuberosity. Fig. 1087.-Upper epiphy- sis of the tibia (Warren Mu- seum, specimen No. 417). Fig. 1088.-Drawing from o--ray, showing the type of epi- physis without any tongue running down to the tuber- osity of the tibia. way in a cross-break, or a T-fracture or epiphyseal separation,-but limited to motion, one way only if only one tuberosity is broken. Fig. 1089.-z-Ray showing same type as in last figure Diagnosis rests on local swelling and tenderness, on widening, on the lateral mobility, and on crepitus. Sometimes the broken fragments may be made out clearly by palpation while an assistant manipulates the leg, but by no means always is this the case. The x-ray is often 598 TIBIAL INJURIES JUST BELOW THE KNEE essential for many cases go by under the diagnosis of simple synovitis until disability develops. Replacement is by traction, by manipulation to correct backward displacement, by lateral "jamming" of fragments together, whether there is a T-fracture or a break on one side alone. Retention is by plaster, with adequate felt padding. Permanent traction in the axis of the leg does not harm at worst, and may be of definite value. Such traction may well be combined with the plaster cast. Any tendency to displacement is due not to muscle pull, but to gravity. Backward bowing is common, and carefully to be guarded against by frequent inspection and revision of padding. Results are fair-union is prompt, but with a good deal of thicken- ing, and usually some loss of motion at the knee results. Damage to the external popliteal nerve is not very uncommon. Fig. 1081 shows how exposed it is to trauma at this level. SEPARATION OF THE UPPER EPIPHYSIS OF THE TIBIA This is one of the rarest of epiphyseal separations, and data are scanty. Displacement may be in any direction. Diagnosis is based on the signs of fracture in the given location, with only soft crepitus, at the appropriate age. Reduction is by traction, rocking, and direct pressure. Prognosis, given the proper reduction, is good. There seems to be no special liability to damage of vessels or nerves. Interference with growth is not to be expected. Avulsion lesions of the tibial tubercle are treated on p. 592. CHAPTER XXVIII THE FIBULA LUXATION OF THE UPPER END OF THE FIBULA Luxations of the fibular head are not common, but probably often pass unrecognized.* As to causation, we may divide them into three classes: (1) Posterior luxation, usually caused by muscular traction through the biceps tendon. (2) Anterior luxation, probably from adduction and inward torsion (with the knee in extension), resulting in rupture of the long external lateral ligament. (3) Upward luxation, from upward thrust on the fibula exerted at the ankle (abduction of the foot), with or without associated ankle fracture. This luxation is really only a complication of the ankle injury. Fig. 1090.-Luxation of the fibula upward and outward (diagram). Fig. 1091.-'Luxation of the fibula backward (diagram). When the ankle is pulled back in place, the fibula comes back where it belongs, stays there, and gives no special trouble. The first two forms are troublesome only in so far as the fibrous support of the bone-attachments of the powerful biceps muscle, or of the equally important external lateral ligaments, is rendered less firm. The fresh injury gives much pain and disability. Synovitis of the knee may follow it. Diagnosis in these cases is not easy. There is extreme local tender- ness. What seems a pathognomonic sign-namely sharp pain away up at the fibular head when the foot is everted, developed in the last case. This depends of course on an upward shove on the fibula with this movement. The fibular head may be, but oftener is not, abnormally * Golley (Amer. Jour. Surg., 1907, xxi, p. 171) records a case and reckons the reported cases as about 25. His case was a forward and outward luxation. Stimson gives a like estimate. Probably this is far too small, as the injury is a minor one, and probably the mass of cases are never reported, even if recognized. I have seen four cases, all backward displacements. 599 600 THE FIBULA movable. Measurement from the tibial tubercle to the fibular head is our best evidence. The x-ray may help. Reduction is nearly useless, inasmuch as the joint is a flat joint, and the muscle pull, at least in the backward displacements, is constant, and sure to reproduce at least partial displacement. Treatment consists in immobilization for several weeks. Flexion to relax the biceps is indicated in the backward displacement. Prognosis is good as to general usefulness of the limb. There may be, however, a little weakness referred to this region-a weakness mainly due to the strain exerted through the attachment of the biceps. Four cases of this partial disability have come to my notice. In one the disability was constant, though trifling nothing was done. In the other the patient (a crack woman tennis player) averaged 3 to 4 weeks serious disability every 6 to 12 months, from accidental strains on the luxated joint. This case, at operation, showed a backward displacement of the fibula of at least half an inch. Erosion and a temporary spiking destroyed the joint. For a dozen years she has been entirely well. In the third case, exactly similar, a similar operation was done but with fixation by a suture of fascia lata "rope" lashing fibula and tibia. The result, apparently excellent, is too recent to Speak of end results. FIBULA FRACTURE NEAR THE HEAD Fractures of the head* or neck of the fibula are rare. They may occur with fracture of the tibia much lower down, or independently from torsion, from muscle traction, or from a direct blow without tibia fracture. Their importance is almost solely due to the fact that the peroneal nerve winds about the neck of the fibula, and is here much exposed to trauma in fractures from indirect force, as well as those from direct blows (Figs. 1080, 1081). The fracture is diagnosed by tenderness, crepitus, and the x-ray. The nerve lesion shows itself in toe-drop: loss of sensation is not usual. Treatment is by immobilization: persistent displacement is rare and not worth considering, except for nerve-pressure. Operation to free the nerve is amply justified in any doubtful case, but is unnecessary in most cases. *Stimson and Weir (see also Poland) have recorded cases in which epiphysea separation took the place of the fracture. CHAPTER XXIX THE ANKLE AND FOOT LANDMARKS OF THE FOOT AND ANKLE The most prominent landmarks are the two malleoli. The internal malleolus is palpable over its whole surface in most individuals. In cases of injury, however, with swelling, the lowest point we feel is ths elight ridge that lies distinctly above the tip of the malleolus. The front edge of the malleolus may also be made out, and usually the ridge at the back. The external malleolus always shows a recognizable ridge at its back edge, and a ridge, often spur-like at one point, at the front of its subcutaneous surface. The end of the external malleo- Fig. 1093.-Landmarks of the ankle from the front: 1, Tip of inter- nal malleolus; 2, outer side of head of astragalus (just outside and below this is the deep hollow of the sinus tarsi); 3, the outer edge of the upper articular surface of the astragalus, best felt with the foot in plantar flexion; 4, tubercle of scaphoid; 5, prominence of the base of the fifth metatarsal. Fig. 1094.-Landmarks from the inner side: a, Inter- nal malleolus; x, sharp tip of internal malleolus, not always to be felt; y, tubercle of sca- phoid. A comparison of the measurement a-y on the sound and injured foot is often serviceable in the diagnosis of the various injuries of the ankle. Fig. 1095.-Land- marks from the outer side: 1, Peroneal tu- bercle, always palpa- ble, often prominent; 2, prominent base of the fifth metacarpal. lus is always to be felt as a bony surface, though it may not be possible to reach the extreme tip. What we can feel of the astragalus is, in the first place, the outer edge of the head, to be felt for as shown in Fig. 940, and an equally valuable though often neglected landmark, consisting of the smooth sharp edge of its upper articular surface, is to be felt just in front of the fibula, and recognized in distinction from the fibula by putting one hand on the external malleolus, the other on this ridge, and moving the ankle up and down. Motion between the two is readily made out. Sometimes it is possible to feel the inner side of the neck of the astragalus, and to grasp the neck between the thumb and finger. The inner side of the head is practically covered by the scaphoid. 601 602 THE ANKLE AND FOOT The os calcis shows no palpable points on its inner surface, except at the very back. At the back the two vertical planes to the inner and outer side may be felt, and their direction roughly estimated (Fig. 1098). The outer surface of the os calcis is palpable and practically subcutaneous. The peroneal tubercle may usually be felt just below the external malleolus (Fig. 1095). The scaphoid is always to be made out, and is the only prominent rounded mass on the inner side of the foot (Fig. 1094). In its normal position it occupies a point in prolongation of the line of the front of the tibia (Fig. 1096). This landmark the writer has tested in a great Fig. 1097.-The best measurement of the length of the foot is from the end of the great toe to the posterior convexity of the heel, as shown. This should be a straight line measure- ment, not following the surfaces. Owing to the firmness of the tissues, acute swelling makes very little difference to this measurement. Fig. 1096.-From the inner side, a line running through any two points on the tibial crest prolonged downward just about strikes the scaphoid tubercle. It makes little differ- ence for this test whether the foot is flexed or extended. Fig. 1098.-From behind, the surfaces of the os calcis toward the inner and outer side may be clearly made out by careful palpation; they lie about as shown in the figure. number of patients, and has found it substantially accurate always, irrespective to the position of the foot as regards flexion of extension. The cuboid is not normally palpable, except as a resisting surface, nor are the cuneiforms, unless they are displaced. The base of the first metatarsal may often be made out by its prominent lip on the plantar side. The base of the fifth metatarsal, always prominent, may also be identified (Fig. 1095). Below this point there are no landmarks that are serviceable in a foot swollen from injury. In injuries to the front part of the foot we are very often dependent upon shortening, as shown by lack of corre- spondence in the length of the foot from the heel to the toes. In general, it may be noted that we should never neglect measurement 603 INJURIES AT AND ABOUT THE ANKLE of the total length of the injured as compared with the sound foot. Normal differences are slight. Shortening due to injury (in whatever portion of the foot) is not accurately appreciably by the eye, but is readily measured. Measurement is made from the tip of the great toe to the back of the heel at its greatest convexity. This, of course, must be a straight-line measurement. It is subject to only slight error, for the heel never swells at the back, but at the sides. INJURIES AT AND ABOUT THE ANKLE In all falls on the feet, and in many slips in which the foot is vari- ously twisted, the ankle and foot are subject to damage. More than E F G H Fig. 1099.-'Forms of trauma and usual results: A, Ordinarily gives fracture of the os calcis; B, gives either fracture of the neck of the astragalus, or ankle fracture with lateral displacement; C, may give a crushing of the front of the ankle or a fracture above the joint with forward displace- ment; D, is apt to give one of the forms of subastragaloid or mediotarsal dislocation; E, gives a fracture of the fibula; F, outward rotation (as well as eversion) gives a Pott's fracture or a Pott's fracture with backward displacement and splintering; G, when the weight is received on the front part of the foot, gives only fracture of the fifth metatarsal or sprain of the ankle; H, if internal twist be added to the inversion, produces inverted Pott's fracture, or rarely one of the forms of as- tragalus dislocation. (The arrows show the line of impact of weight and of resistance.) this, direct violence, and indirect violence received by twists of the foot in machinery, etc., are to be reckoned with. From the history of the accident it is impossible, often, to say whether the resulting damage will prove to be above, at, or below the ankle-joint. Of lesions to be reckoned with we have the following: 1. Dislocations of the ankle-joint with or without fracture. 2. Dislocations of the fibula at the ankle. 3. Diastasis of tibia and fibula. 4. Pott's fracture. 5. " Cotton's" fracture.* * Cotton: Trans. Orthopedic Section A. M. A. 1914. 604 THE ANKLE AND FOOT 6. Inverted Pott's fracture. 7. Fracture of both bones, above the ankle. 8. Epiphyseal separation of the tibia. 9. Fracture of the fibula. 10. Fracture of the external malleolus, alone. 11. Sprains of the ankle. 12. Dislocation of astragalus in toto. 13. Rotary luxation of astragalus. 14. Dislocation (subastragaloid). 15. Dislocation (mediotarsal). 16. Fracture of astragalus. (а) Body. (б) Neck. 17. Fracture of os calcis. 18. Luxation of os calcis. 19. Fracture of cuboid. 20. Metatarsal luxation. 21. Metatarsal fracture. The common lesions appear in italics. LUXATIONS OF THE ANKLE JOINT The common luxation of the ankle is that complicating Pott's fracture, which involves necessarily a subluxation outward. Inverted Pott's fracture involves subluxation inward. Fig. 1100.-Posterior dislocation, with frac- ture of tibia into joint (also fracture of the fibula) (drawn after A. Cooper's Plate XIX, Fig. 1). Fig. 1101.-Anterior displacement of large fragment split loose from forward edge of tibia, and carried forward with astragalus. Uncomplicated luxation at the ankle is rendered extremely difficult by the deep mortise of bone and the strong ligaments but it may, nevertheless, occur without any fracture. LUXATIONS OF THE ANKLE JOINT 605 Uncomplicated luxation may occur forward, back, inward, or outward. All these forms are rare, and luxation is to be looked on merely Fig. 1102.--Anterior dislocation, with extensive fracture and displacement of the anterior edge of the tibia; also fibula fracture. Old case-about one year after accident (z-ray, 19490). Fig. 1103.-Same case as Fig. 1102, front view. as an unusual variant result of the forces ordinarily producing the common ankle fractures. Forward.-Of forward luxations, Stimson lists only 10 in all. The cases I have seen (three) have shown also a fracture of the front edge of the tibia.* (See Fig. 1102.) Dorsal flexion, even pushed to the extreme, is more apt apparently to give fracture than luxation, unless the flexion is associated with some force that drives the foot forward. Backward.-The listed cases of back- Fig. 1104.-Whether the posterior disloca- tion is accompanied by fracture or not, there is entire loss of bearing surface for the astra- galus and nothing to resist progressive de- formity until repair is complete. The condition' is entirely similar in cases of anterior displace- ment. Fig. 1105.-In the anterior luxation of the foot the projection of the tibia backward is readily palpable. If there is no fracture, the top of the astragalus can be felt in front, but this is obscured by the fragments if the front edge of the tibia is also broken. ward luxation are very few. Malgaigne's list was eighteen, probably including, like most of the ancient lists, some fracture luxations, given as simple dislocations. * This does not include one case of pathological luxation from infective arthritis. 606 THE ANKLE AND FOOT Obviously, such luxations backward are favored, if not directly caused, by plantar flexion. Inward.-Inward luxation is about equally rare. It seems from the records that there is a very large range of adduction of the foot associated with these inward dislocations; that is, the luxation is largely by rotation, rather than by inward displacement. Outward.-There seem to be no definite data as to outward luxation (uncomplicated with fibular fracture). Backward or forward luxation occurs as a complication of any form of fracture where the structure of the joint mortise is extensively damaged, where ligaments are also much torn. Backward dislocation as a complication of Pott's fracture is rare. Typically luxation back- ward involves a fracture of its own, namely, a splitting-off of the pos- terior surface of the tibia with the internal malleolus, and fibular fracture is also present. The writer has found this lesion in cases Fig. 1106.-Pott's fracture, with anterior dis- placement of the foot. Displacement of the astragalus forward without fracture of the tibia at the front edge. Fracture of fibula with dis- placement forward (the small explanatory sketch gives details). Fig. 1107.-Normal astragalus, showing the characteristic shape of the upper articu- lar surface, which has been called the "Sara- toga-trunk shape." operated on for deformity years after the accident, and also in many fresh cases, demonstrated by the z-ray.* So often have I demonstrated this lesion (over 70 cases of which I have notes, beside cases seen in casual consultation with hospital services, other than my own) that the House officers at the City Hospital have come to call this "Cotton's fracture." The lesion is serious because the astragalus follows the posterior fragment, and this displacement is apt to result in a broadening from the front to the back of the joint, which results in a loss of dorsal flexion from direct contact of the front edge of the tibia against the neck of the astragalus: moreover, the supporting column is weak and is out of proper line (Fig. 1104). In anterior luxation we may find a corresponding fracture of the anterior edge of the tibia. * Fracture luxation is the rule, pure luxation the exception. Cotton: Trans. Orthop. Section A. M. A., 1914. DIAGNOSIS 607 Anterior luxation, less common, entails a like disability from defec- tive support, to say nothing of the shortened leverage of the tendo Achillis and consequent loss of power. (Figs. 1105, 1106, 1109.) Diagnosis Diagnosis of the various luxations is not difficult, except in so far as swelling interferes. If the scaphoid can be made out, it will be found to lie either for- ward or back of the line of the tibial crest. (See Fig. 1096.) Fig. 1108.-Measurement from internal mal- leolus (A) to the great toe (B) and to the heel (C) respectively, may be very useful, but is, of course, useless if the malleolus itself is damaged. Fig. 1109.- Diagram of outlines in posterior and_anterior dislocations respectively. In backward dislocation the front of the tibia may be felt with a hollow beneath its lower end (Fig. 1109). In anterior luxation the articular surface of the astragalus may be felt in front of the tibia. Its "Saratoga-trunk" shape in characteristic (Fig. 1107). Measurements from either malleolus to the tip of the great toe or to the end of the heel will show shortening or lengthening, Fig. 1110.--Manoeuver for reduction of anterior dislocation. The foot, carried into moderate plantar flexion, is thrust down and backward while the leg is pulled forward to give resistance. characteristic for either type, provided the malleoli are intact (Fig. 1108). In practice, anterior or posterior luxation is obvious to the trained eye or fingers on touch, if not from simple inspection. The outlines (see Fig. 1109) are characteristic. The lateral luxations are obvious, the only question is of associated fracture. It is to be recalled that inward luxations involve rotation in- 608 THE ANKLE AND FOOT ward about the vertical axis, as well as inward displacement. If there is any question of the identification of landmarks, it may be settled by movement of the foot at the ankle. Even if a malleolus is broken, its range of motion is incomparably less on manipulation than that of the normal tarsal bones. Fig. 1111.-Reduction of posterior dislocation. Foot in moderate plantar flexion; thumbs on the-front of the tibial shaft; hands clasped about the foot; fingers behind the heel. Reduction is by lift forward in a sweeping motion, while the thumbs exert pressure backward. Reduction of anterior luxations is by direct shove backward (see Fig. 1110), the foot being in plantar flexion to slacken the tendo Achillis. Backward luxation is best reduced by the grip shown in Fig. 1111 the foot being held in moderate plantar flexion. Lateral luxations are best reduced by traction and a rocking motion applied to the foot, aided by direct pressure. If the displacement is inward, we may wisely rotate as well as rock. The tendency of the dislocations to recur is depen- dent on associated fracture. If there is no such frac- ture, there is no such tendency, so long as the foot is kept at a right angle. Pads beneath the leg above the level of the ankle in anterior dislocations, and a "doughnut" pad beneath the heel in posterior cases, will usually suffice to maintain reduction. Lateral luxations do not tend to recur except where there has been severe fracture. Appropriate points for pressure from the inner and outer side to be applied in such cases are shown in Fig. 1112. The results of these various luxations, properly reduced, seem to be excellent. The tendency to recurrence in case of complicating fracture must be guarded against, of course, and the prognosis in these cases is Reduction Fig. 1112.-Points of pressure to maintain in reduction of inward luxation, with or with- out fracture. Dotted line shows original dis- placement. DIASTASIS OF TIBIA AND FIBULA 609 that of the fracture itself-no worse than in uncomplicated fracture, provided the tendency to recurrence is efficiently dealt with. Fig. 1113.-Compound dislocation of the tibia; avulsion of the malleolus; all the ligaments torn; fracture of the fibula. Drawing made direct from the injured leg. This injury was reduced with a good primary result, but, owing to the extreme crushing of the skin, there was sloughing and late secondary infection, finally necessitating amputation. FIBULA; LUXATION OF THE LOWER END This is a very rare accident. The displacement seems to be usually of the fibula backward or outward, with or without some displace- ment of the tarsus. The diagnosis depends on inspection and on mobility of the bone. The cause may be either direct or indirect violence. The reduction is by direct pressure; if there is tarsal displacement also, reduction of this will usually take care of the fibular displacement as well. Upward luxation (with luxation of the upper end also) has already been considered. It is similarly reduced by reduction of the displaced foot. (See Luxation of Upper End of Fibula, p. 599.) DIASTASIS OF TIBIA AND FIBULA Fibular luxation outward is described as dias- tasis of tibia and fibula, a very rare accident, charac- terized, of course, by great broadening, and associated with dislocation of the foot (academically, at least) up between the two bones. (See Figs. 1113, 1114, 1116.) Fig. 1114.--Dias- tasis of tibia and fibula is the term applied where there is enor- mous tearing and sep- aration, without, or practically without, fracture. This may be so extreme as to per- mit the ascent of the astragalus between the two leg bones, as is.here sketched. 610 THE ANKLE AND FOOT Diastasis of the tibia and fibula may be a complication of various fractures in this region. It is rare at best, and will be considered as affecting only two types of fracture, both to be classed roughly as Pott's fracture. There may be a total separation (diastasis) of tibia and fibula, with a separation of the malleoli and with an ascent of the astragalus between the two bones. A case cited by Cooper is the type, and a sketch from his plate is given in Fig. 1116. There should be no difficulty in recognizing this condition, or in reduction of the de- formity by traction. Maintenance of position by the usual inversion, would seem to promise fair results. The other type of case is that in which a tearing off of the fibula by rupture of the ligament, or by tearing away of the scale of the Fig. 1115.-Diastasis of tibia and fibula; in this case there was also, as usual, a fracture of the internal malleolus, none of the fibula. Fig. 1116.-Atypical Pott's fracture, with diastasis of the bones and dislocation of the as- tragalus between them (sketched from Cooper's Plate XVIII). tibia to which the ligament is attached, is the equivalent of the fibula fracture, and when accompanied by a fracture of the internal malleolus or a tearing of the internal ligament, gives a clinical picture almost exactly like that of Pott's fracture. Its recognition must be based on the excessive broadening, and especially on the absence of signs of a fractured fibula. Treatment and prognosis are not different from those of the more usual fracture. Reduction is by traction downward, reduction of the astragalus, by pressure, into its proper relation with the tibia, and then by forcing the two leg bones together by lateral pressure and holding them there. POTT'S FRACTURE This fracture, first described by Percival Pott, is accepted as the type of ankle fractures. The name is used to cover many lesions which have nothing to do with what Pott described, and in the large hospitals pott's fracture 611 the house-surgeons and students are very apt to "lump" all the frac- tures of the ankle together as "Pott's." Pott's fracture is, in fact, a common lesion but not the most common in this region. Fractures involving the fibula alone are certainly much more frequently met with. What Pott described (in his Chirurgical Works, vol. i, p. 436 of the 1779 edition) is the form consisting of a fracture of the fibula a short distance above the joint, with a dislocation outward of the foot and a tearing of the internal lateral ligament. The lesion is shown in an admirable plate in his book. By common consent, however, the term of Pott's fracture is held today to cover also those cases in which a tearing away of the tip of the internal malleolus takes the place of the ligamentous rupture he described. The lesion is in either case the same, so far as treatment and results go. In either case the astragalus Fig. 1117.-Pott's fracture, with out- ward dislocation: a is not part of the astra- galus, but the internal malleolus is torn loose from & (courtesy of Dr. C. G. Cumston; x-ray. by Dr. Percy Brown). Fig. 1118.--Pott's fracture, with extreme tearing of the ligaments. Posterior ligaments all gone; internal malleolus torn loose (drawn from the Warren Museum specimen No. 9581; alco- holic specimen). is so far loosened in its mortise that it is free to follow the lower fragment of the fibula in its displacement outward. The causation of this fracture seems to be, as Stimson has pointed out, not a simple external rolling of the foot, as used to be taught, but rather a sharp abduction of the foot about a vertical axis, combined with such rotation.* The probable mechanism is that the fibula gives way first, and that the continuation of the force tears the internal support of the joint through the ligament or through the bone to which this ligament is attached. The astragalus is displaced outward, but is not rotated outward unless weight is borne on the foot. There may rarely be an associated backward dislocation, or less commonly a forward dislocation, of the astragalus. These are usually only partial dislocations. * According to Stimson, eversion fractures at the ankle give a break across the fibula low down, while Pott's fracture from twist gives a higher fracture of the fibula, with a spiral line. 612 THE ANKLE AND FOOT Lesions.-The fracture of the fibula occurs above the joint and above the ligaments-usually two to three inches above the joint. It may be nearly transverse, but more commonly is oblique upward and backward, with a somewhat spiral fracture-line. The displace- ment of the fibula is a shoving of the upper end of the lower fragment toward the tibia, while the lower end of the fragment tilts outward. Fig. 1119.-Pott's fracture, with extensive ligament tearing: 1, Fibula; 2, os calcis; 3, large frag- ment of internal malleolus torn off from tibia. Wide tear across the front of the joint, exposing joint surfaces of astragalus and fibula; wide separation between broken malleolus and tibia. (Warren Museum, specimen No. 9774; alcoholic specimen.) Sometimes the upper end of the lower fibular fragment is tilted sharply forward, the external malleolus displaced backward. The lesion on the inner side, if the tibia is involved, is merely a tearing off of the malleolus at, or just below, the level of the top of the joint. This fracture is nearly always a clean transverse fracture, unlike that found in the " inversion Pott's." If the malleolus is POTT's FRACTURE 613 intact, the internal lateral ligament is torn away close to the tip of the malleolus. Something more than a simple tearing of this single ligament is probably usual, and must necessarily be present if there is any considerable backward dislocation of the foot. The examination of certain specimens shows that there may also be very extensive tearing across either the anterior or the posterior capsule of the joint (Figs. 1118 and 1119). Fig. 1120.-Pott's fracture, with increased distance between internal malleolus and as- tragalus, due to tearing of ligaments. Fig. 1121.-Shows the same as Fig. 1120. Pott's fracture is not apt to be accompanied by lesions of vessels orjiervcs. It is rarely complicated by any injuries to the bones of the foot. Not infrequently, however, Pott's fractures are compound, always by protrusion through the skin of the internal malleolus or the sharp edge of the tibia, from which the malleolus has been torn away. Fig. 1122.-Pott's fracture. Displacement of broken internal malleolus not entirely re- duced. Astragalus somewhat tilt edi.out ward. Fig. 1123.-Pott's fracture; internal mal- leolus torn loose; still much displaced. Frac- ture of fibula unusually low. Diagnosis of Pott's Fracture.-The symptoms of Pott's fracture are those of an obviously severe lesion. I have known of no case in which the patient could walk after receiving this injury. 614 THE ANKLE AND FOOT The occurrence of great swelling and the formation of blebs are by no means constant, however. The pain is not especially great, though the initial shock is apt to be pretty severe for a time. The foot is held in a position of partial plantar flexion, and in some Fig. 1124.--Outward displacement in Pott's frac- ture, not entirely reduced. Fig. 1125.-Pott's fracture, with comminution of fibula, x-ray outlines reinforced. cases it is slightly everted. Often enough, however, the deformity has been reduced by bystanders or by the patient before the surgeon sees the case, and the deformity often shows no tendency to recur after such reduction. Eversion of the foot is not a necessary symptom. There is tenderness over the fibula at the point of fracture, and there is Fig. 1126.-Pott's fracture; foot with astra- galus displaced outward and rotated outward. The fibular fragment displaced; the broken inter- nal malleolus dragged downward and inward by its ligamentous connections with the astragalus. Fig. 1127.-Pott's fracture, with unusually large fragment of internal malleolus separated. Old case. Hardly a typical Pott's fracture. marked tenderness at or below the internal malleolus, and at this point there is always some swelling, even within a few minutes after the fracture. (Where only the fibula is broken, we do not get this swelling on the inner side. pott's fracture 615 In a Pott's fracture there is no tenderness on pressure below the external malleolus nor on the external malleolus, unless pressure is severe enough to move the fibula. Pressure on the fibula well above Fig. 1128.--Pott's fracture, with splin- tered fibula, internal malleolus apparently not fully torn off; no displacement. Fig. 1129.-Clinically, in Pott's fracture, even where the displacement is not great, we are apt to find a sharp projecting edge at the point here indicated, the edge left where the internal malleolus has been torn away. Fig. 1130.-Grip to test for abnormal lateral mobility in Pott's fracture. Fig. 131.-Line of measurement to detect backward displacement of the foot on the leg. Measurement from the cleft of the toes to the prominent surface of the front of the tibia. the site of suspected fracture gives pain at the level of the break of the fibula, distinct from any soreness at the point pressed on. For accurate diagnosis it is necessary to employ the following manceuver. 616 THE ANKLE AND FOOT The ankle is grasped with one hand just above the joint, while the other hand is placed beneath the sole, with the thumb on one side of the foot, the fingers on the other below the malleoli (Fig. 1130). If the foot is grasped firmly and pushed inward and outward, the presence of an ab- normal lateral mobility is easily recognized. Crepitus is also usually felt in the fibula. The presence of a fracture of the internal malleolus as distinct from the ligamentous tear may usually be determined by running the finger down the Fig. 1132.---Pott's fracture with considerable outward and apparently some posterior displace- ment. Fig. 1133.--Old Pott's fracture, united, with some widening of the joint mortise and some tendency to rotation of the astragalus as a result. inner surface of the tibia, while the foot is strongly pushed outward. The malleolar fragment may not al- ways be felt, but the sharp edge of the bone from which it was torn away is always palpable (Fig. 1129). For this examination etherization is advisable, but not indispensable. The test for lateral mobility is the best single proof of Pott's fracture. It occurs in no other fracture except the "inversion Pott's," is readily perceiv- ed, and may be or inch in range. The question of backward or for- ward dislocation complicating a frac- ture may be tested in four ways: First, by feeling down the front of the ankle for the projection made by the tibia in backward dislocation, by the top of the astragalus if the dislocation is forward. (See Figs. 1100, 1105 and 1109.) Fig. 1134.-Fracture of internal malleolus (fracture of fibula not shown) properly re- duced (outlines reinforced). POTT'S FRACTURE 617 Second, by noting the line of the front of the tibia looked at from the side: this should, under normal circumstances, just about hit the tubercle of the scaphoid if prolonged downward. This rule is not mathematically accurate, but sufficiently so to detect actual displace- Fig. 1135.-Reduction of Pott's fracture with knee flexed, countertraction under the bent knee; foot so grasped as to render downward traction and inversion easy. A preferable method if reduction proves difficult. Not a routine method. ments (Fig. 1096). The tubercle of the scaphoid may always be felt, even through much swelling. Third, by measurement. (See Fig. 1131.) Fourth, by grasping the ankle as before, grasping the foot as shown in Fig. 1110, and then alternately lifting and depress- ing the foot, we shall reduce-thereby recognize- any such dislocations as exist. These displacements Fig. 1136.-Pillow-and- side-splint. The foot is laid in a large pillow, the middle of which has been pounded down to form a hollow for the foot and leg. Fig. 1137.-The pillow is brought up at the sides and fitted to the leg, and is sojfolded that it can be comfortably overlapped under the sole of the foot. Fig. 1138.-The edges of the pillow are then pinned in front, overlapped and pinned beneath the sole. Straight side-splints, with or without a straight posterior splint, are then applied and strapped tightly enough to give the nec- essary support. are always readily reducible in this way, provided care is taken not to put the tendo Achillis on the stretch during manipulations. Examination with the x-ray is of service in "checking" the result of a correction and in giving information as to unusual details of frac- 618 THE ANKLE AND FOOT ture-lines. It should not be necessary, however, as a means of diagno- sis in these cases. Treatment of Pott's Fracture.-The first thing is to reduce any Fig. 1139.-Pillow-and-side-splints in actual use. In this case the splints are held in place by band- age instead of webbing straps. An equally serviceable way, but more liable to stretch. displacement that exists. First grasping the foot, as during the exami- nation (see Fig. 1130), we force it sharply inward, at the same time somewhat inverting the foot as a whola. Then any possible posterior Fig. 1140.-Points at which pressure is to be made in retaining Pott's fracture in place, whether in splints or plaster. Pressure on the inner side is to be made on the tibia above the joint; on the outer side pressure is to be made on the foot, both on the outer side of the os calcis, and over the cuboid and fifth meta- tarsal. Fig. 1141.-Holding the foot by the toes during the application of the plaster bandage. The most serviceable method in most cases when there is no tendency to anterior displace- ment. Curiously enough, this is not only effec- tive, but is comfortable to the patient. displacement is guarded against by pulling the heel forward, as in Fig. 1111. The foot is then laid in a pillow, still held by the surgeon's hand in the desired position, while the assistant envelops the leg and foot in a pillow and applies straps on the back and side-splints, adding pads pott's FRACTURE 619 if necessary between the splint and pillow, above the ankle on the inner side, and opposite the side of the foot on the outer side (Fig. 1140). As a- rule, the tendency to displacement is only slight, if any, and the position is readily held in this way. The detailed application of this "pillow-and side-splints" apparatus is shown in the Figs. 1136, 1137, 1138. Only exceptionally is it wise to put on a plaster-of-Paris dressing immediately. This fracture is a serious one. There may be a good deal of swelling, and not uncommonly there is a formation of blebs, which break, and can best be dealt with outside of a rigid plaster-of-Paris dressing. After three days to a week the plaster-of-Paris dressing may be applied. Any blebs that may still be present may be broken open after alcohol sterilization of the skin, and then dusted over with com- pound alum or other powder, and a small sterile gauze dress- ing placed on them. The limb from the knee to the toes is then wrapped in sheet-wadding, about two thicknesses being used everywhere except at the heel, where it may be well to make it a little thicker. Dur- ing the application of this and of the plaster bandage the foot is held by an assistant in such fashion as to prevent displace- ment. If there is no anterior dislocation, the best way to hold it is by the toes, as shown in Fig. 1141. The plaster is laid on in circular turns from below the knee* to the toes, carefully avoiding any tension during the application of these turns. When the bandages are all on, the surgeon grasps the foot, with one hand pulling outward, pressing just above the internal malleo- lus; with the other hand the heel and foot are so grasped that the fin- gers hold the heel, while the base of the thumb exerts a pressure inward on the outer side of the foot (Fig. 1142). Care must be taken that this pressure is exerted evenly over a considerable surface. With the hands in this position the foot is held inverted and is sharply shoved inward. A moderate inversion is enough. Pressure inward is limited only by what we think the outer side of the foot will stand without slough and without much pain. There is no danger of shoving the foot too far. The external ligaments permit no motion beyond the normal position Fig. 1142.-Grasp of hand on plaster-of-Paris bandage (begun while the plaster is still soft and maintained until it is thoroughly set), to insure reduc- tion and the maintenance of pressure at the points noted in Fig. 1140. * Only in case of tendency to rotatory displacement need the plaster go above the knee. 620 THE ANKLE AND FOOT of the astragalus. The pressure of the surgeon's hand is kept up until the plaster is reasonably firm. Care must be taken to secure, as nearly as may be, a right angle between the leg and foot. Failure to do this means difficulty in walk- ing during early convalescence and possible impair- ment of ankle motion permanently. The plaster should be trimmed so that no uncom- fortable pressure is exerted on the little toe or on the distal end of the fifth metatarsal, and should be cut behind the knee to such an extent that moder- ate flexion of the knee will not cause it to dig into the skin. The foot may be laid in any position that is com- fortable. Usually patients prefer to have the toes pointing upward or to have the foot somewhat turned on its outer side, with the knee slightly bent and supported by a pillow or sand-bag. For this reduction of the fracture, which is meant to be permanent, it is usually well to give ether if practicable, though it is often not neces- sary. In very nervous or very muscular patients it is hardly possible to do good work without ether, and in most cases it is of advantage to use it if we can. After-treatment of Pott's Fracture.-Not infrequently there is some pain following the application of plaster, pain resulting from tension. This lasts but a couple of days at worst, and may be combated with mor- phin, but must be differentiated sharply from pain due to pressure, which means trouble and calls for cutting of the plaster. Pain from pressure is persistently localized at the point of pressure, and usually, unlike tension-pain, tends to increase and not decrease from the beginning. The first thing to be done in the way of treatment after the plaster is on is to get an x-ray if possible. Good enough x-rays can be obtained through a plaster dressing after it is fully dry-that is, after two days at most-to tell us all we need to know about reduction in these cases. At any time with- in two weeks we can correct misplacements that may have escaped notice, and can correct them usually with- out ether. After this date, information of this sort is apt to be useless. If everything is going well, and if there was no great swelling when the plaster went on, there is no reason for cutting down a good plaster earlier than three weeks from the time of injury. By this time union Fig. 1143-Prop- er lines for cutting plaster. Plaster so cut may be strapped to- gether with adhesive plaster or with web- bing straps so firmly as to have much of its original efficiency. Fig. 1144.--Stimson's dressing for Pott's fracture or fracture of the fibula. Two long strips of plaster, 6 inches wide, about 10 inches longer than the distance from the heel to the popliteal space, and about 12 bandages thick, are prepared. One of these is laid on the leg, over light padding, on the back of the calf, under the heel, and up over the sole of the foot. (See sketch, a, b, e.) The other starts on the dorsum, goes outward under the sole, and up the outer side of the leg (see in sketch 1, 2, 3, 4). These are rubbed together where they overlap, and bandaged in place. port's FRACTURE 621 is beginning; there is no tendency toward displacement, and we may wisely begin massage and guarded motion. Active motion is less likely to do harm than passive, and is preferred. The plaster may be removed once or twice a day for this purpose, and then strapped on again. If backward or forward dislocation is present with the fracture, as shown by the x-ray, it is obvious that attention should be paid particu- larly to a proper support of the heel until union is firm, and that weight-bearing should be begun very carefully. By the end of the second week the patient should already be on crutches in most cases. In cases without great tendency to swelling there is no reason why crutches should not be used more or less cautiously after the first week. No weight is to be borne on the foot until after at least a month, and no considerable weight for about six weeks. At this time it is wise, especially in heavy patients, to fit a brace or plate as for flat-foot. The tend- ency to a weakened arch is almost universal after this form of fracture; with due care dur- ing convalescence the necessity for a plate is only temporary. Sometimes it may be well to use strapping (see Fig. 1145), as well as a plate. Strapping is often useful before the plate can be fitted. The only alternative to the plaster dress- ing of the ordinary type is the ingenious modi- fied plaster introduced by Dr. Stimson* (Fig. 1144). This I have repeatedly used, and found it very satisfactory, although it is not quite so rigid as the ordinary form, and is better suited for the more careful class of patients. It is made of the ordinary plaster bandage, wet, laid over and over on a board in such fashion as to make a bandage of 10 to 15 thicknesses, and about 6 inches wide, long enough to reach from the knee around the heel up the sole of the foot to the tip of the toes. A second similar strip is prepared of the same thickness and a little longer. The foot and leg are wrapped in sheet-wadding in the usual way. These plaster strips, still soft, are laid on as shown in Fig. 1144, the edges of the two being rubbed together where they overlap, and the whole is held in place by a gauze bandage wrapped around outside. The correction of the fracture and the securing of inversion are then carried out with the hands as described above; after the plaster has set the gauze bandage is removed, the corners of the plaster are trimmed to suit, the sheet-wadding is split and trimmed Fig. 1145.-Pad and adhe- sive-plaster strap to maintain the arch of the foot after fracture. * The old-fashioned carved side-splints are not an efficient dressing. 622 THE ANKLE AND FOOT away over the front of the leg, and the dressing is finished by a few turns of ordinary bandage carried around the upper end about the leg. It is distinctly more comfortable than the ordinary plaster, and better permits the inspection of the leg and ankle. End-results.-A consideration of the end-results of this fracture will be postponed to the end of this chapter, when end-results of this and of other ankle fractures will be considered. THE SO-CALLED "COTTON'S FRACTURE"* This is a not uncommon lesion, and a very serious one, meaning, as it does, not only a dislocation backward, but a dislocation with a great tendency to recur, after reduction. - The lesion is a splitting-off of the posterior articular edge of the tibia, including usually a third to a half of its depth. This fragment Fig. 1146.-x-ray of a posterior dislocation, with fracture and displacement of the posterior edge of the tibia. may be in one piece with the portion of the malleolus that is knocked off. The lesion is here classified as a variant of Pott's fracture, although it should probably be made a separate type. There are no anatomic specimens of the fracture that I know of, but, judging from x-rays and cases operated, I should describe it as a lesion consisting of a tibial fracture, in which the fracture-line separates the internal malleolus and runs backward (in a curved plane) in such a way as to split off the whole back edge of the tibial articulating surface, separately or in one piece with the malleolus, and of a fibular fracture a little above the ankle-joint. The attachments of the posterior capsule are not torn, and the astragalus drops back, accompanied by the internal malleolus with the posterior fragment to which the capsule is attached, and is drawn up * Journal of the American Medical Association, Jan. 23, 1915, Ixiv, p. 318. THE SO-CALLED COTTON'S FRACTURE 623 Fig. 1147.-Posterior dislocation, with fracture of the tibia and fibula at the ankle: (1) Posterior fragment of tibia; (2) fragment of fibula; (3) inter- nal malleolus broken off. Fig. 1148.-Front view of case shown in lig. 1147. The posterior fragment of the tibia did not show in this view. Fig. 1149.--Fracture of the posterior edge of the tibia, with luxation backward of the foot. Diagnosis doubtful in detail. (Warren Museum, specimen No. 591540. Plaster cast.) Fig. 1150.-If there is a dislocation with fracture, the total backward displacement is less; the palpable projection of the tibia forward is less, and the lesion is more readily overlooked. Fig. 1151.-Fracture of the posterior edge of tibia, with fibula fracture, with backward luxation. Old case, consolidated with nearly useless ankle: 1, Fragment of tibia; 2, fibula (lines reinforced). Fig. 1152.--Fracture of posterior edge of tibia with slight displacement backward. 624 THE ANKLE AND FOOT behind the tibia. With this displacement we often have the familiar deformity of Pott's fracture-displacement outward. Diagnosis.-Diagnosis depends, first, on recognition of the back- ward dislocation, and on observation of the tendency to recurrence. The trouble is that it is difficult to say whether or not a posterior dislocation is or is not accompanied by such a fracture, for dislocation Fig. 1153.-Type lesion, extreme displacement back and outward: a, posterior tibial fragment; b, b', outlines belonging to the broken fibula; c, line of the tibial surface from which fragment a was broken away. (Jour. Am. Med. Assoc., 1915, Ixiv, p. 319.) may, perhaps, recur. Crepitus does not help us; it is present anyhow. The one point that can help is that the prominence of the front edge of the tibia is less than would be the case in dislocation (Fig. 1150). I have recognized and successfully reduced this fracture in many Fig. 1154.-Pott's fracture, with lateral and posterior displacement, without evident fracture of the back edge of the tibia. Fig. 1155.-Same case as Fig. 1154 cases before the skiagraph was taken; ordinarily, confirmation by the x-ray will be sought rather before than after, if this lesion is suspected. There is reason for thinking such fracture very common in propor- tion to the number of backward dislocations with fracture, and prob- ably it may be well, in case of backward dislocation-fracture, to assume that fracture of this posterior lip is present, and not to trust too much to the probability of a reduced dislocation staying in place. THE SO-CALLED COTTON'S FRACTURE 625 As to frequency, I can only say that I have treated over 60 fresh cases of this injury, have seen x-rays of many more, and have operated on 8 or 10 old cases in which this was the obvious original lesion, within the last few years. If this lesion is promptly recognized, there is no difficulty in reduc- ing the fragment and no great difficulty in holding it. I have found it necessary to use plaster-of-Paris from the first, and have employed a position of maximum dorsal flexion to prevent redisplacement. Fig. 1156.-Posterior dislocation of the ankle, with Pott's fracture and a splitting-off of the posterior edge of tibia. Foot slipped oft the mat during wrestling bout. Extreme displacement, promptly reproducing itself after reduction. This plate was taken one week after permanent reduction, and showed only an oblique line of fracture of the back edge of the tibia, practically without displacement. This plate shows in reproduction only the break in the cortical layer of function and motion (x-ray plate by Dr. Percy E. Brown). After-treatment.-After-treatment is that of Pott's fracture, with the difference that the absence of a firm tibial surface to bear weight will incline us not to allow weight-bearing, in most cases, under eight weeks. Results.-The results in properly reduced cases have been perfect. Where the deformity has been allowed to persist, there has been grave disability, due to the imperfect mechanism of the altered joint, resulting in loss of motion and lameness. These cases have been greatly benefited by operation, often restored to near normal; but the operation is difficult 626 THE ANKLE AND FOOT This lesion, somewhat similar to Pott's fracture, is produced by a simple inversion of the foot. Both fibula and internal malleolus are INVERTED POTT'S FRACTURE Fig. 1157.--Typical inversion Pott's frac- ture. Fibula broken at the level of the joint. Internal malleolus broken off obliquely and dis- placed inward (outlines reinforced). Fig. 1158.--A typical case of inversion Pott's fracture. Extra large inner fragment. broken, but in a different line from that found in the ordinary form. Of the exact mechanism of the fracture nothing is known except that forced inversion causes it: probably in- ward rotation plays a part. It seems probable that the tibia gives way first. The lesion is often confused with Pott's fracture, sometimes with deplor- able results, for the treatment is very different. Fig. 1159.-Inverted Pott's fracture. Fibrous union of tibia; bad position. Fig. 1160.-x-ray of same case as in Fig. 1150 (outlines reinforced). Lesions.-The fracture of the fibula in these cases occurs at about the level of the joint, or a little above it; invariably lower than the height usual in Pott's fracture. The fracture of the internal malleolus INVERTED POTT'S FRACTURE 627 is not a breaking off of the tip, but a breaking away of the whole malleolus, usually in a line somewhat oblique, upward and inward. Fig. 1161.-Typical inversion Pott's frac- ture. Evidently only one edge of the fracture plane is shown. Poor plate (outlines reinforced). Fig. 1162.-Inversion Pott's fracture (outlines reinforced). This line starts not lower than the angle in the articular cartilage between the internal malleolus and the bearing surface of the tibia, and may encroach considerably on this bearing surface. The liability to tearing of ligaments and to backward and forward dislocation Fig. 1163.--Typical in- version Pott's fracture. This case united only by fibrous union, was opened down on, refreshed, and pegged tempor- arily. Perfect result (x-ray 15975). Fig. 1164.-Inversion Pott's fracture. Sketch from x-ray plate. Fig. 1165.--Fracture of the internal malleolus, appar- ently by inversion; no frac- ture of the fibula. seems less in these cases than in Pott's fracture, and they are less apt to be compound. Diagnosis.-Here, as in Pott's fractures, there may be no deformity at'all at the time the case is seen. There may be, however, especially 628 THE ANKLE AND FOOT in the cases that run well into the tibial articular surface, a marked inversion and inward displacement of the foot, hard to correct, and recurring very easily. Lateral mobility is obtainable by the same test as with Pott's fracture, but the free mobility is inward, not outward. Tenderness on the inner side is found higher up in this form, and Fig. 1166.--Application of pressure and pull to reduce and maintain reduction of in- version Pott's fracture. Fig. 1167.-Lane staple (Terry's modifica- tion), used in place of a nail. This staple is left in the tissues, x-ray, outlines reinforced, of case of "inversion Pott's." there is usually no difficulty in palpating the fragment of the tibia or in obtaining crepitus. On the outer side tenderness is not above, but just about at, the joint, and the swelling involves the outer side of the foot. Treatment.-If there is no great tendency to displacement, the foot is to be put up at first in pillow and side-splints. In cases in which there is inversion it may often be necessary to put on a plaster immediately because the deformity can not be prevented from recurring in any other way. In this case Fig. 1168.-Inversion Pott's fracture. Fibula fracture unusually high. Fig. 1169.--Inversion Pott's fracture. Un- usually large inner fragment Fibula unbroken: (sketch from x-ray). the plaster must be padded with unusual care, and will have to be changed as soon as the swelling goes down. The position to be aimed at is in this case not an overcorrection, but a correction to normal. Overcorrection, even if attainable, would carry too much chance of a later flat-foot. After-treatment.-This is carried out on the same lines as with the ordinary Pott's fracture, excepting that in cases where there has been much tendency to inversion (meaning usually a splitting of the FRACTURE INVOLVING BOTH BONES JUST ABOVE THE JOINT 629 fragment well into the joint on the inner side), weight-bearing may well be postponed a little longer in this form. Long-delayed union or even non-union sometimes occurs in this form, as it apparently does not in true Pott's fracture.* FRACTURE INVOLVING BOTH BONES JUST ABOVE THE JOINT Fractures just above the ankle are not to be distinguished, so far as the cause is concerned, from those through the joint level, save for the Fig. 1170.-Fracture of the tibia low down; marked outward bowing; union. (War- ren Museum, specimen 1146.) Fig. 1171.-Fracture of the tibia, low, oblique, considerable displacement. High frac- ture of fibula (drawn from Warren Museum specimen No. 8303). few that result from direct violence. As might be expected, they show no constancy in the obliquity of the line. In a general way the same line is continued through both bones. Inasmuch as there is no long bone left to maintain the length of the leg, the displacement in frac- tures of this type may be extreme, and it is very common, relatively * The writer has seen several cases of non-union-one united after operation (Fig. 1008), one (Fig. 1001) never got union. Two were more recent patients. Both cases, under proper orthopedic treatment, recovered without permanent disability. Stimson and others have recognized the peculiar chance of failure of bone union in this special fracture 630 THE ANKLE AND FOOT speaking, to have projection of one fragment of the tibia through the skin. There is no difficulty about the diagnosis of this type of frac- Fig. 1172.--Fracture of both bones low, slight displacement (courtesy of Dr. McKechnie, of Cambridge). The patient walked on this leg to some extent for ten days before seeking a doctor. Fig. 1173.--Side view of same case as Fig. 1172. It is interesting to note that the ap- parent separation of the internal malleolus at the point shown by the arrow is an illusion; there is no break at this point (x-ray by Dr. McKechnie). ture, unless in regard to the exact line followed. Like fractures higher up in the leg, these may not uncom- monly be spiral rather than directly oblique, and, like other spiral frac- tures, may show a chipping off of one or the other tip of bone fragment. There may be much comminution Fig. 1174.--Oblique spiral fracture of tibia close above joint. Fracture of fibula. Fig. 1175.-Side view of same case as Fig. 1174. of bone. Inasmuch as the strong muscles of the leg have free action in these cases there may be extreme deformity in any direction, FRACTURE INVOLVING BOTH BONES JUST ABOVE THE JOINT 631 according to the muscle pull, as well as gravity. As these fractures most commonly come from an outward twist of the foot, the deformity to be combated is apt to be in this direction. Backward or forward Fig. 1176.-Atypical fracture from a fall on the foot. Fracture of the internal malleolus; fracture of the fibula; separate transverse frac- ture of the tibia above the joint. Fig. 1177.-Side view of same case as Fig. 1176. This case recovered with practi- cally no deformity, perfect motion, perfect function. bowing is not unusual. In children these fractures may be of " green- stick" type. Diagnosis.-Mobility of both malleoli (with the foot) on the leg Fig. 1178.-Irregular oblique splintering of the lower end of the tibia; fibula fracture higher up. 1 Fig. 1179.-Spiral of the tibia, low. settles the diagnosis. Only in case of great swelling should there be any trouble in diagnosis. 632 THE ANKLE AND FOOT Treatment.-If such fractures are compound, they will often need some artificial fixation applied through the open wound. By choice Fig. 1180.-Long split into joint; low fracture of fibula: (1) Internal malleolus; (2) front edge of tibial fragment; (3) top of astrag- alus (outlines reinforced). Fig. 1181.-Fracture of the tibia close to the joint, with some backward displacement (x-ray 15945). This seems to be a fracture by avulsion from plantar flexion, but this is not certain. this will be a suture of kangaroo tendon through the bone edges, or a steel staple.* At times it is possible with the compound spiral frac- tures, to obtain exact reposition, in which case the tendency to dis- Fig. 1182.-Fracture of both bones, low; that of the fibula a greenstick fracture only. Fig. 1183.--Sketch of x-ray of a fresh case, similar to that shown in Fig. 1179. placement practically disappears. This means exact reposition of the tibia: exact reposition of the fibula is hardly possible, and is of no importance. *Of the type originated by W. Arbuthnot Lane, perfected by Terry. (See Fig. 1167.) FRACTURE INVOLVING BOTH BONES JUST ABOVE THE JOINT 633 If the fracture is simple, there is usually a good deal of swelling, and pillow and side-splints for a few days may be sufficient, as they are certainly desirable. As a rule, however, the tendency to displacement Fig. 1184.-Fracture of both bones, low down; displacement slight (x-ray No. 9136). Fig. 1185.-Clove-hitch for getting a traction grip on the ankle, for reduction. Fig. 1186.-Comminuted fracture of tibia, low. is so great that an immediate plaster-of-Paris dressing is necessary to secure decent position. In these fractures above, but close to, the joint, it is often justifiable, in the interest of accurate replacement, to allow some plantar flexion of the foot. To insist upon the right angle is often to insure backward bowing at the point of fracture. 634 THE ANKLE AND FOOT We must today take notice of the Delbet Technic of reduction under traction, with immediate plaster application-a specillay modelled plaster. Efficient. It is as yet an expert's method. Plaster is usually sufficient to maintain tolerable position. Now and then active traction is necessary. This may be obtained most readily Fig. 1187.- Oblique fracture of tibia, low. Fig. 1188.-Greenstick fracture of both bones. Fig. 1189.-Leather or cloth anklet for getting traction on the ankle. Fig. 1190.--Adhesive-plaster strapping to the foot and lower leg; may be used with weight traction to get a pull on fractures even close to the ankle. with an anklet or by applying adhesive plaster to the foot and heel, and exerting pulley traction on this, while the leg is properly supported and steadied in plaster with proper pads. A weight of five to twelve pounds will usually suffice. Today one has the further choice of using a Thomas splint with traction applied with a "Sinclair skate." This method however has not yet proved its place for routine work. Such traction may be removed at ten days to three weeks without recurrence FRACTURE INVOLVING BOTH BONES JUST ABOVE THE JOINT 635 of the shortening, and an ordinary plaster bandage may then be applied.* A "posterior wire" splint with flat side splints may be made to do excellent service in this class of cases, but a certain familiarity with its use is essential to the best results. It is not to be recommended for general use. (See Figs. 1066, 1191.) Fig. 1191.- Methods of supporting the foot when using a posterior splint, a, Padding beneath tendo Achillis; b, ring under heel; c, sling of adhesive plaster. Fig. 1192.--Normal epiphyses at ankle (x-ray) Fig. 1193.-Actual case of separation of lower epiphyses of tibia (x-ray after reduction) 1, Level of tibial epiphysis; 2, level of epiphysis of fibula. Whatever the line of fracture in these cases, it must be remembered that an inward deviation of the foot is of far less importance than an outward displacement, and that a backward bowing usually means definite disability. In the severer fractures at this point some deform- ity is inevitable, and it is within our power to choose in which direction this slight deviation shall be. * Up to recent years the "short Dupuytren splint " was much used for traction, but is now practically abandoned. It is efficient, but not comfortable or handy. 636 THE ANKLE AND FOOT SEPARATION OF THE LOWER EPIPHYSIS OF TIBIA AND FIBULA Epiphyseal lesions at the ankle are rather uncommon.* At times some peculiar cross-strain in a child gives rise to separation of epiphyses of both tibia and fibula. Such separations may occur up to sixteen or seventeen years of age. Save for the soft crepitus, they are hardly to be recognized from transverse fractures. The nearness of the lesion to the joint and the directly transverse direction of the displacement are, of course, suggestive. The displacement in these cases seems apt not Fig. 1194.--Separation of lower epiphysis of tibia- with fibular fracture. Fig. 1195.-Normal epiphyses at the ankle (x-ray sketch). to be very great. Not rarely the fibula is broken just above the epi- physis, with the tibia gone at the epiphyseal line. As with most other epiphyseal separations, replacement is not difficult. In this case the separation follows the epiphyseal line closely, as a rule. The tibial epiphysis is cap-shaped, and does not tend to become dis- placed when once exactly reduced. Separation of the epiphysis of the fibula alone is rare.f It is mechanically the equivalent of fibula fracture. The diagnosis rests on the patient's age, the location of the lesion, and the presence of cartilaginous crepitus, if any. I have read of no case in which there was any considerable displacement or any difficulty in reduction or retention. * A good many cases are on record. Monod (Revue d'Orthopedie, 1901, No. 2) reports a recent case that is typical. Most of us have seen one or two. f Even Poland's great work records but four instances of this lesion. FRACTURE OF THE FIBULA ALONE, AT OR ABOVE THE JOINT 637 FRACTURE OF THE FIBULA ALONE, AT OR ABOVE THE JOINT Fracture of the fibula alone may result from a force which, if Fig. 1196.-Fracture of the fibula alone (sketch from x-ray 8739). Fig. 1197.-Fracture of fibula alone (sketch from .r-ray 8679). Fig. 1198.--Fracture of fibula alone (sketch from z-ray 8825 a). sufficient, would have produced a Pott's fracture, or more often from a simple inversion of the foot, such as more usually causes a simple sprain. It is the commonest type of ankle fracture. Lesions.-The fibula may be broken across at any level, more usually within a few inches of the joint. If the fracture Fig. 1199.-Fracture of fibula alone Fig. 1200.--Lateral view of fracture of fibula. Re- produced here to show how vague the lateral view is as to diagnosis. The fracture of the fibula may be shown or may not, but we are left entirely in the dark as to any damage to the tibia (lines reinforced). is well above the joint, it is very apt, unless the result of a direct blow, to partake more or less of the spiral type. Fractures may occur within the 638 THE ANKLE AND FOOT area of insertion of the tibiofibular ligament. Such fractures show slight displacement, and are apparently usually the result of inversion, while the fractures higher up may occur from any form of twist or from a blow. The fractures very close to the joint level may show any line of break, but are more apt to be transverse, or nearly so, than in the case of fractures higher up. Diagnosis.-Fracture of the fibula does not destroy the mechanical strength of the ankle-joint to any great extent. Commonly enough, such a fracture is not more painful than the average sprain. Patients can perfectly well walk after this injury, though not without pain. The classic instance is that of John Wilkes Booth, who, after the assassination of Lincoln, escaped, despite the fact that his fibula had been fractured in the leap from the stage. Similar instances are by no means uncommon. If the fibula has been broken, there will be local tenderness at the point of the break. This tenderness will, of course, extend all about the circumfer- ence of the bone. If the break is above the ligaments, pressure on the fibula above the break will give pain at the site of injury. If the break is through the ligamentous attachment, this sign is not trustworthy. With fracture by eversion there may be slight tenderness on the inner side of the ankle; there is no tenderness on the outer side, except directly about the fracture. Inversion strain gives tenderness below the exter- nal malleolus, and up along the per- oneal tendons, irrespective of the condition of the fibula. If the fibula has been fractured well above the joint, referred pain on pres- sure above the fracture and tenderness of the fibula itself will give the diagnosis. If the fracture is lower, there will be local tenderness at some portion of the subcutaneous area of the fibula. (See Fig. 1202.) This subcutaneous area can not be in- volved and is never tender in cases of simple sprain, therefore tender- ness here is apt to be significant. Ecchymosis and swelling may be very slight or absent, and pain (distinguished from tenderness) may be trifling. Laxity of the mortise with abnormal lateral mobility is the exception in fractures of the fibula alone. Tenderness about the ligaments between tibia and fibula, well localized at the front, is common to most sprains, as well as breaks, Fig. 1201.-Fibula fracture alone (sketch from x-ray). FRACTURE OF THE FIBULA ALONE, AT OR ABOVE THE JOINT 639 and is practically without value in distinguishing between the two. It may mean tear-it certainly does not mean fracture.* Treatment.-These cases require simply rest until such time as the fibula has begun to be firmly held by callus. Malposition is apparently of no consequence whatever, and trifling malposition certainly calls for Fig. 1202.--Shaded area shows the subcutaneous surface of the fibula. Fig. 1203.--Cottrell-Gib- ney adhesive strapping for convalescence in ankle in- juries. Fig. 1204.-Padding oi felt sewed to leather insole The area of the pad (sloped to nothing at the outer edge) is shown at the right. The thickness of the pad in eleva- tion is shown to the left. no pains-taking reduction. Such reduction is, moreover, impossible to secure with any accuracy because of the intact tibia. We have no leverage that can be used. If such cases are allowed to walk early, they become disabled presently on account of the development of tenderness about the site of fracture, and callus-formation may then become excessive. Fig. 1205.-Fracture of the left fibula near the lower end; united. View from outer side. (Warren Museum, specimen 1150.) Fig. 1206.--Fracture of the tip of the lower end of the left fibula; united. View from inner side. (Warren Museum, specimen 1151.) If they are allowed to remain in plaster for two or three weeks, there is no objection to allowing moderate weight-bearing after this date, with progressively increasing use of the foot. After removal of the plaster-of-Paris adhesive-plaster strapping of the Cottrell-Gibney * In one case observed tenderness at this point in a sprain was followed by periosteal thickening-evidently the ligament insertion had been lifted from the bone. 640 THE ANKLE AND FOOT type is often of service. (See Fig. 1203.) If there is any tendency to flat-foot, temporary padding (of saddler's felt sewed in a leather insole) may be of service, and is often advisable, or a metal plate may be needed. (See Fig. 1204.) Massage and passive motion are usually superfluous in this lesion, except for comfort. FRACTURE OF THE EXTERNAL MALLEOLUS Fractures of the external malleolus are not uncommon, occurring usually a little below the level of the ankle-joint proper. They are apt to be nearly transverse. As a rule, they seem to result from inversion of the foot. Diagnosis.-The disability is about the same as in the low fractures of the fibular shaft. Pressure on the fibula higher up is not painful. Swelling is about the same as in an ordinary sprain. The diagnostic feature is that the pres- sure upon the external malleolus (at a point where it is subcutaneous) is pain- ful. Pressure at this point in a sprained ankle is not painful. Crepitus may occa- Fig. 1207.--Sketch from the x-ray of a case of fracture of the external malleolus into the joint without displacement. (Sketch from x-ray 980.) 'Fig. 1208.--Adhesive-plaster strap to pre- vent inversion of the foot in fractures of the external malleolus. sionally be made out, and if swelling has not yet become considerable, it may be possible to make out mobility of the lower fragment by grasping it in the fingers. Mobility of the ankle, due to loosening of the mortise, is so slight as not to be a serviceable point in diagnosis. Treatment.-As with most other fibula fractures, no reduction is necessary; simply rest and fixation in a natural position are called for, with the foot at or near the right angle. This fracture should fall within the rule of fractures largely included within the joint cavity, but does not, in fact, show any tendency to non-union, so far as I know. A fixation of three weeks, with gradual resumption of function, is sufficient for excellent results. COMPOUND FRACTURES AT OR NEAR THE ANKLE These are uncommon. Least unusual is the type in which the sharp edge left at the end of the tibia, by separation of the internal malleolus COMPOUND FRACTURES AT OR NEAR THE ANKLE 641 in Pott's fracture, is driven through the skin as the foot is carried outward. Nothing need be said save as to the gravity of compound fractures here as a class, a gravity due to the fact that the joint is opened and is Fig. 1209.--Compound Pott's fracture. The exposed bone surface is that from which the internal malleolus has been torn away. Note the (as yet unreduced) outward displacement of the foot. in communication with the outside wound, and that the foot is not a very clean region. Aseptically handled, these cases give results about as good as in the Fig. 1210.-Situation of swelling and ecchy- mosis in the usual ankle sprain; this ecchy- mosis is in the looser tissues, not in the tendon-sheaths or deeper structures. Fig. 1211.-The cross-shaded areas show the points where joint effusion and tenderness are most obvious in synovitis. The dotted ellipse shows the area involved in swelling after sprains, etc., usually called tenosynovitis simple cases, though results are obtained, as a rule, somewhat more slowly. If sepsis occurs, the results must be poor. Often they are very bad indeed, for the difficulty in holding the fragments is great, and when union at length occurs, the position is usually bad, to say nothing of the stiffness. 41 642 THE ANKLE AND FOOT COMPLICATIONS OF ANKLE FRACTURES The complications on the part of nerves and vessels in these cases of ankle fracture are surprisingly few; they seem limited almost entirely to such nerve injuries as cause occasional paresthesia in the fore part of the foot, and such injuries of the veins as apparently give somewhat more swelling than would be looked for below the point of hurt. It is somewhat surprising that the injury of the fibula at the lower end may not only show marked displace- ment, but even a marked displacement backward into the region of the nerve, apparently without imping- ing on the nerve at all. As a matter of fact, forward or backward displace- ment of fragments of the fibula seems to be of little or no importance at any point below the middle of the bone. SPRAINS OF THE ANKLE These injuries are very common indeed. They result, as a rule, from "turning the ankle"-i. e., from a misstep in which the foot is twisted inward. There is a sharp, sickening pain and some imme- diate loss of use. In the common inversion sprains the damage, as shown by early subjective as well as objective signs, is entirely on the outer side of the ankle. There is enough strain or tear of tibio- or fibulo- astragaloid ligaments to determine, as a rule, some synovitis of the ankle, with soreness and later effusion (Fig. 1211). There is tenderness between the fibula and ✓- the tibia in front, localized, dependent on some tearing of ligaments (Fig. 1212). The bulk of the swelling and soreness is on the outer side, over the joint. Swelling may be great, and may be accompanied by much ecchymosis and by a good deal of tenderness localized below and in front of the external malleolus. Fig. 1212-The point X shows a com- mon point of maximum tenderness in ankle sprain. This is over the anterior tibio- fibular ligament; at times there is later a thickening at this point; evidently this is when ligament fibers have been pulled loose from the bone. Fig. 1213.-Old backward luxation, with fracture of posterior edge of tibia (Cotton's type.) RESULTS OF FRACTURES THROUGH AND NEAR THE ANKLE JOINT 643 Diagnosis.-Diagnosis depends on the lack of deformity, of crepitus or abnormal mobility, in sprain, and on the presence, in the fibular fracture, of tenderness localized somewhere on the subcutaneous sur- face of the bone, or pain on pressure on the malleolar tip. In "sprains" the subcutaneous surface of the fibula is not tender, except at the point marked x in Fig. 1212. The swelling of a sprain varies in exact location, not following the outline of any anatomic structures; in general, it lies about as sketched in Fig. 1210. Sprains by other trauma than inversion show swelling elsewhere, of course, and do not show any characteristic types of swelling or of localized tenderness. RESULTS OF FRACTURES THROUGH AND NEAR THE ANKLE JOINT* Apart from the stiffening effects of overlong fixation, the results are dependent on mechanical conditions. In fractures involving the ankle-joint itself we have certain special factors bearing on the disability, viz.: Displace- ment of joint surfaces, including backward, for- ward, inward or outward dislocation; weakening or stretching of the ligaments; destruction, partial or complete, of the ankle-joint considered as a mor- tise, permitting abnormal lateral motion; irregu- larity of joint surfaces. Displacement of Joint Surfaces.-Backward dislocation gives absolute loss of dorsal flexion and gives a weakened bearing surface to receive the astragalus and carry the body-weight. This is true whether the dislocation be a pure disloca- tion or whether a bit of bone be carried up and backward with the astragalus. , As the result of forward dislocation with fracture unreduced there is loss of most of the motion of the foot, a loss of power in the ankle due to a short leverage of the calf muscles, and a bearing surface at best ill-adapted to carry the weight, sometimes no bearing surface worth mentioning opposite the astragalus. Moreover, no proper hold for the ankle-joint mortise can be afforded by the irregular and narrow surface of the back part of the astragalus. Inward dislocation uncorrected, associated with the displacement upward of the internal malleolus, means a destruction of the mechan- ical solidity of the mortise. It means also inversion of the foot and a disadvantageous pull of the peroneal muscles, which might otherwise be relied on to correct this inversion. Fig. 1214.-Sketch from a case of the writer's; fracture of back edge of tibia, with backward luxa- tion. Increased distance from internal malleolus to heel. Old case, many months after injury. * For a fuller consideration of this matter see "Causes of Disability after Frac- ture of the Lower Leg and Ankle," F. J. Cotton, Trans, of the Massachusetts Med. Soc. for 1905, and Boston Med. and Surgical Journ., 1905, cliii, p. 263. 644 THE ANKLE AND FOOT In such cases the patient can usually walk on the foot after a while, but tends to walk on the outer side of it. He is easily fatigued and very uncertain of his footing. Fig. 1215.-x-ray of similar case and similar displacement as in Fig. 1213. Already consolidated (outlines reinforced). If there be persistent outward displacement we have the "static" trouble, to be considered later, but there may also be a lax joint. Widening of the mortise between tibia and fibula has already been spoken of. Exactly how large a part it plays in disability is usually Fig. 1216.--Anteroposterior view of same ease shown in Fig. 1215 (outlines rein- forced). Fig. 1217.--Complicated fracture of lower end of tibia; old case. Massive new-bone forma- tion in the region of 1 and 2; the fragment at 3 displaced forward, allowing luxation of the astrag- alus. hard to make sure of. That it does play a part is not open to question, for we see cases in which the outward rotation of the astragalus is RESULTS OF FRACTURES THROUGH AND NEAR THE ANKLE JOINT 645 obvious in the x-ray, a rotation made possible only by this widening (Fig. 1222). Weakening of the ligaments is important as a result Pott's fracture (Fig. 1221). Its equivalent, lowering of the internal mal- Fig. 1218.-Photograph of same case as shown in Fig. 1215. Shows thickening behind the ankle; does not show the luxation clearly. Operation in this case cleared away the obstruction caused by new bone. No attempt was made to reconstruct the joint; fair result. leolus during healing, has a precisely similar effect. (See Fig. 1220.) In either case the ligamentous support of the inner side of the foot is lengthened and lessened. This is the side of the foot that is subject to strain in ordinary use, and such weakening is very apt to favor, if it does not actually cause, the gradual development of flat-foot. In neglected cases we may have absolute crippling. In properly supported cases the ligaments may contract later in the process of repair, and render any permanent support of the arch unnecessary. There may be, on the other hand, a per- manent lengthening of ligament with a per- manent need for corresponding support. Irregularities of joint surface do not mean ankylosis. Ankylosis in the true sense does not occur so long as there is no lesion of the astragalus. Irregularities do, however, mean friction in the joint, and do result, in certain predisposed cases, in the occurrence of a "traumatic arthritis," with much consequent disability. Apart from these disabilities, special to the fractures involving the joint itself, we have those common to any and all fractures in the lower portion of the leg. It is my belief, based upon a special examination of some 50 odd cases of end-results carefully studied, and upon casual observation of many times this number, that the usual causes of disability in fractures in this region are largely independent of the exact fracture lesions. Fig. 1219.-Inverted Pott's fracture; same case as Fig. 1166 after operation; attempt to secure bony union and failure. Func- tional result slightly improved (x- ray 10687). 646 THE ANKLE AND FOOT Fig. 1220.-Old case: Pott's fracture with the broken internal malleolus healed by bony union much longer than its original shape (outlines reinforced). Fig. 1221.-Sketch from plate of an old Pott's fracture. Note the great rotation of the astragalus and its distance from the internal malleolus. In this case the deformity was pro- gressive, dependent mainly on lack of liga- ments. (Courtesy of Dr. G. H. Monks.) Fig. 1222.-Deviation of foot inward. In this case caused considerable disability, calling for osteotomy later, which was wholly successful. 647 RESULTS OF FRACTURES THROUGH AND NEAR THE ANKLE JOINT They depend, in the main, on two factors-on deviation of the foot from the line of weight-bearing and on loss of motion due to stiffening of the joint structures, to excessive new- bone formation, or more usually due to muscle stiffening from long disuse, etc. Fig. 1224.-Widening of mortise at ankle: a, Displacement without widening; b, displace- ment with the mortise actually widened. Fig. 1225.-1, Backward bowing, the weight-bearing axis falls behind the heel; 2, it lies to the outer side; 3, to the inner side. Shortening of the leg, under one inch, is ordinarily a negligible factor. To sum up this matter; so far as the question of malposition goes, we have four main directions of devia- tion, as shown in Fig. 1225 and 1239. Deviation of the foot inward Fig. 1226.--Sketch of Warren Museum specimen No. 1190. Plaster cast. Details of fracture not known; probably Pott's fracture, with extreme lateral and some backward dis- placement. This is a type of displacement that makes trouble. Fig. 1227.-Outward displacement, due to displacement of fragments in ankle fracture. It will be noted here that there is no flat-foot and that the muscular power of the foot is ob- viously good. Author's case. means no strain on the arch, but does mean some added strain on the outer ligaments and the tendons above the ankle, and means an awk- ward gait with a considerable tendency to " inversion strain" of the ankle. Extreme deviation is crippling (Fig. 1219). Ordinary degrees 648 THE ANKLE AND FOOT Fig. 1228.--Outward deviation of the foot and consequent shifting of the weight to the nner side of the triangle of support. Fig. 1229.-a;-ray of same case as shown in Fig. 1228. Fig. 1230. Fig. 1231. Fig. 1230.--Outward deviation of the foot; old ankle fracture. In this case the deviation is, n fact, due not so much to displacement at the fracture as to entire muscular insufficiency following the fracture, which has resulted in extreme flat-foot, with eversion. Operation without subsequent treatment with plates, exercises, etc., would be of very little use in this case. Fig. 1231.-Same case as Fig. 1230. RESULTS OF FRACTURES THROUGH AND NEAR THE ANKLE JOINT 649 cause simply some clumsiness of the gait or some tendency toward fatigue. Deviation in the other direction outward is a very common cause of severe disability (Figs. 1226 to 1229). Even a deviation of the foot inch outward from its proper place means a distinctly increased strain on the muscles and other structures that maintain the arch. So long as these muscles suffice for their work we have no necessary limp, and sometimes there is no disability. When they give way, we have the limp and disa- bility and deformity characteristic of the strain, as in ordinary flat-foot, differing from static flat-foot only in that it is harder to remedy by support, owing to the mechanical dis- advantage of muscle pull. Any con- siderable deviation in the outward direction due to fracture is, therefore, almost certain to interfere with a good result, and may give very bad results indeed. Not only in these cases with bony deformity, but in cases like that in Fig. 1230, we are gradually learning to use support during convalescence. With a support like that shown in Fig. 1230a, we can allow weight bearing far earlier without risk of trouble. As mobility and muscle power return the brace can be discarded. After this one needs no more than care in shoeing, not forgetting the useful Thomas heel, in the cases with a tendency to valgus deformity. Fig. 1230a.-Support for use after an- kle fracture-the double upright type, with ankle joint. The single upright is just the same save for omission of the one upright, the place of which is filled by a "T" strap from the sole, buckling around the ankle and about the one upright. Fig. 1232.-The triangle of support; broadly speaking, every strain of weight-bear- ing, the line of which falls outside or inside this triangle, represents an unnatural strain on muscles, etc. Fig. 1233.--Deviation of the foot out- ward. Different as they look, these forms of deformity involve equal strain at ankle and foot. 650 THE ANKLE AND FOOT Forward displacement of the foot, that is to say, backward bowing near the joint, gives a mechanical disadvantage in propulsion, as is shown in Fig. 1235, and if the deformity is considerable it gives some awkwardness in gait. It may be a trouble- some deformity, but is not crippling, as a rule. Displacement of the foot backward (for- Fig. 1234.-Considerable deformity at the site of the fracture. Not much displacement ofjthe weight-bearing line. This foot is func- tionally perfect. Sketch direct from a case of the writer's. JFig. 1235.-Backward bowing; the handi- cap in propulsion depends on the fact that the weight-bearing line falls over the heel, not the ankle: the lift is greater, and a clumsy gait results. ward bowing) is unusual: it does not seem, in the few cases observed, to be a factor in disability unless the joint is directly involved. Fig. 1236.-Backward bowing of both bones, with forward displacement of the foot. Fig. 1237.-a;-ray plate of same case as shown in Fig. 1236. What the importance of rotatory displacement is it is hard to say. There seem to be no data except those of ordinary unrecorded observa- 651 RESULTS OF FRACTURES THROUGH AND NEAR THE ANKLE JOINT tion, and I can only give my impression that a fracture that makes a foot "toe in" thereby conduces to an ungraceful gait, and that one which makes toeing out a necessity causes not only an awkward gait, but some increased tendency to flat-foot, as well as some mechanical loss of motor power. Fig. 1238.-Ankle rigid (without actual ankylosis, but with bony overgrowths) in the equinus position. Very considerable disability. More important even than the deviation in axis is the amount of loss of joint motion. Loss of anteroposterior motion in the joint is the least troublesome defect. It may not uncommonly cause the forma- tion of a habit of toeing outward, and eventually a flat-foot, from what the orthopedists call "metatarsal strain," but does not cause much direct trouble as a rule. Loss of lateral motion, on the other hand, is a constant source of lameness. In the ordinary use of the foot the lateral motions (carried out between astragalus and os calcis, and in some measure at the mediotarsal joint) are the means whereby the foot accommodates itself to the inequalities of the ground on which we walk.* If such accommodation is impossible, an enormous strain is thrown on shortened muscles and ligaments; they react in the way that such structures do react to overstrain, by producing lameness. It is very common to find that a patient just recovering from an ankle fracture says that he can walk perfectly well in the house, but not Fig. 1239-For- ward bowing. Obvi- ously gives clumsiness of gait, though no great disability (diagram). * For the mechanism of such accommodation, see R. W. Lovett and F. J. Cot- ton, Transactions Am. Orthopedic Assn., 1898, xi, p. 298. 652 THE ANKLE AND FOOT without pain on the street, which is to say he cannot walk on any sur- face other than a perfectly level one. During the first few weeks of repair the tendency is for limitation of motion to disappear under judicious movement. After a lapse of some months, however, fibrous changes have taken place, and the strain of attempted motion falls on rigid structures, which show little tendency to lose their rigidity. Just what structures are involved in this stiffening is a matter of secondary importance. My notion is that shortening of muscles plays a very important part. We know that simple fixation of a sound limb causes little change in the muscles, little stiffness of the joint-often none at all. With an injured limb, however, it is an entirely different matter. Just why this is so is unknown, but in case of fracture a very short series of observations will convince any one of the tendency to loss of motion in joints near the fracture. The nearer the frac- Fig. 1240.--Painful union. Ordinarily, considerable displacement gives no local pain after consolidation is complete; where, how- ever, the mass of bone is relatively small, as, for instance, in such a case as is shown in the sketch, we sometimes get persistent sensitive- ness.and pain at the fracture on use (diagram). Fig. 1241.-The fracture sketched on the left gives a bad prognosis; that sketched on the right, apparently almost exactly similar, gives a good prognosis as to use because the general line of the shaft of the tibia is not dis- turbed in its relation to the foot; in the case shown to the left it is. ture is to the given joint, the greater is this tendency. Such stiffening is greater in the aged, but occurs even with children. In children the tendency to permanent stiffness is practically nil, but temporary stiff- ening may take some months to disappear. In healthy patients under thirty the stiffening is but moderate, and usually disappears in the main with time and use. In older patients it is usually permanent, if once established, and not remediable by the use of massage. How are we to prevent such loss of motion? Simply by not allow- ing it to establish itself. We have already learned to avoid stiff fingers in Colles' fracture, but seem to have learned little about stiff ankles. The method of avoidance is the same in one case as in the other-simply sufficient motion, begun sufficiently early to prevent stiffening. Proper position is important, and fixation is necessary. We need not follow Lucas-Championniere and his school so far as to discard what we should regard as proper fixation, but we may remove frac- tures from the plaster for a few minutes every day (after ten days to OPERATIVE TREATMENT OF ANKLE FRACTURES 653 three weeks) in order to insure the maintenance of supple joints by passive and by active motion. In the worst cases the surgeon may combat any tendency to displacement with his hands while such motions are carried out. The surgeon must be his own judge as to the danger of displacement in a given fracture, and as to the possibility that motion may tend toward delayed union or non-union. I believe this latter possibility to be very slight. At all events, it is along these lines that we must combat the tendency to stiffening. Later I am very apt to use a supporting brace for a few weeks as a routine in all ankle fractures till the muscles get good again under carefully prescribed exercise. (See Fig. 1223.) Golding-Bird and others have familiarized us with the alleged role of the projecting ("riding") fragment, and much ingenuity has been spent on proposals for combating local displacement. It is, no doubt, true that projecting fragments may be tender, and that "spurs" may require removal later. It is also true that marked displacement of bone-ends means slower union. It is true also that a union such as is sketched in Fig. 1240 may give persistent local pain, apparently from persistent weakness at the point of fracture, but, after a rather careful study of this point, extending over several years and many cases, I have failed to convince myself that a fracture such as is shown in Fig. 1234 or Fig. 1241 shows any more tendency of disability than one with good bony apposition, provided the original trauma, with its destruction of soft parts, is the same; provided, also, that the stiffen- ing (from trauma plus fixation) is the same, and provided that in each case the foot is equally far removed from its proper relation to the weight-bearing axis of the leg. OPERATIVE TREATMENT OF ANKLE FRACTURES Operative treatment will rarely be wise as a primary measure, save in compound cases: with proper treatment it will rarely be needed at all. Fig. 1242.-Lines of incision for bimalleolar osteotomy for correction of deformity in old Pott's fracture. Old fractures, however, in which the result is bad, may often be improved very greatly by operation. Particularly, deformed ankles from Pott's fracture or from inversion Pott's fractures are amenable to treatment. For Pott's fracture the best operation (first done apparently by Stimson) is a cross-section of both malleoli at the level of the joint (see 654 THE ANKLE AND FOOT Fig. 1242), with cutting and tearing of the ligaments, until adduction of the foot is possible (Fig. 1243). The wounds are sewed up, and correction in sharp inversion is maintained by plaster. I have done this operation in a number of cases, always with an improved result, and often with very great improvement. Fig. 1243.--Bimalleolar osteotomy for de- formity in old Pott's fracture. A and B, the chisel cuts, are at the level of the joint surface. After the malleoli are cut the ligaments are torn to some extent by wrenching the foot, and then the astragalus and both malleoli are bodily carried inward until the deformity is corrected. Fig 1244.--Operation for inversion Pott's to correct displacement or failure of union. Broken surfaces are refreshed, the foot car- ried into abduction, and a nail driven in through the malleolus into the shaft. To be left in about three weeks. In inversion fracture the incisions are the same. The fibula is chiseled at the joint level, and, according to the solidity of union, the old fracture-line in the tibia is reopened, or the malleolus is chiseled across at the joint level. The foot is then reduced into the appropriate eversion position. If an old oblique fracture-line in the tibia has been Fig. 1245.-Alternative operation in backward displacement. Cutting away the shaded por- tion clears the impediment to dorsal flexion and is often all that is needed for decent comfortable function. In this way one need not cut the malleoli and there is no waiting for bone union. reopened, it will be wise to peg the bones into place by a nail or drill (see Fig. 1244), to be removed after ten days to three weeks. Save for the chance of failure of union (in cases operated on for non-union), the operation is a satisfactory one. Cases of backward or forward luxation with joint fracture may be operated on through similar incisions. Wide cutting and tearing of ligaments and much cutting of new bone are needed, but in the end the OPERATIVE TREATMENT OF ANKLE FRACTURES 655 astragalus may be brought back to its normal place, and held there by a properly applied plaster. If the new posterior joint is solid it may be better to cut away, liberally, from the normal front edge of the tibia that blocks motion and leave the new joint: at least I have found this advisable in a few cases. Fig. 1246.--End-results after operation, showing the range of motion. Case of fracture o tibia and fibula, with backward and outward displacement. Same case as shown in Figs. 1213 and 1227. These operations are very tedious and difficult, but the results are well worth the trouble. (See Fig. 1246.) Operation for removal of bone-masses interfering with the tendons behind the internal malleolus has been done by the writer in two cases, with excellent results. (See Fig. 1218.) All these operations are done without drainage. Early motion, passive and active, is called for. The results, while rarely comparable to those of properly treated fresh fractures, are surprisingly good in the general run of cases. CHAPTER XXX ASTRAGALUS LUXATIONS AND FRACTURE TOTAL LUXATION OF THE ASTRAGALUS By this title is meant that form of luxation in which the astragalus is torn not only from its attachments to tibia and fibula, but from its relations to the os calcis and the scaphoid as well. It is displaced in one or the other direction, and usually rotated about its long axis. Not uncommonly it is fractured as well as displaced. The injury is often a compound one. There may be associated fracture of the fibula. This luxation is a curious and unexplained sort of injury. The astragalus has no muscular attachments, but is the " block" of a sort of "block and pulley" arrangement, held in place by the tendons that run across it, as well as by strong ligaments. It must be "jumped" out of place by sudden one-sided strain. So far as case-histo- ries go, the cause of the luxation seems to be the same sort of fall that gives the typical ankle frac- tures oi' the subastragaloid luxation. Lesions.-The bone is torn loose from most, probably not from all, of its attachments. The question whether there are any attachments still left can not be answered in a given case. The lesion is often a compound one; when the displacement is inward, it must almost necessarily be compound, if not at first, then secondarily from sloughing, if not promptly reduced. Even with the head projecting on the outer side a sloughing of the integument seems inevitable if the tension be not relieved. The astragalus is a large bone, and the tissues about the ankle are tight. The displacement may be inward or outward, with various rotations (there seems no fixed rule) on its long axis and also about a vertical axis. Fracture of the bone may be associated. Most often it is of the body rather than of the neck alone, and may be a splitting of the bone lengthwise. Fig. 1247.-Dislocation of the astragalus inward (dislocated clear of both ankle and foot) (draw from A. Cooper's plate). 656 TOTAL LUXATION OF THE ASTRAGALUS 657 Luxations backward are described, and said to be associated com- monly with fracture of the neck of the astragalus. Diagnosis.-Both malleoli, whether intact or not, are substantially in their normal relation to the leg. The foot is displaced in or outward. There is a mass in front of the ankle-to the outer side if the foot be swung in; to the inner side if the foot be displaced outward; the mass may have been displaced backward and be palpable at the back, leav- ing a hollow at the front. This mass is not in normal relation either to the malleoli or to the bones of the foot below it. It may be directly recognizable by the "Saratoga-trunk" upper articular surface of the astragalus, with its well- defined edges (see Fig. 1107); the other Fig. 1248, 1249.-Astragalus dislocated outward {in toto). Reduced by Dr. Lothrop later. There was later necrosis of part of the broken astragalus, and resection was done. (Courtesy of Dr. H. A. Lothrop.) recognizable surfaces are the rounded head and the deep concavity which should articulate with the os calcis below and behind. The presence of fracture may be indicated by crepitus. The situa- tion of such fracture is not likely to be made out by palpation. The x-ray may define any fracture present. Beyond this it is not likely to do more than confirm what we can feel. Treatment.-Reduction of this luxation has not, as a rule, been brilliantly successful. Here and there the bone has been reduced. In some such cases one wonders if the luxation was not subastragaloid. Certainly there has been, as Hutchinson has pointed out, much con- fusion between these two forms of displacement: The difficulties of reduction are: (a) Lack of tendon attachments to pull on-and the small leverage for direct pressure. (b) The presence of rotation with displacement. (c) Entanglement of some of the many tendons that cross at this level. 658 ASTRAGALUS LUXATIONS AND FRACTURE (d) The not uncommon complicating fracture. Reduction.-The manoeuvers for reduction that have been approved may be summed up as follows: Inward luxation. With the foot in slight plantar flexion. Exert traction of the foot. Swing it outward. Fig. 1250.-a>ray plate. Same cas' as Figs. 1248. 1249. It will be noted that,.the body of the astragalus has been broken in two Make pressure on the prominent bone-shoving outward and back. Modify pressure to correct any rotation of the bone. Fig. 1251.-rr-ray of the same case as Fig. 1252, years after excision of the astragalus Assist reduction by swinging and rotating the foot so as to manceuver any entangled tendons out of the way if possible. Outward luxation-reverse the above motions: Plantar flexion. Traction. TOTAL LUXATION OF THE ASTRAGALUS 659 Inward traction. Inward pressure on the astragalus, etc. Backward luxation: Plantar flexion. Traction downward. Direct forward pressure on the astragalus. Inversion of the foot. Tenotomy of tendons (tendo Achillis or tendo tibialis postici) is said to be of assistance in these reductions. In case of fracture with the dislocation these measures can hardly be modified more than to insure pressure on any projecting points dur- ing reduction. • We are to try these measures fully. If reduction fails, what is next to be done? The question of open reduction by incision is forced on us in this instance by the grave prob- Fig. 1252.-Views of foot shown in Fig. 1251, at present time, years after excision of astragalus. Fair function; same tendency to inversion of the foot; fibula prominent, sometimes painful from pressure of boot. ability of sloughing if nothing is done, to say nothing of poor function even if sloughing and infection are avoided. It was long urged that in these cases the nutrition of the bone was so compromised that it could not live, and even for simple irreducible cases excision was de rigeur. The exhaustive anatomic research spent on this question in the closet was, as usual, wasted. Recent cases have shown that if kept clear of infection the astragalus, even if broken as well as torn loose, will somehow get nutrition enough, at least in some cases. In any ordinary case that can not be reduced otherwise, open reduction is indicated; owing to the danger of sloughing, it should not be delayed. Today excision is not to be thought of unless infection or necrosis develop later. 660 ASTRAGALUS LUXATIONS AND FRACTURE In compound cases the problem is somewhat different. Here we must judge each case for itself. The displaced bone is viable only under favorable conditions in compound cases. Any considerable lapse of time since injury, a dirty wound, an enfeebled patient-any one of these factors may rightly, in the surgeon's judgment, justify primary excision of the astragalus in compound cases. In this, as in all open reductions, drainage is assured by loose suturing only-the dressing is dry gauze, and the whole foot and lower leg go up in plaster, not to be disturbed until all reasonable chance of sepsis is gone by. Within two weeks, unless there is associated fracture or cut tendons, massage and passive motion are begun. In case of successful simple reduction without cutting, massage and Fig. 1253.-Another case of astragalus resection for dislocation. Function now perfect for ordinary walking-not even any limp perceptible as he walks on the street. passive motion are in place about the same time. Weight-bearing may be postponed to four to five weeks. According to the nature of any fracture present, we must prolong fixation somewhat longer if there is a fracture of the neck than if there is a longitudinal split not tend- ing to displacement. Results.-If the luxation is successfully reduced, the result is an approximately normal foot, whether the reduction was open or not. Associated fractures increase disability, but apparently to a less extent than one would think. Expectant treatment, if there is no sloughing, may be not altogether bad, as the following case* shows: C. E. C., aged fifty-five, entered the Boston City Hospital for treat- ment of an old injury of the ankle received several years previously. * Courtesy of Dr. George W. Gay, reported from the Boston City Hospital records. ASTRAGALUS FRACTURE 661 He could walk, but his toes were contracted and the ankle thick on the inner side. He had no pain in treading on the heel, but much pain on putting weight on the toes. There was a hard, irregularly rounded mass, "including the lower end of the tibia and running back- ward." Operation showed this mass to be the astragalus so rotated that the upper articular surface looked inward. No reduction was attempted. Expectant treatment, where sloughs occur, means secondary exci- sion, safer as to life perhaps than the primary incision, but no better in functional result. Excision of the bone, much vaunted, seems to me very undesirable; plates herewith given show skiagraphs of one case in which function after excision is excellent; a second case in which permanent partial crippling was the result. Like cases are recorded here and there in the literature. The operation, at its best, gives a foot that can be used, but the joint is between the ankle mortise and the back part of the os calcis-with nothing to prevent rolling of the foot and no firm purchase, * results to make us shun the operation if it can be avoided. As a rule early open operation. From the outside, cutting the tendons of the peronei. dislocating the foot inward, replacing the bone, resuturing tendons:-'This seems to me the procedure of choice. Fig. 1254.-Fracture of neck of astragalus (see explanatory sketch in upper right-hand corner) ASTRAGALUS FRACTURE Fractures of the astragalus are to be classed as: (а) Fractures of the neck. (б) Fractures of the body. Fractures of the neck are, in the rule, approximately transverse. * Probably if excision seems unavoidable, wise surgery would dictate fitting the end of the tibia to the space left by the astragalus, after denuding all surfaces of cartilage and periosteum, and trying for a stiff ankle, with the alternative of amputation at the point of the election if the residt of excision proves poor. Results observed in a number of war-time astragalectomies have not increased my regard for this operation. I have seen one stiff astragalectomy that is pretty good and the Mass. Gen. Hosp, have one reputed case that is said to be really good. 662 ASTRAGALUS LUXATIONS AND FRACTURE They result from cross-breaking "shearing" strain, rather than from crushing, and are in many cases the result of falls on the feet. Where we find, as in the case shown in Fig. 1258, for instance, a fracture of the Fig. 1255.-Fracture of neck of astragalus. Drawing from a;-ray plate of left foot in the same patient whose right foot is shown in Fig. 1254. In neither case, right or left, was there any con- siderable displacement of fragments. Fig. 1256.-Fracture of neck of astragalus, with displacement of the head upward (the arrow at the back shows the "apophysis" broken loose also). Fig. 1257.-Fracture of neck of astrag- alus; see light line running down and back from the point of the arrow. No dis- placement; solid union; good result. astragalus on one side, of the calcis on the other, the presumption is that the astragalus breaks if the ball of the foot, not the heel, receives the force. Direct proof of this is lacking. This fracture is said by 663 FRACTURES OF THE NECK Helf erich to occur alone only rarely: all cases I have seen have been uncomplicated, and there seems no other authority for the statement. Fractures of The Neck The displacement is typically of the head upward, but not far upward. Diagnosis.-There is total disability. There is swelling. There is no marked deformity, as a rule. There is local tenderness on pressure. Fig. 1258.-Fracture of the neck of the astragalus in a boy of about eleven years (case seen by courtesy of Dr. E. G. Brackett) (a;-ray by A. W. George, M.D., outlines reinforced). Fig. 1259.-End-results in case seen in Fig. 1258. Perfect motion and function three years later. Nothing to show for fracture except slight local thickening. There is filling up of the hollow at the outer side of the neck of the astragalus-thickening in the "sinus tarsi." There is crepitus, readily obtainable on lateral motion. There is pain on motion, most marked in dorsal flexion. Treatment.-Treatment consists, obviously, of the best possible replacement of fragments and of fixation. To secure and hold this replacement it is wise not to be too literal about maintaining the traditional right angle at the ankle-joint. Any plantar flexion resulting can be corrected later. Fixation is continued until the consolidation is at least tolerably firm; after this, massage and passive motion are in order. The bone is not fit to bear weight for many weeks; there are no exact data, but eight weeks is hardly too long. Excision of a part or the whole of the bone is only to be considered in unfavorable compound fractures. I suspect it is likely to be unwise as a primary measure, even in these cases, if the wound can be made reasonably clean. Prognosis.-Unlike some other tarsal fractures, this break, lying in the main between two joints, seems to unite by bone. With decently Fig. 1260-This sketch (after Luxem- bourg's plate) shows fracture with rotation, a much more serious lesion than the usual form shown above, and requiring much care, perhaps needing opera- tive reduction. 664 ASTRAGALUS LUXATIONS AND FRACTURE accurate replacement the results are excellent. There is a minimal loss of motion, but practically perfect function of the foot. Fracture of The Body of The Astragalus Unlike the fractures of the neck, the fractures of the body follow no type. They may be transverse, longitudinal, or irregular crushing fractures. Diagnosis.-The diagnosis is apt to be vague unless there is asso- ciated dislocation. Crepitus and localized tenderness may help us as to the presence of fracture, but accurate detailed diagnosis of the fracture, even if there be sharp separation of frag- ments, is rarely possible except through the x-ray, not always then. Treatment.-The best possible reposition of fragments, and fixation, are the obvious indications. This Fig. 1261.-Fracture of the body of the astrag- alus. The dotted line shows the line of fracture, visible in the plate, but not in the print. There was no displacement. The diagnosis was made on the basis of disability and sharply localized tenderness (case seen with Dr. Brearton, Dor- chester, Mass.; x-ray by H. F. R. Watts, M.D.). Fig. 1262.-Longitudinal fracture of the left astragalus. Autopsy specimen. Sketched by courtesy of Dr. T. Leary. (Seen from above and from the outer side.) means reduction by traction and direct pressure, fixation in a position of very slight plantar flexion in plaster-of-Paris for a matter of four to six weeks, then massage and passive motion, with gradual resumption of use, but no weight-bearing until after six weeks, at least. Latterly I have seen several cases that I. could reduce only by open operation, cutting the peroneal tendons and resuturing them afterward. This is far better than astragalectomy. Prognosis.-There seem to be no data available bearing on progno- sis. The assumption is apparently that prognosis is favorable. I have no reason to doubt it. The cases I have seen have gotten good results both the operation cases and the others. CHAPTER XXXI LUXUATIONS BELOW THE ASTRAGALUS These are to be divided into two classes-dislocation of the foot as a whole below the astragalus, including the os calcis, and the dis- location at the mediotarsal joint, with the calcis still in place. SUBASTRAGALOID LUXATION (Luxation of the Foot, Including the Os Calcis, Beneath the Astragalus*) Considering the strength of the calcaneo-astragaloid ligaments, this luxation seems well-nigh impossible, yet it occurs, and is not even very Fig. 1263.-Subastragaloid dislocation of the foot inward, a few hours after injury. Injury received in a runaway accident. Reduction proved impossible; the astragalus was excised. The illustration is drawn from a faded, though originally excellent, photograph (now about ten years old), kindly placed at my disposal by Dr. Wm. P. Bolles. rare.f The forces causing it are the usual causes of ankle damage, in- version or eversion of the foot, usually under the body-weight in falls. The dislocation may rarely be complicated with fracture. Mac- Cormac and Pollock report cases complicated with fracture of the neck * First adequately described by Broca (1853) and Henke (1858). f According to Trendel (Bruns' Beitrage, 1905, xlv, p. 360), of Bruns' clinic, this is the rarest of the dislocations involving the astragalus, occurring but once in ten years in Bruns' large clinic, and reported but once in thirty years of reports of the German army. Trendel has, however, collected 82 cases-40 of inward luxation, and in a limited experience I have met with three. 665 666 LUXATIONS BELOW THE ASTRAGALUS of the astragalus, but the lesion is ordinarily uncomplicated. It may be compound, but not often. The displacement of the foot may be inward or outward, forward or back. Fig. 1264.-From below (diagram). The foot, unchanged in length or shape, is tilted inward (or outward) under the stationary leg and astragalus (compare with Fig. 1266). Fig. 1265.-Subastragaloid luxation of the foot outward (sketch after Jeney's plate). Diagnosis.-The astragalus is in normal relation to the malleoli. The head of the astragalus projects inward or outward, not covered by or in contact with the scaphoid. The foot is displaced and rotated inward or outward, as may be. The calcis is not in its normal relation Fig. 1266.--Subastragaloid luxation. Note that the heel is displaced, with the rest of the foot inward. This case was readily and per- fectly reduced (courtesy of Dr. L. R. G. Cran- don). Fig. 1267.-Subastragaloid dislocation in- ward (service of Dr. F. S. Watson; patient refused any treatment) (print given me by Dr. A. Fraser). to the malleoli, but is twisted in the same direction as the rest of the foot. SUBASTRAGALOID LUXATION 667 The sustentaculum tali may be palpable in cases with inward dis- placement, according to Stimson. The determination of the position of the os calcis is by no means easy, especially in a fresh case with swelling, and the distinction of this form from the mediotarsal luxation Fig. 1268.-Subastragaloid dislocation of foot inward. Drawn from a sketch in the old records of the Boston City Hospital. Fig. 1269.-Subastragaloid luxation of the foot up and outward (sketched from Wendel's x-ray). Fig. 1270.-Subastragaloid luxation of foot backward (sketch from Luxembourg's x- ray plate). is not simple. Fracture of the neck of the astragalus with displace- ment of the head may give a not dissimilar picture, though crepitus should be obtainable. The writer has seen two such cases recently with luxation inward, both showing the same clinical picture, both caused by falls in which Fig. 1271.-x-ray view of same case shown in Fig. 1266 (rights and lefts are reversed in compar- ing Figs. 1266 and 1271): 1, la, Astragalus; 2, os calcis; 2a, scaphoid (outlines reinforced). the foot was turned inward. The general appearance of the foot is not unlike that of the so-called "inversion Pott's." The internal malleo- lus is no longer prominent, the external is unduly prominent. The sole of the foot faces inward, and any correction of displacement is impossible. The diagnostic points are as follows: The upper edge of the astragalus 668 LUXATIONS BELOW THE ASTRAGALUS may be felt just in front of the fibula, the outer side of the head of the astragalus is extra prominent* at about its normal position; the scaphoid is to be made out near the position of the internal malleolus, a little Fig. 1272.-Subastragaloid dislocation of foot inward. Case readily reduced (sketch from a case of the writer's). Fig. 1273.-Reduction of subastragaloid luxation inward. The astragalus is held fixed by the hand, as shown; then the foot is carried inward and swept outward in tbe direction indicated by the arrows. This reduction was used in cases shown in Figs. 1266 and 1272. in front, and the distance between the tubercle of the scaphoid and the outer side of the astragaloid head is increased. The os calcis is * There is, with the inward luxation of the foot, some forward and outward dis- placement of the astragalus-sizbluxation-in the mortise. SUBASTRAGALOID LUXATION 669 tilted out of its usual position and inclined inward. Its total displace- ment inward is slight. There is no interference with the up-and-down motion in the ankle- joint proper. There is, of course, total disability so far as use of the foot is concerned. Reduction of Inward Luxation.-An assistant grasps the ankle Fig. 1274.-Reduction of luxation of foot forward under astragalus (diagram) firmly while the surgeon grasps the heel with one hand, the dorsum of the foot with the other, and makes strong traction in the line of the axis of the leg. Then the foot is adducted slightly, without letting up on the traction, and then is swung strongly outward. Reduction occurs with a snap. In one case, owing to the slight mobility of the astraga- Fig. 1275.-Subastragaloid luxation backward. Grip for reduction. Plantar flexion, forward pull countertraction. lus laterally, it was found necessary for the assistant to fix the head of the astragalus with his thumbs, in order to hold this portion of the foot firm enough to facilitate reduction (Fig. 1273). If this does not work, circumduct in both directions in hope of clear- ing any tendons that may be caught, and then repeat the attempt. For the outward displacement the motions are simply reversed. 670 This method, or even simple traction and direct pressure, is usually efficient in reduction. If the dislocation is otherwise irreducile, open incision is fully justified. Through an incision, reduction over blunt levers is relatively a simple matter. Moreover, entangled tendons can be dealt with. Compound luxations are obviously not to be experimented with long before open reduction is resorted to. Inasmuch as the astragalus in this lesion still retains its connection with tibia and fibula, it is a question if primary excision of the astraga- lus is ever called for. Prognosis.-Once reduced, this injury gives little trouble and seems not even to weaken the foot materially. The period of disability in some cases is only a couple of weeks or so. The following is apparently the only instance showing any possibil- ity or recurrence: LUXATIONS BELOW THE ASTRAGALUS Fig. 1276.--Subastragaloid luxation outward. Grip for reduction; traction downward, combined with adduction of the foot. F. W., aged thirty-seven; acrobat; of alcoholic habits, entered the Boston City Hospital, October 31, 1890, with a "partial" luxation of the right astragalus; this was reduced under ether; he went out in a week. Two days later he came back, the joint was again dislocated; this time the displacement was of the foot outward; reduced; went out after two days against advice. October 17, 1891, reentered; luxation of astragalus forward; reduced; went out after two days. April 14, 1892 reentered with luxation of foot inward beneath the astragalus; reduced; went out after two days; the same night back again with the dislocation reproduced as result of a fall. This was reduced; he left and did not reappear. In one of the rare cases of this sort in children is one recorded of a lad of five years in whom some slight permanent projection of the head of the bone resulted after successful reduction. Ordinarily, however, these cases do perfectly well. As to the results of this lesion, if unrecognized and unreduced, there seem to be no data. Obviously, there must be marked permanent varus (or valgus) deformity and much loss of function. 671 LUXATION AT THE MEDIOTARSAL JOINT LUXATION AT THE MEDIOTARSAL JOINT (DISPLACEMENT OF SCA- PHOID AWAY FROM THE ASTRAGALUS, OF THE CUBOID FROM ITS ARTICULATION WITH THE OS CALCIS) This lesion occurs from forces apparently like those that produce subastragaloid displacement. The two lesions are about equally un- common. The lesion under consideration is usually a displacement of the scaphoid inward and necessarily downward, or upward. Associated with this is a luxation, or a subluxation, of the cuboid inward and up (or down) from its articulation with the os calcis. There is marked adduction of the front part of the foot. In all the few cases I have seen the dis- placement has been uniformly inward, Fig. 1277.-Mediotarsal luxation from below (diagram). Note that the heel is not displaced; the foot is shortened; adduction and inward rotation of the front part of the foot are evident. Fig. 1278.--Complicated fracture luxation of tarsus. Luxation of scaphoid and cuboid up and backward. Crushing of os calcis and astragalus; 1, cuboid, 2, third cuneiform (Warren Museum, speci- men 6584). in the varus position; the reverse deformity is said to be rarer, but does occur. The clinical picture is exactly similar to that of subastragaloid luxation in all respects except for the lack of inclination of the os calcis inward, a point not always easy to determine. The cuboid is separated from the os calcis and subluxated or luxated inward, but in the cases seen by the writer it has not, curiously enough, been possible to feel any definite prominence at the anterior end of the os calcis. This means (and the x-ray confirms it) that the luxation at the outer side of the foot is incomplete. Diagnosis.-Adduction (or sharp abduction) of the whole front of the foot. Normal relation of the os calcis to the malleoli. 672 LUXATIONS BELOW THE ASTRAGALUS Normal motion in ankle flexion and extension, with loss of lateral motion and of rotation. Obvious prominence of the head of the astragalus to the outer side. Shortening of the foot, present in none of the other lesions so far described. (See Fig. 1277.) Fig. 1279.-Mediotarsal luxation, one year after accident. Adult woman. Walks almost without hmp, but uncertain and apt to fall. Curiously enough, the heel in this case is somewhat inverted, giving a picture here very similar to that of subastragaloid luxation (compare Fig. 1266). Fig. 1280.-Same case, seen below. I can not see that this shows anything save slightly greater inversion of the whole right foot. There was singularly little deformity in this case. Varus deformity of the whole foot, seen from below, less marked than in any of the previous forms (Figs. 1279 and 1280). Treatment.-Reduction in the fresh case is simpler than with the other forms of tarsal luxation. The front part of the foot is firmly grasped with both hands (see Fig. 1284) while the assistant steadies the ankle, with a thumb on the astragalus. Traction down and LUXATION AT THE MEDIOTARSAL JOINT 673 Fig. 1281.-Mediotarsal luxation in a boy, three years after the accident. Walks with much limp. Fig. 1282.-x-ray of same case-mediotarsa, luxation; 1, Scaphoid; 2, astragalus (head); 31 astragalus (body); 4, os calcis; 5, front end of so calcis; 6, cuboid. Fig. 1283.-x-ray, side view of same case. 1, 1', 1", 1"' give outline of displaced scaphoid; 2 is the head of the astragalus. 674 LUXATIONS BELOW THE ASTRAGALUS inward, with some plantar flexion, is then made on the front of the foot, and then it is swung out and upward, attention being paid to Fig. 1284.--Mediotarsal luxation. Grips and lines of force for reduction. Fig. 1285.-End-result after operation on the case shown in Fig. 1281. The head of the astragalus was partly resected before reduction was possible. Function much improved. Still some stiffness from short- ened tendons and muscles, which will improve. Fig. 1286.-Su&luxation of scaphoid inward Case of writer's (outline reinforced). Fig. 1287.-Apparent subluxation of sca- phoid inward. This is, in fact, an z-ray of a perfectly normal foot in which the scaphoid tubercle is prominent. lifting the scaphoid into its place on the astragalus-the cuboid takes care of itself. The foot is ready for some weight within three or four weeks. With reversed displacement reverse the manceuver. LUXATION AT THE MEDIOTARSAL JOINT 675 Results.-Inasmuch as none of the strong ligaments of the foot are usually torn in this luxation, it involves no weakening of the arch. With early reduction the foot is substantially undamaged and is soon fit to use. In the old unrecognized unreduced cases the foot can be used, but is distinctly a clubfoot in shape and use, carrying the weight on the outer side of the sole, and having very little useful motion of any part. Late Reduction by Operation.-The writer recently had an oppor- tunity to observe the result in an old unrecognized dislocation of this sort of a year's duration in a woman of forty-two years. There was marked inversion of the foot, with entire inability to evert, but the foot was perfectly capable of bearing weight and was painless, giving, however, much clumsiness in gait and a good deal of uncertainty, because of the liability of the foot to tip over when walking on an uneven surface. Operation by open incision was resorted to, and reduction effected without great difficulty. The results of this opera- tion were excellent with the sole of the foot no longer turned inward, and with lateral motions possible to about half the normal range. (See Fig. 1279.) In inveterate cases this form of luxation gives a chance of marked shortening of ligaments and tendons. I have operated on one such case of a duration of three years in a boy of twelve years, and found this the principal difficulty, calling for a good deal of cutting of ligaments and for some sacrifice of bone from the astragalus. Reduction was accomplished, and the end-result was very satisfactory, with moderate motion preserved. (See Figs. 1281, 1285.) Subluxation.-The writer has seen one case in which there was a subluxation in this joint (rotatory up and in, with the cuboid in place), with displacement of the foot inward, shown clinically and confirmed by, the x-ray. The patient left the hospital to return in a couple of days for reduction, but did not reappear for a month. During this period he had begun to walk, and the displacement had partially cor- rected itself. He did not recall any sudden snapping back. Further treatment was declined. Function was good and was improving (Fig. 1286). CHAPTER XXXII FRACTURE OF THE OS CALCIS This is by far the commonest injury of the tarsus, and is, at least in the practice of the larger metropolitan hospitals, a not uncommon fracture.* There are three forms of this fracture, the one in which a Fig. 1287a.-Avulsion fracture of the os calcis before attempted reduction. Fig. 12876.-Avulsion fracture of the os calcis after attempted reduction. Courtesy Dr. C. H. Baldwin, Utica, N. Y. part of the bone is carried away by strain thrown on the tendo Achillis, a form in which the bone is simply crushed, and a third form, the frac- ture of the sustentaculum tali. * For additional data the reader is referred to Fractures of the Os Calcis, F. J. Cotton, and Louis F. Wilson, Boston Med. and Surg. Jour., October 29, 1908, vol. clix, No.18, pp. 559-565, Cotton and Henderson, Am. Journal of Orthop. Surgery, May, 1919, and Cotton, Annals of Surgery, Oct. 1916. 676 FRACTURE OF THE OS CALCIS 677 The majority of these cases, in fact an overwhelming majority, belong to the second class-the class in which there is a more or less formless comminution of the bone as a whole; this is usually the result Fig. 1288.-Drawings from a specimen of fresh fracture of the os calcis from the author's collec- tion. This was originally a simple fracture of the os calcis of the ordinary type; a skin slough devel- oped, with subsequent sepsis of bone, necessitating amputation. The upper sketch shows the bones as they appeared after maceration; some bone splinters were missing. The os calcis, as a whole, was much displaced upward and outward; the lower sketch shows a reconstruction of the bone, showing fracture-lines; there was irregular splintering in the region of the inner tuberosity, and a fracture- line running through the sustentaculum; the sketch to the left shows the os calcis from above, the last-named fracture-line appears, splitting the sustentaculum; another fracture-line branching from it entirely separates the back half of the sustentaculum; an irregular fracture-line separates the thick cortical plate of the outer side of the bone for a considerable distance. It is not believed that there is anything typical about this fracture-line, as will presently be shown; the rr-rays seem to show all sorts of irregular, complicated lines of fracture. I believe, however, that the damage in this particular case is not more than in the cases we are in the habit of seeing. of a fall upon the feet from the top of a building, from a ladder or from some other height. Strangely, the lesion is often overlooked.* * Since the Workmen's Compensation law has caused a more systematic review of end-results, the frequency of overlooked fractures of the os calcis proves aston- ishingly large, and the results of treatment far from good, in Massachusetts. 678 FRACTURE OF THE OS CALCIS A similar form of fracture may rarely occur from a simple slip and twist of the foot. I have seen one case in which there seems to be no doubt that the fracture was produced in this way.* Lesions.-The comminution in these cases has certain relatively constant characters. The bone is broken through in something near a vertical plane, just in front of, or through, the posterior articulation between the astragalus and calcis. From this vertical line of fracture Fig. 1289.--Sketches from x-rays in author's collection--fracture of os calcis of various types or lack of type. The upper figure shows fracture of the "apophysis" at the back, also. there is apt to be another line, running backward more or less horizon- tally, but not completed as a single line of fracture. It runs off into irregular planes of fracture at the back end of the bone, planes not always shown in the skiagraph. The outer side of the bone, which has a considerable cortical layer, seems to be constantly split away from the rest of the bone as a sort of plate (Fig. 1288). Fig. 1290.-Rocklin (R.). Fig. 1291.-Rocklin (L.). Fig. 1292.-Kuntz (R.). Fig. 1293.-Kuntz (L.). Figs.-1290-1293.-Sketches from x-ray plates in fracture of the os calcis. As might be expected from the violence which produces the frac- ture, what is left of the back end of the bone is pushed-one cannot say displaced, in any exact sense-upward and not infrequently more or less outward as well. (See Fig. 1289.) Sometimes there is a dis- tinct tilting downward of the forward end of the posterior fragment. * The "escalator," particularly the freight escalator, has brought a new type of calcis fracture. A workman's heel slips between the platform and the moving incline, and is bitten off, clean, the back part of the os calcis being amputated. The problem here is one of plastic surgery, not fracture treatment. FRACTURE OF THE OS CALCIS 679 There is apt to be some diminution of the total depth of the bone, especi- ally at its forward end. The irregularity of the comminution in these cases may be judged from the fragments pictured in Figs. 1289 to 1293. Fig. 1288 was a case primarily differing in no way from those Fig. 1294.-The vertical diameter of the bone is notably decreased. Skiagraph of a healed fracture shows also, anteriorly, a deeply projecting spur that must give troublesome pressure in the sole of the foot (Annals of Surgery, J. B. Lippincott Co.). Fig.71295.-Shows Jthe projection of outwardly displaced bone fragments close up under the external 'malleolus. The point X is as far out as the malleolus, Y instead of one-half to three- quarters inch deeper in. This distortion is very evident on palpation (Annals of Surgery, J. B Lippincott Co.). we usually see, in which the specimen was obtained after amputation, the amputation being rendered necessary by sepsis introduced through a slough. It will here be seen that it is useless to speak of typical fracture lines in such cases. 680 FRACTURE OF THE OS CALCIS Fig. 1296.-View of normal os calcis, seen looking down from behind-plate under the sole of the foot. X is the outer side (Annals of Surgery, J. B. Lippincott Co.). Fig. 1297.---Like view of two old crippled cases of calcis fracture. Note the bulge in each cut, X, on the outer side, and, in B especially, the great total broadening of the heel bone (Annals of Surgery, J. B. Lippincott Co.). Fig. 1298.-After reduction. A case with marked deformity at the start (arrays taken lost). Shows, after reduction, both general bone outline and joint relations not far from normal. This man recovered nearly all his lateral motion and obtained an excellent result (Annals of Surgery, J. B. Lippincott Co.). 681 FRACTURE OF THE OS CALCIS Fig. 1299.-Distortion of posterior astragalo-calcaneal joint by displacement of fragments (Annals of Surgery, J. B. Lippincott Co.). Fig. 1300.-Old case. Note decreased vertical diameter of the forward end of the bone. Note also the fragment projecting into the sole, well forward (see Fig. 1294). Also, note the posterior calcaneo-astragaloid joint, while perhaps not actually broken into, is so distorted as to be useless as a joint. In fact, this patient had no lateral mobility of the foot. Same case as Fig. 1298, A (Annals of Surgery, J. B. Lippincott Co.). Fig. 1301.-Old case, crippled. Note the short* heel, short anteroposteriorly, and the short- ening of the available joint surface of the calcis side of the posterior calcaneo-astragaloid joint (Annals of Surgery, J. B. Lippincott Co.). 682 FRACTURE OF THE OS CALCIS It is, however, true that the general situation of the fractures ap- proximates that given above, as is illustrated in the x-rays given here- with. Only very, very rarely do we find approximately transverse fractures across the neck of the bone, behind the joint surface. (Fig. 1311 was a case of this sort.) Even more rarely do we find fracture by avulsion. (See Fig. 1287a.) In one case was observed a loosening without displacement of the Fig. 1302.-Before correction. Note the involvement of the posterior joint; also loss of vertical depths (Annals of Surgery, J. B. Lippincott Co.). Fig. 1303.-Same case as Fig. 1302, after tolerable correction and impaction (Annals of Surgery J. B. Lippincott Co.). Figs. 1304 and 1305.--Before and after reduction. Fig. 1304 shows not only deformity but j oint distortion as well. Fig. 1305 (taken through the plaster and not clear) shows obvious improve- ment in both respects (Annals of Surgery, J. B. Lippincott Co.). epiphysis of the os calcis from a fall on the foot.* (See Fig. 1328, for the relations of the epiphysis.) Symptoms.-As a rule, the patient, after receipt of this injury, is unablS to walk at all. He naturally cannot walk on his heel, and, owing to the strain put on the bone by the tendo Achillis in such attempt, he can not walk even on the ball of the foot. I have seen one patient who could walk, but this was a case of comparatively very little displacement with solid impaction. * Case of Dr. Walter M. Boothby. FRACTURE OF THE OS CALCIS 683 Swelling in these cases is usually prompt, but not extreme. Pain is constant, but not especially severe. Diagnosis.-Curiously enough, no symptoms are ordinarily given in the books by which we may recognize this fracture, excepting crepi- Fig. 1306 Fig. 1307. Fig. 1308. Fig. 1309. Fig. 1310. Fig. 1311. Fig. 1312. Fig. 1313. Fig. 1314. Fig. 1315. Fig. 1316. Fig. 1317. Fig. 1318. Fig. 1319. Fig. 1320. Fig. 1321. Figs. 1306-1321.-Sketches from a;-ray plates in fracture of the os calcis in the author's collection. tus and broadening of the heel.* There is, in fact, no difficulty about the diagnosis, and ordinarily it can be made in entire independence of the skiagraph. The swelling and thickening lie entirely behind the * Helferich does recognize the loss of lateral motion. 684 FRACTURE OF THE OS CALCIS mediotarsal joint. There is thickening both to the inner and outer side of the foot. The malleoli are in their normal position and relation, and there is little, if any, interference with flexion and extension in the ankle-joint proper. There is in many cases limitation, often absolute, Fig. 1324.-x-ray of fracture of the os calcis; unusually great displacement of the posterior portion upward and forward (shortening of heel). of the lateral motions of the foot. In the presence of a swelling (almost always at hand) it is hard to say whether upward displacement or outward displacement of the heel is present unless it is extreme. There is commonly the appearance of a shortening of the backward Fig. 1325.-Fracture of os calcis; front split away from back portion; not very much displacement. Fig. 1326.-Fracture by avulsion. The upper portion of the back of the os calcis is torn away by the action of the gastrocnemius and soleus muscles acting through the tendo Achillis; this is, in fact, a very rare lesion (this figure sketched after an x-ray plate by Branco). projection of the heel, but this is deceptive; such shortening may be present (Fig. 1324): there is usually little or no shortening of the foot as a whole to be made out by measuring or shown by the x-ray. On palpation we find more or less thickening below and behind the internal malleolus, and below the external malleolus there is always a consider- FRACTURE OF THE OS CALCIS 685 able thickening, giving commonly an entire loss of the projection usually shown by the external malleolus itself. On closer examination we find that this thickening below the mal- leolus is not soft swelling, but an obviously bony thickening. It is, in fact, the bone-plate of the outer surface of the bone, forced outward by the spreading of the bone beneath it. (See Fig. 1288.) This one sign seems to be nearly pathognomonic of this fracture. For two years past I have tested it on a large number of cases and have failed to find it only in one case where there was a fracture of the os calcis, this being a case shown by the x-ray to be atypical and without comminution. If we find this bony thickening in a case in which a fall upon the foot has been followed by dis- ability and swelling below and behind the ankle, there need be no doubt about the diagnosis. If, in addition to this, we find marked loss of the lateral motions of the foot, we may say not only that there is a fracture of the os calcis, but also that this fracture has in some way involved the joints between the astragalus and the os calcis. This sign seems to be perfectly definite in those cases in which this is the only motion which is limited. In some cases this results from direct smashing into the joint (Figs. 1312, 1315, 1318, and 1325) between the astragalus and the os calcis (the rear joint, for there are two; for this joint see Fig. 1288), or it results from such gen- eral change in the shape of the bones as inter- feres with the action of the joint (as, for instance, in the case shown in Fig. 1312). *'Tn either case, it pretty surely goes out of commission more or less completely, as an effective mechanism. This is important, for R. W. Lovett and I showed long ago that it is almost purely between astragalus and calcis that the movements we call pronation and supination occur. "With the joints between os calcis and astragalus gone, pro- and supination disappears, and this is precisely what we nearly always find in os calcis fractures; lateral motion gone-up and down movement; preserved. "These then are the features that are nearly constant: (a) Pushing up of the heel; (6) broadening of the bone, mainly outward; (c) inter- ference with lateral mobility." The x-ray is of decided value in these cases, but not for the purpose of diagnosis of the gross lesion so much as to give us information as to Fig. 1327.--Fracture of the os calcis by crushing in a child of four. The astragalus and os calcis are shaded. In the upper corner are shown the astragalus and os calcis from another plate of this same case. The result in this case was perfect function and very little thickening. Case unusually young for this fracture (sketch from o:-ray plate). Courtesy of Dr. Thomas F. Leen. * Quoted from Os Calcis Fracture. Cotton: Annals of Surgery, 1916. 686 FRACTURE OF THE OS CALCIS the amount of displacement. For this purpose x-rays should always be taken of the sound foot, as well as of the injured one (Figs. 1335, 1336). With the great variations in the shape of this bone in different individ- Fig. 1328.-Normal epiphysis of os calcis. Apt to be confusing if not borne in mind uals, it is only in this way that we can form any idea of the amount of distortion. It is not at all uncommon for good house officers in the Fig. 1329.-Old case; fracture of right os calcis in boy of thirteen, two years after frac- ture. Note broadening of heel and promi- nence of peroneal tubercle to the outer side of the os calcis. Fig. 1330.-Crushing fracture of leftfos calcis. Note broadening below malleoli on either side of the tendo Achillis, as compared with the sound foot. hospitals to overlook this fracture, even where the skiagraph is at hand, for the fracture-lines are very often not obvious. Treatment.-Inasmuch as the fragments in this form of fracture are usually entangled so as to fix them, even if there is no real impaction, FRACTURE OF THE OS CALCIS 687 the question of treatment becomes one of determining which cases call for reduction and which will do well enough if simply fixed and allowed to consolidate. There are a fair number of these cases in which the displacement is not very great, and in which pretty good results may be obtained by simply putting them up in plaster until union takes place. This does not mean, however, that this should be, as it has usually been, the routine treatment. A consideration of the results of routine treatment, to be cited later, leaves no doubt that in most of these cases we should try for an improvement of position, more particularly as there seems to be no possibility of making things any worse. Now we all know that the usual treatment of os calcis fractures (even when not treated for sprain) is to put them up in plaster and trust to obtain the good results called for in all respectable text-books. What kind of results do we get? Wilson and I concluded in 1908, from a series of 22 cases found in an attempt to "round-up" 84 cases treated at the hospital, that at least half the cases, probably more, had some serious permanent disability; not always enough to prevent some work, but serious. I do not think that this statement is overdrawn. Latterly I have had referred to me a series of fourteen cases of calcis fracture, varying from eight weeks to two years after the fracture. They run as follows: Case I.-J. A., aged fifty-six; examined at 6 months; much thicken- ing and tenderness; lateral motion lost; totally disabled. Case II.-M. J. C., aged sixty-four; examined at 3 months; refused reduction after accident; lateral thickening; tenderness on outer side; short heel; relatively little loss of motion; entirely disabled. Re- examined at months; better; slow and clumsy; totally disabled. Case III.-J. F. D., aged thirty-eight; examined at 5 months. As he stands, the external malleolus is in contact with the calcis; heel broad and flat; very little lateral motion; can walk a half hour, then has to quit; disabled. Case IV.-J. G., aged forty-four; examined at 17 months; typical deformity; not extreme; little lateral motion; disability mainly from contact of fibula with calcis; has tried plates, etc.; has much pain and disability. At 2 years 3 months after injury he reports that he is no better, despite exercises, etc. Case V.-C. H., aged forty-two; examined at months; typical deformity; not extreme; up and down motion normal; lateral motion fair; pain entirely on outer side; still disabled; may have some dis- ability but promises a useful foot. Case VI.-J. T. L., aged forty-eight; examined at 3 months; much broadening; little displacement of the heel; lateral motions fair; now crippled but probably going to have a useful foot. Case VII.-G. J. J., middle aged; examination at 4 months; almost no displacement; disability mainly from the rare factor of spastic contracture of the peroneals; totally disabled but disability probably remediable. Case VIII.-H. L., aged thirty-seven; examined after two years; operated on for total disability at the Massachusetts General Hospital, 688 FRACTURE OF THE OS CALCIS where some bone was removed. Has loss of lateral motion; some thickening and much tenderness on outer side; totally disabled. Case IX.-D. M., aged twenty-five; examination at 9 months; fracture of os calcis, right and left. Shows usual deformity in both feet; loss of lateral motion in both feet; much thickening, externally, especially on the left. Can walk for half an hour only; it is very stiff and sore in the morning; still improving very slowly; good for nothing after nine months, and unlikely ever to go back to labor again, though he may improve. Case X.-B. C., aged thirty-eight; examined at months; broad- ening of heel, well marked; external thickening; up and down motions normal; lateral motions entirely gone. Re-examined at 3L£ months; shows no return of motion; much pain at outer side on walking; entirely disabled; prospects certainly very poor. Case XI.-J. B., aged twenty-seven; examined at 2 months; treated as a sprain; great thickening on outer side; total displacement small; motions fair; gets about fairly well; promises to get a useful foot, but probably some trouble from the massive thickening under the external malleolus. Case XII.-J. J. S., aged thirty (about); examined after 13 months; thickening present, especially on outer side; up and down motion nor- mal; lateral motion entirely gone; is wearing a plate; gets about with considerable discomfort and not handily; entirely disabled for active fire duty. Case XIII.-V. S., middle aged; examined after 10 months; typical deformity; also had a fracture above the ankle; well reduced and united; has tendo Achillis contracture as well as total loss of lateral motion. A perfectly useless limb, but with the disability not entirely due to os calcis fracture. Case XIV.-C. W., aged twenty-six; examined at 4 months; type deformity; not extreme; considerable loss of lateral motion; up and down movements normal; total disability mainly due to pain on the outer side from contact of the fibula with the greatly thickened calcis. Later I cleared away much of the superfluous bone and stretched the foot into pro- and supination, with almost entire relief of symptoms. Out of fourteen, none fit to work, when seen, and but 3 that looked at all promising. A pretty poor showing, when we remember that insurance companies nearly always call for examinations if a man is not on the job in 2 or 3 months; so these are probably pretty near an average run of cases. Besides this series, Dr. Francis Henderson has been trying for months past to track down cases treated at the City Hospital within the last four years. Those of you who have followed the laborer in a big city, in his kaleidoscopic hittings and disappearances, will not be surprised at his indifferent success. Some cases have been found, however, as follows: Case XV.-L. B., aged fifty; examined at 3 months; was in hospital and had some manipulation; now shows limitation of all motions; lateral motion entirely lost; has a limp and much pain; is, as yet, entirely disabled. 689 FRACTURE OF THE OS CALCIS Case XVI.-G. P., aged forty-five; examined at 18 months; taken to hospital but would not remain. Shows general thickening about the heel, especially to outer side; lateral motions entirely gone; up and down motion fair; gets about with an extreme limp and much pain; entirely disabled. Case XVII.-D. D. D., aged fifty-four; examined at 7 months; fracture never treated. Shows much limitation of flexion and exten- sion; lateral motions entirely lost; all attempts at motion very painful; has not been able to walk at all on this foot since the accident; a;-ray shows the type deformity. Case XVIII.-W. C. D., aged fifty-eight; examined years after; had had no reduction; unable to walk for 9 months; still has a bad limp; lateral motions gone; other motions poor; walks with a stick; practically crippled. Case XIX.-A. J., aged thirty-eight; examined after 20 months; much deformity of the heel; arch gone; all motions practically gone; walks with a limp, using a stick, disabled. Case XX.-A. D., aged fifty-four; examined after years; original x-ray shows not very severe displacement. After years he still limps; shows a great deal of thickening under the external malleolus with some tenderness there; up and down motion fair; lateral motion entirely gone; a good deal of pain; has serious disability but manages to work as a painter. Case XXI.-J. M., aged eighteen; examined 2 years after accident; was on crutches 9 months; since then he has walked with a limp and has a great deal of pain in the morning; shows general thickening; lateral motions entirely lost; up and down motion not good; works as a painter despite his disability. The foregoing cases were untreated or treated only by manipulation and plaster. Those that follow had some real attempt made to correct conditions. The City Hospital staff have been taking os calcis cases seriously enough of late to do something, or have the house surgeon do something. Case XXII.-J. J. H., aged forty-four; examined 3 years later; was unable to walk for 8 months; now walks with a limp; there is much thickening under the external malleolus; up and down motions good; lateral motions gone; complains of much pain; unable to stand for any time; completely disabled. (This case had only a hammer impaction done.) Case XXIII.-J. R., aged thirty-five; examined 2 years after; had hammer impaction done under ether; began to walk at 15 weeks; has marked restriction of lateral motion; has a very slight limp; is working as engine house fireman; disability slight. Case XXIV.--J. R., aged thirty-nine; examined after 2 years and 10 months; had some sort of reduction done and comparison of original x-rays before and after shows marked improvement. Shows much restriction of lateral motion; up and down motion fair; shows a good deal of thickening; has a considerable limp but works as striker on a coal team; disability slight. Case XXV.-D. M. G., aged fifty; examined after 3 years; "reduction under ether:" noted as having shown a marked flattening; 690 FRACTURE OF THE OS CALCIS went to work after 13 months; did some work for a year; shows broad- ening and thickening; lateral motion gone; up and down motion poor; has to use a stick to walk any distance; entirely disabled. (No im- paction done in this case.) Case XXVI.-S. S., aged twenty-four; examined after 3 years; said to have been "partially reduced;" shows only moderate thicken- ing but lateral motions are gone; flexion and extension perfect; has a good deal of pain and lameness in the morning; works as a sign painter; disability not great. Case XXVII.-M. S., aged forty; examined after 2 years; was reduced by the house surgeon after my method; original x-ray shows much crushing; has a great deal of thickening; a good deal of loss of lateral motion; limps and says he has a great deal of pain when he has been on his feet all day; disability considerable. Case XXVIII.-<J. R., aged forty; examined years later; reduced according to my method; returned to work in 11 weeks as a carpenter but had trouble for 6 months. Now shows all motions practically perfect; no considerable deformity; walks well and has no pain; at work; perfect result. (Original x-ray shows displacement not extreme; joint not involved.) Case XXIX.-D. H.; double fracture; reduced my way; 6 weeks later getting around pretty well. Investigation years later found he had died. (Immediate result of reduction good.) Case XXX.-G. M., aged fifty-six; examined 3 years later; was reduced by my method; noted as a case with much thickening exter- nally; lame for 7 months. Now shows slight thickening; a little limitation of lateral motion; has no pain; is back at work in Navy Yard; perfect result. With these should go private cases: Case XXXI.-A man of forty-five for whom I did an impaction last winter, who has now a practically perfect foot. Case XXXII.-A friend of mine, a doctor, on whom I did the first impaction, with a perfect foot. Case XXXIII.-A case seen for Dr. Emil Geist last year, in which, despite obvious deformity, everlasting massage and exercises brought about very good function. Now, imperfect as the series is, it covers an end-result investigation of 55 cases, out of original lists of 153; reduced for error to 144 cases with real data on 55. Now it is perfectly evident, from the cases cited, that First, results without more treatment than the traditional plaster are appallingly bad. Second, with some pains taken (some attempt at reduction) the results are better; sometimes even excellent. Within the past 10 years my own rule has been that cases that showed an obvious deformity or loss of motion-cases in which the skiagraph showed more than perhaps a quarter of an inch displace- ment-cases in which the x-ray showed spurs likely to make trouble by pressure in the sole or elsewhere (Fig. 1339), and cases in which the FRACTURE OF THE OS CALCIS 691 projection beneath the external malleolus was really considerable, should all have an attempt made to improve the position under ether. The method of going about to obtain such improvement is as follows: The patient is fully anesthetized, the foot is brought into plantar flexion so as to relax the tendo Achillis, and the os calcis is grasped firmly just in front of the tendo Achillis, and an attempt is made to drag it downward. If this fails, as it usually does, on account of the difficulty of securing a sufficient grip, we attempt to break up the impaction by a lateral rocking movement and then bring the bone down- ward after the fragments are loosened. If this does not work, there is one method, which sounds very radical, but is really perfectly safe and simple,* by which we may attain the desired result. After dis- infection, we make a small hole in the skin just in front of the tendo Achillis, on both outer and inner sides, and then thrust a steel spindle (most conveniently a sound of about 22 caliber, French) through from side to side in front of the tendo Achillis (Fig. 1337). With this grip there is no difficulty in bringing the bone down where we want it, at any time within a week or so of the in- Fig. 1331-Sketch from x-ray plate of> pre- vious case (Fig. 1330). Os calcis flattened; fracture-lines rather ir- regular. Fig. 1332.-Fracture of both ossa calcis. one year after accident. jury. Sometimes I have used the commercial ice-tongs-specially ground sharp at the tip-to get a corresponding grip for traction. They are as good as the spindle-perhaps not better.f Lately, 1921, Jopson has used a steel pin, similarly placed, for constant traction in a Thomas splint: he and I did one case in his Philadelphia clinic by combining my reduction with the later traction; admirable result; method worth further trial. * Cotton and Wilson: Boston Med. and Surg. Jour., October 29, 1908. f Differently placed, this reads a follows-quoted from Cotton, loc. cit., 1916. 692 FRACTURE OF THE OS CALC IS (1) Loosen up the fracture by manipulation. (2) Pull the heel down. We used to put a sound through from side to in front of the heel-cord, and pull down; latterly I use ice-tongs as easier to handle and affording a better grip. Fig. 1333.-Same case as Fig. 1332. Fracture of os calcis on both sides, with much displacement (3) Free the joint motion between astragalus and calcis. (4) Push in the displaced bone under the external malleolus; this narrows and shapes the whole bone. We do it by slowly striking with a Fig. 1334.--Same case as two preceding, another view. big mallet on the outer side of the foot; padding with felt to take the blow; supporting the inner side of the foot on a sand-bag. This im- pacts, and, owing to the fact that the outer plate is firm, the impaction is usually fairly solid. FRACTURE OF THE OS CALC1S 693 (5) We put the foot up in plaster; not at a right angle but with the heel-cord slack; also we avoid direct pressure on the heel. It is well after the impaction to test again as to the presence of lateral motion. If the impaction has impaired it, work the joints loose again and re-impact. I have done this impaction many times; have never failed to get improved position and have usually succeeded in entirely abolishing the abnormal prominence below the external malleolus, and in restoring the lateral motion and in getting a serviceable impaction. Bringing the heel down where it belongs does not always work out so well, but is less important. When the position has been corrected, there is little tendency to redisplacement unless the ankle is dorsally flexed. Fig. 1335.-Fracture of the os calcis; irregular fracture lines (outlines reinforced at one point). Fig. 1336.-y-ray from sound foot of same case as shown in Fig. 1335; essential for com- parison in many cases, not only for diagnosis, but for appreciation of amount of displacement and the necessity of operative interference. We next test the lateral motion and make sure that pronation and supination (lateral rotation of the foot) can be fully carried out. If necessary, we force these motions to their limit before being satisfied with the condition of things. , After this is done we have two things to attend to: first, a reduction of the prominence of the bone under the external malleolus, and, second, the best possible securing of impaction of the various frag- ments. Both these objects are secured by strong lateral pressure simultaneously exerted on both sides of the bone. The fragments are so much splintered that in this way I have often found it easy to secure a pretty satisfactory impaction with no other force than the hands, and have, at the same time, reduced the prominence of the outer surface of the bone almost to the normal plane. More often it is necessary to lay the foot on its inner side, on a firm sand-bag (Fig. 1338), and reimpact the fragments with a heavy mallet, using a folded 694 FRACTURE OF THE OS CALCIS felt pad to protect the skin and to make sure against striking the external malleolus. When the reduction has been accomplished, the foot is put up in plaster in slight plantar flexion with a " saddle " pad of felt about the top of the heel, and a sheet of felt across the dorsum of the foot. As the plaster sets, traction downward is made on the heel, while the posi- tion of the foot is secured by pressing down on the dorsum and molding the plaster upward to fit the arch of the foot. Curiously enough, cases so treated never show any considerable painful reaction, and rarely even any increase in swelling. The only danger is that of making the fracture compound, and that is a theoretic possibility: it has never happened yet. The improvement in position is very satisfactory indeed. Union in these cases is very prompt. After a week the fragments are immovable, and after three weeks there seems to be no giving, even under weight. I have, however, felt that at least a month should be Fig. 1337.-Inser- tion of spindle in front of tendo Achillis to give traction on bone frag- ments when needed. Fig. 1338.-Treatment by impaction. The foot is laid on a sand-bag, a felt pad held to protect the outer side of the os calcis, which is then impacted by blows from the mallet. allowed before putting weight upon the foot, and an even longer time if both heels have been broken. No later than ten days from the time of the reduction the plaster should be cut and active motion of the foot allowed and encouraged for certain periods in the day, the cut plaster being reapplied in the intervals. As to the time after the accident best suited to the reduction, there need be no rules, because the hemorrhage and the primary reaction in FRACTURE OF THE OS CALCIS 695 these fractures are comparatively slight, and the reaction after reduc- tion is almost nothing. Even if we use the spindle in front of the Achilles tendon to aid reduction, the fracture is not thereby made compound, and we run no additional risk. Treatment of Fracture of the Avulsion Type or of Transverse Fracture.-Here the deformity is one of upward displacement only, maintained by the pull of the heel-cord. Therefore treatment must be in plantar flexion or by tenotomy of the tendon.* Simple replace- ment and holding with pads has been tried: open operation is the alternative. This I have done once with good results: the bone was held with kangaroo tendon sutures. Tenotomy and fixation by suture or by temporary nailing seems to be the rational combination. Results in any case seem to be good. Compound Fractures of the Os Calcis.-These are, fortunately, rare, but occur as-(a) ordinary compound fractures from the accident; Fig. 1339.-Small fragment projecting into the sole, sure to give trouble; readily removable. Fig. 1340.-Projection of a fragment down- ward; most often the sharp anterior end of the posterior fragment gives a pressure-point in the heel that makes walking practically impossible (diagram). (&) as secondarily open fractures exposed by sloughing of the skin. Owing to the comminution, the prognosis of either type is bad. I have seen three of type a, with one amputation and two cases apparently healing well when seen, and two of type 6, of which one came to amputation for active sepsis and one lost most of the calcis by necrosis, but after many months got a foot on which he walks after a fashion, with fair reproduction of bone by the periosteum. Probably some of these cases may need a "two-stage" grafting of skin and subcutaneous tissue, to cover in the bone: This I have once done with good results-and Dr. C. F. Painter has had a parallel case with equally good result from this manceuver. Results in Os Calcis Fractures.-The results of these fractures when treated by ordinary conservative methods are often very unsatis- factory. I have taken pains to look up a good many of these cases. Some, perhaps a half, have serviceable though not normal feet, but * Tenotomy of the tendo Achillis is a matter of no risk or disadvantage. If the tendon is cut within an inch of its insertion, there is no tendency to great retraction (there is no tendon-sheath), and in three weeks' time we have a fairly strong new endon. 696 FRACTURE OF THE OS CALCIS a surprising proportion are more or less crippled, and the disability is not one that will improve with time. The causes of disability are: (а) Loss of arch of the foot, resulting in pressure on the structures of the sole. (б) Loss of the arch with projection of fragments into the sole (Figs. 13.' 9 and 1340), giving unbearable ten- derness of the heel. (c) Outward deviation of the heel, with secondary static flat-foot (Fig. 1343). (d) Simple flat-foot from weakness of liga- ment, etc. (e) Pain from pressure of the external malleolus against the thickened outer side of the os calcis (Fig. 1345). This corresponds exactly with the similar pain from pressure associated with exaggerated flat-foot, where the external malleolus touches the os calcis. (/) Loss of motion of the foot in pronation and supination, due to damage in or near the posterior joint between astragalus and os calcis. These causes of disability may naturally be variously combined in the single case. The projection of fragments into the sole of the foot may be dealt with by operation, with removal of such fragments. Pressure on the Fig. 1342.-Where there has been a good deal of upward displacement of the heel, direct bony pressure on the nerves and other soft parts in the arch may give pain. This is, in part, re- lievable by building up a support under the heel, thereby relieving the arch from pressure. Fig. 1343.-There may be an outward deviation of the heel, sufficient to determine much trouble from static flat- foot. Unfortunately, inas- much as the point of support is changed, these cases are very difficult to relieve with plates. The tracing of the foot to the left (see the cross) shows the outward twist of the foot in these cases. Fig. 1344.-Gleich's opera- tion for flat-foot; applicable to flat-foot from os calcis fracture. The os calcis is completely sawed across (best with a Gigli saw), and the heel portion carried forward and inward as far as we wish, and pegged or otherwise fas- tened into place. Fig. 1345.-The loosen- ing of the outer plate with the thickening from callus is apt to give a thickening of the bone against which the external malleolus comes in contact, giving a point of very painful pressure. structures of the sole, due to simple loss of the arch, can not be remedied in this way, but may be alleviated by wearing in the shoe a thick pad of felt under the heel itself (Fig. 1342). Outward deviation of the heel with the flat-foot resulting can not be relieved in most cases by the use of any plate or support. All that can be done is to resort to Gleich's operation (devised for flat-foot), which consists in cutting across the os calcis at its neck, and shifting the posterior portion down and FRACTURE OF THE OS CALCIS 697 inward. (See Fig. 1344.) This I have done in two cases, with consid- erable improvement, but it is an undesirably extensive operation. Pain from pressure of the external malleolus may be relieved by chiseling out the major portion of the bony projection which is in the way (Fig. 1345). There is little tendency, it seems, to reformation of this bone. This operation I have done but 10 or 12 times, and am not ready to generalize, though the result in these cases was good. Loss of motion in the foot may be somewhat improved by forcible correction under ether, but inasmuch as it is partly due to limitation from fracture into the joint, partly to shortening of muscles and ten- dons, the improvement to be gained is limited if this measure is postponed until after the fracture is united. It will be seen, from what has been stated, that this fracture is one which, in my belief, has been somewhat neglected, and in which it is possible, by careful treatment based on study of the individual case, to obtain much better results than the very unsatisfactory ones which now so frequently result from this injury. For the sake of completeness it may be well to note that Ekehorn (Nord. Med. Ark., Stockholm, 1904, iv. Afd. I, No. 15) reported an "isolated luxation of the calcaneum." This article I have not been able to obtain. CHAPTER XXXIII OTHER TARSAL LESIONS LUXATION OF THE SCAPHOID BONE May occur. I have seen one case reduce without incision and stayed in place. FRACTURE OF THE SCAPHOID Not very rare. Often not to be handled without open operation for reduction. In the three or four cases I have operated on. the conspicuous thing has been the full regeneration of bone outline despite rather liberal removal of loose fragments. My results have been good. LUXATION OF THE CUBOID BONE Isolated luxation of the cuboid is recorded. The luxation may be up, down, or outward. Partial luxations of the cuboid on the os calcis without other injury are on record (Bahr). More usually such subluxa- tion is only part of a mediotarsal dis- placement, a displacement in this case rotatory, for the cuboid is here the axis, so to speak, of a twisting luxa- tion. (See Fig. 1282.) Except where the luxation is part of the mediotarsal lesion and is reduced with it, our obvious means of reduc- tion will be by traction and adduction of the front part of the foot, com- bined with appropriate direct pres- sure. If this measure, with rockings and rotations, fails, our recourse must be open reduction, and, failing in that, resection of the cuboid. Nothing especial is to be said about later treatment, or, so far as the data go, about results. FRACTURE OF THE CUBOID This results apparently only from crushing injuries; it is, therefore> likely to be a comminuted fracture, and may be compound. There is not apt to be any great displacement unless there are luxations or fractures of other bones of the tarsus associated with this fracture. Diagnosis is made by signs of localized injury, by crepitus (crepitus here and in other tarsal injuries is often enough not obtainable where we might reasonably expect it), and, most definitely, by the skiagraph. Fig. 1346.-Fracture of the cuboid by crushing. Little displacement. 698 LUXATION OF THE CUNEIFORMS 699 Treatment.-Save for general restoration of the outlines of the foot we can do nothing to improve position. The foot may best be put up in a plaster-of-Paris dressing reaching from the ball of the foot to just below the knee. Consolidation is prompt. Unless associated injuries of soft parts, etc., are severe, passive motion may be allowed at three weeks; weight-bearing may be begun to some degree at four or five weeks after the injury. Prognosis.-So far as we have any data, no especial disability at- taches to this lesion. Naturally, some lameness persists for a time and there is some tendency to pronation of the foot, to be guarded against as in all injuries in this region. LUXATION OF THE CUNEIFORMS Luxations of the cuneiform bones as a group, or singly, upward or downward, with or without displacement of the corresponding metatar- Fig. 1347.-Dislocation upward and backward of the cuneiforms on the scaphoid (reduced by Dr. '~4 A. Fraser, House Surgeon, City Hospital, Boston). Fig. 1348.-Old fracture of scaphoid and cuneiform, with some loss of bone; entire loss of arch; much disability. Note the shortening of interval between the base of the metatarsal and head of the astragalus; also the complete flattening of the arch. sal or metatarsals, do occasionally occur. The causes are not clear. The trauma usually seems disproportionately slight. Diagnosis depends on direct examination. Reduction is by traction and pressure. Reduction of a bone dis- located singly obviously presents the greatest difficulty; reduction 700 OTHER TARSAL LESIONS may, indeed, be impracticable; if so, and if the displaced bone is prominent, it may be well to excise it. Apparently the loss of even the first cuneiform is not a very serious matter. After-treatment.-Fixation for three weeks to six weeks, according to the severity of injury. Prognosis.-Good-with the usual reservation as to necessary precautions in regard to pronation that apply to all tarsal injuries. Prognosis must take large account of associated injuries. FRACTURE OF CUNEIFORM BONES These fractures are rare; they occur as a result of complicated smashing injury of the foot. Diagnosis.-Inferentially made on the basis of disturbed relation of landmarks; definite diagnosis im- possible save by x-ray. Treatment. Restoration of the general contour of the foot-restora- tion (as nearly as may be) of the rela- tions between landmarks; there are no definite schemes of manipulation. Prognosis.-The prognosis is es- sentially that pertaining, in general, to crushing injuries of the foot, pro- vided a reasonably accurate read- justment has been made. OTHER FRACTURES OF THE TARSUS Other fractures of the tarsus may occur (usually from direct smash- ing) , but are so rare and so obscure that we have no accurate knowledge of them save as operation or the skiagraph furnish us information. Ordinarily, the lesions are multiple. Such fractures are not rarely compound. Fortunately, the displacement is apt to be slight, and the treatment called for is only routine fixation, with mobilization not too long- delayed. Substantially the presence of fracture or its absence does not ob- viously affect treatment or prognosis in the crushing injuries of the foot in which such fractures occur. Failure to recover complete function is not uncommon and occurs at times even when no skeletal damage can be made out: the crushing of soft parts seems the impor- tant factor. There is a curious tendency to full reproduction of bones of the tarsus after fracture or operation. I have seen this in os calsis cases of course but have noted it particularly in scaphoid fracture in the foot: con- trary to what one would suspect there is no tendency to shortening- under proper treatment: what one has to guard against is pronation. Fig. 1349.-Fracture of the upper portion of the scaphoid, with comminution of the fragments. CHAPTER XXXIV METATARSALS The metatarsals, as a whole row, may not uncommonly be dis- located upward on cuneiforms and cuboid. Dislocation in other direc- tions is rare. The lesion commonly occurs from apparently slight trauma-a misstep in stepping on a curbing, a slight unexpected fall on the ball of the foot, entanglement of the foot in a stirrup, etc. It may, of course, result from severer trauma, in twists of the foot caught in machinery, etc. Diagnosis presents the only difficulty. The foot is naturally swollen, and the deformity produced is unbe- lievably slight. Accurate examination of landmarks should give the diagnosis. DISLOCATION Fig. 1350.-Backward dislocation of first metatarsal; fracture luxation of the outer cuneiform Sketch from case of the author's. There is some shortening of the foot, measured from tips of toes to convexity of heel-this will rarely be over to % inch. Pressure on the metatarsals in the "ball" of the foot (see Fig. 1365) in these cases, as in fractures, gives tenderness, but this does not help us in diagnosis of luxation versus fracture. Reduction is by traction exerted in the direction of the long axis of the foot, combined with a rocking motion up and down, and direct pressure on the projecting bases of the metatarsal bones. There seem to be no cases of failure to reduce the luxation if diagnosis has been made. After-treatment follows general lines. Prognosis.-If the luxation has been reduced, there seems to be no especial disability associated with this lesion. 701 702 METATAKSALS The prognosis is good despite the wide tearing of ligaments neces- sarily associated. There seems to be no more tendency to flat-foot than with other Fig. 1351.-Downward and backward dislocation of the first two metatarsals'(outlines reinforced) tarsal injuries. There may be some pain on plantar flexion, persisting for some time. Even if the lesion is overlooked and unreduced on account of Fig. 1352.-Same case as Fig. 1351. swelling, the spontaneous restoration of function seems to be better than might be expected, though there is some deformity, some prona- tion, and an entire inability to rise on the toes or to exert a proper thrust with the front foot in walking. DISLOCATION 703 Fig. 1353.-Dislocation down and back of the first three metatarsals from the cuneiforms (old un- reduced case; much disability). Fig. 1354.--Dislocation of metatar- sals upward on cuneiform (old case; un- reduced). Fig. 1355.-Sketch of complicated luxation of metatarsus; amputated. Writer's case. 704 METATARSALS Fig. 1356.--Same case as in Fig. 1355, from in front. Fig. 1357.--Same case as in Figs. 1355 and 1356, from the inner side. DISLOCATION 705 Fig. 1358.-Same, dissected; a, Torn extensor minimi digiti; 6, extensor communis; c, peroneus ongus; d, torn end of peroneus tertius; e, nerve (saphenous); / and/', cuboid (note crack on articular ace); g, fourth metatarsal; h, third metatarsal; i, second metatarsal (with fracture of articular acet); j, second cuneiform; k, first cuneiform. Fig. 1360.-Divergent luxation of the meta- tarsals. Fig. 13 59.-'Metatarsals dislocated up and back on the cuneiforms. Sketch aft r R. W. Smith's plate (same case as Fig. 1354). 706 METATARSALS METATARSALS-ISOLATED LUXATIONS Any one or any group of the metatarsals may be luxated up or down. Isolated luxation occurs oftenest with the first. Recognition of displacement must be made, in these cases, purely on localization of swelling and tenderness, on recognition of the bony deformity by touch, and by pressure on the ball of the foot (Fig. 1365). Reduction is by traction and direct pressure. If this fails, we have no means of relief save recourse to incision and reduction of the dis- placed bone. FRACTURE OF THE METATARSALS Fracture of the metatarsals, save for the fifth, results from direct violence only: that is, from a weight falling or pressing on the foot- on the dorsum. So far as appears, impaction fractures analogous to those of the metacarpus do not occur. We may have fracture any- where in the shaft of the metatarsals from the base down. Most commonly it is at or about the middle. Only rarely is it close to either end. In one case (see Fig. 1363) have I seen separation of the proximal epiphysis of the first metatarsal.* Very commonly more than one metatar- sal is involved, f As a rule, the fracture occurs toward the middle of the shaft. A. Freiberg of Cincinnati has found cer- tain cases of crushing of the lower face of the metatarsal heads alone, causing serious disability. His plates leave no question of the lesion; no question but that it must have been overlooked by all of us. Camp- bell has had cases and C. F. Painter (1920) has recorded his. I have seen one case of separation of the distal epiphysis of the fifth. It was successfully replaced by open operation. Another lesion in this same region is referred to under sesamoid injuries (p. 713). Namely the splitting, or the enlargement without splitting, of the sesamoids of the great toe. I have had to remove them twice for persistent disability resulting. The removal leaves a perfectly serviceable foot. Diagnosis.-Crushing injuries of the foot have certain peculiarities. Irrespective of bony damage, we find in these cases great swelling Fig. 1361.-Fracture of the first four metatarsals (drawing from x- ray plate). * Note that only the first metacarpal has a proximal epiphysis. t Curiously enough, there is an unexplained tendency to fracture of the second, third, or fourth metatarsal (especially the first two) in cases where the given history seems to point strongly to fracture of the first or fifth or of the whole row. FRACTURE OF THE METATARSALS 707 promptly following the accident, total disability, much pain, and tenderness. The swelling rapidly becomes so tense that we can feel Fig. 1361s.--Infraction of second metatarsal head. Tennis injury six months previous in a girl of sixteen. (Courtesy of A. H. Freiberg, reproduced from Surg. Gyn. and Obst., 1914.) Fig. 13616. --Infraction of second metatarsal with two large loose bodies which required removal. There was marked grating during passive motion. (Courtesy of Dr. A. H. Freiberg.) nothing; the whole foot is so sensitive that any localized tenderness goes for nothing. 708 METATARSALS So far as direct examination goes, we have little to go on. Differ- ential diagnosis as to which bone is involved is dependent on one sign Fig. 1362.--Same condition. (Courtesy of Dr. C. F. Painter.) Fig. 1363.--Separation of epiphysis (re- duced) of the base of the first metatarsal, proximal end. This was a separation with quite a little displacement before reduction. Fig. 1364.--Fracture of the first metatarsal. only, namely, the presence of deep tenderness on pressure in the long axis of the bone. (See Fig. 1365.) This gives us some indication. 709 FRACTURE OF THE METATARSALS Beyond this I must confess that I have usually found all signs useless. Here more than in almost any region of the body, we are dependent on the x-ray for detailed diagnosis. Treatment.-With the diagnosis once made, treatment must be Fig. 1365.-Pressure on the ball of the foot in the line of the metatarsals; localized pain elicited by pressure of this sort on the head of a single metatarsal is our best single sign of fracture where there is swelling. directed toward the best possible reduction and fixation of the frag- ments, but with particular attention to two factors-namely, pro- jection on the dorsum and projection downward into the plantar structures. Accurate reposition laterally is not very important, but if there is a projection of either fragment upward, boot pres- sure is almost certain to make trouble, and any considerable projection downward on the plantar side is almost certain to cause permanent ten- derness of a serious sort. Our best guide here is the z-ray. Any dis- placement found to exist may be, and should be, reduced at once or even at the end of one or two weeks. In general we may say that upward displace- ments are less serious and more likely to be recognized. Consequently our attention is di- rected to downward displacement. In default of exact data we are safe in put- ting up such a case in plaster, or, still better, in a plantar splint with felt padding (Fig. 1366), in such fashion that the arch of the bone is not only restored, but perhaps slightly exaggerated. After-treatment.-Metatarsal bones carry a good deal of strain and, except in cases where the first metatarsal is not involved, fixation and rest is in order for not less than five weeks, followed by massage, passive motion, and gradual use. Fig. 1 366 .-Plantar splint; cut to the shape of the sole, as shown in the lower sketch; applied as shown in the upper sketch. Note posi- tion and direction of adhe- sivestraps. There should be special padding, preferably of felt, at A, to preserve the curve of the arch; at B, to maintain a comfortable posi- tion of the toes (the toes are not comfortable when held straight out). 710 METATARSALS Prognosis.-Properly handled, fractures of the metatarsals leave no disability of consequence unless there has been much damage to the soft parts. Fractures healed with upward displacement are apt to give a good deal of trouble from friction of shoes. Fig. 1366a.-The type of metatarsal fracture that is apt to give trouble from tender points in the tread of the foot. A loss of the convexity of the bone gives some static disturbance, and is apt, according to its degree, and according to the bone involved,* to conduce to the occurrence of flat-foot. Projection of either fragment into the sole gives pressure either on the nerves or on the other soft parts, and is apt to give a good deal Fig. 1367.-Displacement of the sort shown in the sketch is apt to give trouble from friction of the shoe. Fig. 1368.-The same displacement may give trouble from pressure in the sole, from pinching nerves or other soft parts between the projection of the fragment and the sole of the boot. of disturbance. This may be relievable by pads that distribute the weight, or a late operation may be called for-a removal of the project- ing spur. * Anatomically, according to von Meyer and others, the second and third metacarpals carry the strain of the arch. In fact, clinically, it seems to be the first metacarpal that is peculiarly important for the preservation of this arch. 711 FRACTURE OF THE FIFTH METATARSAL FRACTURE OF THE FIFTH METATARSAL This bone may, of course, be broken by smashing, but there is a Fig. 1369.-Luxation backward of phalanges of all toes, as a row (schematic). Fig. 1370.-Mechanism of fracture of the fifth metatarsal at the base. If the body-weight is re- ceived on the outer side of the foot, well out toward the .toes, the strain comes on the fifth metatarsal; the base of this metatarsal is held by very solid liga- ments to the "base of the fourth metatarsal; there- fore any lateral strain transmitted through the shaft will break the bone at or near the end of this fixed portion. Fractures of this sort are common and often overlooked. Fig. 1371.-Pressure for diagnosis of fracture of the fifth metatarsal. On lateral pressure, as shown, localize ten- derness is developed at point shown by cross; this is definitely diagnostic. Local tenderness may be very slight; lameness, only moderate. Fig. 1372.-Tracings from r-ray negatives: author's cases. fracture peculiar to it-peculiar in both cause and character,-namely, the fracture of the fifth metatarsal by inversion. Apparently never recognized previous to Jones' description in 1902, * * Robert Jones, Ann. Surg., 1902, vol. xxxv, p. 697. 712 METATARSALS it seems none the less to be relatively common. I reported cases in 1903,* and Bricknerf and others have added to the list. The fracture is a pure inversion fracture, caused by treading on the outer side of the foot. Usually such turning of the foot is due to a Fig. 1373.-Fracture of fifth metatarsal by inversion (courtesy of Dr. E. H. Nichols). Fig. 1374.-Fracture of the fifth metatarsal by inversion (author's case). slight miscalculation of the ground level or to a misstep. In one of my cases the patient, a woman, slightly turned her ankle in dancing. The force producing the injury is usually slight. J The mechanism is Fig. 1375.-Oblique fracture of fifth metatarsal, from inversion of foot obviously a sharp adduction of the front end of the metatarsal bone, bringing a cross-strain to bear just in front of the broad basal portion of the bone, which is held firmly appressed to the similarly broad base of * Cotton and Sylvester, Boston Med. and Surg. Jour., 1903, cxlix, 735; and Cotton, ibid , 1906, civ, p. 229. t Brickner, American Jour, of Surg., Oct., 1906. t The case of Fig. 1281 showed a similar lesion complicating a mediotarsal luxa- tion, due to similar but severer force. FRACTURE OF SESAMOID 713 the fourth metatarsal by very strong ligaments. Near the front of the broad base the metatarsal gives way. There may be a fissure of the outer side only, or a clean break across. The site varies somewhat, as shown by the tracings appended. The pain is not great, and the immediate disability is only partial. All the cases I have seen have been assumed to be a sprain of the ankle, and the patient has walked more or less after the injury. Naturally the foot grows worse with use. Diagnosis is dependent on localization of tenderness, slight local swelling, tenderness at the base of the bone on inward pressure at the distal end (Fig. 1371), and confirmation (not absolutely necessary) by the x-ray. Treatment consists in the application of an arch-pad of felt with firm strapping of the foot-there is no deformity to reduce. Absolute rest for seven to ten days, with careful use thereafter under protection of pads and strapping, gives good results with no unpleasant sequelae. FRACTURE OF SESAMOID Occasionally one finds local tenderness beneath the ball of the great toe, usually following a fall in which the weight comes on this point. In some of these cases, the x-ray shows a fracture of one or the other sesamoid. * With or without fracture, such inj ury may lead to enlarge- ment of the sesamoid and consequent great disability. Padding may give relief. I have twice removed such injured sesamoids, with entire cure. * Remember, though, that double sesamoids are not very rare, and may lead to confusion. CHAPTER XXXV THE PHALANGES LUXATION OF THE TOES Luxation of the toes is common enough, and not very important if recognized. Most important is the displacement of the great toe, occurring most often as an upward displacement of the distal phalanx. Fig. 1379 shows the lesion and the deformity; here, as also with dislocation of the Fig. 1379.--Dislocation backward of first phalanx of great toe of right foot (drawn from a case of the author's). Below, diagram of displacement. Arrows show lines of traction in reduc- tion. It is to be noted in this case, as in all luxations about the toes, that the apparent displace- ment is slight--less than would be looked for. proximal phalanges on the metatarsal, the deformity is less than we would expect. Not rarely more than one toe is dislocated; at times the whole row of five toes may be luxated from the corresponding metatarsals (Fig. 1369). 714 715 FRACTURE OF THE TOES Displacement may be of the distal bone up or down, oftener up; rarely we see lateral luxation or oftener subluxation. Diagnosis depends on the obvious disturbance of relations as com- pared with those of the sound foot, more particularly in regard to short- ening, which is invariably present in all these luxations. The lack of crepitus, the difficulty of reduction, the lack of tendency to recur, speak against fracture. Reduction is by traction, with a rocking motion and with direct pressure. In backward luxations hyperextension with downward push may be called for. There are no especial obstacles met with in luxation of the toes like those opposing reduction of luxations in the hand. Prognosis is good if displacements are reduced. Fig. 1380.-Thumb and finger grip for reduction of phalangeal dislocations. Fig. 1381.--Fracture of the proxi- mal phalanx of the fifth toe. Fracture of the toes is common enough, and results usually from direct violence. The only trauma that we may classify as indirect vio- lence is that in which the toe is struck on the end or spread away from its fellow. Such injuries occur to the bare foot only, usually from "stubbing" the toes against a chair or bed in a dark room at night. Either fracture or luxation may result. The common fracture is from crushing. Any phalanx may be broken. Swelling is prompt, and the signs of crushing are apt to mask the fracture. Even with crushing, com- minuted fracture is the exception. If the great toe is involved, we not rarely have compound fracture- compound on the dorsum. Compound fracture of other toes is unusual. Diagnosis is by abnormal mobility and crepitus. FRACTURE OF THE TOES 716 THE PHALANGES Treatment.-Immobilization is all that is needed save in compound cases. Ordinarily, there is no tendency to displacement-a plantar splint is enough. "Chip" fractures of the tip give delay in union, occasionally call for incision to relieve tension but do well in the end, unless there is, in case of the great toe, a projection of bone downward, which gives some persisting sensitiveness. Results.-No serious result is to be apprehended. The usual trouble is tenderness and inability to wear a shoe, even for some time after union is firm, on account of thickening and soreness. End-results are uniformly good, even if there is some deformity. CHAPTER XXXVI TECHNIC: SPLINTS, PLASTER WORK, ETC. (Including the consideration of the "Army" splints) Of technic, one can learn, or teach, but little in a book. For technic is, in no small measure, a matter of skill of hand, a skill which fate or a "Yankee tinker" ancestry gives to some from birth; others gain it through a youthful experience of stress, contriving tops and kites, sleds and double runners and "express" wagons. My good friend, Dr. Bapst Blake, expressed most of it in the phrase: "You can't expect a man to mend the broken leg of a man who couldn't mend the broken leg of a chair!" A decent ingenuity, knowledge of the world about us in three dimen- sions-these are essential, and to these one must add some skill in grip and leverage, and to this at the end long practice in the trade itself. "So brief the lyf So longe the art to lerne!" But, at that, we have as have other mechanics our chest of tools. And to this chest this brief chapter is dedicated. But, before we start, remember we have but a few things that one may do with these tools however well we may use them. For the most part we can not saw or jack-plane our fractures, nor rabbett the ends or chamfer our edges, and worst of all we can not have the bones in a decent bench-vise to work on. Apart from open operations-(useful but not without risk and often enough with real certainty) we can do only the following things. 1. Pull-once or continuously. 2. Bend. 3. Twist. 4. Put on lateral pressure. 5. Push, and impact. 6. Put up in forced positions to help items 2, 3, 4, 5. It sounds like a very little, yet it is all there is, I think to the non- operative treatment of fractures, if one considers. And, today, we are all moving away from the operative treatment, all over the country-away from inlay-grafts, from plates and bands and other "stunt" operative measures. Back in the time when my forbears were in the "Massachusetts Grants,"-now the "State of Maine," there were no surgeons, almost no doctors, but there, as in all New England, there were "bonesetters." 717 718 technic: splints, plaster work, etc. Though of the younger generation, I well remember "the Sweets" of Rhode Island, Connecticut, and Massachusetts, and have seen their work. Untrained they were in our more modern sense of training, but they were earnest, keen, busy, and, best of all, they were mechanics, and, so far as I have seen, their work was rather good. A lot they didn't know, of course-and they had "wrecks," but the average result seems to have been curiously good. What I want to stress is that the fracture game is a mechanical problem! Now as to the tools available: for the pull- first, Buck's extension second, Thomas splint third, Thomas-Pierson with skeletal traction fourth, the same without skeletal traction fifth, arm traction downward, Thomas splint (Here I break out of line. I see no excuse for this arm traction thing, except, perhaps, in shattered fractures of the humerus, and then only for a brief period.) sixth, traction in abduction- (a) Jones abduction splint with traction seventh, abduction (6) Cleary's splint eighth, abduction (c) "Monks' triangle" ninth, abduction (d) Osgood-Penhallow splint tenth, traction on the lower leg (a) adhesive method, direct eleventh (6) Sinclair skate twelfth (c) skeletal traction with Thomas splint All these are accepted methods, each with its technic-and here a word to each. 1. Buck's extension. (See Figs. 958 and 959.) (а) in. strips of adhesive out and inside the leg, up to the point of break (б) spirals to hold the (a) strips in place-never circular adhesive strips (c) a spreader, below the sole of the foot (d) a rope running over a pulley-(the kind of pulley is imma- terial) to a weight hanging free below the foot of the bed (e) Ham-splint. (See Fig. 914.) (J) coaptation splints* (<?) bed-blocks to raise the foot of the bed about 9 in. for counter traction by the weight of the body. (/i) long T splint-often not necessary. (See Fig. 790.) *Coaptation splints are best made by laying a bit of splint board on adhe- sive plaster, half-splitting the board in % in. widths, and curving it to part of the curve of a 6 in. cylinder. (See Fig. 283.) technic: splints, plaster work, etc 719 Of late one would think the older methods of traction out of date. Not yet! At our City Hospital we have been checking up a bit carefully for a couple of years-studying our results. As a consequence, my IV Surgical Service, without suggestions from me, have entirely abandoned suspension treatment of fractures in children, and are pressing for the Buck's extension more and more. Suspension gives neither accurate, reliable traction nor even approximate fixation, and we have had enough of it. It may work with infants: it does not work with children over four. Why we prefer Buck's to the Thomas splint--ceteris paribus-is another matter. Thomas Splint.-Originally devised many years ago by Hugh Thomas as a fixation splint to use in tuberculous knee joints: shifts the weight from foot to crotch and to the tuber ischii. This original type of splint efficient but not easy to fit. Revived as a war splint, made by the hundred, unfitted, used right or left as the cards fell-efficient for temporary traction-essentially a splint for transportation of the wounded, and a good one for this purpose. Unfortunately many, especially of the younger surgeons, came home with the idea that this was a treatment splint, and as a result there have been a lot of messes. The fact is that one can not put on much traction in a Thomas splint without a secondary traction on the splint, as in the Balkan frame, without risk. I have seen some horrid perineal sloughs as a result of this failure in clear thinking. The Thomas splint with " Spanish-windlass " traction will maintain any length one secures. Then, one puts on traction, and traction acts, not only to lengthen the leg but to drag the ring of the Thomas splint out of the crotch where it is raising all sorts of trouble if one doesn't watch. The most comfortable rig is the Balkan frame in which one gets both suspension and traction and every hospital should, and presently must, have these frames. The Thomas splint is shown in Fig. 1382. Fig. 1382.-The Thomas leg splint . 720 technic: splints, plaster work, etc. The Spanish Windlass in Fig. 1383. Fig. 1383.--"Spanish windlass" traction. The stick aa1 is twisted till the drag down is suffi- cient then let snap in place against the bars of the Thomas splint. The loops b and b1 keep the traction strips from dangerous pressure on the sides of ankle and foot. The Balkan Frame (Fig. 1384. See Fig. 978). Fig. 1384.-The Balkan frame with suspension trolley, U. S. Army Standard. To. "maintain alignment one carries a number of slings across beneath leg and thigh. Most secure of all, and my routine, are slings of 3 in. adhesive strips carried across from bar to bar under the leg with the non-adhe- sive side up. The strip is then continued across behind: this brings adhesive face to adhesive face and leaves no sticky surface to entangle the bed-sheets. Nearly as good-better if one expects to have adjustments to make, or if dressings need attention, is the war scheme of strips of cloth TECHNIC: SPLINTS, PLASTER WORK, ETC. 721 held onto either bar by spring paper-clips which hold very firmly the bandage end which is folded over the bar. Of value in maintaining alignment are the arms (Pierson's) clamped to the bars, carrying a set screw with a padded plate on its end (Fig. 1385). With them one may produce any desired pressure Fig. 1385.-Pierson's counter pressure pads for fractured femur at any point. Sometimes they are indispensable, quite as often coap- tation splints with heavy felt pads, the whole held down by adhesive strips or with buckle straps, do the work as well. Third: The possibility of preserving knee motion without sacrific- ing traction on the thigh was little appreciated until the war. With skeletal traction-insertion of "ice-tongs" into the femoral condyles, one may get any desired traction, and yet, with the leg slung into the adjustable-angle Pierson's attachment, Fig. 1386, Fig. 1386.-Pierson's attachment for flexion of the knee. flexion motions at the joint may be kept up without in any way inter- fering with traction or with the maintenance of the femoral shaft at the desired length. Fourth: One may secure, without skeletal traction and its slight risk, a very decent traction with adhesive and yet use the movable lower leg section to avoid stiffening. Fifth: Arm traction-downward. For such traction I have no use and do not care to discuss it. Temporary, but not negligible, subluxations with deltoid paralysis are too easy to produce by downward traction and I have seen enough 722 technic: splints, plaster work, etc. to feel that this splint has no place except in a few compound lesions at the elbow. Sixth: Traction in abduction, per contra, is most useful. The Murray-Jones splint with a rocking hinged ring is the neatest way, and a comfortable way, for all bed cases. Application should be obvious from Fig. 1387. Fig. 1387.-The Murray-Jones arm splint for transportation. There are many cases of bursitis etc. as well as fractures, that call for treatment in abduction, with or without traction, carried beyond the bed stage. Seventh: abduction: The "aviation" splint of the army sounds reasonable but is so clumsy, hard to fit, and uncomfortable that most patients in civil life object grievously. (See Fig. 1388.) Fig. 1388.-Jones abduction arm splint, U. S. Army Standard. Cleary's splint is more comfortable but not popular. My only objection to it is lack of rigidity. In other than fracture cases it is fine. The apparatus that patients like, the one that I am using every day, is not a war product at all. Eighth: Monks' Triangle: Dr. George Monks devised it long ago when he was 0. P. D. surgeon at the City Hospital-when I was a "student dresser." Fig. 286 shows it. Ninth: Osgood-Penhallow Splint: When one is ready to let the arm down part way out of abduction our best splint is the Osgood-Pen- hallow shown in Figs. 377 and 378. This gives position and some traction, all one needs at this stage. Tenth: Traction on lower leg and foot. technic: splints, plaster work, etc. 723 (a) We may use direct traction with adhesive strips, differing in no way from the same sort of traction applied to the femur, only, one can not get as much pull. With the pull one uses as much pressure at desired points as seems needful-either with the adjustable arms or with padded coaptation splints. Eleventh: (b) A much better method of traction, if one will learn to use it, is the Sinclair skate, consisting of a sole from which traction is made starting from a ring-bolt so adjus- table in a slide on the bottom of the sole that traction may be made to centre forward or back as desired. This gives control of direction of the pull on fragments much more accurate than with any other method, and also a fixa- tion of the foot angle that usually renders superfluous any of the dozen tricks to prevent toe drop. (Fig. 1389.) The edges of the skate are notched and it is held to the sides of the foot by strips of adhesive, or cloth strips fastened on with Heusner's or any glue, or with a solution of celluloid in acetone. The secret of safety is in the manner of application. There must be a good inch clear up the dorsum of the foot and at the front of the ankle, and strips must not cross the tendo achillis. I have seen ghastly sloughs where the straps lapped across the dor- sum, never any damage when the clear strip was left open. A surprising amount of pull can be exerted through use of this device without serious dis- comfort. Twelfth: (c) Skeletal traction applied to mal- leoli by tongs, Fig. 1390, through the calcis with the Steinman pin, across in front of the tendo Achillis with Adams pin, is of limited usefulness probably. The use of the Steinman pin through the back part of the calcis in calcis fractures is about the only thing one can't do in another way. I have no real quarrel with skeletal traction here or elsewhere, but have seen enough trouble from low grade infection not to give it the position of first choice in routine cases. CONVALESCENT SPLINTS These are very important in leg and ankle fractures and often in the thigh. Most of them are recognized types of orthopedic apparatus, devised for joint disease and the detail of construction is found in_the orthopedic text-books. In case of hip fractures, theoretically one should use the Taylor type with slings through the perineum. In fact the Thomas knee splint, carefully fitted so as to let the patient's weight come on to the Fig. 1389.- Sinclair skate. Fig. 1390.-Edmonton ex- tension tongs. 724 technic: splints, plaster work, etc. ring through the tuberosity as well as the perineum* does just as well, and is far more comfortable, and in practice we use the caliper, not the patten bottom. In this type the ends set into the heel of the boot and the length is so adjusted that the ball of the foot bears a little weight but the heel is kept clear off the ground. This type of Thomas splint does well enough for knee and high leg- fractures. For lower leg fractures, especially delayed unions, the useful splint is that shown in Fig. 1230a with or without a movable ankle Fig. 1392.-Outside upright, inside T-strap shows the outward pull. Fig. 1391.-Outside upright with inside T-strap as used for convalescence in Pott's fracture. seems wise. With leathers lacing both front and back, a very accurate and solid fixation is possible, so that the good effects of weight-bearing function may be secured without rocking the fragments at all. For ankle fractures, single or double upright braces do the work. For Pott's cases I am apt to use the outside upright with the inside "T" strap fastened to the boot, running around outside the upright. With this splint early use after 5 weeks or so is harmless. (Figs. 1391 and 1392.) For cases with tendency to backward displacement of the foot the double upright with leather band laced across above thejinkle in front, gives our factor of safety. * This is really a fitted splint, not like the stock, "Thomas." technic: splints, plaster work, etc. 725 For most leg and ankle fractures a "Thomas heel" raised on the inner side in. is a safeguard against flatfoot development in later convalescence. Many cases, especially women, may wisely and comfortably wear "flatfoot" plates of the usual type, carefully fitted for some months. Many tarsal injuries need the support given by the "rocker" plate devised by Whitman, which has its flanges carried up on inner and outer sides and gives admirable support. Plaster technic: "Dental" plaster of first grade. Crinoline, washed or as it comes, or a rather coarse-meshed gauze bandage. These properly rolled into a rather loose roll with a space running through the centre, will wet through properly and quickly. A little salt in the water is customary. The bandage should not be wrung out but used wet. It should be "run on," not bandaged on with a pull. A little dry plaster sifted on here and there, and rubbed in, helps amazingly. Plaster should always go on over padding but not too much padding. Sheet wadding is the usual padding and is good but gets soggy, shrinks in bulk, ceases to act as a pad, and almost disappears after a while. If much thickness is used the loss of support presently is serious. The best pad for continued support is saddlers felt. The nicest plaster goes on over only a "stockinet" covering but there is a lot of chance of undue pressure in working in this way with fractures. This is an experts' method. If there is any question of tightness split the plaster as soon as it sets and spread in. or so-one sleeps better! I always do this with plasters in wrist fracture. See Figs. 1143 and 1393. Fig. 1393.-Plaster as applied for Colles fracture, split and spread properly to avoid risk of possible constriction. Generally speaking, plaster-of-Paris is good to maintain attitude, as in hip or wrist lesions, not so good to maintain reduction, as in leg fractures-no good at all for such things as maintaining a femur fracture. One can not set a difficult fracture and then put on a plaster and be sure of it. If we can "slap on" a plaster after reduction without 726 technic: splints, plaster work, etc. loosening it, and then, with our hands outside, press in at the points where maintaining pressure is needed, then all right. That is what one does in ankle fractures, for instance; see Fig. 1143. There is one exception-Delbet's method in leg fractures in which the plaster is modelled close about malleoli and below the knee while traction is maintained. This method, just beginning to be used in the United States, is a good method though not for the inexpert to rely on. Generally speaking the more assistance and the less apparatus the better. Traction straps and leg-holding straps, etc., are lost track of inside the plaster, and one doesn't quite know if they are doing harm. I use a Hawley or Lemon table a lot, but people not bandages hold the legs if I can get the people. Reinforcement of plaster with wood, tin, etc. is not very satisfactory. The plaster "rope," a bandage twisted up lengthwise, does it better: for example, in the cross-bar between the knees of a double spica, I never use anything but plaster bandage strung and twisted and wound about, and so secure a bar, 15 in. upward in length, in. in thickness, by which one can pick up patient and plaster securely. . One may use plaster rubbed into burlap and wet-the "Bavarian" splint-or may cut patterns in loose cloth plastered like the bandage stock and then mold it on, wet. The Delbet method uses this scheme. In general, however, the plaster-of-Paris bandage is the usual material and it is worth while to be a little expert in its use if one has much fracture work. INDEX Abduction arm splint, Jones', 722 Colles' fracture, 377, 387 in hip fracture, 521 traction in, 722 Acetabulum, fracture of, 460 through, 461 with penetration, 463 Acromioclavicular dislocation, dressing for, 166 Acromion as shoulder landmark, 181 epiphysis of, 177 fracture of, 177 treatment, 178 spur of, as shoulder landmark, 182 Acute flexion, Figs. 292-391, 296 Adams' pin, 723 Adhesions as cause of stiff joints, 385 Adhesive strap, method of applying, 296 strapping, Cottrell-Gibney, for con- valescence in ankle injuries, 639 to foot and lower leg, 634 to prevent inversion of foot in fractures of external malleolus, 640 Adults, elbow fractures in, 280 Age as cause of fracture, 25 Alignment, Pierson's counter pressure for maintaining, 721 Allis, 488 Allis' reduction of anterior luxation of hip, 494, 495 of posterior luxation of hip, 490 Anatomic method of treatment in unimpacted fractures of femoral neck, 524 neck of humerus, fractures of, 224 with shoulder luxation, 211 Angle of Louis, 149 Angular splint, internal, 243, 292, 293 application, 320 Ankle, compound fractures, at or near, 640 Cotton's fracture, 622 diastasis of tibia and fibula, 609 exercises, 56 fractures, complications, 642 displacement of joint surfaces, 643 irregularities of joint surface in, 645 of both bones, 629 diagnosis, 631 treatment, 632 of external malleolus, 640 of fibula alone, 637 operative treatment, 653 Ankle fractures, results, 643 weakening of ligaments in, 645 injuries at and about, 603 inversion Pott's fracture, 612, 616 inverted Pott's fracture, 626 joint, causes of disability after frac- tures of, 643 luxations of, 604 landmarks of, 601 lesions of, 603 luxations of, 604 diagnosis, 607 of lower end of fibula, 609 reduction of, 608 Pott's fracture, 610 inverted, 626 with posterior fragment, 622 separation of epiphyses of tibia and fibula, 636 sprains of, 642 Anklet, leather or cloth, for traction on ankle, 634 Anterior suspension splint, 547 Anterior-superior spine, 471 separation of, 467 Arch pad, 639 weakening of, after ankle fracture, 645 Arrachement, fracture of, 364 Artery, axillary, rupture of, in shoulder luxation, 216 brachial, in elbow luxations, 253 Arthritis, traumatic, 46 treatment, 48 Astley Cooper's method of reduction, 192 Astragalus, displacement of scaphoid away from, 671 fracture, 661 longitudinal, 664 of body, 664 of neck, 663 luxations, 656 below, 665 reduction, 658 results, 660 total, 656 separation of epiphysis, 636 Atlas, diastasis of axis and, 85 dislocations of occiput on, 85 on axis, 85 Attitudes in shoulder injuries, 187, 202 Aviation splints, 245, 722 Avulsion fracture of os calcis, Fig. 1287, 676 727 728 INDEX Avulsion of tibia at knee, 596 of tibial tubercle, 592 Axillary artery, rupture of, in shoulder luxation, 216 pad, 243 vein, tearing of, 217 Axis, cervical vertebra; below, defor- mity in lesions of, 110 diastasis of atlas and, 85 dislocations of atlas on, 85 injuries below, differential diagnosis, 109 Bacillus, gas, 63 Balkan frame, 719, 720 Baking, 53 hot sand, 53 Bandage, circular adhesive, 198 felt shoulder-cap, wrist-sling, 227, 243 roll in palm, 440 tight, signs of, 395 Velpeau, 171, 198 Banjo splint, 435 Barton's fracture, 356, 358, 361 reversed, 361, 362 Bases of metacarpus, fracture of, 442 Baths, 53 whirlpool, 53 Bavarian splint, 726 Bennett's stave fracture, 435 Biceps tendon in elbow luxations, 253 rupture of, complicating shoulder luxation, 222 operation for, 223 torn loose, 210 Bigelow's method of reduction of pos- terior luxation of hip, 492, 493 Bladder, tearing of, in pelvic fracture, 451 Blood-vessels, rupture of, complicating shoulder luxation, 216 Blow, round-arm, 429 Sullivan, 429 Bolles' splint, elbow, 292, 326 wrist, 395 Bone or bones, carpal, fracture of, 427 cyst, 26, 40 metacarpal, fractures of, 436 luxations of, 431 resorption of, 35 spike in hip fracture, 527, 528 syphilis, 39 Bone-graft in non-union, 43, 45 essentials of, 45 Brachial artery injury in elbow lux- ations, 253 plexus, tearing of, in shoulder luxa- tion, 213 treatment, 215 Bradford frame, 135 hammock frame, 524 Brisement force, 51 Bryant's triangle, 473 Buck's extension apparatus, 537, 538 technic, 718 Bullet wounds, fractures from, 62 Burrell's operation for recurrent shoul- der luxation, 220 Bursal lesions complicating shoulder luxation, 223 Cabot splint, 549 Calcaneum, fracture of, 676 Callus, 34 Cancer and non-union, 24 Capitellum of humerus, fracture of, 287 Capsule of hip, lesions in luxation, 477 obstacle to reduction, 501 Carcinomas, metastatic, 26 Carpal bones, fracture of, 427 dislocations with fracture, 421 scaphoid, fractures of, 422 with total semilunar luxation, 427 Carpus, anatomy, 411 fractures of, 422 with carpal dislocations, 421 injuries of, 411 operative treatment, 417 luxations of, 411 of one row on other, 411 of single bones, 418 scaphoid fracture, 422 with total semilunar luxation, 427 Carrel-Dakin treatment in compound fracture, 63, 64 Carrying angle, 293 Cartilage, dislocation of rib from, 156 ensiform, dislocation of, 150 rib, fracture of, 154 semilunar, dislocation of, 557 separation, 153 Caterpillar exercise, 55, 244 Central luxation of hip, 463, 487 Cervical spine, injuries of, 82 landmarks, 83 vertebra, below axis, deformity in lesions of, 110 differential diagnosis of injuries, 109 diastasis of, 108 first and second, fractures and luxa- tions, 85 fracture-luxations of, treatment, 115 with displacement, 108 fractures of, treatment, 115 lesions of, prognosis, 117 luxations of, treatment, 112 second, dislocations below, 100 bilateral backward, 107 forward, 105 double rotatory, 105 unilateral backward, 105 forward, complete, 102 incomplete, 101 lesions below, 99 upper, diagnosis of lesions, 88 729 INDEX Cervical vertebra, upper, prognosis in lesions of, 95 treatment of lesions, 90 Charcot knee, 41 Chauffeur's fracture, 365, 366 Children, elbow fractures in, 303 diagnosis, 314 operations in, 331 supracondylar, 309 treatment, 319 separation of external condyle of humerus in, 312 of internal epicondyle in, 313 of whole epiphysis of humerus in, 310 subluxation of head of radius in, 274 T-fractures of humerus in, 313 Chip fractures of toes, 716 Circular adhesive bandage, 198 swathe, felt shoulder-cap and wrist- sling, 227, 243 Circulation, test of, 395 Circumduction method of reduction of posterior luxation of hip, 492 Circumflex nerve injury in shoulder luxation, 214 Clavicle, 159 dislocations of, 159 of inner end, 159 of outer end, 163 diagnosis, 165 lesions, 163 operative treatment, 167 results, 168 treatment, 166 epiphyses of, separation of, 172 fracture of, of outer end, 169 diagnosis, 171 function of, 159 spur, as landmark, 182 subluxations of, 160 prognosis, 162 reduction and treatment, 161 Cleary's splint, 722 Clove-hitch for traction grip on ankle, 633 Cloth or leather anklet for traction on ankle, 634 Club-foot, 26 Coaptation splint, 242, 718 applied, 243 internal, used with internal angu- lar splint, 320 Coccyx, 145 diagnosis, 147 lesions of, 145 treatment, 147 Collar, Thomas, 93, 94 Colles' fracture, 43, 362 abduction, 377, 387 after-treatment, 400 arthritis, secondary in, 402 comminuted transverse fracture in, 368 compound, 384 Colles' fracture, cracks of radius not penetrating width of bone, 378 deformity after, 403 entanglement of ulnar styloid in, 388 etiology, 364 fracture luxation of radial stvloid in, 377 of ulnar styloid in, 381 Greenstick fracture of both bones in, 379 historical, 362 impaction in, 385 injuries to vessels and nerves in, 384 lesions in, 366 of ligaments, 382 of periosteum, 384 of ulna, 380 oblique downward and outward, 378 upward and backward, 372 and forward, 373 and outward, 376 operative treatment, 404 pads in treatment of, 394 plaster applied for, 725 reduction in, 390 results, 401 reversed, 356 separation of radial epiphysis in, 370 silver-fork deformity in, 386 simple transverse fracture in, 368 splint pressure in, 393 splints for, 393, 394 symptoms, 386 transverse cracks of radius in, 378 treatment, 388 with simple adhesive strapping, 396 z-ray in, 388 Comminuted fractures, 23 Complex fracture, 24 Complicated fracture, 24 Compound dislocations, 61 fractures, 23, 61 at ankle, 640 at wrist, 384 and non-union, 36 diagnosis, 62 of humerus at elbow, 290 of os calcis, 695 operation, 63 results, 65 treatment, 62 luxation of hip, 499 of shoulder, 221 Condyle as elbow landmark, 248 external, as elbow landmark, 251 of humerus, fracture of, 285, 312 treatment, 298 internal, of humerus, fracture, 287 treatment, 298 Condyles of femur, fracture of either, near knee, 572 fractures above, at knee, 561 730 INDEX Delbet's technic of plaster in leg frac- tures, 726 Deltoid paralysis, 214 Diabetes, 26 Diagnosis of fractures, 26 personal training in, 30 of luxations, 27 Diastasis of atlas and axis, 85 of cervical vertebra, 108 of sacro-iliac joint in pelvic fractures, 467 of tibia and fibula at ankle, 609 Digital fossa, 471 Dip exercise, 247 Direct method of reduction of posterior luxation of hip, 490 Diseases predisposing to fracture, 26 Dislocation. See also Luxation. acromioclavicular, dressing for, 166 backward of metacarpus of thumb, 429 below second cervical vertebrae, 100 bilateral forward, 105 double rotatory, 105 unilateral backward, 105 forward, complete, 102 incomplete, 101 carpal, with fracture, 421 compound, 61 costochondral, 156 definition, 21 of atlas on axis, 85 of clavicle, 159 of inner end, 159 of outer end, 163 diagnosis, 165 lesions, 163 operative treatment, 167 results, 168 treatment, 166 of coracoid process, 182 of dorsal spine, 120 of elbow, 252 backward, lesions, 253 complications, 253 of ensiform cartilage, 150 of front end of rib, 153 of hip, 474 with fracture of femur, 499 of jaw, backward, 75 forward, 69 diagnosis, 71 of lower jaw forward, operative treatment, 74 of jaw, forward, pathology, 69 prognosis, 74 treatment, 72 inward, 76 outward, 76 reduction, 77 recurrent, 75 upward, 76 of knee, 553. See also Knee, luxa- tions of. of knuckles, 431 Congenital backward luxation of shoul- der, 206 luxations, 26 at knee, 557 definition, 22 of patella, 578 of radius, 278 of scapula, 174 of shoulder, 221 of wrist, 361 Contracture, Volkmann's, 333 Convalescent splints, 723 Cooper's method of reduction, 192 Coracohumeral ligament, 186 Coracoid, fracture of, 182 process alone, fracture of, 80 as shoulder landmark, 182 dislocation of, 182 fracture of, 176 of forearm, fracture of, 338 Costochondral dislocation, 156 joint, subluxations of, 158 Cotton's fracture, 606, 622 after treatment, 625 diagnosis, 624 results, 625 method of applying adhesive to maintain acute flexion, 247 of reducing fracture of sternum, 149 reduction manoeuvre for os calcis fractures, 691 Cottrell-Gibney adhesive strapping for convalescence in ankle injuries, 639 Counter pressure pads for fractured femur, Pierson's, 721 Coxa vara, 526, 533, 535 Cradle to keep bed clothes from leg, 522 Crepitus, transmission of, 28 Crest, iliac, fracture of, 466 Cubitus valgus, 331 varus, 331 Cuboid, displacement from its articula- tion with os calcis, 671 fracture of, 698 luxation of, 698 Cuirass, plaster, 92 Cuneiforms, fracture of, 700 luxation of, 699 Cyst, bone, 26, 40 Deaths in hip fracture, 521 Debridement, 63 Definitions, 21 Deformity after Colles' fracture, 403 gunstock, 29, 324, 331 operation for, 331 in dorsal spine lesions, 124 in lumbar vertebrae lesions, 138 in supracondylar fractures of humerus, 318 silver-fork, 386 Madelung's, 360, 361, 408 Delayed union. See Non-union. Delbet's technic for reduction under traction, 634 INDEX 731 Dislocation of lower jaw, 69 of metatarsals, 701 of neck, 100 prognosis, 117 of occiput on atlas, 85 of patella, 574. See also Patella, dislocations of. of phalangeo-metacarpals, 431 of phalanges, 444 of radius and ulna, divergent, 268 forward, 267 of rib from cartilage, 156 on vertebrae, 152 of scapula, 174 of semilunar cartilages, 557 of thumb at metacarpophalangeal joint, 431 open, definition, 61 treatment, 50 Displacement of cuboid from articula- tion with os calcis, 671 of great toe, 714 of scaphoid away from astragalus, 671 Distortion, 82 definition, 21 Distraction, 82 definition, 21 of cervical spine, 82 of dorsal spine, 123 Divergent luxation at elbow, 268 Dorsal spine, 119 dislocations, 120 distraction, 123 fracture dislocation, 121 of spine without displacement of bodies, 122 injuries, 119 after-treatment, 135 causes, 119 deformity in, 124 diagnosis, 123 differential diagnosis, 125 forcible correction, 133 reduction, 134 gravity reduction, 134 laminectomy for, 132 prognosis, 129 treatment, 131 of cases without paralysis, 131 of paraplegic cases, 132 landmarks, 119 Double vertical fracture of Malgaigne, 453, 454 Double-inclined plane splint, 547, 548 Down-dropping exercise, 245 Dressing, adhesive, to support arm, 198 for acromioclavicular dislocation, 166 Sayre's clavicle, 170 Stimson's adhesive, 167 Dropped knuckle, 438 Dugas' test, 188 Dupuytren's fracture, 362 splint, short, 635 Eau-coukant, 53 Edmonton extension tongs, 723 Effleurage, 52 Effusion in patella fracture, 582, 583 Elbow, 248 dislocations, 252 backward, lesions, 253 complications, 253 exercises, 55 fractures, 279 at, separation of external condyle, 312 external condyle, 312 fracture of humerus at, 279 in adults, 280 capitellum, 287 compound, 290 external condyle, 285 internal condyle, 287 epicondyle, 287, 288 lesions, 280 nerve injuries in, 291 pathologic, 302 results, 300 supracondylar, 281 symptoms, 280 T-fractures, 284 treatment, 292 vessel injuries, 291 in children, 279 diagnosis, 314 of humerus at, 303 operations in, 331 separation of humeral epiphyses, 310 supracondylar, 309 T-fractures, 313 treatment, 319 internal epicondyle, 313 of humerus at, in children, 303 classification, 306 of radius, 274 splint for, 299 supracondylar, 309 landmarks, 248 luxation, 252 after-treatment, 269 backward, 253, 255 reduction, 256 complications, 253 compound, 253 divergent, 254 forward, 254 general diagnosis, 254 inward, 254, 266 myositis ossificans complicating, 269 nerve complications, 269 outward, 261 diagnosis, 262 reduction, 265 prognosis, 269 rotatory, 254 supracondylar fractures, 309 Electrotherapy, 54 732 INDEX Embolism, 65 fat, 66 diagnosis, 68 onset of symptoms, 67 prognosis, 68 symptoms, 67 treatment, 68 Epicondyle, external, of humerus, frac- ture of, 285 internal, as elbow landmark, 250 of humerus, fracture, 288 treatment, 300 separation of, 312 of femur, fracture of, near knee, 572 Epiphyses of clavicle, separation of, 172 of femoral head, separation of, 533 of femur near knee, separation of, 565 of fibula, alone, separation of, 636 of great trochanter, separation of, 550 of hand, anatomy of, 428 of humerus, anatomy, 303 separation of, 310 treatment, 232 of' olecranon, separation of, 346 of phalanges, fracture of, 448 of radius, separation of, in Colles' fracture, 370 upper, separation of, 353 of tibia and fibula, separation at ankle, 636 upper, separation of, 598 Epitrochlear fracture, 288 Ensiform cartilage, dislocation of, 150 Ether, primary, 388 Everted thyroid luxation, 487 Excision of astragalus, 661 Exercises, 54 ankle, 56 caterpillar, 55, 244 dip, 247 down-dropping, 245 elbow, 55 finger, 54 for forearm rotation, 55 hand, 54 hip, 55 knee, 55 shoulder, 55 Extension apparatus, Buck's, 537, 538 Buck's, technic, 718 tongs, Edmonton, 718, 723 treatment, 51 External condyle of humerus, fracture of, 285, 312 epicondyle of humerus, fracture of, 287 malleolus, fracture of, at ankle, 640 popliteal nerve, damage to, 566, 600 Fascia lata, 472 Fat embolism, 66 diagnosis, 68 onset of symptoms, 67 prognosis, 68 symptoms, 67 treatment, 68 Femur, fractures of, at base of neck, 535 diagnosis of impacted fracture, 536 of unimpacted fracture, 537 prognosis, 541 treatment, 538 below trochanters, 543 dislocation of hip with, 499 head of, 505 near knee, 561 above condyles, 561 epiphyseal separations, 565 of either condyle, 572 of epicondyles, 572 T-fractures, 563 of great trochanter alone or sepa- ration of its epiphysis, 550 of lesser trochanter, 552 of neck, 506 lesions in, 507 results of treatment, 529 signs in unimpacted fracture, 518 of imp action, 517 symptoms, 509 treatment, 520 of unimpacted fracture, 523 524 separation of epiphysis, 533 through trochanters, 542 Fibula, 599 and tibia, diastasis of, at ankle, 609 fracture of, above ankle joint, 629 separation of epiphyses at ankle, 636 epiphysis of, alone, separation of, 636 fracture of, at ankle, 637 diagnosis, 638 treatment, 639 near head, 600 luxation of lower end, 609 of upper end, 599 outward, 609 Finger and thumb grip for reduction of phalangeal dislocations, 715 exercises, 54 knuckle, line of, 438, 439 luxation with tendon rupture, 444 Fingers, fracture of, 446 Fixation, dangers of, 50 Flatfoot after ankle fracture, 645 from os calcis fracture, 696 plates, 725 Floating ribs, 153 Foot, cuboid fracture, 698 luxation, 671-698 cuneiform fracture, 700 luxation, 699 fracture of fifth metatarsal by inver- sion, 711 landmarks of, 601 luxation of, including os calcis, beneath astragalus, 665 of phalanges, 714 measurement of, 602, 603 medio-tarsal luxation, 671 INDEX 733 Foot, metatarsal fracture, 706 luxation, 701 os calcis fracture, 676 supports for in ankle fracture, 649 scaphoid displacement, 671 fracture, 698 luxation, 698 sesamoid fracture, 713 subastragaloid luxation, 665 tarsal fractures, unclassified, 700 Forearm, fracture of, below elbow, 333 of both bones (high), 334 of coronoid process, 338 of olecranon, 340 of radius, 348 luxation, backward, 255 forward, 267 inward, 266 outward, 261 of ulna alone, 336 separation of epiphysis of ole- cranon, 346 of upper radial epiphysis, 353 Greenstick fracture of, 379 rotation, exercises for, 55 Fractura rotuli humeri, 287 Fracture or fractures, at base of neck of femur, 535 at elbow in children, diagnosis, 314 operations in, 331 supracondylar, 309 T-fractures, 313 treatment, 319 separation of external condyle, 312 Barton's, 356, 358, 361 reversed, 361, 362 below trochanters, 543 Bennett's, 435 chauffeur's, 365, 366 chip, of toes, 716 Colles', 41, 362. See also Colles' fracture. comminuted, 23 complex, 24 complicated, 24 complicating shoulder luxation, 208 compound, 23, 61 at ankle, 640 at elbow, 290 at wrist, 640 of humerus at elbow, 290 Cotton's, 606, 622 definition, 22 diagnosis of, 26 personal training in, 30 diseases predisposing to, 26 dislocation of dorsal spine, 121 double vertical, of Malgaigne, 453, 454 Dupuytren's, 362 elbow, 279 in adults, 279 capitellum, 287 compound, 290 external condyle, 285 Fracture, elbow, in adults, external epicondyle, 287 internal condyle, 287 epicondyle, 288 lesions, 280 nerve injuries in, 291 pathologic, 302 results, 300 supracondylar, 281 symptoms, 280 T-fractures, 284 treatment, 292 vessel injuries, 291 in children, 279 epitrochlear, 288 forms of, 23 from bullet wounds, 62 greenstick, definition, 22 of both bones at wrist, 379 incomplete, 26 definition, 22 increase of knowledge, 28 inversion, of fifth metatarsal, 711 knuckle, 437 luxations of cervical vertebra; with displacement, 108 of lumbar vertebr®, 137 radial styloid, 377 of acetabulum, 460 of acromion, 177 treatment, 178 of anatomic neck complicating shoul- der luxations, 211 of anterior-superior spine, 467 of arrachement, 364 of astragalus, 661 of base of metacarpal of thumb, 434 of bases of metacarpus, 441 of body of astragalus, 664 of a vertebra, 122 of both bones of forearm (high), 334 of capitellum of humerus, 287 of carpal bones, 427 scaphoid, 422 with total semilunar luxation, 427 of carpus, 422 with carpal dislocations, 421 of cervical vertebrae, treatment, 115 of clavicle, outer end, 169 diagnosis, 171 treatment, 172 of coracoid, 182 process, 176 of coronoid process alone, 80 of forearm, 338 of cuboid, 698 of cuneiforms, 700 of elbow, 279 in adults, 280 in children, 279 of epiphyses of phalanges, 448 of external condyle of humerus, 312 treatment, 298 epicondyle of humerus, 287 malleolus at ankle, 640 734 INDEX Fracture of femur, at base of neck, 535 below trochanters, 543 dislocation of hip with, 499 head of, 505 near knee, 561 above condyles, 561 epiphyseal separations, 565 of either condyle, 572 of epicondyles, 572 T-fractures, 563 neck of, 506 of great trochanter alone or separa- tion of its epiphysis, 550 of lesser trochanter, 552 separation of epiphysis, 533 through trochanters, 542 of fibula at ankle, 637 near head, 600 of fingers, 446 of first and second cervical vertebra;, 85 of forearm below elbow, 333 of front end of rib, 153 of glenoid cavity, 176 complicating shoulder luxation, 208 of great trochanter alone or separa- tion of its epiphysis, 550 of head of femur, 505 j of fibula, 600 of hip, 505 at base of neck of femur, 535 below trochanters, 543 classification, 505 head of femur, 505 neck of femur, 506 of great trochanter alone or separa- tion of its epiphysis, 550 of lesser trochanter, 552 separation of epiphysis, 533 through trochanters, 542 of humerus, 224 at elbow, 279 diagnosis, 314 operations in, 331 pathologic, 302 results, 300 treatment, 292, 319 in children, 303 classification, 306 of anatomic neck, 224 treatment, 226 of greater tuberosities, 227, 228 of head, 224 of lesser tuberosities, 227, 228 of surgical neck, 234 separation of epiphyses, 229 treatment, 232 through or below tuberosities, 234 treatment, 240 upper end, 224 of iliac crest, 466 of insane, 25 of internal condyle of humerus, 287 treatment, 298 epicondyle of humerus, 288, 313 Fracture of internal epicondyle of humerus, treatment, 300 of jaw; 78 at or near angle, 78 operation, 79 of lamina, 122 of lesser trochanter, 552 tuberosity complicating shoulder luxation, 210 of metacarpus, 434 of bases, 442 of shaft, 441 of metatarsals, 706 of neck of astragalus, 663 of femur, 506 of jaw below condyle, 80 symptoms, 80 treatment, 81 prognosis, 117 treatment, 115 of olecranon, 340 of os calcis, 676 of other metacarpal bones, 436 of patella, 579 of pelvis, 449 through rami, 450 with fracture posteriorly or with sacro iliac separation, 453 of phalanges of hand, 446 of rami of pelvis, 450 with fracture posteriorly or with sacro-iliac separation, 453 of radius at wrist, 368-386 Greenstick, 22 near elbow, 348 of rib cartilage, 154 of scaphoid, 698 of scapula, of body, 179 of spine, 178 of surgical neck, 175 of sesamoid, 713 of shaft of metacarpus, 441 of a spinous process, 122 treatment, 123 of sternum, 150 of surgical neck of humerus compli- cating shoulder luxation, 211 treatment, 240 of scapula, 175 of tarsus, 700 of tibia and fibula above ankle joint, 629 of toes, 715 of trochlea, 287 of tuber ischii, 466 of ulna alone, 336 with luxation of radius, 272 of ulnar styloidin Colles' fracture, 381 oblique, 23 open, 23, 61 operative treatment, 57 Pott's, 604, 606, 610. See also Pott's fracture. INDEX 735 Fracture, sacral, 470 Smith's, 356 spiral, 23 spontaneous, 24, 25,[26 sprain, 29 stave, Bennett's, 435 stellate, of wrist, 378 strain, 553 subperiosteal, definition, 22 supracondylar, 281 treatment, 292, 718 through acetabulum, 461 through trochanters, 542 transverse, 23 treatment, 50 with penetration of acetabulum, 463 x-ray in, 28 Fragilitas ossium, 26 Frame, Balkan, 719, 720 Bradford, 135 hammock, 524 Fringes in knee, pinching of, 558 Frog plaster, 521 Gangrene in epiphyseal separation at knee, 566 Gas bacillus, 63 infection, 64 General principles of treatment, 50 Generalities, 21 Genu recurvatum, 26, 556, 557, 578 Gibney-Cottrell adhesive strapping for convalescence in ankle injuries, 639 Girdle, pelvic, 468 Girdle-pains, 139 Gladiolus, luxation of, on manubrium, 148 Gleich's operation in os calcis fracture, 696 Glenoid cavity, fracture of, 176 fractures of, complicating shoulder luxation, 208 new, formation of, in neglected shoulder luxation, 217 of temporal bone, 76 Goldthwait's thumb splint, 435 Gravity method of reduction of pos- terior luxation of hip, 490 Great toe, displacement of, 714 Greater trochanter alone, fracture of, or separation of its epiphysis, 550 tuberosity, of humerus, fracture of, 228 separation of, complicating shoul- der luxation, 209 Greenstick fracture, definition, 22 of forearm, 379 of radius, 22 Grip for reduction of luxation of thumb, 433 to hold foot, 618 to test for abnormal lateral mobil- ity in Pott's fracture, 615, 616 Gunshot wounds, 62 Gunstock deformity, 29, 324, 331 Gunstock deformity in supracondylar fracture of humerus, 318 operation for, 331 Gutter splint of tin, 430 Habitual dislocation of semilunar cartilages, 557 subluxation forward of jaw, without trauma, 75 Ham-splint, 718 Hand, epiphyses of, anatomy, 428 exercises, 54 phalanges of, fractures of, 446 subluxation of phalanges, 444 Hand-grips for reduction of wrist frac- ture, 389-391,397 Head of fibula, fracture near, 600 of humerus, fracture of, 224 of radius, subluxation in children, 274 Heat, application of, 53 Heel in axilla, 192, 195 Thomas, 725 Hereditary luxation of patella, 578 Hey's internal derangement of knee, 557 Hip, central luxation of, 463 dislocation of, 474 anterior, 483 position of head in, 484 reduction, 494, 497 by Allis' method, 495 by inward rotation, 495 by outward rotation, 496 symptoms in, 484 central, 487 ischiatic, 482 lesions in, 483 obturator, reduction, 498 old, reduction, 500 perineal, reduction, 498 posterior, 476 causes, 476 lesions in, 477 position of head in, 478 reduction by Allis' method, 490 by Bigelow's method, 492, 493 by circumduction, 492 by direct method, 490 by gravity method, 490 symptoms, 479 reductions, 488 after treatment, 500 obstacles to, 501 capsule, 501 muscles, 502 sciatic nerve, 503 prognosis, 500 reversed thyroid, reduction, 498 suprapubic, reduction, 498 with fracture of femur, 499 exercises, 55 fractures of, 505 at base of neck of femur, 535 below trochanters, 543 classification, 505 head of femur, 506 736 INDEX Hip, fractures of, neck of femur, 506 of great trochanter alone or separa- tion of its epiphysis, 550 of lesser trochanter, 552 separation of epiphysis, 533 through trochanters, 542 ischiatic luxations, 482 landmarks of, 471 luxation, central, 487 compound, 499 everted anterior, 487 dorsal, reduction, 492 thyroid, 487 infraspinous, 486 obturator, 487 perineal, 487 pubic, 485 reductions, 488 after treatment, 500 subspinous, 486 suprapubic, 486 Hoffa's table for leg traction, 525, 526 Humerus as elbow landmark, 251 epiphyses of, anatomy, 303 separation of, 229, 310 treatment, 232 fractures of, 224 at elbow, 279 diagnosis, 314 operations in, 331 pathologic, 302 results, 300 treatment, 292, 319 in children, 303 classification, 306 separation of external condvle, 312 compound, at elbow, 290 of anatomic neck, 224 treatment, 226 of capitellum, 287 of external condyle, 285 treatment, 298 epicondyle, 287 of greater tuberosities, 227, 228 of head, 224 of internal condyle, 287 treatment, 298 epicondyle, 288 treatment, 300 of lesser tuberosities, 227, 228 of surgical neck, 234 separation of epiphyses, 229 treatment, 232 through or below tuberosities, 234 treatment, 240 upper end, 224 head of, as shoulder landmark, 182 separation of epiphyses, 229 treatment, 232 of internal epicondyle of, 313 supracondylar fracture of, deformity in, 318 Hydrotherapy, 53 Hyperextension jacket, 135 Iliac crest, fracture of, 466 Ilium, fracture of, 466, 467 of crest, 466 of anterior-superior spine, 467 Incisions, multiple, 58 Inclinaison, Malgaigne's, 86 Incomplete fractures, 26 Infection, gas-bacillus, 64 Infractions, 26 definition, 23 Infraspinous luxation of hip, 486 Insane, fractures of, 25 Internal angular splint, 243, 292, 293 application, 320 coaptation splint used with internal angular splint, 320 condyle of humerus, fracture, 287 derangement of knee, Hey's, 557 epicondyle of humerus, fracture of, 288 separation of, 312 Intrathoracic luxation of humerus, 205 Inversion fracture of fifth metatarsal, 711 Inverted Pott's fracture, 626 Inward dislocation of elbow, 266 luxation of patella, 577 of shoulder, 205 Ischemic paralysis, 332 Ischiatic luxations of hip, 482 Ischium, tuberosity of, fracture of, 466 Jacket, hyperextension, 135 plaster, 133, 136 Jaw, coronoid process, fracture of, 80 dislocation of, 69 backward, 75 forward, 69 treatment, 72 inward, 76 outward, 76 reduction, 77 upward, 76 fractures of, 78 at or near angle, 78 operation, 79 of neck, 80 symptoms, 80 treatment, 81 habitual subluxation forward without trauma, 75 lower, dislocation, 69 fracture, 78 Joint, metacarpophalangeal, disloca- tion of thumb at, 431 mice, 558, 559, 573 sacro-iliac, 467 anatomy, 468 diastasis of, in pelvic fractures, 467 Jones' abduction arm splint, 722 Jones-Murray splint, 722 Knee, Charcot, 41 dislocations, 553 exercises, 55 fractures of femur at, 561 INDEX 737 Knee, fractures of femur above con- dyles, 561 epiphyseal separations, 565 of either condyle, 572 of epicondyles, 572 T-fractures, 563 of patella at, 579 internal derangement of, 557 luxation, anterior, 553 backward, 555 congenital, 557 inward, 555 of semilunar cartilages, 557 outward, 556 subluxation outward, 556 tibial injuries just below, 595 Kocher's reduction, 190, 191 Knuckles, dislocations of, 431 dropped, 438 fracture, 437 treatment, 439 Lamina, fracture of, 122 Laminectomy for dorsal spine injuries, 132 Landmarks of cervical spine, 83 of elbow, 248 of pelvis and hip, 471 of shoulder, 181 Lane plates, 45 staple, 45 Terry's modification, 628 Leather or cloth anklet for traction on ankle, 634 wrist-band, 401 Leg, measurement of, 474 errors in, 475 Legg's disease, 533 Lesser trochanter, fracture of, 525 tuberosity, fractures of, complicating shoulder luxation, 210 of shoulder, fracture of, 228 Levis splint, 394 Ligament, Poupart's, 471 Ligaments, lesions of, in Colles' frac- ture, 382 weakening of, after ankle fracture, 645 Ligamentum patellae, rupture of, 592 Lumbar vertebrae, 137 deformity in lesions of, 138 diagnosis of lesions, 139 differential diagnosis of lesions, 140 direct physical signs of displace- ment, 139 distraction injuries, 142 fracture luxations, 137 fractures of transverse processes, 142 indirect signs of displacement, 139 luxations of, 137 etiology, 137 muscle strain, treatment, 144 prognosis of lesions, 143 sprains and contusions of, 142 treatment of lesions, 143 47 Lund swathe, 297 Luxatio erecta, 184, 194, 204 Luxation. See also dislocation. at wrist, backward, 356 forward, 358 below astragalus, 665 central, of hip, 463 compound, definition, 22 congenital, 26 definition, 22 diagnosis, 27 fracture, of cervical vertebrae with displacement, 108 of radial styloid, 377 Malgaigne's, 274 of ankle joint, 604 of astragalus, 656 of carpus, 411 of one row on other, 411 of single bones, 418 of cervical vertebra), treatment, 112 of cuboid bone, 698 of cuneiforms, 699 of elbow, 252 after-treatment, 269 backward, 253, 255 reduction, 256 complications, 253 compound, 253 divergent, 254 forward, 254 general diagnosis, 254 inward, 254, 266 myositis ossificans complicating, 269 nerve complications, 269 outward, 261 diagnosis, 262 reduction, 265 prognosis, 269 rotatory, 254 of first and second cervical vertebrae, 85 of foot including os calcis beneath astragalus, 665 of gladiolus on manubrium, 148 of hip, anterior, 483 reduction, 494 central, 487 compound, 499 everted anterior, 487 dorsal, 478 thyroid, 487 high dorsal, 478 infraspinous, 486 ischiatic, 478, 482 low dorsal, 478 obturator, 487 old, reduction, 500 perineal, 487 posterior, 476 pubic, 485 reductions, 488 obstacles to, 501 738 INDEX Luxation of hip, reductions, prognosis, 500 subspinous, 486 suprapubic, 486 with fracture of femur, 499 of knee, 553. See also Knee, luxa- tions of. of lower end of fibula, 609 of lumbar vertebrae, 137 of metacarpals, 429 of neck, prognosis, 117 of patella, congenital or hereditary, 578 incomplete outward, 577 inward, 577 recurrent outward, 577 rotatory, 578 of pelvis, 449 of phalanges of foot, 714 of hand, 444 of radius at elbow, backward, 269 reduction, 270 congenital, 278 forward, at elbow, 271 outward, at elbow, 271 with ulnar fracture, 272 of scaphoid bone, 698 of scapula, congenital, 174 inward, 174 of shoulder, 183, 184 compound, 217 congenital, 221 old cases, 217 pathologic, 221 recurrent, 221 of sternum, 148 of toes, 714 of ulna alone, at elbow, 273 at wrist, 404 backward, 405 chronic backward, 407 forward, 408 inward, 408 recurrent, 409 backward, at elbow, 273 forward, at elbow, 274 of upper end of fibula, 599 paralytic, 26 radiocarpal, 356 recurrent, definition, 22 sacro-iliac, 469 chronic, 468 shoulder, 27 spontaneous and pathologic, 24 definition, 21 subastragaloid, 665 Madelung's deformity, 360, 361, 408 Male pelvis, 450 Malgaigne on dorsal hip luxations, 478 Malgaigne's double vertical fracture, 453, 454 fracture of pelvis, 453 inclinaison, 86 luxation of elbow, 274 Malleoli as landmarks, 601 Malleolus, external, fracture of, at ankle, 640 Malnutrition, 26 Malum coxae senile, 529 Manubrium, luxation of gladiolus on, 148 Massage, 52 in non-union, 39 Maxwell - Phillips-Ruth anatomic method of treatment in unimpacted fractures of femoral neck, 524 Measurements in hip fracture, 518 of leg, errors in, 475 of length of foot, 602, 603 to detect backward displacement in Pott's fracture. 615 Mechanotherapy, 54 Medio tarsal luxation, 671 operation for, 675 reduction, 672 treatment, 672 subluxation, 675 Metacarpal bones, fractures of, 436 injuries, 429 luxations of, 429, 431 Metacarpophalangeal joint, dislocation of thumb at, 431 Metacarpus, fracture of, 434 of bases, 442 of shaft, 441 of thumb, dislocation backward, 429 fracture of base, 434 Metatarsal strain, 651 Metatarsals, dislocation, 701 fifth, inversion fracture of, 711 fracture of, 706 isolated luxations, 706 Mice, joint, 558, 559, 573 Mitteldorpp's triangle, 245 Mobilization, 50 Monks' triangle, 243, 245,722 Motor paralysis in elbow luxation, 269 Multiple incisions, 58 Murray-Jones splint, 722 Muscle action as cause of patellar luxation, 574 injuries in hip luxation, 477 interposition of, in non-union, 36 strain in lumbar region, treatment, 144 Muscles of hip joint as obstacle to reduction, 502 Myelomata, 26 Myositis ossificans, 46, 48 complicating elbow luxation, 269 Nailing in hip fracture, 527, 528 Neck, dislocations of, 100 prognosis, 117 fracture-luxations of, treatment, 115 with displacement, 108 fractures, deformity in, 110 diagnosis, 109 prognosis, 117 INDEX 739 Neck fractures, sensory areas, 109, 110 treatment, 115 luxations, bilateral backward, 107 forward, 105 double rotatory, 105 prognosis, 117 treatment, 112 unilateral backward, 105 forward, complete, 102 incomplete, 101 of humerus, anatomic, fractures of, 224 surgical, fractures of, 234 Nelaton line, 473 Neoplasms, 26 Nerve, circumflex, injury, in shoulder luxation, 214 complications in elbow luxations, 253 injury in Colles' fracture, 384 in elbow fracture, 291 lesions in shoulder luxation, 213 Nerve-root pressure relieved by hyper- extension, 132 symptoms in dorsal lesions, 128 in fracture of lumbar vertebrae, 139 Never-again plaster, 244 Non-union, 35 causes, 36, 42 constitutional causes, 37 defective fixation as cause, 38 from interposed muscle, 36 periosteum, 36 from new-growths, 37 from scurvy, 37 in compound fractures, 36 in diabetes, 26, 37 in local bone disease, 37 in multiple fractures, 36 in syphilis, 37 in tabetics, 37 massage in, 39 operative treatment for, 42 poor position in, 36 sepsis in, 36 treatment, 39 weight-bearing in, 38 Numbness and pain in elbow luxations, 253 Oblique fractures, 23 Obstetric paralysis, 222 Obstacles to reduction of hip luxa- tion, 501 of old shoulder luxation, 217 Obturator luxation of hip, 487 reduction, 446 Occiput, dislocations of, on atlas, 85 Old shoulder luxations, 217 Olecranon as elbow landmark, 250 fracture of, 340 separation of epiphysis, 346 Open fractures, 23, 61 Operative treatment, 57 outline for, 58 Os calcis, displacement of cuboid from its articulation with, 671 fracture of, 676 avulsion type, treatment, 695 compound, 695 diagnosis, 683 lesions, 678 reduction, 691 results, 690, 695 symptoms, 682 transverse, 695 treatment, 686 luxation of foot including, beneath astragalus, 665 Osgood and Penhallow splint, 245, 295, 722 Osteogenesis imperfecta, 25 Osteomalacia, 26 Osteomyelitis and fracture, 26 Osteopsathyrosis, 25 Osteotomy in old ankle fractures, 653 Pad and adhesive plaster strap to maintain arch of foot after fracture, 621 , 696 arch, 639 axillary, 243 Pads, counter pressure for fractured femur, Pierson's, 721 in treatment of Colles' fracture, 394 Pain and numbness in elbow luxations, 253 Pains, girdle-, 139 Palm, bandage roll in, 440 Palmar splint, 441 Palpation for fracture of ramus of jaw, 80 of anterior surfaces of cervical ver- tebra? through pharynx, 84 of external condyle, 251 of front surface of humerus, 252 of transverse process, 83 Paralysis in dorsal spine injuries, 124 in neck injuries, 109, 110 ischemic, 332 motor, in elbow luxation, 269 obstetric, 222 Paralytic luxations, 26, 221 Paraplegia in dorsal spine fractures, 132 Parham bands, 45 Parrot's disease, 566 Passive motion, dangers of, 52 Patella, dislocations of, 574 outward, 574 fractures of, 579 after treatment, 588 comminuted, 580 diagnosis, 582 differential, 584 lesions in, 581 non-operative treatment, 587 old, 590 operative treatment, 587 symptoms, 582 transverse, 579 740 INDEX Patella, fractures of, treatment, 584 luxation of, congenital or hereditary, 578 incomplete outward, 577 inward, 577 rotatory, 578 recurrent outward, 577 refracture of, 588 Pathologic fractures of humerus near elbow, 302 luxation, 24 of shoulder, 221 Pelvic girdle, 468 Pelvis, fractures, 449 diagnosis, 451 diastasis of sacro-iliac joint, 467 of acetabulum, 460 of anterior-superior spine, 467 of iliac crest, 466 of rami, 450 of tuber ischii, 466 reduction, 452 sacral, 470 sacro-iliac luxation complicating, 469 through acetabulum, 461 through rami, 450 with fracture posteriorly or with sacro-iliac separation, 453 treatment, 452 with penetration of acetabulum, 463 landmarks of, 471 luxations, 449 male, 450 separation of symphysis, 457 Penhallow and Osgood splint, 245, 722 Perineal luxations of hip, 487 Periosteum, lesions of, in Colles' fracture, 384 Perthes' disease, 533 Petrissage, 52 Phalangeo-metacarpals-, dislocations of, 431 PhalangeSj 444 dislocations of, 444 epiphyses of, fracture of, 448 of foot, luxation of, 714 of hand, fractures of, 446 subluxation of, with tendon rup- ture, 444 of thumb and index, anatomy, 444 Phillips-Maxwell-Ruth anatomic method of treatment in unimpacted fractures of femoral neck, 524 Physiotherapy, 52 Pierson's attachment for skeletal trac- tion, 721 counter pressure pads for fractured femur, 721 Pillow and side splints for Pott's fracture, 617, 618 Plantar splint, 709 Plaster applied for Colles' fracture, 725 cuirass, 92 frog, 521 jacket, 133, 136 never-again, 244 of Paris in Pott's fracture, 619 spica bandage, 526 rope, 726 shell, 144 spica for femur fracture, 526 work, technic, 725 Plates, flatfoot, 725 rocker, Whitman, 725 Posterior wire splint, 635 Posterior-superior spine, 471 Pott's fracture, 604, 606, 610 after treatment, 620 causation, 611 diagnosis, 613 end results, 622 inversion, 612, 616 inverted, 626 lesions, 612 treatment, 618 T-strap with upright traces for, 724 weakening of ligaments after, 645 Poupart's ligament, 471 Pression methodique, 52 Priapism, 110, 123 Pubic luxation of hip, 485 rami, fracture of, 450 spine, 471 Pulmonary embolism, 65, 67 Quadriceps tendon, rupture of, 591 Radial styloid, fracture luxation of, 377 Radiocarpal luxation, 356 Radius and ulna, dislocation, divergent, 268 forward, 267/. cracks of, not penetrating width of bone, in Colles' fracture, 378 epiphyses of, separation of, in Colles' fracture, 370 fractures at wrist, comminuted trans- verse, 368 greenstick, 379 oblique downward and outward, 378 upward and backward, 372 and forward, 373 and outward, 376 simple transverse, 368 Greenstick, 22 near elbow, 348 luxation of, backward, at elbow, 269 reduction, 270 congenital, 278 forward, at elbow, 271 outward, at elbow, 271 with ulnar fracture, 272 separation of upper epiphysis of, 353 INDEX 741 Radius subluxation at elbow, 274 of head in children, 274 transverse cracks in Colles' fracture, 378 Ramus of ischium, 471 of pelvis, fracture of, 450 with fracture posteriorly or with sacro-iliac separation, 453 Recurrent luxation of ulna at wrist, 409 shoulder luxations, 221 Reduction, Cooper's, 192 Kocher's, 190, 191 Stimson's, 194, 196 x-ray after, 32 Reefing operation for recurrent disloca- tion of shoulder, 220 Refracture of patella, 588 Relaxation, sacro-iliac, 468 Repair, 34 Resorption of bone, 35 Reversed Barton's fracture, 359-361 Colles' fracture, 356 thyroid luxation, 487 Ribs, 152 cartilage, fracture of, 154 dislocation of, 152 from cartilage, 156 floating, 153 front end, dislocation of, 153 fracture of, 153 separation of, from sternum, 154 Rickets, 23, 26 "Riding fragment," 653 Rigidity in neck fractures, 111 Rocker plates, Whitman's, 725 Roser-Nelaton line, 473 Rotation, forearm, exercises for, 55 Rotatory luxations in neck, 99, 105 of patella, 578 Round-arm blow, 429 Rupture of biceps tendon complicating shoulder luxation, 222 of blood-vessels complicating shoul- der luxation, 216 of ligamentum patellse, 592] of quadriceps tendon, 591 tendon, with subluxation of pha- langes of hand, 444 Ruth-Phillips-Maxwell anatomic me- thod of treatment in unimpacted fractures of femoral neck, 524 Sacral fracture, 470 Sacro-iliac joint, 467 anatomy, 468 diastasis of, in pelvic fractures, 467 luxation, 469 chronic, 468 separation with pelvic fracture through rami, 453 Sacrum, 145 diagnosis of lesions, 145 treatment of lesions, 145 Saddler's felt for splint pads, 394 Sand baking, 53 Sarcoma, 26 in non-union, 37 Sayre's clavicle dressing, 170 Scaphoid bone, luxation of, 698 carpal, fractures of, 422 with total semilunar luxation, 427 displacement away from astragalus, 671 fracture of, 698 Scapula, 174 dislocation of, 174 fracture of body, 179 of spine, 178 of surgical neck, 175 luxation of, congenital, 174 inward, 174 Sciatic nerve as obstacle to treatment in hip luxation, 503 Scurvy, 26 in non-union of fractures, 37 Semilunar bone, luxation of, with sca- phoid fracture, 427 cartilages, dislocation of, 557 after-treatment, 560 diagnosis, 558 symptoms, 558 treatment, 559 Senn's method of treatment in hip fracture, 526 Separation of anterior-superior spine, 467 of cartilage, 153 of epiphyses at ankle, 636 of clavicle, 172 of femoral head, 533 of femur at knee, 565 of external condyle of humerus, 312 of greater tuberosity complicating shoulder subluxation, 209 of internal epicondyle of humerus, 313 of olecranon epiphysis, 346 of radial epiphyses, 370 of ribs from sternum, 154 of symphysis, 457 of upper epiphysis of tibia, 598 radial epiphysis, 353 Sepsis as cause of non-union, 36 Sesamoid, fracture of, 713 Shell, plaster, 144 Sherman plates, 45 Shock and non-union, 42 Shoulder, 181 exercises, 55 injuries, attitudes in, 187, 202 landmarks, 181 luxation, 27, 183 bursal lesions complicating, 223 compound, 217 congenital, 221 forward, 184 fractures complicating, 208 of anatomic neck complicating, 211 742 INDEX Shoulder luxation, fractures of glenoid complicating, 208 of lesser tuberosity complicating, 210 of surgical neck complicating, 211 inward, 205 intracoracoid, 200 intrathoracic, 205 luxatio erecta, 204 nerve lesions in, 213 old cases, 217 pathologic, 221 posterior, 205 recurrent, 221 reduction, 207 rupture of biceps tendon com- plicating, 222 separation of greater tuberosity complicating, 209 subacromial, 205 subclavicular, 200 treatment, 201 subcoracoid, 184 after-treatment, 197 diagnosis, 188 downward traction with lever- age, 193 etiology, 184 Kocher's reduction in, 190, 191 lesions, 185 reduction by outward traction, 193 by upward traction, 194 with heel in axilla, 192 results, 189 symptoms of, 188 treatment, 189 subglenoid, 2Q1 subspinous, 205 supraglenoid, 204 types, 184 vessel rupture complicating, 216 subluxation downward, 203 Shoulder-cap, felt, circular swathe and wrist-sling, 227, 243 Silver-fork deformity, 386 Sinclair skate, 634, 723 Skate, Sinclair, 634, 723 Skeletal traction, Pierson's attachment for, 721 with tongs applied to malleolis, 723 Sling, 198 device for putting on plaster jackets, 136 proper application of, 294 wrist-, Jones', 299 wrong way to apply, 294 Smith's fracture, 356 Spanish windlass traction with Thomas splint, 719 Spica bandage of plaster of Paris, 526 Spike of bone in hip fracture, 527 Spine, anterior-superior, separation of, 467 Spine, anteroposterior deviation of, 125 cervical, injuries of, 82 landmarks, 83 dorsal, 119 dislocations, 120 distraction, 123 fracture dislocation, 121 of spine without displacement of bodies, 122 injuries, 119 after-treatment, 135 causes, 119 deformity in, 124 diagnosis, 123 differential diagnosis, 125 forcible correction, 133 reduction, 134 gravity reduction, 134 laminectomy for, 132 prognosis, 129 treatment, of cases without paralysis, 131 of paraplegic cases, 132 landmarks, 119 lateral deviation of, 125 of scapula, fracture of, 178 Spinous process, fracture of, 122 treatment, 123 Spiral fractures, 23 Splint, abduction, Jones', 722 anterior suspension, 547 aviation, 245, 722 banjo, 435 Bavarian, 726 Bolles', 326 elbow, 292 Cabot, 549 Cleary's, 722 coaptation, 242, 718 applied, 243 convalescent, 723 double-inclined plane, 547, 548 Dupuytren, short, 635 for Colles' fracture, 393, 394 for elbow fractures, 299 for fracture of patella, 586 gutter, of tin, 430 ham-, 718 internal angular, 243, 292, 293 application, 320 coaptation used with internal angu- lar splint, 320 Jones' abduction, 722 Levis, 394 Osgood-Penhallow, 245, 295, 722 Murray-Jones, 722 palmar, 441 plantar, 709 posterior wire, 635 side, and pillow for Pott's fracture, 617, 618 Thomas, technic, 719 with Spanish windlass traction, 719 thumb, Goldthwait's, 435 vertical suspension, 548 INDEX 743 Splint, Walker's, 395 Splints, technic, 717 Spontaneous and pathologic luxations, 24 fractures, 24, 25, 26 luxations, definition, 21 Spondylitis traumatica, 130 Spondylolisthesis, 138 Sprain-fracture, 21, 29 Sprains, definition, 21 of ankle, 642 Spur, clavicle, as landmark, 182 of acromion as shoulder landmark, 182 Staple, Lane, 45 Terry's modification, 628 Stave fracture, Bennett's, 435 Stellate fractures of wrist, 378 Sternum, 148 fracture of, 150 luxation of, 148 diagnosis, 148 pathology, 148 prognosis, 149 treatment, 149 separation of ribs from, 154 Stimson's adhesive dressing, 167 dressing for Pott's fracture, 620, 621 reduction, 194, 196 Stirrup to hold foot up in femur frac- ture, 522 Strain fractures, 553 metatarsal, 651 muscle, in lumbar region, treatment, 144 Strap, adhesive, method of applying, 296 T-, with upright braces in Pott's fracture, 724 Styloid, radial, fracture luxation of, 377 ulnar, fracture of, in Colles' fracture, 381 Subacromial luxation, 205 reduction, 207 Subastragaloid luxation, 665 reduction, 669 Subcapital fracture, of femur, 506 Subclavicular luxation, 200 reduction, 201 Subcoracoid luxation, 184 reduction, 189 symptoms, 188 Subglenoid luxation, 201 reduction, 203 Subluxation, definition, 21 of clavicle, 160 prognosis, 162 reduction and treatment, 161 of club-foot, 26 of costochondral joint, 158 of head of radius in children, 274 of jaw, forward, habitual, without trauma, 75 of phalanges with tendon rupture, 444 of radius at elbow, 274 Subluxation of radius, reduction, 276 results, 276 of shoulder, downward, 203 sacro-iliac, 469 Subperiosteal fracture, definition, 22 Subspinous luxation, 205 of hip, 486 reduction, 207 Subtrochanteric fractures, 543 Sullivan blow, 429 Superior-anterior spine, separation, 467 Support for use after ankle fracture, 649 Supracondylar fractures, 281 in children, 309 treatment, 292 Supraglenoid luxation, 204 Suprapubic luxation of hip, 486 Suspension in femur fractures, 547-549 Symphysis, 471 separation of, 457 Syphilis and non-union, 37 of bone, 39 Syphilitic osteomyelitic processes, 24, 26 Table dorsalis and fracture, 24 Tabes for obtaining extension by adhesive-plaster traction and winches, 525, 526 Tarsus, fractures of, 700 lesions of, 698 Technic of open operations, 57-63 of splints and plaster, 717 Tendon, biceps, rupture of, complicat- ing shoulder luxation, 222 quadriceps, rupture of, 591 rupture with subluxation of pha- langes of hand, 444 sheaths, adhesions in, 386 Terms of description, 24 Terry's modification of Lane staple, 628 Test of circulation, 395 Tests for pelvic fractures, 451 Tetanus, 63 T-fracture at elbow, 284 in children, 313 treatment, 297 of femur above knee, 563 of humerus near elbow, 284 treatment, 297 of tibia, 595 Thermotherapy, 53 Thomas collar, 93, 94 heel, 725 splint, technic, 719 with Spanish windlass traction, 719 Thomas-Pierson attachment for skeletal traction, 721 Thrombi, 65 Thrombus formation, 65 Thumb and finger grip for reduction of phalangeal dislocations, 715 and index, phalanges of, anatomy, .444 744 INDEX Thumb, dislocation of, at metacarpopha- langeal joint, 431 reduction, 432 luxation of, lateral, 444 metacarpus of, dislocation backward, 429 fracture of, 434 of base, 434 treatment, 430 splint, Goldthwait's, 435 1 Thyroid luxation everted, 487 jl of hip, reversed, 487-498 Tibia and fibula, diastasis of, at ankle, 609 fracture of, above ankle joint, 629 separation of epiphyses at ankle, 636 epiphysis of, upper, separation of, 598 injuries just below knee, 595 T-fracture of, 595 tuberosity of, fracture, 595 Tibial tubercle, avulsion of, 592 Tibio-astragaloid luxation, 656 Tight bandage, signs of, 395-£99 Tin, gutter splint of, 430 Toe, great, displacement of,'714 Toe-drop, 600 Toes, fracture of, 715 luxation of, 714 Tongs, extension, Edmonton, 723 Torticollis, 112 right-sided, 110 Tourniquet, 58 Traction, in abduction, 722 in neck injuries, 113, 114 on lower leg and foot, 720 skeletal, 719 Pierson's attachment for, 721 with tongs applied to malleoli, 723 splint for humerus fractures, 243 treatment, 51 Transverse fracture, 23 of patella, 579 Traumatic arthritis, 46 treatment, 48 Treatment, operative, outline for, 58 Triangle, Bryant's, 473 Mitteldorpp's, 245 Monks', 243, 245 722 Trochanter, great, fracture of, or separation of its epiphysis, 550 fractures below, 543 through, 542 lesser, fracture of, 552 major, 471 Trochlea, fracture of, 287 T-strap with upright braces in Pott's fracture, 724 Tuber ischii, 471 fracture of, 466 Tubercle, tibial, avulsion of, 592 • Tubercular osteomyelitic processes, 26 Tuberculosis and fracture, 24-26 Tuberosities of humerus, fractures of, 227 through or below, 234 Tuberosity, greater, separation of, com- plicating shoulder luxation, 209 lesser, fractures of, complicating shoulder luxation, 210 Ulna and radius, dislocation, diver- gent, 268 forward, 267 fracture of, 334 greenstick, 379 fracture of, alone, 336 with luxation of radius, 272 lesions of, in Colles' fracture, 380 luxation of, alone, at elbow, 273 at wrist, 404 backward, 405 chronic backward, 405 forward, 408 inward, 408 backward, at albow, 273 forward at elbow, 274 recurrent, 409 Ulnar nerve, identification of, 250 in elbow luxation, 253 styloid, fracture of, in Colles' frac- ture, 381 Union, delayed, 35 Urethra, tearing of, in pelvic fracture, 451 Vein, axillary, tearing of, 217 Velpeau bandage, 171, 198 Verkleinerte lid-spalte, 110 Vertebra prominens, 119 Vertebrae, cervical, below axis, defor- mity in lesions of, 110 differential diagnosis of in- juries, 109 diastasis of, 108 first and second, fractures and luxations, 85 fracture-luxations with displace- ment, 108 treatment, 115 fractures of, treatment, 115 luxations of, treatment, 112 second, dislocations below, 100 bilateral backward, 107 forward, 105 double rotatory, 105 unilateral backward, 105 forward, complete, 102 incomplete, 101 lesions below, 99 upper, diagnosis of lesions, 88 prognosis in lesions of, 95 treatment of lesions, 90 fracture of body of, 122 lumbar, 137 deformity in lesions of, 138 diagnosis of lesions, 139 differential diagnosis of lesions, 140 direct physical signs of displace- ment, 139 distraction injuries, 142 INDEX 745 Vertebrae, lumbar, fracture luxations, 137 fractures of transverse processes, 142 indirect signs of displacement, 139 luxations of, 137 etiology, 137 muscle strain, treatment, 144 prognosis of lesions, 143 sprains and contusions of, 142 treatment of lesions, 143 Vertical fracture of Malgaigne, double, 453, 454 suspension splint, 548 Vessel damage in epiphyseal separation at knee, 566 injuries in elbow fracture, 291 rupture complicating elbow luxation, 253 shoulder luxation, 216 Volkmann's contracture, 333 deformity, 26 Walker's splint, 395 Weakening of ligaments after ankle fracture, 645 Weight bearing axis, deviations of, 647 Whirlpool baths, 53 Whitman's method of treatment in hip fracture, 526 rocker plate, 725 Windlass, Spanish, 719 Wounds, gunshot, 62 Wrestling-grip, 194, 197 Wrist, 354 fracture-luxations, 361 displaced outward, 361 greenstick fracture of both bones at, 379 injuries of, classification, 354 luxations of, backward, 356 forward, 358 of ulna, 404 backward, 405 chronic backward, 407 forward, 408 inward, 408 recurrent, 409 sprained, 354 Wrist-band, leather, 401 Wrist-sling, 243 felt shoulder-cap and circular swathe, 227, 243 Jones', 299 Wry-neck, 112 right-sided, 110 X-ray, 28 after reduction, 32 in Colles' fracture, 388 late, 33 routine use of, 30 Y-ligament, 475, 477 mechanism, 489