f^X)\C>\ "^•a^. Columbia ^nibcrfiitp in tf}t Citp of i^eto l^orfe CoUegc of ^!)j»gicians; anb burgeons! l^titxtntt Hibrarp FRACTURES AND DISLOCATIONS Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/fracturesdislocaOOpres FRACTUKES AND DISLOCATIONS DIAGNOSIS AND TREATMENT BY MILLER E. PRESTON, A.B., M.D. FIRST LIEUT. M. R. C, U. S. A. ; SURGICAL EXAMINER, COLORADO STATE BOARD OF MEDICAL EXAMINERS ; FORMERLY POLICE SURGEON, CITY AND COUNTY OF DENVER, INSTRUCTOR IN ANATOMY, UNIVERSITY OF DENVER, AND VISITING GYNECOLOGIST TO CITY AND COUNTY HOSPITAL, DENVER, COLORADO. WITH A CHAPTER ON RONTGENOLOGY- BtH. G. stover, M.D. PROFESSOR OF RONTGENOLOGY, SCHOOL OF MEDICINE, UNIVERSITY OF COLORADO; MEMBER OP AMERICAN RONTGEN RAY SOCIETY ; VISITING RONTGENOLOGIST TO CITY AND COUNTY HOSPITAL, ST. JOSEPH'S HOSPITAL AND CHILDREN'S HOSPITAL, DENVER, COLORADO. 860 ILLUSTRATIONS ST. LOUIS C. V. MOSBY COMPANY 1915 CoPVKIi;llT. 1915, BY C- v. MoSBV CoMPANV M y PrexK (if C. Y. Moshil Ciiinpanii St. Louis TO CHAS. B. LYMAN, M.D., F.A.C.S. From Whom the Author Received His First Instruction IN Fractures and Dislocations FOREWORD The object of this book has been to offer the reader a working knowledge of the subject in as few words as possible, avoiding for the most part all theories and arguments which are void of practical value for the surgeon who has to diagnose and treat the various in- juries which are met with in actual practice. The author has en- deavored to make the reader an eye witness to the various deformi- ties as they appear immediately following the accident, rather than to offer him lengthy text in describing the lesions. There is much to be learned by inspection in the average case of fracture or dislo- cation, and the information thus gained may be put to immediate use with a minimum amount of manipulation of the parts and without being obliged to await the returns of an X-ray examination. The more one learns by inspection, in establishing a diagnosis in a given case, the less there remains to be determined by palpation, and if the surgeon develops the faculty of recognizing what he sees the patient will many times be relieved of much unnecessary manip- ulation and suffering to say nothing of the damage which may be inflicted on the already traumatized soft tissues. Photography, therefore, is the best means of recording the initial deformities, but the excitement, confusion and pain attending the average case of fracture are conditions anything but favorable for picture- taking. Moreover the varying conditions of light and the sur- roundings in which we find the patient, together with the neces- sity of having the photographic apparatus available and in good working order, are additional factors which work against the se- curing of such valuable clinical data and explain the scarcity of pictures of these deformities in medical literature. The illustra- tions of such deformities shown on the following pages have been taken under unfavorable circumstances, in a large proportion of cases, and (although the photographic appliances were the best obtainable including the fastest Goerz and Zeiss anastigmat lenses) the results, from a photographic standpoint, have been none too good in many instances. The pictures shown have been chosen from a large number of such photographs with the intention of \n\ FOREWORD familiarizing the reader with the average clinical defonnity, rather than for the pur[)ose of recording rare cases or those in which tiie pathology is obscure. The time-honored, academic classification of fracfnres under one heading and dislocations under another has been abandoned, and the more practical method of eonsidei-ing the injuries according to the region in which they occur has been followed. Thus the reader will find all the injuries to which a given region is sub- ject (including fractures, dislocations, joint fractures and frac- ture-dislocations) without looking up the different conditions in widely separated sections of the book or even consulting another volume. The development of the Rontgen ray has been of inestimable value in the diagnosis of fractures and dislocations, and its use cannot ])c too highly commended; but, on the other hand, this very aid has resulted in our becoming more lax in other methods of. diagnosis. The X-ray is a most valuable supplement to other physical clinical methods but it should not be expected to sup- plant them. The surgeon should make a practice of determining the nature and location of the fracture as accurately as possible (due care being exercised to avoid unnecessary manipulation) be- fore the X-ray is taken, and later to compare his conception of the condition with the Rontgenogram. By making this a routine meas- ure he will find that his diagnostic acumen will be materially in- creased as time goes on. A certain mechanical sense is most essential in the treatment of fractures and dislocations, and no text-book can supply this to one naturally deficient in this respect. However, an attempt has been made in the following pages to supply the necessary data for the development of this sense and to place before the reader, as far as possible, some of the author's experiences. The more common fractures have been accorded the greatest amount of attention since they are the conditions with which the average practitioner will have to deal most frequently. Occasion is here taken to thank a number of members of the medical profession in Denver who have been of service in various ways in obtaining the material for and in the preparation of this work. Among others the author wishes particularly to express his gratitude to: Drs. C. B. Lyman, T. E. Carmody, Leonard Ely, H. R. ]\IcGraw, Benj. Matthews, V. D. .McKelvey, J. M. Barney, PXJREWORD IX R. K. Beere, W. G. Mudd, C. B. Ackley, II. G. Harvey, Traeey Love, E. W. Lazell, W. M. Wilkinson, S. B. Childs, L. G. Crosby, J. B. Davis, Mr. Frank Barmettler and members of the staff and in- ternes of the City and County Hospital. Due credit for the few illustrations not original is given in the legends accompanying them. The chapter on the use of the Rontgen ray is written by Dr. H. G. Stover, and most of the Rontgenograms have been taken for me by him, or have been drawn from his collection of over thirteen thousand plates. Miller E. Preston. Uknvee, Colorado. CONTENTS Chapter II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. XIII. XIV. XV. XVI. XVII. XVIII. XIX. XX. XXI. XXII. XXIII. XXIV. PART I. UPPER EXTREMITY. Page Fractures of the Clavicle and Injuries to the Clavicu- lar Articulations 3 Dislocations of the Sternal End of the Clavicle . . 5 Fractures of the Clavicle 11 Dislocations of the Outer End of the Clavicle ... 30 Fractures of the Scapula 37 Dislocations of the Shoulder 44 Fractures of the Upper End of the Humerus .... 82 Fractures of the Shaft of the Humerus 108 Fractures of the Lower End of the Humerus . . . 120 Dislocations of the Elbovp 154 Dislocations of the Ulna Alone (Rotary) .... 175 Dislocations of the Head of the Radius ..... 177 Fractures of the Bones of the Forearm 184 Fractures of the Upper End of the Ulna 185 Fractures of the Upper End of the Radius .... 197 Fractures of the Radial and Ulnar Shafts .... 204 Fractures of the Lovfer End of the Ulna . ... 232 LXTXATIONS OF THE LOVFER EnD OF THE UlNA 237 Fractures of the Lower End of the Radius .... 242 Injuries to Carpus (Dislocations of Wrist, Medico-car- pal Luxations and Fractures and Dislocations of the Individual Carpal Bones) 277 Luxations of the Carpometacarpal Articulation . .294 Fractures of the Metacarpals 297 OAT Fractures of the Fingers Dislocations of the Fingers . ; XXV. XXVI. XXVII. XXVIII. XXIX. PART II. HEAD AND TRUNK. Fractures of the Nose Fractures of the Malar Bone and Zygomatic Arch . . 334 Fractures of the Superior Maxilla ^43 Fractures of the Lower Jaw 37f5 Dislocations of the Jaw xi Xll CONTENTS Chapter Page \\\. ScAi.p Wounds 370 \.\.\l. I-'KACTIKKS OF THE SkUI.L . . liit 1 .\.\\ll. Fkactiues of the Stekmm ... 4.'):{ X.WIII. Fk.VCTIKES of the IvIHS 4.")!t .\\\l\. Kkactuke-Dislocations of the Spine 4(>.") WW. Fractures and Dislocations of the Pelvis .... 4!t'2 PART III. LOWER KXTRKMITV. WW 1. XXXVll. WW! II. X.WIX. XL. XLl. XLI I. \L11J. XLI\ . XL\ . XL\ J. XLVIl. XLVIJI. XLIX. L. LI. LIL Llll. LI\ . L\ . L\ J. Dislocations of the Hip .')L") Fractures of the Upper End of the Femir .... 531 Fractures of the Femoral Shaft .>58 Fractures of the Lower End of the Fe.muk .... 374 Fkactukes and Luxations of the Semiunah Cartilages . 587 Fractures of the Patella 594 Dislocations of the Patella (Ktit Dislocations of the Knee 1^3 INJURIES Just Below the Knee — Fractures of the J'iiua and Fibula (Upper Ends) ()20 Fractures of the Shafts of the Bones of the Leg . t)34 Pott's Fracture (io!) Fractures of the Lower Ends of the Tibia and Fibula . (575 Dislocations of the Ankle t)84 Fr.\ctx'res and Dislocations of the Astragalus . . (592 Subastragalar Luxations 699 Fractures and Dislocations of the Calcaneus . . . 703 Medio-Tarsal Luxations 709 Fractures and Luxations of the Cuboid, Scaphoid and Cuneiforms 710 Tarso-!Metatarsal Luxations 713 Fractures of the Metatarsals 714 Fractures and Lixations of the Phalanges .... 7?.(> PART IV. SPECIAL SUBJECTS. L\ 11. Terms and Definitions 725 L\lil. The Use of the X-Ray. By II. (!. Stover, M.D. . . . 735 J^IX. The Open Treatment of Fractures 754 LX. Bone Transplantation 771 LXl. Treatment of Compound Fractures .\nd Dislocations . 789 ILLUSTRATIONS. FIG. PAGE 1. Mviscular and ligamentous attachments of clavicle 5 2. iSuperior surface of right clavicle 12 3. Inferior surface of right clavicle 12 4 and 5. Internal structure of right clavicle 12 6. Relation of brachial plexus to first rib and clavicle 13 7. Fracture of clavicle in child. Rontgenogram 13 8. Fracture of clavicle in its inner third. Rontgenogram .... 14 9. Greenstick fracture of clavicle. Rontgenogram 14 10. Fracture of middle of clavicle. Rontgenogram 15 11. Fracture of clavicle with usual deformity. Rontgenogram . . 15 12. Comminuted fracture of outer end of clavicle. Rontgenogram . 16 13. Comminuted fracture of clavicle. Rontgenogram 16 14. Fracture of right clavicle (recent). Photograph 17 15. Recent fracture of clavicle. Photograph 17 16. Side view of same case 17 17. Recent fracture of right clavicle. Photograph 18 18. Side view of same case 18 19. Fracture of clavicle 24 hours old. Photograph 18 20. Side view of same case 18 21. Recent fracture of left clavicle. Photograph 19 22. Another view of same case 19 23. Delayed union of fractured clavicle. Photograph 19 24. Another view of same case 19 25. Fracture of clavicle in elderly woman. Photograph .... 20 26. Old fracture of clavicle with deformity. Photograph .... 20 27 and 28. Demonstrate the outlines of clavicles. Photographs . . 21 29. Recent fracture of right clavicle 23 30 to 33. Application of modified Sayre's dressing 24 34. Molar's figure-of-eight . 25 35. The application of Velpeau's bandage 25 36. Case showing result of recvimbent treatment 26 37 and 38. C. F. Taylor's brace 27 39. Dislocation of outer end of clavicle and separation of acromial epiphysis. Rontgenogram 31 40. Recent dislocation of outer end of clavicle. Photograph ... 32 41. Dislocation of outer end of clavicle. Photograph 33 42. Lateral view of same case 33 43. Downward dislocation of outer end of clavicle. Photograph . . 34 44. Dressing for dislocation of outer end of clavicle 35 45. Same principle carried out with adhesive plaster 35 46. Ventral surface of right scapula 37 47. Dorsal surface of right scapula 37 48. View of right scapula from axillary border .38 49. Fracture of neck of scapula. Rontgenogram 39 50. Palpation of scapula 41 51. Strapping of chest for fracture of scapula 42 52. Action of capsule in adduction of arm. Diagram 43 53. Action of capsule in abduction of arm. Diagram 43 54. Bones of normal shoulder 47 55. Subcoracoid dislocation 47 56. Intracoracoid or subclavicular dislocation . .47 xiii XIV ILLUSTRATIONS FIG. PAGE 57. Intraclavicular dislocation with moderate deformity 47 58. Subglenoid dislocation 48 59. Luxatio ereeta 48 CO. Subacromial dislocation of shoulder 48 61. Subspinous dislocation of shoulder 48 62. Low subcoraeoid dislocation. Kontgenograni 50 63. Recent subcoraeoid dislocation of left shoulder 52 64. Subcoraeoid dislocation of left slioulder 53 05. Examination of same ease showing depression below acromion . . 53 66. Recent subcoraeoid dislocation of right shoulder 54 67. Another view of same case 54 68. Another view of same case 55 69. Recent subcoraeoid dislocation of right shoulder 55 70. Another view of same case 55 71. Low subcoraeoid dislocation of shoulder 50 72. Low subcoraeoid dislocation of shoulder 56 73. Another view of same case 56 74. Palpating recent subglenoid dislocation of shoulder 57 75. Palpating recent subglenoid dislocation of shoulder 57 76. Retentive dressing for dislocation of shoulder 58 77. Recent typical subglenoid dislocation of left shoulder .... 59 78. Recent subcoraeoid dislocation of left shoulder 59 79. Attitude of lea.st pain in subcoraeoid dislocation 59 80. Attitude of least discomfort in subglenoid dislocation .... 60 81. Another view of same case 60 82. Luxatio ereeta 61 83. Another view of same case 61 84. Posterior dislocation of right shoulder 62 85. Another view of same case. Palpation of liead 62 86. Another view of same case 63 87. Case of avulsion of upper extremity . • 63 88. Subcoraeoid dislocation in fleshy woman 64 89. Subcoraeoid dislocation of shoulder in fleshy man 65 90. Subcoraeoid dislocation of right shoulder 67 91. First step in Kocher's method 67 92. Second step in Kocher's method 67 93. Third step m Kocher's method 67 94. Illustrating principles of Kocher's method 68 95. McBurney's hook 72 90. Dislocation of shoulder complicated by fracture of anatomical neck of humerus 72 97. Rontgenogram of same case before operation 73 98. Rontgenogram of same case after operation 73 99. Same case after operation 74 HJO and 101. Stereoscopic Rontgenogram of fracture and dislocation of shoulder 74 102. Subcoraeoid dislocation with fracture of greater tuberosity . . 75 103 and 104. Contracture following dislocation of shoulder .... 76 105, 100 and 107. Old unreduced dislocation of shoulder .... 78 108. Recurrent dislocation of shoulder 79 109. Upper end of humerus 83 110. Structure of upper end of humerus . . 83 111. Rontgenogi'am of upper end of humerus showing epiphyseal carti- lage 84 112. Rontgenogram of fracture of anatomical neck of humerus ... 85 113. Rontgenogram of fracture of surgical neck of humerus .... 86 114. Rontgenogram of comminuted fracture of surgical neck ... 87 115. Rontgenogram of fracture of surgical neck 68 116. Rontgenogram of fracture of surgical neck 89 117. Recent fracture of surgical neck of humerus 90 ILLUSTRATIONS XV FIG. PAGE 118. Another view of same case 90 119. Same case seen in recumbent position 90 120. Rontgenogram of fracture of surgical neck 91 121. Fracture of surgical neck of humerus 91 122. Another view of same case 92 123. Rontgenogram of same case 93 124. Low fracture of surgical neck 93 125. Same case seen in recumbent position 94 12G. Old fracture of surgical neck 94 127. Lateral view of same case 94 128. Rontgenogram of same case 95 129. Measuring length of humerus 96 130. Palpating humeral head during rotation 96 131. Palpating liumeral head through axilla 96 132. Cigar-box boards used in making axillary pad 98 133. Axillary pad completed 99 134. 135 and 136. lliree views of axillary pad in place 99 137. Plaster shoulder cap 101 138. Axillary pad in position and arm bandaged 101 139. Same after the plaster shoulder cap has been applied .... 101 140. Body swathe used to secure arm to side and act as sling . . . 101 141. Middledorf triangle 102 142. Monks triangle 102 143. Osgood-Penhallow splint 102 144. Plaster cast applied with arm in abduction 104 145. Plaster cast applied with arm in abduction; forearm raised . . 104 146. Anterior surface of right hvimerus 109 147. Posterior surface of right liumerus 109 148. Spiral, comminuted fracture of humerus. Rontgenogram . . .110 149. Fracture of humeral shaft. Rontgenogram 110 150. Multiple fracture of humeral shaft. Rontgenogram . . . . . Ill 151. Oblique fracture of humeral shaft. Rontgenogram Ill 152. Recent fracture of shaft of left humerus 112 153. Crushing injury of arm. Fracture of humeral shaft . . . .112 154. Stromeyer cushion 114 155. Axillary pad in place and arm bandaged 114 156. Coaptation splints applied to arm 114 157. Body swathe applied 114 158. Rontgenogram of spiral fracture of humeral shaft 117 159. Same after operation and reduction with internal fixation . . .117 160. Rontgenogram of same case nine months later 118 161. 162 and 163. Photographs of bone (same case) showing result . 118 164, 165 and 166. Views of lower end of humerus 120 167 and 168. Rontgenogram of fracture of lower end of liumerus . .121 169 and 170. Rontgenogram of fracture of lower end of humerus . . 122 171 to 174. Rontgenogram of fracture of lower end of humerus . . 123 175 to 178. Rontgenogram of fracture of lower end of humerus . . 124 179. Fpipliyseal separation of epitrochlea. Rontgenogram .... 125 180. Lateral view of same case. Rontgenogram 125 181. Rontgenogram of fracture of internal epicondyle 126 182. Rontgenogram of epipliyseal separation of external condyle . . 126 183. Rontgenogram of epiphyseal separation of internal epicondyle . 126 1184. Recent fracture of external epicondyle with deformity . . . 129 185. Recent fracture of lower end of liumerus 130 186. Another view of same case 130 187. Recent fracture of lower end of humerus. (Splitting.) . . . 130 188. Recent transverse fracture of lower end of humerus .... 132 189. Another view of same case in sitting position 132 190 and 191. Rontgenograms of same case 133 192. Recent compound comminuted fracture of lower end of humerus . 133 XVl ILLUSTRATIONS FIO. r.\GE 193. Another viow of samo oaso I'.VA 194. Ki'Ci'iit compouiul comiiiiimtfd fracture oi lower i-iul of Imiiicius i:{4 195. Another view of same ease l.M 196. Old <;unstoek deformity result of fracture almve and lich)\\ ell)o\v . 135 197. Anotlu'r view of same case 135 198. Old ease of diaeondylar fracture of lower end of humerus . 13() 199. Another view of same case 13(1 200. Examination of case in which carrying angh- luis heen lost . 137 201. Examiiuition of same case with elhows extended 137 202. I'Xamination of jtronouneed uinistoek defoi-mity in Ih'xion . . 138 203. Same ease with ell)ow extended 138 204. Another view of same case 139 205. Old fracture of lower end of humerus with musculo-si)iral ]iaralysis 140 206. Another view of same case showino; contracture 141 207. Same case seen from ulnar side of forearm 141 208. Case of cuhitus varus in one arm and cubitus valgus in tlie other . 142 209. Pronounced normal carrying angle 142 210. Dressing for treating arm with elhow in Hexion 145 211. Du])uy internal riglit-angle splint 146 212. Dupuv extenuU right-angle splint 146 213. Internal riglit-angle splint a])i)lied 146 214. Internal right-angle splint with traction 146 215. Plaster splints for ui)i)er extremity 147 216 and 217. Adjustable s])lints for elbow 148 218. Splitting of lower end of humerus. Rontgenogram 149 219. Rontgenogram of same case five years after operation .... 149 220 and 221. Range of motion in elbow of same case five years after operation 150 222 and 223. Ligaments of elbow 154 224. Recent posterior dislocation of right elbow 157 225, 226 and 227. Additional views of same case .... 157 and 158 228. Recent posterior dislocation of left elbow 159 229. Palpating head of radixis and empty sigmoid in same case . . 159 230. Posterior view of same case 160 231. Lateral dislocation of elbow 160 232. Another view of same case 160 233. 234 and 235. Diagrammatic comparison of posterior dislocation of elbow, supracondylar and diaeondylar fractures 163 236. Swelling of elbow following simple strain 164 237. Swelling of elbow 24 hours following dislocation 165 238. Another view of same case 165 239. Rontgenogram of forward dislocation of eliiow with fracture of olecranon 166 240. Rontgenogram of fracture of coronoid complicating backward dis- location of elbow 166 241. Backward dislocation with fracture of tip of coronoid. Rontgeno- gram 167 242. Backward dislocation with comminuted fracture of coronoid proc- ess. Riintgenogram 167 243. Fracture of coronoid \\ith displacement i)roduced by backward dis- location of elbow. Rontgenogram 167 244. Fracture of coronoid with slight displacement. Rontgenogram . 167 245. Method of reducing backward dislocation of elbow 168 246. Another method of reducing Imckward dislocation of elbow . 168 247 and 248. Range of motion fourteen days following backward dislo- cation of ell)ow 172 249. Forward dislocation of head of radius 179 250 and 251. Rontgenograms of same case 179 252. Fracture of olecranon. Rrmtgonogram 186 253. Fracture of olecranon; elbow extended. Rontgenogram .187 ILLUSTRATIONS XVll FIG. I'AGE 254. Same case; elbow sliglitly Hexed. Roiitj^eiioKi'Hrn 187 255. Fracture of olecranon one week following accident 189 256. Palpation of same case 189 257. The straight splint used in the treatment of fractures of the ole- cranon 191 258. Fracture of olecranon. Uontgenogram 193 259. Same case after operation with internal fixation 193 260. The use of passive motion following fracture of olecranon . . .195 261. Fracture of head and neck of radius. Rikitgenogram .... 197 262. Comminvited fracture of head of radius. Rontgenogram . . .197 263. Fracture of head and neck of radius. Rontgenogram .... 198 264. Fracture of head of radius. Rontgenogram 199 265. Fracture of head of radius. Rontgenogram 199 266 and 267. Gunstock deformity result of fracture of both bones of forearm just below elbow 201 268. Structure of radius 204 269. Structure of ulna 204 270. Recent fracture of both bones of forearm 206 271. Another view of same case 207 272 and 273. Rontgenograms of same case 207 274 and 275. Rontgenograms of same case after operation .... 208 276. Recent fracture of both bones of forearm 208 277. Recent fracture of both bones of the forearm 209 278. Another view of same case 209 279. Reduction of same case 210 280. Same case seen from ventral surface of forearm 210 281 and 282. Rontgenograms of same case after reduction .... 211 283 and 284. Same case seen after splints have been applied . . . .212 2185 and 286. Same case at time of removal of splints 212 287 and 288. Fracture of radial shaft 213 289 and 290. Opposite arm of same case examined for comparison . .213 291 and 292. Rontgenograms of same case taken after reduction . .214 293 and 294. Rontgenograms of same case taken after second reduction 214 295 and 296. Rontgenograms of same case taken after operation and in- ternal fixation 215 297. Fracture of both bones of forearm with unusual deformity . . 215 298 and 299. Two views of recent fracture of both bones of the forearm 216 300. Recent fracture of both bones of the forearm near wrist . . .216 301 and 302. Recent fracture of both bones of the forearm near wrist with slight deformity 217 303. Fracture of radius and free radial styloid. Rontgenogram . . 217 304 and 305. Rontgenogram of green-stick fracture of ulna .... 218 306. Testing lateral spring in bones of forearm 220 307. Recent fracture of both bones of forearm 223 308. Same case. Deformity corrected and anterior splint applied . . 223 309. Same case showing "cut-out" in ventral splint 223 310. Same case. Dorsal splint applied 223 311. Splints bandaged 223 312. Removal of dorsal splint for inspection 224 313 and 314. Rontgenograms of fracture of both bones of forearm with overriding deformity 227 315 and 316. Rontgenograms of same case after operation and internal fixation 227 317. Slight bowing of bones of forearm following imperfect reduction . 229 318, 319 and 320. Volkmann's contracture 230 321. Fracture of both bones of the forearm and separation of lower ulnar epiphysis 233 322 and 323. Rontgenograms of same case 233 324. Fracture and separation of lower ixlnar epiphysis 234 325. Backward dislocation of lower end of ulna 238 xviii ILLUSTRATIONS FIG. PAGE 326, 327, 328, 329, 330 and 331. Rijntgenograma of different types of fracture of lower end of radius 243 332, 333, 334. Rontgenograms of '-Reversed CoUes' " 244 335 and 336. Fracture of lower end of radius produced by "auto-kick." Rontgcnogram 244 337, 338 and 339. Rontgenograms of Colles' transverse Colles' fracture with impaction 245 340. Fracture of lower end of radius produced by auto-kick. Rontgcno- gram 246 341 and 342. Lateral and anteroposterior views of Colles' fracture with slight deformity. Rontgenograms 247 343. Ri'.ntgenogram of comminuted Colles' fracture. Rontgenogram . 247 344 and 345. Rotgenogram of transverse Colles' fracture with impaction 248 346 and 347. Rontgenograms of oblique Colles' fracture . . . . . 248 348 and 349. Rontgenograms of separation of lower radial epiphysis complicated by fracture 249 350 and 351. Separation and fracture of lower radial epiphysis . . 250 352 and 353. Separation and fracture of lower radial epiphysis . . 250 354. Recent typical Colles" fracture 252 355. Recent Colles' fracture 252 356. Recent Colles' fracture showing radial displacement of hand . . 253 357 and 358. Two views of recent Colles" fracture 253 359. Recent Colles' fracture showing displacement of articular surface 254 360 and 361. Two views of recent Colles' fracture 254 362 and 363. Two views of recent Colles' fracture 255 364 and 365. Two views of recent Colles' fracture 255 366 and 367. Two views of recent oblique Colles' fracture .... 256 368 and 369. Two views of separation of lower radial epiphysis . . 258 370. Another view of same case 259 371. Recent epiphyseal separation of lower end of radius .... 259 372. Same case immediately following reduction 259 373. Radial view of recent Colles' fracture 261 374. Ulnar view of recent Colles' fracture 261 375. Same case. Ventral view 261 376. Same case. Comparison of levels of two styloids 261 377. Same case. Comparison of levels of two styloids 261 378 and 379. Photographic comparison of Colles' fracture and backward dislocation of wrist 262 380 and 381. Radial and ulnar views of recent Colles' fracture . . . 263 382 and 383. Same case showing two methods of reducing Colles' frac- ture 264 384. Diagrams illustrating principles involved in reducing Colles' frac- ture 264 385. Flat ventral splint 265 386. Flat dorsal splint 265 387. Flat dorsal splint with "ulnar cut-out" 265 388. The Walker splint 266 389. Short splints and adhesive; for Colles' fracture 267 390. Proper position for carrying wrist in sling 267 391. Improper position for carrying wrist in sling 267 392. Rontgenogram showing radial epiphysis displaced to radial side . 270 393. Same case after operation and internal fixation 270 394. Colles' fracture 24 hours old. Swelling pronounced .... 272 395 and 396. Old Colles' fracture with deformity 273 397. Old Colles' fracture with deformity 274 398. Loss of function following Colles' fracture 274 399. Rontgenogram of same case showing osteitis of carpus .... 274 400 and 401. Contracture following Colles' fracture 275 402 and 403. Ligaments of wrist 277 404. Rontgenogram of normal bones of carpus and metacarpus . . 278 ILLUSTRATIONS XIX FIG. I'^^OJ^ 405. Old Colles' and anomalous triangulare 279 406. Old Colles' and anomalous triangulare 279 407. Rontgenogram of anomalous centrale 279 408. Rontgenogram of anomalous space corresponding to centrale . . 279 409. Old united fracture of scaphoid 280 410. Rontgenogram of fracture of semilunar 280 411. Rontgenogram of fractured scaphoid 280 412. Rontgenogram of fractured semilunar 281 413 and 414. Rontgenograms of luxated semilunar 281 415 and 416. Old Colles' fracture and abnormal condition of scaphoid. Rontgenogram 282 417. Rontgenogram of "Divided Scaphoid" 283 418. Centrale present and fused with os magnum. Rontgenogram . . 284 419. Rontgenogram of Colles' fracture and fractured trapezium . . 284 420. Severe compound fracture dislocation of wrist 287 421. Old injury of carpus 288 422. Rontgenogram of Bennett's fracture 297 423. Rontgenogram of gunshot fracture of metacarpal 298 424. Recent Bennett's fracture 299 425. 426 and 427. Recent Bennett's fracture 300 428. Recent fracture of index metacarpal 301 429. Fracture of metacarpals 301 430. Fracture of metacarpal 302 431 and 432. Recent fracture of metacarpal 302 433. Old fracture of fourth metacarpal 303 434, 435, 436 and 437. Roller bandage dressing for fracture of meta- carpals 304 438. Compound fracture of base of terminal phalanx 308 439. Severe compound fracture of phalanges 308 440. Plaster splint for thumb 309 441. Plaster splint for finger 309 442. Board splint for finger 310 443 and 444. Goldthwaite tin splint for fracture of thumb .... 311 445. Tin splint applied to finger 311 446. Claw nail resulting from injury to finger 312 447. Dislocation of thumb 315 448 and 449. Compound lateral dislocation of thumb 315 450. Old unreduced lateral dislocation of thumb 450 451 and 452. Recent dislocation of finger 316 453. Ventral dislocation of second knuckle 316 454. Dorsal dislocation of finger 316 455. Backward luxation of second joint of middle finger 316 456 and 457. Sagittal section through the nasal cavity 323 4518. Old fracture of nasal bones with lateral displacement .... 326 459. Old fracture of nasal bones with lateral displacement .... 326 460. Separation and lateral displacement of lateral and septal cartilages 326 461. Fracture of nasal bones and partial separation of cartilages . 326 462 and 463. Destruction of nasal bridge from syphilis 327 464. Falling in of nasal cartilages in old case of syphilis .... 328 465. Saddle nose in hereditary syphilis 328 466. Raising the depressed nasal bones 329 467. Packing nasal cavities 329 468. Asche nasal splints 329 469. Author's moulded dental composition splint . - 330 470. The Cobb nasal splint 330 471. Relations of the nasal, lachrymal, superior maxilla and malar bones 335 472. Zygomatic arch seen from below 335 473. Recent fracture of left malar bone 337 474. Fracture of malar bone 24 hours after injury 337 475. Fracture of malar and zygoma 338 XX ILLUSTRATIONS FIG. PAGE 47G. Old fracture of malar 341 477 and 47S. Old fracture of malar with great deformity .341 479. Superior maxilla 343 480. Fracture of superior maxilla 34.5 481 and 482. Two views of inferior maxilla 348 483. Recent fracture of inferior maxilla at symphysis 351 484. Rontgenogram of same case 351 485. Fracture of lower jaw just anterior to rigiit canine 352 486. Fracture of lower jaw 352 487. Fracture of lower jaw between canine and lateral incisor . . 353 488. Fracture of lower jaw anterior to tirst molar 354 489. Old fracture of jaw witii deformity 355 490. Fracture of lower jaw behind last molar 355 491. Rontgenogram of same case 356 492 and 493. Fourtailed bandage made of adhesive . . .... 358 494. Interdental splint of vulcanite 359 495. !Metal dental splint with arms for counter-pressure 361 496. Vulcanite splint with arms for counter-pressure 361 497. Matas splint for fracture of lower jaw 362 498 and 499. Heath metal splint . . .' 363 500. Edmund's forceps for clamping metal splint to teeth .... 364 501. Cast aluminum splint cemented to teeth 364 502. Oliver's method of wiring the lower to the upjjcr law . . 366 503 and 504. Manner of placing loops in wiring jaws together . . 369 505 and 506. Wiring jaws together. Four points of fixation . . . 361) 507. Jaws wired together in fracture of lower jaw 370 508 and 509. Angle's bands and bars 371 510 and 511. Angle's bands with knobs 371 512. Scalp wound prepared for suture 387 513. Same case. Sutures in place 387 514. Same case. Bandaged 387 515. Interior surface of right half of skull 397 516. Interior surface of right half of base of skull 398 517 and 518. Craniometric points of importance 400 519. Most common sites of meningeal hemorrhage 400 520. Cortical centers 400 521. Old depressed fracture of vault 413 522. Old depressed fracture of frontal region 414 523. Old depressed fracture of skull in left parietal region .... 414 524. Old depressed fracture of vault 415 525. Fracture of base of skull 415 526. Old depressed fracture of frontal region 416 527. Severe fracture encircling skull 416 528. Severe compoiuid, comminuted fracture of vault 417 529. Severe gunshot fracture of skull 417 530. Rontgenogram of bullet within skull 418 531. Swelling and ecchymosis about eyes suggestive of fracture of skull 419 532. Calvarium of patient whq previously had depressed compound frac- ture of vault .419 533 and 534. Diagrams indicating steps in performing osteoplastic oper- ation on skull 447 535. DeVilbiss bone cutting forceps 448 536. Small trephine . 448 537. Relations of sternum 453 538. Rontgenogram of fracture of sternum 455 539 and 540. Reduction of fracture of sternum 457 541. Rontgenogram of fractures of third, fourth, fifth and sixth ribs . 460 542. Caving in of chest 461 543. Fracture and displacement of costal cartilage 461 544. Adhesive plaster strapping for fracture of ribs 463 ILLUSTRATIONS XXI FIG. PAGE 545. RontgenooTani of fracture of cervical sj)inc 466 546. Rontgenogram of fracturc-diHlocation of cervical spine .... 467 547. Rontgenogram of disloeati(jn between first and second cervical verte- brie 468 548. Rontgenogram of fracture of the lower dorsal and upper lumbar vertebrae 460 549. 550 and 551. Two views and section of old fractured spine . . . 470 552. Rfmtgenogram of fracture of spine 471 553. Rontgenogram of fracture of body of fifth lumbar vertebra . . 472 554 and 555. Fracture of cervical spine 474 556 and 557. Fracture of lower dorsal spine 475 558. Old fracture of lower dorsal spine 477 559. Charco's spine 477 560. Methods of wiring spine 488 561. Incisions used in performing a laminectomy and in making osteo- plastic flap 489 562. The pelvis 492 563. Lateral view of pelvis 493 564. Rontgenogram of fracture of pelvis through acetabulum . . . 494 565 and 566. Fracture of ilium and tearing away of abdominal muscles 499 567. RontgenogTam of lateral dislocation of coccyx 501 568. Double plaster spica used in treatment of fracture of pelvis . . 508 569. The ilio-femoral or Y-ligament of Bigelow 516 570. Iliac dislocation of hip 517 571. Sciatic dislocation of hip 517 572. Ilio-pectineal dislocation of hip 518 573. Pubic dislocation of hip 518 574. Obturator or thyroid dislocation of hip 518 575. Perineal dislocation of hip 518 576. Everted dorsal dislocation of hip ; . . . . 519 577. Attitude in dorsal dislocation of hip 521 578. Attitude in anterior dislocation of hip 521 579 and 580. Old unreduced dorsal dislocation of hip 522 581. Reduction of dorsal dislocation of hip 525 582. Stimson's method of reducing luxations of hip . . - . . . . 526 583. Author's modification of Bigelow's method 526 584. Allis' method of securing pelvis to floor 527 585 and 586. Internal structure of upper end of femur 531 587. Nelaton's line and Bryant's triangle. Diagram 534 5i88. Rontgenogram of impacted fracture of femoral neck .... 535 589. Rontgenogram of old ununited fracture of femoral neck . . . 589 590. Rontgenogram of impacted fracture of neck of femur .... 589 591. Rontgenogram of fracture of femoral neck 535 592. Rontgenogram of fracture of rim of acetabulum 536 593. Rontgenogram of fracture of great trochanter 536 594. Rontgenogram of middle of femoral neck 536 595. R6ntgenogi-am of base of femoral neck with splitting off of lesser trochanter 536 596. Impacted fracture of neck of femur 538 597. Impacted fracture of neck of femur 538 598. Fracture of right femur through gxeat trochanter 538 599. Fracture of femur jvist below great trochanter 538 600. Drawing Nelaton's line on patient 539 601 and 602. Measuring length of lower extremity 540 603 and 604. Diagrams showing effect of tipping of pelvis . . . . . 541 605. Relaxation of fascia lata resvilt of raising of trochanter . . . 541 606 and 607. Application of Buck's extension 543 608. Weight iised with Buck's extension 543 609. Pulley used with Buck's extension 543 610. Long'T-splint 544 XXll ILLUSTRATIONS FIG. P-^E 611. T-splint applied and extension in use 544 612. Diagram showing principles of Ruth-Maxwell method .... 546 613. The use of sand hags in fracture of hip 546 614. Plaster cast applied with thigh abducted 547 615. Plaster cast applied with hip and knee semiflexed 548 616. Author's screw plates for internal fixation of fracture of the hip 530 617. Usual sites of fracture through femoral neck 551 618. Tendency to displacement when screw is used in fixation of liip . 551 610. Author's screw plate in position 551 620. The Thomas hip splint 553 621. The ambulator}' pneumatic splint 554 622. Diagrams illustrating the development of coxa vara after Whit- man 556 623. Anterior surface of femur 559 624. Posterior surface of femur 559 625. Eontgenogram of transverse fracture of femoral shaft . . . 560 626. Recent fracture of riglit femoral shaft 561 627. Old fracture of right femoral shaft 561 628. Recent fracture of left femoral shaft 562 629. Recent fracture of left femoral shaft 562 630. Correction of deformity by lateral traction. Diagram .... 564 631. Adjustable inclined plane 564 632 and 633. Treatment of fracture of femoral shaft in children by suspension 565 634. The Bradford frame 565 635. The Nichols frame 569 636. Rontgenogram of double spiral fracture of shaft of femur . . . 570 637. Rontgenogram of same case after operation 570 638. Rontgenogram of same case two years after operation . . . .571 639. Rontgenogram of same case six years after operation . . . .571 640. Lateral surface of lower end of femur 575 641. Internal structure of lower end of femur 575 642. Rontgenogram of knee showing locations of epiphyseal cartilages 576 643. Fracture of lower end of femur with angular deformity. Rontgeno- gram 577 644. Supracondylar fracture with pronounced overriding. Rontgeno- gram 577 645. Rontgenogram of old displaced fracture with refracture through callus 577 646. Rontgenogram of fracture of femur with lateral deformity . . 577 647. Fracture of lower third of shaft of femur 578 648. Compound comminuted fracture of lower end of femur .... 578 649. Cabot posterior wire hip splint 580 650. Same, bent to form double inclined plane .580 651. Dupuy's splint used as double inclined plane 581 652. Dupuy's splint 581 653. Adjustable double inclined plane fracture box 582 654. Hogden's splint 582 655. Adjustable ambulatory pneumatic splint 585 656 and 657. Subluxation of knee with lateral dislocation of patella and displacement of semilunar cartilage 589 658. Old fracture of patella with separation of fragments .... 596 659. Fracture of both patellae 596 660. Dressing for fracture of patella 598 661. Ham splint 599 662. Silver wire mattress suture of patella 600 663. Internal structure of patella 600 664. Rontgenogram of recent fracture of patella 601 665. Same case after operation 601 666. Wired fracture of patella three years after operation .... 603 ILLUSTRATIONS XXlll no. PAGE 667. Wired fracture of patella two years after operation .... 603 668. Passive motion in after-treatment of fracture of patella .... 606 669. Diagram of normal relations of patella 610 670. Diagram of lateral dislocation of patella 610 671. Diagram of rotary displacement of patella and lateral dislocation "on edge" 610 672 and 673. Ligaments of knee 614 674. Lateral view of upper epiphysis of tibia. Rontgenogram . . . 621 675 and 676. Anomalous ossification of upper end of tibia .... 622 677 and 678. Rontgenogram of vertical fracture of upper end of tibia . 623 679. Rontgenogram of fracture of upper end of tibia 623 680. Rontgenogram of splitting of upper end of tibia 623 681. Fracture of upper end of tibia 625 682. Fracture of upper end of right tibia 626 683. Compound fracture of both bones of the leg 636 684. Fracture of both bones of the leg 636 685. Compound fracture of both bones of the leg 636 686 and 687. Fracture of both bones of the leg 637 6818. Fracture of both bones of the leg 638 689. Same case four days later showing blood blebs 638 690. Green-stick fracture of tibia in child 639 691. Compoimd fracture of both bones of leg 639 692 and 693. Fracture of tibia near ankle 640 694 and 695. Severe compound comminuted fracture of both bones of leg 641 696 and 697. Severe compound fracture of both bones of the leg . . 642 698. Folding fracture-box laid open 643 699. Same box closed 643 700. Padding used with fracture-box and method of holding box to- gether 643 701 and 702. Use of fracture-box in treating fractures of the leg . . 644 703 and 704. Short Desault splint 645 705. The Cabot posterior wire splint 646 706. The N. R. Smith splint 646 707. Elevated fracture-box 647 708. Cradle used to keep bed clothes off leg 647 709 and 710. Methods of securing traction on fractures near the ankle 647 711. Use of old shoe and adhesive in obtaining extension 647 712. Padding to relieve heel from pressure 647 713. Plaster of Paris splints for fracture of leg 648 714. Plaster stirrup for fractures of the leg 648 715 and 716. Two views of comminuted fractures of tibia and fibula near ankle. Rontgenograms 651 717. Rontgenogram of same case after operation 652 718. Same case. Anterior plaster splint removed to show field of opera- tion 652 719. Ambulatory pneumatic splint as applied to fractures of the leg . 655 720. Old fracture of tibia and fibula with discharging sinus . . . 656 721. Persistent swelling following fracture of leg 656 722. 723, 724 and 725. Diagrams illustrating the manner in which the leg is thrown "off center" when union occurs with deformity . . 657 726 and 727. Normal relations of the calcaneum, astragalus and bones of the leg 660 728. Rontgenogram of normal ankle showing epiphyses 661 729. Rontgenogram of Pott's fracture 662 730. Rontgenogram of variant of Pott's fracture 662 731. 732 and 733. Rontgenogram of Pott's fracture 662 734 to 737. Rontgenogram of Pott's fracture 663 738. Rontgenogram of old Pott's fracture 663 739. Rontgenogi-am of Pott's fracture. Lateral view 663 740. Recent Pott's fracture of left ankle 664 XXIV ILLUSTRATIONS FIG. PAGE 741 and 742. Two views of a recent Pott's fracture fldf) 743. Another view of same case OfiCi 744. Eecent Tott'p fracture seen from behind (i7t) 754. Epiphyseal separation of lower end of tibia complicated l)y frac- ture 07() 755 and 756. Sujiramalleolar fracture 677 757 and 758. Supramalleolar fracture 677 750 and 760. Supramalleolar fracture with pronounced deformity . . 670 761 and 762. Si)litting of lower end of tibia 680 763. Old fracture of both bones of the leg with backward displacement 681 764 and 765. Ligaments of ankle 685 766 and 767. Inward fracture-luxation of ankle 688 768. Anterior dislocation of ankle 688 760 and 770. Anteroposterior and lateral views of fracture-luxation of astragalus. Eontgenogram 692 771. Rontgenogram of lateral dislocation of astragalus 693 772. Deformed astragalus removed to restore function 697 773 and 774. Compound subastragalar luxation 700 775. Rontgenogram of fracture of calcaneum 704 776. Anomalous trigonum 704 777 and 778. Rontgenograms of fractures of calcaneum 704 779 and 780. Crushing injuries of tarsus 711 781 and 782. Rontgenograms of fractures of fifth metatarsals . . .715 783. Oblique fracture of shaft of fifth metatarsal 716 784. Rontgenogram of fracture of base of fifth metatarsal . . . .716 785. Rontgenogram of compovmd crushing injury of metacarpus . . .716 786. INIethod of detecting fracture in the metatarsal bones . . . .717 787. Crushing injviry of foot 717 788. Example of simple transverse fracture. Rontgenogram . . . 726 789. Example of multiple fracture. Rontgenogram 726 790 and 791. Surface form and section of fracture united in deformity 727 792 and 793. Rontgenograms of carcinoma of bone with spontaneous fracture . 728 794. Carcinoma of lower end of femur with extensive destruction of bone. Rontgenogram 729 795. Syphilitic dactylitis with spontaneous fracture. Rontgenogram . 730 796. Spontaneous fracture following osteo-sarcoma 730 797. Osteo-carcinoma with spontaneous fracture. Rontgenogram . . 731 798. Case of fetal rickets with spontaneous fracture. Rontgenograms . 732 799 to 802. Rontgenograms of lower extremities of same case . , . 733 803. The Rose portable coil 738 804. The Rose portable coil. Larger instrument 739 805. Special type of Crook's tube 740 806. Metallic numbers for marking X-ray plates ....... 740 807 and 808. Diagram illustrating use of X-ray 742 809, 810 and 811. Diagram illustrating use of X-ray 743 812. Radio-chronometer 746 813. The Bauer qualimeter 746 814. Linear fracture of upper end of tibia 747 815 and 816. Antero-posterior and lateral views of fracture of radius. Rontgenograms 748 817 to 820. Four Rontgenograms of same case taken from different po- sitions 749 821 and 822. Stereoscopic Rontgenogram 751 ILLUSTRATIONS XXV FIG. PAGE 823. Methods of using wire in internal fixation of fractures .... 758 824 and 825. An example of the use of a single loop of wire . . . 759 826. Instruments serviceable in passing wire about bone 760 827. The Lane bone drill 760 828 and 820. Bone forceps 761 830. Gerster's turn-buckles 762 831. Appliance for holding plate in position 763 832. Compound fracture of both bones of the leg 764 833. Same case after fixation with Freeman's clamp 764 834. Set of Lane's bone plates 765 385. Comparison of wood screw and Sherman's "tap-screw" . . . 766 836. Sherman's tap-screws and screw driver 76(i 837. Examples of broken plates 767 838 and 830. Antero-posterior and lateral views of fracture of hoth bones of leg. Rontgenograms 7(J7 840 and 841. Antero-posterior and lateral views of same case two years later. Plate in place. Rontgenograms 767 842. Infected tibia from which Lane plate has been removed. Rontgcn- ogram 76!) 843. Old ununited fracture of til)ial shaft. Diagram 778 844. Same, after ends are squared and medullary cavity reamed out. Diagram ' 778 845. Same with medullary dowel graft in place. Diagram 778 846. Making saw cuts in obtaining medullary graft. Diagram . . . 770 847. Removing medullary graft with chisel. Diagram 770 848. Removing medullary graft with rotary saw. Diagram .... 779 849. Inlay graft in place. Diagram 782 850. Method of securing same with kangaroo tendon. Diagram . . . 782 851. Motor saw equipment including twin saws 783 852. Doweling machine 783 853. First step in Albee's technique in recent fractures. Diagram . . 784 854. Same with "short piece" removed. Diagram 784 855. Same with "long piece" held in place by bone pegs. Diagram . . 784 856. Upper end of humerus replaced by upper end of fibula. Diagram . 786 857. Loss of tibial shaft. Diagram 787 858. (Same after upper end of fibular shaft has been implanted in upper tibial fragment. Diagram 787 859. Same after operation has been completed 787 860. Gangrene of leg following thrombosis 792 PART I. UPPER EXTREMITY. FRACTURES AND DISLOCATIONS CHAPTER I. FRACTURES OF THE CLAVICLE AND INJURIES TO THE CLAVICULAR ARTICULATIONS. The clavicle may be fractured by direct or indirect violence, or either end of the bone may be dislocated. The early ossification of the clavicle accounts for the frequency with which it is fractured in children, and the fact that the sterno-clavicular ligaments extend outward onto the diaphysis, explains the rarity of separation of the single clavicular epiphysis situated at the inner end of the bone. Dislocation of either end of the clavicle is rare as compared with fracture. Males are more subject to injury of this bone and its articulations because of their occupations, and heavier muscula- ture. The coraco-clavicular ligaments are an important element in determining the site of fracture when due to indirect violence, and in limiting the displacement in both fractures and dislocations. The stability of either end of the clavicle depends on ligaments, rather than the conformation of the articular surfaces. The acromial end is dislocated nearly four times as often as is the sternal end, while all the dislocations of the clavicle make up about four percent of the luxations of the entire body. Dislocations of both ends of the bone, and simultaneous dislocations of both clavicles, are conditions which have been recorded, though they are extremely rare. Injuries to the clavicle and its articulations will be taken up in the following order: Dislocation of the sternal end. Forward. Backward. Upward. Fracture of the clavicle. 3 4 FRACTURES AND DISLOCATIONS Dislocation of the acromial end. Upward. Downward. Sub-eoracoid. Fracture of this bone is so common and dislocation so rare that examination of the ends of the clavicle is often neglected, espe- cially in the presence of fracture. The fact should never be lost sight of that two or more lesions may be present at the same time. A systematic examination of the entire region should be made in addition to determining the condition of the bone in question. The surgeon should remember that the examination is not neces- sarily concluded with the finding of a given lesion ; further damage may have been done to adjoining bones or joints. Particularly, care should be exercised in examining children becaiLse of the mild and indefinite character of the symptoms accompanying the frac- ture of the clavicle in the early years of life. CHAPTER II. DISLOCATIONS OF THE STERNAL END OF THE CLAVICLE. Surgical Anatomy. — The articular end of the clavicle is much larger than the articular facet on the sternum, and the integrity of the joint is almost entirely dependent on the ligaments that sur- round the joint and bind the two bones together. The capsule is attached to the margins of the two articular surfaces and com- pletely encloses the joint cavity. It is reinforced in front and behind by the anterior and posterior sterno-clavicular ligaments. To the inner side and above, it is overlaid by the interclavicular Fig. 1. — Muscular and ligamentous attachments of the cla^vicle. T., trapezius; S.M., sterno-mastoid ; D., deltoid; P.M., pectoralis major; B., hiceps ; R., rhomboid ligament; C.C, coraco-clavicular ligament; A.G., acromio-clavicular ligament; G.A., coraco-acromial ligament. The interclavicular ligament may be seen attached to the upper aspect of the inner end of the bone. ligament which is attached to both clavicles. Externally the rhomboid ligament, extending from the under surface of the clavicle to the cartilage of the first rib, greatly strengthens the articulation. This ligament is in relation posteriorly with the subclavian vein. The ends of the bones entering into this articulation are very poorly adapted to each other and when dislocation takes place recurrence of deformity is prompt, unless prevented by retentive dressings. The rhomboid ligament is seldom completely torn and will tend to limit the displacement. 6 ■ FRACTURES AND DISLOPATIONS Displacement of the sternal end is usually the result of indirect violence. If the long axis of the clavicle is continued inward it will pass in front of the sternum, and accordingly the most common type of luxation of the sternal end is forward. The displacement may be partial or complete and accordingly the condition is spoken of as either a luxation or a subluxation. Forced backward dis- placement of the shoulder may produce a luxation of tlio inner end of the clavicle by leverage against the first rib. Forward dislocation is by far the most common luxation seen at this joint, and is usually the result of the shoulder having been driven forcibly backward beyond the normal limitation of motion. If the shoulder be carried backward the inner end of the clavicle comes in contact with the first rib, and if forced still further back- ward this contact with the first rib acts as a fulcrum by means of which the inner end of the bone is torn away from the sternum and displaced forward. This mechanism seems to be the usual cause of displacement, though there are some instances in which the condition has taken place gradually and has apparently been the result of a general relaxation of the ligaments about the joint. Backward luxations are not as common as the type just descri])ed, though they are next in order of frequency. They are usually the result of violence which forces the shoulder forward and inward, though they are sometimes caused by a direct force which drives the inner end of the clavicle backward. The trachea, oesophagus and the large vessels of the neck lie behind the inner end of the clavicle, and when a posterior displacement occurs any or all of these structures may be pressed upon. Upward luxation of the sternal end of the clavicle is extremely rare and is usually the result of violence which depresses the shoulder. The ligaments are more or less torn according to the severity of the causative trauma. Luxations of the inner end of the clavicle are rare, as compared with fractures of the clavicle. Symptoms. — Pain is more or less pronounced at the site of the lesion and is increased with motion of the shoulder. Loss of function varies with the completeness of the dislocation and the amount of pain suffered by the patient. There is more or less swelling about the inner end of the bone. The deformity varies with the direction of the luxation. In forward luxations the inner end of the bone is more prominent than normal and is often found displaced downward onto the DISLOCATIONS OF STERNAL END OF CLAVICLE 7 anterior surface of the sternum, as well as forward. The lowered position of the inner end of the bone changes the axis of the clavicle, which deformity can often be recognized by inspection alone. In backward luxations it will be noted that the normal promi- nence of the inner end of the clavicle is absent, and the axis of the bone is changed. Palpation of the shaft of the clavicle will dis- close the altered position. Passive congestion of the face on the side of the luxation may be present, and in severe cases cyanosis may be pronounced. Dysphagia and dyspnoea are not uncommon. The acuteness of these symptoms usually subsides even though the displacement be allowed to go uncorrected. There is no reported case of permanent injury to the structures thus pressed upon and accordingly these symptoms are not alarming. The shoulder is displaced downward and forward and is a little nearer the thorax than normal. This displacement is often slight and if the shoulder is not compared with the opposite side the deformity may go unrecognized. In upivard luxations there is a variable amount of disturbance in function and pain at the seat of injury. Inspection and palpa- tion will show the change in the axis of the bone and the upward displacement of the inner end. The inner end of the bone is abnormally mobile. Diagnosis. — The clavicle is subcutaneous throughout and the sternal notch may be palpated without difficulty. Accordingly displacements of the inner end of the bone are easily determined. Differentiation of fractures of the clavicle from luxations of the inner end presents no particular difficulty unless the swelling is pronounced. In fractures of this bone crepitus is almost invariably distinct, and the absence of this symptom in luxations is significant. The distance between the tip of the acromion and the middle of the suprasternal notch is lessened in both fractures and luxations. Dislocations of the inner end of the clavicle are not infrequently overlooked because of associated lesions which are more evident. The X-ray is of value as a routine measure but is seldom necessary to establish the diagnosis. Treatment. — Keduction is, as a rule, easily accomplished but it is usually a difficult matter to retain the articular surfaces in their proper relations. Certain positions are known to be favorable in the prevention of the recurrence of deformity but the surgeon should determine for himself in each and every case just what b FRACTrRKS AXn niST.OrATTONS position is most favoi';il)lf in holdinii' the aiiictihif surfju^os in apposition. In forward fu.niUcHs the condition is easily ]-eco«;niz('(l and tlicfe is little (liftii'iilty in rcdticing the displacement. Ontward and upward traction on the shoulder with direct pressure on the end of the bone will usually be all that is necessary to effect reduction. The displacing action resulting from contact between the clavicle and first rib is avoided by preventing extreme backward displace- ment of the shoulder during the after-treatment. Any form of dressing wliich will properly immobilize the shoulder without carrying it too far backward will accomplish the desired result. "When the ligamentous tearing has been extensive it may be neces- sary to employ some form of dressing which will support the weight of the upper extremity and overcome the action of the muscles which pull the shoulder downward, forward and inward. In accomplishing this purpose care should be exercised not to pull the shoulder too far backward. A figure-of-eight of both shoulders with the turns passing in front of the chest, and another figure-of- eight with the turns across the back will fix the shoulder sufficiently for all practical purposes. A plaster of Paris spica will immobilize the shoulder very perfectly but is seldom necessary. It is often advisable to employ direct pressure over the sternal end of the clavicle by means of pads and strips of adhesive plaster. When pressure is used in this way it should be remembered that the end of the bone is subcutaneous and that sloughing of the skin may follow if the pressure is too severe or too long continued. It is probably better to exert the pressure over the inner two inches of the shaft rather than directly over the end of the bone. The necessity for direct pressure will depend on the tendencj^ to recur- rence of deformity after the shoulder has been fixed. There is probably no dressing which will perfectly fill all requirements in all instances. Each case must be considered by itself and the par- ticular dressing employed is of secondary moment, provided the shoulder is immobilized with the luxation in reduction and in a position showing the least tendency to the recurrence of deformity. It will be found practically impossible to entirely correct the anterior displacement, but absolute reduction is not essential to complete restoration of fnnetion, and the slight deformity remain- ing is of little moment. Young W'Omen may be desirous, for cosmetic reasons, of securing DISLOCATIONS OF STERNAL END OP CLAVICLE 9 as perfect reduction as possible, and in such instances the shoulder should be fixed and the displacement treated in the recumbent position for a period varying from ten days to two weeks. In backward dislocalions of tlie inner end of the clavicle reduction is accomplished by traction upward, outward and backward, and is, as a rule, attended by little difficulty. If additional manipula- tion is required the clavicle may be grasped in its middle third, where it is free from heavy muscular attachment, and direct trac- tion made to replace the inner end of the bone as the shoulder is being pulled outward and backward. Reduction is much more easily maintained than in the forward variety, though the shoulder should be immobilized and the case kept under observation as in forward dislocations. The shoulder may be immobilized by the double figure-of-eight as already described, or the Velpeau or Sayre dressing may be employed. (See Figs. 30 to 35.) Direct pressure over the inner end of the bone is seldom required in this form of luxation. In upward luxation of the sterno-clavicular joint, reduction is accomplished by outward traction on the shoulder accompanied by direct downward pressure on the inner end of the clavicle. INIain- taining the end of the bone in proper position is attended with difficulty here, as in other types of luxation at this joint. The shoulder should be immobilized and the arm supported to prevent downward displacement. If there is much displacement of the clavicle it may be w^ell to place a pad in the axilla, and bind the arm to the side to maintain the proper distance of the shoulder from the thorax. The principles involved in the treatment of this dislocation are similar to those already described in the two pre- ceding types of luxation. Operative Treatment. — Operative intervention is, as a rule, indicated only in old cases with loss of function, and in cases of recurrent dislocation which have not responded to non-operative measures. Proper reduction can almost invariably be had in recent cases by proper fixation, but should recurrence of deformity take place in spite of appropriate dressings, it may be advisable to expose the end of the bone and secure it in position with suture. An incision parallel to the clavicle is made exposing the parts; the end of the clavicle is then dissected out from the fibrous tissue which surrounds it in its displaced position in old cases. It is then returned to its proper relation with the sternum and fixed in 10 FRACTURES AND DISLOCATIONS position. It may be possible in some eases to repair tlie ligaments sufficiently to retain the end of the bone in place. In other instances it may be necessary to drill holes in the end of the clavicle and the upper end of the sternum and prevent recurrence by some form of suture material, either absorbable or otherwise. The rela- tion of the great vessels of the neck should be kept in mind when operating in this region. In cases of recurrent or habitual disloca- tion a repair of the ligaments will frequently be all that is required. The same results have been obtained by the repeated injection of small quantities of alcohol in the region of the anterior sterno- clavicular ligament, thus producing inflammatory reaction and secondary fibrosis. Resection of the articular end of the clavicle, with the subsequent formation of a false joint, is a method which has been followed by excellent results in habitual luxations. Operative treatment is rarely indicated in backward or upward luxations, but should the necessity arise for open treatment in either type the principles will be the same as already given. After-Treatment. — In simple cases the retentive dressings may be dispensed with at the end of a month, and pressure over the sternal end is seldom of use after ten days to two weeks. During the progress of the case the dressings should be examined frequently to correct alteration in position, and when pressure is employed the parts should be carefully watched so that irritation of the skin may be immediately detected if it appears. Activities sub- jecting the articulation to much strain should be avoided for another month to six weeks following removal of all dressings, "When these simple details are followed the patient will almost invariably make a perfect functional recovery, though there is usually some prominence remaining at the site of the dislocation. The after-treatment is the same in all forms of luxation of the sterno-clavicular joint. Prognosis. — With proper reduction and immobilization restora- tion of function should be practically complete. If the end of the bone is allowed to remain in displacement there will be more or less loss of function. If strain is placed on the joint too soon following the initial luxation the condition may become recurrent. CHAPTER III. FRACTURES OF THE CLAVICLE. Surgical Anatomy. — The clavicle is the most frequently broken single bone in the entire body, and this fact renders a study of its anatomy particularly advisable. This fracture is especially com- mon in children. The clavicle is the only bone connecting the upper extremity with the trunk, and its position is quite superficial. These two facts expose the bone to fracture, both from direct and indirect violence. The most common fracture is the result of indirect violence and the break is usually situated at or near the junction of the outer and middle thirds where the two curves of the shaft meet, and the bone changes in form from "prismatic" to "flat." The shaft of the clavicle is well ossified before birth, and the bone has but one epiphysis which is situated at the sternal end. This single epiphysis begins to ossify at about the eighteenth year and joins the shaft during the twenty-fifth year. The ligaments of the sterno-clavicular articulation extend beyond the epiphysis and are attached to the shaft of the bone so that epiphyseal separations are almost never seen. The clavicle is situated in a muscular plane which should be understood to appreciate the displacements which take place when fracture occurs. On the inner end of the bone is attached the clavicular origin of the sterno-mastoid above, while opposite it on the anterior and lower aspect of the bone is attached the clavicular origin of the pectoralis major. In the presence of fracture in the usual site, it might seem that these muscles would counteract each other, but if the direction of the fibres of these two muscles is observed it will be noted that those of the pectoralis approach the bone at an acute angle, while the clavicular head of the sterno- mastoid is placed at nearly right angles with the shaft. This gives the sterno-mastoid the mechanical advantage, and accordingly the inner fragment is displaced upward. The subclavius is attached to the inferior surface of the shaft, in its middle third, and when 11 12 KKAITI'KKS AND OISLOCATIONS the bone is lirokcn and depressed against the first rib and the structures passing into the axilla, it acts, to some extent, as a cushion. To the anterior border of the outer third is attached the deltoid, and on the posterior border of the same corresponding portion of bone is found the clavicular insertion of the trapezius. These two muscles about balance each other and are seldom respon- sible for displacement of fragments. The ligaments of the clavicle play an important part in preventing and limiting dis- placement of the fi-agments. The rlioniljoid ligament is a heavy Fig. 2. Fig. 3. Fig. 4. Fis. 5. Figs. 2 and 3 show the superior surfaces of the riglit clavicle. Dotted lines indicate the margins of muscular and ligamentous attachments. Figs. 4 and 5 show the internal structure of the same bone. Note the preponderance of compact tissue in the shaft and region corresponding to the oblique line. structure Avhich passes from the first costal cartilage to the under surface of the inner end of the clavicle. The sterno-mastoid usually displaces the inner fragment upward until this ligament becomes taut, when further deformity is checked. When the fracture lies internal to the coraco-clavicular (eoronoid and trapezoid) ligament the inner fragment is free to move upward, while the outer frag- ment falls downward, inward and forward with the shoulder. "When the fract^^re passes through this ligament both fragments remain attached to the coracoid and displacement is slight or absent. Fractures of the clavicle between the coraco-clavicular and acromio-clavicular ligaments are usually not accompanied by much deformity. FRACTURES OP THE CLAVICLE 13 It is not often necessary to operate on the clavicle, but when the occasion does arise the surgeon should appreciate the internal structure of the bone. Figs. 4 and 5 show a horizontal section of the bone. The clavicle is composed largely of compact tissue, the cancellous bone being confined to the extremities. The compact Fig. 6. — Diagram showing the relations of tlie brachial plexus to the first rib and clavicle. Section of clavicle removed. tissue is particularly heayy in the region of the oblique line where the coraco-clavicular ligaments are attached. The clavicle is subcutaneous throughout and easily palpated. It should be noted that the acromion stands directly external to the Fig. 7. — Fracture of the clavicle with overriding deformity in a child. outer end of the bone, as well as behind it. The rounding of the outer aspect of the shoulder is caused by the head of the humerus beneath the deltoid, and not by either clavicle or acromion. Any portion of the clavicle may be broken, but by far the most common site of fracture is in the outer end of the middle third and 14 FRACTURES AND DISLOCATIONS is decidedly oblique. Fracture iu this region is usually the result of indirect violence and is almost always produced by a fall on the shoulder; Trauma sustained in this way more often produces a Fig. 9. — Green-stick fracture of the clavicle. dislocation of the shoulder in adults, while in children fracture is more common because the clavicle is relatively weaker. Incom- plete fracture is common in children. Fractures in either the FRACTURES OP THE CLAVICLE 15 inner or outer third are comparatively rare and usually the result of direct violence. Muscular action is sometimes, though rarely, responsible for fracture of the clavicle. It should be remembered that fracture internal to the coraco- clavicular ligament completely destroys all bony and ligamentous 4PI Fig. 10. — Fracture of the middle third of the clavicle with the usual deformity — up- ward displacement of the inner fragment. Fig. 11. — Fracture of the clavicle with the usual deformity. connection between the scapula and sternum, but when the break occurs through, or external to, this ligament, a heavy bond is main- tained between the inner fragment and the shoulder blade. Simultaneous fracture of both clavicles is occasionally seen as a result of transverse crushes of the shoulders. Symptoms. — The patient complains of pain immediately follow- ing the accident, and there is almost complete loss of function 16 FRACTURES AND DISLOCATIONS Fig. 12. — Coiuniimited fractuit of the outer end of llie clavicle (rare). -Coniminuled fracture of tlie clavicle with ovei-ridiii^'. as a result of pain and of the disturbed mechanism of the shoulder. Swelling usually develops within a few hours and obliterates the supra- and infra-clavicular fossae. The surgeon can hardly fail to recognize the obliteration of these fossfe if the opposite shoulder is inspected and compared. If the inner fragment is free of the coraco-clavicular ligament the deformity will be so pronounced that the nature of the injury should be recognized by inspection alone. The shoulder is displaced inward, forward and downward, the injured member is supported with the opposite hand and the head FRACTURES OF THE CLAVICLE 17 is inclined to the injured side to relax tlie pull of the stenio-inastoid. The patient is unable to draw the shoukhu- forward, as sliown in normal cases in Figs. 27 and 28. The inner fragment is usually Fig. 14. — Fracture of the right clavicle about twenty minutes after the accident. The injury was sustained by a fall on the shoulder. Note the swelling in the region of the fracture and the slight' falling of the shoulder. The manner in which the patient grasps and supports the injured member is characteristic. If need be the diagnosis might be made by inspection alone. Palpation reveals abnormal mobility and crepitus at the site of fracture. F\e:. 15. Fig. 16. Figs. 15 and 16. — Front and side views of fracture of the clavicle with moderate deformity. Note the prominence produced by the outer end of the inner fragment. Photograplis taken about thirty minutes following the accident. displaced upward and can, as a rule, be palpated and moved without difficulty. The nearer the fracture is situated to the inner third of the bone the more pronounced will be the angle of upward 18 FRACTURES AND DISLOCATIONS displacement. The distance between the supra-sternal notch and the acromion process is decreased on the injured side; in other words the shoulder is shortened. When the fracture lies through Figs. 17 and 18. — Fracture of the right clavicle at about its middle. Note the promineuce of the outer end of the inner fragment. Photographs taken about twenty minutes following the accident. Fia; Fig. 20. Figs. 19 and 20. — Fracture of left clavicle about twenty-four hours following in- jury. Note the falling of the injured shoulder and the swelling which obliterates the supra- and infra-clavicular fossag. The side view shows the forward displacement of the shoulder which is common in fractures of this bone. or external to the coraco-clavicular ligament the deformity will usually be too slight to recognize by inspection, and the patient will FRACTURES OF THE CLAVICI;E 19 not show the usual anxiety in supporting the injured member. Pain, local tenderness and less pronounced loss of function will, however, be present. If the surgeon fixes the shoulder with one hand, the fingers of the opposite hand will detect abnormal mobility Fig. 21. Figs. 21 and 22. — Fracture of the left clavicle with pronounced upward displace- ment of the inner fragment which is not bound down by the coraco-clavicular ligament. The following points are significant in making a diagnosis from inspection alone : Contour of shoulder normal, axis of arm normal, shoulder as a whole slightly lowered and patient grasps forearm. Deformity of clavicle plainly visible as well as palpable. Photographs taken a few minutes following the accident. Fig. 23. Figs. 23 and 24. — Delayed union of clavicle due to poor approximation of frag- ments. The inner fragment is above and anterior to the external fragment. This de- formity is chiefly the result of the action of the clavicular attachment of the sterno- mastoid. Fracture nearer the median line than visual. Injury the result of direct violence. Patient first seen by author six weeks after the accident. by alternate forward and backward pressure on the clavicle, in the region of the fracture. The middle third of the clavicle is free from heavy muscular attachments and can be grasped without diffi- culty in testing the integrity of the bone. When the normal 20 FRACTURES AND DISLOCATIONS Fig. 25. — Fracture of the left chivicle in an elderly woman some days following the accident. Note the ecchyniosis in the region of the fracture and the obliteration by swelling of the supra- and infra-clavicular fossie. Falling of shoulder not apparent because elbow is supported by the arm of the chair. Fig. 26. — Fracture of right clavicle with i)r(jiiounced deformity following improper treatment. This case (according to the history given by the patient) was treated by means of a plaster east of the shoulder and the deformity recognized only when the dressing wa.s removed some weeks later. Function of shoulder much impaired and symptoms of brachial ple.xus irritation present. This condition is a striking example of what may follow treatment which is not based on proper principles. FRACTURES OF TflR OT.AVTOI^E 21 shoulder is thrown forward this middle third stands out promi- nently as shown in Figs. 27 and 28. Ecchymosis usually develops within the first day or two and is almost pathognomonic of fracture. In children the fracture is often incomplete and the symptoms are much less pronounced. Local tenderness and pain are present but the child may not show any perceptible disturbance in the use of the arm and hand. More commonly, however, there is a disin- Fig. 28. Figs. 27 and 28. — These two pictures were taken to demonstrate the manner in which the outlines of the clavicles may be brought out by throwing the shoulders for- ward. This movement not only brings out the outline of the bone but shows whether or not the clavicle is properly performing its function. If the clavicle is fractured the action of the shoulder will be quite different when the patient is requested to throw the shoulder forward. In adipose and well-muscled persons it is more difficult to see the outline of the clavicle, yet the signs and symptoms of fracture are almost always suiificiently pronounced to form a diagnosis if the examiner is observant and systematic. clination to use the hand of the injured side and the patient will cry out when the arm, forearm or shoulder is manipulated. Local swelling is usually present. When the fracture is complete the symptoms will be more pronounced though deformity is almost always slight in children. Fracture of the clavicle is rarely compound and injury to the structures passing beneath the clavicle are rare, considering the frequency with which the clavicle is fractured. If the brachial plexus or axillary artery is injured symptoms of paralysis or nerve irritation or disturbance in the circulation of the upper extremity will develop. Crepitus is a symptom which can almost always be elicited in 22 FRACTURES AND DISLOCATIONS fractures of the clavicle, except in the incomplete form occurring in children. Diagnosis. — There is, as a rule, little difficulty in recognizing fracture of the clavicle if the region of the shoulder is carefully examined. The diagnosis is based on the symptoms just given. Incomplete fractures in children, and fractures of the outer end of the bone are most likely to be overlooked. In establishing a diagnosis of fracture of the clavicle it is not sufficient to note the presence of a break in a given region, but the entire shoulder should be examined to exclude associated lesions. The clavicle should be palpated from end to end; occasionally the fracture is multiple. The spine of the scapula and the acromion should be palpated and the condition and position of the upper end of the humerus should be determined. The circulation of the forearm should be exam- ined and the reflexes noted. Treatment. — Reduction of the deformity in fractures of the clavicle is usually a simple matter, being accomplished by pulling the shoulder outward, upward and backward. The deformity recurs, however, as soon as the parts are released. Correction of the displacement, therefore, is useless prior to the application of retentive dressings. Innumerable dressings have been devised for maintaining the fragments in reduction, but only those which have proven most satisfactory will be considered. The modified Sayre adhesive plaster dressing will be found most satisfactory in the largest number of cases and is applied with three strips of adhesive plaster, each about four inches wide and long enough to encircle the trunk one and a half times. Zinc-oxide plaster should be used as it is less irritating. Before the adhesive is applied the axilla should be cleansed, and the arm and chest sponged with alcohol and thoroughly dried. A folded towel should be placed in the axilla or a few layers of gauze secured in position to prevent the arm from coming in contact with the chest. If the upper extremity is immobilized and skin is allowed to come in contact with skin, cutaneous irritation is almost sure to follow and may be severe. A light folded towel or folded gauze should also be placed about the middle of the arm before the first strip of adhesive is applied. The first strip of adhesive encircles the arm (the loop being secured with a safety pin) half way between the shoulder and PRACTtTRER OV Tfll'] CI.AVKJLE 23 elbow; the strip is then continued under tension, across the back, under the opposite arm and on to the chest anteriorly. This strip of adhesive, when in place, should pull the arm well backward. The portion of the dressing encircling the arm should be equi- distant from the shoulder and elbow; neither above nor below this point. The second strip begins behind the shoulder, extends down the back of the arm, under the elbow, along the dorsal surface of the forearm and hand, and over the opposite shoulder. As this strip passes under the elbow the adhesive should be split and a generous padding of cotton placed in position to prevent irrita- Fig. 29. — Fracture of the right clavicle with the usual symptoms. The following figures show the application of a modified Sayre's dressing to this case. tion at the point of the elbow. As the end of the strip is being attached to the opposite shoulder the hand should be raised on the chest and the elbow pulled forward. This second strip pulls the elbow forward (thus displacing the shoulder backward with the middle of the arm fixed by the first strip ) and raises the entire arm. When these two straps are in position the shoulder is pulled upward, backward and outward, thus meeting the requirements for reduction of the displaced fragments. A third strip of adhesive plaster is then passed horizontally around the chest and arm to fix the arm to the side. Instead of this strip a body-swathe may be used to steady the member. This dressing, when properly applied, immobilizes the shoulder most satisfactorily. The author has found, however, that the patient usually complains of the confinement of the hand which often shows considerable irritation 24 FRACTURES AND DISLOCATIONS Fig. 31. Fig. 32. Fig. 33. Author's modification of a Sayre's dressing applied to the fractured clavicle shown in Fig. 29. In this dressing the hand is not included, which is a great comfort to the patient and does not render the dressing less effective. Sayre's dressing will meet the indications better in the greatest number of cases. When employed in the treatment of children, special care should be taken in watching for signs of irritation to the delicate skin. (See Figs. 37 and 38. — The Taylor brace, which is of great advantage in the treatment of children.) Fig. 30. — First strap of adhesive encircles the arm and then the body, pulling the arm backward. Fig. 31. — Second strap of adhesive passing down the posterior aspect of the arm, under the elbow and over the opposite shoulder. Fig. 32. — Third strap of adhesive which passes down the outer side of the arm, under the elbow and under the hand to the opposite shoulder. Fig. 33. — Another view of the dressing showing the attachment of the straps po8 teriorly. FRACTURES OP THE CLAVICLE 25 where it comes in contact with the adhesive. To obviate this the author has been in the habit of dividing the second strip into two narrow strips applied as shown in Figs. 32 and 33. The first strip passes down the posterior aspect of the arm, under the elbow, and then diagonally across the forearm so that it passes above the hand and over the opposite shoulder. The second strip passes down the outer side of the arm, under the elbow on its outer aspect, and then diagonally across the forearm in the opposite direction so that it passes below the hand and over the opposite shoulder. The hand is thus left exposed and free from irritation, and the patient may move it at will, thus relieving the discomfort of the cramped position without in any way disturbing the fixation. (See Figs. 29 to 33.) In some instances, especially when the fracture is in the inner half of the bone, additional direct pressure may be Fig. 34. — Mohr's figure-of-eight. Fig. 35. — Shows the turns used in Vel peau's bandage. necessary to prevent upward displacement of the inner fragment. This is accomplished by means of pads of gauze or cotton held in position by strips of adhesive. When adhesive plaster is not available Mohr's figure-of-eight, Velpeau's bandage or a posterior figure-of-eight with the turns passing behind the shoulders will serve the purpose as an emergency dressing. These dressings, however, are all too insecure to be relied upon in permanent fixation of the clavicle. The recumbent position will almost invariably maintain the frag- ments in good position when all forms of ambulatory treatment prove inefficient. The patient should be placed on a firm narrow bed, the arm secured to the side by means of a swathe, and a small firm pillow placed between the seapulge and fixed in position on 26 PRACTITRES AND DISLOCATIONS the back l)y iiu-ans oL" strips of adhesive. ^lultiple fracture of tlie clavicle or simultaneous fracture of botli clavicles can ])e success- fully treated by this method. (See Vi^. 'A6.) The test of any dressing is the position occupii-d by tlie fragments and the absence of undue constriction of the arm and forearm. No matter wliat method is employed either the presence of deformity or strangulation of the upper extremity is a condition which calls for correction and indicates the inefficiency of the dressing. In adults, es})eeially large persons, considerable strength is necessary in the dressing to maintain the proper position of the Fig. 36. — 111 ililVhiih iM.srs nTiniilrriii 1 i-i.;itinciii Will -i\r l;(iocI results when otlier methods would tail. This ijliolot;iai)li was taken aljoul live yeais atter fracture of both clavicles (one clavicle in two places) and fractuve of the first and second ribs on both sides. Recumbent treatment was employed. At the time this photograph was taken it was impossible to determine by palpation the former positions of the fractures in the clavicles. upper extremity, and accordingly the points of greatest pressure (the middle of the arm and the point of the elbow in Sayre's dressing) should be particularly well padded. Taylor's brace (see Fig. 37) is especially well adapted to frac- tures of the clavicle in children, and allows freedom of motion of both arms. Sayre's dressing, however, will answer the purpose very well, though the delicate skin of a child must be closely watched for irritation when adhesive plaster is employed. Operative Treatment. — Nearly all cases of fractured clavicle can be successfully treated either by Sayre's dressing or the recumbent method and hence operative intervention is rarely indicated in FRACTURES OF THE CLAVICLE 27 recent cases. When, however, operation is demanded a single loop of suture material will usually accomplish all that is required to hold the fragments in position; the Lane plate is almost never needed. The incision is best made a little below and parallel to the bone, rather than directly on it. If the incision is a little below the clavicle a short flap may be made, and the danger of infecting the wound from the cut skin edges will be lessened. Most surgeons prefer absorbable suture material (such as kanga- roo tendon) to wire, in securing the ends of the fragments. In operating on the inner end of the bone the surgeon should have in Figs. 37 and 38. — The C. F. Taylor brace which is particularly satisfactory in the treatment of fractures of the clavicle in children. mind the relations of the important structures passing between the clavicle and the first rib. The subclavian vein lies directly behind, and in contact with, the clavicle and subclavius muscle, and just external to and behind the rhomboid ligament. A little external to the vein and separated from it by the scalenius anticus is the subclavian artery, which is also in relation with the clavicle and subclavius muscle. If the surgeon does not exercise great care either of these vessels may be injured, thus giving rise to serious and troublesome hemorrhage. External to the artery is the brachial plexus descending from the neck into the axilla. Fortunately however fracture of the clavicle in the region of these structures is rare. Operation is sometimes demanded in old cases because of injury 28 FRACTURES AND DISLOCATIONS to the brachial plexus with resultant paralyses. These injuries are usually due to pressure alone (without laceration of the nerves) and if the condition is not too old removal of pressure, by dividing the bone and raising the depressed fragment, will be all that is required. Following operation it will, as a rule, be wise to fix the parts with a Sayre's dressing to relieve the internal fixation of as much strain as possible. After-Treatment. — Sayre's dressing is the most secure known, yet it requires watching from day to day to correct slipping and to take up the slack as it develops. The fact that reduction is perfect and immobilization is secure after the dressing is in place should not lead the surgeon to assume that the same conditions will prevail a week later. ]\Iost text-books advise the removal of the dressing at the end of a few days to inspect the skin for evidences of irritation and to see that reduction is maintained. This will seldom be needed if the dressing has been properly applied in the first place. Additional strips of adhesive following the course of the "second strip," as described in the application of Sayre's dressing, may be used as needed to raise the elbow and correct the downward slipping. The case should be carefully watched for signs of cutaneous irritation, strangulation of the circulation of the arm and for the partial recur- rence of deformity. In the uncomplicated case in a child, union may be expected at the end of two and a half or three weeks, though the callus at this time is in no condition to withstand any considerable strain. In adults a month or a little more is necessary for the fragments to unite. The dressings may be removed at the end of three to five weeks, according to the age of the patient, and the arm carried in a sling for another week or ten days. During the after-treatment the dressing should be changed every ten days and the parts carefully inspected and cleansed. In removing the dressing the patient is best placed in the recumbent position so that the clavicle will not be subjected to strain during the change from the old dressing to the new. Care should be exercised not to pull the shoulder forward as the old dressing is being removed and the new one applied. With the upper extremity released it is well to fully extend the elbow and gently abduct the shoulder without disturbing the clavicle. This will aid in keeping these joints free, and will be followed by more rapid resumption of function when the dressings FRACTURES OP THE CLAVICLE 29 are permanently removed. If the dressings are replaced in the sitting position the surgeon should have an assistant to confine his entire attention to holding the shoulder upward, backward and outward while the dressings are being changed. Massage and passive motion should be instituted as soon as the dressings are permanently removed, but care should be exercised not to submit the clavicle to strain before the callus is well formed. These measures are of the greatest value in keeping up the tone of the muscles and in maintaining the integrity of the articular surfaces following operations on the nerves, pending the regeneration of these structures. Prognosis. — In the usual fracture of the clavicle complete resto- ration of function and strength should follow proper treatment. If the fragments have been allowed to unite in deformity there will be some loss of function, varying with the degree of deformity, and if the brachial plexus is impinged upon there may be a more or less complete paralysis of the upper extremity. If the disturb- ance in function is due simply to mechanical causes surprising improvement may take place as the years go by. The complication most often rendering the prognosis bad is injury to the brachial plexus. "When this structure is damaged the outlook will depend on the nature arid extent of the injury, and the length of time the paralysis has been established. "With paralysis existing a year or two there is little chance of improving the condition by operation, but even under these circumstances there is everything to gain and nothing to lose, and it is advisable, therefore, to expose the plexus and do what can be done by relieving pressure and suturing divided nerve ends. In recent cases the prognosis is not bad if operated early, although the process of regeneration may extend over months or even a year. In the uncomplicated case of fracture of the clavicle the prog- nosis is good whether in child or adult, provided proper treatment is carried out. CHAPTER IV. DISLOCATIONS OF THE OUTER END OF THE CLAVICLE. Surgical Anatomy. — The acromio-elavicular articulation is of the arthrodial type and is composed of two small, nearly flat, oval facets, one on the acromion and the other on the outer end of the clavicle. The plane of this articulation is not at right angles with the long axis of the clavicle but is so placed that the clavicular facet looks downward, outward and backM^ard. The result then (when the acromion is forced inward toward the base of the neck) is that the clavicle will tend to slip upward onto the top of the acromion. Violence of this type, however, is more likely to pro- duce fracture of the clavicle than dislocation of either end. An inter-articular fibro-cartilage is sometimes present between the two articular facets. The joint depends entirely on the ligaments sur- rounding it and those passing between the coracoid and the clavicle. The coraco-clavicular ligaments play an important part in reinforc- ing this joint and are iisually torn when the displacement is pronounced. Nearly all the dislocations of the acromio-elavicular joint are of the upward type. About a dozen cases of downward luxation have been reported. Another form of dislocation is one in which the clavicle is displaced downward and forward beneath the coracoid process, but the few cases reported are questionable and the type is doubtful. The upward luxation is described as complete or incomplete, according to whether or not the articular facets clear each other. The acromio-elavicular ligaments are more or less completely torn, and the coraco-clavicular ligaments may be partially or completely ruptured, depending on the extent of the displacement and the degree of violence. Direct violence is usually responsible for luxations of the acromio- clavicular joint, though muscular action is known to have produced the condition. A downward blow on the acromion may displace this process downward while the clavicle is prevented, to some 30 DISLOCATIONS OF OUTER END OF CLAVICLE 31 Fig. 39. — Dislocation of the outer end of the clavicle and separation of acromial epiphysis. The lower arrow points to the displaced epiphysis. 32 FRACTURES AND DISLOCATIONS extent, from accompanying it by the action of the trapezius. The same type of violence which produces fracture of the clavicle may in rare instances be responsible for luxations of the outer end. Symptoms. — Dislocations of the clavicle vary with the direction of the displacement and the extent of ligamentary rupture. There is always more or less pain in the region of the acromio-clavicular articulation which is increased by both active and passive motion of the sliouldcr. Disabilitv varies greatly in different cases. Cora- Fig. 40.- — Dislocation of the outer end of tin clavii-le a few minute.s following the accident. Note the prominence indicated by the arrow. plete loss of function may be present in some cases while in others the patient may be able to use the shoulder, though the action of the part is more or less restricted by pain. It is probable that this variation in disability depends largely on the extent of laceration in the coraco-clavicular ligaments. The nature of the deformity varies with the type of luxation. In the common upward variety a distinct prominence is noted at the outer end of the clavicle. In the incomplete form the promi- nence of the displaced outer end is not great, being as a rule less than the thickness of the bone. In the complete form the outer end of the bone stands out prominently and may be moved about on palpation. By pressing on the outer end of the clavicle and raising DISLOCATIONS OP OUTER END OP CLAVICLE 33 the shoulder, the prominence may be made to disappear as the luxa- tion is reduced. Recurrence of deformity is prompt with release of the shoulder. A rotary displacement of the scapula is noted in some instances; the tip of the body being more prominent than normal, while the spine and acromion are depressed. If the clavicle is grasped in its middle third, where it is free from heavy muscular attachments, and manipulated, pain will be produced at the outer end. Fig. 41 Figs. 41 and 42. — Dislocation of the acromial end of the clavicle shortly following accident. Note the forward and downward displacement of the shoulder and the ab- normal prominence of the outer end of the clavicle which slightly overlaps the acromion. Further displacement is prevented by the coraco-clavicular ligaments which remain intact. In the downward type of luxation the outer end of the bone lies below the acromion and is displaced backward. The middle third of the shaft is less prominent than normal, the trunk is inclined to the injured side and the shoulder is lowered. The downward dis- placement of the outer end causes the sternal extremity to become unduly prominent. The entire inner border of the acromion is palpable and the articular facet may be felt. It will usually be possible to feel the clavicle at the point .where it passes under the acromion. In the suhcoracoid form the clavicle is said to be lodged under the coracoid process. The outer end of the bone lies in the axilla and there is great ecchymosis in the region of the coracoid. Diagnosis. — In the usual type of acromio-clavicular luxation the 34 FRACTURES AND DISLOCATIONS diagnosis may be tentatively made by inspection alone. The nature and position of the prominence is characteristic. Manipulation of the clavicle or shoulder causes motion at the acromio-clavicular joint. The region of the prominence should be carefully i)alpated to exclude fracture of the outer end of the clavicle, and fracture of the acromion. Eitlier of these conditions is productive of crepitus. The ligaments sometimes avulse a small portion of either clavicle or acromion in lieu of rupture of the ligament itself, ami when this Fig. 43. — Downward (lisslocatinn cf of the clavicle is cau2:lit under the acromion the one of least discomfort. i-i- .■,1.1 (if till' clavicle. The outer end nd tlic [latipnt assumes this attitude as occurs the surgeon may be able to elicit crepitus and mistake the condition for fracture. Careful palpation, however, will determine the false motion in the joint itself and not to the outer or inner side of it. The displaced axis of the clavicle and the relatively raised acromion should suggest the condition in the rare downward type. Treatment. — In the common type of luxation reduction is, as a rule, easily eft'ected by upward, outward and backward traction on the shoulder. Recurrence of deformity, however, is the rule and retentive dressing should be at hand to maintain the outer end of the clavicle in position as soon as reduction is accomplished. Stimson's adhesive plaster dressing is quite satisfactory in prevent- DISLOCATIONS OF OUTER END OP CLAriCI.E 85 ing redisplacement. The axilla is first cleansed, sponged with alcohol, and dried and a folded towel is placed between the arm and the chest to prevent skin coming in contact with skin during the subsequent immobilization. The arm is then placed at the side and the elbow semiflexed. A strip of adhesive four feet long and three or four inches wide is then placed under the elbow. One end is carried up the anterior aspect of the arm and over the shoulder at the site of luxation. The posterior end of the plaster is carried up the posterior aspect of the arm in a similar manner and carried forward over the shoulder. As the ends of this dressing are being Fig. 45. Fig. 44. — Dressing to maintain reduction in luxation of the outer end of clavicle. Fig. 45. — .S.ame principle carried out witli adhesive jjlaster instead of bandage. Note the pad over outer end of clavicle. brought into position the shoulder should be raised upward, back- ward and outward, and pressure should be made on the outer end of the clavicle. When the plaster is properly placed it pulls upward on the semiflexed elbow and exerts downward pressure on the outer third of the clavicle. The arm is then secured to the side by means of a body swathe and the forearm carried in a sling. In the downward type of luxation reduction is accomplished by outward traction on the shoulder and direct manipulation of the clavicle by grasping it in its middle third. Recurrence of deform- ity does not, as a rule, occur following reduction, and accordingly^ 36 . FRACTURES AND DISLOCATIONS no retentive apparatus other than a sling and body swathe will be needed. Operative Treatment. — Open treatment is seldom indicated since reduction can, as a rule, be niaiiitained by the dressings just described. In exceptional instances suture of the outer end of the clavicle to the acromion may be needed to prevent recurrence of deformity. Both wire and absorbable suture material have been successfully employed. It may be possible in some eases to suture the ligaments about the end of the bone in such a manner as to obviate the necessity of drilling into the bone. In the downward variety of luxation operation may be called for to disengage the outer end of the clavicle. After-Treatment. — The clavicle should be watched for recurrence of deformity especially following the upward type of luxation. A certain amount of slipping will take place in the dressings and should be corrected to keep the end of the bone in position. Irrita- tion may develop at the site of pressure and require attention. Three to four weeks should be allowed for the ligaments to heal. Prognosis. — The outlook in the ordinary case of luxation of the outer end of the clavicle is good as far as restoration of function is concerned. The prominence of the articulation may be a little greater than normal when recovery is complete, and in some cases a slight amount of displacement maj' persist, but these conditions are not incompatible with free use of the part and a strong joint. Downward luxations may be attended by injury to the brachial plexus since this displacement decreases the space between the clavicle and the first rib, and the prognosis will depend on the severity of the plexus involvement. Old unreduced luxations often show a remarkable restoration of function and the formation of a new joint. CHAPTER Y. FRACTURES OF THE SCAPULA. Surgical Anatomy. — The freedom of motion in this bone and the fact that it is almost entirely surrounded by heavy muscles, account for the rarity with which it is fractured. Some portions of the scapula (spine and acromion process) are subcutaneous and accord- ingly more often injured. The acromial epiphysis usually joins the remainder of the bone between the eighteenth and twenty-fifth Figs. 46 and 47. — Ventral and dorsal surfaces of the right clavicle. A., Acromion sss ; C, Coracoid process ; G., Glenoid cavity. process years, although it may remain ununited throughout life. This condition has been mistaken for fracture. The attachments of the deltoid and trapezius tend to prevent displacement when this portion of the bone is broken. The attachment of these muscles and the heavy fibrous tissue surrounding the acromion and spine explain the difficulty of eliciting crepitus in the presence of fracture in this region. When, however, these structures are lacerated 37 38 FRACTrRES AND DISLOCATIONS sufficiently to allow displacement, crei)itus, abiioniial mohility and deformity are recognized without ditificulty. If the fracture is internal to theacromio-clavicular articulation we have a condition closely resembling dislocation of the outer end of the clavicle. Fracture of the coracoid is an extremely rare occurrence. It has been broken as the result of muscular action due to the pull of the short head of the biceps, coraco-brachialis and pectoralis minor. Epiphyseal separation of tliis ])roeess has been known to occur Fig. 48. — ^View of the same honi' fioni the axillary border. Note the relation of the coracoid and acromial processes to the glenoid cavity. prior to the seventeenth 3^ear, at which time ossification makes it continuous with the rest of the bone. Fracture of the glenoid cavity usually results from violence transmitted through the head of the humerus. It may exist as a complication of fracture or dislocation of the humeral head. Fracture of the neck of the scapula may occur from similar causes. The thinnest and best protected portion of the bone is the hody. Fracture rarely occurs in this region, but when it does it is almost invariably the result of direct violence. The spring of the ribs supporting the scapula undoubtedly enables it to withstand greater violence, but when trauma is severe we may have fracture of the FRACTURES OF TIIR SCAPULA 39 underlying ribs as well as of the body of the bone. When such is the case, the more superficial fracture may conceal the injury to the ribs. Fracture of the body is usually transverse below the spine. Comminution is sometimes observed and in rare instances Fig. 49. — Fracture of the neck of tin- the line of fracture may cross the spine. The attachments of the infraspinatus, subscapularis, serratus magnus, rhomboid and teres muscles are such that pronounced displacement rarely occurs and palpation is difficult. 40 FRACTURES AND DISLOCATIONS Symptoms. — Loss of fuuetiou, and pain (wliieli is increased on moliDii) are always present. Deep respiration causes suffering, though tlic j-ai)id sliallow breathing, characteristic of fractures of tlie ribs, is absent. The body of the scapula may be grasped as sliown in Fig. 50 when abnormal mobility and crepitus are elicited, completing the list of symptoms. Fracture of the acromion process produces localized pain, tender- ness, and sometimes limited mobility and crepitus. The symptoms vai-y with the position of the fracture in relation to the acromio- clavicuUir articulation. Fracture of the acromion, external to the acromio-clavii'ular joint, produces local pain and tenderness. Crepitus and abnormal mobility may be present on manipulation, but deformity is almost uniformly absent. Fracture of the acromion entering the articulation gives rise to symptoms closely resembling fracture external to the joint, though mo- tions of the shoulder are usually more painful. Fracture of the acromion internal to its articulation with the clavicle, is accom- panied by symptoms almost identical with dislocation of the outer end of the clavicle, especially if the muscular and fibrous attach- ments of the process have been torn sufficiently to allow deformity. The shoulder drops downward, forward and inward, and undue prominence is observed at the outer end of the clavicle. Palpation reveals the acromial fragment attached to the outer end of the collar bone. Abnormal mobility of the displaced acromial frag- ment is present, but crepitus is absent unless the fractured surfaces have remained in contact. Fracture of the coracoid gives rise to localized pain and tender- ness just below the junction of the middle and outer thirds of the clavicle. Displacement, if present, is very slight owing to the fact that the rhomboid and trapezoid ligaments are seldom torn. These ligaments securely hold the fragment in position against the actions of the attached muscles. The tip of the coracoid may be palpated if pressure is made at the proper point below the clavicle. It is impossible, however, to grasp the process betw'een the fingers, and for this reason it is difficult to elicit crepitus and abnormal mobility. Fracture of the surgical neck of the scapida gives a picture somewhat resembling dislocation of the shoulder, although the deformity is not characteristic of any type of shoulder luxation, and crepitus can usually be elicited by manipulation. Fracture of the glenoid cavity, especially a fragment from the anterior edge. FRACTURES OF THE SCAPULA 41 is a complication sometimes occurring in dislocations of the shoulder, and results in spontaneous recurrence of deformity fol- lowing reduction. Crepitus may, or may not, be present. Diagnosis. — A consideration of the symptoms occurring in frac- tures of different regions of the scapula should render the diagnosis in most cases easy. Fracture of the acromion and body are by far the most common injuries seen in this bone. Fracture of the surgical neck may, at times, be extremely difficult to differentiate from dislocations of the shoulder and fractures of the upper end of Fig. fracture. 50. — Method of grasping the body of the scapula to detect the presence of The fingers of the right hand are palpating the spine of the scapula. the humerus. Deep palpation of the axilla may detect the glenoid cavity moving with the head in its inward displacement. Fractures of the glenoid cavity, surgical neck and coracoid, may require the use of the X-ray before diagnosis can be established. The fre- quency with which radiography reveals unsuspected conditions in and about the shoulder demonstrates the value of the X-ray as a routine measure in injuries of this region. The difficulty of diagnosis is greatly increased if the case is not seen for twenty-four or forty-eight hours following the accident. By this time the swelling and tenderness have so increased that less is learned from inspection or palpation, and manipulation of the parts is seriously objected to by the patient. An anesthetic is often neees- 42 FRACTURES AND DISLOCATIONS sary to deterniiiio the condition, especially if the X-ray is not available. Treatment. — The treatment must, of necessity, vary with the region and function of the portion of the bone injured. Fracture of the body of the bone calls for strapping of the chest in such a manner that the scapula will be immobilized. In addition the arm should be fixed to the side of the chest by a swathe or additional strapping. The Velpeau bandage may be used to advantage, especially when reinforced with starch or plaster of Paris. Oppos- ing surfaces of skin should be protected by the intei'po-ition of some Fig. 51. — Oblique strapping with adhesive plaster to immobilize the body of the scapula. absorbent material, such as cotton. In fracture of the acromial process, especially with displacement, the indications in treatment are similar to those of fracture of the clavicle. A Sayre's dressing, or modification, such as shown on page 24, will answer the purpose satisfactorily. Additional pressure directly over the fragment may be had by means of a strap of adhesive and pad of gauze appro- priately placed. In fracture of the coracoid process direct immo- bilization of the fragment is hardly possible, yet the arm should be so fixed to the side as to prevent action of the three muscles attached to the process. The indications in the treatment of fractures of the surgical neck of the scapula are similar to those of fracture of the upper end of the humerus. The axillary pad and plaster of Paris shoulder cap can, as a rule, be so applied that the fragment is held in proper reduction. (See Figs. 332 to 140.) It is FRACTfJRES OF THE SCAPULA 43 usually unwise to allow use of the forearm or hand in fractures of any portion of the scapula. In the less severe conditions the arm should at least be carried in a sling, while the remainder of the upper extremity is securely immobilized. After-Treatment. — Union will usually take place within a month. When fracture occurs in parts of the scapula which are subject to considerable strain, such as the neck of the bone or the acromion, internal to its articulation with the clavicle, immobilization should be maintained for about two weeks longer. The dressings should be carefully inspected daily for the first week to avoid loosening and slipping. If irritation of the skin occurs it should receive proper attention. Prognosis. — Fractures of the body of the scapula seldom produce permanent impairment of function. Fractures of the surgical neck, and of the acromion with displacement, may be followed by some loss of function, if not properly reduced. Perfect function is likely to follow fibrous union of the coracoid. CHAPTER YI. DISLOCATIONS OF THE SHOULDER. Surgical Anatomy. — The peculiar construction of the shoulder joint, its wide range of motion and exposed position, result in its being the most common site of dislocation in the body. The articulation is typical of the ball and socket joint. The bones entering into its formation are the head of the humerus and the glenoid cavity of the scapula. The acromion and eoracoid processes, with the coraco-acromial ligament stretching between them, are not considered a part of the joint proper, yet they play an important part in preventing upward displacement of the humeral head. The wide range of motion possible in this joint is the result of the disproportion in the sizes of the articular surfaces of the humeral head and glenoid cavity. Extreme mobility renders the upper extremity more serviceable in many ways, but on the other hand it is evident that this type of joint construction is dependent almost entirely on ligaments and muscles for its stability. The coraco-acromial and capsular are the only ligaments of surgical importance in the shoulder joint. The coraco-acromial ligament arches over the head of the humerus, filling in the space between the two processes and serves to prevent upward displace- ment of the humerus. The capsular ligament entirely surrounds the articulation, being attached to the rim of the glenoid cavity just beyond the glenoid ligament, and externally to the anatomical neck of the humerus. This ligament is much too lax on all sides to keep the articular surfaces in contact, but this very laxity is necessary to allow the freedom of motion which this joint enjoys. A portion of the capsule becomes taut only when the arm is carried to the extreme limit of motion in a given direction. (See Figs. 52 and 53.) Some portions of the capsule are more subject to strain than others, and accordingly Ave find such parts reinforced by muscle tendons or thickenings in the capsule itself. These thickenings have been given special names, such as the coraco- humeral in the upper part of the joint, and the ligaments of Flood 44 DISLOCATIONS OP THE SHOULDER #■ and Schlemm anteriorly. The transverse humeral ligament serves to confine the long tendon of the biceps within the bici[)itfil groove, and the glenoid ligament forms a margin around the glenoid cavity, increasing its depth. The ligaments surrounding the joint prevent dislocation by limiting the range of motion, while the muscles, by their tonicity, actively hold the articular surfaces in apposition. The deltoid arising from the clavicle, acromion and spine of the scapula keeps the humerus well up in place against the under sur- face of the arch made by the coracoid, coraco-acromial ligament end acromion. Paralysis of this muscle results in a dropping of Fig. 53. Fiss. 52 and 53. — Diagrams illustrating the action of the capsule in different posi- tions of the joint. It is apparent that it must be lax enough on all sides to allow motion of the humerus in different directions and that its function is to limit motion and not to hold the humeral head firmly against the glenoid cavity. the humerus with separation of the articular surfaces in the shoulder joint. The tendon of the long head of the biceps strengthens the upper part of the capsule, keeps the head of the humerus in proper apposition with the glenoid during the various movements of the arm and prevents the head from being pulled too closely upward under the acromion. The action of the coraco- brachialis is similar to that of the deltoid in holding the humerus up. The tendon of the subscapularis reinforces the capsule, and in the anterior dislocations is not infrequently torn when this particular portion of the capsule is penetrated by the head. The tendons of the supraspinatus, infraspinatus and teres minor rein- force the capsule and aid in maintaining the proper relations of 46 FRACTURES AND DISLOCATIONS tlie articular surfaces. The brachial plexus and axillary artery occupy a position internal to the head as they descend through the axilla, and may be injured in dislocations o£ the slioulder. In the forward and downward types of luxation direct pressure may be made on these structures by the humeral head; the pulsating axil- lary artery may often be palpated as it stretches across the head in subglenoid luxations. The injuries sustained by the structures about the joint depend on the direction taken l)y the head as it leaves the glenoid and the degree of violence producing the luxa- tion. The planes of least resistance about the joint lie between the muscles rather than through them, though naturally the greater the violence producing the dislocation the greater the probability of a muscle being penetrated by the head. The subscapularis is the muscle most frequently penetrated in this manner. The capsular ligament is practically always torn at the point where the head leaves the glenoid fossa and, since the common dis- placements are of the anterior variety, the rent Avill usually be found in the antero-inferior portion of the capsule. A few cases of anterior luxation without injury to the capsule have been reported in which the joint was previously much relaxed and the capsule unusually roomy. Injury to the capsule is not infrequently accompanied by injury to the tendons which overlie and reenforce it and, when the violence producing the luxation is great, there may be a destruction of tendon continuity. The trauma causing the luxation may at the same time produce a fracture of the glenoid cavity or of the upper end of the humerus. The anterior rim of the glenoid may be broken off by the head of the humerus as the articular surfaces are forced past each other. The head and tuberosities may suffer a variety of fractures which are so diverse that two cases are rarely seen alike. The greater tuberosity is sometimes found parted from the shaft and displaced in the line of the pull of the muscles attached to it. This frag- ment may lie in the glenoid cavity where it offers obstruction to reduction. Fractures of the surgical neck, with or without dislo- cation of the shoulder, are more constant in type than fractures of the anatomical neck. Fracture of the anatomical neck, especially when complicated by dislocation, is sometimes represented by a comminuted, crushed condition of the upper end of the humerus, in which the lines of fracture are extremely variable. The cap of bone represented by the articular surface is usually less com- DISLOCATIONS OF THK SMOULDER 47 minuted than either the underlying structure or the tiibfrosities. Fracture of the upper end of the humerus more often occurs in those cases of dislocation which have been produced by direct Fig. 54. Fig. .5.5. Fig. 54. — Normal shoulder. CI., clavicle; C, coracoid process; A., acromion proc- ess; G., glenoid cavity; H.H., humeral head; H.S., humeral shaft. Fig. 55. — Subcoracoid dislocation. Fig. 56. Fig. 57. Fig. 56. — Intracoracoid or subclavicular dislocation. CL, clavicle; C, coracoid proc- ess; A., acromion process; 6., glenoid cavity; H.H., humeral head; H.S., humeral shaft. Fig. 57. — Intraclavicular dislocation with moderate deformity. violence, the blow having been sustained on the outer side of the shoulder just below the acromion. 48 FRACTURES AND DISLOCATIONS Separation of the lesser tuberosity has been noted as a compli- cation of dislocation of the shoulder, though it is much rarer than fracture of the necks or greater tuberosity. The most important structures which may be injured by the Fig. 58. Fig. 59. Fig. 58. — Subglenoid dislocation. 67.. clavicle; C, coracoid process; A., acromion process; G., glenoid cavity; E.H., humeral head; H.S., humeral shaft. Fig. 59. — Luxatio erecta. A variation of the subglenoid type. Fig. 60. Fig. 61. Fig. 60. — -Subacromial dislocation. The les.s pronounced of the two posterior luxa- tions. H.H., humeral head; H.S., humeral shaft; A., acromion process; S.S., spine of SC3rPUl&. Fig. 61. — Subspinous dislocation. An exaggeration of the subacromial type. DISLOCATIONS OF THE SHOULDER 49 displaced head are the brachial plexus and axillary artery which lie just internal to it in the axilla. When the artery is torn hemor- rhage into the axilla will follow, while simple pressure on the vessel will only temporarily interfere with the pulse in the arm below. Pressure on the brachial plexus may result in partial or complete paralysis of the parts supplied by it. The exact mechanism of injury to the brachial plexus is not thoroughly understood ; some waiters consider it a result of direct pressure on the nerves by the head or neck of the bone, while others are of the opinion that the stretching sustained by the plexus is the usual method of injury. In any case this complication is fortunately rare, and the resulting paralysis usually transient. There is little doubt that the plexus may be injured in attempts at reduction, especially when the older method of using a fulcrum in the axilla is resorted to. Permanent injury to the artery is seldom seen ; as a rule we may look for nothing more than a temporary suspension of circulation below the point of pressure, during the time the head is out. When the dislocation is allowed to remain unreduced for a few weeks fibrous tissue is formed about the head, which will ultimately make a new socket, and in many instances we see remarkable restoration of function. The usefulness of the joint, however, can never be expected to approach the normal under such circumstances. The head of the humerus may pass from the glenoid in almost any direction, and this fact has given rise to a variety of classifications which in many instances have but served to confuse rather than help us to a clearer understanding of the subject. The simplest classification will be used here : 1 Subcoracoid J Subclavicular (or intracoracoid) Downward Backward /Subglenoid ^Subglenoid erect (Luxatio erecta) [Subacromial 1 Subspinous Upward (very rare) By far the most frequent dislocation of the shoulder is forward, and of the two subvarieties the subcoracoid is much more common. The subglenoid is next in order of frequency, while the erect type is more uncommon than either of the posterior varieties. 50 FRACTURES AND DISLOCATIONS In the subcoracoid type the head lies below the coracoid process, having escaped through the antero-inferior portion of the capsule. The line to be drawn between this luxation and the subclavicular variety is purely artificial and arbitraiy. If more than three- fourths of the transverse diameter of the humeral head lie internal to tlie coracoid the luxation is known as subclavicular. More or less inward rotation of tlic Inuncius is present. The tendon of Fig. 62. — Outlined X-ray of a low subcoracoid dislocation of stioulder. the subscapularis is not infrequently torn, and in rare instances injury may be sustained by the supraspinatus, infraspinatus or teres muscles. Tearing of the coraco-huineral ligaments practically never occurs in this type of luxation. The head of the bone often lies on the anterior edge of the glenoid cavity. In the subclavicular type the head continues inward, clears the coracoid process and rises to a slightly higher level. The tearing of the capsular ligament is usually more severe than in the sub- coracoid form and rupture of the tendons inserted into the upper end of the humerus is more common. The coraco-humeral liga- DISLOCATIONS OF THE SHOULDER 51 ment is often extensively torn and aocordinj^'ly Ko(;lier's metliod of reduction will fail. Subglenoid luxations. — In the typical subglenoid dislocation the head of the bone lies below the glenoid cavity. There is no hard and fast line to be drawn between the subcoracoid and subglenoid varieties, since in practice we find the head may occupy a position anywhere along the anterior rim of the glenoid cavity. In the e7'ect type of subglenoid luxation (luxatio erecta) the head lies below the glenoid but the arm is in a position of extreme abduction. In the subacromial type the head of the bone lies behind the glenoid cavity just under cover of the acromion. The rent is in the posterior portion of the capsule. The biceps tendon may be torn out of its groove and the bellies or tendons of the muscles inserted into the greater tuberosity (especially the infraspinatus) may be extensively torn. Complicating fracture of the greater tuberosity is more common in this type of luxation than in the subcoracoid form. The tendon of the subscapularis may be torn from its insertion into the lesser tuberosity. The subspinous form is an exaggeration of the subacromial, in which the head continues in its backward course till it lies in the infraspinous fossa just below the spine of the scapula. The vio- lence producing this form is great and it is usually only a short time following the accident until the surrounding tissues and skin covering the head are filled with ecchymotic blood. Injury to surrounding muscles and ligaments is usually more extensive than in the subacromial type. The upward variety is only possible when the acromion has been fractured, and is so extremely rare that it might better be consid- ered a surgical curiosity. There is no hard and fast line to be drawn between the subcora- coid and subglenoid varieties since in practice we find the humeral head may occupy positions at different levels anywhere along the anterior rim of the glenoid cavity. This fact is demonstrated by the accompanying photographs and Rontgenograms. In like manner the subcoracoid luxation merges into the subclavicular type. Etiology. — This is the most common dislocation in the entire body. It occurs most frequently in adult life and results from various types of trauma applied to the shoulder. The most com- 52 FRACTURES AND DISLOCATIONS moil form of luxation is usually produced by violence applied to the shouldei- when the arm is in extreme abduction. Symptoms.- limiicdialely rollowin^u' tlie accident llie i)atient suffers severe, acutt', nauseating pain which is increased l)y motion of the affected shouldei'. Loss of function is produced by the inhibitory effect of pain, by the retlex spasm of tlic muscles and by Fig. 63. — Recent subeoracoid dislocation of left shoulder. Note the tlattened shoul- der as indicated by the arrow, tliie change in the axis of the humerus and the lower- ing of the axillary fold. This picture is quite typical of the subeoracoid form of luxa- tion. It will be noted that the patient makes no attempt to support the injured member as is commonly done in fractures of the clavicle or humerus, especially the latter. the mechanical disturbance in the joint. If the luxation is allowed to go uncorrected the first two conditions grow gradually less while the last named persists and results in permanent disability. The nature of the deformity will depend on the type of luxation. In the suhcoracoid variety there is a flattening of the shoulder which when palpated, as shown in Fig. 65, allows the examining fingers to pass inward under the acromion process. The upper end of the humerus is displaced inward and the axis of the arm DISLOCATIONS OP THE SHOULDER 53 Fig. 64. — Simple subcoracoid dislocation of left shoulder presenting the usual symptoms: flattening of the shoulder, change in axis of arm and lowering of the axillary fold. Fig. 65. — Examining depression below the shoulder. Note how, with moderate pressure, the fingers sink in below the acromion. Photograph taken just after the accident and immediately prior to reduction by Kocher's method. 54 FRACTrRES AND DISLOCATIONS is altered. This chanice in tlie axis of the Imraerus may be recog- uized at a glance. The liunieral head rests beneath the tip of the coracoid process and occupies a slightly lower position tlian normal. Lowering of the humerus as a whole lowers the attaclnuent of the peetoralis nuijor and accordingly the anterior axiHary fold will be lower on the injured side. An abnormal prominence will be noted Ix'low the coracoid where the head has found its new resting plat-c. The elbow seldom lies in contact with the side of the chest Fig. 66. Fig. 67. Figs. 66 and 67. — Lateral and aniciior views of a subcoracoid lu.xation of right shoulder. This shoulder has been dislocated eight times, the first luxation being about ten years ago. The manner in which the fibres of the deltoid pass in straight lines from" tlie acromion to their insertion indicates the absence of the head of the humerus from the glenoid cavity. Reduction accomplished by Kocher's method with the patient in the sitting position. and any attempt at adduction will meet with resistance and cause additional pain. Abduction Avill bring out the lines of the already prominent acromion, accentuate the flattening of the shoulder and is not specially productive of resistance and pain. It is difficult to place the hand of the injured side on the opposite shoulder and when this has been accomplished it will be found impossible to keep the el])ow in contact with the chest. This symptom is character- istic of anterior luxations and is the result of the head being "off center." A simple though unnecessary test is to place a ruler on the outer side of the arm; it will be noted that the ruler can be placed in contact with the acromion and external epicondyle simul- DISLOCATIONS OF THE SIIOHLDKR Fig. 68. — Another view of the same case showing the position of the humeral head as indicated by palpation. The head lies between the two fingers on the shoulder. Fig. 70. Figs. 69 and 70. — ^Another subcoracoid dislocation of the shoulder presenting the usual symptoms. In this case the head of the humerus occupies a slightly lower posi- tion than seen in the cases shown on the preceding pages. The slight deltoid angle present is the result of this lower position of the head. The change in the humeral axis, flattening of the shoulder, lowering of the axillary fold and "deltoid angle" are all more pronounced than seen in the typical subcoracoid luxation. This is due to fact that the head of the bone is lower and the dislocation assumes slightly the characteristics of the subglenoid type. 56 FRACTURES AND DISLOCATIONS i i Fi?. 71. — An anterior dislocatiou of tUu shoulder ubout half-way between the sub- coracoid and subglenoid types. Compare this case with those shown in Figs. H3, 64, 67, 75 and 77. Fig. 72. Fig. 73. Figs. 72 and 73. — Anterior dislocation of the right shoulder with the head occu- pying a slightly lower position than that seen in the preceding case (Fig. 71). This case might properly be termed a high subglenoid luxation. The empty glenoid is well indicated by the straight lines of the deltoid muscle and the prominence of the cora- coid process with its attached muscles. The thumb pressed into the shoulder lies di- rectly above the displaced head. Note how closely this case resembles the typical sub- glenoid luxation shown in Fig. 77. disijOCAtions of the shoulder 57 taneously, which is impossible in the normal shoulder. The head of the bone may be palpated in its new position in the axilla. Slight abduction of the arm facilitates this portion of the exam- ination. The head may also be palpated through the deltoid aud pectoralis major as shown in Fig. 68. The patient's attitude is characteristic. In standing the body is inclined slightly forward and toward the injured side. This position is assumed so the displaced humeral axis may be ])rought more nearly to the vertical. There is very seldom any attempt made to support the injured member but instead it hangs limp from Fig. 74. Fig. 75. Fig. 74. — Subglenoid dislocation of right shoulder. The head of the humerus lies below the palpating finger. While plowing the share struck a rock and the handles of the implement were thrown violently upward and the right shoulder dislocated. Fig. 75. — Same case. Tlie head of the humerus lies between the two index fingers. The brachial plexus and pulsating axillary artery can be felt stretched across the head by the fingers palliating in the axilla. the shoulder. In the sitting position the arm is rested on some convenient object such as a table, or the arm of a chair. In the typical subcoracoid luxation the elbow is close to, but not in contact with, the side. When the head occupies a lower position on the anterior rim of the glenoid abduction of the arm will be more pro- nounced. In the subclavicular or intracoracoid type the shoulder is flatter and the prominence below the clavicle, caused by the head, is nearer the median line. After the head clears the coracoid in its inward course it rises to a higher level, and thus the whole humerus occupies a higher position than that seen in the subcoracoid type. 58 FRACTURES AND DISLOCATIONS Tlie level of the anterior axillary fold is variable. The deformity depends somewhat on the completeness of rupture of the coraco- humeral ligament. If this ligament is completely ruptured the arm is usually closely applied to the chest wall. If it is only partially ruptured abduction of the arm may be pronounced even to the extent of being held in a nearly horizontal position. It may be possible to palpate the empty glenoid cavity. The arm usually shows more or less shortening which is accentuated by abduction. When the eoraco-humeral ligament is completely ruptured the head may occupy an unusually low position beneath the clavicle. Fig. 76. — Same case after hixatioii had been reduced. Arm bandaged and fi.xed to side by strip of adhesive encircling tlie chest. In the suhglenoid variety the humeral head rests on the long head of the triceps below the glenoid cavity, though this position is occupied only in the most pronounced cases. All the symptoms noted in the subcoracoid type are present in exaggerated form in the subglenoid variety. The arm is lengthened, the axillary fold much lowered, the axis of the humerus pronouncedly altered and abduction of the arm is a prominent symptom. The lowering of the humerus is greater in this form than in any other type of luxa- tion occurring at the shoulder joint. The outer side of the arm forms an angle ("deltoid angle") with the insertion of the deltoid as the apex. This angle is the result of abduction and indicates the low position of the head. DISLOCATIONS OP THE SHOULDER 59 Fig. 77. — A typical subglenoid dislocation of the left shoulder. Flattening of the shoulder, lowering of the axillary fold and change in the humeral axis are much more pronounced than in the subcoracoid type. In the subcoracoid type the outer surface of the arm is approximately a straight line but in this case it will be noted that a distinct angle is formed which for convenience has been termed the "deltoid angle." The apex of the angle is indicated by the arrow. The upper arm of the angle extends to the acromion while the lower arm extends to the external epicondyle. The lower the posi- tion occupied by the luxated head the more pronounced will this angle be. Fig. 78. — Typical subglenoid dislocation of left shoulder. Fig. 79. — Attitude assumed by patient since it is accompanied by less pain than any other position. This attitude is not especially uncommon in subglenoid luxations. 60 FRACTURES AND DISLOCATIONS Compare the clinical appearance of the cases shown in the accom- panying illustrations. Fig. 77 shoM's a typical subglenoid luxa- tion. Fig. 72 shows a higher form wliile Fig. .69 .sliows wliat iiiiiilit be tcniicd a low siibcoi-acoid. Fig. 80. — Subglenoid luxation. Attitude of least discomfort similar to one seen in Fig. 79. Fig. 81. — .\noth('r view of pMliciit sliinvn in Kit;. 80. In the erect type of siihglcnoid tusatiejn (luxatio erecta) the shoulder is dislocated while the arm is in extreme abduction and the DISLOCATIONS OF THE SHOULDER 61 head comes to rest at the lowest possible point, being in some cases even caught under the long head of the triceps. The attitude is characteristic; the arm is raised and the hand usually rests on the Fig. 82. — Luxatio erecta. Patient was liit liy a train and sustained numerous in- juries, among them the one shown here. Extension in the altered axis of the arm and direct pressure on the head accomplished reduction without difficulty. Two days later the patient died as a result of associated injuries and immediately following death the dislocation was reproduced, the upper extremity placed in the same position as when first seen and the photograph taken. It was not feasible to take a picture when the patient was first seen but the position and appearance of the extremity as shown here are the same as existed immediately following the accident. Pig. 83. — Another view of patient shown in Fig. 82. top of the head. The patient is unable to adduct the arm and the head may be seen as well as felt in the axilla. The condition is really a subglenoid luxation but the appearance of the patient is quite different from the usual subglenoid. 62 FRACTURES AND DISLOCATIONS In the subacromial type the head lies behind the glenoid, having been driven across its posterior lip. The anterior portion of the anatomical neck rests on the posterior edge of the glenoid and the articular surface looks into the infraspinoiis fossa. A prominence will be noted on the posterior aspect of the shoulder while anteriorly the shoulder will be flattened and the acromion prominent. The arm is usually shortened and more or less fixed with tlie elbow- forward. (See Figs. 84 and 85.) Fig. 85. Fig. 84. — Posterior dislocation of riglit shoulder. Tlie humeral head projecting on the posterior aspect of the shoulder is plainly visible. Note shortening of arm and change in axis. Fig. 85. — Palpation of displaced head, fingers and thumbs. Its position is outlined by the two index The subspinous type is simply an exaggeration of the preceding. The head is driven further backward on the posterior surface of the scapula till it comes to rest under the spine of the bone. This form is very rare and is usuallj^ the result of great violence. The symptoms of the subspinous type are those of the subacromial in pronounced form. The arm is shortened, moderately abducted, rotated inw^ard and the elbow on a plane anterior to the chest. The trauma of the head plowing through the tissues causes more or less extravasation of blood and it is usually only a short time following the accident until the skin covering the head of the bone becomes ecchymotic. The further the head passes backward under the V DISLOCATIONS OF THE SHOULDER 63 Fig. 86. — Another view of the case shown in Pigs. 84 and 85. Fig. 87. — Case of complete avulsion of the upper extremity. Case reported be cause it indicates to some extent the weakest points in the various structures which hold the shoulder together. Capsule torn cleanly from the anatomical neck except over the greater tuberosity where a triangular piece with a base equal to the breadth of the tuberosity and about three-ciuarters of an inch to the apex. Supra- and infra-spinatous muscles "have been torn from the tuberosity and scales of bone corresponding to the insertions of the tendons have been detached. Tendon of teres minor torn across about two inches from its insertion. Subscapularis torn cleanly from lesser tuberosity. Small shreds of the pectoralis major remain attached to the external bicipital ridge, large shred of lower portion of this muscle (about three inches long) remains attached to humerus. Teres major and latissimus dorsi torn cleanly from humerus. Long head of biceps torn near origin. Short head torn a little below the point at which the tendon joins the belly. About two inches of the coraco-brachialis remains attached to the humerus (transverse tear thi-ough muscular tissue). Long or middle head of triceps torn transversely below tendon, at about level of the surgical neck. Median and ulnar nerves torn at level of surgical neck. Deltoid torn loose from clavicular and scapular origins with the exception of the portion arising from the acromion. The acromion is fractured transversely about three-quarters of an inch from the tip, the fragment re- maining attached to the deltoid. Insertion of deltoid torn cleanly from humerus leav- ing deltoid eminence free from shreds. Compound comminuted fracture of radius and ulna, and backward dislocation of wrist. (The wrist was reduced before the picture was taken.) Injury sustained in centrifugal wi-inger in laundry. The patient recovered. 64 FRACTURES AND DISLOCATIONS spine of the scapula the more liable the arm is to be fixed in its new axis. In the extremely rare upward luxation the arm is shortened, the acromion fractured and the anterior axillary fold raised. The head of the bone may be felt as a pi-ominence at the point of the shoulder and crepitus is present if the fragment of the acromion is manipulated. Fig. 88. — Example of a snbcoracoid dislocation in a fleshy woman. Tlie symptoms in obese persons are somewhat obscured by the adipose tissue and the condition has not infrequently been overlooked under these circumstances. If the case is carefully in- spected, however, there should be no reason for failure in diagnosis. Diagnosis. — There is a good deal of difference in the deformities of the different types of luxation occurring at the shoulder yet each is characteristic in its way, and if the surgeon is acquainted with the appearance of these deformities there should seldom be an}'- difficulty in recognizing the condition. There is a nice pro- portion existing between the various symptoms in an ordinary snb- coracoid or subglenoid luxation and it is of value for the surgeon to recognize this fact. A given amount of flattening of the shoulder usually goes with a certain degree of change in the humeral axis and lowering of the axillary fold. This relation between the different objective symptoms can best be appreciated DISLOCATIONS OP THE SHOULDER 65 by comparing' the accompanying illustrations. (Figs. 63 to 77.) These symptoms bear an almost constant relation to each other in simple luxations, but this relation is frequently disturbed when fracture is present. In Fig. 96 flattening of the shoulder is shown without any change in the axis of the humerus. The condition is one of fracture of the anatomical neck with dislocation of the head Fig. 89. — Another example of the same condition as sliown in preceding illustra- tion. The patient is excessively heavy yet the flattening of the shoulder, change in humeral axis and lowering of the axillary fold are sufficiently pronounced to recognize the condition by inspection alone. of the bone. In Figs. 117 and 118 the change in the axis of the humerus is apparent but there is no flattening of the shoulder. The condition is one of fracture of the surgical neck. Nearly all the objective symptoms are less pronounced, in fleshy persons, yet this fact should be no excuse for failure to diagnose the condition when present. (See Figs. 88 and 89.) In luxa- tions of the shoulder the patient seldom makes any attempt to support the injured member with the opposite hand but allows the upper extremity to hang limp at the side with a slight inclination of the trunk forward and to the same side. In the exceptional cases in which he does support the arm the act is casual and he will usually release it if requested. This is quite different from the attitude assumed by the patient in the presence of fracture of the humerus. He will then grasp and support the injured member 66 FRACTURES AND DISLOCATIONS witii the greatest care and anxiety, and can seldom he induced to release it Avhen in the standing or sitting position. The diagnosis nnist be made on the symptoms, and relief afiPorded the patient at once. The X-ray is therefore seldom of value except in verifying reduction and in the exclusion of complicating frac- tures, after the head has been returned to the glenoid cavity. Treatment. — hi all forms of luxation llie indications are to return tlic head to the glenoid cavity at llic earliest possible moment and to maintain the parts at rest until the torn ligaments are healed. The methods of reduction vary with the type of luxation. The suhcoracoid hixafion is best reduced b}- -what is known as Kocher's method, which consists of three steps and is as follows: "With the patient seated in a straight, armless chair the surgeon grasps the elbow with his opposite hand. The elbow is then held firmly against the side while the free hand secures the wrist, brings the forearm to a right angle and then carries it outward away from the median plane. This produces outward rotation of the humerus and opens the rent in the capsule. (See Fig, 91.) The second step in the manipulation consists in gently forcing the elbow forward and inward across the chest while the patient's hand is maintained in a relatively stationary position. (See Fig. 92.) Resistance is here often encountered and should be met by an insistent springing motion in the direction indicated by the arrow in Fig. 94. It is during this second step that the head of the humerus usually slips back into the socket Avith a distinct snap. When Kocher's method fails it is usually due to the fact that the surgeon is not maintaining outward rotation of the arm during the time the ell)ow is being brought forward across the chest. In other words the common fault is in allowing the hand to come forward and inward at the same time that the elbow is being carried across the chest. If reduction is not accomplished during the second step the head is almost sure to remain displaced during the third, and the whole manipulation will have to be repeated. The third step consists in carrying the hand to the opposite shoulder but is not an essential part of the manipulation. Figs. 91, 92 and 93 not only demonstrate the proper steps and positions of the upper extremity in performing Kocher's method but actually show the reduction of a suhcoracoid luxation done before the camera. A study of these plates will give the reader a better DISLOCATIONS OF THE SHOULDER 67 Fig. 90. Pig. 91. Fig. 92. Fig. 93. Demonstration of Koclier's method on a case of subcoracoid dislocation of the right shoulder. Case presented for treatment immediately following the accident with the usual characteristic symptoms. Fig. 90. — Appearance of case after being stripped to waist to facilitate examination and reduction. Fig. 91.- — First step in Kocher's method. Head is still displaced as evidenced by the contour of the shoulder. Fig. 92. — Second step in Kocher's method. (See text.) Note the rounded contour of the shoulder : the head has just been returned to the glenoid. Fig. 93. — Third step of Kocher's method. Hand is carried to opposite side of chest. 68 FRAOTITRES AND DISLOCATIONS idea of tlit^ iiuiiiipiilatioii than rould \)v conveyed by pages of text. Many surgeons prefer the recumbent position in performing Koeher's method and in some respects it is more convenient. Not infrequently the i)atient hindei's the sui-geon by a sort of squirming motion in which he arclies tlie l)ody toward the injured shoulder and nuiy even slich' off tlie tabU' away fi-om the operator. This may be avoicU^d by passing a hirge towel or slieet about the chest and under the dislocated shoulder. The ends lie in front Fig. 94. — This plate sliow.s the essential aetion in Koeher's method. The patient's elbow should be carried iu the direction indicated by arrow CD. while the point A. re- mains stationarj- or is carried slightly away from the median plane. Resistance is usually encountered and should be met by an insistent, springing motion in the direcfion indicated by the arrow. If the head of the humerus does not return to the socket dur- ing this stage of the manipulation Koeher's method will probably have to be repeated from the beginning. When the capsule has been so extensively torn that no resistance is encountered in carrying the elbow inward Koeher's method will prove useless and reduction will have to be accomplished by horizontal traction and direct pressure with the finger tips on the head of the humerus. of and behind the opposite shoulder and are used by an assistant in steadying the patient. If a slit be made in a folded sheet and the injured arm passed through it we will have an efficient means of steadying the patient and preventing motion of the scapula. If Koeher's method is properly employed it should be possible, in the usual uncomplicated subcoracoid luxation, to accomplish reduction at the first attempt and without the aid of an anesthetic. DISLOCATIONS OP TPIE SHOULDER 69 The efficiency of Koelier's metliod depends on the integrity of the capsule, especially that portion known as the coraco-humeral liga- ment, and when this has been extensively torn the following method will generally succeed. Horizontal extension and manipulation. — Raise the arm laterally until it reaches the level of the shoulder, grasp the humerus just above the elbow and exercise traction while an assistant holds the patient about the chest. Place the opposite hand in the axilla, make gentle pressure on the head with the finger tips in the direc- tion of the socket and the luxation will be reduced provided the capsule and coraco-humeral ligament are extensively torn. The lower the head rests on the anterior rim of the glenoid the greater the probability of this method succeeding after Kocher's method has failed. A slight rotary motion of the humerus on its axis during traction will sometimes facilitate replacement. This method will sometimes effect reduction when a displaced tendon of the biceps or detached tuberosity has caused Kocher's method to fail. Stimson's method is effective though not extensively used. It requires a certain amount of apparatus and time for its accomplish- ment. The patient is placed on a canvas cot and the arm passed through a slit previously made in the canvas. A weight of about ten pounds is attached to the wrist. Stimson claims an average of about six minutes for reduction, during which time the patient is fairly comfortable. This method may be tried as a last resort before operating in otherwise irreducible cases. Extetision outward and downward. — This method is probably the oldest known and has been in use extensively in England and America up to recent years. Place the patient in a recumbent position and abduct the arm until it occupies an angle of about forty -five degrees with the body; then make traction in the long axis of the humerus while the body is secured by an assistant. The arm may be rotated during traction. It has been customary for years to supplement the above by placing the unbooted heel in the axilla as a fulcrum ; when this was done additional force was gained by bringing the patient's hand toward the median plane, thus forcing the upper end of the lever outward toward the glenoid. The use of the heel or any other hard body in the axilla as a fulcrum cannot be too strongly condemned; such methods should be dis- carded as a relic of barbarism for they have outlived their useful- ness. No pressure in the axilla should be used, which is greater 70 FRACTURES AND DISLOCATIONS tliaii can be exerted by tbe finger tips of the surgeon, and even then direct pressure on the nerves or vessels slioubl l)e avoided. TravlwH outward mid upicard is j>ractically the same as hori- zontal traction, since elevation of tlic arm al)ove tlie horizontal is accomplished by rotation of the scapula rather than l)y alteration in the anatomical relations of the shoulder joint. Great force was advocated by some of the older writers. Duplay cmj^loyed horizontal traction by means of an elaborate sj'stem of block and tackle, dynamometer, etc. At the present time there is no excuse for the employment of such force. Cases which do not respond to the less violent and more rational methods should be treated b}^ open incision. Sulygletwid dislocations of the shoulder can usually be reduced by Kocher's method though the position of the head below the glenoid is not as favorable for reduction as it is in the subcoracoid form. The lower the head lies on the anterior rim of the glenoid the further back the elbow should be in starting the manipulation. In other words, the lower the head the greater the importance of the tirst step in Kocher's method. In the typical subglenoid luxa- tion (see Fig. 77) the elbow should not be further forward than the midaxillary line at the beginning of Kocher's method. During the first step the head may be caused to ride upward on the anterior rim of the glenoid cavity. The condition then approaches the subcoracoid type and can be reduced as such. (See Figs. 91, 92 and 93.) The capsule is often extensively torn in the low sub- coracoid and subglenoid types and in such instances the head may be reduced by direct manipulation with extension and counter- extension. The erect form of the subglenoid is extremely rare and the few cases seen by the author have been easily reduced by extension in the line of the axis of the displaced arm with digital pressure on the head. Siihacromial and suhspinous luxations are usually reduced with- out difficulty by traction in the axis of the arm ; axial rotation and manipulation may sometimes be necessary in addition to extension and counter-extension. The posterior forms are usually accom- panied by extensive laceration of the capsule, and hence their easy reduction. Following reduction the X-ray is of value in determining the presence of fracture and the position of the head. After the head DISLOCATIONS OP THE SHOULDER 71 has been returned to the glenoid cavity the following points should be noted to avoid overlooking complications. Place the two arms by the side symmetrically and inspect the case from a point a few feet in front of the patient and again from the side. This is for the purpose of recognizing deformity. The distance between the acromion and external epicondyle should be carefully measured and compared with the uninjured side. If the distance is lessened it usually means complicating fracture of the humerus. If it is increased it commonly indicates that the head is not properly seated in the glenoid cavity. The anterior aspect of the two shoulders should be carefully compared ; any undue prominence on the injured side suggests fracture of the upper end of the humerus or the interposition of some obstructing tissue between the head of the humerus and the glenoid. Undue prominence on the anterior aspect of the shoulder and shortening of the arm are symptoms indicative of fracture and are well shown in Figs. 119, 124 and 127. Compare the cases of fracture of the upper end of the humerus with the cases of luxation of the shoulder in the accompanying illustrations. Motion, sensation, the condition of the reflexes and the circulation should be tested in the injured arm before and after reduction. The treatment of luxations of the shoulder will vary according to whether or not complications exist. In simple cases the arm should be immobilized for a period sufficiently long to allow proper healing of the ligaments as indicated in the after-treatment. (See page 79.) Displacement of the long head of the biceps from its groove may sometimes be corrected by raising the arm well forward, even above the horizontal and employing axial rotation. This complication, however, rarely occurs without fracture of the greater tuberosity, and under such circumstances the tendon and fragment are best replaced and held in position by open incision. Complicating fracture of the upper end of the humerus usually calls for opera- tive intervention to obtain the best results. Operative Treatment. — Operation is practically never called for to effect reduction of simple uncomplicated cases. It is often indi- cated in luxations complicated by fracture, in injury to nerves and vessels, in old unreduced luxations, in habitual luxations and in instances in which the dislocation is compound. The details of 72 FRACTURES AND DISLOCATIONS the operative procedure will depend largely on the nature of the complication. Fracture of the surgical neck of the liunierus complicating luxa- Fig. 95. — McBurney's hook. Hon is fortunately a rare condition, there being something like 150 reported cases. The older method of treating this double condition ufs to either ficc.ire union of the fracture fir.'t and reduce the dislo- Fig. 96. — Fracture of the aiiiitomii-Ml nock of th.' liiuiu'rus with displac(?ment of the humeral head beneath the coracoid process. The condition resembles a subcoracuid dislocation of the shoulder on casual inspection. The flattening of the shoulder is the same as seen in dislocations (and properly so since the head is displaced) but it will be noted that the axis of the humerus remains unchanged and the anterior a.xillary fold is not lowered to the extent seen in uncomplicated subcoracoid dislocations. Moreover the patient supports the injured member with the opposite hand, which is uncommon in dislocations of the shoulder. On manipulating the arm distinct bony crepitus is elicited and an abnormal bony prominence is noted on the anterior aspect of the shoulder. The displaced head could be felt high in the axilla. An X-ray plate confirmed the diagnosis of fracture of the anatomical neck with subcoracoid displacement of the head. Twenty-four hours later ecchymosis appeared covering tlie anterior portion of the shoul- der. Case was operated seven days following the injury. The displaced cap of bone was pulled back onto the upper end of shaft and wired in position. Outer and upper portion of greater tuberosity considerably comminuted. Bony iinion resulted and func- tion in articulation restored though extreme abduction remains slightly restricted. Wire remains in place at the present time, five years later. Photograph taken about fifteen minutes following the accident. Fracture produced by fall from bicycle, the blow being sustained on the outer aspect of the shoulder. DISLOCATIONS OF THE SHOULDER 73 cation later, or to obtain a false joint at the seat of the fracture. Both methods must, at the present time, be considered uusurj^ical and obsolete. McBurney was the first to deal with this condition in a satisfactory manner, treating the fracture and the dislocation at the same time by open incision. He devised a hook (see Fig. 95 j by means of which he was able to manipulate the upper fragment so as to return the head to the glenoid, after which the fragments were adjusted, and wired or not as thought best. The end of the Fig. 97. Fig. 98. Fig. 97. — X-ray of case shown in Fig. 96 taken before operation. Fracture of anatomical neck with displacement of the head into the axilla beneath the coracoid. Fig. 98. — Same case after operation. Head has been replaced and secured in position with a loop of wire. Perfect apposition not possible because of the crushing of cancellous tissue in the upper end of the bone. hook is inserted into a hole of proper size drilled into the upper fragment, the necessary leverage being thus secured. In fracture of the anatomical neck (which is even more unusual than fracture of the surgical neck) the McBurney hook is of little service in reducing a dislocation of the upper fragment. The cap of bone must be handled by means of tenacula because of its friable, can- cellous structure, and if reduction is impossible should be excised. Very serviceable joints frequently result after removal of the head. 74 FRACTURES AND DISLOCATIONS Fig. 99. — Same case after operation and recovery. Picture taken about eight weeks ifter operation. Pigs. 100 and 101. — Stereoscopic view of a comminuted fracture of the anatomical nock of the humerus with subglenoid dislocation of the humeral head. The arrow points to the displaced head. DISLOCATIONS OP THE SHOULDER 75 When the head can be replaced it is often found necessary to secure it in position, which is most easily accomplished by wire (see Fig. 98). A peculiar point to be noted here is that the head of the humerus almost never suffers necrosis, even though the upper frag- Fig. 102. — Siihcoracoid dislocation complicated by fracture of the greater tuberosity. Fragment displaced. Arrows point to lines of fracture. ment includes only the articular surface ; and it is here that one might expect necrosis since the upper fragment is apparently cut off from its blood supply. Either of the tuberosities may he fractured in dislocations of the 76 FRACTURKS AND DISLOCATIONS sli(>uhl( r and may lie displaced in the line of pull of tlie attached muscles. Reposition l)y open incision and fixation l)y nutans of a loop of silver w'in^ will he found n)ost satisfactoiy. Two modes of approach are employed, one incision (the external) passes through the deltoid on the outer side of the shoulder, and the other (the anterior) is made in the sulcus hetween the deltoid and pectoralis major. In making- the external incision the circum- flex nerve may he encountered in the lower part of the wound and should be avoided. In the low forms of the subcoracoid or the subglenoid dislocations some of the nerves of the brachial plexus or even the axillai-y artery may lie in fi'ont of the head, and in nuiking- the anterior incision the surgvon should be on the lookout for these structures. Injuries to the liracMal plexus call for operative intervention, Init before this is attempted a careful neurological examination should be made to determine as accurately as possible the extent Fig. inn. Fig. 104. Figs. 103 and 104. — Two views of contracture of hand following dislocation of shoulder with injury to brachial plexus. of the damage and the region of the plexu.s injured. It should be remembered that the upper part of the plexus may be torn by the pull on the nerves when the humerus is disi)laced downward. Nothing in an operative way is indicated in instances in which one DISLOCATIONS OP THE SHOULDER 77 or more of the nerves are bruised or stretched but when laceration occurs the ends should be approximated and sutured together. The patient should be fully appraised of the doubtfulness of the prognosis under such circumstances. Rupture of the axillary artery or vein with the development of an axillary hematoma (frequently of the pulsating type, when the artery is torn) calls for immediate operative intervention. The artery is temporarily compressed against the first rib to control hemorrhage and an incision made to expose the vessel in the region of the injury. Suture of the injured vessel is rarely possible. Ligation will be indicated. Old luxations of the shoulder may in some instances be reduced by manipulation, even after the head has been out of the glenoid for four or five months, though the longer the dislocation has existed the less the chance of reduction without open incision (see Fig. 105). Great force should not be used in attempting to reduce these old dislocations because of the liability of injury to vessels or nerves or of producing fracture of the humerus. The fibrous tissue surrounding the head may involve the brachial plexus or axillary artery, and when the head is forcibly returned to the glenoid these structures may be torn. AVhen gentle manipulation does not produce the desired results open incision should be resorted to. The anterior incision is better adapted to freeing the head from the fibrous tissue surrounding it, while the external incision affords better access to the glenoid cavity for the removal of fibrous tissue which so frequently fills it. After the parts have been exposed, the head liberated and the glenoid cavity cleaned out there should be little difficulty experienced in returning the head to its normal position. Old rents in the capsule should be approximated by suture after the edges have been scarified. AVhen the incision enters the joint the divided capsule should be closed with catgut after reduction has been accomplished. Provision for the escape of blood which may subsequently ooze into the wound and joint should be made, so that there may be no dead spaces to favor infection. (See "Open Treatment of Fractures," page 754.) Recurrent dislocations sometimes become so frequent that the usefulness of the arm is much impaired, and the only relief is through operative intervention, Avhicli consists in repairing the rent in the capsule and in plicating the same when necessary. Compound luxations of the shoulder are extremely rare. The 78 FRACTURES AND DISLOCATIONS Figs. 105, 106 and 107. — 'ilirce views ol an old subcoracoid dislocation of left shoulder of nearly five months' standing at the time the photographs were taken. This dislocation was reduced at the first attempt by means of Kocher's method with the patient in the standing position, which goes to show that cases of long standing are not necessarily operative cases. DISLOCATIONS OF THE SHOULDER 79 treatment of these conditions is essentially operative and should be carried out according to the principles laid down in the chapter on "Treatment of Compound Fractures and Luxations," page 789. Pig. 108. — This case is a stiikuij; example of recurrent dislocation of tlie shoulder. The photograph was taken imuiediateh following reduction of the seventy-second dislo- cation of the patient's left shoulder. The use of the left arm is much impaired as the patient is continually guarding against the positions which he has learned from experi- ence are likely to produce displacement. The condition has extended over a period of many years and as a result of the disturbed function the muscles of the left shoulder show a very slight atrophy. After-Treatment. — In the uncomplicated cases of dislocation of the shoulder the arm should be immobilized for a period of three weeks, but under no consideration should we fail to employ passive motion as soon as the acute traumatic reaction has subsided. This will usually be at the end of five or six days. The arm should be fixed to the side and the forearm carried in a sling. A con- venient method is to sew the sleeve of the undershirt to the body of the garment. This prevents the arm from being carried far enough away from the body to strain the capsule. In performing passive motion the surgeon should avoid external rotation and extreme abduction since the former tends to open the rent in the capsule, while the latter causes the injured portion of the capsule 80 FRACTURES AXD IMsr.OCATIONS to be stretclu'd across the head of the bone. The duration of ininio- bilization should be governed by the extent of the eapsuhir lacera- tion. Prolonged immobilization without passive motion will result in more or less permanent loss of mobility, wliile on the other liand, unrestricted use of the member following reduction will almost surely be followed by a condition of recurrent dislocation. When fracture complicates dislocation the arm should be innno- bilized as in sim})le fi-acture of the humerus, from four to si.\ weeks, until union takes ])lace. Passive motion under these circumstances is not permissible prior to union, though careful massage may be begun as soon as the traumatic reaction has subsided. If it is found that the joint is nuich restricted in its motion after union is firm we may break up the joint adhesions by passive motion, using an anesthetic if necessary. This should not be attempted inside of two months following the injury, and only then when the X-ray shows a good callus at the seat of fracture. (See "Treatment of Fractures of the T^j^pei" End of the Humerus," page 97.) Prognosis. — In the simple uncomplicated elislocation (especially of the subcoracoid type) the restoration of function should be practically complete provided passive motion is instituted early and the patient is prevented from using the arm before the liga- ments have healed. The prognosis is rendered worse according to the presence and nature of complications. In injury to the axil- lary vessels collateral circulation is usually established if the mem- ber is properly cared for. Injury to the brachial plexus or some of its branches is not exceptionally rare and deserves a most guarded prognosis. It is true that injury to nerves has occurred during reduction, especially in cases in which the heel has been used as a fulcrum in the axilla, but on the other hand the surgeon not infre- quently has been blamed for paralyses which were produced at the time of the accident and for which he was in no way responsible. These unfortunate circumstances demonstrate the value of exam- ining the condition of the reflexes and of motion and sensation in the arm before any attempt at reduction is made. Pressure on the nerves by the head of the bone is usually accompanied by transitory symptoms and complete recovery. Laceration of the nerves is followed by permanent paralyses unless the nerve ends are united. Operation renders the prognosis better, though recovery is usually prolonged and often incomplete, especially if the condition is of long standing at the time of operation. In old unreduced luxations DISLOCATIONS OP THE SHOULDER 81 the patient sometimes develops surprisingly good us(; of the arm as years go on. The betterment of the condition by operation is usually quite gratifjdng. Most recurrent luxations can be com- pletely cured by operation. Compound luxations are usually pro- duced only by great trauma and the prognosis will depend on the injury sustained by the surrounding soft tissues and the subsequent development of infection. The prognosis of these luxations is grave though modern operative treatment has improved the outlook greatly. CHAPTER YII. FRACTURES OF THE UPPER END OF THE HUMERUS. Surgical Anatomy. — The upper end of the humerus is deeply seated and extremely difficult of palpation unless dislocated. It will be noted that the normal lateral prominence of the shoulder is due to the head of the humerus beneath the deltoid muscle, and not to the acromion. The upper extremity of the bone is composed of cancellous tissue, as shown in Fig-. 110, there being only a thin laj^er of compact bone on the surface. The manner in which the compact tissue of the shaft grows rapidly thinner as the end of the bone is approached is well shown in the section of bone just referred to in Fig. 110. The internal structure is deserving of careful study since it explains some of the deformities and the variations in the types of fracture occurring at different levels. In addition the surgeon should appreciate the internal structure as well as the surface form in performing operations for the direct fixation of fragments. The attachment of the capsule corresponds to the anatomical neck except on the inner aspect of the bone where it is attached a little below the line of the neck. The nuiscles attached to the upper end of the bone are important in explaining the de- formities occurring in the presence of fracture. The muscles inserted into tlie greater tuberosity are, from before backward, the supraspinatus, infraspinatus and teres minor. These three muscles arise from the supraspinous fossa, infraspinous fossa and axillary border of the scapula respectively, and pass in almost straight lines to their insertions into the greater tuberosity. These muscles when unopposed by the weight of the limb and the muscles inserted into the shaft, tend to produce outward rotation and abduction of the upper fragment. The subscapularis arises from the subscapular fossa and passes directly to its insertion into the lesser tuberosity. When unopposed it tends to produce inward rotation. It lies to the inner side of the joint and is in contact with the capsule. When the shaft is separated from the upper end of the bone the muscles attached in the region of the bicipital groove tend to produce 82 FRACTURES OF UPPER END OF HUMERUS 83 inward displacement of the upper end of the lower fragment. These muscles are the pectoralis major, teres major and latissimus dorsi. Fractures of the upper end of the humerus may show great varia- tion, yet in most instances the injury will conform more or less accurately to one or more of the following types: fracture of the Fig-. 109. Fig. 110. Fig. 109. — Upper end of humerus in young subject. Note position of epiphyseal line. E.. epiphysis; E.L., epiphyseal line; 1)., diaphysis. Fig. 110. — Coronal section of same bone. M., metaphysis. Note the manner in which the diaphysis projects into the epiphysis and the relative distribution of can- cellous tissue. anatomical neck, fracture of the tuberosities, fracture of the surgi- cal neck and separation of the epiphysis. Fracture of the anatomical neck occurs in middle and old age and is usually the result of direct violence. The line of fracture seldom corresponds exactly with the anatomical neck. The most usual variations of fracture of the anatomical neck are : fracture of the 84 FRACTURES AND DISLOCATIONS anatomical neck through its inner lialf or two-thirds (the outer l)ortion of the fracture being so placed as to include the greater tuberosity with the upper fragment), — splitting of the upper end of the bone with fi-acture of the anatomical neck and impaction of Fig. 111. — R<>nti;(iiuLrram of shoulder of child nine years of age. of the epiphyseal cartilage and compare with Figs. 109 and 110. Xote the relations the head into and between the tuberosities, — fracture of the anatomic neck in its outer half with a portion of the inner side of the shaft attached to the upper fragment. The line of fracture very rarely follows the anatomical neck tliroughout, but when it FRACTURES OP UPPER END OF HUMERUS 85 does the upper fragment is left free from muscular and ligamentous attachments and is as likely to be displaced in one direction as another. Fracture of the anatomical neck is usually accompanied by more or less crushing of the internal cancellous tissue in the Fig. 112. — Fracture of ajiatomical neck of humerus. Fracture in this region seldom follows tl^e anatomical neck througliout but inchides tlie upper portion of tlie greater tuberosity with the head, as in this case. upper end of the bone and impaction of the fragments is not un- common. Fractures of the tuberosities as isolated injuries are extremely rare. . They are most commonly associated with dislocations of the shoulder and may occur with fracture of either the anatomical or 86 FRACTURES AND DISLOCATIONS surgical iiee-k. Avulsion of a scale of boue from the greater tuber- osity corresponding to the insertions of one or more of the attached muscles has been reported in a few cases and is the result of muscu- lar action. Undoubtedly this condition has existed in many cases and been mistaken for a "sprain." Isolated fracture of the lesser Fig. 113. — Fracture of surgical neck of humerus. Good position of fragments. tuberosity is even more rare than fracture of the greater tuberosity. It is known to have been avulsed by overaction of the subscapularis. Fracture of the lesser tuberosity is most often seen as a complica- tion of dislocations of the shoulder, especially those of the posterior variety. The fragment is displaced by the pull of the attached FRACTURES OP UPPER END OP TirjMERIIR 87 muscle and usually lies in the axilla internal to and below the head. Fractures of the surgical neck are much more common injuries. The surgical neck is that portion of the bone between the epiphy- seal cartilage and the insertions of the pectoralis and teres major. When fracture occurs in this region the lower fragment will be displaced inward by the pull of the pectoralis major, latissimus dorsi and teres major and overriding will be effected by the action Fig. 114. — Fractur, fracture. iical neck with considerable comminution along line of of the biceps, triceps, deltoid and coraco-brachialis. The upper fragment will be controlled by the muscles attached to the tuberosi- ties and is usually displaced forward and may be abducted or adducted. The lower fragment may be driven upward into the upper fragment, or the serrated surfaces sufficiently engaged to partially or completely oppose the displacing action of these muscles. Pronounced inward displacement of the upper end of the lower fragment may produce injury to vessels and nerves. The lesions 8» FRACTURES AND DISLOCATIONS ■will be similar to those already incut ioiicd as occasionally coiiipli- catiug dislocations of the shoulder. Epipliyseal separation of the upper end of the humerus is not an uncommon accident. The upper epiphysis of the humerus is ossified from two centers, one for the head and one for the greater tuberosity. Occasionally an additional center is seen for the lesser tuberosity. The ossific center for the head is present at birth, that for the greater tuberosity is tirst seen during the third year. When the lesser tuberosity is ossified by a separate center it is usually not seen until the fifth year. The head and greater tuberosity are fused at the sixth year so that the epiphysis is one piece of bone. Fig. 115. — Fracture of surjiical mn-k with deformity. Coiniiiimition of upper frao:ment. The epiphysis joins the shaft at about the twentieth year. Sep- aration of the epiphysis may occur at any time prior to the twentieth year, but is most commonly seen from the ninth to the seventeenth years. The position of the epiphyseal cartilage is well shown in Figs. 110 and 111. It will be noted that the cartilage is roughly horizontal but that the center is much higher than the margins. This is i)robably due to the fact that the epiphysis is ossified from two centere. The conical conformation of the end of the diaphysis accounts for the fact that recurrence of deformity is seldom seen following reduction of an epiphyseal separation in this region. The joint cavity may be opened, but more often is not. When the diaphysis is displaced the deformity is similar to that seen in FRACTURES OF UPPER END OF HUMERUS 89 fractures of the surgical neck ; that is, the uj)per end of the shaft is pulled inward by the action of the pectoralis major, teres major and latissimus dorsi and raised by the muscles of the arm. Etiology. — Fractures of the upper end of the humerus are the result of direct and indirect violence. Fracture af the surgical neck is the most common break in this region. Fracture of the anatomical neck occurs mostly in the aged. Epi])hyseal separations are seen only in children and adolescents. Various types of frac- ture of the upper end of the humerus are occasionally seen as com- plications of luxations of the shoulder. Fig. 116. — Transverse fracture of the surgical neck with pronounced deformity. Symptoms. — The symptoms accompanying fracture of the upper end of the humerus will vary according to the nature and severity of the lesion. If the fragments are free the symptoms will usually be pronounced. When impaction exists the symptoms may be so slight at first that the patient continues to use the part, although there is always more or less pain and discomfort. Swelling about the shoulder is almost constant and an abnormal prominence anteriorly (see Figs. 119 and 124) usually accompanies fractures in this region. Function is completely lost in unimpacted cases but is often only partially so when the fragments are impacted. Pain is constant though the degree is quite variable. It is always more severe in unimpacted cases. Eccliymosis usualh'' develops within twelve to twenty-four hours following the fracture. The 90 FRACTURES AND DISLOCATIONS attitude of the patient is usually characteristic. The upper part of the trunk is inclined forward and toward the injured side, and the injured arm is supported with the opposite liand. This attitude Figs. 117 and 118. — Two views of recent fracture of the surgical neck of the humerus. Note the abnormal prominence on the anterior aspect of the shoulder, also change in a.xis of humerus which i.s not accompanied by Hattening of the shoulder as seen in dislocations. Yery slight shortening of the arm present. Note how patient grasps the injured member with opposite hand (an attitude seldom seen in dislocations of the shoulder). Picture taken about half an hour following the accident. Fig. 119. — Same case seen in the recumbent position. Note that the abnormal prominence on the anterior aspect of the shoulder is not changed bj' the patient's lying down. is usually not assumed in isolated fracture of one of the tuberosities but only when there is solution of continuity in the humeral shaft. In fracture of the anatomical neck impaction is not uncommon and accordingly the symptoms may not be severe. Pain is present FRACTURES OF UPPER END OF PIUMERUS 91 on moving the shoulder. Swelling is constant. Abnormal mobility will be present unless the fracture is impacted but the proximity of the shoulder joint to the point of false motion often renders the condition difficult of recognition. Deformity may be present but is much less common than is the case in fracture of the surgical neck. Slight flattening of the shoulder may be noted but is uncom- mon. The humeral neck is usually thickened. Alteration in the humeral axis may be apparent in the uncommon cases in which there is lateral displacement of the fragments. In fracture of the greater tuberosity the power of outward rota- tion will be diminished and motion of the shoulder, especially rota- Fig. 120. — X-ray of case shown in Figs. 117, 118 and 119. Fracture of surgical neck of humerus. tion, will be attended by pain. Swelling is variable. Local tender- ness is constant. By applying a stethoscope to the shoulder and rotating the humerus it may be possible to detect crepitus which would otherwise escape recognition. The normal joint sounds and those occurring in arthritis should not be confused with true crepitus. It may in some cases be possible to palpate the displaced fragment. 7n fracture of the lesser tuberosity the power of internal rotation will be lost or lessened and it may be possible to palpate the displaced fragment in the axilla, below and to the inner side of the humeral neck. 92 FRACTURES AND DISLOCATIONS /;(■ fracture of the siiri/icdJ iifck tlic syiiii)toins ;ire more i)ro- nounced and constant. Inipaction is rare, pronounced defoi-niity is the rule. Tlie upper end of the lower fragment is usually displaced upward, foi'ward aiul inwai'd. or upwai'd and inwai'd. The more pronounced the lateral (lisi)laci'ment the more apparent will be tlie cliauiic in tlu' axis of the humeral shaft. Pain is usually severe and the sult'erinti' gi'catly inci'cased hy motion of the shouhler. Injuries to nerves and vessels ai'c unusutd tlioug'h the\' are more common in this fi'actui'e than in any other occui'rin^' in Ihe up])ei' end of the liumerus. jind Ihe acc()m|)anyiiiL; symptoms nvv similar to those Fig. 121 Figs. 121 and 122.- — Fracture of surgical neck of humerus twelve hours after injury. Note the undue prominence of the shoulder anteriorly which is greater than would be present in simple swelling of the shoulder following sprain. Note also tlie ecchymosis which almost never follows dislocation. Note the attitude of the patient in grasping the in.iured member with the opposite hand. In dislocations the patient seldom makes any attempt to support the injured member but in fractures of this region it is often difficult to get him to let go of it even for an instant. Injury sustained in this case by blow on the upper and outer a.spect of the arm. Patient about 60 years of age. described under "Dislocations of the Shoulder," page 76. Pain, mobility, crepitus, loss of function, swelling, ecchymosis and deformity are more pronounced and characteristic in fracture of the surgical neck than they are in any other fracture occurring in the upper end of the humerus. The accompanying illustrations will give the reader a good idea of the usual clinical picture accompany- ing fractures of the surgical neck. In epiphyseal separations of the upper end of the humerus the symptoms are similar to those seen in fractures of the surgical neck. Displacement, however, is not as constant, loss of function is variable, and crepitus soft and cartilaginous. Separation of the FRACTURES OP UPPER END OF HdMERUS 93 Fig. 123. — Rontgenogram of case shown in Figs. 121 and 122. Fig. 124. — Low fractui'e of sargical neck of right humerus. Note the shortening of the arm on injured side. The lower end of the upper fragment is displaced forward, producing the abnormal prominence indicated by arrow, while the lower fragment is displaced upward. Note the tight grasp on the fingers of the injured member. This attitude was assumed even after the patient was requested to release his hold on the forearm higher up. (See Dia-gnosis.) Only slight change in humeral axis. Photograph taken about three hours following injury. (Note evidence of syphilis in nose and com- pare with Figs. 463 to 46.5,) 94 FRACTURES AND DISLOCATIONS Pig. 125. — Same case (Fig. 124) seen in recumbent position. Note that the change in position does not influence the prominence on the anterior aspect of the shoulder. It is easy to see that the prominence indicated by arrow is produced by forward displacement of the upper fragment since the axis of the arm and therefore of the lower fragment is only slightly altered. Compare with Fig. 127, in which both fragments are angulated. Fig. 127. Figs. 126 and 127. — Youth, age 15 years. Fell about fifteen feet and struck on left shoulder. Pain and disability present on rising from ground. Promptly attended by physician who diagnosed dislocation and treated same by Kocher's method. Case seen by another physician a few days later. First seen by author about three weeks following injury when photographs were taken. Note prominence on anterior aspect of shoulder and shortening of arm, both signs indicative of fracture. Pen outline on arm indicates the positions of the fragments as revealed by palpation. Arm can be carried only a short distance forward because of the deformity interfering. Diagnosis confirmed by X-ray. (See Fig. 128.) FRACTURES OF UPPER END OF HUMERUS 95 upper epiphysis may occur without displacement and the loss of function may be only partial. Under these conditions the surgeon may fail to recognize the nature of the injury. When deformity is present the upper end of the diaphysis is usually displaced for- ward and inward and on examination of the shoulder the lesion is noted at a higher level than that seen in fracture of the surgical neck. The anterior aspect of the shoulder is characteristic. The prominence caused by the upper end of the diaphysis can, as a rule, be appreciated by inspection alone. An epiphyseal separation without deformity may easily escape recognition immediately following the injury. If the shoulder is Fig. 128. — X-ray of case shown in Figs. 126 and 127. not immobilized subsequent strain is likely to produce displacement and the characteristic deformity, together with the accentuation of the symptoms, discloses the nature of the injury. Diagnosis. — The diagnosis of fractures of the upper end of the humerus is based on the symptoms just enumerated and when these are typical there should be little difficulty in determining the nature of the injury. A thorough and systematic examination of the shoulder should be made in every case and the possibility of associated fractures of the clavicle and of dislocations of the shoulder and acromio-clavicular joint should be kept in mind. With the patient seated in a straight chair the arms are placed 96 FRACTURES AND DISLOCATIONS ill syiiinietrieal positions and tlie parts carefully inspected before any manipulation is attempted. ^lucli can l)e learned l)y insi)ectioii alone and if this source of information is fully utilized imicli un- necessary manipulation can, as a rule, be avoided. In fractures of the clavicle tiie shoulder is usually lowered but the arm itself is not shortened. The over-riding deformity so common in fractures of the clavicle is usually apparent. .In dislocations of the shoulder the change in humeral axis, flattening of the shoulder and lowering of the axillary fold should indicate the nature of the injury at a glance. The attilude in dislocations is characteristic in lliat the Fig. 129. — Measuring humeral length — from acromion to externnl epicondyle. Fig. 130. — Palpating humeral head through deltoid. Fig. 131. — Palpating humeral head with finder tips pressed into axilla. patient seldom makes any attempt to support the injured member with the opposite hand. In fractures of the upper end of the humerus the injured arm is grasped and supported with the greatest anxiety. Both active and passive motion are restricted in disloca- tions while abnormal mobility is the rule in fractures. Ecchymosis is common about the shoulder Avithin twelve to twent3^-four hours following a fracture, but in luxations it is almost never seen except in the rare subspinous type. Flattening of the shoulder is some- times seen in fractures of the anatomical neck but it is never as pronounced as in dislocations and is not accompanied by change in the humeral axis. The head of the humerus should be palpated through the deltoid and again through the axilla. If the arm is carried through rota- tion while the head is palpated the surgeon may determine to his satisfaction whether or not the head follows the movements of the shaft. The shaft of the humerus should be measured from the edge PRACTLIRES OF HIPPER END OF irinvTERlIS 97 of the acromion to the external epicondyle and compared with the opposite side. Shortening usually means fracture, while length- ening is indicative of the more common types of dislocation fsuh- coracoid and subglenoid). The coracoid process should be i)alpated where it approaches the surface about an inch below the junction of the middle and outer thirds of the clavicle. The clavicle, acromion and spine of the scapula should be palpated. The arm should be carried through the normal range of motion and restric- tion in any given direction and increase of pain should be noted. Fracture of the neck of the scapula may be difficult to distinguish from fracture of the upper end of the humerus. If fracture of the upper end of the humerus can be excluded and still there is ab- normal mobility of the upper end of the bone with crepitus, the symptoms are indicative of fracture of the glenoid or neck of the scapula. It may be possible in some cases to palpate the margin of the displaced glenoid in the axilla. Differentiation of fractures of the upper end of the humerus from luxations of the shoulder and fractures and dislocations of the clavicle is usually not difficult, but to distinguish between the differ- ent types of fracture occurring in the upper end of this bone is often not an easy matter without the aid of the X-ray. The symptoms of fracture of the anatomical neck, surgical neck, tuberosities and epiphyseal separations have been enumerated and will serve in making a differential diagnosis in typical cases pending the making of a Rontgenogram. The possibility of increasing the damage to the soft parts should be borne in mind and manipulation should be as gentle and brief as possible. Motion, sensation and the deep reflexes of the upper extremity should be tested to recognize complicating injuries to the nerves and vessels. The condition of the circumflex may be ascer- tained by tapping the deltoid and noting the contraction of its fibres. If manipulation is especially painful or the swelling pronounced, the examination is best conducted under anesthesia. Treatment. — Reduction of the fragments should in most cases be done under anesthesia. A careful consideration of the physical signs and symptoms will, as a rule, afford the surgeon sufficient information concerning the fracture to correct the deformity. The parts should then be immobilized and an X-ray taken to deter- mine the position of the fragments and the details of the fracture. 98 FRACTURES AND DISLOCATIONS The upper end of the sliaft may he displaced in any direction and aecordingrly the maiiipidations of reduction will vary in ditt'erent cases. The usual (Icfoi'inily, however, consists in an upward and inward displacement of tlie upper end of the lower fragment. Re- duction will therefoi-e usually consist in forcing the upper end of the shaft outward, while traction is being exerted on the arm. In making outward pressure on the upper end of the shaft the surgeon should avoid exerting the pi-essure directly over the end of the frag- ment, othei-wise vessels and nerves may be forced against the sharp serrated end and injured. The efifect of manipulation can, as a rule, be recognized by pal|)ation through the axilla. With the frag- Fi?. i;j2. — Shows cig;ir-1»ox bonrds cut to proper size to make a diagonal axillary pad. The ends to the right have been hinged together with adhesive plaster. ments in good position there should be a disappearance of deformity. In impacted cases, however, and in those accompanied by consid- erable crushing of cancellous tissue, a certain amount of shortening may persist, which is impossible to correct. The deformity in frac- tures of the upper end of the humerus varies greatly, but if the surgeon appreciates the relative positions of the fragments and the nature of the break he w'ill usually be able to effect a satisfactory reduction by means of extension, counter-extension and manipula- tion. The reduction of epiphyseal separations involves the same principles. With reduction accomplished the question of fixation arises. The methods of immobilization are similar for most types of frac- FRACTURES OP TIPPER END OP TTrTMERIIR 99 ture of the upper end of the humerus. The most common method of immobilization, and one which will be adapted to the largest number of cases, is accomplished by means of the axillary pad and the moulded plaster shoulder cap. Various methods of preparing Fig. 133. — Shows axillary pad completed. Cotton has been packed in between the boai'ds and a layer of cotton used to cover the surface. The whole is then bandaged. and applying these two elements in the dressing have been described and there is little to be said of any of them as long as they accom- plish the desired result, which is fixation of the fragments in proper position without undue constriction of the arm or irritation of the Fig. 134. Fig. 135. Fig. 136. Pig. 134. — View of axillary pad from behind. Note how the pad supports the humerus down to the internal epicondyle. Pig. 135. — Same seen from the front. Pig. 136. — Same with arm raised. Note the oblique lower end of pad. skin. The details of the most satisfactory methods will be described. The key-note to the proper immobilization of the shoulder is the axillary pad. The axillary pad should support as much of the humerus as pos- 100 FRACTURES AND DISLOCATIONS sible without interfering; with the upper part of tlie forearm which is maintained in a position of semitlexion. A very satisfaetoi-y pad is made in the following maiuuT: take two |)ieces of cigar-box (the lid and bottom) and cut them so that tliey will be a little broader than the arm and tlien hinge two of the ends together inside and out with adhesive as shown in Fig. ]'.V2. Tlie Ijoai'ds are then placed in the ojiposite axilla (hinged ends ui)) for the puri)0sc of measuring and marking tlie j)roper length. The pad when comi)leted should come to about the level of the internal ei)icondyle posteriorly, l)ut should be short enough anterioi-l}^ to clear the top of the semi- flexed forearm. To aecom])lish this it will be found necessary to cut the lower ends of the boards diagonally (as shown in Fig. 132). With the boards cut to the proper size (due allowance being made for the padding) the angle is stutfed with cotton till a wedge of the proper thickness is obtained. The outside of the pad is then cov- ered with cotton and finished by securing the padding in position with a roller bandage. The tendency for those not accustomed to constructing this dressing is to make the pad too long, and when this is done the antero-inferior angle will nmke the patient miserable by pressing into the upper part of the forearm, or else the pad will tend to slip backward and fail to properly support the humerus. The outer side of the pad should be evenly covered so that it will present a flat plane for the humerus to rest on. The pad is secured in position by three pieces of adhesive as shown in Figs. 135 and 136. Two of them pass over the opposite shoulder while the third encircles the body. The surgeon should see to it that the pad is properly fitted and placed before he proceeds with the making of the shoulder cap. Heavy card board (book-binders board) may be used in jjlace of the wood, but if the material is too light the sides will tend to bow when the angle is stuffed with cotton, as described above. When this occurs the side of the pad does not present the necessarj'^ flat surface for the humerus to rest against. Light card board is entirely inadequate, and stuffing of the space between the body and trunk with folded towels is mentioned simply to be condemned. I\Iany different methods of making an axillary pad may be followed but the above will be found as satisfactory as any. The plaster shoulder cap is shown in Fig. 137 and is applied as follows: After reduction has been effected and the axillary pad placed in position, a i)attern is cut out of sheet-cotton to properly FRACTURES OF TIPPER END OF HUMERUS 101 embrace the arm and shoulder. It is best to lay the cotton on the shoulder and cut the pattern in this position. Ten or twelve layers of crinolin (or half again as many layers of gauze) are then cut ■ 1 H ■ ^^^^^^^Bi ' j^^^^k ^ ^^H \ " ■. ^B 1^ 1 1 1 li L. \^A m ^1 Fig. 137. — Plaster shoulder caiJ in position. i>Iote tlie encircling strap of adhesive plaster. according to the pattern, immersed in plaster cream, wrung out and applied to the shoulder. The sheet-cotton pattern is applied to the shoulder first and acts as the lining for the shoulder cap. The I Fig. 138. Fig. 139. Fig. 140. Fig. 138. — Axillary pad in position and arm bandaged. Fig. 139. — Plaster shoulder cap in position. Fig. 140. — Swathe encircling body and taking place of sling. shoulder cap should be secured to the body as quickly as possible with a wide roller bandage and the patient kept perfectly quiet until the plaster has thoroughly set and dried. Later on the 102 FRACTITRES AND DISLOCATIONS bandages may be removed and the cap secured in position by means of a body swatlie or strips of adhesive plaster. Another method of securing the arm and splint to the body is by encircling both with a sufficient nuhiber of turns of plaster bandage. Wet crinolin bandage may be used instead. When this is done the trunk should Fis. 1-)1. 143. Fig. 141. — Middeldorf triangle. Fig. 142. — The Monks triangle. A. shows the wire bent to proper form. B. shows same padded and bandaged. Fig. 143. — Osgood-Penhallow splint for treatment of fractures of the upper end of the humerus in abduction. be protected with sheet cotton to prevent subsequent irritation of the skin. The cap should cover the shoulder on all sides, and if additional security is desired it may be made to extend well onto the chest both in front and behind. In fractures of the upper end of the humerus it will seldom be necessary to include the elbow or forearm in the splint. FRACTURES OP UPPER END OF HUMERUS lOo It is well to snugly bandage the arm, forearm and hand with a flannel bandage before the pad and shoulder cap are ap[)lied. A method offering very solid fixation is a phister spica of the arm and chest though it does not permit of frequent removal or easy adjustment during the after-treatment. When the spica is em- ployed the arm and chest should be well covered with sheet cotton, and after the dressing is finished an axillary pad should be placed in position to support the arm. The cravat sling is called for with any of tlie plaster dressings about the shoulder except when the forearm is included in the splint. It is advisable in most cases of fracture of the upper end of the humerus to employ an anesthetic during examination and reduc- tion though it is more satisfactory to apply a plaster dressing when the patient is conscious and able to assume a convenient position. When the causative trauma is great and the ensuing traumatic reaction pronounced it is often better to treat the patient in bed during the first few days and to delay the application of a perma- nent dressing. During this time the arm may be secured on an axillary pad and sand bags applied to the outer side of the arm to steady the parts. The local and intermittent use of the ice cap will be of service in controlling the inflammatory reaction. In some instances the patient will be more comfortable with the arm resting on a pillow. If the suffering is great, morphine should be ex- hibited. Occasionally cases are seen in which reduction cannot be main- tained with the arm in a position such as assumed when the axillary pad and plaster shoulder cap are employed. Abduction, outward rotation or a forward displacement of the upper fragment may require a corresponding position of the lower fragment to keep the fractured surfaces in apposition and the fragments in align- ment. To meet the requirements in such cases a number of splints have been devised. The Middledorf triangle maintains the arm in a position of partial abduction and inward rotation and is effec- tive in some cases in preventing recurrence of deformity. (See Fig. 141.) The Monks triangle holds the arm in a nearly horizontal position with the elbow carried forward. (See Fig. 142.) By means of a plaster cast of the upper extremity and trunk the arm may be fixed in almost any position desired. Taking every- thing into consideration it is probably the most satisfactory form 104 FRACTURES AND DISLOCATIONS ol" iimiiubili/alioii in instaiie-i's in wliicli tlic arm may not be treated at tlie sitle Ijceause oi* displaeement of llie iippei- fi-agmeut. AVheu uncomfortable and awkward positions, sueli as maintained by the above -splints, are necessary to keep the fragments in proper relation, the question of operation should be considered. It is the author's opinion that most cases of this kind (in which reduction cannot be nuiintained with the arm by the side) should be operated upon, and the fragments secured in position by direct fixation. Fig. 144. — Plaster cast for treatment of fracture of the upper end of the li-.in ir -.s in abduction. In applying the cast the humerus may be fixed in almost any yj^^ii'dn desired. Fig. 145. — Plaster cast for treatment of fractures of the upper end of the humerus in abduction. This cast fixes the humerus in a position of greater outward rot.i- tion. Operative Treatment. — The oases of fracture of the upper end of the humerus in which operation is indicated are nvimerous but the proper selection of these eases requires the most seasoned surgi- cal judgment. Fractures in which the displacement is pronounced and not reducible by ordinary methods should be operated. Recur- rence of deformity during the after-treatment is ordinarily an indi- cation for operative intervention. Cases in which the upper frag- ment is abducted, rotated, or displaced forward may be treated by some form of dressing which immobilizes the arm in a position corresponding to the deformity of the upper fragment. Such dress- ings, however, are more or less uncomfortable and insecure and in most instances it wall be advisable to expose the fragments, wdre or plate them together and then fix the arm by the side with the ordinary axillary pad and shoulder cap dressing. FRACTURES OP UPPER END OP HUMERUS 105 The fragments are to l)e exposed through a vertical incision on the anterior or external aspect of the slioulder. The ('irciunflcx nerve will he found winding around the surgical neck of the bone and should be avoided. It is best to expose the fragments by dull dissection in the deeper part of the wound until the nerve has been located and isolated. With the fragments exposed the needs of the case are determined and the details of the operation from this time on will vary accordingly. Reduction of deformity is performed by means of extension, counter-extension and manipulation, and is rendered easier by direct manipulation of the fragments when necessary. The fact that the fragments may be directly inspected during manipulation is of the greatest service in correcting the displacement. If a firm engagement between the fragments can be obtained by manipulation the wound may be closed and the opera- tion concluded; if, however, there is a tendency to redisplacement some form of internal fixation must be employed. A consideration of the illustration on page 83 will show that the structure of the bone above the surgical neck is composed of a wide-meshed cancel- lous tissue covered only by a very thin layer of compact bone, and it is in this formation that very little dependence can be placed on nails, pegs, screws, etc. Silver wire will afford the most trust- worthy fixation and should be given the preference in the region of the anatomical neck. It is frequently the case that a simple loop of wire passing through the outer side of the fracture as shown in Fig. 98 will secure a safe and accurate apposition. The Lane plate has been used in the region of the greater tuberosity though it is not reasonable to expect security from it when the screws holding it are not placed in a fairly heavy layer of compact tissue. Accordingly it is of greater value a little lower in the bone. It is sometimes necessary to excise the head of the bone because of extensive comminution, or in old eases because of non-union. It is well to remember that the head very rarely suffers necrosis follow- ing separation from the shaft. Attempts to save the head are usually successful with accurate apposition and the proper degree of fixation. Reduction and fixation of fractures of the surgical neck are not as a rule attended by great difficulty unless there is extensive comminution of the upper fragment. When the upper fragment is broken into many pieces it may be impossible to com- pletely restore the bone to its original lines. A wire encircling the surgical neck, with notches in the bone to prevent its slipping down- 106 FRACTURES AND DISLOCATIONS wai-d. may be of great value in lonofitudinal splitting. It should be so placed as not to iiilcrfd'c with the long head of the biceps. Isolated fractures ul' llie tuberosities are rare injuries. Little difficulty should be experienced in returning the detaelied tuberosity to its original position and securing it in place. In epii)hy.seal separations reduction of the deformity will usually be all that is required, as displacement is prevented by the projec- tion of the center of tbe diaphysis upward into the epiphysis. (See Figs. 110 and 111.) Suture of the periosteum on the outer side of the bone will iuci-ease the security of reduction. If a tend- enc}'' to recurrenee of deformity is present absorbable suture material may be passed through drill holes in the bone. Non- absorbable suture material should not be used across an epiphyseal cartilage. It is well to insert a small drain of silkworm gut before the wound is closed to relieve the joint of blood and serum ; this drain should be removed in from twenty-four to forty-eight hours. After-Treatment. — In the average child or young adult union may be expected at the end of four weeks, while a middle-aged person should be allowed from live to six weeks for callous forma- tion. In the aged union may be much delayed. The acute swelling about the joint will usually have subsided at the end of ten days or two weeks. During the time the shoulder is decreasing in size the padding on the inside of the shoulder cap will require frequent changing and adjustment so that the cap may properly fit the shoulder. If the swelling has been great it may be nece.ssary to apply a new cap when the shoulder approaches the normal in size. The ease should be seen daily for the first ten days, after which every two or three days will be sufficient. The axillary pad some- times becomes loosened and is likely to slip downward or back- ward, and if not replaced may be responsible for a change in the position of the fragments. Gentle passive motion should be begun at the end of two or two and a half weeks in uncomplicated cases. Passive motion should at all times be gentle, and the production of pain must represent the limit of motion. The splints should be removed at the end of four to six weeks, according to the age and condition of the patient, and the arm carried in a sling for another ten daj^s. The patient should be especially cautioned not to submit the arm to any great strain for the first two months fol- lowing the removal of splints. Extreme abduction is the last mo- FRACTURES OF UFPER END OF HUMERUS 107 tion to be regained by the patient and in elderly persons it is not infrequently lost permanently. Should paralysis of any of the nerves supervene during the after-treatment (as evidenced by wrist drop or contractures) we should lose no time in exploring the nerve involved where it crosses the line of fracture. The circum- flex is the single nerve most frequently involved in fractures of the upper end of the humerus. End results following operations on the nerves cannot be expected inside of four to six months at the earliest. Atrophy of the deltoid not infrequently occurs from disuse alone without injury to the circumflex. This condition is not in itself a cause for anxiety since the muscle will regain its size and tone with use. Following reduction of an epiphyseal separation fixation should be maintained for three or four weeks. Early passive motion is of the greatest value in fractures of the upper end of the humerus. Restricted motion in the shoulder is often the result of a too prolonged immobilization. If joint ad- hesions are present after union is firm they may be forcibly broken up under anesthesia, but before this is attempted the surgeon should be positive that the callus is firm enough to stand the manipulation Mdthout refraeture. Prognosis. — The outlook in fractures of the upper end of the humerus will depend on the severity of the break and the age and condition of the patient. A fair degree of reduction will usually be followed by perfect recovery in youthful subjects. The older the patient the greater the probability of incomplete restoration of function. In the aged non-union may follow in spite of the most perfect treatment. In patients past middle life there is often slight restriction of motion and pain about the joint occurring with changes in the weather. The range of motion may be free and yet the shoulder weak. Loss of growth following epiphyseal separation is an extremely rare condition and need not be expected if anything like a fair reduction has been accomplished following the accident. Moderate deformity, if present, will decrease as the years go by. CHAPTER VIII. FRACTURES OF THE SHAFT OF THE HUMERUS. Surgical Anatomy. — To appreciate the deformities aeconipanying fraetures of tlie sliaft of the humerus the attachments and directions of pull of the tlifferent muscles should be known. (See Figs. 146 and 147.) AViien the line of fracture is through the insertions of the peetoralis major, latissimus dorsi and teres major the deformity is usually slight and consists of an inward displacement of both fragments so that the deformity is, as a rule, purely angular. "When the fracture is below the insertions of these muscles, but above the deltoid eminence, the lower fragment will usually be displaced upward and outward by the deltoid, while the upper fragment is drawn inward by the pull of the peetoralis, teres, and latissimus. AYhen the fracture is below the insertion of the deltoid the u])per fragment will be displaced outward. In any fracture of the humeral shaft the serrated ends may be firmly enough engaged to prevent lateral and overriding displacement, and under such cir- cumstances the deformity is purely angular if present at all. Shortening of the arm is caused for the most part by the action of the biceps and triceps. The humerus has a wider range of motion than any other bone in the body and the varieties of strain to which it may be subjected are great. Accordingly we may see any type of fracture common to long bones. The shaft of the humerus is composed of a heavy tube of compact tissue which grows larger in circumference and lighter in structure as the extremities are approached. The musculo-spiral nerve supplying the extensors and supinators descends obliquely, from above, downward and outward, between the two humeral heads of the triceps. It lies in contact with the bone in the musculo-spiral groove and in this position is particu- lai-ly exposed to injury in fractures of the humeral shaft. It may be injured by direct contusion and laceration at the time of the accident or it may be subsequently caught and compressed by the callus. 108 FRACTURES OP SHAFT OK TTTJMRRKS 109 r.MiN. ECU -^ "^ Tro. — c. ~—E.K- Fig. 146. Fig. 147. Figs. 146 ard 147. — ^Views of the anterior and posterior surfaces of the riglit humerus. The arrows indicate the pull of the attached muscles. S., Head of the humerus; A.N., Anatomical neck; S.N., Surgical neck; L.D.. At- tachment of the latissimus dorsi ; T.M., Attachment of the teres major; Cb., Coraco- brachialis; T'., Outer head of the triceps; T"., Inner head of the triceps; M.S., Musculo- spiral groove; B., Bicipital groove; P.M.. Insertion of the pectoralis major; /.. Infra- spinatus; T.Min., Teres minor; D., Insertion of the deltoid; S.L., Supinator longus; E.O.R.L., Extensor carpi radialis longior ; 17., Groove for ulnar nerve; P.R., Pronator radii teres; F.F., Flexors of the forearm; F.G.TJ., Flexor carpi ulnaris ; Iro., Trochlear surface of humerus; C, Capitellum; E.F., Extensors of the forearm. 110 FRACTCRES AND DISLOCATIONS Inward displacement of one or both of the fragments may be the cause of laceration or compression of the brachial artery which lies to the inner side of the shaft. Green-stick fractures are seldom seen and multiple breaks are uncommon. Direct violence is usually responsible for fractures of the transverse type ; spiral and oblique fractures are the result of twisting strains. IMusculai- action is especially productive of frac- Fig. 148. Fig. 149. Fig. 148. — Spiral, comminuted fractiire of luimcral shaft. Fig. 149. — Fracture of shaft witli overriding and rotary deformity. ture of the humeral shaft, and in some cases (particularly in elderly persons) the degree of causative trauma may be disproportionately small. Impaction of the fragments is almost never seen. The most common seat of fracture is at or a little below the middle of the shaft. Symptoms.^ — There is pain, lo.ss of function, crepitus, abnormal mobility and varying deformity. Swelling usually develops rapidly and ecchymosis is seen within the first day. The relative position of the fragments varies with the level of the break and has been PRACTIJRKS OF SHAFT OF JIUMERUS 111 explained under "Snrsicul Anatomy," page 108. The deformity is almost always sufficiently pronounced to be recognized by inspec- tion alone. The patient supports the injured member with the opposite hand in a manner which is characteristic, (See Diagnosis under "Dislocations of the Shoulder," page 65.) The patient is able to move the hand and fingers, and the reflexes below the site of the fracture are intact unless some of the nerves have been injured. Fig. 150 Fig. 150. — Multiple spiral fracture of humeral shaft with pronounced deformity. Fig. 151. — Oblique fracture of humeral shaft with separation of fragments. (Taken through heavy fibre splint.) A weakening or absence of the radial pulse indicates laceration or compression of the brachial artery.^ The development of a hematoma may sometimes be recognized in the arm following tearing of the artery. Diagnosis. — Fractures of the humeral shaft are, as a rule, recognized without difficulty. The deformity is usually so pro- nounced that the diagnosis can be made by inspection alone. As soon as the arm is manipulated the point of abnormal mobility is apparent in almost all cases. Fracture of the shaft is a common fracture and is not infrequently associated with injuries to neigh- 1 A thrombosis of the brachial artery may be slow in forming and when it is the alteration in the pulse will be delayed. 112 FRACTURES AND DISLOCATIONS boring bones or joints. The surgeon should therefore be system- atic in his examination and determine tlie eonditinns of llu^ clavicle, i Fisr. 152. — Oblique fracture of humerus a little below its middle with nvciinliu;; aut angular displacement of the fragments. Upper fragment anterior and e.^ternal to lower fragment. Line of fracture passes bflow in-ertion of deltoid, hence the outward dis- placement of upper fragment, while the biceps and triceps cause the fragments to over- ride. Tn this t'pe of fracture complete reduction is often impossible without operative intervention, rhotosrrarh t;ikpn within an haur of the accident. Fig. 153. — Crushing injury of arm. This case was struck by a falling wall, the humerus fractured and the upper portion of arm forced through rent in skin. Skin and fascia only tissues connecting upper and lower portions of arm. Arrow points to lower end of upper fragment directly above which may be seen tip of hemostat holding end of brachial artery. Amputation. Recovery. Photograph tjiken while patient is under anesthetic and just prior to operation. scapula, elbow, ribs, etc., before the diagnosis can be considered complete. An X-ray plate should be made to afford further information concerning the nature of the fracture. FRACTURES OF SHAFT OF HUMERUS 113 Treatment. — The treatmt^nt will vary according to the location of the fracture and the direction and degree of displacement. It is best in most instances to reduce the deformity under anesthesia. Traction, counter-traction and manipulation will suffice in many cases to bring the fragments into proper apposition and alignment. In transverse fractures with overriding (especially when the ends are deeply serrated), reduction can best be effected by producing angular deformity and manipulating the fragments in this position until the serrated ends have been engaged. The bone is then straightened and appropriate dressings applied. In producing angular deformity for the purpose of engaging the ends, the arm should be bowed outward, to avoid stretching of the artery and nerves which lie on the inner side of the shaft. It is usually not difficult to effect reduction of a spiral or oblique fracture but it is frequently impossible to prevent recurrence of deformity in breaks of these types without resorting to internal fixation. Out- ward rotation of the upper fragment in a spiral or oblique fracture may act as a serious obstacle to reduction. Fractures of the upper third of the shaft are to be treated with dressings such as already described in the Treatment of "Fractures of the Upper End of the Humerus" (page 101), namely axillary pad, plaster shoulder cap, cravat sling, body swathe, etc. There is this to be said, however, in regard to the shoulder cap ; the lower the fracture the greater the need of extending this dressing down- ward to include the forearm. Coaptation splints are often used in fractures of the middle of the shaft though they may well be dis- pensed with, as a permanent dressing, in favor of a properly applied shoulder cap. It is a common practice to treat the condition during the onset and subsidence of swelling with the axillary pad, coapta- tion splints, body swathe and sling. Later on the coaptation splints are replaced by the plaster shoulder cap as a permanent dressing. In fractures of the lower third the elbow should be solidly immobil- ized. The axillary pad is not appropriate, and carrying the arm in a sling is entirely inadequate to secure fixation if the fracture is near the elbow. A most satisfactory method of fixation in this portion of the shaft is that shown in Fig. 215 and is described below. The following may be considered a fair example of the treatment of a fracture of the shaft of the humerus shortly following the acci- dent. The patient is placed in as comfortable a position as possible, preferably the recumbent, and an examination made of the parts, 114 KRA("TUR1':S AND DISLOt'ATlONS to detenniiu' as accurately as may bo the exact nature and position of the fracture. Tlie examination is more satisfactorily carried out under anesthesia. It should be remembered that the less the parts are manipulated the better it will be for the soft tissues surrounding the jagged eiuls of the fragments. After the fracture has been diagnosed the proper dressings should be prepared so that every- tliiner mav be in readiness as soon as reduction has been effected. Strouie\ er riishion. It is needless to add that the surgeon should, at this time, satisfy himself as to -which form of dressing will best meet the requirements of the case in liaiid. In instances in which the trauma has been great it is often best to leave the parts undisturbed and to treat the patient in the reeundDent position for a week or ten days until the acute inflammatorv reaction has sul)sided. During this time Fig. 155. — .\rm biiiuUiKed and axillary i>ad in position. Fig. 15G. — Coaptation splints applied. Fig. 157. — Swathe encircling body and acting as sling. elusive. ) Pig. 157. (See Pigs. 132 to 142 the arm may be supported on a pillow and the ice cap used to control the reaction. The Stromeyer cushion, or one of its modifi- cations, may be used to advantage. If, on the other hand, it seems advisable to immobilize the arm at once the following details may be observed. The arm and side of the chest are sponged, dried and dusted with talcum powder, special attention being paid to the axilla. An axillary pad is then constructed as described on page FRACTURES OF SHAFT OF HUMERUS 115 100. Coaptation splints arc next made, by placing thin wood on adhesive plaster (cigar-box wood is excellent) and splitting llie wood with a knife. The splint should include as mucli of tli(! arm, from the shoulder to the elbow, as possible without pressing into the axillary fold above, or the top of the flexed forearm below. 'Vhv. portion of the coaptation splint on the outer side of the arm may be longer than that on the inner side. A body swathe is next pre- pared of two or three thicknesses of heavy muslin. It should be long enough to encircle the body and injured member and broad enough to extend from the top of the shoulder to a point below the elbow. A cravat sling is then prepared and the necessary materials are ready. The axillary pad is placed in position and secured with adhesive plaster, after which the surgeon is ready to attempt reduction. The injured member is grasped above and below the seat of frac- ture, and the fragments gently but firuily manipulated until the senses of sight and touch pronounce the joosition satisfactory. The coaptation splint is then well padded, applied and secured in position with adhesive plaster. The arm is then firmly placed against the axillary pad and secured by the body swathe. The cravat sling completes the dressing, or in lieu of the sling the fore- arm may be included in the swathe, allowing the hand to emerge between the layers where they are pinned together. This form of dressing is least likely to strangulate the arm during the first week of treatment when the traumatic reaction and swelling are in progress. A very satisfactory method of fixation in fractures below the middle of the shaft is one in which internal and external plaster splints are used, as shown in Fig. 215. These splints are made of plain gauze (from fifteen to twenty ply) and should be reinforced at the elbow by the insertion of additional layers of gauze between the layers of the splint. The external splint extends from a point well up on the shoulder, along the back of the arm and forearm to the wrist, while the internal splint extends from just below the axillary fold to the wrist on the anterior aspect of the upper extremity. They are applied to the injured member while wet and rapidly secured in position with a roller bandage. The surgeon holds the fragments in proper reduction until the plaster has set. Specific instructions should be given to the patient and his attend- ants not to allow the splints to be covered with clothing or bed 116 FRACTURES AND DISLOCATIONS covers for at least twenty-four hours so tlie plaster may beconie thoroughly dried out. One or two foldeil towels should be placed between the arm and the body, and a liglit swathe used encircling the chest and injured meml)er. The following day the splints should be removed one at a time, lined with a layer of sheet cotton and re|)laced. The splints should then be secured in position by means of strips of adhesive plaster encircling the arm. The body swathe may be used in securing the arm by the side, or strips of adhesive may be used for this purpose. Sufficient padding should be placed in the external splint in the I'cgion of the olecranon to avoid chating and discomfort. This dressing is quite secure but requires careful watching to avoid strangulation when swelling sets in. It is of particular advantage in compound fractures of the lower end of the humeral shaft sinc^e the arm may be perma- nently secured to one splint while the other is removed daily for inspection and dressing of the wound. After the arm is immobilized (whatever the type of dressing may be) an X-ray should be taken, when possible, to verify the diagnosis and to determine the accuracy of reduction. When overriding deformity cannot be corrected by solid engage- ment of the fractured ends weights may be attached to the elbow to control the action of the biceps and triceps. (Fig. 214.) The use of extension may be indicated in some cases if employed in the recumbent position, but as an ambulatory method it is, in the author's opinion, entirely too haphazard and untrustworthy to be relied upon, notwithstanding statements to the contrary. It may be stated as a rule that fractures of the shaft requiring permanent extension to maintain reduction should be submitted to operation, and the fragments wired or plated in position. If ambulatory extension is employed, and fails, we have a condition of deform- ity which we know only too well might have been prevented by proper operative intervention. Operative Treatment. — Fractures of the humeral shaft are fre- quently of the oblique or spiral type and accurate reduction is often impossible without open incision and internal fixation. The frequency with which one sees deformity following fractures of the humeral shaft treated by non-operative methods, indicates the value of open incision in the treatment of breaks in this region. It is usually best to approach the bone through an external longi- tudinal incision of sufficient length to allow free access for manipu- FRACTURES OP SHAFT OF HUMERUS 117 lation and reduction. The greatest care should be used to avoid injury to the niusculo-spiral nerve in making the iiieision and in accomplishing reduction and fixation. Destruction of the function of this nerve will be more disastrous to the patient than non-union of the fragments or union with deformity. It should be kept in mind therefore that it is possible for tlie surgeon to i)roduce an Fig. 158 Fig. 158. — Rontgenogi'am of spiral fracture of humerus after two attempts at re- duction. Rotary and lateral deformity present. Fig. 159. — Same case after operation, showing fragments held in reduction by two wires. The lower wire encircles the bone while the other, at a higher level, penetrates the shaft and secures leverage for the lower wire. injury which is far worse than the condition which he is operating to correct ; accordingly the course of the musculo-spiral nerve should be thoroughly appreciated before operation in this region is attempted. After the fragments have been exposed the nature of the fracture is accurately ascertained, reduction accomplished and the best method of fixation determined. Each case must be considered by itself, and the nature of the deformity fully appreciated before 118 FRACTURES AND niST.OOATIONS Fig. 160. — X-ray of same bone after it had been 1 inioved from soft tissues. Note the density and dis- position of the callus nine months after operation and compare this plate with the photographs of the lione shown in Figs. 161, 162 and 163. Figs. 161, 162 and 163. — Same case as shown ill Figs. 158, 159 and 160. Patient had suffered from chronic chorea for past twenty-five years and susttiined fracture as a result of the staggering gait wliitli caused the fall. Fixation was particularly dilli- cult on account of the nature of the fracture and tlie choreoid spasms and wiring was resorted to. Nine inontlis later patient died in the terminal dementia following Huntingdon's chorea and humerus was ob- tained at autopsy. By comparing this specimen with I'igs. 158, 159 and 160 the disposition of the callus I overing the wire will be readily appreciated. Tlie wire A. encircling the shaft has been covered by c : Uus where it crosses the line of fracture. The wire /.'. was passed tlirough a drill liole in both fragments and did not encircle the shaft; this wire also is cov- el ed by callus where it crosses the line of fracture, licstoration of function was complete some montlis liiior to death. The dotted outline shows wlicre the nui.-culo-spiral nerve crosses the bone in tlie fresh specimen: wire A. was originally passed between the nerve and the bone. Fig. 160. Fig. 162. A Fig. 163. FRACTURES OF SHAFT OF HUMERUS 119 internal fixation is employed. Lateral displacement and over- riding deformity in spiral fractures can usually be prevented by a wire encircling the shaft and including both fragments. (See Figs. 158 and 159.) A second wire is then placed a short distance from the first to secure the proper leverage in preventing angular deformity. In passing the circular wire about the shaft some form of hook (such as shown in Fig. 826) should be used to avoid includ- ing the musculo-spiral nerve. The Lane plate has been used in this region with most satisfying results and has much to commend it (see page 766). After-Treatment. — The after-care of fractures of the humeral shaft is as important as reduction. The bone is deeply seated and difficult to immobilize and the dressings require daily inspection and adjustment during the first ten days. Undue constriction of the parts must be avoided and still the dressings must be tight enough to properly support and immobilize the arm. In other words, the arm is changing in size because of the swelling, and the dressings must be made to vary accordingly, so they may fulfill their proper function. AVhen fixation is satisfactory union should be present at the end of four weeks in children, and in from five to six weeks in adults. The older the patient the slower the bone will be in uniting. After the removal of splints the arm should be carried in a sling for another two or three weeks. Massage, early passive motion and hot applications will hasten the restoration of function. The arm should not be subjected to excessive strain for three to four months following the injury. Prognosis. — In children and healthy young adults the restora- tion of function should be rapid and complete, if proper reduction and immobilization have been carried out, and union is usually firm at the end of four weeks. In adults five to six weeks is necessary. Non-union is more common here than in any other bone in the body, and is usually due to incomplete reduction or lack of proper im- mobilization. Laceration of the musculo-spiral nerve at the time of injury will be followed by paralysis and contractures, if not exposed and repaired. Even when the ends are united recovery is tedious and often incomplete. The development of paralysis of this nerve during the after-treatment may be due to compression by the callus and unless relieved by operation gives a bad prognosis. CHAPTER IX. FRACTURES OF THE LOWER END OF THE HUMERUS. Surgical Anatomy. — The lower end of the humerus articulates with two boni's; the types of these artieulatious are entirely dilt'(;rent and the fractures occurring in this region are complex. The lower Fig. 164 (top) Viti. 166. Fig. 164. — Anterior surface of lowor end of right luuiierus. J.E., internal epicon dyle; C, capitelluni; T., trochlea. Fig. 165. — Lower end of left humerus seen from below. T., trochlea; C, capitel- lum; I.E., internal epicondyle ; E.E., external epicondyle. Fig. 166. — Me.sial aspect of lower end of left humerus. I.E., internal epicondyle; E.T., edge of trochlea. end of the bone curves forward and is flattened from before back- ward. The articular surfaces may be described roughly as a cylinder mounted on the lower end of the shaft, with the axis of the cylinder nearly transverse to the long axis of the shaft. The outer 120 FRACTTTRER OF LOWER END OF TIUMERTTS 121 end of the cylinder is at a slightly higher kivel than the inner end. When the elbow is fully extended the arm and forearm are not in the same straight line but form an angle of about 170 degrees. The difference between this angle and a straight line is 10 degrees, half of which is caused by the obliquity of the articular surfaces of the lower end of the humerus, while the other half is the result of the position of the bones of the forearm. In complete extension, therefore, we have the "carrying angle" while in complete flexion the forearm comes in contact with and folds directly upon the arm. When the fragments, in fractures of the lower end of the humerus, Fig. 167. Fig. 168. Fig. 167. — "Crescentie" fracture of lower end of humenis. Slight lateral displace- ment. Fig. 168. — "Crescentie" fracture of lower end of humerus with more pronounced lateral displacement. are allowed to unite in deformity there may be a disturbance in the carrying angle which is apparent when the arm is extended, and in addition there may also be a deformity in which the fore- arm does not fold directly against the arm in acute flexion. The carrying angle varies considerably in different individuals and the examination should therefore include comparison with the unin- jured elbow. A certain amount of hyperextension is normal in the elbow, and by means of this position longitudinal stress may be borne by the upper extremity independently of the extensor muscles, the action resembling that seen in the knee when the joint is hyperext ended. 122 FRACTURES AND DISLOCATIONS The lower end of the humerus is deserving of detailed considera- tion so that the fractures occurring in tliis portion of tlie bone may be more thoroughly understood. The external condyle (epicondyle) is a small, tubercular eminence situated just above and a little external to the capitellum. It affords attachment to the external lateral ligament and some of the extensor and supinator nuiscles of the forearm. It is rarely fractured without at least a portion of the capitellum being included with the fragment. The capitellum is the rounded eminence occupying the outer part of the articular surface. It articulates with the head of the Fisf. 170. Fig. 169. — Vertical fracture of lower end of luunenis separating external condyle from remainder of bone. Fig. 170. — Fracture of the external condyle with lateral displacement of elbow. Fracture of the olecranon present but not discernible from this angle. radius, and is rarely injured except when involved in some of the more common fractures of the external condyle. The radius artic- ulates below with the carpus and above with the capitellum, and in falls on the hand violence is transmitted directly to the capitellum through the radius. This type of violence, however, is much more likely to produce Colle's fracture or a break in the shaft, neck or head of the radius. The oblicpiity of the fibres of the interosseous ligament enables the ulna to absorb a portion of the shock when violence is sustained in this way. The capitellum occupies only the front and lower part of the bone. The inner portion of the articular surface is taken uj) by the FRACTURES OF LOWER END OF HUMERUS ]23 trochlea which articulates with the greater sigmoid cavity of the ulna. It presents a pronounced groove running from before back- ward which is bounded on either side by prominent ridges, the inner being the most marked and extending to a lower level. Tlie Fig. 171. Fig. 172. Fig. 171. — T-fracture of lower end of humerus. Pronounced inward and backward displacement of lower fragments. Fig. 172. — "Crescentic" fracture of lower end of liumei-us witli lateral and back- ward displacement of lower fragment. Fig. 173. Fig. 174. Fig. 173. — Supracondylar fracture with pronounced inward and backward displace- ment of lower fragment. Fig. 174. — ^Same case after reduction. trochlea is slightly spiral so that the posterior end is a little external to the anterior extremity. Just above the anterior end of the trochlea is situated the coronoid fossa which, during flexion of the elbow, receives the process on the ulna of the same name. On the 124 FRACTURES AND DISLOCATIONS posterior aspect of the bone in tlic same corresponding position is fonnd the olecranon fossa, 'riiese two fossip are ordinarily sep- arated I)y only a thin layer of bone and when the de]n-essi(nis are F\s. 175 Fig. ]T(i Pi?. 17.5. Fig. 176. 'Crescent ic" fracture with backward and rotary displacement. Fracture of lower end of humerus with backward and rotary displace- Fig. 177. Fig. 177. — Fracture of lower end of humerus. Deformity not apparent in antero- posterior view. Fig. 178. — Same case seen laterally. Slight backward displacement of lower frag- ment. well marked the bone may be perforated, forming the supracondylar foramen. These two fossse materially weaken the constniction of the lower end of the humerus and are usually entered by transverse FRACTURES OF LOWER END OF HUMERUS 125 fractures in this region, and by vertical fractures involving the articular surfaces. The internal condyle (epitrochlea) is much more prominent and larger than the external condyle, and affords attachment to tlie internal lateral ligament and some of the pronators and flexors of the forearm. It is more easily broken than the external condyle. Directly behind this process is a groove for the ulnar nerve whicli is not infrequently injured in fractures of the internal condyle. The manner in which the lower epiphysis of the humerus is ossified is of importance in explaining epiphyseal separations in this region, though the resultant conditioiis are treated in a manner similar to fractures of the same parts. At birth the epiphysis is entirely cartilaginous and throws no shadow under the X-ray, while the lower end of the diaphysis is rounded. (See Fig. 251.) Fig. 179. Fi:;. ISO. Fig. 179. — EpipliYsenl separation of epitrochlea. Fig. ISO. — Lateral view of same case. Before the end of the first year the center for the capitellum makes its appearance. At the sixth year the center for the internal condyle is seen; during the eleventh year the trochlea begins to ossify and the center for the external condyle is first seen during the twelfth year. The outer three centers usually fuse with each other and join the diaphysis during the fifteenth year, before the center for the epitrochlea becomes continuous with either epiphysis or diaphysis. The internal condyle joins the rest of the bone at about the eighteenth year. During the latter part of the develop- ment of the lower end of the humerus the diaphysis is seen to project progressively further into the epiphysis so that it comes nearly to the surface between the centers for the internal epicondyle and trochlea. The order in which these centers join the shaft and the thinning of the epiphysis between the trochlea and internal 126 FRACTURES AND DISLOCATIONS epicondyle account for the relative frequency of epiphyseal sep- arations of the internal epicondyle. The ligaments about the elbow phiy an important i)art in pro- duction of fractures. AVith the elbow partially flexed, abduction or adduction of the forearm produces rotation of the humerus. With the elbow fully extended, liowever, there is practically no rotary ett'ect on the liumcius but instead extreme tension is pro- duced on one of the lateral ligaments. If the forearm is abducted the head of the radius is forced against the capitelluiu and the internal lateral ligament is placed under tension. If the violence Fi^;. Irt2. Fis. is; Fig. 181. — Fracture of internal epicondyle. Fig. 182. — Separation of epiphysis of external condyle. Fig. 183. — Separation of epiphysis of internal epicondyle. is sulBcient the capitellura is fractured, or the bone supporting it is broken off from the remainder of the lower end of the hum-erus. Instead of either of these lesions tlie internal lateral ligament may suffer rupture, or an equivalent fracture of the internal ejueondyle or trochlea may take place. When the elbow is extended and the forearm forcibly adducted the reverse mechanism obtains. If the forearm is forcibly extended beyond the normal limita- tions of motion the usual result is either rupture of the ligaments or fracture of the lower end of the humerus, with backward dis- placement of the fragment. A much more exceptional fracture is one produced by extreme flexion. The types of fracture occurring in the lower end of the humerus are numerous, and have for the most part been named according FRACTURES OF LOWER END OF HUMERUS 3 27 to the portion of the bone involved. The terminology employed by different authors varies and the result has been rather confusing. The usual fractures occurring in this region are : Fracture of the epicondyle. Fracture of the external condyle including the capitellum. Fracture of the internal condyle including the trochlea. Fracture of the epitrochlea. Dia-conclylar fracture, the break passing transversely tlirough the condyles. Supra-condylar fracture, the break passing just al)ove the con- dyles. T- or Y-fraeture, in which a vertical break divides the lower fragment of a supra- or dia-condylar fracture. Comminuted fracture of the lower end of the humerus, in which the lower end of the bone is so broken up that it is difficult to recognize any particular type of fracture. Fracture limited to the capitellum as a result of violence trans- mitted tlirough the radius in falls on the hand. Epiphyseal separations as described above. It will be noted that all of the above fractures, except the last two named, may be described as either ''transverse" or "vertical" or a combination of these two. The supra-condylar and dia- condylar fractures are essentially transverse, while the fractures involving the condyles and traversing the articular surfaces are vertical. The Y- or T-fracture shows both vertical and transverse elements. Nearly all transverse fractures pass through the ole- cranon fossa as do the vertical fractures involving the articular surfaces. Transverse fractures are usually the result of forced hyper- extension of the elbow, and the lower fragment is almost invariably displaced backward. In the typical transverse fracture the lower fragment is crescentic, the concavity looking upward. This type of fracture has frequently been mistaken for an epiphyseal sep- aration in spite of the fact that there should be no difficult}^ in differentiating the two conditions when the X-ray is employed. The upper end of vertical fractures may cross either the internal or external supracondylar ridge, but the lower end of the break is frequently placed so that the trochlea is separated from the capitel- lum. This separation of the two articular surfaces on the lower 128 FRACTURES AND DISLOCATIONS end of the humerus allows a flail-like lateral mobility at the elbow M'hieh is characteristic of the injury. A rare disi)lacpinent, some- times seen in transverse fractures, is one first described by Posadas, in which the lower fragment is displaced forward wliile the bones of the forearm arc luxated backward. Wli(>n the condyles are sepai'ated fi'om each other by a vertical ffiU'ture, one or liotli of tlie condyles may be displaced so that the n-lation of the tlii'ee l)ony prominences is disturbed. In the normal elbow the prominence of the olecranon and the two condyles should be about on the same sti'aight line M'hen the elbow is fully extended. The olecranon is a trifle nearer the inner con- dyle. AVhen the elbow is in a ])osition of acute flexion these tliree bony prominences should occupy the apices of an eciuilateral tri- angle. This anatomical relation is of great value both in diagnosis and treatment. The inuscles attached to the condyles may exert a displacing action when either of these processes is detached. In vertical fractures the condyles arc usually further apart than they should be, and the condyle on the detached fragment may be dis- placed forward, backward, upward or downward. In any fracture in which the lateral stability of the elbow is destroyed the carrying angle is lost as the arm hangs by the side, and if the condition is severe the forearm may diverge to the inner side, producing the familiar "gunstock deformity," or cubitus varus. This deformity may occur with any of the transverse fractures and with the vertical fractures involving the articular surfaces. Immediately following the accident this deformity is due to gravity and to the position occupied by the displaced fragment or fragments. If the frag- ments are not replaced and recurrence of displacement prevented the deformity will become permanent when union takes place. In the rare T-fracture or in extensive comminution of the lower end of the humerus the lateral stability of the joint is most com- pletely broken up since both condyles are separated from the shaft and from each other, and the line of fracture divides the articular surface. This type of fracture usually results from a fall directly on the flexed or semiflexed elbow. Symptoms. — The symptoms accompanying fractures of the lower end of the humerus vary considerably according to the position of the fracture and tlie severity of the lesion. Pain, swelling, local tenderness, loss of function and deformity are all present though they vary somewhat with the nature of the fracture. The traumatic FRACTURES OF LOWER END OF ITTJMERTTS 129 reaction following fractures of tlu; lower end of llic, liumerus is usually pronounced, and a few days following the a(;cident the region of the elbow may be covered with ))lel)s containing blood or serum. Ecchymosis usually develops within twelve to twenty- four hours and may be extensive. The loss of function is usually complete following transverse fractures or those which involve the articular surfaces. In isolated fracture of either the epicondyle or epitrochlea the loss of function may be surprisingly slight. The patient will be able to use the elbow to some extent though of course the action of the part is somewhat limited by pain. The symptoms peculiar to the different fractures in this region v\'ill be considered in detail. Fig. 184. — Fracture of e\tei n.il epicondyle with upward displacement of fragment. Prominence on external aspect of elbow suggestive; palpation reveals fragment. Joint is intact, there being no involvement of articular surface. Condition rare. Fractures of the epicondyle (fractures in which the joint is not entered and the capitellum remains intact) are extremelj^ rare and the symptoms are not pronounced. Moderate local swelling and tenderness in the region of the external condyle is present. The fragment may remain in position or may be displaced in an,y direc- tion. When deformity exists the fragment is usuallj^ displaced downward. The detached particle of bone can, as a rule, be directly 130 FRACTURES AM) DISLOCATIONS palpated and, if tlie fractured surfaces eau be rubbed together, crepitus will be noted. Crepitus may be difficult to elicit if the fragment is not displaced and the swelling is pronounced. De- tachment of the epicondylc will destroy, to a greater or less extent, tlio fuiictinn of tlu^ cxtci-iial l.-itcrnl li^jimctit and accordingly the Figs. 185 aiul 186. — Two views of .i l'i;ii1niv of lower end of humerus witliout the characteristic backward displacement of lower fiaament. Note prominence of e.\ternal epicondyle which is detached. The .ioint reni;uns intact and hence the ahsence of de- formity such as seen in l<'igs. ISS and 189. Fig. 187. — Splitting of lower end of humerus with separation of external condyle. Gun-stock deformity and abnormal lateral mobility. Picture taken a few hours follow- ing accident. lateral stability of the elbow may be somewdiat disturbed. A vary- ing degree of abnormal adduction of tlie elbow is often possible. Fractures of the e.rternal condyle (vertical fractures which enter the joint and include the capitellum in the detached fragment) are much more common than fractures of the epicondyle and the FRACTURES OF IjOWRR END OF irUMERTTS 131 symptoms arf^ decidedly more pronounced. Pain is severe, loss of function complete and swelling pronounced. The lateral stability of the elbow is usually completely lost and the joint is flail-like in a transverse direction. Crepitus is, as a rule, recognized as soon as the parts are manipulated. On palpating the condyles the epi- condyle is found detached from the humerus, while the epitroclilea is continuous with the rest of the bone. The forearm is usually supported by the uninjured member and the patient is reluctant to release it for examination. When the arm hangs by the side the helplessness of the member is apparent and the usual "gunstock" deformity is recognized at a glance. The fragment is usually dis- placed downward and may be so rotated that the fractured surfaces are no longer parallel and facing each other (see Fig. 218). Fractures of the internal condyle (vertical fractures entering the joint and separating all, or a portion, of the trochlea from the remainder of the bone) . The symptoms are similar to those already described in the preceding type except that the inner side of the elbow is the most painful and tender, and the internal condyle is found to be the movable part. Loss of lateral stability is even more pronounced than in fracture of the external condyle. Fracture of the epitrochlea (a vertical fracture separating the internal epicondyle from the remainder of the bone without entering the joint or involving the trochlea) is not an uncommon injury, and since neither the joint cavity nor the articular surfaces are involved the symptoms are usually slight. There is some local tenderness and pain on the inner side of the elbow, and ecchymosis is usually seen within the first day. Flexion and extension of the elbow are not painful except in as much as they disturb the detached fragment. Extreme extension or acute flexion may be attended by pain. Local swelling is usually present. The symptoms are often so slight that the condition is not infrequently mistaken for a sprain and treated as such. Supracondylar and diacondylar fractures are similar conditions and the symptoms so resemble each other that they will be de- scribed together. Swelling, pain, tenderness, loss of function, crepitus, and mobility are present as in vertical fractures involving the articular surfaces. Loss of carrying angle and even gunstock deformity are usually prominent symptoms. The deform it}- is often characteristic, the bones of the forearm and humeral frag- ment being displaced backward in such a way as to produce a strong 132 FRACTURES AND DISLOCATIONS Fis:. 188. — Transverse fraclure of tlie lower end of the humerus. Note the back- Wind diKphitenieiit of the elbow. Palpation reveals the three bony prominences all dis- placed backward without disturbance in tlieir relative positions. Sigmoid cavity of ulna not empty, as in Fig. 229. Picture taken about twent\-four hours following accident. Note swelling and slight ecchymosis. /^< Fig. 189. — Same cai^i' in i-itliiig ]Hisiliiiii. Note ihat lice deformity persists with change of position. The elbow is Hail-liUe yet tlie action of the biceps and triceps pro- duce and maintain the deformity. FRACTURES OF LOWER END OF HUMERUS 383 Fig. 190. Fig. 191. Figs. 190 and 191. — X-ray plates of case shown in Figs. 188 and 189 after incom- plete reduction. P"*!!* Fig. 192. Fig. 193. Figs. 192 and 193. — Compound comminuted fracture of lower end of humerus. Note the backward and inward displacement which is characteristic. Forearm is cov- ered with blood which accounts for its darkened condition in the photograph. Arrow points to the wound just above and behind the elbow. Picture taken about one hour after injury. 134 FHACTITRES AN1> DISLOCATIONS reseHil)laiiee to backward dislocations of the elbow (see page 159). The character of the deformity is well shown in Figs. 188 and 189. On palpation the two condyles are fonnd to be no longer continuous with the shaft of the humerus thongh they are continuous with each other and move togc^ther. If the upper end of the ulna is palpated Fig. 194. Figs. 194 and 19.5. — Compound comminuted fracture of tlie lower end of tiie humerus. Note the deformity and flail-like condition. the greater sigmoid cavity will be found occupied by tlie lower end of the humerus and not emi)ty as in backward luxation. The lateral stability of the elbow is destroyed. The characteristic deformity of a supra- or dia-condylar fracture is first the backward displacement of the elbow and second the "gunstoek" deformity. (See Figs. 192 and 193.) In ihe T- or Y-fracture of the lower end of the humerus or in FRACTURES OF liOWER END OF TrUMRR[TS 135 cases in which the lower end of the hone is extensively comminuted practically all the symptoms of the above described transverse and vertical fractures are |)resent in exaggerated form. The lateral Figs. 196 and 197. — Old case of gunstock deformity and almost complete loss of function of elbow due to fractures above and below the joint. X-ray examination shows supracondylar fracture in lower end of humerus and fracture of ulna below coronoid process. stability of the elbow is more completely destroyed in these types than in other forms of fracture in the lower end of the humerus. The traumatic reaction is usually severe and the fracture is not 136 FRACTURES AND DISLOCATIONS infrequently eompound. On i)alpation crepitus is readily recog- nized, and when the eonnninution is extensive the region of the elbow may give one the sensation of a sack of marbles. When the condition is compound the wound is not infrequently located just above the olecranon on the posterior aspect of the arm. Fracture limited to the capitellum is extremely rare and presents no characteristic symptoms. Local tenderness and pain with use of the elbow are present, but the condition is seldom recognized without the aid of the X-rav. Fig. 198. Fiff. 199. Figs. 198 and 199. — Old case of diacondylar fracture with the usual backward dis- placement of elbow. Deformity closely resembles backward luxation of the eibow. The characteristic depressions at the back of the elbow are absent and palpation of the sig- moid determines that it is not empty. (Compare with Figs. 225 to 230.) Diagnosis. — The diagnosis of fractures of the lower end of the humerus is based on the symptoms just enumerated. Swelling about the elbow is usually rapid in onset and pronounced following fractures in this region, and the earlier the surgeon sees the case after the accident the less difficulty there will be in establishing a diagnosis. Firm, local, gentle and continued pressure in a given FRACTURES OF LOWER END OF HUMERUS 137 spot will in many cases so displace the fluids within the swollen tissues as to render recognition of the underlying bone possible. If there is difficulty in determining the nature of the fracture the examination should be systematically conducted so that all the data possible may be gathered before the surgeon forms an opinion of the condition. If the traumatic reaction is pronounced it will usually be advisable to anesthetize the patient before examining the parts. The expense of repeated Rontgenographic examinations is frequently objected to by the patient, and under these circumstances it may be advisable to learn all that is possible from a physical 200 Fig. 201. Fig. 200. — Examination of three bony prominences with elbows acutely flexed. Note the slight backward and upward displacement of the patient's right internal condyle. Fig. 201. — ^With full extension it will be noted that there is a loss of carrying angle in the patient's right arm. The left arm is normal. Old fracture of lower end of right humerus. examination under anesthesia, reduce the fracture and then have an X-ray plate taken to verify the diagnosis and the completeness of reduction at the same time. A careful inspection of the parts is of the greatest value and should be done before the arm is sub- jected to any manipulation whatever. The character of the deform- ity and the attitude of the patient will often be sufficient to indicate the nature of the injury so that the diagnosis is confirmed by the least possible manipulation and palpation. The less the parts are disturbed and the more gentle the manipulation the better. If inspection indicates the nature of the injur}^ the surgeon should examine the part suspected first. Otherwise the lower end of the 138 FRACTURES AND DISLOCATIONS bone should be covered systematically. The external condyle should be palpated and note made of whether or not the process is continuous vvith tlie shaft of the humerus and the opi)osite con- dyle. The same examination should then be made of the inner condyle. The lateral stability of the elbow should next be tested witli the forearm fully extended. In detei'iniiiiiig tliis point the 202. Fig. 203. Figs. 202 and 203. — Old fracture of lower end of humerus with union in deformity. Pronounced gun-stock deformity and shortening of arm. The positions of the three bony prominences have been marked and the displacement is apparent. A line drawn through the two condyles is not at right angles to the shaft of the humerus. By examining the elbow in this position one can tell the position which the forearm will occupy when extended. ( See accompanying text. ) Function good considering the deformity. Case first seen six years after the injury at which time these photographs were taken. lower end of the arm is grasped above the elbow to steady the humerus while the opposite hand grasps the wrist and an attempt is made to adduct and then abduct the forearm. The wrist nor- mally moves inward in passing from the position of supination to pronation, and the distance traversed is nearly equal to the breadth of the wrist. This motion, however, is accomplished entirely by the low'er end of the radius encircling the head of tlie ulna and in FRACTURES OF LOWER END OP HUMERUS 139 no wise means ]ateral motion at the elbow. Lateral motion does not exist in the normal elbow. The relation of the three bony prominences of the elbow shoulfl be carefully noted, and if the normal relation is disturbed the surgeon should determine which of the prominences is displaced. The olecranon should be carefully palpated and its continuity with Fig. 204. — Another view of case shown in Pigs. 202 and 203, showing the striking deformity. the ulnar shaft determined. The head of the radius should be palpated and note made of whether or not the head rotates with the radial shaft during pronation and supination of the forearm. The forearm should be carried through its normal range of motion and any restriction of action or pain should be noted. The backward displacement accompanying transverse fractures 140 FRACTURES AND DISLOCATIONS of the lower end of the humerus closely resembles the deformity seen in backward luxations of the elbow. In luxations, however, the deformity is usually more pronounced and the sigmoid cavity is found empty on palpation (compare the appearances of the cases shown in Figs. 1!)9 and 229). In fractures mobility is increased, while in luxations it is usually restricted. Fig. 205. — Fracture about two inches above the condyles three years after the accident. Note the inward angular displacement of the lower fragment and resultant gun-stock deformity. Paralysis result of injury to musculo-spiral nerve at the level of the fracture. Nerve in.iury" not recognized at the time of the injury and nothing done subsequently to rep.'iir the damage. Patient has practically no use of the member. Case first seen by author at time of taking this photograph. Fractures of the lower end of the humerus must be differentiated from Dislocations of the elbow. Dislocations of the ulna alone, Dislocations of the radial head. Fractures of the olecranon, Fractures of the coronoid and ulna below the elbow, Fractures of tlie radial head, neck, or shaft. Simple sprain of the elbow. FRACTURES OP LOWER END OP IIUMERtlft 141 Fig. 206. — Annthei- view of case shown in Fig. 205. Patient cannot extend arm beyond position shown here. Note waist-drop, contracture and atrophy. Fig. 207. — Another view of case shown in Figs. 20.5 and 206. 142 FRACTrRES -VXD DIl^LOCATIONS Fi". 208. A rare cnse vhich demonstrates two deformities in the same patient. Both arms' were broken some years ago ,iust above the elbow and both elbow joints were involved After union had taken place the deformities were recognized. Valgus in one elbow and varus in the opposite. The left arm shows exaggerated carrying angle while the right arm shows "gun-stock" deformity. Case first seen by author at the time this picture was taken. Function in both arms fair considering the deformities. Fig. 209. — Picture taken to show how pronounced the normal carrying angle may be and the necessity of always examining the opposite eXhow. (Left elbow has been painted with iodine following sprain.) FRACTURES OF LOWER END OF TTUMERtlS 143 The reflexes and condition of the circulation below the level of the fracture should be tested both before and after reduction. The ulnar nerve is the structure most commonly injured, especially in fractures of the internal condyle, and its function shoidd be most carefully tested. The value of the X-ray cannot be overestimated in the diagnosis of fractures of the lower end of the humerus and should be made use of whenever possible. The plates taken should be at right angles to each other or else made stereoscopically. Treatment. — An accurate appreciation of the nature of the fracture is essential to the intelligent treatment of fractures of the lower end of the humerus. As a rule anesthesia should be employed in reducing the displacement and in fixing the arm. Reduction is easily accomplished in many cases, yet it is not uncommon to encounter a condition in which reduction and fixation can be had only with open treatment. Transverse fractures can usually be reduced by grasping the lower end of the arm above the elbow to steady the humerus, and then making traction in the axis of the semiflexed forearm. This pulls the bones of the forearm forward and with them the lower fragment seated in the sigmoid cavity of the ulna. AVlien the fragment has been brought back into position the elbow is flexed and immobilized in this position. Treatment of these fractures in acute flexion will give the best results in the greatest number of cases, yet the value of this position should not be overestimated nor should it be employed blindly. The best position in v^^hich to treat fractures of this region is the position which will most accurately and securely maintain reduction, and just which position this is must be determined in each and every case to the satisfaction of the surgeon. Much has been said and M^ritten of the value of the three bony prominences in the diagnosis of fractures about the elbow, yet their chief value lies in the treat- ment of these conditions and seems to have been overlooked. A careful consideration of these three points with the elbow flexed will enable the surgeon to determine the position the forearm will occupy when extended. This determination is made in much the same manner as one would foretell the position a door would occupy when open, by a study of the position of the hinges when closed. This point is well illustrated in Figs. 202 and 203. In reducing a fracture in this region the surgeon should have the two condyles directly under his touch, so that he may follow the effect 144 FRACTURES AND DISLOCATIONS on the fragments as the forearm is slowly carried through flexion and extension. Tlie degree of flexion in which the fragments seem to occupy a position nearest to normal should be maintained, and dressings then applied which will immobilize the elbow. The two condyles should be in a line at right angles to the axis of the shaft of the humerus, and neither should occupy a position anterior to the other (taking the posterior surface of the humerus as a base). The tip of the olecranon should be at about the same level as the condyles if extension is complete, at the apex of an equilateral triangle in acute flexion and proportionately sitiiated between these two points in the various degrees of flexion. It will usually be found that posterior displacement of the lower fragment is cor- rected, more or less completely, by acute flexion, and we therefore seldom find the extended position available in the treatment of these cases. An arm may appear well reduced in the flexed position, and the surgeon may be pleased with the outlook of the case, and yet after union has taken place, the splints removed and the arm extended, a condition such as shown in Fig. 203 may become evident, to the chagrin of the surgeon and the dissatisfaction of the patient. Such results might be avoided by a careful examination of the three bony prominences following reduction as described above. In the treatment of vertical fractures involving the articular surfaces similar principles are to be followed out. Acute flexion, however, is not nearly as efficient in preventing recurrence of de- formity in these vertical fractures as it is when the break is trans- verse. During reduction lateral pressure should be made on the fragments in order that they may be forced closer together. Meas- urements of the distance between the two condyles should be made following reduction and compared wath the opposite elbow. In some instances a detached condyle may follow the movements of the forearm during flexion and extension, and when this occurs the elbow should be fixed in the degree of flexion in which the fragment occupies a position nearest to normal. If the fragment is rotated it may be necessary to operate to effect reduction. It should be remembered that the displacing action of the muscles of the fore- arm attached to the condyles varies witli the degree of flexion of the elbow. In acute flexion the pull is upward and forward, in semiflexion it is forward, while in complete extension it is down- ward. FRACTURES OF LOWER END OF HUMERUS 145 The principles involved in the treatment of epiphyseal separa- tions are the same as those given in the treatment of fractures of the corresponding parts. Special padding of the splint may be of aid in retaining the frag- ments though it is not so satisfactory a method as might be desired. Displacement depends somewhat on the extent to which the intermuscular septa and fascial have been torn, and accordingly we experience less difficulty in those cases in which the damage sustained by these tissues has been slight. Fig. 210. — Method of fixing the arm iu a position short of acute flexion for the treatment of certain fractures at the elbow. This method is far better than passing adhesive about the wrist and upper part of the arm as is commonly done. Fractures entering the articular surfaces demand the most accu- rate reduction. Perfect apposition means a small callus and is essential to restoration of joint function. The dressings employed to fix the part vary with the degree of flexion in which the elbow is immobilized. In cases in which the traumatic reaction is pronounced it is advisable to delay the appli- cation of dressings until it has subsided. During this time the patient should be in bed, the injured arm supported on a pillow and the ice cap applied at intervals. If the position of acute flexion is to be employed layei*s of 146 FRACTURES AND DISLUCATIONS gauze slioiild bo placed in the bend of tlie elbow, and in the axilla, to absoi-b the secretions and prevent ehating of the skin. The inner Fis. 211. Fig. 212. Fig. 211. — Internal right angle Dupuy splint. Fig. 212. — External right angle Dupuy splint. surface of the arm and forearm should be prevented from coming in contact with the chest for the same reasons. This is accomplished by layers of gauze appropriately placed. The usual method of Fig. 214. Fig. 213. — Internal, right-angle splint padded and secured in position with four strips of adhesive plaster. Fig. 214. — Method of securing traction with right-angli' s])lint and weight. Seldom advisable. (See text.) maintaining acute flexion by means of a strip of adhesive binding the wrist to the upper part of the arm, is mechanically cumber- FRACTURES OF LOWER END OP irUMERTJR 147 some and productive of discomfort. The most satisfactory method of securing the upper extremity in this position is shown in Fig. 210. A strip of adhesive encircles the wrist and passes over the shoulder of the same side. In this way any position from semi- flexion to the most acute flexion may be had, and the amount of flexion may be increased from time to time during the subsidence of the swelling with the least possible disturbance of the elbow. If additional security is desired the axillary pad may be employed as described in the "Treatment of Fractures of the Upper End of the Humerus" on page 99. A body swathe may be used to secure the arm to the side. Pig. 215. — Plaster splints applied to upper extremity and held in position by straps of adhesive plaster. If a position of semiflexion is chosen in which to immobilize the elbow the ordinary right angle splint may be employed. Either an internal or an external right angle splint will accomplish the purpose, though the former is usually preferable. This splint should be secured to the arm first by strips of adhesive, and then fastened to the forearm while traction is being made on the wrist to draw the fragment forward. When it is necessary to immobilize the forearm in positions between complete extension and semiflexion, plaster splints will usually be found most satisfactory (see Fig. 215). 148 FRACTURES AND DISLOCATIONS Any form of splint applied to the upper extremity should be well padded with sheet eotton, and the ent-ircliii'; bandages or strips of adhesive used to secure it in position should not be so tightly applied as to "cause constriction of the member. This precaution is of the greatest importance during the onset of swelling and if not observed may result in great damage. A dressing may fit properly at the time of application and yet a few hours later may be causing serious constriction. After the height of the traumatic reaction lias passed ;ni(l the size of the arm and forearm is dimin- ishing, snug ban(higing will often accomplish mnch in reducing the swelling. Fig. 216. Fig. 217. Figs. 216 and 217. — Two types of adjustal)le splints for use in fractures about the elbow. Operative Treatment. — The open method is productive of the best results in many cases and we should not hesitate to resort to it when the proper surgical facilities are available and the ordinary methods are not efficient. No surgeon should operate on the lower end of the humerus without having well in mind the details of the anatomy of the region. The bone is peculiarly shaped, and without an accurate knowledge of its formation and the structures surround- ing it, the surgeon may do more harm than good. There is con- siderable compact tissue in the region of the condyles and above them in the shaft, but the bony structure supporting the articular surfaces is altogether cancellous. In order to acquire a good appre- ciation of the internal structure of the bone it will more than repay the student to open a humerus in coronal and sagittal section, using an ordinary hack-saw for the purpose, after which he may study the nature of the bone structure with which he has to work. In placing wire or nails we should rely as much as possible on the compact tissue; a knowledge of its disposition and density will be of the greatest value. It is better to approach the fragments through an internal longi- tudinal incision or an external longitudinal incision or both, and FRACTURES OF LOWER END OP HUMERUS 149 to avoid, as much as possible, injury to the soft tissu(?s about the joint. In this regard it slionid be rernetnbercid tliat the museulo- spiral nerve and its brandies descend o))li(jiiely between the supinator longus and the brachialis antieus on tlie outer side of the elbow, and that the ulnar nerve follows an almost vertical course and passes directly behind the prominent internal epiconclyle. The external incision is best made behind the musculo-spiral, and the internal incision slightly anterior to the ulnar nerve and posterior Fig. 218. Fig. 219. Fig. 218. — Vertical fracture of lower end of humerus. Capitellum iucluded in frag- ment which is displaced downward and rotated. When au attempt is made to flex arm the edge of the fragment threatens to penetrate the skin. Fragment nailed in position at operation and fracture treated in a position of semiflexion. X-ray by H. G. Stover. Fig. 219. — Same case five years later showing nail in place, fragment in reduction and carrying angle restored. Note the callus at upper end of fracture. Nail has not loosened and bony tissue next to nail shows no changes. Restoration of function com- plete. Injured member as useful and strong as opisosite arm. X-ray by S. B. Childs. to the brachial artery and median nerve. If the elbow is ap- proached through either of the above incisions the median nerve will not be in the field of operation. After the bone has been exposed an analysis of the line or lines of fracture should be made, together with a consideration of the forces preventing reduction. The points of advantage for the placing of fixation materials are determined and the fragments reduced. A single nail will sometimes accomplish all that is re- quired (see Fig. 219), while in other cases it will tax the ingenuity 150 FRACTl'RES AND DISI.orATIOXS of tlie most capable to secure the fi-agniciits. A T-fracture may sometimes be securely held by a througli and tlirough wire, while in other instances a circular wire may be made to hind two or more fragments togetiier. In comiuinuted conditions it may be possible to secure one or more large fragments to the shaft, or to bind the fragments of the lower end of the bone together by a wire above the condyles, and then accomplish the balance of reduction by acute flexion. Wiiile the bone is exposed the elbow should be carried Figs. 220 and 221. — Same ease as seen in Figs. 218 and 219 showing range of motion at elbows and normal carrying angle. Note the noi-mal relations of the three bony prominences when the elbows are fully flexed. through flexion and extension to determine the position which tends least to displace the fragments, and this position should be main- tained in the after-treatment. Care should be taken not to enter either the olecranon or coronoid fossa with nail or wire, as this may be an obstacle to flexion or extension after recovery. Provision for the escape of blood and exudates should be made by leaving a small drain of silk worm gut, which is to be removed in from tweutv-four to fortv-eight hours. FRACTURES OV LOWER END OF HUMERUS 151 The lower end of the liunierus not infrequently presents conditions of fracture as difiicult to handle as any other bone in the body. After-Treatment. — During the early part of the after-treatment the arm should be most carefully watched to avoid constriction. The dressings should be inspected at least daily to see that they remain in proper position. The axilla and bend of the elbow are points likely to show irritation of the skin and require special attention. If a posterior splint is employed the point of the elbow may need special padding to avoid undue pressure. If acute flexion is the position holding the fragments in reduction it should be increased as the swelling subsides and the danger of constriction grows less. The production and ossification of the callus is rapid about the elbow, and passive motion and massage should be begun at the earliest possible moment consistent with immobilization of the frag- ments. Gentle massage may be begun soon after the subsidence of the traumatic reaction provided care is taken to avoid disturbing the fragments. Gentle passive motion may be instituted in most cases at the end of from three to five weeks according to the age of the patient. Certain cautions should be noted, however, as much harm may be done by injudicious motion. The movements should be most guarded and gentle when first begun, and the condyles should be under touch of the surgeon to see that movement of the lower fragment is not produced. Motion should in no case be carried far enough to produce pain, which may be taken as an indi- cation that more harm than good is being done. Many surgeons prefer to delay passive motion until union is firm (four to six weeks or even later) and then if necessary the adhesions of the joint may be broken up under anesthesia. In some cases it will be neces- sary to anesthetize the patient a number of times, at intervals of a week or ten days, to keep the joint surfaces free until they are thoroughly healed. During the intervals the elbow is immobilized to allow the accompanying traumatic inflammation to subside. Such a procedure is tedious to both patient and surgeon but the subsequent results usually more than compensate for the additional trouble. The arm should be watched most carefully during the first ten days to avoid constriction on the one hand and loosening of the splints on the other. Strangulation of the limb is more likely to occur when the arm is maintained in a position of acute flexion, 152 FRACTURES AND DISLOCATIONS wliilc sli])])iner of llio splints is most often seen in positions between senii-tlexion aiul extension. An arm slioukl never be bandaged in a more or less extended position and tben tiexed, as constriction at the elbow is sure to take place. The plaster east is a most dangerous dressing, especially if employed in the early part of the after- treatment. Its rigidity does not allow for the swelling of the niein- ber and may be followed by damaging constriction and Volkmann's contracture. When the internal or external angular splint is used it should be fixed with adhesive plaster in at least three places as shown in Fig. 214. If doubt exist as to the progress of union an X-ray plate should be taken. If the callus is heavy enough to throw a shadow it will usually be safe to employ passive motion. The removal of the splints or dressings should be gradual ; that is, they should be removed for an hour or two each day, gradually increasing the time until they are permanently removed at the end of a week. A sling should be used for some time following removal of the splints. Exercise is to be gradually instituted, taking as a guide the fatigue produced. There should be no sense of fatigue after half to three quarters of an hour following exercise. It should be remembered that the most valuable and useful part of the function of the elbow joint lies in the range of motion included between acute flexion and semi-flexion. Prognosis. — The prognosis in fractures of the lower end of the humerus varies with, the age of the patient, the severity of the lesion and whether or not the fracture enters the joint. Loss of motion in the elbow has been an unfortunately common sequel to fractures in this region, but with the advent of improved treatment, especiall}' the open method, the number of cases of stiff elbow is being materially reduced. If the usual case of fracture of the lower end of the humerus is treated by the open method, the fragments accuratelj^ reduced, internal fixation employed and early passive motion instituted, the result will almost invariably be a functionally perfect joint without deformity. The prognosis is of course equally good in cases in M'hich accurate reduction can be accomplished with- out operation, but the X-ray is continually demonstrating the fact that these cases are less numerous than was formerly supposed. Surprisingly good function often follows these fractures in children, even when deformity and non-union are present. Dis- turbances in the longitudinal growth of the bone in epiphyseal sep- arations are very unusual, being seen onlj^ in instances in which a FBACTTTRER OF I/)WER END OP ITTJMERUS 153 portion or part of the epiphysis is widely separated from the diaphysis. The bad prognosis so frequently given in text-books is based on the frequency of incomplete reduction and the common practice of prolonged immobilization. For the surgeon 's protection, however, he should be quite guarded in the forecast given the patient or his family even when the case is uncomplicated. One never knows what complications may arise during the course of the case, and it has not uncommonly happened that the surgeon found that he had to deal with the exceptional case after a most favorable prognosis had been given. The outlook in compound cases is of course worse, yet if the principles laid down in the chapter on "The Treatment of Compound Fractures" (page 789) are followed out a large percentage of these open cases may be made to result as favorably as simple fractures in this region. The unfavorable results following fractures of the lower end of the humerus are : Volkmann 's contracture, flail-elbow resulting from non-union ; cubitus varus, cubitus valgus, backward displacement of the lower fragment, and loss of motion varying in different cases from a solid ankylosis to a slight restriction of either complete flexion or extension. Volkmann 's contracture is a most disabling condition notwithstanding the fact that some improvement may follow opera- tion to liberate the nerves. This complication will not develop unless the arm has been unduly constricted by the dressings during the after-treatment. A flail-elbow will not follow if accurate reduction has been accomplished and, when present, may be corrected by a secondary operation. Cubitus varus and valgus are not as a rule productive of much disability. AVhen pronounced, however, they may materially weaken the elbow and render the patient conspicuous on account of the deformity. Complete loss of motion in the elbow is rare. Loss of complete extension or acute flexion is common, though the disturbance in function is Usually so slight as to be un- noticed by the patient. Sixty degrees of motion at the elbow will give the patient a serviceable joint even though the action is much less than the normal range of motion. The sooner the fracture is reduced the less marked will be the traumatic reaction. In compound suppurating cases the outlook is of course gloomy, especially when the fracture enters the joint cavity, yet it should not be forgotten that union may be obtained even in the presence of pus if free drainage is provided for. Much may be done in ankylosis by arthroclasia and arthroplasty. CHAPTER X. DISLOCATIONS OF TIIK ELBOW. I'lidcf tills lieading ar<' iiicliidcd only tli( lit.\;i1 ions in wiiieli botli bones of the foreann are displaeed on the humerus. Ijuxations of eitlier the ulna, or radius alone will be taken up later. Surgical Anatomy. — jMueli that has been stated under the head- ing- of "Surgical Anatomy" in "Fractures of the Lower End of the Humerus'' applies equally well in dislocations of the elbow (see page 120). The bones entering into the formation of the elbow joint are the humerus above, and the radius and ulna below. The articulation Fi2. 222. — Ligaments of elbow from radial side. //., Humerus; R., Radius; U., Ulna: O.L., Olecranon; E.L., E.xternal lateral ligament; O., Orbicular ligament. Fig. 223. — Another view of the elbow. T., Tuberosity of radius; O.L., Oblique ligament; O., Orbicular ligament. between the humerus and ulna is of the ginglymus or hinge type. The articulation between the humerus and the head of the radius is of the ball-and-socket type, though the attachments existing between the bones of the forarm necessitate the radius following the ulna in flexion and extension of the forearm. The strength of the elbow, especially its lateral stability, depends on the humero-ulnar articu- 154 DISLOCATIONS OF THE ELBOW 155 lation and the lateral ligaments of the elbow. The internal lateral ligament consists of two divergent bands arising from the epiti-ocli- lea; the anterior band is attached to the inner side of tlie coronoid and the posterior band to the inner side of the olecranon, posteriorly. The external lateral ligament is similar to the internal ; it is com- posed of two bands arising from the epieondyle. The anterior band passes downward and forward, blends with the orbicular ligament and is attached just in front of the lesser sigmoid cavity of the ulna. The posterior band blends with the orbicular ligament, passes behind the head of the radius and is attached behind the lesser sigmoid ca v- ity. Extension of the elbow is limited by the anterior i)ortion of the capsule, by the anterior bands of the lateral ligaments, by the tip of the olecranon coming in contact with the bottom of the olecranon fossa, and by the tension of the biceps and brachialis anticus. Flexion is limited by the arm coming in contact with the forearm, by tension on the posterior bands of the lateral ligament, and by seating of the coronoid process in the fossa of the same name. In the usual dislocation of the elbow the orbicular ligament remains intact and the radius is displaced with the ulna. The overwhelming majority of luxations of the elbow are of the backward type and are usually produced by forced hyperextension of the joint. If the ligaments prove stronger than the lower end of the humerus, frac- ture is the result ; if not, luxation of the elbow is produced. The bones of the forearm may be displaced in any direction, and accordingly the luxations occurring at the elbow have been classified as follows: Backward (common). Outward (next in order of frequency). Inward (rare). Forward (rare). Divergent, antero-posteriorly (very rare). Divergent, laterally (very rare). Dislocation of the bones of the forearm from the humerus must of necessity be accompanied by extensive ligamentary tearing; the lateral ligaments being the ones usually suffering most extensive laceration. It not infrequently happens that a given ligament is stronger than the bone to which it is attached, and accordingly frac- ture is not an uncommon complication of dislocations of the elbow. The external condyle may be broken off and the fragment remain 156 FRACTURES AND DISLOCATIONS attached to and displaced witli the radius. 'I'he cpitroclilea is even more eonimonly avulsed and displaced by the action of the internal lateral ligament, and the detached fragment may act as an obstacle to reduction by becoming interposed between the trochlea and sigmoid cavity. The ])ei'iosteum is probably always more or less stripped up from the posterior surface of the humerus, the pull being transmitted through the posterior ligament. When the liga- ment proves stronger than the bone the olecranon process may be fractured. This stripping wp of the periosteum accounts for the deposit of bony tissue seen on the posterior surface of the humerus following backward luxations. Fracture of the radial head or neck may occur as a complication in luxations of the elbow, and fracture of the shaft or lower end of the bone has been noted. Probably the most connnon fracture occurring in dislocations of this joint is that of the eoronoid. This process is broken off as the ulna is driven backward across the trochlea. The braehialis anticus is attached to the anterior surface of the eoronoid, and when the fragment is displaced upward it is usually tilted so the anterior surface looks more nearly in an upward direction. Instances of this complicating fracture are shown in Figs. 240 to 24-1:. Injuries to vessels and nerves are fortunately seldom seen except in the most severe compound luxations. The median and musculo- spiral nerves are known to have been injured by the lower end of the humerus projecting into the bend of the elbow anteriorly. The ulnar nerve may be injured as it passes behind the epitroehlea, especially when this process is fractured or in the rare anterior luxation. Cases of laceration of the brachial artery are on record, but are extremely rare. Hyperextension, forced abduction or adduction, and wrenches and twists of the forearm are the types of violence usually responsible for luxations of the elbow. Symptoms. — Pain, tenderness, loss of function, restricted mobility and swelling of the parts about the elbow are symptoms common to all types of luxation of this joint. The patient is unable to use the forearm following injury (usually a fall on the outstretched hand) and complains of pain which is greatly increased on motion. The elbow is usually restricted in motion, especially flexion, but there may be some abnormal lateral mobility. There is no true crepitus unless fracture complicates the luxation. The degree of swelling is variable though it usually appears promptly and is frequently DISLOCATIONS OF THE ELBOW 157 pronounced. The relation of the three bony prominences is dis- turbed (except in anterior hhxation with fracture of the ulna) and on examination the olecranon will be found to be the displaced ele- ment. The displacement of the ulna varies with the type of luxa- tion. The attitude of the patient is suggestive of the Ifsioii, though by ^ ' ^•1 ^■r .i^ifer*^'" Fig. 224. — Simple bnokwavd dislocation of elbow a few minutes after the accident. Fig. 225. — Same case seen from lieliind. no means as characteristic as in luxations of the shoulder. In the posterior luxations the injured member is usually allowed to hang uselessly at the side, or is rested on some convenient support such as a table. In the lateral or forward dislocations with fracture, the injured arm is, as a rule, supported by the opposite hand and the patient is reluctant to release it for examination. Deformity is the symptom which varies most in the different types of luxation. 158 KHACTIRES AM) DISLOCATIONS The posterior variety is by far the most common dislocation at the elbow, and is "vvell represented by the eases shown in Fiprs 224 to 230. The -forearm is usually in a position between complete extension and semiflexion, and motion in either direction, beyond a few degrees, is painful and restricted ])oth by spasm of the muscles and the disturbed mechanism of the joint itself. The olecranon is raised above its normal level, and more prominent than it should be. The tendon of the triceps stands out prominently, and the fore- arm is shortened. Inspection of the forearm at the elbow often Figs. 226 and 227. — Additional views of the same case. Note the prominence of the triceps tendon in the picture to the left and the gun-stock deformity in the picture to the right. This picture calls attention to the fact that gun-stock deformity may exist in dislocations of the elbow as well as in fractures of the lower end of the humerus. shows that it is rotated slightly inward and displaced outward (see Fig. 230). This rotation is due to the fact that the inner lip of the trochlea pro.ieets downward further than does the external lip, and thus pushes the ulna to the radial side, when the projection is no longer received in tlie cavity of the sigmoid. The lateral stability of the elbow is not, as a rule, so much impaired as in fractures of the lower end of the humerus. In palpating the elbow in backward dislocations, tlie fingers may be pressed into the empty sigmoid cavity of the ulna and the thumb may he placed in the shallow depression on the head of the radius, as shown in Fig. 229. The joint is painful as long as it is out of position, yet the pain is only intense when the elbow is moved. This displacement is probably not as painful as dislocation of the shoulder. The coronoid process DISLOCATIONS OK THE ELBOW 159 (unless broken off) rests behind the trochlea, and if the elbow is much extended it enters the olecranon fossa. The liead of the radius lies behind the capitellum. Figs. 228 and 229. — Simple backward dislocation of tlie elbow about half an hour following the accident. Note the depression or dimple behind the elbow which is char- acteristic of this condition. Compare this case with Figs. 188, 189, 193 and 199. Fig. 229 shows palpation of same case. Tlie tip of the thumb rests in the depression on "top of the head of the radius. The sigmoid cavity of the ulna lies between the thumb and index finger of the examining hand and is felt to be empty. The leverage of the triceps is increased while that of the biceps is lessened and hence the position of least pain is greater than semiflexion. Lateral dislocations of the elbow may be divided into internal and external. External lateral dislocations may be complete or ineom- 160 FRACTURES AND DISLOCATIONS l)lt'tf, niid lliiM-c may or may not be an element of rotation present, as well as the lateral displacement. The incomplete external dislo- cation is the most common of the lateral disi)lacements, but is much Fig. 230. — In backward luxations there is often a slight displacement of the ulna to the outer side which can be best appreciated by looking at the elbow from behind. This element in the deformity is caused by the inner lip of the trochlea which is more prominent than the outer. Note the prominence of the triceps tendon and the depres- sions on either side of it. Fig. 231. Fig. 232. Figs. 231 and 232. — Outward dislocation of the elbow. The upper ends of the radius and ulna have been displaced outward and the forearm rotated so that the radius lies above the ulna. O., the position of the olecranon. I., the inner edge of the trochlea. Picture taken a few minutes following accident and the swelling is only slight. less frequently seen than the backward luxation just described. There is no hard and fast line between posterior and external lateral dislocations, which point should be remembered in dealing Avith DISLOCATIONS OP THE ELBOW ]61 luxations of the elbow. Cases are seen with backward dislocation accompanied by an external displacement, and cases of external dislocation are seen with an element of l)ackward displacement, and it is difficult, in many cases, to say which element of the condition is more prominent. An arbitrary dividing- line is considered by some to be the position of the coronoid ; if this process lies anterior to the trochlea the dislocation is lateral, but if it lies behind the trochlea it is posterior. Such a division makes the conditions fit tlie classification, rather than the classification fitting the condition. The external lateral dislocation is usually incomplete, the sigmoid of the ulna embraces the capitellum, and the head of the radius stands out externally ; more frequently the head of the radius is raised above the level of the ulna and lies on, or close to, the epicondyle. This elevation of the head of the radius produces an inward rotation of the forearm, and the condition is spoken of as lateral dislocation with rotation or pronation. In other instances we find a complete external displacement of the bones of the fore- arm. In such cases the ulna has been carried further outward and rests on the surface of the epicondyle ; the radius may lie external to the ulna or above it, and accordingly we have complete external dislocation with or without rotation or pronation of the forearm. The ligaments are more or less torn according to the degree of dis- placement, but only in rare instances may the injury to the liga- ments (especially the anterior and internal) be considered slight. It is not uncommon to find the internal lateral ligament stronger than the bone to which it is attached, which accounts for the occa- sional fracture and outward displacement of the epitrochlea. This fragment may act as an obstacle to reduction by becoming inter- posed between the articular surfaces of the ulna and humerus. The elbow will be found broadened according to the degree of displace- ment. The relation of the three bony prominences is disturbed. The olecranon will be felt external to its normal position and the head of the radius located external to the epicondyle. The internal condyle is subcutaneous and very prominent, and the inner edge of the trochlea may be palpated below it, just under the skin. The epicondyle is not palpable because of the external displacement of the bones of the forearm. One not accustomed to these conditions of the elbow may become confused in attempting to identify the three bony prominences, and a diagnosis of fracture in such eases is common, when none really exists. 162 FRACTURES AND DISLOCATIONS Infernal lateral elislocation of the elbow is quite rare and only seen in tlie incomplete variety. The sigmoid of the ulna embraces the internal epicondyle, while the head of the radius is displaced more or less inwai'd onto the outer portion of the trochlea. The forearm is inclined to a jiosition of supination, and the olcci-anon is out of relation with the condyles of the humerus. Complications in lateral dislocations are extremeh' rare, and consist for the most part in fracture of the internal epicondyle; fracture of the external condyle has been reported. Forward dislocation of ihc elbow is extremely rare and seems to lip secondary to fracture of the olecranon. Fracture of this pi-ocess, at the bottom of the sigmoid cavity, may result in the distal frag- ment of the ulna being driven upward in front of the humerus by the same force that produced the fracture. Complete anterior dislocation, without fracture of the olecranon, is so rare that it had better be considered an anomaly. The fractured olecranon may be recognized by palpation and the abnormally high position of the upper part of the forearm, and its change in axis may be determined without difficulty (see Fig. 239). When the olecranon is not fractured it either lies in front of the lower end of the humerus or (in the incomplete form) the end of the process rests on the trochlea, the lateral ligaments having suffered extensive laceration. Divergent dislocations of the elbow are very rare indeed, being usually the result of great trauma. They are sometimes seen in falls from a height and in severe machinery accidents. One reason for the rarity of these dislocations is that the arm is seldom caught in just such a manner as to tear both the heavy orbicular ligament and the interosseous membrane, and the force so directed as to displace the bones in different directions. There are two forms of divergent dislocation — antero-posterior and lateral. In the antero- posterior the radius lies anterior to the humerus, and the ulna behind it. The posterior aspect of the elbow resembles quite closely the simple posterior variety of dislocation, the point of differentiation being the presence of the head of the radius in front of the elbow. The lateral variety is so rare that few cases have been reported. The ulna lies to the inner side of the humerus, while the radius is displaced externally, and the elbow is accordingly increased in breadth to nearly twice that of normal. The symptoms produced by injury to nerves or vessels will depend DISLOCATIONS OF THE ELBOW 163 on which of these structures has been damaged. The paralyses or disturbances in circulation are the same as follow injury to the nerves and vessels of the upper extremity from causes other than dislocation of the elbow. Figs. 233, 234 and 235. — Diagrams showing tlie bony relations in the three most common injuries at the elbow. The npper diagram is of a posterior dislocation. Not-e the empty sigmoid cavity. The middle drawing is of a dia-condylar fracture while the lower is of a supracond,\"lar fracture. There is no hard and fast line between the supra- and dia-condylar fractures yet the terms are used to indicate the level of the break. Diagnosis. — The recognition and differentiation of the various types of luxation of the elbow are made on the symptoms just described. In establishing a diagnosis of dislocation of the elbow the surgeon must keep in mind — first, the bony lesions which are 164 KUACnilKS AN'n 1)IS1,OCATIONS most conimonly niistakcii i'or luxation; second, the complicating' fractures which sometimes accompany dislocations; and third, the complicatinii; lesions of the soft tissues, such as injury to vessels and nerves. The condition most freiiucut ly confounded with dislo- cation is fracture or epiphyseal separation of the lower end of the humerus. In fracture of the lower end of the humerus with back- ward displacement, the sigmoid is not found tiii|)ty and it is impossible to feel tlu^ ('up-sha])od depression on the head of the Fig. 236. — Case of simple sprain of the elbow twenty-four hours after the acci- dent. Note the swelling which is a« great as is seen following fracture or dislocation and materially interferes with examination and diagnosis. Note, however, that there is no ecchymosis which is so common in fractures, after the first twelve or twenty-four hours. radius as shown in Fig. 229. The backward displacement is usually less prominent in fractures, and the deformity is, as a rule, per- ceptibly higher. The relation of the three bony prominences is dis- turbed in vertical fractures of the lower end of the humerus, in dislocations of the elbow and in fractures of the olecranon, but not in transverse fractures of the lower end of the humerus. (See Figs. 233 to 235 and compare the deformities.) Dislocations of the upper end of the ulna alone are differentiated from luxations DISIiOCATIONS OP TTTK VAAiOW 165 of the elbow by the position of the head of tlie radius which rcmaitis in its proper relation with the capitellum. To avoid mistakes it is well to identify the ulna at its lower end and trace the posterior subcutaneous border up to the olecranon; the head of the radius may next be identified and rotated by supinating and pronating the forearm. After these two points have been positively identified there will usually be little difficulty in recognizing the other landmarks of the elbow. When the case is Fig. 237. — Case of lateral dislocation of the elbow twenty-four hours after injury and reduction. Note the swelling about the elbow. Fig. 238. — Same case after palpation of three bony prominences and marking same with ink. seen early a tentative diagnosis can, as a rule, be made by inspection alone, but if first seen after swelling has developed it may be quite difficult to examine and determine the condition. Gentle, firm and continued pressure with the fingers in the region of the condyles and olecranon will usually displace the fluids within the tissues sufficiently to allow the surgeon to determine the positions and conditions of the three bony prominences. An anes- thetic is often advisable if the traumatic reaction is pronounced at the time of the examination. An even better procedure under these ion FRArTl'RES AXD nTSI,( jfATIOXS circ'iiinstanees (provided the defonuity is not '^rcil iiiul llic X-ray is promptly available^ is to le;ive llic pints nudist ui-IumI jiikI dctei-- miiie the natui'e of the in,iiii-\- I'l-om ;i litintiicnoLiiani. Pig. 239. — Anterior luxation of the ellmw willi I'rMcturr of llio olccraiioii. (SriKill nails seen in plate are in sijlint.) Fig. 240. — A not uncommon complication of backward dislocations of the elbow. The coronoid process has been broken off and is displaced upward by the brachialis anticus. This muscle is inserted into the anterior surface as well as the tip of the process which accounts for the tipping of the fragment as it is pulled upward. Fracture of the coronoid is often difficult to recognize because of the swelling. It is frequently impossible to palpate the detached DISLOCATIONS OP THE ELBOW 167 particle of bone, and the fact that the fragment is usually displaced upward prevents crepitus. Complications are fortunately rare yet they do occasionally occur and should, if possible, be recognized before reduction. The diagnosis of these conditions is often made only after reduction Fig. 241. Fig. 241. — Backward luxation fracture of the tip of the coronoid process. Fig. 242. — Backward hixation with comminuted fracture of coronoid process. Fig. 243 Frac- Fig. 243. — Large fragment of coronoid displaced upward by action of biceps, ture result of backward luxation of elbow. Fig. 244. — Fracture of coronoid with only slight displacement. Result of back- ward luxation of elbow. has been attempted or accomplished, and many cases would go un- recognized if it were not for the X-ray. The condition of the reflexes and the circulation below the level of the lesion should be determined both before and after reduction. Eecurrence of de- formity following reduction is suggestive of fracture of the lower end of the humerus or of the coronoid process of the ulna. Treatment. — The treatment of dislocations of the elbow consists in returning the ulna and radius to their normal relations with the humerus, and immobilizing the elbow for a period sufficiently long to allow complete healing of the ligaments. The case should be attended as soon following the accident as possible. The longer the luxation exists the more difficult will be the diagnosis, the more painful the parts and the more pronounced the secondary traumatic 168 FRACTURES AND DISLOCATIONS reaction. Reduction of the dislocation is usually not difficult, and according to the most coiiunoii nictliod, consists (for 1)ack\vard luxations) in trai-tioii ami coinilci'-ti-actioii with liyjicr-extension of the joint followed by tlexion. Tlic ai-iii is tirnily grasped above Fig. 245. — Method of reducing backward luxation of tin- illi.iw. Traction on tlie forearm at the wrist with counter-traction with the opposite hand on the arm. A greater degree of extension is often necessary to help the coronoid to clear the trochlea. Fig. 240. — Another method of reducing backward lu.xations of the elbow. The lower part of the arm is grasped with both hands as shown in illustration ^yhile the thumbs force the olecranon downward into position. With the hand fixed on the table any desired degree of flexion at the elbow may be obtained during the manipulation. the elbow with one hand while the other makes traction from the wrist ; during this traction the forearm is somewhat hyper-extended to allow the coronoid to clear the trochlea, after which the forearm is flexed and reduction is complete. The ligaments are usually torn DISLOCATIONS OP THE ELBOW 169 to such an extent that they offer little resistance to reduction, but the muscles, especially in well developed [)ersons, may as a result of spasm, render reduction extremely difficult. A method of reduc- tion, particularly adapted to children, consists in forcing the olecranon into place with the thumbs while the fingers fix the arm above the elbow as shown in Fig. 246. By having the patient's hand resting on a table flexion and extension may be controlled by raising or lowering the elbow during the manipulation, thus helping the coronoid to clear the trochlea. Still another method is one in which the joint surfaces are separated and flexion of the elbow accomplished over the operator's knee. Keduction may also be accomplished by means of continuous traction with weights, but the first method described will be found as satisfactory as any in the average case of posterior luxation. The muscles offer the chief obstacle to reduction and accordingly the use of an anesthetic will render difficult cases easy. The liga- ments are already much torn and we should avoid manipulations which will subject them to further injury ; this point should be kept well in mind when using an anesthetic, as the joint, under such conditions, is no longer protected by the action of the muscles. When the bones are displaced outward further than is caused by the internal lip of the trochlea (see Figs. 231 and 232), they should be converted into a simple backward dislocation before reduction is attempted. The less force used the better, and in a given case it is often preferable to try different methods with moderate force, before using any particular one with much force. There is probably no method, in backward dislocations of the elbow, which meets the indications as scientifically as does Kocher's in reduction of anterior luxations of the shoulder, yet the ones in use are effective and though not ideal are at least satisfactory. In reducing an outward luxation it is of the greatest advantage to have an assistant fix the lower end of the humerus, thus affording the surgeon a solid basis on which to force the bones of the forearm into position. Before reduction is attempted the surgeon should know whether or not rotation is present, as well as lateral displace- ment. With the lower end of the arm fixed, traction is made on the wrist, while the opposite hand grasps the elbow and forces the upper ends of the radius and ulna downward and inward around the lower end of the humerus. If the bones of the forearm are dis- placed backward as well as outward it may be advisable to accom- 170 FRACTURES AND DISLOCATIONS plish reduction as if the displacement were straight backward, with the addition of hiteral pressure as the joint surfaces are beinj? brought together. The most eonunon obsti'uetion to I'eduetion is the lodgment of an epitrochlear fragment between the articular sur- faces. If the elbow is liyper-extended this fragment can as a rule be gotten out from l)etween the articuhn- surfaces. Downward traction on the semiflexed forearm with a rocking motion will some- times be effective in displacing the fragment. Reduction of an inivard dislocation is aceom|)lish('d in a manner similar to correction of the outward displacement except that out- ward pressure is exerted during traction, instead of inward pres- sure. There is usually little difficulty in reducing this type of luxa- tion. In forward Iterations with the usu'd fracture of the olecranon, reduction is accomplished by downward pressure on the upper part of the semiflexed forearm, thus forcing the head of the radius back onto the capitellum and the ulna back into alignment with the frag- ment of the olecranon. In the rare instances in which fracture of the olecranon does not complicate the luxation, reduction is accom- plished by acutely flexing the forearm, and then forcing the tip of the olecranon past the trochlea by downward pressure. In the incomplete form of the dislocation, in which the olecranon lies on and not in front of the trochlea, this manipulation is fairly safe, but in the complete form there is grave danger of injury to the ulnar nerve. To lessen this danger the arm should be adducted until the olecranon has passed the trochlea. Complete forward luxation of the elbow is however extremely rare. In divergent luxations of the elbow traction is to be made on the extended forearm and each bone reduced separately. After reducing a dislocation of the elbow, regardless of the type, the joint should be carried through its normal range of motion and the parts carefully examined so that complications may not be over- looked. Operative Treatment. — Operation is indicated when, after repeated trials under an anesthetic, the joint remains displaced and in cases in which complications such as irreducible fracture or injury to vessels or nerves exist. The joint may be approached by an external longitudinal or an internal longitudinal incision, accord- ing to the preference of the surgeon and the conditions present. The ulnar nerve lies internal to the elbow behind the epitrochlea, DISLOCATIONS OF THE KLBOW 171 while the musculo-spiral descends behind the supinator longus as described in Operative Treatment of "Fractures of the Lower End of the Humerus" on page 148, and should be protected from injury during operation. It may occasionally be necessary to divide some of the ligaments to replace the bones. The external condyle may be broken off and displaced backward with the radius, and if the frag- ment cannot be accurately reduced by manipulation it is advisable to secure it with a nail or wire. The internal epicondyle may be separated, and when the fragment becomes wedged between the articular surfaces it may be necessary to operate to release it and effect reduction. Not infrequently internal fixation is indicated to maintain reduction of the fragment when fracture complicates the luxation, and the principles involved are the same as have already been described under the heading of Operative Treatment of "Fractures of the Lower End of the Humerus" on page 148. Frac- ture of the coronoid is not an uncommon complication and may, as a rule, be successfully treated with the elbow in the tlexed position. When, however, the fragment is large and the upward displacement is so pronounced as to prevent approximation by flexion, it will be advisable to operate and suture the fragment in position. Suture of the ligament and surrounding soft tissues will, as a rule, suffice in holding the fragment in place. Complicating fracture of the head of the radius does not call for operative intervention except in very rare cases. When fracture of the olecranon exists it may be difficult to keep the fragments in apposition ; open incision and internal fixation may be called for to secure proper reduction of the process. (See Oper- ative Treatment of "Fracture of the Olecranon," page 191.) The advisability of operating for the correction of old unreduced luxations depends almost entirely on the amount of function lost. If the patient is enjoying free use of the joint and the elbow is strong, it will be absurd to advise operation simply to correct the deformity. Operation for the correction of old displacements is performed according to the same principles, and the same precau- tions are to be observed, as already given in the open treatment of recent cases. A certain amount of fibrous tissue will usually be found within the sigmoid cavity and should be removed before the luxation is reduced. After-Treatment. — The after-treatment consists in immobilizing the joint sufficiently long to allow proper healing of the ligaments. 172 FRACTURES AND DISLOCATIONS In posterior luxations tlic anterior lifxament is most extensively torn and the flexed position will be the one which will bring the torn ends nearest together ; the same holds true when the coronoid has been fractured, therefore the best position will be found to be one just short of acute tiexioji. Complete flexion is a position which is quite uncomfortable and poorly adapted to the swelling of the elbow which is to follow, and for these reasons a position a few degrees short of complete flexion is advised. The arm and forearm should be bandaged in this position and the axilla protected to Fig. 248. Figs. 247 and 248. — These two figures show the range of motion fourteen days after a posterior luxation of the elbow. Note how the swelling has subsided as compared with the case seen twenty-four hours after the dislocation, as shown in Figs. 237 and 238. prevent skin coming in contact with skin, and some means of fixa- tion applied as has already been described under the head of "Frac- tures of the Lower End of the Humerus," page 210. Passive motion of the joint should not be begun until the acute traumatic reaction has fully subsided, which will be at the end of a week or ten days. This will allow some time for the capsule to heal, but immobilization should not be too prolonged, as unnecessary stiifen- ing of the elbow may result. Passive motion should not be delayed longer than two weeks and should at all times be gentle. When DISLOCATIONS OF THI5 ELBOW M'A once begun it should be practised every two to four days until complete or nearly complete motion is regained. The use of hot applications and massage daily will hasten recovery. The carrying of weights will materially increase extension during the latter part of the after-treatment. The elbow will show more or less stiffness when the dressings have been removed and will remain so for a short time but this is no occasion for anxiety as function will return with passive motion, massage, and use of the arm. Complete extension will be the last to return and may never be fully regained if the periosteum on the back- of the humerus has been extensively stripped up and followed by a deposit of new bone under it in the region of the olecranon fossa. The fixation does not need to be as absolute as is maintained in fracture, but should be kept up for two to three weeks, and action requiring much strength should be avoided for another two to three weeks. The attitude to be partic- ularly avoided is complete extension within a week of the injurj^, and this should be the last position in which muscular effort is per- missible, after the patient is again using the arm. Fixation in a position of supination will tend to relax the supina- tors and should be employed when complicating fracture of the external condyle or epicondyle exists. Flexion and pronation will relax the pull on the internal condyle and epitrochlea in the presence of fracture in this region. The after-treatment of forward dislocations is much the same as has already been described. The presence of complications, such as nerve or vessel injury, may necessitate operation. The ulnar nerve may be stretched or torn and require suture. The after-treatment of divergent dislocations is much the same as other dislocations about the elbow. The joint should be put at rest for a month to allow the ligaments to heal, but absolute fixa- tion is not as desirable as it is in fracture. It is well to fix the elbow in a posterior right angle splint for the first ten days to two weeks, after which a sling may be used which supports the entire forearm. After the splint has been removed gentle passive motion may be employed at intervals of four or five days, but should be painless. Some restriction of motion may follow the injury and subsequent immobilization, but this is better than a condition of recurrent dislocation. Accordingly, in view of the extensive injury sustained by the ligaments and soft tissues, it is preferable to incline toward the safer course and not allow motion too soon. Extreme 174 FRACTURES AND DISLOCATIONS extension should be avoided during passive motion ajid the patient should be warned against strain in this position for some months following the accident. Prognosis. — The prognosis in luxations of the elbow dei)ends ou the extent of laceration sustained by the ligaments and the presence of complications. The amount of damage to the ligaments is in direct proportion to the extent of displacement. In simple cases of posterior luxation we may look for complete restoration of func- tion if the after-treatment is properly carried out. The last few degrees of extension may be permanently lost, but this does not disturb the usefulness of the joint and is negligible. Extensive injury to the soft tissues and complicating fracture will, of course, render the prognosis more doubtful. Young persons make more rapid and complete recovery, while on the other hand those advanced in years (especially with rheumatic diathesis) are liable to be troubled with the joint for a long time. Fortunately the more common forms of dislocation are followed by useful and strong joints, if the ligaments are allowed time to heal. The dislocations that are accompanied by great laceration of the ligaments are most likely to be followed by weakness of the parts or recurrence of the displacement. Nerve injury accompanying the accident may be followed by paralysis and anesthesia, the same as nerve injur^'^ from other causes. Damage to nerves usually consists of simple stretching and is generally not severe. As a rule recovery takes place within a few months at most. Complete rupture of a nerve results in a permanent paralysis unless operated, and even then recovery may be extremely long and tedious. The ulnar nerve is most frequently involved, the musculo-spiral next, while the median nerve rarely suffers injury. Considering the frequency with which the elbow is dislocated injury to the nerves in this region is rare, and the ultimate prognosis, even in cases of complete sever- ance, is good, if the divided ends are brought together and properly sutured soon after the accident. CHAPTER XI. DISLOCATIONS OF THE ULNA ALONE (ROTARY). Surgical Anatomy. — The surgical anatomy of luxations of the upper end of the ulna alone, is similar to that already given in "Dislocations of the Elbow" on page 154. Dislocations of this type are quite rare, whereas luxations of the elbow (both bones) are by no means uncommon. The upper end of the ulna may be displaced either backward or forward, describing the arc of a circle, of which the undisplaced radial head is the center. Both types are exceedingly rare, but of the two the posterior is the more common. In either form the inter- osseous membrane and oblique ligament are probably not torn, and the head of the radius remains in position on the capitellum. The injury is probably produced by trauma which twists the forearm at the same time adducting or abducting it. Symptoms. — The posterior variety presents a characteristic clinical picture. The forearm is more or less extended and there is a pronounced "gunstock deformity." The olecranon is promi- nent and raised, though the displacement is usually not as pro- nounced as seen in posterior luxations of both bones. The tip of the coronoid may rest on the trochlea, or behind it, or the upper end of the bone may be still further displaced so that it rests behind the external condyle. The further the backward displacement of the upper end of the ulna, the more external will be the position occu- pied by the olecranon and the more pronounced will be the cubitus varus. The epitrochlea is prominent and more anteriorly situated than normal, with relation to the forearm. There is a compensatory outward rotation of the humerus to accommodate the altered position of the forearm. The internal lateral ligament may be ruptured or an equivalent avulsion of the epitrochlea may exist. In forward luxations the ligamentary laceration, especially on the inner side of the elbow, is greater and the causative trauma is more severe. The forearm may lie anywhere between semiflexion and complete extension. There is abnormal lateral mobility in the 175 176 FRACTURES AND DISLOCATIONS direction of abduction. The top of the olecranon lies either on, or in front of, the trochlea and the position of the forearm is one of prononneed abduction. In other words, the carrying angle is greatly exaggerated. A third form of luxation, so rare as to scarcely deserve descrip- tion, is one of iitward luxation. In this type the upper end of tlie ulna is displaced inward so that the sigmoid embraces the epi- trochlea, while the radius remains in contact with the capitellum. The interosseous membrane, oblicpie and orbicular ligaments are of necessity ruptured and the upper part of the forearm is greatly broadened. In all three forms of luxation of the ulna the head of tlie radius probably suffers a slight subluxation, but since it remains in contact with the capitellum it may for practical ])urposes be considered in nornud position. Treatment. — In hacl-icard luxations reduction is easily accom- plished by extension and counter-extension in nuich the same way as has been described in the "Treatment" of "Dislocations of the Elbow." The adduction, which is due to the radius remaining in place, must be taken into account and requires a forced abduction of the elbow as extension and counter-extension are being made. In forward luxations the ulna is returned to its normal posi- tion by iuM^ard rotation of the upper end of the forearm, accom- panied by adduction of the forearm as the olecranon clears the trochlea. The After-Treatment, Operative Treatment and Prognosis are similar to those already given under "Luxations of the Elbow," pages 170, 171 and 174. CHAPTER XII. DISLOCATIONS OF THE HEAD OF THE RADIUS. Surgical Anatomy. — The head of the radius may be likened to a short cylinder. The upper end of the cylinder articulates with the capitellum and is slightly concave. The sides of the cylinder are in contact with the orbicular ligament and lesser sigmoid cavity while the lower end of the cylinder is continued into the neck of the radius. The lower end is slightly less in diameter than the upper end of the cylinder, and the orbicular ligament thus secures a hold on the upper extremity of the bone which tends to prevent downward displacement. The interosseous membrane and the ob- lique ligament, together with the orbicular ligament, bind the radius to the ulna though they allow free motion in pronation and supination. The external lateral ligament of the elbow is not attached to the radius but divides and blends with the orbicular ligament, passes in front of and behind the radial head, and is at- tached to the ulna anterior and posterior to the lesser sigmoid cavity. The head of the radius articulates with the lower end of the humerus and with the ulna at the lesser sigmoid cavity. The radial head may be displaced : backward, outward, forward or downward. The exact mechanism of dislocations of the radius is not clear. The matters of importance are that the head is dis- placed and requires reduction. Fracture of the radial head or neck or of the upper end of the ulna may accompany the luxa- tion. Malgaigne's luxation (downward subluxation) has also been the subject of much discussion and there is little known concerning the mechanism of the injury. The consensus of opinion, however, is that there is a slight downward luxation of the radial head, and that there may be some infolding of the ligaments between the articular surfaces. This luxation is confined to children, usually under three or three and a half years of age, and is due to trac- tion in the axis of the radius. There is no hard and fast line to be drawn between outward and 177 178 FRACTURES AND DISLOCATIONS backward luxations of tlio radial head, one form merges into the otlier. The relation ])etween these two types is much the same as that already noted between backward and outward luxations of the elbow. Any form of isolated luxation of tlio radial head is rare as compared with luxations of the elbow. Symptoms. — In any type of luxation of the head of tlie radius there is pain in the region of the injury and loss of function im- mediately following the accident. The deformity will vary with tlie direction of the displacement. hi ihc bdrhn-ard or oiifirard types the head is felt standing out in a position anywliere between posterior and external to its normal position, and may be identified by the characteristic cup-shaped ex- tremity and by its rotation with the sliaft during pronation and supination. The forearm is, as a rule, completely pronated and in a position just short of complete extension. Further examination shows that supination is cheeked by the altered mechanism of the joint, though strange to say this function seems to be regained in old unreduced luxations. //( forward luxations the elbow is partially flexed and the fore- arm may be either supinated or pronated, usually the latter. Pro- nation is, as a rule, complete, and passive supination blocked. Flexion beyond a right angle is never possible in recent cases; the head of the radius coming in contact with the anterior surface of the bone prevents flexion. Palpation of the forearm below the external condyle reveals the absence of the radial head from its normal position. The bend of the elbow is usually swollen and the displaced end of the bone may be palpated, though it is seldom as distinctly felt as is the case in backward and outward luxations. Old unreduced cases may show remarkable restoration of function as in the backward and outward types. Downwurd luxation is productive of very mild symptoms. The child flinches at the time of the injury and may cr^' out. Dis- inclination to use the arm is at once noted, the forearm being held in a position of slight flexion and complete pronation. The child suffers little or no pain as long as the elbow is not brought into play, and accordingly the patient is very averse to liaving the mem- ber examined or in any way disturbed. If it were not for this disinclination to use of the member, the injuiy might frequently escape recognition. There is, as a rule, no deformity about the elbow to be appreciated by either inspection or palpation. In some DISLOCATIONS OF HEAD OF'^ RADIUS 179 Fig. 249. — Forward luxation of tlie liead of radius. Prominence indicated by arrow is caused by tiie displaced radial head. Note the exaggerated carrying angle which re- sults from the head of the radius not bearing on the capitellum of the humerus. Flexion limited by the displaced radial head. Fig. 250. Fig. 2.51. Figs. 250 and 251. — X-rays of same case showing luxated radial head. 180 FRACTURES AND DTRI.OCATIONS instances there iii;iy lie a sli^lit separation l)etween tlie head of the radius and capitt'lluin bnt this is usually so trivial as to be scarcely perceptible. Loss of function may persist for a long time if proper treatment is not instituted, though ultimate disability of the nicniber seldom occurs. Diagnosis. — The diagnosis of luxations of the radial licad depends on the restriction of motion, the characteristic attitude and pal- pation of the head of the bone in its displaced position while the upper end of the ulna remains normally placed. The diagnosis of IMalgaigne's luxation is based largely on the history of the case and the disinclination on the part of the child to use the member. The history is typical. The condition is the result of the per- nicious habit of lifting a child by the hand ; mothers are prone to do this in helping children on and off of street cars, and in hurry- ing them along the street. Following injury to the arm in this way the child fails to use the member and objects to having it disturbed. The X-ray is of value chiefly in determining associated lesions, such as fracture of the radial head or neck or of the external con- dyle of the humerus, or a break in the ulna. Treatment. — Reduction in the backward and outward, types is usually easy, though the head may tend to slip out again as soon as the arm is released. Retentive dressings should be in readiness before returning the head to its normal position. Extension and counterextension, accompanied by direct pressure on the head in the direction of the capitellum, will, as a rule, effect reduction. The degree of flexion in which there is least tendency for the head to slip out of position should be determined in each case and the joint immobilized in this position. A pad maintained in place by straps of adhesive and exerting direct pressure on the upper end of the bone may be of service in preventing recurrence of de- formity. The head of the bone may be fractured against the capitellum as it is driven out of place, and when this complication exists it may increase the tendency to reluxation. In forward luxations similar principles are employed. Reduc- tion is accomplished by extension, counterextension and direct backward pressure on the displaced head. "When the head of the radius is felt to move backward the elbow is flexed and the ma- nipulation is complete. To prevent recurrence of deformity the elbow should be immobilized in a position just short of acute flexion DISLOCATIONS OF HEAD OF RADIUS 181 (see Fig. 210). When luxation of the radial head is complicated by fracture of the ulna, increased difficulty may be experienced in preventing- reluxation. In addition to treating the dislocation we have the fragments of the ulna to maintain in apposition. Under these circumstances internal and external angular splints will be found more efficient than the position of acute flexion ad- vised in the uncomplicated anterior dislocation. If the elbow is to be immobilized at a right angle the ordinary internal and ex- ternal angular splints will be satisfactory. If, however, some other degree of flexion is desired plaster splints may be needed. If ordinary means are not efficient in preventing deformity in either the fracture or the luxation operation should be resorted to. The reduction of Malgaigne's luxation is usually accomplished without difficulty. It consists in forcing the head of the radius upward against the capitellum, and is accomplished in the fol- lowing manner. The surgeon grasps the lower part of the arm to fix the humerus while the opposite hand secures the forearm at about its middle; the forearm is then rotated (supinated and pronated) while upward pressure in the axis of the radius forces the head of the bone up against the capitellum. Keduction is usually accom- panied by a soft click, after which all the functions of the joint are found to be normal and painless. Aften this maneuver is complete the elbow is tested by carrying the forearm through flexion, extension, supination and pronation. If the function is not completely restored and painless the manipulation should be repeated. It may be necessary to alternate extension with upward pressure. It will only be a few hours following reduction until the child is using the arm freely and without discomfort. The condition is not a serious one even if allowed to go unreduced, but proper treatment will relieve the child and obviate much anxiety. The displacement will not return unless the same forces which first produced the subluxation are again inflicted on the parts, and accordingly all that is necessary to prevent recurrence is to see that those having to do with the child are thoroughly informed and cautioned concerning the manner in which the injury was pro- duced. Operative Treatment. — The open method is indicated when other means fail to accomplish and maintain reduction for the correction of ancient luxations and occasionally in the treatment of compli- cations. A longitudinal incision is made over the head of the 182 fracti;res and dislocations radius, tlie bone exposed and rednetion effeeted by direct nianipii- latioii. It may be possible to suture tlie torn orbieular ligament after the head has been replaced, lliouiili in some eases it may be dififienlt to recognize this structure. In any case it is proper to suture the structures surrounding the upper end of the bone in such a manner as to prevent redisplacement. When the radial head is much connninuted it is often better to remove the frag- ments, round up the end of the bone and suture the tissues about it. Rotation of the upper end of the bone, as evidenced by supina- tion and pronation, is seldom lost following these operations if the axis of the radial shaft remains unchanged. INIoreover these cases usually show a surprising stability of the joint when recovery is complete. Complicating fracture of the upper end of the ulnar shaft is not an uncommon condition accompanying anterior luxation and may demand operation to maintain reduction in both fracture and dislocation. The dislocation is not particularly prone to recur but the fracture is sometimes difficult to hold in reduction because of the instability of the radio-humeral articulation. It is more often necessary to wire the fracture in the ulna than it is to operate on the luxation. If the ulna is approached through a posterior incision and the fragments secured by internal fixation it will often be possible to treat the luxation in the flexed position, and thus prevent displacement of the radial head. If the upper end of the bone has been allowed to remain dis- placed the removal of longitudinal pressure commonly results in an over-growth of the bone with a corresponding increase in length. In operating on ancient luxations, therefore, it may be necessary to resect the head of the bone before the shaft can be brought back into alignment. Old anterior luxations come to operation more frequently than either the outward or posterior types because of the loss of acute flexion in forward dislocations. The excellent functional results following operation on old cases, even when the head is resected, are often surprising. ]\Ialgaigne 's subluxation never requires operation. After-Treatment, — The elbow should be fixed in the position hast favorable to recurrence for a period of at least twenty-five to thirty days. In anterior luxations there is usually less tendency to recurrence and accordingly the period of fixation need not be so long. Three to four weeks will, as a rule, be ample. When frac- DISLOCATIONS OF HEAD OP RADIUS 183 ture complicates luxation union of the fragments is the chief con- sideration in the after-treatment and the retentive dressings should be removed only after one is satisfied that union is firm (usually four or five weeks) . When fracture is present the case will require more careful supervision. The traumatic reaction is greater and the same precautions are to be observed as cited under fractures of the bones of the forearm. Malgaigne's luxation requires no after-treatment. Prognosis. — In the uncomplicated luxation of the head of the radius, where reduction has been effected, restoration of function should he complete. If complications exist the prognosis varies with the nature of the associated injury. CHAPTEK Xlll. FRACTURES OF THE l^OXKS OF THE FOREARM. In considering t'ractiu'es of the i-adiiis and ulna it will be found more satisfactory to describe them accortling to tlie level of the break ratlier than to take up eacli bone separately from end to end. It is well appreciati'd that various coiubiiiatious of fractures may exist in the forearm regardless of the level; thus the lower end of the radius and the upper end of the ulna may be broken at the same time, or a fracture of the neck of the radius may be ac- companied by a break in the lower end of either bone. It is mani- festly impracticable to enter into the details of these various pos- sible cond)inations of fracture, but if tlie student appreciates the nature of the breaks as described in the following pages he wdll be able to modify the treatment to meet the requirements of un- usual combinations of fracture as they occur. The order in which fractures of the bones of the forearm will be considered is as follows : Fractures of the upper end of the ulna. Fractures of the ujjper end of the radius. Fractures of the shafts of the radius and ulna. Fractures of the lower end of the ulna. Fractures of the lower end of the radius. 184 CHAPTER XIV. FRACTURES OF THE UPPER END OP THE ULNA. Surgical Anatomy. — Much that has already been said concerning the anatomy of "Fractures of the Lower End of the Humerus" (page 120) and "Dislocations of the Elbow" (page 154) is equally important in fractures of the upper end of the ulna since the re- gion is the same. Fractures of the upper extremity of this bone may be of the olecranon, the coronoid or just below the latter process in the upper thickened portion of the shaft. Occasionally the nature of the break or its position is atypical. The most im- portant and at the same time the most common fracture occurring in the upper end of the ulna is of the olecranon process. This process is large, thick and curved, and projects upward behind the lower end of the humerus when the elbow is extended. Its upper surface is roughly quadrilateral and affords attachment to the tendon of the triceps. A portion of this tendon is continued through a heavy aponeurosis onto the posterior surface of the process, and thus the pull of the triceps may be exerted on the lower fragment in fractures of the olecranon, when the aponeu- rosis is not torn. The upper margin of the olecranon, anterior to the insertion of the triceps, affords attachment to the posterior bands of the lateral ligaments. These ligaments serve to keep the anterior surface of the process in contact with the trochlea when broken off from the remainder of the bone. The posterior surface of the olecranon is covered by a bursa and when this bursa is inflamed or enlarged as in " miner 's elbow ' ' the deformity may be marked. It does not resemble fracture but has been mis- taken for it. The interior of the olecranon is composed of a fine ineshed can- cellous tissue, while the surface consists of compact tissue, varying in thickness in different regions of the process. The compact bone is thickest in the region corresponding to the sigmoid cavity. That covering the posterior surface of the process is a little heavier than occurs in the adjoining regions. The cancellous tissue below 185 186 FRACTURES AND DISI.OCATIONS tlie coronoid process is quite wide meshed and not as strong as that found in the olecranon. About lialf an inch below the coro- noid the compact bone begins to grow thicker and rapidly in- creases in weight as the middle of the shaft is approached. The structure of the bone in the olecranon explains the inadvisability of using nails or screws when securing the fragments by internal fixation. (See Fig. 269, page 204.) The upper epiphysis of the ulna consists of a thin layer or scale of bone at the top of the olecranon which first shows ossification ill tlu- tenth year, and joins the shaft during the sixteenth or ^;evenleenth year. The fact that the tricejis is attached not only to the uppei- end of the olecranon but to the posterior surface, Fig. 252. — Avulsion of corlicul layer of fompact tissiiu in wliirh triceps finds inser- tion. accounts for the comparative rarity of avulsion and separation of this epiphysis. The line of the epiphyseal cartilage has been mistaken for fracture. As previously stated the powerful triceps is inserted into the olecranon process of the ulna, but its antagonist the biceps is at- tached to the bicipital tuberosity of the radius. Thus it will be noted that the heavy extensor and flexor muscles of the forearm are able to balance each other only because the two bones of the forearm are firmly bound together. Fracture of the olecranon, or fracture below the level of the sigmoid cavity with separation of the fragments, destroys the balance between the biceps and triceps. The brachialis anticus attached to the coronoid process is a flexor, and in fractures below the process this muscle tends to FRACTURES OP UPPER END OP ULNA 187 counteract the pull of the triceps, but its relative weakness results in the upper fragment being carried into extension if the aponeu- roses have been torn sufficiently to allow deformity. The mechanism of fracture of the olecranon has been the subject of considerable discussion ; suffice it to say that most fractures of the olecranon are probably the result of a combination of direct violence and muscular action. Thus when a person falls heavily Fig. 253. — Practuve of olecranon. Elbow extended. Fig. 254. — Same case. Elbow slightly flexed, showing increase of distance be- tween fragments. on the outstretched hand the triceps is firmly fixed in anticipation of the blow. If the force is great the hand is forced toward the body and a heavy strain is sustained by the process. Under these circumstances the elbow usually strikes the ground as flexion increases. Thus there is a combination of direct and indirect violence, and it is difficult to distinguish which of the two is the more important etiologic element. Cases are known in which the 188 FRACTURES AND DISLOCATIONS injury seems to have l)i'eii jirodneed entirely by muscular action, while in other instances direct violence alone has undoubtedly been responsible for the fracture. Fracture of the olecranon produced experimenlally by dirt^ct violence has been of a different type than that commoidy seen clinically. The amount of displace- ment of the upper fragment is usually greatest in cases resulting from nuiscular aetioii though great separation is sometimes seen where the injui-y has been caused by a blow on the elbow. The displacenuMit depends, to a great extent, on the tearing of the aponeurosis on tlie posterior surface of the ]>r()eess. The line of fiaelure is usually transverse and most often oeeui's at the l)ottom of the sigmoid fossa where the process is thinnest. The break usually enters the joint ap.d when compound the elbow is exposed to infection. The deformity is usually characteristic ; the upper fragment follows the curved surface of the trochlea so that the space left between the broken surfaces is the shape of a truncated wedge, with the narrow end of the wedge transversely situated against the trochlea while the base stands backward and down- ward. Fracture of the coronoid is an extremely rare condition except as a complication of backward dislocation of the elbow (q. v.). In fractures below the coronoid it is not uncommon to find the head of the radius luxated forward, which condition has been described under "Dislocations of the Head of the Radius." Symptoms.— Immediately following the injury the patient finds that he is unable to actively extend the forearm, though motion may be accomplished passively or by the action of gravity. ^lotion is painful and the patient usually supports the forearm in a semi- flexed position with the uninjured member. When separation is present the deformity is characteristic if seen early before the elbow is much swollen. The point of the elbow is gone ; the pos- terior aspect of the joint has a rounded effect instead of its normal angularity, and in some cases the position of the displaced frag- ment may be determined by inspection alone. Swelling of the parts comes on rapidly in most cases, and after it is well established there is nothing characteristic in the outline to differentiate the condition from the swollen states seen following other injuries about the elbow. Palpation, however, readily clears up the diag- nosis as sho\\Ti in Fig. 256. In many cases there is separation of the fragments when the forearm is flexed but none with the elbow FRACTURES OP UPPER END OP TJLNA 189 in extension, and accordingly the evidences of separation will vary with the degree of flexion at the elbow. Lateral mobility may be noted, especially abnormal abduction of the forearm. The dis- Fig'. 255. — Fracture of the olecranon about one week following the accident. The characteristic deformity seen in recent cases is here obscured by the intense swelling. Note ecchymosis. Diagnosis cannot be made by inspection alone. Fig. 256. — Same case. Diagnosis e.'^tablished by palpation. Thumb rests on top of olecranon. The index finger occupies the depression between the fragments. The middle finger rests on the upper end of the lower fragment. Note how the index finger sinks in between the fragments. tance between the fragments is variable, the greatest separation being seen in old cases with fibrous union, in which the bond has stretched with use. 190 FRACTURES AND DISLOCATIONS It is not uiieoniinon to see fracture of the oleoranon with little or no separation of the fragments, and nnder these cirennistanees some of the cJiaracteristic symptoms will he wanting. The power of active extension will be slightly if at all disturbed though the action will be painful. Lateral mobility of the process and crepitus are usually present though they are often not well marked when the fracture has been accompanied by only slight tearing of the aponeurosis. With separation of the fragments crepitus can only be elicited when the fragments are approximated and the broken surfaces rubbed together. Ecchymosis is almost invariably seen within twenty-four hours of the accident. In compound cases the wound is usually situated on the pos- terior aspect of the elbow and it may be possible to see the line of fracture and the displaced fragment. Fractures of the coronoid and fractures of the ulna just below this process have been considered under ''Dislocations of the Elbow." Isolated fracture of the ulna just below the coronoid is an extremely rare accident and is usually the result of direct violence. It will be accompanied by abnormal mobility, crepitus, loss of function, etc. Diagnosis. — If the case is seen early there will usually be little difficulty in recognizing fracture of the olecranon if the sjnnptoms just described are sought. Fracture without displacement may escape recognition if the parts are not thoroughly and carefully examined. The posterior border of the ulna is subcutaneous throughout and by tracing it upward from below the position of the fracture and the displaced fragment can as a rule be felt. Even where there is no displacement it is often possible to detect some loss of alignment on the posterior border of the olecranon and by grasping the process laterally, motion and crepitus may be elicited. In establishing a diagnosis of fracture of the olecranon the elbow should be examined systematically as already described under "Fractures of the Lower End of the Humerus" (page 137) and in "Dislocations of the Elbow" (page 163). The condition must be differentiated especially from fractures of the lower end of the humerus and backward luxation of the elbow. Treatment. — The methods of treatment employed will depend entirely on the conditions present. Where there is no separation the right angle splint will meet the requirements of the case, in FRACTURES OP UPPER END OF ULNA 191 V V; addition diagonal strips of zinc oxide adhesive should be so placed as to bind down the olecranon and relieve the upper fragment of the displacing action of the triceps. When displacement exists the time-honored straight splint is indicated. The elbow slioiiUI not be treated in extreme extension because in the first place, the position becomes intolerable to the patient in a short time and secondly, the tip of the olecranon in this attitude is not sufficiently promi- nent to afford the proper purchase for the straps of adhesive used in binding the fragment in a po- sition of reduction. A straight board may be used a little broader than the arm, and with sufficient padding at the elbow to allow a few degrees of flexion. The splint should be secured by three strips of adhesive plaster encircling the member; one at either extremity of the splint and the third just above the elbow. It should extend from a point just below the axillary fold to the wrist; there is little to be gained by extending the splint downward to include the hand, the patient being much more comfortable when some action at the wrist and fingers is allowed. The straight splint is very cum- bersome at best and is not a desirable method of fixation when other means can be made to ac- complish the purpose- A neat and satisfactory method of making a straight splint is to use quarter- inch iron wire ; this is bent to fit the arm in a posi- tion short of complete extension and bandaged the same as the Cabot posterior wire splint employed in the treatment of fractures of the leg. A slight bend is made at the elbow to allow a little flexion of the forearm. When the fracture is compound it should be treated according to the principles laid down under ''The Treatment of Compound Frac- tures and Luxations," on page 789. Operative Treatment. — Of late years operation has, to a great extent, supplanted the ordinary methods, and there has been a great deal of discussion on the subject, pro and con. There is a large proportion of cases which make excellent functional re- coveries without operation, and it is unwise to resort to the open Fig. 257. — Illus- trates the use of the straight splint in the non-operative treat- ment of fracture of the olecranon. Note the diagonal strap of adhesive which binds the up- per fragment in po- sition. Slight flex- ion of the elbow affords a better hold for this strip of ad- hesive. 192 FRACTURES AND DISLOCATIONS method in all cases. When the fracture is not conipouncl and there is no displacement of the fragments operative intervention can ac- complish nothing, hut on the other hand when there is displacement which cannot be perfectly corrected or when the fracture is com- pound there is no method that will be as successful as operation. Between these two types is a third class in which the best mode of procedure is not so evident. When the condition is not compound and there is only moderate separation, wliich can be faii-ly well corrected by other means, the question tlicn arises: dors the ])atient prefer to submit to an operation for the sake of a more rapid and perfect result, or would he rather endure a more protracted convalescence and assume the responsibility of an imperfect func- tional result whicli may go with fibrous union .' In llicsc l)order- land cases the situation should be laid before the patient and he should be the one to assume the responsibility if operation is rejected. Fibrous union, when the fragments are close and the mass of fibrous tissue heavy, is usually accompanied by excellent results, and cases in which these conditions obtain are a strong argnment against operation. It should be remembered, however, that it is impossible to foretell just how strong fibrous union will be in a given case. The age, condition and occupation of the patient are factors which must be taken into consideration in advising the proper method of procedure. Limitation of full extension is directly proportionate to the separation of the frag- ments. If the broken olecranon is displaced upward it becomes seated in tlie olecranon fossa before the elbow is fully extended, and thus motion is limited. Full extension, therefore, cannot be expected unless the fragments are in accurate apposition. It might be stated as a rule that young or middle aged persons, especially of the working class, should be operated when the fragments can- not be approximated l)y ordinary methods. By the open method convalescence is shortened and the function of the joint is more completely restored. The process is exposed through a longitudinal incision external to the posterior surface of the olecranon. The scar in this position is not exposed to pressure when the patient rests the elbow on a table or other convenient object. After the fragments are ex- posed two transvei'se holes are drilled one above and the other below the plane of the fracture. All loose tissues are then cleared away between the two fractured surfaces and the upper fragment FRACTURES OF UPPER END OF ULNA ]93 brought down and accurately fitted into the serrations of the lower one. Suture material is then passed through the holes and the fragments solidlv secured in position Instead of this method a heavy mattress suture may be placed, as shown in Fig. 259. Fig. 258. — Fracture of olecranon showing separation of fragments in spite of dressings tending to correct the deformity. Fig. 259. — Same case sliowing accurate reduction following operation in which mat- tress suture of silver wire was used to maintain reduction. There has been considerable discussion concerning the best type of suture, and of late absorbable materials such as chromic catgvit and kangaroo tendon have been frequently employed. The author much prefers wire to absorbable material, since the latter is more or less likely to soften and stretch before the callus is firm enough to 194 FRACTURES AND DISLOCATIONS withstand llic unavoidable tension of the triceps, .and when it does there will bo at least some slight separation of the fragments. Silver wire h,as no streteh in it and will hold the fragments in position as long as may be necessary, and in addition will permit of early and repeated passive motion with greater safety. (See "Operative Treatment of Fraetnres," page 758.) In compound cases the wound sliould be irrigated with a few gallons of physi- ologic sterile s ..t J Figs. 293 and 294. — Sliows same case after a second reduction and recurrence of deformity. FRAf!TlIKr;S OF RADIAT. AND lILNAIt SKAK'I'S 215 The heavy aponeurosis attached to the posterior border tends to prevent lateral displacement. Fiff. 296. Figs. 295 and 296. — Same case after operation sliowing correction of deformity and securing of fragments in position by means of a loop of silver wire. Fig. 297. — Fracture of botli bones of the right forearm in a child two and a half years of age. The deformity in this case is unusual in that the forearm is bowed back- ward. Photograph taken before reduction and about one hour following accident. When ioth tones are broken the deformity is usually pronounced and may be of either the overriding or angular type. The bones of the forearm may be displaced in any direction but the common 216 FRACTURES AND DISLOCATIONS deformity consists in a l)a<-k\vai-(l lu'iidiiiii of the forearm; — tlie dorsal surface of the forearm forms an obtuse angh^ while the ventral surface forms the salient anule. A much less eonnnon dis- Fig. 298. Fig. 299. Figs. 298 and 299. — Fractui-e of both bones of tbo forearm seen from radia* and ulnar sides. Tlie fraetures are so low that the condition is likely to be ciinfounded with Colles' fracture. It will be noted, however, that the ulnar deformit.v begins at a higher level in this case than it does in Colles' fracture. Tlie level of the ulnar fracture is not as apparent by inspection as it is when palpated. The lower ulnar fragment may be felt displaced backward. Fig. 300. — Fracture of both bones of the forearm near the wrist. Condition closely resembles Colles' fracture. Inspection and pali)ation of the ulnar side of the wrist dis- closes the break in the ulna and the backward displacement of the lower fragment. placement is that shown in Fig. 297 in which the forearm is bent forward instead of backward. Forward or backward displacement may take place and be pronounced without any element of over- riding in either bone. When however the hand and lower part FRACTURKS OP RADIAL AND UI.NAR STTAKTS 217 FiS. £02. Fis't. eoi aiul SO'^ — Fiaituve (if bcitli bones of thr fore inn a r-h'jrt distance abjve tlie wrist willi \ei\ slii;lit detorniity. Nole llie sliglit backward licnding of the forearm. Fig. 303. — Upper arrow points to free radial styloid (auomalous) . Lower arrow- points to fracture of the shaft of the radius. 218 FRACTURES AND DISI-OfATIONS of the forearm are displaced to either the radial or ulnar side, the bone on the concave side of the forearm will nsually show over- riding deformity. If the displacement is a combination of antero- posterior and lateral (for example, if the hand is displaced backward and also to the radial side) it will be due either to over- riding and angular deformity of the shaft on the concave side of ^04. Fig. 305. Figs. 304 and 305. — Green-stick fracture of the ulna in a child. This condition might be easily overlooked if the X-ray had not been employed. Lateral compression of the two bones, however, showed more "spring" than normal in the ulnar shaft. (See Fig. 307.) Comparison with the opposite ulna renders recognition of the condi- tion easier. the forearm, or else the fractures are at different levels and the forearm folds back diagonally. The nature of the deformity and the crease on the dorsal surface of the forearm will usually indi- cate the relative levels of the two fractures. This crease represents the apex of the angle of displacement and when the fractures are at the same level the crease will run transversely across the back of the forearm. When the fractures are at different levels the FRACTURES OF RADIAL AND ULNAR SHAFTS 219 crease will be more or less obliquely placed. It is well shown in Figs. 271 and 277. In some instances the fragments of both bones will show only overriding deformity with thickening of the fore- arm where the fragments overlap. This thickening is often diffi- cult to distinguish from the usual swelling at the site of fracture, but the accompanying shortening of the forearm and the resultant flail-like condition will disclose the nature of the injury. An ex- cellent example of this condition is shown in Figs. 313 and 314. The loss of function is complete when both bones are broken and the attitude in which the patient supports the entire length of the forearm with the opposite member is characteristic. In "green-sticli" fractures of the forearm there is more or less bowing of the shafts of both bones, as a rule, either forward or backward. The deformity is seldom as distinctly angular as seen in adults but presents more of a curved effect. The condition is not flail-like and mobility is absent. The lateral spring of both bones, however, is usually increased. This increase in spring is particularly noticeable if pressure is made on the concave side of the deformity. The symptoms in children are occasionally quite mild, producing little more in the way of disability than would result from a bad sprain or bruising of the forearm. This fact calls attention to the necessity of a careful examination and the use of the X-ray in doubtful cases following injury of the forearm in a child. Diagnosis. — In making a diagnosis of fracture of the forearm the parts should be carefully and systematically examined. There is much which can be learned by inspection alone since the majority of fractures in this region are accompanied by characteristic de- formities, as shown in the accompanying illustrations. The more the surgeon can gather by inspection the less there will remain to be determined by palpation and the shorter will be manipulation which only increases the damage to the already traumatized so£t tissues. The deformities shown in the accompanying illustrations are not exceptional but represent the average run of cases, and a study of these photographs should be of service to the student in enabling him to recognize these conditions with the least possible disturbance of the parts. It is always advisable to have a Ront- genogram taken of the case to determine the accuracy of reduction, if not for the purposes of establishing a diagnosis. Theoretically an X-ray examination is of great value before reduction is at- 220 FRACTURES AND DISLOCATIONS tempted, hut jirtu'ticilly I he time necessary to secure such an examination often reiHlcrs it inrxpcdicnt. HMic lon.ii'er the deform- ity exists the greater the .sufreiin^ and the more i)rononneed tlie secondary traumatic reaction. It is therefore iii(um1)ent on the surgeon to effect reduction at tli(> eai'liest |)ossil)h' moineiit and to k'arn all that is possihh' \)y iiispeet ion and |»;d|»;ili<)n het'oi'e the Fig. 306. — Testing the .'^iJi'iiiy in the Itones of the I'oreiirni li.\- means of lateral pressure. fragnients are brought back into alignment. When one is accus- tomed to interpreting these deformities a successfid reduction will often be possible before the X-ray is made, while, on the other hand, if these physical signs are neglected a secondary manipula- tion will usually be needed after the X-ray returns are available. Treatment. — Reduction of isolated fractures of the radius may be easy or difficult according to the nature of the break and the displacement present. When the fracture is high, the anterior dis- placing action of the biceps may require immobilization in a posi- tion just short of acute flexion. (See Fig. 210 and page 145 under Treatment of "Fractures of the Lower End of the Humerus.") If the fracture is between the insertions of the biceps and pronator radii teres the condition is usually best treated with the forearm in a position of semiflexion and complete supination. (See "Anatomy" on page 205.) This places the lower fragment in a position of supination to correspond to the upper fragment which has been snpinated by the biceps and supinator brevis. If the fracture in the radius is low, the upper end of the lower fragment may be displaced toward the ulna; strong traction on the wrist FRACTURES OF RADIAL AND ULNAR SHAFTS 221 with adduction of the hand may be necessary to bring the lower fragment back into alignment. If reduction cannot be effected by manipulation operation is indicated. "When the fracture is high the elbow should be immobilized, and when near the wrist it may be necessary to include the hand in the splint. The splints to be used and the precautions to be observed in applying them are the same as will be described shortly in the treatment of frac- tures of the shafts of both bones of the forearm. In instances in which the serrations are coarse there may be difficulty in securing a satisfactory engagement. Under these conditions reduction may sometimes be facilitated by temporarily increasing the angular de- formity while attempting to engage the fractured ends. With the ends thus engaged the angular deformity is easily corrected since the ulna maintains the length of the forearm. The reduction of isolated fractures of the ulnar shaft is ac- complished in a manner similar to that employed in fractures of the radial shaft. Keduction is usually not attended by much difficulty as long as overriding of the fragments is prevented by an intact radius. Traction on the hand can accomplish noth- ing. Displacement of the lower fragment toward the radius is common and is to be corrected by digital pressure between the bones. It is often possible to secure an engagement of the ser- rated ends so that this deformity will not recur. When the con- dition is compound it should be treated according to the principles laid down under the heading of "The Treatment of Compound Fractures and Luxations," on page 789. Unfortunately fracture of the shafts of both hones of the fore- arm is much more common than fracture of either bone separately and the condition is more difficult to treat, not only because there are two bones to be reduced but because neither bone enjoys the supporting effect of the other. It is only by appreciating the dif- ferent types of deformity and what they indicate that one is qualified to return the fragments to their proper positions with the greatest accuracy and dispatch. When the deformity is purely angular and the fractures approximately transverse there will seldom be any difficulty in effecting reduction. Wh(;n however there is overriding of one or both pairs of fragments correction of the displacement is much more difficult. The overriding de- formity should be reduced before the angular displacement is corrected. One is thus enabled to secure an engagement of the 222 FRACTURES AXO DISI.OCATIONS serrated ends before the fra.mneiits are bi-ou^lit l)!U'k iiilo nlifiiinient. It should be remembered during all manipulations that tlic shjivp serrated ends of the fragments may be made to do serious injury to the soft tissues. AVheu it is foiuul ncccssiirx- lo in;ike lateral pressure on a fragment the force should be ai)|ili((l a little above or below the seat of fracture, as the case may be, and not directly on the displaced end. Fracture of the radius between the i)iser- tions of the biceps and pronator radii teres, calls for innnobiliza- tion of the forearm in the supinated position, the same as already mentioned in the treatment of isolated fractures of the radial shaft. AVhen the fragments of only one shaft are found to be overriding (more often the radius) our attention may be confined almost entirely to correcting the deformity of this one bone. The lateral displacement is first reduced and then the angular de- formity; the opposite bone will follow provided it shows only angular displacement. When reduction is ditficult or the patient nervous and hard to control it may be advisable to accomplish re- duction under anesthesia. It is well to remember that children are not as safe subjects for anesthesia as adults and reduction in many cases entails only an instant of pain if properly per- formed. In reducing green-stick fractures in children it may be possible to simply correct the bowing and straighten the bone but more often it will be found necessary to complete the fracture by bending the shaft in the direction of the bowing and then treat- ing the condition as a complete fracture. If the surgeon has reason to anticipate any special dit!iculty in effecting reduction it may be well to prepare for operation before giving the anesthetic, and then if it is found that reduction can- not be accomplished by manipulation he is ready to correct the displacement by open incision. Thus an additional anesthetic is avoided, time is saved and there are no failures to be explained. The splints employed in immobilization of fractures of the forearm are the same whether one or both bones are broken. Flat anterior and posterior splints will be found to meet the require- ments in the largest number of cases. They should be a little broader than the widest portion of the forearm and well padded before being applied. Light quarter-inch wood will answer the purpose well. Pliable wood such as yucca board may be em- ployed but should be used with the greatest caution and must never be bandaged in place tightly enough to force it to conform to the FRACTTTRKS OK RADIATy AND TTT.NAR STTAFTR 223 A I'I'I.ICA'I'ION OV Sl'MNTS 'I'O 'rill': KOKKAK.M. Fig. 307. — Fracture of liotli Ikhips of tlie forpiirm jirior to reduction. (See Figs. 385 and 38-6.) Fig-. 308. — Ventral splint apiilied followina; reduction and held in position Ijy two straps of adhesive — A. and B. Fig. 309. — Forearm turned so that thenar "cut-out" may be seen. Fig. 310. — Dorsal splint applied and held in position by two additional straps of adhesive — C. and D. Fig. 311. — Bandaging covering both splints. When the forearm is broken above the middle this dressing should be supplemented by an internal right angle splint. (See Fig. 213.) 224 FRACTIKES AXn DISLOCATIONS contour of the forearm, as otherwise eonstrietion may result. The anterior splint should extend from the middle of the palm of the hand to a point just lielow the bend of the elbow when the fore- arm is semirie'xed. The radial side of the lower end of tlie splint should be eut away to clear the thenar eminence as shown in Fi^-. 309. The cotton padding should be thicker jiist above the wrist and opposite the palm of the hand. The posterior si)lint should extend from the metacarpo-phalangeal knuckles to a point a short distance below the elbow. The forearm nnist not be bandaged before the splints are applied as the circulation may thus be in- terfered with. One splint is put in place (usually the palmar) and secured with two strips of adhesive as shown in Fig. 308 and the parts examined to see that reduction is maintained. The second splint is then ai)i)lied and secured with strips of adhesive Fig. 312. — Shows same dressing opened up for inspection during the after-treat- ment. Straps C. and D. have been cut and dorsal splint turned back, thus allowing inspection and palpation of the forearm while it is still secured to the ventral splint. (See aJso Figs. 283 and 284.) which encircle both splints. The splints should be loosely ban- daged, especially when the dressing is first applied. Gangrene of the forearm or Volkmann's contracture may follow too tight bandaging, and the surgeon cannot alwaj^s depend on the sensa- tions of the patient to give warning that damage is being done. Gangrene is known to have occurred without attracting the pa- tient's attention. Phlegmonous inflammation is not uncommon, and pus developing within the tissues may cause extensive dam- age by burrowing. It must be remembered in this connection that a bandage may be of the proper snugness at the time of applica- tion and yet a few hours of swelling may result in dangerous strangulation of the forearm. Any form of splint which is curved to conform to the surface of the forearm, or a rolled bandage applied to the forearm before flat splints are put in place, is more likel}" to produce strangulation than is the simple flat splint. Splints making pressure between the bones of the forearm to FRACTURES OP RADIAL AND ULNAR SHAFTS 225 prevent approximation of the fragments across the interosseous space are dangerous and should never be used. If 1Ih' fracturf^ or fractures are in the upper half of the foreai-m an intcr-iial or external right angle splint should be used in addition to the flat splints employed in immobilijcing the forearm. If the break is near the elbow it will be impossible to secure proper fixation with- out immobilizing the elbow. The thumb and fingers shoubl Ix- left exposed in all cases so that the condition of the circulation may be known without removing the dressings. The secondary traumatic reaction is often pronounced in frac- tures of the forearm, and must be taken into consideration in the treatment of fractures in this region. If the trauma to the soft tissues is great it may be best to defer the application of splints until the swelling is decreasing and under control. It is often possible to foretell approximately the degree of swelling which will follow, by the extent of bruising of the tissues of the forearm, and when the surgeon has reason to anticipate a severe reaction the case should be treated for the first few days along the follow- ing lines. The deformity is reduced immediately and the forearm loosely bandaged on a single splint. The patient is then put to bed, the parts kept perfectly quiet and the ice cap applied at intervals to the region of fracture. Sedatives or opiates may be necessary if the pain is severe. The arm should be examined every few hours to see that the swelling is not great enough to cause constriction of the forearm within the bandages. During this time an X-ray should be taken to determine the exact nature of the fracture. When the swelling is well subsided the arm may be immobilized with splints as previously described. Operative Treatment. — The open method is indicated in recent cases when proper reduction cannot be had by manipulation and in compound cases. Simple angular deformity can, as a rule, be corrected by manipulation unless some of the soft tissues become interposed between the fractured surfaces. Overriding deformity of one or both bones and multiple fracture of one of the shafts are the conditions most often rendering operation necessary. Fracture of the raelius is best exposed through a longitudinal inci- sion on the outer aspect of the forearm. The skin, fascia" and aponeuroses are divided with the scalpel and the underlying mus- cles separated by blunt dissection. When the fracture is low in the radial shaft care should be taken not to divide the tendons of 226 FRACTURES AXO DIST.orATTOXS the extensor muscles of the thumb which i)ass obliquely across the outer aspect of the lower end of the radius. The position of the radial pulse should be noted before making the incision to avoid injury to the artery when anomalously placed. With the fragments exposed reduction is accomplished by direct manii)ula- tion and the serrations fitted accurately together. IniciiiMl fixa- tion will usually be unnecessary if the ulna has not been injured. Not infrequently one or both fragments show a disposition to slip out of place toward the ulna. "When this occurs it may. be possible to prevent recurrence of deformity by a single loop of wire holding the fractured surfaces opposed or it may be necessary to employ a small, light Lane i)late. In operating on the ulna)- shaft it is best to expose fhe frag- ments through a longitudinal incision a little internal to the pos- terior subcutaneous border. The fragments are reduced in a man- ner similar to that just described in operating on the radial shaft, and internal fixation used or not, according to the needs of the case in hand. When hoth hones are fractured the shafts should be exposed through two incisions as already described in operating on isolated fractures of either shaft. It is a mistake to attempt to expose both shafts through one incision since the injury to the soft tissues will be more extensive. Theoretically this Avould not seem to be the case, but practically it will be found to be true. Internal fixation is more frequently necessary when both bones are frac- tured than in instances of isolated fracture of either the radial or ulnar shaft. In severe compound cases w^here there has been considerable loss of bony tissue in one of the shafts it has often been found neces- sary to resect a portion of the opposite shaft to make the two bones of equal length. This procedure has in man.y instances resulted in useful arms which would otherwise have been severely crippled, but before it is employed in any given case we should consider the possibility of an autoplastic transplantation of a portion of the shaft of the patient's fibula or a section of the tibial crest into the shaft of the deficient bone. (See "Bone Transplantation" on page 771.) Severe compound cases should be treated according to the prin- ciples laid down under the heading of "The Treatment of Com- pound Fractures and Luxations" on page 789. Severed arteries FRACTIIRRS OF RADIAT. AND UT.NAK SHAFTS 227 Fig. 3i;!. — Anl('r()-ii(is(('ri(H- view iil' rriicliirc of ovpvriding; dt't'drniity. Ndn-opcr.-il i\c i-i'(luc( icni irii]iiis.silili r ilif forearm with Fig. 314. — Lateral view of same case. Fig. 315. — Antero-i)osterior view of same case after operation and internal fixation. Fig. 310. — Lateral view after operation. 22S FKAcrruKs axd disloca-i'iuxs should 1)0 li.uiilfil ;iinl iM'iVfs siitiii'cd ill cases wluTc tlicy arc t'oniul divided. After-Treatment. Duriiiu' the lirst few da\s llic haiidatics slumUl be very loose and Hie dressings frequently inspected to see that there is no strangulation of the parts. The condition of the cir- culation F)eneath the nails iiia\ he easily ascertained and conipareil with the opposite side. Theiv is no region in the hody in which strangulation is more likely to take place llian in the foreann and the results may be disastrous. X'olkniaiiii "s eont lael ui-e is a ])0S- sibility which must l)e kept constant ly in mind diiiinu' the aftei-- treatment of fractures of Hie foreann. (See " X'olkiiianii 's Con- tractui'e," page 281.) The skin oxer the head of the ulna often calls for special care to avoid irritation, (ientle massage after the subsidence of the traumatic swelling is of gi'eat value in keeping the soft tissues in good condition during the process of bone heal- ing but the greatest care sliouhl be exercised to avoid disturbing the fragments. Union may be expected in children in three weeks or even less, but the forearm should be prolected j)y retaining the posterior splint for another ten days. The forearm should be sub- jected to only the gentlest use for two or three weeks following the removal of all splints. Active motion in all directions will be weak and limited on removal of the splints, but function will return rapidly Avith use and massage. The parts should be in- spected at least daily for the first ten days to properly accommo- date the dressings to the varying size of the forearm; after ten days the dressings should be removed at least twice a week to recognize and correct deformity, should it take place. If fiat splints are used, as shown in Figs. 283 and 312, one splint may be removed without disturbing the other, and we are thus enabled to inspect the parts wdthout entirely removing the support from the liroken bones. Plaster s{)lints and the plaster cast have been suc- cessfully used in the treatment of fractures of the forearm but they are dangerous appliances except in the hands of the expert. If plaster of Paris had never been emplo\'ed in the treatment of fractures of the forearm Yolkmaiurs contracture would have been much less common. If the fractures are at or above the middle of tln^ shafts the internal or external right angle splint should be retained through- out as a necessary part of the dressing. Bowing may result from using the forearm too soon and the FRACTURES OP RADIATj AND ULNAR SIIAPTS 229 patient should be warned to avoid nridue strain on tlic boiKis i'or a period varying from one to four months folk)wino' fracture. When there is doubt as to the satisfactory ossification of the callus it is advisable to base our after-treatment on X-ray tindini>s. In adults four to five weeks will be necessary before the callus is strong enough to allow permanent removal of the splints. Old persons produce bone slowly and should be allowed 15 to 20 per- Fig. 317. — Slight bowing deformity following fracture of both bones of the fore- arm. The deformity here is due to overriding of the radial fragments. Note the hand which is displaced " slightly to the radial side and a little backward. Operation was advised in this case but refused. Function restored but slight deformity persists. A deformity such as this will diminish with years provided the patient is young. Picture taken about four and a half weeks following fracture. cent more time than is allowed healthy adults. During the after- treatment the fingers should be manipulated daily, especially in old persons, as otherwise adhesions form about the tendons and mus- cles and between the joint surfaces, which may prove a permanent source of restricted motion. Prognosis. — The prognosis in fractures of the bones of the fore- arm varies greatly according to the conditions present. Accurate reduction of the fragments in a healthy child or adult should be 230 FRACTURES ANP IMSI.OPATIONS followed by complete restoration of function. Deformity may pro- duce loss of function. The rotary action of the forearm is most frequently interfered witli, the most common causes being an outward bowing of the shaft of the radius or the extension of the callus from the shaft of the ulna to the radius when the fragments of tliese two bones are disjilaced toward each otlier. Loss of the Fig. 318. Jb'ig. 319 (top). Fig. 320. Figs. 318, 319 and 320. — Three views of a case of Volkmann's paralysis. This case is an e.xample of a most disastrous condition which may follow too tight bandaging of the forearm. In this case there had been no fracture. The patient sustained a lacerated wound involving one of the large arteries and an Esmarch tourniquet was applied and left in position for over twelve hours while the patient was being brought to the city for surgical treatment. Myositis, paralysis and contracture followed. Case first seen by author some years after the injury. power of supination may follow fracture of the radial shaft be- tween the insertions of the biceps and pronator radii teres if not treated in supination as previously mentioned. Non-union of frac- tures of the forearm is not common but when it does take place it is usually the result of the interposition of soft tissues between the fractured ends rather than to constitutional causes or defective immobilization. When due to the interposition of muscle or fascia the prognosis will depend on whether or not operative procedures are instituted and the fractured surfaces brought into contact. A careful study of X-ray plates taken in two planes will as a rule disclose the presence of interposed tissues early in the course of the case, and if the proper surgical measures are then instituted FRACTURES OP RADIAL AND ULNAR SHAFTS 231 there will be no occasion for noii-niiion. Slight bovvin<^' in a child will usnally correct itself as years go by l)ut this fortunate condi- tion is no reason for the surgeon not insisting on th(; most perfect possible reduction following tlie accident. Volkmann's paralysis (or contracture) is a paralysis of the fore- arm with wasting of the muscles and contracture. The first cause is said to be an ischemia which is followed by myositis and ultimate destruction of muscular tissue which is replaced by scar tissue. The function of the nerves may be subsequently destroyed by con- traction of the scar tissue as well as by disuse. The points at which nerve constriction most commonly takes place are where the median passes between the heads of the pronator radii teres, and the ulnar nerve between the heads of the flexor carpi ulnaris. Volkmann's paralysis usually follows fractures of the upper extremity in chil- dren (especially fractures of the forearm) and is the result of too tight bandaging or interference with the circulation from some other cause. Pain may be present with the onset of the condition, but is no guide whatever to the damage the forearm may be undergoing from too tight bandaging. The fingers are swollen and show passive congestion, the hand and forearm are numb and uncomfortable but seldom painful. Later on contracture develops in which the wrist is flexed, the proximal row of phalanges hyperextended and the middle and distal rows flexed. (See Figs. 318, 319 and 320.) If the condition is allowed to go uncorrected, contraction of the scar tissue replacing the muscles is likely to destroy the nerves, and all electric reaction will be lost. If the case is seen early (within a few days or a week), massage and forcible passive motion with removal of all dressing, regardless of the presence of fracture, should be followed by complete restora- tion of function. If the ease is first seen after the establishment of the contracture, surgical measures will be necessary, and even then the restoration of function is usually only partial. The condition of the nerves should be determined and then the procedure most likely to give good results chosen, ]\Iyotomy may be performed, the nerves may be dissected out, the flexor tendons may be lengthened or the radius and ulna may be shortened. Passive motion and massage are most important following operation. CHAPTER XYII. FRACTURES OF THE LOWER END OF THE ULNA. Surgical Anatomy. — Isolated fracture of the lower end of the ulna is not a common injury and its importance is much less than fractures of the lower end of the radius. Uncomplicated fracture in this region is almost invariably due to direct violence. The lower end of the ulna is only slightly larger than the shaft above it and transverse stress is about the only tyi)e of strain to which it is subjected. It forms the center about which the lower end of the radius revolves during supination and pronation. Longi- tudinal stress, such as sustained in falls on the hand, is transmitted through the radius directly to the humerus, and from the radius to the ulnar shaft b,y means of the interosseous membrane. The lower end of the ulna remains free from this type of strain, be- coming involved only when the radius breaks ; the pull of the triangular fibro-cartilage may then fracture the ulnar styloid. The lower end of the ulna does not enter into the formation of the wrist joint but articulates with the upper surface of the triangular fibro-cartilage and the sigmoid cavity of the radius. In pronation, the head of the ulna presents at the back of the wrist, while in supination the styloid process alone is palpable. Fractures of the lower end of the ulna are often situated just above the head and are usually transverse., though thej^ may be oblique or longitudinal and involve the head or styloid process. The most common break of this portion of the ulna is seen accompanying Colles' fracture and consists in an avulsion of the styloid. (See Figs. 326 to 331.) Epiphyseal separations may occur but are quite rare. The lower epiphysis (including the head and styloid) is ossified from a single center which is first seen about the fourth year. It joins the shaft at about the twentieth year. An anomalous ossicle, the triangulare, is sometimes seen just below the tip of the ulnar styloid and may be mistaken for fracture of this process in interpreting X-ray plates of this region. (See Figs. 405 and 406.) On the posterior aspect of the lower end of the bone is a shallow 232 FRACTURES OF LOWER END OF ULNA 233 Fig. 321. — Fracture of both bones of the forearm and separation of the lower ulnar epiphysis. The separated epiphysis forms a slight prominence on the ulnar side of the wrist which may be seen and felt. Photogi-aph taken a few minutes following ar-cident. 323. Figs. 822 and 323. — X-ray plates showing antero-posterior and lateral views of the case seen in Fig. 321. l and 2, fracture in ulnar shaft; 3 and 4, fracture in radial shaft; 5, displaced ulnar epiphysis. 234 FRACTURES AND DISLOCATIONS ^i-()()vc toi- tlio passaji:o of the tendon of the extensor ear])i ulnaris. Symptoms. — Tlie symptoms accompanying isohited fracture of the lower end of the ulna are often surprisingly mild. There is local pain, tenderness, swelling and a varial)le degree of loss of function. Since the condition usually results from direct violence there will, as a rule, be evidences of the blow on tiic skin in this region. If the trauma is severe the condition may he compound. Su|)ination and i)ronation are often particuhirly painful and the Fig. 324. — Fracture and beparaliou ol' a portitm of tlie ulnar epipliysis including the styloid process. wrist lacks lateral stability though the movements of the wrist itself are mechanically undisturbed. Direct palpation will elicit crepitvis if the fragments are manipulated. The lower end of the upper fragment may be displaced in any directioii though it is more connnon to find it nearer the radius than normal and })rom- inent posteriorly. Deformity, however, is usually slight. Diagnosis. — Fracture of the lower end of the ulna can, as a rule, be recogni/ed without difficulty if the parts are carefully exam- ined. There is no characteristic deformity and hence inspection FRACTURES OF LOWER END OP UI^NA 235 alone is of little value. Tlie condition is most frequently over- looked when it occurs accorni)anyin<^ (Jolles' fracture. The broad- ening of the wrist seen in Colles' fracture is due to rupture of the triangular fibro-cartilage or to avulsion of the styloid (usually the latter) and is suggestive of fracture of the lower end of the ulna. When doubt exists the X-ray should be employed. Treatment. — This fracture is not a serious one as compared to other breaks in this region and reduction of the displacement is usually accomplished without difficulty. If the tendon of the extensor carpi ulnaris tends to displace the lower fragment the hand should be treated in a position of dorsal flexion and ad- duction. A single anterior splint extending from the base of the fingers to the upper part of the forearm will usually suffice in immobilizing the parts. Direct pressure may be exerted by pads of gauze secured in position by strips of adhesive plaster. Direct pressure is not often indicated, but when it is it will usually be found necessary because of a tendency on the part of the lower end of the upper fragment to backward deformity. Under these cir- cumstances direct pressure should be exerted on the shaft of the bone above the level of the fracture. Tight bandaging is as dan- gerous here as in the treatment of fractures of the shafts of the bones of the forearm, and the same precautions are to be observed as already mentioned in the preceding section. The forearm should be carried in a sling which supports its entire length as otherwise it may exert a displacing action on the fragments. Operative Treatment. — Open treatment is rarely indicated in recent cases aside from compound conditions. When the fracture is open it is to be treated according to the principles laid down under "The Treatment of Compound Fractures and Luxations," on page 789. If deformity recurs or persists and cannot be con- trolled by ordinary methods the fragments should be secured by internal fixation (see page 754). After-Treatment. — The forearm should be frequently inspected during the first week or ten days, especially if the secondary traumatic reaction is pronounced. Undue constriction of the fore- arm is as dangerous here as in fractures of the shafts of the bones of the forearm and may lead to Volkmann's Contracture (see page 230). Immobilization for three to four wrecks should result in union. Fracture of the styloid and displacement of the lower end of the ulna will be considered under "Fractures of the Lower 236 FRACTURES AND DISLOCATIONS End of the Radius," since it most l're(|uriitly oeeiirs as a comi)!!- cation of Colles' fracture. Prognosis. — The outlook in unconiplieated fracture of tlie lower end of the ulna is pood hotli as to function and deformity. Fibrous union is sometimes seen hut does not as a rule materially lessen function. AVhen the condition is compound the ])ro,u'nosis is of course worse, but it is rare to see disability t'ollowiim fractures in this region. CHAPTER XVIIT. LUXATIONS OF THE LOWER END OF THE ULNA. Surgical Anatomy. — The lower end of the ulna articulates with the superior surface of the triangular fibro-cartilage and the sig- moid cavity of the radius. The lower end of the radius describes an arc about the head of the ulna during supination and pronation and the center of the arc thus described is the attachment of the apex of the triangular fibro-cartilage in the depression between the ulnar head and styloid. This triangular cartilage is the only ligament in the lower radio-ulnar articulation which main- tains the ends of the bones in apposition. The anterior and pos- terior radio-ulnar ligaments extend transversely in front of, and behind, the joint and limit its rotary action. The lower end of the ulna does not enter into the formation of the w^rist joint. A separate synovial sac exists between the lower end of the ulna and the cartilage, and extends upward between the radius and ulna. Isolated luxation of the lower end of the ulna is an extremely rare accident though it has been recorded in a sufficient number of cases to establish it as a type. A more or less complete dislocation of this joint is not an uncommon complication of Colles' fracture and is the result of rupture of the triangular fibro-cartilage or an avulsion of its ulnar attachment. This condition has been fully considered under "Fractures of the Lower End of the Radius," (page 242), and appropriately so, since it is secondary to and a complication of Colles' fracture. It is probable that no one observer has seen more than one un- complicated luxation of the lower end of the ulna and hence the details of the condition are not as Avell known as they might be. The author has seen but one case. Experiments which the author has conducted on the cadaver showed that rupture of the tri- angular fibro-cartilage or avulsion of one of its attachments was necessary for inward luxation. Rupture of the posterior radio- ulnar ligament was regularly found in posterior dislocations and tearing of the anterior ligament was noted in forward luxations. 237 238 FRACTURES AND DISLOCATIONS Extreme pi-oiiatioii produced tension on the posterior fibres of the triangular tibro-eartilage while extreme supination rendered the anterior fibres taut. Eeduction was accompanied by a distinct snap in all cases in wliidi tlie triangular fil)ro-c*artilage remained unruptured. Clinically, three types of luxation of the lower end of the ulna have been observed : — namely, backward, forward and inward. In the haclxward type the head occupies a position just behind the postero-internal angle of the quadrilateral lower end of the radius. The posterior ligament is torn while the triangular fibro-cartilage remains intact. This type of luxation is more commonly seen as a complication of ''reversed Colles' fracture" and is due to hyper- pronation of the wrist. I)i fix forward type of luxation the lower end of the ulna is displaced forward and slightly outward, and in isolated cases is probably caused by hypersupination. As a complication of fracture of the lower end of the radius it is not uncommon. The inward, type occurs only with ru])ture of the interarticular cartilage and as an isolated injury is so rare as to be questionable. As a complication of Colles' fracture it is not at all uncommon. Symptoms. — The symptoms accompanying luxations of the lower end of the ulna depend on the length of time the displacement has persisted and the position occupied by the head of the ulna. In recent cases tliere is pain, swelling, tenderness, loss of func- Fig. 325. — 'Posterior luxation of lower end of ulna. X'ote the abnormal prominence at the back of the wrist on tlie ulnar side. tion, etc. The deformity and disturbance in function depend on the type of luxation. //; iJie bad- ward va rift y the wrist is in extreme pronation, narrower than noi-mal and the prominence of the displaced head is apparent. The hand is slightly adducted. LUXATIONS OF LOWER END OP ULNA 239 supination is impossible as loni;- as Ihc luxation exists, and there is loss of power in the finders and wrist. In the forward type the forearm is fixed in supination and the ulnar head may he palpated on the palmar aspect of the wrist above the pisiform. The wrist appears narrower than normal and the absence of the ulnar head from its normal position is apparent. The inward type of luxa- tion shows a broadening of the wrist with loss of power in the rotary action of the forearm. The symptoms of inward luxation are a part of the clinical picture in many cases of Colles' fracture, and as such have been described under "Fractures of the Lower End of the Radius." As an isolated injury this dislocation is a surgical curiosity. Chronic and recurrent luxations of the lower end of the ulna are occasionally seen and the symptoms differ considerably from the acute condition. A chronic backward subluxation is sometimes seen in children as a result of heavy Avork while the bones are still in a soft and developmental stage and is known as ]\Iadelung's deformity. This backward displacement develops gradually as the radial deformity increases, and with removal of longitudinal pres- sure the ulna grows proportionately faster than the radius. Recurrent luxation of the lower end of the ulna is an extremely rare condition sometimes seen following trauma in this region. The displacement is usually not pronounced, but the lower end of the ulna is likely to slip out of position with extreme supination or pronation. Reduction is easy and usually accomplished by the patient. The annoyance and interference with function may be marked and is sometimes accompanied by ulnar neuritis. Diagnosis. — There should be little difficulty in recognizing dislo- cations of the lower end of the ulna. The displaced head of the bone may be palpated and is characteristic of the luxation accord- ing to the direction of displacement. In the forward type the wrist is narrower than normal and fixed in supination. In the backward type it is narrower than normal and fixed in pronation. The broadening of the wrist is typical of inward luxations which are almost never seen except as a complication of Colles' fracture. Luxations of this joint are most frequently overlooked when they exist as complications of Colles' fracture, and this is because one is apt to feel that the diagnosis is complete as soon as the fracture has been recognized. Treatment. — The method of reduction will depend on the type 240 FRACTURES AND DISLOCATIONS of luxation present. In backward dislocations pressure should be exerted with the thumbs to force the lower ends of the bones apart while the' wrist is being carried into supination. The object is to force the head of the ulna around the postero-internal angle of the lower end of the radius and then carry the forear-ni into supination. Reduction is accompanied by a distinct snap as the ulnar head clears the prominence and settles back into the sig- moid cavity of the radius. Reduction of the anterior luxation is accomplished by forcing the ulnar head backward and inward around the antero-internal angle of the lower end of the radius and then carrying the forearm into pronation. Reduction of this luxation is also accompanied by a distinct snap if tlie triangular tibro-cartilage is not ruptured. Uncomplicated inward luxation of the head of the ulna would probably offer little or no resistance to reduction and the tendency to recurrence would be slight. The condition, however, is practically unknown as an isolated injury. When it occurs as a complication of CoUes' fracture it is difficult to keep the luxated ulnar head in position because the radius has been shortened by fracture. In recent cases there is little tend- ency to recurrence of deformity if the luxation is either forward or backward. In old cases it may be impossible to effect reduction by manipulation, especially if the ulna has outgrown the radius in length. Operative Treatment. — Operative treatment is practically never indicated in recent cases unless the condition is a complication of Colles' fracture and the break calls for open treatment to effect or maintain reduction. In old unreduced luxations and when the condition is congenital it may be necessary to operate to restore the bones to their normal relations. In old cases it may be necessary to resect the ulnar head when the ulna has outgrown the radius. With the end of the bone removed reduction may be accomplished and recurrence of deformity prevented by suturing the soft tissues. In recurrent cases it may be possible to shorten the lower radio-ulnar ligaments or their tension may be increased by dividing the radius about two inches from the lower end and tipping the lower fragment so that the styloid will occupy a lower level. After-Treatment. — In recent forward or backward luxations the deformity does not tend to recur and hence no special retentive apparatus will be required aside from avoiding extreme supination LUXATIONS OP LOWER END OF ULNA 241 or pronation according to the type of luxation. Should a tend- ency to recurrence be present the forearm should be immobilized in a position of rotation opposite to that in which the luxation occurred. A backward dislocation should be fixed in supination while an anterior luxation should be immobilized in pronation. Two to three weeks should be allowed for the ligaments to henl. Following operation the forearm should be immobilized for two or three weeks, or even longer in exceptional cases. If the condition is compound it should be treated according to the principles Inid down in "The Treatment of Compound Fractures and Luxations," on page 789. Prognosis. — The outlook in uncomplicated luxations of the lower end of the ulna is excellent if reduction is accomplished early. Old unreduced cases of forward or backward luxation usually show considerable disturbance in function especially in the rotary action of the forearm. In congenital luxations the loss of function is often surprisingly slight, consisting for the most part in loss of complete supination, slight weakness of the wrist and of early tiring when heavy work is performed. The same type of symptoms prevail in the backward subluxation seen in children as a result of heavy work during the years when the bones are soft. The operations recorded have been few but the results are encouraging. CHAPTER XIX. FRACTrRES OF THE LOWER END OF THE RADII'S. Surgical Anatomy. — The region of the wrist is compact and contains numerous tendons, nerves and vessels in close relation with the radius, ulna and carpus. The normal relations of these struc- tures and the surface landmarks should be known before one is qualified to recognize and fully appreciate the deformities accom- panying fractures of the lower end of the radius. Variations within normal limits are common in the lower ends of the radius and ulna, and the carpus is frequently the seat of pronounced anomalies. It is necessary, therefore, that the opposite wrist be examined carefully before determining the conditions i)resent in the injured member. The styloid process of the radius normally occupies a lower level than the ulnar styloid. Nearly all fractures of the lower end of the radius are accompanied by an elevation of the radial styloid ; this condition is determined by comparing the relative levels of the two styloid processes as shown in Fig. 376. The uninjured M-rist is used as the standard of comparison in as- certaining the distance the radial styloid has been raised. On the anterior surface of the wrist will be noted two eminences. To the radial side is the thenar eminence; the upper margin of which is at a slightly low^er level than the corresi)onding margin of the hypothenar eminence which is situated at the ulnar side of the wrist. AVhen the outer side of the forearm is shortened by frac- ture of the radius the thenar eminence is raised according to the extent of the deformity. The outer aspect of the lower end of the radius is the only portion of the bone which is strictly sub- cutaneous, yet the lower half of the radius may be palpated with- out difficulty since there is little else than tendons interposed betvveen the skin and the bone. On the posterior surface of the lower expanded quadrilatei'al extremity of the radius are a number of vertical grooves foi- the acconunodation of the extensor tendons passing from the fore- arm to the hand. At about the middle of this surface will be 242 FRACTURES OF LOWER END OF RADIUS 248 noted a prominent rid^e wliicli foi^nis tin; outer niarjiiin of tlie groove for the passage of the extensor longus pollieis. The tejulons of the extensor ossis metaciirpi |)olli('is (ind extensor brevis pollieis pass to the outer side of the radius, o})liquely aeross the base of Fia:. 329. Fig. 330. Fig. 331. Fig. 326. — Impacted fracture of lower end of rwdius. Fracture of ulnar st.vloid. Fig. 327. — Pronounced imisactiou of lower end of radius. Fracture of ulnar st.vloid at its base. Fig. 328. — Fracture of ulnar side of lower end of radius and fracture of ulnar styloid. Fig. 329. — ^Vertical fracture of lower end of radius and fracture of ulnar st.vloid. Fig. 330. — Comminution of lower end of radius and fracture of ulnar styloid. Fig. 331. — Extensive splitting and comminution of lower end of radius and frac- ture of ulnar styloid. the styloid process. The flexor tendons, radial artery, and median nerve pass in front of the lower end of the bone. The radial nerve as it courses down the outer side of the forearm and under the tendon of the supinator longus is sometimes injured and may 244 FKACTITRES AND DISLOCATIONS give rise to considerable pain diiriiig the after-treatment. Tlie inner aspeet of tlie lower end of the radius jiresents the ''sigmoid Fig. a32. Fig. 3iJ3. Figs. 332, 333 and 334. — Three good examples of Reversed Colles' fracture. The 'gardener's spade" defariuity is present instead of the "silver-fork" deformity. Fig. ;!3fj. Figs. 335 and 336. — Antero-posterior and lateral views of a fracture of the lower end of the radius produced by an "autokick." cavity of the radius" for articulation with the head of the ulna; just beneath the lower margin of this surface is attached the base of tlie triangular fibro-cartilage, whicli binds the radius and ulna FRACTURES OP I/)WER END OF KADTITS 245 together. With the forearm seinipronated the ulnar styloid may be palpated as a prominence of bone which is continuous with the posterior subcutaneous border of the ulna. The tip of the process is on a level with the articulation of the wrist. When the forearm is carried into complete pronation the ulnar head, instead of the styloid process, presents beneath the skin. The inferior surface of the lower end of the radius articulates with the upper row of carpal bones and looks downward and slightly forward. The internal structure of the lower end of tlie radius shoidfi be studied to fully appreciate the mechanism of fractures of this Figs. 337, 338 and 339.- — Three views of a transverse Colles' fracture with impaction of the proximal fragment into tlie cancellous tissue of tlie distal fragment. region. A short distance above the lower end of the bone the sur- face layer of compact tissue changes rapidly into the heavy tube of compact bone which forms the shaft of the radius, and it is here that fracture most often occurs. It is not uncommon to find the end of the upper fragment driven into the lower fragment, which means a more or less extensive crushing and comminution of the cancellous tissue in the lower end of the radius, and accounts to some extent for the tendency to recurrence of deformity following- reduction. Thus, when the lower fragment is pulled back into position following impaction, there is a Avedge-shaped space in the 246 KKACTl'RES AND DISLOCATIONS lower fragment eorrcspoiulino' to the crushed cancellous tissue, and unless the layer of compact bone on the posterior aspect of the lower fragment is firmly engaged the deformity will return when the iiarts are released. A consideration of the internal structure of the lower end of the radius as sliown in Figs. 268 and 384 will explain this tendency to recurrence of deformity, and the necessity for overcorrecting the displacement so that the dorsal layer of compact tissue may properly engage the upper fragment. Fig. 340. — Fracture of lower end (if radius i)1-(i<1uiih1 liy '"autii Uiclc.' Fractures in this region of tiic skeleton show cousiderable varia- tion, but the overwhelming majority corresi)onds, more or less closely to the type described by CoUes. Ilis original description in 1814 was of a fracture one and a half inches above the articular surface, but subsequent exp"erience has shown that the usual break is within three-fourths of an inch of the lower end of the bone. At the present time, therefore, Colles' name is used to indicate a condition slightly different from the one originally described by FRACTdRES OF LOWER END OF RADIUS 247 him. The typical Colles' fracture is transverse or oblique, does not enter the articular surface and is accoini)anied by a backward Fig. 341. Fig. 342. Figs. 341 and 342. — Lateral and anteroposterior views of Colles' fracture with very slight deformity. Note fracture of ulnar styloid. Fig. 343. — Colles' fracture with comminution of the distal fragment. displacement of the lower fragment. Tliis backward displacement of the distal fragment produces the typical "silver-fork" deformity which is so characteristic of Colles' fracture (see Figs. 354 to 367). 248 FRACTURES AND DISLOCATIONS Fig. 345. Figs. 344 and 345. — Antero-posterior and lateral views of transverse CoUes' fracture with impaction of upper fragment into lower, after attempt at reduction. Same case as shown in Fig. 355. Figs. 3i0 and 347. — Anteroposterior and lateral views of oblique Colles' fracture after reduction. Same case as shown in Figs. 366 and 367 before reduction. Note obliquity of plane of fracture and absence of crushing of cancellous tissue by impaction. FRACTURKS OF r/)WKR END OK RADIUS 249 The nature of the deformity varies somewhat with the line of frac- ture (see "Symptoms," page 252). The usual Colles' fracture is the result of a fall on tlie out- stretched hand. If the fall is sustained on the palm of tlie liatid, Fig. 348. Figs. 348 and 349. — Antero-posterior and lateral views of separation of lower radial epiphysis complicated by fracture of the end of the diaphysis. Same case as shown in Figs. 368, 369 and 370. as is usual, the distal fragment is displaced backward and the typical Colles' fracture is the result. If impaction is present it is the cancellous tissue near the posterior surface of the lower fragment which suffers most. In rare instances the distal frag- 250 FRACTURES AND DISLOCATIONS Fig. 35tl. Fig. 351. Figs. 350 and 351. — .Viitero-pusterior and lateral views of epiphyseal separation of lower end of radius complicated by fracture of the lower end of the diaphysis. Deform- ity corresponds to "reversed Colles'." Fig. 353. Figs. 352 and 353. — Antero-posterior and lateral views of separation of the lower radial epiphysis after rediittion. Note the cDtnplicating fractures of botli epiphysis and diaphysis. FRACTURES OP LOWER END OF RADIUS 251 ment may be displaced ventrally and the coiidilioti is tlien spokf-n of as a "reversed Colles' fraeture." Tliis type of deformity is usually produced when the causative trauma is received on the dorsal aspect of the hand with the wrist in flexion. Examples of reversed Colles' fracture are shown in Figs. 332 to 334. An oblique fracture passing from the posterior surface of the lower end of the radius into the articular surface, with dorsal dis- placement of the fragment, is known as Barton's fracture. When the break enters the articular surface from the anterior aspect of the lower end of the radius, with ventral displacement of the frag- ment, the condition is spoken of as a ' ' reversed Barton 's fracture. ' ' This terminology is rather unfortunate since these two conditions are in reality luxations of the wrist complicated by fracture of the lower end of the radius. Thus Barton's fracture is a backward luxation with fracture of the posterior lip of the radius, while reversed Barton's fracture is an anterior luxation with fracture of the anterior lip of the radius. The mechanism of Barton's frac- ture and reversed Barton's fracture is similar to that obtaining in Colles' fracture and its reversed form. Atypical fractures of the lower end of the radius show con- siderable variation : the styloid process may be broken off, a ver- tical fracture may pass from the shaft into the articular surface, oblique fractures may pass from either the inner or outer aspect of the bone into the articular surface, the distal fragment of a Colles' fracture may be broken into two or more pieces or may be extensively comminuted, and the same condition sometimes exists in a separated epiphysis, and finally the lower end of the bone may be so extensively comminuted that it does not resemble any of the above described fractures. In some rare instances the upper row of carpal bones have been driven upward through the articular surface of the radius so that they rested partially within the can- cellous tissue of the lower end of the bone. In many of these atypical fractures the degree and nature of the deformity depend largely on the severity and direction of the causative trauma. The lower epiphysis of the radius is ossified by a single center which makes its appearance about the end of the second year. The epiphyseal cartilage is obliterated during the twentieth year. The causes of epiphyseal separations are similar to those producing Colles' fracture, and the deformity usually consists in a backward displacement of the lower fragment. It is not uncommon to find 252 FRACTURES AND DISLOCATIONS epiphyseal separations of the lower end of the radins complieated by fracture; examples of this condition are shown in Figs. 3-18 to 353. Symptoms. — The patient almost invariably gives a history of ha\inu- fallen on the outstretched hand. The injury is followed innnediately by severe pain and loss of function, and the sufferer tig. 354. — lypic'iil Colles' fracture a few minutes following the accideut. Fracture transverse and iinpaetion present. Compare this deformity with the other Colles' frac- tures shown in thi.s ehai-ter ;ind wilh the backward dislocation shown in Fig. 378. Fig. 355. — .Simple (holies' fracture the result of a fall on tlie liand. Picture taken a short time following the accident. Appearance typical. presents himself for treatment and relief. The attitude is usually characteristic. He stands with the shoulders slightly forward and the forearms held horizontally across the body. The injured mem- ber is supported by the opposite hand and there is considerable FRACTURES OF LOWER END OP RADIUS 253 Pig. 356. An example of the radiiil (lis|)l;iit'ment of the distal fragment sometimes seen in Colles' fracture. Note how the whole hand is displaced to the radial side. Pig. 357. Pigs. 357 and 358. — Transverse, impacted Colles' fracture a few minutes following fall on hand. This is the type of deformity illustrated in B., Fig. 384. Compare this case with the deformity accompanying an oblique Colles' fracture as shown in Figs. 366 and 367. Angular deformity is here present as a result of the impaction, and the direc- tion in which the articular surface of the radius looks has been changed. Note the prominence on the ventral and ulnar side of the wrist produced by the displaced head of the ulna. 254 FRVCTFRES AND DISLOCATIONS anxiety in botli altitude and uait lest tlic injured wi-ist hr dis- turbed. The onset of swelling about the wrist is prompt and sometimes pronounced, and, unless the case is seen inunediately following the accident, the deformity is to some extent masked. Fig. :j59. — Fhotogr;ii)h of a recent C'olles' fi'acture showing the change in Uip con- tour of the wrist resulting from the disphicenient of the distal fragment. The articular surface of the radius looks downward and backward instead of downward and slightly forward as is normal. Note the curve on the anterior surface of the wrist which is less sharp than is seen in a normal wrist in this position. Fig. 361. Figs. 360 and 361. — Colles' fracture a few minutes following injury. Prominence on ventral surface of forearm is due to distention of the fle.xor tendon sheaths. Loss of function in the liand and wrist is, as a rule, complete, and even in instances in which it might be possible for the patient to perform some acts with the injured member the pain is usually severe enough to inhibit all function. The usual silver-fork deformity is characteristic of Colles' frac- FRACTURES OP LOWER END OP RADIUS 255 Fig. 363. Figs. 362 and 363. — Radial and ulnar views of recent Colles' fracture. Line of fracture a little higher than usual and dorsal displacement pronounced. Fig. 364. Figs. 364 and 365. — Radial and ulnar views of Colles' fracture in old woman a few minutes following the accident. Angular deformity and impaction present. Moderate displacement of lower fragment. Note prominence of ulnar head and displacement of hand to radial side. 256 FRACTURES AND DISLOCATIONS ture and can best be appreciated by a study of the accompanying photoGTaphs. No amount of text will convey an idea of the nature of this deformity as readily as these illustrations. The radial sty- loid is usually raised above its normal level, though in many in- stances the displacement is not marked enough to bring the tip of the process above the level of the end of the ulnar styloid. (See Figs. 370 and 377.) In a ti'aiisverse Colics' fracture with Fig. 366. Figs. 366 and 367. — Oblique Colles' fracture a few minutes following injury. Forearm somewhat resembles fracture of both bones of the forearm though palpation discloses an intact ulna. The obliquity of the fracture is shown by the deformity. Note how low and pronounted the anterior deformity is as compared with the dorsal outline. Compare this deformity with the cases of transverse Colles' fracture previously shown and examine the accompanying Rontgenograms. X-ray of this case is shown in Figs. 346 and 347. impaction there is generally rotation and angular deformity as well as backward displacement of the lower fragment. Under these circumstances it will be noted that the radial side of the w-rist is displaced further backward than the ulnar side, and that the axis of the lower fragment is not parallel with the axis of the shaft. Crepitus is easily detected in unimpacted cases. In im- pacted cases crepitus will be absent until the impaction has been FRACTURES OF IjOWER END OF RADIUS 257 broken up. In more than half of the eases of Colles' fracture the condition is complicated by rupture of the triMiis'ular fibro-earti- lage or an equivalent avulsion of its uhiar altaehrncnt so that the head of the ulna and the lower radial fragment are separated and the wrist broadened. Fracture of the ulnar styloid, so commonly seen in Rontgenograms of Colles' fracture, is an evidence of the action of this ligament. The lower end of the ulna is, as a rule, displaced forward as well as inward, and. the absence of the prominent ulnar head from the dorsum of the wrist is notice- able. In the usual Colles' fracture the hand is inclined slightly to the radial side and the base of the thenar eminence is higher than normal. This radial displacement is sometimes pronounced, as shown in Figs. 356 and 364. In fractures showing extensive comminution of the lower end of the radius the deformity is often not characteristic and the condi- tion may be compound. When the fracture is produced by an auto-crank kick the displacement is often slight and the break is usually transverse. A Colles' fracture without deformity is some- times seen, though the condition is extremely rare. Even when the deformity is slight, it is, as a rule, characteristic. In oblique Colles' fractures the ventral deformity is more pronounced and lower than in the transverse type. "When the break is oblique the plane of the fracture is usually similar to that shown in Fig. 347, and the deformity is somewhat different from that seen in trans- verse Colles' fracture. In oblique Colles' fractures impaction, crushing of cancellous tissue and comminution are rarely present, and the rotary and angular elements in the deformity previously described are slight or absent. The lower fragment is displaced backward and slightly upward, but the axes of the two fragments are parallel, or nearly so, and the direction in which the articular surface looks remains unchanged. In Barton's fracture the deformity is slightly lower and more abrupt than in the typical Colles' fracture. The position of the radial styloid remains unchanged and the wrist is not broadened. Crepitus is elicited during reduction and it will usually be pos- sible to determine that the lower fragment includes only a small portion of the lower end and posterior aspect of the radius. In the reversed type of Barton's fracture the carpus is displaced for- ward instead of backward, and the radial styloid and posterior 258 FRACTURES AND DISLOCATIONS aspect of the lower extremity of the bone are found to be intact and unduly ]irominent when palpated. The symptojns of atypical fractures of the lower end of the radius vary \vi1h Ihe jiosition of the fracture ;iiiil the direction of tlie displaeeinent. Vertical fractures of the lower end of this bone are not accompanied by silver-fork deformity thoujjh they are almost invariabl}' prodnetive of considei-able broadening' of the wrist. An oblique fracture jiassino' from the inner l)order of the 1 one to the articular surface is often quite difficult to recojinize without the aid of the X-ray. An example of this type of fracture Fig. 369. Fig.s. 368 and 369. — Two views of an old epiphyseal separation complicated by frac- ture of the posterior aspect of the diaphysis. X-ray of this case shown in Figs. 348 and 349. Note the low ventral deformity caused by the lower end of the upper fragment and the lateral prominence of the lower end of the ulna. Deformity resembles Barton's fracture. Case first seen by author six weeks following accident. is show^i in Fio-. 329. In severe crushing injuries of the lower end of the radius the condition may be flail-like and quite apparent on the most superficial examination. The deformity accompanying epiphyseal separations is similar to that seen in the ordinary Colles' fracture. It is, however, slightly lower and more abrupt in outline and not accompanied by true crepitus unless complicated by fracture. Epiphyseal sep- arations are often complicated by fracture as shown in Figs. 348 to 353. "When the posterior aspect of the diaphysis is broken off and displaced with the epiphysis the deformity closely resembles FRACTURES OF LOWP^R END 0[<^ RADIUS 259 that seen in oblique Colles' fracture. The dorsal deformity is slight while the ventral deformity is pronounced and low. 'I'lic deformity accompanying- an uncorii[)licated epi[)}iyseal sef)ai-;i1ion is shown in Fig. 371. Fig. 371. _ Fig. 372. Fig. 371. — Uncomplicated epiphyseal separation of lower end of radius. Fi§. 372. — ^Same case immediately following reduction. Forearm partly secured to ventral splint. 260 FRACTTRKS AND DISLOCATIONS Diagnosis. — Colles' fracture is the most common break occurring ill the lower end of the radius and the symptoms are, as a rule, so characteristic that there should be little difficulty in recognizing the injury. The history of the case, the typical silver-fork de- formity, the elevation of the radial styloid, and the broadening of the wrist are symptoms which should be recognized at a glance. In typical cases the diagnosis of Colles' fracture is established with- out difficulty but the exact nature and position of the break and the presence of complicating fractures of the lower end of the ulna or of the carpus are often learned only when the wrist is submitted to the X-ray. J\Iany of the salient features of the fracture may be determined by the nature of the deformity (see "Symptoms," page 252), and the surgeon should gather these data during the examination. Prompt reduction is indicated and it is seldom advisable to await the returns of an X-ray examination before correcting the displacement. It is apparent, therefore, that no detail in the physical examination should be slighted which will aid in disclosing the nature of the fracture or the character of the displacement. When a fracture in this region is suspected the surgeon should compare the injured parts with the opposite wrist. The transverse diameters of the two wrists should be carefully compared. The possibility of associated lesions must be kept in mind while examining fractures of the lower end of the radius. Fractures of both bones of the forearm near the wrist, luxations of the lower tnd of the ulna, dislocations of the wrist and fractures or luxa- tions of the carpal bones are conditions which must be differen- tiated from fractures of the radius, and recognized as complications when they exist. When both bones of the forearm are fractured near the wrist, crepitus and abnormal mobility of the ulnar head may be detected on manipulation. It is often difficult to recog- nize complicating fracture of the ulnar styloid without the aid of the X-ray. Dislocations of the wrist are extremely rare and are seldom mistaken for Colles' fracture. Colles' fracture, however, is not infrequently wrongly diagnosticated as a dislocation. There should be no excuse for this mistake if the two deformities are compared. (See photographic comparison of the two condi- tions as shown in Figs. 378 and 379.) The deformity in disloca- tion is much lower and more abrupt in outline and the extensor tendons stand out prominently as they pass from the forearm to FRACTURES OP IjOWER ENJ) 0I<' RADIUS 2G Pig. 376. — Comparing the levels of the two styloids. The radial styloid is raised though its tip is still at a lower level than the tip of the ulnar styloid. Pig. 377. — Same comijarison seen from the dorsal aspect of foreavai. 262 FRACTLKKS AND DISLOCATIONS tlie hand. Neither the anterior nor the posterior type of luxation of the ulnar head occurs as a complication of Colles' fracture and as isolated, injuries the symptoms of these two dislocations are too characteristic and pronounced to require differentiation. In- ward luxation of the ulnar head, however, is a very common com- plication of Colles' fracture and is frequently overlooked. Broad- ening of the wrist, with inward and forward slumping of the ulnar head, is indicative of this rumplieation. On i)alpatioii, the lower end of the ulna is found less firmly attached to the radius than normal. It may be possible to palpate the fractured styloid. It is usually not difficult to difl'ereutiate fractures and luxations of Figs. 378 and 379. — Photogrnpliie compiivisoii of Colles' fracture and backward dislocation of wrist. The dislocation (lower picture) shows a much more abrupt deformity, except where the tendons cross the articulation and the ventral deformity is much lower. the carpus from ('olle.-i' fracture, yet lesioixs of the carpus accom- panying Colles' fracture are not very uncommon and may be overlooked. The carpus should be examined for deformity and crepitus. If doubt exists after the wrist is thoroughly examined it is advisable to resort to the X-ray. Thus the diagnosis is estab- lished, the details of the lesion or lesions are disclosed and the parts will have been subjected to the least possible manipulation and trauma. When, on the other hand, the presence of fracture is apparent on examination and the deformity has been imme- diately corrected, a Rontgenogram should be made to determine the completeness of reduction, to verify the diagnosis and to ex- clude associated lesions of adjoining bones. FRACTURES OF LOWER END OF RADIUS 263 Th(3 differentiation of Colles' fracture from simple sprain of the wrist is at times more confusing than would at first appear. Swell- ing of the parts and distention of the synovial slicnths following Fig. 381. Figs. 380 and 381. — Radial and ulnar views of Colles' fracture just before reduction. (See Figs. 382 and 383.) Figs. 382 and 383. — Two methods of grasping the wrist in reducing Colles' fracture. The arrows indicate the lines of force employed. a sprain may simulate, to some extent, the deformity of Colles' fracture. Unless one is familiar with the condition and a careful examination is made, a sprain may be mistaken for a fracture, or 264 FRACTURES AND DISLUCATIONS vice versa. Tlie soft crepitation of a synovitis should not be mis- taken for the true crepitus aceouipanying fracture. Synovial crepi- tation is limited to the course of the tendons and is not produced by sti-('ss (Ml tlu' lower end of the radius. Treatment. — Reduction should be effected at the earliest possible moment. The sooner the deformity is corrected the less pro- nounced will he the subsequent tiauniatic reaction. Reduction Fig. 384. — Shows the principles to be followed in reducing the usual transverse impacted Colles' fracture. A. Section of normal radius. B. Transverse impacted Col- les' of common type. G. shows lower fragment forced back into position. Note wedre- shaped space, the result of crushed cancellous tissue. If the fragment is released in this position deformity will recur since the posterior layer of compact tissue is not engaged. D. shows distal fragment forced forward, thus obtaining an engagement which prevents recurrence of deformity. E. represents a form of fracture in which ihe posterior cortical layer of the distal fragment is broken up. F. shows the use of pads on the splints to maintain reduction when the fracture is of the type shown in E. is best accomplished under anesthesia. In many cases a satis- factory adjustment of the frag-ment can be accomplished without this aid, yet with the patient unconscious and free from pain the surgeon is better enabled to obtain an accurate reposition of the fragment. If the fracture is impacted considerable force may be needed to free the lower fragment so that it may be replaced. In oblique Colles' fracture the lower fragment can, as a rule, be slid FRACTURES OF LOWER END OF RADIUS 265 back into position ])ut the derormity is lik'cly to recur if tfic fragments are not firinly engaged following reduction. For this reason the fractured surfaces should be forced together after the fragment has been replaced. When the fracture is transverse and there is impaction and crushing of cancellous tissue, reduction requires a somewhat different manipulation. In this form of fracture the fragments must be separated by traction and counter- traction to pull the lower end of the upper fragment out of the lower fragment. When this has been accomplished the lower frag- ment is pulled downward and forward and the deformity slightly over-corrected. In this way the layer of compact tissue on the UfcTx-toCa^ 5-joii>ya;: Fig. 385. ^/kn,- of the posterior splint below the plane of fracture and of the anterior si)lint above the break will tend to prevent the return of the silver-foi-k deformity. The best material for this sjieeial paddinu' is saddler's felt which may be obtained from any harness shop. It is elastic, holds its shape well and may be cut into pads of desired i)roportions. The splints should be a little broader than the forearm in its thickest part and should be loosely enough applied to avoid constriction. The forearm should not be bandaged before the splints are placed in position. The padding is never used with the expectation of actively forcing the fragments back into i)lace but only for the jmrpose of ])reventing redisplacement. One splint, usually the anterior, is secured in place by strips of adhesive. The opposite splint is then applied and may be removed separately during the after-treatment without depriving the fracture of the support offered by the opposite splint. (See Figs. 307 to 312.) In this way. the anterior splint supports the forearm and wrist while the surgeon is inspecting the parts and readjusting the dressing. It is of paramount importance that free circulation be present after the dressings are in place. During the first few days following the injury due allowance should be made for the swelling which comes with traumatic reaction. Constriction may be readily de- tected by examining the nails. The dangers of too tight bandaging and strangulation of the forearm have already been mentioned under "Fractures of Bones of the Forearm." The Bond splint and others of the same type which maintain the wrist in a position of ulnar flexion are of service in some cases but their value has been greatly overestimated. It has been customary for years to consider the position of the hand as exerting great influence on the recurrence of deformity. As a matter of fact there are a few conditions in which the position of the hand affects the position of the fragment, but in nearly all fractures in this region the prime requisite in avoiding the recurrence of deformity is the proper reduction of the deformity and firm engagement of the fragments. If the lower radio-ulnar articulation remains intact ulnar fiexion will tend to hold the lower radial fragment in reduction, but if the articulation has been broken up, this position will only increase the displacement of the ulnar head. Comminution of the lower FRACTURES OF l.OWKR END OF RADIUS 269 end of the radius, crushing of the cancellous tissue in this region and ohliquity in the plane of fracture are the inost eornraou causes of recurrence of deformity following proper redu(;tion, and the position of the hand during the after-treatment has little influence in maintaining reduction when these conditions exist. Flexion of the wrist places the extensor tendons on the stretch and they are thus supposed to exert a splinting action on the fragments. Ulnar flexion throws more strain on the ulna and relieves the radius, to some extent, of the shortening effect of the muscles of the forearm. It is questionable, however, if either of these posi- tions makes enough difference to be of practical importance in the treatment of Colles' fracture. Extensive comminution of the lower end of the radius renders the fragments difficult to maintain in good reduction and it is here that ulnar flexion will be found of most value, provided the lower radio-ulnar articulation has not been broken up. The reduction of Barton's fracture involves the same principles as already described in correcting the deformity of Colles' frac- ture. In atypical fractures of the lower end of the radius the surgeon must be guided by the nature of the fracture and the character of the displacement. If the type of the fracture is fully appreciated the surgeon will be better able to correct the deformity and hence the value of the X-ray, especially in instances in which difficulty is experienced in correcting the displacement. Occasionally cases are encountered in which reduction cannot be accomplished wdthout resorting to open incision. The local use of the ice bag during the first twenty-four to forty-eight hours wall be found of great service in controlling the traumatic reaction, especially in cases in Mdiich the causative trauma has been severe. Operative Treatment. — Operation is sometimes indicated when a satisfactory reduction cannot be otherwise obtained. A small fragment of bone may become interposed between the fractured surfaces and require removal before the deformity can be cor- rected. Direct reposition of the fragments through the incision will be all that is required in most cases. The common fracture of the lower end of the radius is best ap- proached through a longitudinal incision on the outer side of the wrist. This incision exposes the radial artery and nerve and the extensors of the thumb. Under cover of the posterior lip of the wound will be found the radial extensors of the carpus. The 270 KRACTI'RES AND DISLOCATIONS course of tlio radial artery is sometimes anomalous, winding: around the lower fourth of the radius instead of passing throuuli llie ana- tomical snuff-box. This condition may be recognized by palpating the arter}^ even before the incision is made. Oblique Colles' frac- ture and some of the atypical breaks seen in the lower end of the radius may need some form of internal fixation to prevent recur- rence of deformity. The placing of this material will depend en- tirely on the nature of the fracture and the character of the displacement. In oblique fractures which cannot otherwise be Fig. 392. Fig. 393. Fig. 392. — Skiagram showing radial epipliysis displaced to the radial side and a portion of the shaft of the bone carried with it. (Haubold — Journal A. 31. A.) Fig. 393. — Skiagram showing the detached fragment nailed to the shaft of tlie bone. (Haubold — Jotirnal A. M. A.) maintained in reduction a small loop of wire passing through the fragments will often accomplish all that is desired. In instances of pronounced radial displacement of the lower fragment a satis- factory fixation may be obtained in some cases by nailing the lower fragment to the upper as shown in Fig. 393. Ei)iphyseal separations seldom require operative intervention. Occasionally an untorn periosteum may offer resistance to the reduction of a dis- placed epiphysis and it may be necessary to divide this tissue be- fore the deformity can ])e corrected. Recurrence of deformity in an epiphyseal separation may be due to a complicating fracture of PRACTURI'^S OK ];()WI';K I'.NU OF liADIHS 271 the diaphysis (see Fig. 349) and to prevent this tciidciiey to dis- placement it may be necessary to wire the fragments of the di- aphysis together. Compound fractures of the lower end of the radius should be treated according to the principles as laid down under the heading of ''Treatment of Compound Fractures and Dislocations," page 789. In some cases of comminution of the lower end of the bone a circular wire will so bind the fragments together that the com- minuted bony area is brought closer together and the deformity lessened. In other cases the comminution may be so extensive that operative procedure is not advisable. Old cases of CoUes' fracture with deformity and pronounced loss of function may require operation for the correction of the de- formity and the breaking up of adhesions. This operation, how- ever, should not be undertaken without a careful study of the case including an X-ray examination. • One should determine, as far as possible, how much of the loss of function is due to the deformity, and how much is the result of joint and tendon adhesions, and whether or not there is a rarifying osteitis of the lower end of the radius. The loss of function is more often due to adhesions than to deformity, and hence the greatest good will, in most cases, result from a breaking up of these adhesions under anesthesia, Mdthout incision of the parts or refracture of the bone. Kecent cases may be refractured without incision, provided the condition is not more than three or four weeks old. It is usually best, how- ever, to produce refracture through an incision since more accurate work can be done in this way. After-Treatment. — The case should be seen daily for the first few days to adjust the dressings to the varying size of the forearm and wrist during the onset and subsidence of traumatic swelling. Recurrence of deformity should be watched for and corrected if it occurs. Disturbance of the circulation or pain (especially in the region of the three pressure points) calls for readjustment of the dressings and inspection of the region of fracture. The three pressure points just referred to are the head of the ulna, the bases of the second and third metacarpals and the thenar eminence. Undue pressure at these points may lead to sloughing of the soft tissues which is a painful, annoying and serious complication. The lower end of the anterior splint should be cut away on the radial 272 FRACTURES AND DISLOCATIONS side to avoid pressure on the thenar eniinenee as already described in the treatment of "Fractures of the Radial and Ulnar Shafts" on page 224. The posterior splint should be well padded oppo- site the hand and wrist to avoid undue pressure on the licad of the ulna and the bases of the metacarpals. If unusual difficulty is experienced in avoiding pressure on these points the posterior splint may have holes drilled through it corresponding to these promi- nences and the padding reapplied. Pain should not be pronounced after six or eight hours. The fingers must be moved daily during the entire course of the treatment. Immobilization of the fingers is folloAved by a loss of function which is probably worse than the sum total of untoward symptoms seen in untreated cases. It is much more important to secure a good functional result than it is to have the fragments in perfect anatomical relation, and it must Fig. 394. — Colles' fracture al)out twenty-four hours following accident. Displace- ment of fragrment slight b\it traumatic reaction pronounced. Swelling; masks deformity to ^eat extent. It is during the first twenty-four or forty-eight hours that there is danger of the circulation being interfered with as a result of the forearm swelling within the dressings. It is therefore imperative that the first dressings be loosely applied and the member closelv watched for signs of strangulation. (See Figs. 318, 319 and 320.) not be forgotten that function depends more on the early and free passive motion of the fingers and thumb during treatment than on anything else. The older the patient the more important is pas- sive motion. At the end of a week or ten days the posterior splint may be dispensed with, and both may be discarded, in the average case, two weeks from the time of accident. A strip of adhesive may then be placed about the wrist and the forearm carried in a sling with the hand hanging dependent in a position of ulnar flexion. In some cases the posterior splint may be retained for a week or ten da^'s longer as a precaution against external violence. This is particularly advisable in the treatment of children. Old patients should be allowed more time for union to take place. Un- FRACTURES OP LOWER END OF RADIUS 273 necessary strain to the wrist should be avoided for a month or more following removal of dressings, but the patient should be urged to use wrist and fingers freely so that function may be fully restored. In favorable cases gentle passive motion of the wrist should be begun as early as the end of a week or ten days follow- ing injury and kept up daily until union is present and function restored. Hot water and massage are of service in restoring the parts to normal free function and should be persisted in until recovery is complete. The after-treatment of atypical fractures and epiphyseal separations of the lower end of the radius involves the same principles as already given in the after-care of a typical Colles' fracture. Prognosis. — Bony union is well established at the end of three weeks in the healthy young adult. Complete supination will usu- Fig. 395. Fig. 396. Figs. 395 and 396. — Characteristic deformity following incomplete reduction of an oblique Colles' fracture. Note slight silver-fork deformity and transverse thickening of the wrist which results from rapture of the lower radio-ulnar ligament of fracture of ulnar styloid. Lateral and ventral slumping of lower end of ulna apparent. Case first seen by author at time this photograph was taken. ally be the last motion to be fully restored; this is particularly true in instances in which the lower radio-ulnar articulation has 274 KKACTrUKS AND DISLOCATIONS Fie. 397. — Aiuitlior ca.so of broadened wrist following' incomplete reduction of Colles' fracture. Patient present.s liimself for treatment becau.se of slow recovery and inability to use hand. "Wrist stiff, painful, etc. Case first seen by author at time this photograph was taken. Fig. 398. — Another case of slow and incomplete recovery following; Colles' fracture. In this ease the reduction has been excellent but the after-treatment has been faulty in that the patient's hand, wrist and fingers were completely immobilized for a period of six weeks. Adhesions between the joint surfaces and within the tendon sheaths have resulted and the X-ray discloses an osteitis of the carpus. Patient 55 years of age. (See Fig. 399.) Case first seen by author at the time this picture was taken. Fig. 399. — Osteitis of (In- carinis and l>asrs (jf llic jiu-lacarpals lollnwiii- .i Colles' fracture in which the condition was treated by prolonged imniol)ilizati()n. Tins condi- tion is not uncommon in patients past middle life in which the parts are immobilized for too long a period. .V condition such as this is very much easier to avoid than it is to treat, after it has become established. It should be remembered that thf possibility of fracture in breaking up adhesions is greater in a case like this than it would be if the carpal bones were normal. FRACTURES OF liOWRR FND OF RADiriS 275 been broken up or in cases in which the fracture has entered the sigmoid cavity of the radius. ]n older persons restoration of func- tion is much slower and adhesions in and about the tendon sheaths and in the wrist joint are more prone to occur and are important elements in restricting motion. The complete restoration of func- Fig. 401. Figs. 400 and 401. — Contracture of the hand following Colles' fracture. Nerves injured either at the time of the accident or during the after-treatment from too tight bandaging. Indication of beginning contracture first noted at the time the splints were removed. First seen by author about eighteen months after the injury. tion depends more on the early and persistent use of passive mo- tion than on the anatomical redviction of the displacement. The prognosis, therefore, is more or less directly dependent on the proper use of passive motion during the after-treatment. In some cases joint and tendon adhesions and rarifj'ing osteitis develop in spite of the most careful treatment (see Fig. 399) but tliese con- 276 FRACTURES AND DISLOCATIONS ditioiis are fortunately rare in cases receiving tlie proper care dur- ing the after-treatment. Restricted motion of the wrist and fingers, and slight pain especially in the region of the ulnar styloid, are conditions which may persist "for months but will, as a rule, pass oft' with massage and hot applications. The more faithfully passive motion is carried out during the time the wrist is immobi- lized the less pronounced will be these annoying sequehe. Destruc- tion of bony tissue izi the lower end of the radius, such as occurs in impaction and extensive comminution, may render accurate re- duction, even under operation, impossible and hence some deformity will result, but this does not necessarily mean any considerable loss of function. An ordinary uncomplicated Colles' fracture which is properly reduced and treated should be followed, in a healthy adult, by complete restoration of function. In older patients a perfect func- tional result will be more difficult to obtain. In atypical fractures of the lower end of the radius the prognosis will vary with the severity and character of the fracture. Uncomplicated epiphyseal separations of the lower end of the radius should be followed by perfect results both functionally and anatomically if the epiphysis is properly reduced. Disturbances in the growth of the radius are rarely seen following epiphyseal separations, if anything like a perfect reduction has been obtained. Even in cases in which pronounced displacement is allowed to persist defective growth is rarelv seen, CHAPTER XX. INJURIES TO THE CARPUS. Under this heading is included: radio-carpal luxations (com- monly spoken of as dislocations of the. wrist), meclio-carpal luxa- tions, and fractures and dislocations of the individual carpal bones. Surgical Anatomy. — The strength of the wrist is such that when subjected to violence fracture is more likely to occur above or Fig. 403. Figs. 402 and 403. — Ventral and dorsal views of ligaments of hand. U.. nlna ; R., radius; TJ.N., uncinate; P., pisiform; T., trapezium. below this region than in the carpus itself. The ligaments bind- ing the bones of the forearm to the carpus, those between the 277 278 FRACTURES AND DISLOCATIONS carpus iiiiil iiu't;ic;irpus, and the inter-cai'pal ligaments are all licax y ami strong but the main strength of the wrist is dependent on Iho numerous and heavy, tendons which pass from the forearm to the liand, and are bound firmly to the bones by the annular ligaments and the fibrous compartments through which they run. It should be remembered that though the carpus is actuated by the flexors and extensors passing from the forearm to the hand, only one of these muscles is inserted into the carpus. The flexor carpi ulnaris is inserted into the pisiform but since this bone is Fi5. 404. — lidiHs (if niinrnil wrist. 1 M, 2 M, 3 M. J ^f , ami 5 M indicate metn- carpals: Tm., Traijeziuin , Td.. Tiap'-zoid; O. M., Cs Magnum; V., Unciform; C, Cunei- form; P., Pisiform; SI., Semilunar; Se., Scaphoid'; VI. , Ulna; R., Radius. functionally a sesamoid bone and not truly a bone of the carpus we may consider the carpus as free from the insertions of the muscles of the forearm. Thus the carpus is actuated indirectly through the metacarpal bones. Some of the intrinsic muscles of the hand arise from the ventral surface of the lower row of carpal bones, but their action is on the metacarpus rather than the carpus. The radio-carpal or wrist joint is a condyloid articulation. The articular surface of the lower end of the radius and the inferior surface of the triangular fibro-cartilage form the socket, while the upper surfaces of the scaphoid, semilunar and cuneiform bones INJURIES TO THE CARPTJR 270 form the condyle. Motion of this articulation is possible in every direction except axial rotation. The plane of the radio-carpal joint is on a level with the tip of the ulnar styloid. Luxations of this joint may take place in any direction but are extremely rare; Fig. 405. Fig. 406. Fig. 405. — Old Colles' fracture. Ti-iangulare present. Indicated by arrow. Fig. 406. — Anotlier old Colles' fracture with anomalous triangulare. Fig. 40 7. Fig. 408. Fig. 407. — Example of anomalous centrale. Fig. 408. — Space in carpus corresponding to site of centrale. Anomalous condition present though the embryonic elements entering into formation of centrale show no signs of ossification. only a few cases of each type having been recorded. Colles' frac- ture is frequently mistaken for dislocation of the wrist, and the cases of this luxation reported prior to the advent of the X-ray are particularly untrustworthy. Dislocation of the wrist compli- cated by fracture of the lower end of the radius is not nearly as 280 FRACTURES AND DISLOCATIONS uncommon as tlie pure luxation. AVIumi the carpus is displaced backward and up\vard and tlie i)osterior lip of the radius is broken off and displaced with the carpus, the condition is known as Bar- ton's fracture and has been desarihed under "Fractures of the Lower End of the Radius." When the i'ever>se condition obtains, that is, when the ventral lip of tlie radius is broken off and dis- Pig. 409. — Old united fracture of scaphoid. Fig. 410. — Fracture of semilunar. Fis;. 411. — Fracture of scaphoid. placed forwai'd and upward with tlie carpus, it is known as a "reversed Barton's fracture."" I^ateral luxations of this joint, either with or without fracture, are too rare to be considered as a type. It is probable that a large proportion of the reported cases of luxation of the radio-carpal joint (especially those not examined with the X-ray) have in reality' been Colles' fractures or at least fracture-luxations of Barton's type. IN.TTTRTER TO TTIE CARPTJR 281 Fig. 412. — Fractured cuneiform. Fig. 413. Fig. 414. Figs. 413 and 414. — Anteroposterior and lateral views of luxated semilunar. 282 FRACTURES AND DISLOCATIONS Luxations of the mcdio-carpal articulation probably never occur as a pure dislocation, following accurately the lines of the medio- carpal articulation. They are usually complicated by fracture of one or more of the carpal bones with displacement of the fragments. Isolated fractures and luxations of the carpal bones are not very uncommon injuries and are now known to accompany frac- tures of thi' lower end of the forearm more frequently than was supposed prior to the establishment of the Rontgen ray as a diag- nostic measure. Fig. 416. Figs. 415 and 416. — Old Colles' fracture showing un-united fracture of ulnar styloid and an abnormal condition in the scaiJhoid. Either an old fracture or a "divided scaphoid." A study of tlie X-ray records of these injuries lias brought up a most important and confusing subject ; namely, the anomalies of the carpal bones. The development of the eari)us shows con- siderable variation and anomalies of the bones of the carpus are comparatively of frequent occurrence. It will be impracticable, here, to enter into all the possible variations ; the reader is referred to the most excellent and thorough work done by Thomas Dwight, as set forth in his book on "Variations of the Bones of the Hand and Foot." Occasion will be taken, however, to call attention to some of the more common anomalies which are, at times, con- INJURIES TO THE CARPUS 283 founded with fracture. Anomalies may consist of supernumerary- bones, due either to the persistence of embryonic elements or to the division of one or more of the carpal bones. Another form of anomaly is seen in instances in which two or more of the carpal bones are fused, or in which fusion has taken place between an accessory bone and one of the bones of the carpus. These anoma- lies of fusion are of anatomic interest onJy, since there is no occasion for mistaking them for fractures as is the case when super- 417. — "Divided, scaphoid." numerary bones are present or when one of the bones of the carpus is divided. The following anomalies are described in detail by Dwight, and from a surgical standpoint are the most important occurring in the carpus. The scaphoid is not uncommonly divided, either partiall^^ or com- pletely, into two lateral portions. An example of this condition is shown in Fig. 417. This anomaly resembles fracture of the scaphoid. 284 FRACTURES AND DISLOCATIONS Fig. 418. — C'entrale iireseiit ami fused witli os magnum. Fig. 419. — Fractured trapezium indicated by upper arrow. CoUes' fracture in- dicated by lower arrow. INJURIES TO THE CARPUS 285 The semihmar sometimes gives the appearance of being divided into a palmar and a dorsal portion, but this is probably due to an accessory bone to be spoken of later (the epihmatum). The cuneiform varies considerably in both size and form but sel- dom presents any anomaly which might be mistaken for fracture. The pisiform may show some variations in size and shape ; there may be an accessory pisiform. The hamular process of the unciform may be separate from the body of the bone and the line of division may be mistaken for a fracture. The epiluiiatum and Jiypolunatum are -two accessory bones which (when present) are situated at the tips of the crescentic-shaped semilunar. The dorsal anomaly (the epilunatum) is more fre- quent and usually of larger size than the hypolunatum which occurs opposite the ventral horn of the semilunar. The epilunatum is sometimes well developed while the semilunar is correspondingly smaller than usual. This condition gives the appearance of a di- vided semilunar and may be mistaken for fracture. The styloid process of the middle metacarpal is sometimes free and appears as a supernumerary bone in the carpus. The centrale is a supernumerary ossicle sometimes seen between the OS magnum, scaphoid and trapezoid. An example of this con- dition is shown in Fig. 407. Fig. 408 shows the same condition except that the anomalous structure has never ossified, though the space for its accommodation persists. Fig. 405 shows an example of the triangulare which may be mis- taken for a fractured ulnar styloid. The radiale externum is an accessory bone situated on the radial side of the scaphoid and is said to be the separated tubercle of the scaphoid. The ulnare externum is an accessory ossicle on the ulnar side of the carpus internal to the cuneiform. The suhcapitatum is an accessory ossicle situated at the base of the OS magnum. It is said to represent the detached base of this bone. . Numerous variations may occur in the carpus which have not been mentioned but those cited above are the ones most likely to be confused with fractures in this region. The recognition of these anomalies and their differentiation from fractures of the carpus will be considered later under Diagnosis. 286 FRACTURES AND DISLOCATIONS The bones of tlio wrist begin to ossify in the following; order: the OS niagniun and Ihe nneiforni during th(> tirst year, the cunei- form during the third year, the semilunai- and trapezium durinoj the fifth year, the seaphoid during the sixth and the trapezoid during the eighth year. The ]iisiform begins to ossify anywhere from the eighth to the twelfth year. The scaphoid is oeeasionally broken as a result of forces similar to those producing Colles' fracture. The line of fracture is usu- ally across the middle of the bone as shown in Fig. 411. This fracture is not an uncommon complication of fractures of the lower end of the radius. A fragment of the scaphoid may be dis- placed or luxation of the entire bone may accompany fracture of the lower end of the radius or some of the other bones of the carpus. The few reported cases of uncomplicated luxation of the scaphoid have been of the backward type and were probably due to forced flexion of the wrist. Forward luxations seem to be in- variably complicated by some other lesion, such as fracture of the lower end of the radius. The semilunar is rarely fractured as an isolated injury. Luxa- tion of this bone, however, is not uncommon and may be accom- panied by fracture of the scaphoid or other lesions in the adjoining carpal bones or in the radius. The displacement in luxations is almost invariably forward, the bone apparently being driven from its position among the other carpal bones by forced dorsal flexion of the wrist. The cuneiform is rarely injured except in general crushes of the carpus. The uncifornh is rarely injured except as the result of direct violence, though a few cases of isolated luxation have been reported. Both fracture and luxation are occasionally seen in the os mag- num though the latter condition is almost always partial, or more properly a subluxation. The displacement is backward and the result of forced flexion of the wrist. Chronic subluxations of the head of the os magnum may result from heavy manual labor, espe- cially in children. Both fractures and luxations of the trapezium and trapezoid are exceptionally rare as isolated injuries. The pisiform, is known to have been broken through the action of the attached flexor carpi ulnaris and luxation of this bone has been reported a number of times. The pisiform is sometimes broken as INJURIES TO THE CARPUS 287 a result of direct violence. The position of this hone is more ex- posed than other bones of the carpus. The displacing action of the flexor carpi ulnaris may separate the fragments. Rupture of the piso-raetacarpal and piso-nncinate (tlie equivalents of the ten- don below the bone) may resvilt in an upward luxation of the pisiform. In crushing injuries of the carpus any or all of the bones ma}' be injured, depending on the nature and severity of the trauma. Symptoms. — The symptoms accompanying fractures and luxa- tions of the carpus depend on the nature of the injury and the position of the resultant lesion or lesions. Ill dislocations of the wrist (radio-carpal joint) the carpus is usually displaced backward. The deformity is low and al^ruj)! in Fig. 420. — Severe compound fracture dislocation of wrist sustained in railroad accident. Skin is the only tissue connecting forearm and hand. Rubber tournic[uet seen in position having been applied to control hemorrhage immediately following acci- dent. Picture taken just prior to amputating. outline and the extensor tendons stand out prominently as they pass from the dorsum of the forearm to the back of the hand. The clinical appearance of this deformity is well shown in Fig. 379. Palpation of the lower end of the radius will show that this bone is intact if the condition is a pure luxation. Pain and loss of function accompany the injury and are pronounced. Swelling 288 FRACTURES AND DISLOCATIONS develops rapidly and if the case is not seen soon after the accident the deformity is to some extent obscured. Tf this luxation is com- plicated by fractui-e of the lower end of thf radius crepitus will be present and" there is likely to be a tendency to recurrence of deformity foUowinu' redm-tion. In the anterior form of luxation the deformity is of the gardener 's-spade type and resembles the displacement seen in reversed Colles' fracture. The deformity, however, is lower and more abrupt in outline and the posterior lip of the lower end of the radius stands out ])i'otiiineiitly. Since this luxation is fre(|uently complicated by fracture of the lower end of the radius crepitus nuiy be present. The symptoms accompanying ni'dio-carixiJ luxations closely re- senil)h' those of dislocation of the radio-carpal articulation. The Fig. 421. — Slight dpformitv following compound crushing injury of the lower end of ulna and radius and the xilnar side of carpus. Wrist was caught in large gears. Picture taken some years after recovery. deformity, how^ever, is slightly lower and it may be possible to pal- pate the proximal row of carpal bones in their normal relations with the radius. Since this luxation is practically alw'ays compli- cated by fracture of the carpal bones or of the lower end of the radius crepitus is to be expected. The luxation may be either for- ward or backward and accordingly the deformity may be either of the silver- fork or gardener 's-spade variety. The symptoms accompanying isolated fractures and luxations of the carpal bones are indistinct and not characteristic as compared with other lesions in this region. This will be found particularly true in cases in which swelling is pronounced. The following symp- toms, however, are more or less peculiar to lesions of the different bones. INJURIES TO TflE CARPUS 289 Fracture of the scaphoid is usually accompanied by local tender- ness in the "anatomical snuff box." The hand may be slightly ab- ducted and the vertical depth of the radial side of the carpus may be somewhat diminished if the scaphoid has been crushed or com- pletely luxated. It may be possible to elicit crepitus and in some cases it may be accurately enough located to be recognized as ema- nating from the scaphoid. Isolated luxation of the scaphoid is a rare condition and the symptoms vary, according to the direction of the dislocation, whether or not the scaphoid is fractured as well as luxated and the completeness of the displacement. Palpation at the back of the wrist may reveal the absence of the scaphoid from its normal position if the luxation is ventral, or on the other hand, there may be an abnormal prominence on the dorsal aspect of the carpus if the luxation is backward. Crepitus may be pres- ent if fracture complicates the luxation. The symptoms accompanying fracture of the semilunar are simi- lar to those of fracture of the scaphoid. Fracture of the semi- lunar, however, rarely occurs as an isolated injury, and when crepitus is detected in this region of the carpus it is fair to pre- sume that the lesion is situated in the scaphoid rather than in the semilunar. In forward luxations of the semilunar the displaced bone may be palpated on the ventral aspect of the wrist. In back- ward luxations it may be recognized as a hard prominence just below the radius and at about the middle of the carpus. Fracture of the cuneiform is practically unknown except as a part of extensive injuries in which the carpus is crushed. The author knows of no case of isolated luxation of this bone. The symptoms to be expected, however, would resemble those accom- panying fracture and luxation of the scaphoid and semilunar. Fracture of the pisiform is not necessarily accompanied by char- acteristic symptoms even though the bone is more superficial than other bones of the carpus. The displacing action of the attached muscle may so separate the fragments that crepitus cannot be ob- tained. Pain on use of the wrist and local tenderness may be the only symptoms. In upward luxations of this bone it may be pos- sible to recognize the altered position. Fracture of the os magnum is accompanied by pain and tender- ness in the center of the carpus, more or less loss of function and crepitus when the carpus is properly manipulated and palpated. The condition, however, is rare and easily confused with other 290 FRACTURES AND DISLOCATIONS fractures in this region. Luxation of tliis bone is quite rare. A number of eases of subluxation of the liead of the os ma«;nuin liave been reported. They have been aeeompanied by an luidnc jironii- iience on the doi-sal aspect of the carpus, especially during com- plete dorsal flexion of the wrist. The loss of function produced by these subluxations is siii'|irisiiii:ly sliuhl. v: Fnicturcs of the Irapeziiim anil traixzuid are extremely rare except in severe crushes of this region. They may occur, however, and are accompanied by crepitus and mobility at the base of the first or second metacarpal, as the case may be. Crepitus in the region of the base of the first metacarpal is almost always caused by Bennett's fracture and rarely by fracture of the trapezium (see "Fractures of the jMetacai-pals," page 297) . Luxations of cither of these bones is extremely rare, and since only dorsal luxations have been reported, the prominence of the displaced bone may be ex- pected on the dorsal aspect of the carpus. Fracture of the tmciform is practically unknown except as a complication of luxation or in severe crushing injuries of the carpus. The process has been reported as broken off accompanying luxation. Diagnosis. — Theoretically the diagnosis of fractures and luxa- tions of these bones should be easy but the difficulty of ascertaining the exact nature of these injuries is shown by the frequency with which the diagnosis is changed after the X-ray has been employed. The appearance of the wrist is so characteristic in luxations of the radio-ulnar joint that it would, seem almost impossible to fail in recognizing the nature of the injury. It is a well known fact, however, that Colles' fracture is freciuently mistaken for disloca- tion of the wrist. One who has never seen a dislocated wrist should hesitate in pronouncing an injury of this region a dislo- cation unles the diagnosis has been confirmed by an X-ray ex- amination. (See Figs. 378 and 379.) Medio-carpal luxations are extremely rare and it wall be safer to make only a tentative diag- nosis pending the report on the X-ray, even though one feel reason- ably certain of the condition. The size of the carpal bones and their compact arrangement are such that accurate diagnoses of isolated lesions of these bones are almost impossible. The important point to be determined by in- spection and palpation is w'hether or not fracture or luxation exists. The treatment of the different traumatic lesions in this INJURIES TO TriE CARPUS 201 region is similar, and the details of the damage done may be learned by resorting to the X-ray. The carpus is most satisfac- torily palpated by flexing the wrist. This position exposes the dorsal surfaces of the carpal bones and palpation will then reveal any abnormal prominence or depression. Slight passive motion while palpating the carpus in this way will usually elicit crepitus in the presence of fracture. One should not fail to use the oppo- site wrist as a standard of comparison. In the interpretation of X-ray plates one should keep in raiud the more common anomalies as mentioned under the heading of "Surgical Anatomy," on page 282. The Rontgenographic recog- nition of anomalous bones depends on the position and structure of the supernumerary ossicle and its presence in the opposite carpus. The X-ray plate should show the structure of the bones of the carpus as well as their outlines. It should be remembered in this connection that the structure of supernumerary bones is similar to that of the normal bones of the carpus. This point is of importance in distinguishing anomalous bones from fractures. The interior of each bone is composed of cancellous tissue while the surface is finished oif by a thin layer of compact bone. A fractured surface will be more or less uneven and the trabeculae of the cancellous tissue will open onto the line of fracture. The trabeculee of an anomalous bone do not open onto any surface but are covered by a thin layer of compact tissue which shows as a thin continuous line in the X-ray plate. Anomalous bones are not necessarily bilateral, yet if an osseous anomaly of development is found in one side of the skeleton an X-ray of the same region on the opposite side of the body will almost invariably show a cor- responding condition. Treatment. — Reduction of luxations of either the radio-carpal or medio-carpal joints is accomplished by traction and counter-trac- tion with direct pressure over the prominent displaced carpus. It is seldom that difficulty is experienced in correcting the dis- placement. There is rarely any tendency to recurrence of deformity in uncomplicated cases. Fracture luxation of the wrist may tend to recur if the radial fragment is large. Following reduction the wrist should be immobilized on a short ventral splint. The further conduct of the case will be considered under ''After- treatment," page 292. Displacement is seldom pronounced in fractures of the carpal bones and when reduction is necessarv it 292 FRACTURES AND DISLOCATIONS will usually oonsist of forcino; prominont fracfments back into posi- tion. Kecluctioii of luxations of the mi-pal bones may bi' readily accomplished iu some cases by direct pressure, while in other in- stances it may be impossible without operative intervention. In dorsal luxation of any bone of the carpus tlie wrist sliould ))e t\('Ki'd until the displaced bone is "started" hack into llic position which it previously oeeui)ied. When the bone is once "started" the hand should be extended until it comes in line with the fore- arm, when traction and countertraction are exerted and the carpal bone driven home l)y direct pressure. In the reduction of ventral luxations the opposite manipulation is followed. The wrist is fully extended, the dislocated bone started back into position, the hand then brought to a straiiiht line witli the forearm and reduction eomi)leted. Following any fracture or luxation of the carpus im- mobilization is indicated. Operative Treatment. — Operation is indicated in compound cases and in instances in Avhich reduction cannot be effected by manipulation. Closed luxations at the wrist seldom call for op- erative measures. Recurrence of deformity in fracture-luxations of the radio-carpal joint may require fixation of the radial frag- ment. Displaced fragments of carpal bones or a completely lux- ated bone may require removal through incision. Old fractures or luxations of the carpal bones with restriction of motion due to mechanical interference from a luxated bone or displaced frag- ment, may require operation with removal of the obstructing bone or fragment. After-Treatment. — Fixation of the wrist following fractures and luxations of the carpus is essential, yet early passive motion is equally necessary if the function of the part is to be fully restored. It is apparent that non-union of any one of the carpal bones would not offer any mechanical obstacle to the full restoration of function. Yet, on the other hand, it is a noteworthy fact that cases which are allowed free use of the wi-ist following the acci- dent do not show the complete and rapid recovery seen in cases treated by proper immobilization and passive motion. Early unre- stricted use of the wrist is followed by a chronic inflammation of the synovial surfaces which results in stiffening of the wrist. Pro- longed immobilization without passive inotion is followed by joint adhesions which are equally detrimental to function. The proper treatment consists in immobilization of the parts with early passive INJURIES TO THE CARPUS 293 motion. Passive motion should be begun as soon as the tranmatic reaction has subsided and shouhl be repeated at intervals of three or four days until the splint is removed. At the end of three or four weeks all dressings may be dispensed with and the patient instructed to gradually increase the use of the wrist. Massage and hot applications are of value in hastening the restoration of func- tion. Prognosis. — Uncomplicated fractures and luxations of the carpus in young or middle aged persons are followed in most in- stances by at least a fair restoration of function. In elderly per- sons the wrist is likely to remain painful and to show more or less restriction of motion in spite of the most painstaking treatment. Compound fractures of the carpus, especially crushes, have a much more unfavorable prognosis. If infection follows in compound cases the chances of a stiff wrist are great, to say nothing of the pos- sible loss of function in the fingers due to adhesions between the tendons and their sheaths. When function is restricted or pain- ful as a result of the displacement of one of the carpal bones, the outlook is good, if the condition is corrected by operative meas- ures. CHAPTER XXT. LUXATIONS OF THE CARPOMETACARPAL ARTICULATION. Surgical Anatomy. — The articulation between the carpus and nietaeaipal bones is heavy and strong, and complete luxations of tliis .joint are extremely rare. From a surgical standpoint the articu- lation may be divided into two parts : first, the articulation between the inner four metacarpals and the carpus, and second, the joint between the trapezium and first metacarpal. Tlie articulations between the inner four metacarpals and the carpus are functionally one continuous joint. The synovial cavity extends from the second to the fifth joint and is not subdivided by the ligaments. The three inner carpal bones articulate with each other above the plane of this joint and the metacarpals below the joint articulate with each other by their lateral surfaces. The inner four metacarpal joints are arthrodial in type ; the fifth joint is capable of a wider range of motion than the other three. The carpo-metacarpal joint of the thumb is one of reciprocal reception (saddle joint) and per- mits of motion in all directions except axial rotation. The articu- lation between the first metacarpal and the trapezium is sur- rounded by a capsule, is separated from the other carpo-metacarpal articulations and has its own synovial membrane. All five carpo- metacarpal articulations are known to have been luxated, and all except that of the little finger have been reported as isolated in- juries. Dislocation may occur in one or more of the joints simul- taneously, and a number of instances of luxation of all five articu- lations have been recorded. Luxation may occur in any direction l)ut the most common forms are either forward or backward. The lateral support which the inner four metacarpals offer each other explains the rarity of lateral luxations. The carpo-metacarpal joint of the thuml) is the most commonly luxated. ]\lore disloca- tions of this joint have been reported than of the other four carpo- metacarpal articulations combined. Backward luxations of the carpo-metacarpal joint of the thumb are by far the most common. 294 LTTXATTONS ()('■' CAUI'O-M KTACAKl'AT; A RTKU !I;ATI()N 205 Forward luxations are oxtrcnicly rare. Ijiixalions of lliis Joint are not infrecjuently eoyn|)li('ate(l l)y fracture of either tin; trape- zium or base of the lirst metacarpal or by luxation of the adjoining carpo-metacarpal joint of the index finger. Ijuxation of the carpo- metacarpal joint of the index finger is next in order of frequency and is more often displaced backward than forward. Luxations of the third, fourth and fifth carpo-metacarpal articulations are extremely rare. They may be either of the forward or backward type. Subluxations, especially of the backward type, are not as rare in the four inner metacarpals as in complete luxation. Di- vergent luxations have been reported in which some of the meta- carpal bases have been displaced backward while others were luxated anteriorly. This form of dislocation, howevei", is extremely rare and can hardly be considered as a type. Severe crushing vio- lence in this region may produce almost any type of fracture- luxation as in the carpus, and because of the superficial position of the bones is likely to be compound. Symptoms. — In luxations of the carpo-metacarpal joint of the thumb there will be loss of function, shortening of the thumb and "Characteristic deformity. In the backward type the base of the first metacarpal will be unduly prominent on the dorsal aspect of the carpus, just below the end of the radius. In the ventral type the trapezium may be palpated and the base of the metacarpal forms a hard prominence beneath the thenar eminence. Various degrees of angular deformity may be present as well as the over- riding displacement. The forward or backward displacement ac- companying luxations of any or all of the inner four articulations can be appreciated without difficulty if the case is seen early. If the injury is not examined before the onset of the traumatic reac- tion the swelling may be so pronounced that the nature of the deformity is not apparent. The shortening of the fingers, however, will be a symptom which will be evident even though the balance of the deformity is obscured by swelling. Diagnosis. — Luxation of any one of these joints should be recog- nized without difficulty if the case is seen early. When four or five of the metacarpals are dislocated simultaneouslj^ the traumatic reaction may be so severe that diagnosis is rendered difficult unless the patient is anesthetized or the X-ray resorted to. Fracture of either the carpals or metacarpals is not an uncommon complication and is recognized by the presence of crepitus. If doubt exists the 296 FRACTURES AND DISLOCATIONS X-ray should be employed. In interpreting X-rays of this region the anomalies mentioned under the Surgical Anatomy ol; "Injuries to the Carpus" on page 283, should be kept in mind. Treatment. — Reduction is usually accomplished without diffi- culty by traction, counter-traction and direct pressure on the dis- placed metacarpal base or bases. Luxation of the earpo-metacarpal of the thumb is more likely to give trouble in reduction than are the corresponding joints of the other fingers. If reduction can- not be effected by manipulation open reduction may be necessary. A tendency to the recurrence of deformity seldom occurs in any of these joints unless fracture complicates the luxation. Following reduction the wrist and hand (but not the fingers) should be im- mobilized on a short splint. The character of the splint is not essential as long as it fits the parts comfortal)ly and effects immo- bilization. Operative Treatment. — Operation is seldom indicated in the reduction of luxations of single joints. In luxations which can- not be reduced by manipulation the articulation should be exposed by a longitudinal incision and the displacement corrected by direct manipulation through the incision. Compound cases should be treated as described under "Treatment of Compound Fractures and Luxations" on page 789. After-Treatment. — The after-care of these cases is practically the same as that already given under "Injuries to the Carpus" (page 292). Early passive motion is most important. Prognosis. — The outlook in luxations of the carpo-metacarpal articulations is similar to that already given under "Injuries to the Carpus. ' ' Loss of function in the first carpo-metacarpal articu- lation will lead to difficulty in opposing the thumb against the fingers, and will constitute a serious handicap in the use of the hand. In compound cases the prognosis is much more unfavorable, especially in the presence of infection. CHAPTER XXII. FRACTURES OF THE METACARPALS. Surg-ical Anatomy. — The structure of the metacarpals resembles that of other long bones with the exception of the ossification. The ossification of the inner four bones is the same. One center for the shaft and base, and one for the distal end or head. The center for the single epiphysis is first seen about the third year Fig. 422. — Fracture of the base of the first metacarpal entering the joint. Bennett's fracture. and joins the shaft during the twentieth. The metacarpal of the thumb has its single epiphysis located at the base. It begins to ossify during the third year and joins the shaft in the twentieth. Occasionally this bone has an additional epiphysis for the head 297 298 FRACTURES AND IHSLOOATK )NS wliicli is visihlf ;i1 the scvnitli or eij;li the nasal cavity. F. R., Vertical plate of frontal; JV., Nasal bone: N. S., Nasal spine; N.P., nasal process of superior maxilla; C. G., Crista Galli ; ,S'. T., Superior turbinate; If. T., Middle turbinate; I. T., Inferior turbinate; S., Body of sphenoid; Pal., Palate bone; P.P., Palatal process of superior maxilla. above with the frontal (at the nasion) and in the median plane with each other. The two nasal bones meet in the median line and rest upon the spine of the frontal in much the same manner as the rafters of a roof rest upon the king-beam. This nasal spine is, in turn, backed up by the vertical plate of the ethmoid. This continuity of bony tissue, from the nasal bone to the christa galli, explains the possibility of a blow on the nose displacing the ver- 323 324 FRACTrRES AND IMSLOCATIONS Ti<';il plate of tlio ctlnnoid upward into the anterior fossa of the skull. In young sul),ieets the artieulations in the bouy fi^aniework of the nose are distinct and eontain more or less intersulural tis- sue, but in old age the sutures are ossified and the dift'erent bones become continuous. It is therefore evident that in the aged a greater amount of the trauma of the nose injuries is transmitted 1() the vertical plate of the ethmoid and septal complications are more conunon. Tlic lower half of the nasal bone is thinner and more friable than the upper half; the inferior border is sharp and has attached to it the upper lateral cartilages of the nose. In the less severe cases fracture is limited to the lower i)ortion of the nasal bones because of the more exposed position and weaker construction. The deep surface of the nasal bones is covered by nuicous mem- liiaiie which is commonly lacerated in fracture with displacement, and hence fractures of the nasal bones, which are usually considered simple (and are simple as far as the skin is concerned) are in reality rendered compound by laceration of the mucous lining on the deep surface. The bony septum is composed of the vertical plate of the eth- moid above and the vomer below (see Fig. 457). The angular interval between the ethmoid and the vomer is filled in by the cartilaginous septum. This cartilaginous septum ar- ticulates with the antero-inferior border of the vertical plate of the ethmoid and is continued into the vomer below. The junction of the cartilaginous septum with the anterior border of the vomer is peculiar because of the unusual manner in which the vomer is ossified. The ossification of the vomer begins in a single center and spreads in such a manner that two lateral plates of bone result, with a median layer of cartilage between them, which is continuous anteriorly with the quadrangular septal cartilage of the nose. Union between the two lateral plates of bone does not take place until after puberty. This peculiar arrangement results in the articulation between the vomer and the cartilage being stronger than the upper articulation between the ethmoid and the same cartilage. These anatomical points, together with the fact that the trauma is more directly transmitted to the upper part of the sep- tum, account for the more frequent displacement taking place between the ethmoid and the quadrangular cartilage in youth. Unless the interior of the nose is carefully inspected earl}^ in the FRACTURES OF THE NOSE 325 treatment, septal displacements may p;o nnreeosnized diirinji: the time that treatment would be most efficient. The angular artery and vein (continuations of the facial vessolsj are found running in a nearly vertical direction behind and lateral to the nasal bones, in which position they may give rise to troublesome hemorrhage when injured in severe compound frac- ture of the nose. The nasal nerve, a branch of the ophthalmic division of the trifacial, runs longitudinally on the internal surface of the nasal bone after having passed from the orbit to the nasal cavity by way of the anterior ethmoidal foramen and nasal slit. The upper portion of the vertical plate of the ethmoid is grooved for the passage of the ethmoidal nerves from the Sclmeiderian membrane to the olfactory bulb. The nasal nerve is, strictly speaking, a nerve of sensation, while the olfactory nerves have to do with the sense of smell ; the juxtaposition of these nerves Avith the bones involved accounts for the frequent disturbances of smell and sensation following fractures in this region. The mucous membrane of the nose is highly vascular, and in cases where a large vessel is lacerated we may experience consider- able difficulty in controlling hemorrhage. Etiology. — Fractures of the nasal bones and adjoining bony structures are tlie result of direct violence, such as blows on the face, falls and trauma sustained by various means. Fractures of the nasal bones constitute between four and five percent of all fractures. The injury is most commonly seen as the result of brawls. Symptoms. — The prominent symptoms of fracture of the nose are deformity, mobility and crepitus. Swelling of the soft parts rapidly follows the trauma and epistaxis is practically constant and appears immediately following the injury. There is more or less obstruction to nasal respiration, depending upon the inward displacement of the fragments, the swelling of the mucous mem- brane and the accumulation of clotted blood within the nasal cavities. The more extensive the region involved by fracture and the more pronounced the trauma, the greater the frequency of pronounced nasal obstruction. In severe cases where the fracture extends well backward involving the nasal canal, in the nasal process of the superior maxilla, we may have obstruction of the nasal duct with consequent lachrj'mation of the aft'ected side. Oc- 326 FRACTURES AND DISLOCATIONS easioiially we havo enipliysenia of llic eyelids and face as a result of air liavinuf been forced fi'oin the nasal jtassaiies ijito the snb- Fig. 458. — Old fracture of nasal bones with lateral displacement. Fig. 459. — Old fracture of nasal bones with lateral displacement. Fig. 4G0. Fis. 401. Fig. 460. — Separation and angular displarcnicnt of lateral and septal cartilage.s to patient's right. Fig. 4C1. — Fracture of nasal bones with displacement to right. Partial separation of lateral and septal cartilages with displacement to left. cutaneous cellular tissue. The nature of the late S3'mptoms will vary according- to the presence or absence of infection. The cir- FRACTURES 0\P THE NOSE '421 culation is extremely free in this region, the vitality and resistance of the tissues great, and accordingly we find recovery more y)rompt and complete than might otherwise be expected. Necrotic hone is seldom seen, and infections, except when virulent, are short-lived. Suppuration, however, when once established, may persist for weeks if there are particles of necrotic bone present. The dis- charge will keep up until these pieces have been removed or thrown off. Diagnosis. — Diagnosis of fracture of the nose is based upon the symptoms already enumerated; deformity, mobility and crepitus. Fig. 463. Figs. 462 and 463. — Two views of a case of destruction of the nasal bridge due to syphilis. Deformity resembles deformity following severe fracture. Deformity, as observed in these cases, is not as reliable from a diagnostic standpoint as it is in fractures of other regions. This fact is due to the variability of the normal nasal outline together with the frequent presence of old unreduced deformities following previous fractures. If the bridge of the nose is gripped between the thumb and the index finger the stability of the bones may be ascertained and crepitus elicited. The question of mobility is rather variable. During examination it is not infrequently possible to displace the fragments from side to side with but slight effort : but on the other hand, we often see cases in which the bones have been for- 328 FRACTURES AND DISLOCATIONS cibly displaced to one side and have apparently become wedged, requiring considerable force to return lliem to their normal rela- tions. A "long slender instruincnt siniilai- 1o the divider, when properly passed upward beliiiul Hie seat of fracture, will enable Fig. 464. — Fulling in of cartilages in old case of syphilis. Fig. 46.1. — Case lied to the lower jaw. The intraoral arm carries a block tin form which is ti'iuimed and bent to lit the teeth while the lower arm caiM'ies a ix'i-foralcd, ad.jnstahli', aluniinum clnn piece for couiitei'-])ressui-e. The inti'aoral bloci^ tin form is notched to facilitate bentling and tittino' to the teeth; this gutter may be filled Fig. 497. — The ^[;^t;^.s spVint. An excellent aiipm-atus for the treatment of cer- tain fractures of the lower jaw. This splint is adjustable and is sujiiilied with differ- ent sizes of chin plates and dental splints. with giitta-i)ei'cha or dental composition to obtain more lirm and accurate contact between teeth and splint. This splint will give very satisfactory results in the usual fracture of the body and may be applied with little difficulty. The three splints just described together with the one following have the common advantage of allowing motion of the lower jaw during the after-treatment. Soft food may be masticated aftei- the first few days and the patient has litth; difficulty in talking. The splint j)ossessing these advantages in the greatest d(;gree is the following : 4. Dental splint cemented to the teeth. (Heath.) This splint is made of metal according to principles similar to those just described in producing the vulcanite splint. The dif- FRACTURES OP LOWER JAW '>H:'> Fiff. 498. — Metal dental splint for cementing to the lower teeth. Pig 499. — Same splint with the teeth in occlusion. In placing this splint lu posi- tion the greatest care should be exercised to see that both splint and teeth are thor- oughly dry, as otherwise the cement will not hold. The mucous surfaces are walled away with sheet cotton. 364 FRACTURES AND DISLOCATIONS fereiice in material, liowcvci-. will necessitate an altered laboratory teehniqiie, whieh is as follows: jilaster easts of the two dental arcades are made and the deformity in the lower one corrected as descrilicd uiidcr hcadiii!^' No. 2, page ;}5!). The cast of the Fig. 500. — Edmund's forceps un- rlaiuiiiiiir iii<'t:il sjiliiit to tlir l.asrs i\i tlii> tppth. Slipping of the instrument imd injury to tlie gums and alveolar process is prevented by the set-screw between the jaws which engages the crown of the tooth. lower denture is built up so as to do away with all undercuts, after which it is shellacked, dusted with soapstone and demoiuited from the articulator. A counter-impression is next made from it in oiled sand and the die formed bv filliiiu' this sand mould with Fig. 501. — Cast aluminum splint cemented to the teeth for tlie fixation of a fracture of the lower jaw at the symphysis. In making this splint the patient's "bite" was taken in wax and the splint made from this so that the upper surface occludes with the upper teeth. Lack of occlusion between the splint and tlie upper teeth is uncomfortable and annoying to the patient during the after-treatment. molten zinc. After cooling the die is removed, inverted in the moulding flask and packed about witli sand so that the tips of the teeth alone are exposed. Molten lead is then poured into the flask to form the first or shallowest counterdie. Three or four counter- FRACTURES OP LOWER JAW 365 dies of graded depths should be made. Tliis is accomplished by lowering the level of the sand in the flask, thus exposing a greater portion of the die to the molten lead. The splint is made by swedging metal between the die and countcrdie. The most shallow counterdie is used first to start the metal of the splint, after which the deeper eounterdies are used in ordej' until by means of the deepest or complete counterdie the metal of the splint is forced into perfect form. Aluminum, silver or gold may be used in making the splint. After swedging is completed th(! splint is trimmed so that the edges will not impinge on the gums or cut the tongue. The final step consists in polishing, after which the splint is ready for use. The hollow side of the splint is then filled with cement and forced onto the teeth, care being taken to pre- vent the cement from being driven downward between the gums and teeth. The fixation of the splint to the teeth is rendered more secure by the use of Edmund's forceps (see Fig. 500) before the cement sets. This instrument is used to clamp the splint about the bases of the teeth, the set screw preventing the sharp jaws from slipping down onto the gums. This splint fits the crowns of the lower dental arcade and is attached to them by means of oxophosphatic cement which requires about one-half hour to become firmly set. During this time dis- placement is to be guarded against by firmly holding or binding the lower jaw to the upper. This method requires considerable laboratory technique but when the patient has a good set of teeth to fasten the splint to, the method is probably the most perfect known. It is neat, efficient and allows easy cleansing of the mouth together with free motion of the jaw during the after-treatment. There are no bandages about the head and no clamps beneath the chin so that the patient is able to go about in public without being an object of curiosity. If wounds of the face accompany the fracture they may be treated without disturbing the fixation of the fragments. 5. Wiring the lower jaw to the tipper. — This is a method which has the disadvantage of not allowing motion of the mandible dur- ing treatment and renders feeding and cleansing of the mouth more difficult. On the other hand it secures good occlusion and does not require any special, complicated apparatus or laboratory technique for its employment. The question of apparatus or the assistance of a dentist is not a hindrance in large cities but when :5H6 FKACTIKES AM) DISLOCATIONS the surgeon is called upon to treat the condition without these aids he will find that \viriii>i together of the jaws, if i)roi)erly car- ried out anti due cari' exercised in tin' subsc(|nent cleansing of the mouth, will ]ii('ft the i-f(|uiriMiiriits in most c'lsrs and is productive of the very best results. The danger of vomiting during the time the jaws are wired together should be constantly borne in mind, and the patient nuist be provided with wii-e cutting pliers so that the jaws may be promi)tly released at any time, h'or the same reason an anes- thetic must not l)e used in i'edueii\u' the I'raeture if this method of immobilizing the fi-agments is ein[)loyed. The details in the technique, of wiring the lower to the upper jaw, vary witli diffei-ent surgeons ])id the (>ssentials are the same. Fig. 502. — Oliver's method of wiring the lower to the upper jaw. A. shows the loop about the upper centrals. B. shows the manner in which the loops are attached to the molars. Whatever method is employed we may expect the wire to stretch during the after-treatment and the torsion strength of the wire used must be sufficient to stand the additional twisting without breaking. The method described by Oliver is probably as satisfactory as any and has the advantage of preventing, e(|ually well, both lateral and perpendicular motion. The method is as follows; — "for purpose of illustrating the method let us suppose a case with simple frac- ture slightly transverse through socktit (distally) of right first bicuspid and mental foramen, slight deformity, articular i)lane deranged, long anterior fragment drooping somewhat and short posterior fragment drawn slightly upward and inward — the typi- cal picture. The mouth is first thoroughly cleansed with hot anti- septic wash and swabs, the location and extent of fracture determined and the fragments adjusted and articular plane re- J'HiACTUUIOS OK liOWKR .(AW ''AH stored. Then a piece of soft drawn copper wire, about four inches long, previously annealed and sharpened at each end, is inserted' from without inward between the right lateral and cuspid, is pulled through about half its length, burnished lingually to cuspid and then inserted from within outward l)etween cuspid and first bicuspid, pulled through buccally again, where it is held. The other end is now brought back and inserted at the latter inter- proximal space, pulled through taut, burnished lingually to first and second bicuspid, carried back across line of fracture, inserted from within outward between first molar and second bicuspid, pulled through buccally again, brought forward taut across line of fracture and twisted with remaining ends at a point opposite an interproximal space. The adjustment of contour and articular plane is now verified ; after which the ends tightly twisted, bring- ing firm traction through axis of each fragment across line of fracture which temporarily will hold the parts in their exact posi- tion. The twisted ends are clipped off, leaving a stub about an eighth of an inch long; this stub is turned upward and inward, entering the interproximal space far enough to prevent it from injuring any soft tissues with which it may come in contact. Im- mobilization is next accomplished by wiring lower to upper teeth, while occupying normal occlusion. This is done by the following original method, which insures against the possibility of any mo- bility, either lateral or perpendicular; first an anchor loop is made by taking a six-inch piece of annealed soft drawn copper wire, 20 gauge (B. & S.), bending it in the middle around a small-sized mandrel about one thirty-second of an inch in diameter, and twist- ing tight by one full turn with flat-nosed pliers (the twist may be strengthened by "tacking" together with a small bit of hard solder). The two long ends are now straightened out and placed parallel to one another, one end being snipped off one-fourth of an inch shorter and both ends pointed. They are now inserted from without inward, between the tvvo superior central incisors, pulled through taut until loop rests, horizontally, firm against both teeth at the mesocervical border. Each end is now carried lat- erally from median line, burnished, respectively, to lingual sur- face of each central, and inserted from within outward between its respective central and lateral, pulled through firmly, brought forward to median line, above loop, and twisted tightly together. 368 FRACTURES AND DISLOCATIONS clipping off and turnint; stub into interproximal space as before noted. Tills forms a solid, permanently Hxi'd. median anchor loop from which coiinler-ti-action may he had fi'om each lateral luilf of the mandible for support and i)revention of lateral mobility. Four pieces of the same wire, about three inches long, are in turn bent around the mandrel as before cited, forming the loop about one-third distant from one end and the long end sharpened. These lateral anchor loops are placed around solid teeth, one on each side, usually first molars or second bicuspids, in both upper and lower jaws, and serve as anchorages for the tiaetion wares, one for each side. These traction wares thi'tadcd Ihrough all the loops commencing with the median, then the supciior latei-al, then inferior lateral and finally twisted wdth ou1er end midway between inferior lateral and median loop, exert a firm and constant pres- sure between upper and lower jaws and at the same time maintain counter-traction laterally. The twist is elipi)ed short and may be turned upward under upper ti'cth. The lateral loops ai'e posi- tioned by inserting long ends into mesoproximal spaces of the respective teeth selected, pulled through taut until loop rests hori- zontally against cervieoproximal border, then carried backward, burnished to lingual surface, inserted from wdthin outward at distoproximal space, pulled through firmly and twisted to outer end as near the latter proximal space as possible in order that the increased size of twist, being too large to pidl back through space, wdll prevent the anchorage loop turning under stress of subsequent traction and also that the twist may be clipped off and turned into the space as above shown. The traction wires are about seven inches long, of same material, and should he annealed before being used. Care should be exercised to keep each one perfectly straight between loops and pulled taut in passing through each loop. When properly placed there will be a triangular geometrical figure W'ith its first ''stretch" a long horizontal line from median to superior lateral loop, a short perpendicular line from the supe- rior to the inferior lateral loop and a long slanting diagonal line from inferior lateral to median loop, in which the twist has been made. AYith these heavy traction wires firmly fastened from each side of the jaw^ with teeth in normal contact, there is little lik'eli- hood of any kind of motion between either tlie fragments or the jaws. Should a wire break or become ineffective from being stretched, a very firm occipito-mental bandage is applied and both FRACTURES OP LOWER JAW 369 traction wires cut and removed. The aiichoraf^e loops are now tightened and new traction wires applied as before."^ The technique of simple wiring of the jaws together is less complicated than Oliver's method, but lacks some of its advan- tages. It is accomplislied by passing loops about the teeth as Fig. 503. Fig. 504. Fig. 503. — Loops of wii-e passed about teeth of lower jaw preparatory to wiring the jaws together. Fig. 504. — Loops of wire passed about the upper teeth corresponding to those shown in Fig. 502. Fig. 505. Fig. 506. Fig. 505. — Two points of fixation in wiring the maxillae together. Fig. 506. — Opposite side in same ease showing line of fracture and two additional points of fixation. shown in Fig. 503. The ends are twisted together to obtain a firm hold on the tooth and fastened with a similar pair of twisted ends which are secured to a tooth in the opposite arcade. With this method it may be necessary to replace the loops about the teeth if the wires break by twisting, or if it becomes necessary to cut the wires in case of vomiting. Moreover the fixation is not 1 R. T. Oliver, D.D.S., Jour. Amer. Med. Assn., Apr. 9, 1910. '670 KKACTrUKS AND DISLOCATIONS (|uite as secure as Oliver's method and it is not possible to release the jaws as quickly in case of emer^^cncN-. Angle's bands and mre. — In place of the ant-lior loops described in Oliver's method we may employ Angle's bands such as shown in Fig. 510. They are ordinarily used in orthodontia but serve the pui-pose in fractures very nicely. They may be obtained at dental su|ii»l\ houses and the knolis for securing the traction wire may be atlaclu'd to the band at any point desired by moans of solder. Fig. 507. — Simple method of wiring: the upper to the lower teeth in fracture of the lower jaw. This is the same method as demonstrated in Figs. 50.3, 504, 505 and 506. Fragments held in good apposition in spite of dental deficiencies. Loops instead of knobs are sometimes used on the bands and are very satisfactory. Threaded bars and jack-screws are made to pass from an Angle band on one of the lower teeth to be anchored on a band placed on one of the teeth in the oi)posite arcade, but these should never be used since the jaws cannot be released quickly with ware cutting forceps in case of emergency. The Angle splint will be considered under the next heading. 6. Securing the fragments hy means of iviring the teeth of the lotrcr jaw. — Various modifications of this principle have been FRACTURES OF IjOWER JAW 371 devised and in many instances the metliod is tlioroujjihly satis- factory. An extremely old and sometimes efficient method is that of wiring the adjoining teeth. A loop of heavy wire is passed about four teeth (two on either side of the fracture) and the ends twisted tightly together, cut off and bent inward Ijetween the teeth so as not to injure the mucous membrane. It is usually difficult to get this wire sufficiently tight by twisting a:;(l when Fig. 5U8. Fig. 5U9. Fig. 508. — Angle's bands and bars applied to fracture of the mandible at the symphysis. Fig. 509. — Angle's bands and bars applied to fracture of the mandible between the second bicuspid and first molar. Fig. 510. Fig. 511. Fig. 510. — Angle's bands with knobs for wiring jaws together. Fig. 511. — Same case as shown in Fig. 510 showing opposite side of jaw with points of fixation on either side of fracture. such is the case a racking wire is passed between the teeth so as to include both arms of the loop. The ends of this wire are twisted tightly together and in so doing the internal arm of the loop is snugged up against the lingual surface of the teeth. The wire must include at least two teeth on each side of the fracture; if only one tooth on each side is included they will almost surely loosen, the object of fixation thus being de- 372 FRACTURES AND DISLOCATIONS feated. A more secure method of wiring; the teeth together is described by Oliver in tlie first part of liis procedure (page 367). Any form of \viring must be closely watched and tightened to compensate for the loosening wliich is sun- 1o lake place. For this reason silver wire is not as satisfactory as some other forms on account of the likelihood of its breaking- when much twisting is reciuired. Bron/c-ahiniinmii wire of large caliber or ordinary electric wire, with the insuhition removed, may be used. In any event the wire should be heavy and the ends pointed to facilitate its passage between the teetli. If it is desired to pass wire between the teeth where there is not sul^cient space an opening may be made slightly below the gums by puncturing with a sliarp instru- ment; this however is very rarely necessary. Wiring will have to be varied according to the nature and disposition of the teeth. When there is nutch tendency toward lateral displacement this method should not be employed; it is particularly inefficient when the line of fracture through the body is oblique, so that one frag- ment tends to slip past the other. Hammond's ware splint, a method which lias been followed by good results, consists of a heavy iron wire encircling all the teeth. One continuous wire follows the lingual and buccal surfaces of the lower dental arcade. This wire should be heavy enough to with- stand the lateral strain and after fitting it to the teeth it is better to remove it and solder the ends together rather than to depend on simple twisting. With the wire in place about the lower denture a number of copper racking wires of lighter material are passed between the lingual and buccal arms of the splint and the ends twisted to secure the appliance in place. Edmund's forceps (Fig. 500) may be used to force the heavy wire of the splint more snugly against the cervical portions of the teeth and to facilitate tightening the racking wires. This method is usually not secure enough to allow motion of the jaw during the after-treatment but should be used in conjunction watli some method of fixing the jaws together. Angle's splint consists of bands fastened about the teeth with a threaded bar passing between them. The bands are similar to those used in wiring the jaws together but have heavy tubes soldered to them instead of the knobs. The tubes are placed liorizontally on the buccal side and have a heavy threaded bar passing through them from one side of the fracture to the other. FRACTURES OF LOWER JAW 373 When the nuts are placed and tightened the fragments are pulled together and held in firm apposition. The splint may be tightened by passing wire from band to band on the lingual aspect. Fracture of the ramus is a rare condition and is not, as a rule, accompanied by much displacement. Some form, of fixing the jaws together will afford the necessary rest for the ramus and will be followed by good results in most cases. When much deformity exists open incision may be indicated to effect reduction. Wiring of the fragments may be called for if there is tendency toward displacement when the jaws are fixed. Fracture of the neck of the condyle, like fracture of the ramus, requires fixation of the jaws, and may require operative intervention if the displacement is pronounced. In operating in this region care must be exercised to avoid injury to Stenson's duct and the facial nerve (see Anat- omy, page 350). Fracture of the coronoid is extremely rare and will probably require only fixation of the jaws for a short time. Operative Treatment. — In some cases it may seem advisable in meeting the requirements of the case in hand to unite the frag- ments of the body of the bone by direct wiring or by the use of a small Lane plate. This is done through an incision parallel to and slightly below the lower border of the jaw. In making this incision care should be taken to avoid the facial artery which crosses the external surface of the bone in an upward and forward direction at the antero-inferior angle of the masseter. The bone having been exposed, holes are drilled in the positions of greatest advantage and wire passed, twisted, cut off and turned in. In oblique fractures with overriding tendency it is often best to have both arms of the loop passing through the plane of fracture in the substance of the bone. In transverse fractures a single loop with one arm on the external and the other on the internal surface of the bone will be sufficient to secure immobilization if the serrated edges of the fragments are well engaged and the wire properly tightened. It is well in any operative procedure about the jaw to refrain from removing loosened teeth and spicules of bone unless entirely separated from the surrounding tissues, since the}^ usually become solid as a result of the free circulation in this region. In some eases of fracture of the jaw we have actual destruction of a con- siderable portion of the bone, and in other cases we have loss of osseous tissue through infection and necrosis and in such instances r{74 FRACTURK8 AND DISLOCATIONS it is ililificiilt to obtain an end result which is perfectly satisfactory. AVhen a portion of the bone is lost good occlusion is not possible and more or less defoi-mity is bound to ensue unless some method other than those previously described is resorted to. In these eases much good can be accomplished by means ol" bone trans- l)lantation, although the method has not been sufficiently employed at tile pi-esent time to state definitely what its limitations may be. However transplantation is justified and indicated, in view of the unhappy results following destruction of a portion of the jaw. The bone transplant is usually taken from some other portion of the patient's skeleton and placed in the mandible according to the principles of bone transplantation laid down in Chapter LX. The usual rules governing union in fractures do not hold good about the face since the free circulation is capable of withstanding greater insult and accomplishes great, rapid and extensive repair. Cases have been I'eported in recent years showing excellent results follow'ing transplantation of bone and what is still more surpris- ing the formation of new bone about metallic framework previously built to fit the requirements of the case. This metallic frame- work has even been successful in the forming of a new condyle. The transplant is most easily and satisfactorily obtained from the crest of the tibia; it should be cut to accurately fit the defi- ciency in the jaw. Its ends must be placed in firm apposition with the freshened, living ends of the maxillary fragments and should be immobilized by wire loops or plates. The transplant must not be exposed within the mouth but should be protected at least by mucous membrane. Transplantation should not be performed in the presence of infection ; it is essential to wait until all dead bone has sloughed out or been removed and the sinuses healed in, before the transplant or any other foreign material is introduced. In closing the incision after operation on the jaw a subcutaneous suture should be run, gathering in considerable tissue between the l)one and the skin ; by this means we will avoid the unsightly re- tracted scars so frequenth^ seen following operations on the jaw. The skin is best closed with hoi'se-hair. If suppuration follows the operation we must see to it that drainage is free and complete but we should not be too hasty in removing foreign materials, since discharging sinuses in this region frequently close of them- PRACTIJRKK OF liOWKR JAW 375 selves in spite of the presence of foreign l)0(li(*s such hs suture materials, plates, etc. After-Treatment.^The after-treatment of fracture of the jaw consists in keeping the mouth clean by means of mild antiseptic washes and seeing to it that the mechanical ai)pliance in use is properly accomplishing its purpose of immobilizing the fragments. When a method is employed which keeps the jaws closed the pa- tient must be fed with liquids ; an aid to the introduction of food will be found in passing a tube between the cheek and the teeth, the end passing behind the last molar. Eggs and milk will form the main part of the diet. These may be combined in different ways and various flavoring materials used to prevent the patient tiring of them. Soups and broths will add variety. It will usually not be necessary to keep the jaws together for a period longer than ten days or two weeks so that the inconvenience of feeding is not a long one. Union is well under way by this time but the mandible will not be in condition to stand any con- siderable strain until two months or more have elapsed from the time of fracture ; the patient should be cautioned in this regard. Prognosis. — The usual case of fracture of the body of the jaw should be followed by perfect function and no deformity. Cases in which the trauma has been severe and in which there have been multiple fractures are much more difficult to treat and ac- cordingly^ are sometimes followed by more or less loss of function and deformity. Protracted cases and those in which infection has occurred may be followed by damage to the articulation and in some instances ankylosis. The more complications the case pre- sents the worse the prognosis. CHAPTER XXIX. DISLOCATIONS OF THE .lAW. Surgical Anatomy. — The teinporo-maxillary articulation pos- sesses niauy anatomical features which shoukl he understood be- fore entering upon the clinical aspects of dislocations of this joint. It is a gingiymo-arthrodial joint. The interarticular fibro-car- tilage, horizontally placed, divides the cavity within the capsule into two distinct articulations, each with its separate and complete synovial membrane. The function of the upper articulation is that of gliding, which is brought into action in the lateral grind- ing motions of the jaw, and when the chin is protruded. The lower articulation, between the cartilage and the condyle, has a purely hinge-like action, used in raising and lowering the man- dible. The peculiar formations of the condyle and glenoid cavity are difficult to appreciate unless one examines these surfaces on the skull, preferably in a fresh specimen. The nature of the articulation permits only of forward dislocation unless fracture complicates the condition. Backward, outward and upward dis- placements have been described though they are extremely rare Backward dislocation may occur when fracture of the neck of the condyle exists, and upward displacements have been reported as the result of the condyle having been driven through the glenoid cavity. The joint has practically three ligaments, the capsular, internal lateral and stylo-maxillary. The external lateral ligament is simply a thickening in the outer portion of the capsule, while the interarticular fibro-cartilage lies within the capsule and is con- tinuous with it. The internal lateral ligament is entirely in- dependent of the capsule, being attached above to the spine of the sphenoid and below to the lingula. The stylo-maxillary ligament extends from the tip of the styloid process to the angle of the jaw. The anterior portion of the capsule is the only ligament limiting anterior displacement of the condyle after it has ridden over the eminentia articularis. 376 DISLOCATIONS OF JAW 377 Dislocation of the jaw is almost always the result of rmiseular action, although violence has been known to have produced the condition. A blow on the chin, or a forward blow on the angle of the jaw while the month is open is known to have caused the luxation. It has occurred in yawning, talking, singing, coughing and vomiting. Overaction of the external pterygoid while the jaw is depressed is responsible for the luxation. When the condyle has been displaced far enough forward to become engaged in front of the prominence of the eminentia articularis, it is held in displacement by spasm of the internal pterygoid, masseter and the posterior fibres of the temporal. Etiology. — This dislocation occurs more commonly in middle aged persons and is more frequently seen in women than in men. It is usually the result of muscular action and rarely caused by violence. Sjnnptoms. — In the usual bilateral dislocation the mouth is opened widely, and the entire jaw displaced forward. Saliva drools from the mouth. Articulation is impossible, and when the patient attempts to talk he is almost unintelligible. Considerable pain is experienced during the time the condylar processes are displaced. In the unilateral dislocation the mouth is open, chin protruded and displaced to the opposite side, which gives the face a peculiar twisted appearance. The displaced condyle may be felt below the zygomatic arch and a depression exists just in front of the ear indicating the empty glenoid cavity. Treatment. — Reduction is accomplished by forcing the rami of the jaw downward and backward as the body of the bone is raised. The thumbs are protected by a towel, or heavy bandages, intro- duced into the mouth and carried as far back as the last molars on either side, the opposing fingers then secure the lower border of the body of the bone. Downward and backward pressure is then made by the thumbs, forcing the condyles over the articular eminences as the body of the bone is raised. The thumbs should be removed before the molars come together. The spasm of the muscles previously referred to sometimes offers a most serious ob- struction to reduction even to the extent of necessitating an anes- thetic. It is surprising with what facility reduction may be ac- complished with the muscles relaxed in cases in which the jaw seemed immovable in its displacement before an anesthetic was given. It is extremely rare to find a case in which reduction can- 378 FRACTURES AND DISLOCATIONS not l)c ;ici-()iiiiilislu'(l uiidi'i- anesthesia. If the displaeenieiit has existed for some months the formation of adhesions about the condyle and changes in the glenoid cavity may necessitate open incision to effect reduction. If necessary the condyle may be rescclctl with a view to the formation of a new joint. After-Treatment. — The jaw should be fi.xed for a i)criod of two weeks followiiii;' the accident. This is readily accoini)lishe(l by means of a four-tailed or Barton bandage. The jjatient should be cautioned not to open the mouth too far for at least another month following the removal of dressings. When dislocation of the jaw has once taken place it is likely to occur again, and unless the patient is apprised of this fact he may feel that the treat- ment was not successful if luxation recurs even at a remote period. Prognosis. — Keduction is usually accomplished without difficulty in recent cases. Restoration of function is ])erfect with the ex- ception of a tendency to habitual luxation which exists in all eases. CHAPTER XXX. SCALP WOUNDS. Wounding of the scalp is such a frequent and important compli- cation of fracture of the skull, that the management of these wounds is best considered before entering upon the subject of injury to the skull and brain. Fracture of the vault of the skull is usually accompanied by wounding of the scalp or, in other words, the fracture is compound; and the successful treatment of the wound will often determine whether or not infection will follow the injury, and hence is of the greatest importance. Surgical Anatomy of the Scalp. — The scalp is composed of five layers : 1. The skin. 2. The subcutaneous layer of fat. 3. The oceipito-frontalis muscle and its aponeurosis. 4. The subaponeurotic connective tissue. 5. The pericranium. These laj^ers individually and collectively are of considerable surgical importance and should be understood when treating wounds of this region. The skin of the scalp, the toughest and thickest in the entire body, is supplied with immerous hair fol- licles and sebaceous glands. The subcutaneous layer of fat has bundles of fibrous tissue passing through it in all directions, and, together with the skin, is firmly adherent to the aponeurosis of the oceipito-frontalis which lies directly below it. The hair fol- licles of the skin extend down into the subcutaneous tissue, and in gaping wounds the bulbous ends of the follicles may be seen by everting the edges. The aponeurotic layer or galea is composed anteriorly, of the frontalis muscle, which is inserted into the skin, posteriorly, of the occipitalis muscle, which arises from the superior curved line of the occipital bone, and the aponeurotic tissue or tendon which extends between these two muscles and divides the scalp surgically into two layers; — the superficial and deep. 379 380 FRACrrRRS axd dist^ocattons AVoniuls whicli divide the aponeiirotic layci- will fjape, while wounds which penetrate only to the galea will i)res('iit approxi- mated edges. Transverse wonnds dividing the galea usii;illy gape more widely than wounds of the same deptli running in an antero- posterior direction. TIk^ three superficial layers just named are loosely connected with the deeper structures by means of an areo- lar tissue which allows free motion of the upper layers over the skull. The layer of subaponeurotic connective tissue is of the greatest surgical importance since infections in this loose areolar tissue, following the lines of least resistance, may spread, and if not prom])tly and freely drained the entire calvarium may he covered hy the infection and the scalp "floated" with pus. The pericranium is the deepest layer, covers the calvarium .ind acts as a modified periosteum. It differs from periosteum in other regions in the following respects : the pericranium does not re-form bone following loss of osseus tissue to the extent observed in peri- osteum elsewhere; the circulation is less free; and it may be stripped from the bone without causing any serious disturbance in the nutrition of the denuded osseous tissue. Where the pericran- ium crosses the sutures it is intimately connected with the inter- sutural connective tissue, though in other portions of the skull it may be readily stripped from tlie bone. The scalp as a whole, together with the hair, affords an excellent protection to the skull and is richly supplied with blood vessels. The main portion of the circulation of the scalp runs in the subcutaneous connective tis- sue and in the skin itself, and its richness accounts for the re- markable reparative properties of the scalp, which are not equalled elsewhere in the skin of the body except the face. Tlie amount of fibrous tissue present in the layer in which the blood vessels run accounts for the profuse and prolonged hemorrhage so common in scalp wounds. This fibrous tissue prevents the vessels from clos- ing as they do elsewhere following injury, and explains the diffi- culty so frequently experienced in catching and ligating vessels in the scalp. The mobility of the scalp will often save the parts from wounding by allowing them to give before the vulnerant body. Vessels of the Scalp. — Tn the frontal region we have the frontal branch of the ophthalmic artery which emerges from the inner angle of the orbit and anastomoses with its fellow of the opposite side and with the sui)raorbital artery. The supraorbital artery is SCALP WOUNDS 381 a branch of the ophthalmic, of larger size than the frontal. It emerges from the orbit through the supraorbital notch at the junction of the inner and middle thirds of the sui)raorbitMl ridge, and divides into superficial and deep branches anastomosing with the frontal and anterior branch of the superficial temporal artery. The side of the scalp is supplied by the superficial temporal, a branch of the external carotid artery, which may be palpated as it ascends just in front of the auricle. This artery divides into an anterior and posterior branch and anastomoses with the deep temporal arteries; the anterior branch of the superficial temporal anastomoses with the supraorbital, and the posterior branch anastomoses with the posterior auricular and occipital arteries. The deep temporal arteries are two branches of the internal maxil- lary; they supply the temporal fossa, anastomose with each other and with the superficial temporal and lachrymal arteries. . The occipital and posterior auricular arteries, — branches of the ex- ternal carotid, — supply the posterior portion of the scalp as far forward as the ears, and anastomose with each other and the posterior branch of the superficial temporal artery. The occipital artery passes onto the scalp at a point about midway between the inion and the external auditory meatus and in this region is more or less exposed to injury ; when opened it may give rise to profuse hemorrhage. It may be temporarily controlled by compressing it against the skull on the proximal side of the wound. All of the arteries of the scalp may be temporarily controlled by the application of an elastic tourniquet about the head, which is kept in place until the main branches are secured with ligature. The arteries most likely to cause free hemorrhage are the occipital and superficial temporal, either of which may be controlled by digital pressure against the skull below the wound. The anastomosis be- tween the above named arteries is very free, and the size of the vessels is large for the region supplied; the result is that the blood supply to the scalp is great, and the vitality of the tissues correspondingly high. The veins of the scalp correspond to the arteries just named, though there are some differences which are worthy of surgical note. The supraorbital vein anastomoses with the cavernous sinus by means of the angular vein near the inner angle of the eye, and thus infection in the region of the forehead may be drained into the cavernous sinus as well as into the facial vein, which is the 382 FR\("rrRES and dtpt.ocations continuation of llif suprnorhital. t'orres{)ondin<2,- to the arterial arrangement in this i-fizioii. The supei'ioi' loniiitiidiiial sinus re- ceives blood I'roiii outside the skull liy lucaiis ol' tlic vein which passes throu^ii the parietal foramen, .ind in like manner connection is established between the scalp and lalerai sinuses through the mastoid and jiosterior condyloid veins. These anastomoses are of importance in showing tlie way in which infection may pass fi-om tlie outei- surface of tlie skull to tlie intracranial sinuses. TIk luiiiplnilic f(ss(ls fonn a tVee anastomosis in the scalp I'roni whicli are derived the main trunks which follow the course of the arteries. The anterior portion of the scalp is drained into the •submaxillary glands; the temporal I'cgion and that portion of the scalp above it is drained into the superficial and deep parotid lym- phatic glands. That i)ortion of the scalp lying behind a vertical line connecting the two external auditory meati is drained into the occipital and ])osterior auricular glands. The nerves of the scalp may be divided into sensory and motor. The sensory nerves are of cranial and cervical origin. The an- terior portion of the scalp is supplied by branches of the fifth cranial nerve and extends upward to about the middle of the vertex. The posterior portion of the scalp is supplied by branches of the upper cervical nerves. The sensory nerves may cause con- siderable pain lasting over a long period of time if they become caught in scar tissue and may necessitate oi)eration to afford the patient relief. All the muscles of the scalp are supplied by the facial nerve ; the occipitalis muscle sometimes receives additional filaments from the occipitalis minor nerve. The upper branch of the "pes an- serinis, " supplying the frontalis, is the most frequently injured motor nerve in the scalp. Inability of the patient to wrinkle the corresponding half of the forehead should lead to a search for the divided ends of this nerve before a scalp wound of this region is closed. Pathology and Symptoms. — AVounds of the scalp may be classi- fied as incised, punctured, lacerated and contused ; the nature of the wound depending on the character of the vulnerant body and the degree of trauma causing the injury. In addition we may have a simple contusion without an opening or wound in the scalp, and although it cannot properly be considered as a scalp wound yet its importance requires consideration under this heading. Simple SCALP WOUNDS 383 contusion of the scalp is common and may lead to collections of blood or serum in any of the various layers of the scalp. When the collection of blood is in the movable layer of the scalp (i.e., above the galea) it will be found to be freely movable with the skin and quite circumscribed. When the fluid is below the galea it is not movable, is much more diffused and may present a cir- cumference of induration which, when palpated in connection witli the softened centre of the effusion, gives one the sensation of a depressed fracture. Continued digital pressure on this margin of induration will usually cause the fluids to be displaced suffi- ciently to differentiate, but if this is not satisfactory a needle may be used or the parts incised. Effusions below the epicranium are rare except in infancy ; when they do occur they will be found limited to one cranial bone of the vault, since the fusion of the epicranium with the intersutural fibrous tissue stays the further spread of the blood. Birtli trauma and the free vascular connection between the epicranium and the skull in infancy accounts for the comparative frequency of such effusions (cephalhematomata) during that period. The incised wound, strictly speaking, is caused by some ob.ject with a sharp or cutting edge, yet there is a distinction which must be made between a truly incised wound and an apparently incised wound which has been produced by some blunt instrument, such as a club. A scalp wound produced by a club may, to the inex- perienced, have all the characteristic appearances of an incision, though on closer inspection it will be found to have a slightly ragged and contused edge and the underlying structures will not be found divided as by a knife. The cause of wounds has an im- portant medico-legal significance, and when the attending surgeon is called upon to give testimony he should be aware of the close similarity existing between true incised wounds and those made by a dull instrument. The mechanism of the pseudo-ineised wound has been likened to the splitting of a kid glove, struck with a cane while the leather is stretched across the knuckle. The punctured variety of wound in the scalp is produced by pointed instruments, and the fact that the depths of the wound are not easily inspected without exploratory incision accounts for the overlooking of injury to the underlying skull and brain in many instances. It should be remembered that the punctured wound has the traumatic energy distributed over a very small area and 384 FRACTURES AXD DTST.OC ATTOXS is tlierefore more likely to do damage to the underlyintj structures. Laceration- of the scalp inav exist in all degrees, t'l'oin a slight tear to a complete avulsion. 'I'lie average scalp wound shows some degree of laceration and nioi'e or less contusion, so tliat foi- ju-ac- tical purposes wounds ])r('S('nting these features are best considered under one heading. I'lie tissues of the scalp nuiy be torn and bruised in various ways, and the degree of injury ranges from the most serious to the most trivial; the important question in each case — so far as the scalp itself is concerned — is, wlial portion of tlie tissues injured has been daiuagt'd beyond recovery? This question can only be answered by a careful examination of the wound and an estimation of the circulation remaining in the ragged, mashed and torn edges. Dirt, cinders, gravel, broken glass and various other materials may be ground into the wound and the surrounding scalp, and if allowed to remain will act as foreign infectious bodies within the tissues. Loose hair is a very common material found witliin the wound and when not removed is almost sure to be followed by suppuration. A connnon form of lacerated, contused scalp wound is one in which the l)low causing the wound has resrdted in the traumatic death of more or less tissue, which will ultimately slough out if not removed at the time of operation. When the edge of the wound shows slight laceration union can often be expected even if the lacerated edges are not trimmed away, but when the lacei-ation is severe and the edges mashed, we may look for more or less sloughing if this tissue is not removed, regardless of the presence or absence of infection. When the devitalized tissue is extensive it may become impossible to remove it and approximate the edges. Inflammatory reaction is much more pronounced in contused wounds than in simple incision or puncture. A type of injury frequently seen is one in which one side of the wound has been slid and separated from the underlying structures as the result of a glancing blow, and the pocket thus formed under the scalp often contains infectious materials which have been forced into the wound at the time of injury. Complications and Sequelae. — The complications may be grouped under three headings: hemorrhage, infections and conditions ac- companying fracture of the skull and brain injury. Late compli- cations or sequelae are painful scar, aneurism of the scalp, deform- SCALP WOUNDS 385 ing contractures of >scar tissue, tumor formation in thoi scar (kel- oids and rarely malignancy) together with the late complifjitions following brain injury. Treatment. — The treatment of these wounds will depend on the conditions present in each individual case and it will be impos- sible to formulate the routine to be followed in all instances. A scalp wound may be present without any evidence of injury to either skull or brain, the patient not having suffered the slightest concussion, while on the other hand the scalp wound may be a part of a serious condition in which the skull is fractured, the brain injured and the patient in extremis. These extremes to- gether with the intermediate conditions require the greatest acu- men and surgical judgment so that we may not subject the patient to unnecessary operation on the one hand, and also avoid the over- looking of serious complications on the other. There are, how- ever, some general principles which should be followed in the treatment of these wounds, though the relative importance of each will vary in different cases. They are as follows : 1. Control hemorrhage. 2. Prevent infection as far as possible. 3. Avoid the overlooking of complications especially of skull and brain. 4. Close the wound as far as may seem advisable, providing drainage when necessary. 1. Control of hemorrhage. — The nature and amount of hemor- rhage will depend upon the character of the wound and the vascular structures divided; it may be arterial or venous, and may consist of a simple oozing or an active spurting. The hemorrhage may be surprisingly profuse, when some of the main arteries of the scalp are divided, and when such is the case the first step in treatment must be the control of this bleeding. "When the artery is accessible it should be secured with hemostats for the time being, until the scalp has been appropriately cleaned; if the hemorrhage consists of moderate or slight oozing it may be neglected during the process of cleansing. In some cases it may become necessary to further open the scalp to expose the bleeding artery. In the most profuse hemorrhages we may secure temporary hemostasis by pack- ing a gauze sponge into the wound and making firm pressure on it with the hand. In the case of hemorrhage from a single large 386 FRACTURES AND DISLOCATIONS aitcry, sucli as tlie occipital or superficial temporal, we may com- press tlie vessel aizainst the skull a short distance to the proximal side of the woiuul pending the proper securing and ligation of the bleeding end. In extreme cases an elastic bandage may be used to encircle the head so that it passes just above the brows and ears and in this manner all the large vessels of the scalp will be compressed against the skull. One of the most annoying forms of hemorrhage is that of a IHM'sistent oozing which continues even after the wound has been thoroughly prepared and is ready for the sutures. This oozing may come from the edge of the wound proper or it may come be- tween the layers of the scalp in cases where the injury has been produced by a glancing blow and one side of the wound has been separated from the underlying tissues by "sliding." Such oozing is not, as a rule, dangerous in itself but if allowed to continue after the wound has been closed, Avill result in the formation of clots which can only favor subsequent suppuration. The drier the wound when closed (other things being equal) the more reason we have to anticipate prompt healing. Oozing ma}- be checked in many ways; by the use of heat, pressure, styptics and sutures, or a combination of these. A method which will in most instances be found all that is required, is as follows: take a gauze sponge of appropriate size wrung out of hot salt solution, pack it into the wound and make firm pressure with the hand from tM^o to three minutes. AVhen the sponge is removed the wound surfaces will be found dry and will not begin to bleed again unless roughly handled. This procedure is best carried out just before closing the wound when the manipulations necessary to preparation have been completed. A solution of 1 :2,000 of adrenalin may be used to advantage in controlling oozing but strong chemical styptics should be avoided because of the injury they do to an already trauma- tized tissue. Oozing from the edge of the wound, especially of the venous type, will almost invariably stop Avhen the sutures are placed and tied. After the wound has been closed it is advisable as an additional precaution to make pressure from one to two min- utes to prevent the continuation of oozing and to express any blood which may have collected under the closed scalp. "When it is necessary to leave buried sutures within the tissues plain cat- gut will be found the best. If hemorrhage can be controlled without the use of buried sutures it should be done. SCALP WOUNDS 387 Fig. 512. — Ordinnry scalp wound prepared for .suture. Note the clean shaving of the scalp. Fig. 513. — Sutures taken to bring the margins of the wound together. Fig. 514. — Recurrent bandage of the injured side of head with strips of adhesive applied to prevent slipping. 388 FRACTURES AND DISLOCATIONS 2. 'IMic iir( n iii ion of iiificiioii is to be aiH'oiiiplisluHl aloiin' lines siinilai- to tjiose already laid down under the "Treatment of Com- ])ouml Fractures" (see page 789). Too much cannot be said in condemnation of the so-called antiseptics, such as bichlorid of mer- cury, which invariably do more harm to the already damaged tis- sues than they do to the germs of infection. The wound should be treated by attempting to remove the infection which has already gained entrance and not by killing it in situ. In other words we should endeavor to render the wound aseptic rather than anti- septic. It is of course practically impossible to remove all infec- tion from the scalp, yet we may so reduce the number of bacteria present Avhen the wound is thoroughly prepared that nature is enabled to dispose of those remaining without the formation of pus, in which case the wound is said to heal by first intention. Crushed and devitalized tissue has no resistance and can serve no i)urpose within the wound except to act as a culture medium for infection and the same may be said of collections of dead blood. The indications therefore are to approximate healthy tis- sue and to avoid the extravasation of blood and serum within the wound. Clinically every scalp wound must be considered infected, yet Ave must not lose sight of the fact that additional infection and germs of different strains may be introduced within the wound by the surgeon, if aseptic regulations are not observed. The first indication in the treatment of scalp wounds (aside from the con- trol of severe hemorrhage) is the shaving of the scalp surrounding the wound and the cleansing of the wound itself. Blood and dirt should be wiped away from the hair which is then clipped away for a distance of two to two and a half inches surrounding the wound. This region is next covered with lather and shaved, care being exercised to prevent the hair and dirt from entering the wound. After this has been accomplished the wound is irrigated with salt solution and the unshaved portions of the scalp dried, with a sterile towel. When the surgical surroundings are favorable an assistant should perform the preparation just described so that the surgeon may approach the prepared scalp with clean hands. If, however, the surgeon is treating the wound unassisted he should re-sterilize his hands and whatever instruments may have come in contact with the wound during preparation in order that the subsequent ma- nipulations may be rendered sterile. The scalp is then once more SCALP WOUNDS 389 irrigated in and about tlie wound and the Kurgfon is ready to explore the depths of the wound to remove infectious materials such as hair, felt, gravel, cinders, etc., and to trim away devitalized tissue. Isolated hairs show a strong tendency to cling to the inside of the wound and it is frequently necessary to pick them out in- dividually with thumb-forceps even after the wound has been thoroughly irrigated and is supposedly clean. Tincture of iodine may be used on the surface of the scalp, either full strength or diluted, but is best kept out of fresh scalp wounds. Other anti- septics within the wound are not only useless but harmful and should not be employed. 3. Detection of complications. — After the hemorrhage has been controlled and infection prevented, as far as possible, the wound is ready for the sutures, but before these are placed the surgeon should satisfy himself that no symptoms of complications have escaped observation. The majority of scalp wounds may be ex- plored sufficiently without incision to satisfy oneself as to the con- dition of the underlying skull, and when further opening of the scalp is necessary it is in most instances easily accomplished under local anesthesia. The local examination should be carried to a conclusion satisfactory to the surgeon and other symptoms of frac- ture of the skull noted when present. The ears and nose should be examined for hemorrhage and the eyes examined as to their position and pupillary reactions, the consciousness of the patient noted and the deep reflexes of the two sides compared. In other words, if fracture of the skull is present or suspected we should examine the patient for all the symptoms both local and general which are known to occur following fracture of the skull. (See symptoms of "Fractures of the Skull," page 411.) 4. Closure of the luound. — After the preceding three steps have been carried out the wound should be closed by interrupted sutures, preferably of silk worm gut, extending down to but not penetrating the galea. The question of drainage is a difficult one to settle and mistakes are sometimes made by those possessing the greatest experience. The greater the contusion or laceration the greater the probability that the wound will need drainage. If the patient can be kept under close observation following the closure of the wound it will usually be unnecessary to provide drainage, since pus can be detected and evacuated with little difficulty should it form within the wound. If, however, the circumstances are such 390 FRACTURES AND DISLOCATIONS that the patient is not soeu for a tlay or two following' tlic lirst treatment, it is safei- to provide drainage. AVhen the drain is em- ployed it should be iihu-ed in the most dependent position possible and when necessary counter-openings are to be made through the scalp and drains inserted. A ruliber tube about the size of a thin lead pencil, sewed into tlie lower angle of the wound will be found a satisfactory form of drain. The wound iua>' then be covered witli gauze and a recurrent baiulage applied to the head. When the wound is small the gauze dressing may be secured to the shaven scalp by means of collodion. After-Treatment. — The most important element in the after- treatment consists of the detection of pus within the wound ; the case should therefore be kept under close observation. The wound should be dressed and inspected at least once in twenty-four hours during the first week and if pus is suspected a fine probe, pre- viously sterilized, in a flame, may be passed into one corner of the wound and the content, if present, evacuated. If pus does develop during the after-treatment, it should be thoroughly evacu- ated and openings maintained sufficiently large to allow free egress of the septic detritus. An infected wound should be freely drained so that granulation tissue wall fill it from the bottom. The aver- age clean wound will be solidly healed in ten days and the stitches should be removed on the eighth or ninth day. When the wound is infected the healing is much slower, sometimes lasting for weeks ; during the treatment of this type of wound granulations may be stimulated by the use of balsam of Peru, and in some cases tincture of iodine painted over a foul granulating surface will render it clean and active in the course of a few days. The way in which iodine acts is uncertain yet excellent results follow its use in selected cases. The application of iodine to granulation tissue is quite different from its use on a fresh wound, where no special resistance has been developed, the circulation of the parts is not intact, and the vitality of the tissues reduced by trauma. When the loss of tissue is such that the scalp cannot be closed at the first treatment, skin-grafting should be resorted to if the defect is one which cannot be filled by granulation within the first two or three weeks. CHAPTER XXXI. FRACTURES OF THE SKULL. The skull is the bony protection of the brain and when this pro- tective wall is injured the brain is likely to suffer, at least in- directly. The brain may suffer injury from penetration of the vulnerant body, by pressure from depressed fragments, by ex- posure of its substance; by concussion, contusion, laceration, in- fection and degenerative sequelee such as cysts and abscesses. Fracture of the skull and injuries to the brain are distinctly different subjects, yet the frequency with which they are asso- ciated makes it necessary to consider them under one heading. If the bone lesion were all that we had to confront us in these cases the matter would be simple, but with the addition of injury to the brain it becomes one of the most complex conditions with which we have to deal. Any, all, or none of the symptoms to be enu- merated may be present in a. given case at the time of examination ; accordingly fracture of the skull may be the easiest or the most difficult of conditions to diagnosticate. The proper treatment will usually depend on the proper diagnosis, and a proper diagnosis often' calls for the most careful observation and consideration of every symptom present. Fracture of the skull may be divided into three groups : 1. Those in which recovery would take place without treat- ment. 2. Immediately fatal cases, and those who live but a few hours (all treatment being futile). 3. Those whose lives can be saved or in whom serious sequels may be averted by proper treatment. The last group is the one to which our attention is directed. It is however no simple matter to determine at the time of examina- tion to which group a given case may belong. The unexpected is more common in head injuries than in other fields of surgerj^; an apparently slight injury may result in death while a case 391 392 FRACTl'KKS AXD niSI,()CATIONS ]>resontiiiji- urave syniptoins may rceovrr. There is no absolute means of avoidinji' mistakes in the diaunosis and ti-eatnient of tliese cases, yet careful observation comhined with sound judgment, — the i'ruil of study and cxitiTicncc. — will I'cchirc tlicsc iiiislakes to a niiuiinnni. Classification. — l^'fat-turcs (,'1' I he slcull ha\'i' been \-ari()usly classi- tied and the terms used indicate the conditions witliout further definition. We have fracture of the vault, fracture of the base and fractures involving- both vault and ])ase. Fractures of the base may be clas.sified according to the fossa involved. There are fissured fractures, depressed fractures, conuninuted fractures, etc., the same terms being used as are applied to fractures in general. Surgical Anatomy. — A knowledge of the anatomy of the skull and ])iain is essential to the proper interpretation of symptoms and tilt' adndnistration of treatment, but the subject is so extensive that it will be possible to consider briefly only the most salient features ; the reader being referred to text-books on anatomy for more de- tailed accounts. Bones of the Skull. — Development. — The bones of the vault (tabular portion of the occipital, parietals, squamo-zygomatic por- tions of the temporals, and the frontal) are ossified in membrane from centers which appear at about the end of the second fcetal month. Ossification beginning in the center of a quadrilateral bone reaches the corners last and accordingly at birth we find the "fontanelles" which represent the unossified por-tions of the bones of the vault. These fontanelles are situated at the four angles of the two parietal bones and are therefore six in number. The four lateral fontanelles at the lower angles of the parietal bones are closed a short time after birth ; the one situated- at the junc- tion of the sagittal and lambdoid sutures closes within the first few months of life ; the one remaining, situated at the bregma, con- tinues open during the first year. Although the process of ossi- fication begins earlier in the vault of the skull than in the base, nevertheless, at birth, the base is far more completely ossified than the vault. The base is ossified in cartilage as is the rest of the skeleton. Wormian bones occur most frequently in the course of the lambdoid suture but are not uncommonly found in the fontanelles; the suture surrounding them may at first sight be mistaken for a linear fracture while exploring wounds of the scalp. In tlie aged the frontal, ]3arietals and occijntal are practically one FRACTURES OF TIIP: SKULL 393 continuous bone due to the ossification of the sutures between th(nn ; the basilar process is continuous with the body of the sphenoid and the lesser wings of the sphenoid are continuous with the orbital plates of the frontal. The lambdoid suture meets the sagittal suture at a point about two and a half inches above the inion. The cen- ter of the anterior fontanelle (the bregma) is at a point about one-fourth inch anterior to a vertical line connecting the external auditory meati. The intersutural fibrous tissue acts as a linear shock absorber which interrupts or reduces vibrations passing from one cranial bone to another. The bones of the skull are com- posed of two layers of compact tissue between which is interposed a layer of cancellous tissue known as the diploe or diploic layer. The outer layer is heavier, stronger and less brittle than the inner. The skull is by no means of a uniform thickness throughout, which fact may be nicely demonstrated by holding the base of the skull up against the light and noting the places which are translucent and those which are opaque. The thin regions are produced, to some extent, by obliteration of the diploe, and these areas of thin- ness and thickness are of importance in trephining and in estimat- ing the probability of penetration in a given region. The thin places in the skull are the orbital plates of the frontal (supporting the frontal lobes), the squamous portions of the temporals (in contact with the spheno-temporal lobes) and the middle of the posterior fossa below the grooves for the lateral sinuses (which accommodate the cerebellum). At any of these places a well directed blow with a pen-knife could penetrate the skull and in- jure the brain. In contrast with the regions of thinness there are ridges which act as buttresses and serve to strengthen the skull. In the vault, they are situated as follows: the torus transversus oc- cipitalis, a thickening in the bone extending laterally from the external occipital protuberance, a median thickening of the skull extending from the glabella to the foramen magnum and corre- sponding to the course of the superior longitudinal and occipital sinus, and the temporal crests ascending from the external angular processes of the frontal to be continued into the temporal ridges. In the base we have the ridges which divide the region into the three fossa and notwithstanding the fact that they are composed largely of thin, brittle compact tissue, they serve nevertheless to reenforce this part of the skull. They are : the petrous portion of the temporal and the lesser wing of the sphenoid. The base of 394 FRACTURES AND DISLOCATIONS the peti-ous portion of the temporal is applied to the skull in a region which corresponds to the mastoid externally and accord- ingly this part is comparatively strong. The foramen magnum is also surrounded by a ridge which is a bifurcation of the internal occipital crest, the two divisions ascending anteriorly to the pos- terior clinoid processes. These thickenings in the skull all have more or less tendency to modify vibrations and hence, to stop or divert lines of fracture. The foramina in the base of the skull are said to weaken it, and are of importance since the study of their positions and con- tents will aid in determining the location of the fracture. In the anterior fossa we have the cribriform plate of the ethmoid, the thinnest and weakest place in the floor of this fossa. It transmits the olfactory and nasal nerves, the latter passing through the nasal slit. In the middle fossa we have the sphenoidal fissure which transmits the nerves and vessels passing to the orbit : The motor occuli, abducens, patheticus, the three branches (nasal, lachrymal and frontal) of the ophthalmic and the sympathetic nerves as they pass from the walls of the cavernous sinus to the orbit. These nerves are accompanied by three vessels: The orbital branch of the middle meningeal artery, a recurrent branch of the lachrymal artery and the ophthalmic vein. The foramen rotuudum and ovale in the same fossa transmit respectively the second and third branches of the fifth cranial nerve together with other structures of minor importance. The middle meningeal artery enters the skull through the foramen spinosum situated in the tip of the great wing of the sphenoid. Through the carotid canal we have the internal carotid artery entering the cranial cavity accompanied by the carotid plexus of the sympathetic, the latter being con- tinued into the cavernous plexus when it reaches the side of the body of the sphenoid. The foramina in the posterior fossa are the foramen lacerum posterius or jugular foramen, the internal audi- tory meatus, the two condyloid foramina and the foramen mag- num. The jugular foramen transmits the glosso-pharyngeal, pneu- mogastric, and spinal-accessory nerves; also the lateral and in- ferior petrosal sinuses and a small artery. The inferior petrosal and lateral sinuses join to form the internal jugular vein a short distance outside the skull. The anterior condyloid foramen trans- mits the twelfth cranial nerve and occasionally an artery, the posterior condyloid foramen transmits a vein which establishes FRACTURES OF THE SKULL 395 communication between the lateral sinus and the deep veins of the neck. The internal auditory meatus transmits the facial, the audi- tory and the pars intermedia of Wrisberg, also a branch from the basilar artery. The gustatory fibres of the seventh join the nerve as it enters the internal auditory canal and leave it by way of the chora tympani. Membranes of the Brain. — The brain as it lies within the skull is enclosed within three membranes which conform more or less closely to its surface. The dura, the most superficial of the three, is composed of tough inelastic tissue which acts as the internal periosteum of the skull and is richly supplied with blood vessels. Most of the nutrition of the bones of the skull is derived from vessels running in this membrane. The dura is composed of two layers, a superficial and a deep. The superficial, or vascular, layer acts as the endosteum while the deep layer is lined with endothelium on its deep surface, and dips down between certain portions of the brain to form partitions and give support. The dura as a whole is more firmly adherent to the skull in childhood and in old age than it is in mid- dle life ; it is more firmly adherent at the base and where it crosses the sutures than elsewhere. Sir Chas. Bell has demonstrated the possibility of separating the dura from the bone without opening the skull; ''Strike the skull of a subject with a heavy mallet; on dissecting you find the dura mater to be shaken from the skull at the point struck. Eepeat the experiment on another subject and inject the head minutely with size injection, and you will find a clot of injection lying betwixt the skull and the dura mater at the part struck, and having an exact resemblance to the coagulum found after violent blows on the head." The reduplications of the dura extending into the cranial cavity between the main portions of the brain are three in number; be- tween the hemispheres of the cerebrum we have the falx cerebri, between the lobes of the cerebellum we have the falx cerebelli, and between the cerebellum and the occipital lobes of the cerebrum we have the tentorium cerebelli. The venous sinuses run between the layers of the dura which go to make up these three infoldings. The tentorium, like other portions of the dura, is a tough, in- elastic membrane and, — since its crescentic margin is firmly at- tached to the grooves on the occipital bone (the upper edge of the petrous portions of the temporal bones and the posterior clinoid 396 FRACTURES AXD niST.OCATTONS processes), — it is more or less liable to be toi-n when the cranium chano:es form durinpf the process of moulding, as it passes through the birth canal. Intracranial hemorrhage may then take place from the sinuses running between its layers. The falx cerebri serves to prevent the hemispheres of the cerebrum from jostling each other when the head is struck or moved quickly, and the falx cerebelli serves the same purpose for the two halves of the cere- bellum. The tentorium cerebelli sustains the weight of the occipi- tal lobes and prevents them from pressing on the cerebellum. The pia mater is a delicate membrane which invests the surface of the brain, contains numerous small vessels which extend per- pendicularly into the substance of the cortex. This membrane dips down into all the sulci, following the surface of the brain in every detail. It also forms the velum interpositum and the choroid plexus. TJie arachnoid lies between the dura and the pia, is composed of a loose areolar tissue and divides the space between the dura and pia into the subdural and the subarachnoid spaces. The arachnoid dips into some of tlie larger sulci, but resembles the dura in this respect more than the pia. The thickness of the membrane varies consideralily in diiferent portions of the brain. On the cerebral hemispheres it is tliin and delicate, while the part investing the pons is heavy and much less vascular. The subarachnoid space (between the arachnoid and pia) is quite large at the base of the brain and is filled with cerebrospinal fluid. The subarachnoid and subdural spaces connect with the ventricular cavities of the brain through the foramen of IMajendie in the posterior medullary velum of the fourth ventricle. The cerebrospinal fluid by its escape into the spinal spaces allows a certain amount of displacement of the cranial content. Vessels of the Membranes. — The vessels running in the dura are often partially accommodated by grooves on the inner surface of the skull, and this intimate contact between bone and vessel renders the latter quite liable to injury when the line of fracture traverses these bony channels. The most important artery in the dura is the middle meningeal, a branch of the first portion of the internal maxillary artery; it gains entrance to the skull through the fora- men spinosum and passes outward onto the internal surface of the squamous portion of the temporal, where it divides into an ante- rior and posterior branch. The anterior branch passes outward FRACTURES OP THE KKtJLL. 397 and forward, while the course of the posterior branch is outward and backward. E'oth branches are continued onto the inner sur- face of the parietal bone. There is considerable normal variation in the courses of these two branches after they reach the parietal bone, and we have no possible means of ascertaining the exact position that they may occupy in a given case. The anterior branch, however, will usually be found passing upward and slightly backward from a point about one and three quarters inches above the zygoma and one and a half inches behind the external angular process of the frontal bone. The course of the artery Pig. 515. — Internal surface of right lialf of skull showing courses of middle menin- geal artery and lateral sinus. In this case the posterior branch of the arterj- is double and calls attention to the frequency with which anomalies occur in the course and distribution of this vessel. A study of this vessel and its anomalies will point out the advantages of the osteoplastic method of opening the skull as compared with trephining, for the removal of clots. from this point is nearly parallel to the coronal suture, running from one-half to three quarters of an inch behind it. A trephine opening with its center about one inch above the external auditory meatus will expose the posterior branch of the middle meningeal. In trephining in this region it should be remembered that the skull is thin, the internal surface irregular and that the anterior branch of the middle meningeal (especially in the region of the pterion) may run in a complete bony canal instead of a groove. Kronlein's diagram gives the three most frequent sites for the location of clots following hemorrhage from this artery. The diagnosis of the position of these clots is often difficult, sometimes impossible. The 398 FRACTURES AND DISLOCATIONS most satisfactory method has been found in the osteo-plastic flap Avhieh exposes enough of the brain to satisfactorily explore its sur- face without missing the site of hemorrhage. IMeningeal hemor- rhage may take place from some of the smaller meningeal arteries and occupy regions in the frontal or occipital lobes. A common form of meningeal liemorrliage is tliat arising from small veins. A linear fracture may divide small veins, and the resulting hemor- Fig. 516. — View of right half of interior of base of skull showing the courses of the middle meningeal artery and lateral sinus. rhage, though slow, not infrequently forms a large coagulum. In this form of hemorrhage the symptoms are slow in developing because it takes a number of hours for the clot to assume sufficient size to cause disturbance. In addition to the middle meningeal artery, there are also other meningeal arteries of smaller size. They are the three meningeals from the ascending pharyngeal : — the anterior meningeal from the internal carotid, the posterior from the vertebral, and the small meningeal from the internal FRACTURES OF THE SKULL 399 maxillary. These arteries, however, are all of small size and rarely the cause of hemorrhage. Intracranial Sinuses. — The most common site of meningeal hemorrhage, after the middle meningeal artery, is the lateral sinus. The walls of the sinuses are formed by a splitting of the dura and are lined by an endothelial layer which is continuous with the lining membrane of the veins. Sinuses may be the site of throm- bosis and suppuration and when ruptured result in intracranial hemorrhage ; they should be specially avoided when trephining the skull. The superior longitudinal sinus corresponds to a line drawn from the glabella to the inion. A line drawn from the inion to a point one and a half inches above the external auditory meatus will correspond to the highest part of the lateral sinus where it crosses the lambdoid suture. The lateral sinus then curves down- ward and forward running on the internal surface of the mastoid portion of the temporal. It is joined by the superior petrosal sinus at the posterior end of the upper border of petrous portion of the temporal and by the inferior petrosal sinus just below the jugular foramen after the two sinuses have passed out of the skull. The two cavernous sinuses situated on either side of the cella Turcica drain the ophthalmic vein, anastomose with each other through tlie circular and transverse sinuses and are themselves drained into the lateral sinuses by means of the petrosal sinuses. A line drawn perpendicular to the surface of the bone just below the inion, if projected into the skull, would correspond to the course of the straight sinus. The straight sinus drains the veins of Galen and the inferior longitudinal sinus which runs in the lower border of the falx cerebri. The blood from the straight sinus is drained by one of the lateral sinuses after having been emptied into torcular Herophili. The occipital is formed by the two marginal sinuses which connect with the sigmoid portion of the lateral sinus; it passes upward and empties into the lateral sinus, the straight sinus or the torcular Herophili; it establishes connection with the deep veins of the neck through the foramen magnum. The origin, course and exit from the skull of the twelve cranial nerves is of importance in diagnosis but the reader will be referred, for this detail, to text-books on the subject. Lesions of different portions of the brain will give different symptoms according to the function of the region injured. We may divide local injuries of the brain into injuries of the cortical 400 FRACTURES AXD DISLOCATIONS (H*iittM-s aiul tlieir tracts, and iiijui-ies of tlie haso. For practical ])uri)os('s we may divide the cortex into motor areas, sensory areas, Kiu'. 318. Fig. :519. Fis. 520. Fig. 517. — M., Midpoint of naso-inionic line; L.ti., Poirier's line and corresponds to Sylvian fissure; 7.JV., Koeher's equatorial line from' nasion to inion; A..B., German base-line and passe.s through inferior edge of orbit and upper border of external auditor}' meatus. Fig. 518. — .v., Jj.K. and 7. A', same as in Fig. 517. A line drawn forward and downward at an angle of 60 from median plane is known as Koeher's anterior meridian and lies over preoentral convolution. Koeher's posterior meridian is drawn downward and backward 60 from the median plane. Fig. 519. — Dotted areas correspond to the most frequent sites of meningeal hemor- rhage. Fig. 520. — Cortical centers. and a number of so-called silent areas. The cortex of the brain is composed of gray matter which in most regions is disposed in five layers. Axis-cylinders from the cells of this gray matter es- FRACTURES OF THE SKULL 401 tablish commimieation between different portions of the cortex and between the cortex and the lower centers situated in the base of the brain and in the cord. The function of the cortex of the brain is to register memories of past experiences. Tinder certain conditions these centers are stimulated and have the capacity of reproducing the events which they have registered. Thus stimu- lation of the occipital lobe gives us the memory of sights seen, stimulation of the temporo-sphenoidal lobe gives us the memories of sounds heard, stimulation of the motor area gives us the mem- ories of acts performed. It is therefore necessary to know what part of the cortex registers certain experiences in order that we may be able to tell just what symptoms would be produced by injury of a given part of the brain. Conversely, this knowledge having been obtained we may be able to state what part of the brain has been injured from the observation of certain symptoms. The cortex as has been said is divided into certain so-called cen- ters. The frontal area is concerned with conscious selective action, the Rolandic area with motor memories and the .reproduction of these memories which results in voluntary motion, while the spinal level is concerned with reflex and vegetative automatism. Experi- ment on lower animals and observation of diseased and traumatic conditions in the human being have determined the function of many regions of the cortex, but there are still many areas the function of which remains unknown. For obvious reasons the more complex and the higher the function of a given area, the more difficult it becomes to ascertain the nature of that function. The occipital lobe on either side of the calcarine fissure is con- cerned with the memories of sights seen; the temporo-sphenoidal, especially the left, with the memory of sounds heard and muscular memories; the left angular gyrus with the memory of written speech; the posterior part of the frontal lobe with the memory of printed speech; and the third frontal convolution on the left side is concerned with the memory of spoken speech. Stereognostic sense is located in the parietal lobe. The centers in the Rolandic sensori-motor area are disposed inversely (i. e., the centers for the head are below those for the upper extremity, etc.). The centers for the lower extremity extend onto the mesial surface of the hemisphere. Fracture of the vault may injure one or more of these areas. If the injury is slight, and the center is not de- stroyed, the lesion is said to be irritative and the center overacts. 402 FRACTURES AND DISLOCATIONS If the lesion is more serious and the center is destroyed the func- tion of that center is lost. Thus if the Rolandic area is irritated, the regions of the body supplied by the corresponding centers are thrown into unwonted activity or spasm ; but if the lesion is more severe, function of the center is lost. This results in loss of mem- ory for muscular movements and consequently they cannot be voluntarily reproduced. If Broca's convolution is destroyed, the memory for the acts connected with motor speech is lost and con- sequently the movements of motor speech cannot be reproduced. Of recent years, however, there has been some doubt as to the function of Broca's convolution, and it is not now thoufi'lit to be so essential to speech as formerly. If the lesion penetrates below the cortex, the fibres which asso- ciate these centers may be lacerated and the normal communica- tion between centers is interfered with. Thus a given center can- not be stimulated, as in tlie normal person, by the activities of an associated center. If a center concerned with speech is destroyed and the function of that part of the cortex lost the patient is said to suffer from aphasia. If the fibres connecting a given cortical center with some other cortical center are lacerated the patient is said to suffer from intereortical aphasia. If the center destroyed is concerned witli motor memories the patient has motor aphasia. If the centers concerned with registering purely sensory ideas are destroyed the patient has sensory aphasia. The base of the brain also has centers distributed through its substance which preside over various important functions of a lower order than those found in the cortex. These centers have running through them fibres from the cortex of the brain, so that, in case of injury, we have not only symptoms of lesions in these lower centers but also symptoms of interruptions of impulses from the cortex. In the anterior fossa we have the center for smell situated in the olfactory lobe. In the middle fossa we have the optic thala- mus, the corpora quadrigemina, and the crus. The optic thalamus is concerned with emotional facial expression and lesions of this body may give rise to athetosis or incoordination of the paralyzed hand and pain in the paralyzed limb. The anterior corpora quad- rigemina are associated with motion of the eyeballs and acuity of vision, the posterior corpora quadrigemina are related to hearing and equilibration. The crus contains the nucleus of the third and FRACTURES OP THE SKUIjL 403 fourth nerves and longitudinal fibres passing from the cerebral cortex to the spinal cord. Lesions of this body give a character- istic set of symptoms in accordance with the nuclei and fibres contained within it: paralysis of the third and fourth nerves will deprive all the muscles of the eye of their nerve supply except the external rectus; injury to the longitudinal fibres may cause hemi- plegia of the opposite side and hemianopsia may be present if the adjacent optic tract is injured by pressure. If both crura are damaged we have a double hemiplegia with paralysis of the third and fourth nerves on both sides, and in some instances optic neu- ritis. In the pons we have a continuation of the longitudinal fibres of the crura, the thermogenic center, and the nuclei of the fifth, sixth, and seventh cranial nerves. Injury to the fibres of the crura as they pass through the pons may produce hemiplegia, disturbance of the thermogenic center, extremely high tempera- ture, and injury to the three cranial nerve nuclei will be followed by symptoms peculiar to each nerve. Injury to the nucleus with loss of function in each nerve will be as follows : for the fifth, hemifacial anesthesia with paralysis of the muscles of mastication ; for the sixth, paralysis of the external rectus of the eye ; and for the seventh, motor paralysis of the muscles of the face. Bilateral symptoms will be present if the lesion involves both sides of the pons. The usual anatomical division of the bulb into pons and medulla is purely artificial. For practical surgical purposes they should be considered together. The medulla resembles the pons and crura in containing longi- tudinal fibres from the cortex together with cranial nerve nuclei. The characteristic symptoms of lesions of the medulla will depend on the nuclei which it contains. In the upper border of the medulla is the nucleus of the eighth cranial nerve which also pro- jects into the pons; in the lower half of the fioor of the fourth ventricle we have the nuclei of the ninth, tenth, and eleventh cranial nerves and at a slightly lower level is found the nucleus of the twelfth. The vomiting center, the vaso-motor center and numerous other centers governing various functions in the body are situated in the bulb, but as yet too little is accurately known concerning them to be of considerable surgical value. Further back in the posterior fossa we have the cerebellum which is concerned in coordinating the various muscular activities 40-4 FRACTURES AXD DISLOCATIONS of the body and in the complex process of equilibration. Another function of the cerebellum consists in the peculiar power of im- parting the proper degree of force to muscular movements. In- jury to the cerebellum may give rise to cerebellar ataxia, obstinate projectile vomiting, and various forms of paralyses and anes- thesias. The association of the cerebellum with the pons, medulla, basal ganglia and cortex is so complete that it is difficult to deter- mine the source of these varied symptoms. The foregoing enumeration is by no means t-oniplete as regards location and function of the cortical centers and basal ganglia ; there is still considerable dispute concerning the functions of these centers and there are numerous other centers which as yet remain with functions unknown. There are many symptoms occurring in head injuries which could be properly explained if we knew more of the anatomy and physiology of the brain, but for the present the description given will be found of service in roughly deter- mining the seat of injury in fracture of the skull. Etiology. — Trauma is the cause of fracture of the skull but the nature and the degree of violence are so extremely variable that the resultant conditions show the greatest differences in detail. The trauma may be sustained over a small or large area of the skull; the vulnerant body may travel at a high rate of speed (bul- let) or at a slow rate (club) ; the violence may be direct or it may be transmitted through the spinal column or inferior maxilla. The violence may be circumscribed or the head may be squeezed or crushed betw^een heavy objects. Fracture of the skull constitutes from four to six percent of all fractures and possibly more, since we are learning of recent years that the milder forms of the condition have only too frequently gone unrecognized in the past. Statistics are specially misleading in this particular injury, for the following reasons: in the first place the most severe cases never reach the hospital because of immediate death, and secondly the condition is frequently asso- ciated and confused with other injuries; thii'dly, the milder cases are often successfully treated at home, and in many cases are not classified as fractures because of mistaken diagnoses. For these reasons figures derived from a service such as the police surgeon's will come nearer the truth, since it includes all classes of fractures ranging from the mildest to those immediately fatal. Occupation is an inqjortant element in the etiology. Fracture of the skull is FRACTURES OF THE SKULL 405 most frequently found in the male and in middle life. The skull in the aged is much more easily fractured than that of the person in middle life, but on the other hand those advanced in years are not so exposed to injury. Mechanism and Pathology. — The various ways in which the skull is broken, the manner in which fragments are displaced, and the region of the cranium involved have all been subjects of careful investigation, and terms, to designate the peculiarities of the con- ditions, have been applied. Before considering the mechanism of these fractures, it is necessary to again refer to the anatomy with respect to the peculiar formations of the vault and base. The structure of the skull is peculiar to itself and any attempt to liken the manner in which it breaks to that of other objects can at best be but incomplete. Circumscribed blows upon the vault of the skull commonly produce a local depressed fracture with or without injury to the underlying structures. A more extreme blow or squeezing of the skull will result in fissures (with or without de- pression) which are prone to extend towards and involve the base. A certain degree of trauma can be withstood by the vault without apparent injury, the shock being absorbed by the natural elas- ticity of the bone. If the trauma be a little greater, and the skull bent inward sufficiently, the internal table may give and we then have a fracture of the inner table alone ; a condition frequently described in text-books, but rarely seen in practice. A still greater trauma results in dissolution of continuity of the entire thickness of the bone. On the other hand a blow from a sharp cutting in- strument may fracture the outer table while the inner table re- mains intact. The skull may be fractured by "bending" or by "bursting." When violence is applied to the skull in a circum- scribed region the immediate site of injury is "bent" inward with resultant local fracture which is said to be "fracture by bending." When the violence is applied over a larger area and more slowly, lines of fracture may be found radiating from the site of impact, often involving the base. The action may be likened to the break- ing of a nut in a nut-cracker. This form of fracture is spoken of as "fracture by bursting"; the most striking examples of which are seen in instances in which the head has been caught and crushed between two heavy objects. We often have evidences of both the bending and bursting action in a given case. If the skull were of a uniform thickness throughout, the mechanism would be 406 FRACTURES AND DISLOCATIONS iinich easier to determine. As it is we find the peculiarities in the structure of the skull directly influence the directions which fissures take. When fractures of the vault, between the frontal and parietal eminences, involve the base they are frequently ac- companied by fissures extending into the middle fossa. When fractures posterior to the parietal eminence are accompanied by basal fissures they usually extend into tlie posterior fossa and in like manner those anterior to the frontal eminence involve the anterior fossa. In gunshot wounds, especially when produced by the modern high-pressure bullet, the skull sometimes presents what would seem to be an explosive effect similar to that produced by shooting through a barrel filled with water. The nature of the vulnerant body is an extremely important element, for example ; the completely jacketed high-velocity rifle ball will usually pene- trate cleanly, is not prone to carry in any extraneous materials, and the wound is frequently sterile throughout. On the other hand a blow from a hammer besides driving a portion of the bone into the brain will frequently be found to have carried in hair, dirt, or felt, and the wound is therefore much more liable to infection. Fracture by contrecoup has been the subject of much discussion and although it may be possible for fracture to occur at the opposite pole of the head as a result of the meeting of vibrations, j^et its occurrence has been, to say the least, greatly exaggerated. Most of the so-called contrecoup fractures will upon further investigation be found to be fractures by bursting or the result of a second blow on the head. For example : a man sustains a blow on the forehead fracturing the anterior part of the skull, falls heavily to tlie sidewalk and strikes the back of his head, producing a second fracture in the occipital region; this second fracture is not infrequently considered a fracture by contrecoup when in realit^y it is but the result of a second blow. The outline and position assumed bj^ depressed fragments will cor- respond, more or less, to the shape of that portion of the vulnerant body which has produced the fracture. The terms ''gutter," "pond," etc., are used to indicate the position of the fragments. When the fragment is depressed and only partially detached from the remainder of the skull, the unbroken bridge of bone connecting the fragment may impart sufficient spring to the depressed portion to pinch and securely hold extraneous materials such as hair and felt. The injuries inflicted by missiles vary with the nature of FRACTURES OF TJIK SKULL 407 the projectile, and the weapon from which fired. The lead ball from an ordinary 32 caliber revolver produces considerable dam- age at the point of entrance, and very commonly remains within the skull, even when fired at close ran^^e. A 38 or 44 caliber is much more likely to pass through the skull. The partially jack- eted or mushroom bullet usually passes through the head with more or less shattering of bone at the wound of entrance, and extreme damage, comminution and laceration at the wound of exit. The completely jacketed high-velocity projectile, such as used in the army, may penetrate the head with a minimum amount of trauma; the wound of entrance is small and clean cut, the wound of exit is only a trifle larger. Any projectile either low or high in velocity is likely to produce extensive comminution when the skull is struck a gianeing IjIow. Symptoms of Concussion, Contusion, Laceration and Com- pression. — The symptoms accompanying fracture of the skull are firstly, those of the fracture itself and secondly, those result- ing from injury to the encephalon, which may be either general or localizing. They will depend upon the extent, nature and posi- tion of the injury sustained by the brain. Symptoms of fracture are often very meager, and of little importance aside from the concomitant brain injury. Before entering upon the symptoms occurring in connection with fractures of the skull and injuries to the brain, it will be necessary to consider a group of conditions which occurs either with or without fracture, namely, — concussion, contusion, laceration and compression. At least one and some- times all of these four conditions are associated with fracture of the skull, but the fact that it is possible for them to be present without accompanying injury of the bone renders the diagnosis of fracture of the skull more difficult. Concussion and contusion of the brain are really the same condition, the difference being one of degree. Concussion consists of a jarring of the brain-substance which results from rapidly putting the head into motion, as by a blow; or by suddenly stopping it while in motion, as in a fall. The symptoms of concussion Avill vary with the severity of the injury. When slight, the patient is momentarily dazed, develops more or less of a headache and may suffer from vertigo and nausea. When the jarring of the brain-substance is more severe, the patient be- comes unconscious, with general muscular relaxation and a cold 408 FRACTURES AND DISLOCATIONS elanuny skin. There may l)e loss of si)liiiK'teri(' eoiitrol at the time of the accident, later on the sphincters may fail in reaction, with resultant overdistention of the bladdei- and howt'ls. There is gen- eral systemic (depression, the pnlse is weak and tliready: the pupils are, as a rule, equal, with a tendency towards dilatation. Keaction to light is present though sluggish. The patient recovers gradu- ally from the unconscious state, requiring some hours, in severe cases, before complete consciousness and good judgment are re- stored. As the patient recovers he is prone to ask many questions, which are usually concerning his whereabouts, the nature of the accident, etc. The manner in which these ciuestions are put and repeated is most characteristic of the condition. For instance, he may ask where he is; then what happened to him, how it hap- pened ; and where some companion may be. These questions are as a rule slowly repeated in the same order, regardless of the fact that they may have been repeatedly answered. It is a peculiar fact that with the loss of memory for the accident and the subse- quent unconsciousness, there is also the loss of memiory for events immediately preceding the accident. This loss of memory pre- ceding the accident will cover a period proportionate to the sever- ity of the concussion, sometimes many hours, days or even months. As memory returns, this blank space is lessened from both ends until, with complete recovery, the patient is able to remember everything that occurred outside the period of coma. With re- turning consciousness the patient is often able to state his name before it is possible for him to recollect anything else. It will be some time later before he is capable of answering questions in- volving numbers, such as his address, date of the month, etc. It is important in this regard to see to it that the patient has fully regained his good judgment as well as his consciousness, since seri- ous consequences may ensue if he be allowed to go about his busi- ness unattended. For example, he may be able to state his name, give his occupation, tell what business he was about when injured, etc., and yet if released may be unable to find his way home or may perform some act contrary to good judgment before he has thoroughly regained his mental balance and is himself again. It is therefore wise to keep him under observation for at least a few hours following the accident. Contusion. — Contusion as previously stated is but a more severe degree of concussion and accordingly we find the symptoms of con- FRACTURES OP THE SKULL 409 cussion present in exaggerated form. Pathologically there is this difference between concussion and contusion : concussion shows no characteristic post-mortem findings, while contusion frequently shows minute punctate hemorrhages throughout the substance of the brain. Like concussion there will be unconsciousness, prostra- tion, disturbances in sphincteric control, cold clammy skin, weak thready pulse, etc. The unconscious period is prolonged and re- covery protracted, so that the condition may cover a period of weeks or even longer. Recovery from unconsciousness is slower, and in rare instances the condition may be followed by mania end- ing in recovery, death or dementia. Protracted and severe head- ache is not uncommon and vomiting is often persistent. During semiconsciousness, headache is evidenced by the patient putting his hand to his head and later when able to talk he complains of the pain. If the intracranial disturbance is severe enough to be irritative, one or both pupils may show contraction, according to the cerebral regions involved. During recovery, which is gradual, the patient may develop an active delirium and if not restrained may leave his bed and wander about aimlessly. During this semi- conscious period he often assumes a perverse, obstinate, mental attitude which renders nursing difficult and sometimes even dan- gerous. In extreme cases the patient may pass into a typhoid state with sordes, coated tongue, sphincteric disturbances, low mut- tering delirium, subsultus tendinum, etc. When contusion is se- vere or prolonged, localizing symptoms are likely to develop ; the condition is then recognized as one of laceration or compression as well as contusion. When symptoms of compression develop early they are likely to be due to hemorrhage or laceration, but if they come on late, edema of the brain is probably the cause. Laceration. — 'Laceration of the brain tissue without fracture may be considered an intensified, local contusion and is due to the same causes. When it is the direct result of depressed fragments or the entrance into the skull of the vulnerant body we find that the condition may occur more or less independently of the symp- toms which usually accompany concussion, contusion and com- pression. Laceration may accompany contusion and concussion without giving rise to localizing symptoms if the region of the brain involved is not capable of producing peripheral disturbances in function. When the region injured is within some of the so- called silent areas, we have no localizing symptoms. Contusions 410 FRACTURES AND DISLOCATIONS and lac-orations ol' tlie brain are a frequent aet'onii)aniiiiciit of frac- tures of the base, the most frequent sites being the under surfaces of the frontal lobes and the tips of the spheno-temporal lobes. In depressed fractures of the vault it is common to find the cortex beneath the fragments .suffering from laceration. The pulse is usually weak and rapid, resembling concussion in this respect; in- creased tension and slow pulse are to be expected only when com- pression develops. The temperature in both concussion and contusion is, as a rule, sul)normal but as the conditions merge into the more severe grades of brain injury, such as laceration, the temperature rises above normal. Compr€lish('d. The canal should uot be plugged with cotton, as commonly i)racticed, since this can onl}^ tend to dam the fluids hack instead of allowing their free and prompt escape. If clots of blood form within the external auditory meatus they should be removed wdth a sterile ear-hook so that the canal may be kept open. Fracture of the base, allowing the escape of blood within the cranium or into the petrous portion of the temporal, is much more favorable in outlook if this blood makes its escape through the ear. The nppcr part of the nasal cavity and of the naso-pharynx are sometimes the seat of basal fractures w^hich establish communi- cation between these cavities and the meninges. When such is the case, as commonly indicated by hemorrhage or the escape of cerebrospinal fluid, the nose and mouth should receive the most careful attention. The nose should be kept free and clean by the removal of clots forming in the lower part of the nose. Alkaline washes, Avhen properly used, may facilitate the removal of these clots, but violent douchings or syringings should be avoided, lest they carry infection into or through the line of fracture. For similar reasons the patient should not be allowed to blow his nose, and if coughing occurs it must be controlled by sedatives. Scre- atus will draw the secretions through the posterior nares and, since it is accompanied by the same result, a negative air pressure within the nasal cavities is to be recommended instead of blowing the nose. Hemorrhage from the nose, unless severe, does not call for checking, and plugging of the nostrils only results in the accumulation of foul and infectious clots within the nasal cavities. The mouth should be frequently washed out and the teeth cleansed with potassium chlorate tooth paste. The cleansing and treatment of scalp wounds has already been described ; when fissures or de- pressions exist at the bottom of the wound irrigation is contra- indicated. FRACTURES OF THE SKULL 447 Operative Treatment. — Operative treatment is called for; — in the treatment of scalp wounds, for the elevation of depressed frag- ments in either simple or compound fracture of the vault, for alleviation of meningeal hemorrhage, for the removal of foreign bodies within the skull, for the correction of secondary complica- tions such as cortical irritation resulting from old scars, and for the treatment of tumors, abscesses or softening. In depression of the vault it is often possible to elevate and remove the fragments with a heavy rat-tooth forceps; but in other instances it may be necessary to trephine on the solid side of one of the margins of the depression, to introduce an elevator beneath the fragments. A 533. Fig. 534. Fig. 533. — Diagram indicating the steps in opening the skull by means of an osteoplastic flap. 1, 2, 3 and 4 indicate the positions of trephine openings. Solid lines indicate division of skull. Line 3-4 indicates where the flap is turned back. Dotted line indicates skin incision. Fig. 534. — Shows the motor area exposed when the flap is turned back. simple fissure without localizing symptoms or indications of intra- cranial pressure does not necessarily call for opening of the skull, but in many cases the safest plan will be the exclusion of menin- geal complication by operative intervention. Of the various meth- ods, however, which have been employed for the removal of a meningeal clot, the osteoplastic flap is the most satisfactory. It is often difficult to accurately determine the site of the hemorrhage, even when localizing symptoms are present, and if an opening in the skull no larger than that produced by the ordinary trephine is made, the chances of failure in locating the clot are many. The change in recent years from simple trephining to the use of the 448 FRACTURES AND DISLOCATIONS osteoplastii' flap has malorially rod\UH'(l the percentage of operative failures. In niakinu- an osteoplastic flap a U-shaped incision with tlie convexity iipwanl is made thronsih the scalp and down to the bone, the sknll is exposed and two small trephine openings are made at the npper angles of the qnadrilateral section of bone to be displaced. A grooved diiector is then introdnccd into one of Fig. 535. — DeVilbiss bone-cutting forceps used in making the osteoplastic flap of skull and scalp. the openings and passed between the dnra and tlie sknll in tlie direction of the opening in the adjoining angle ; by this means a Gigli wire saw is passed from one opening to the other and the bone betAveen the two cnt with the divider in place to protect the meninges. If the upper border of the bone flap is beveled at the expense of the inner table, while being cut with the saw, it will prevent subsequent inward displacement. The vertical sides Fig. 536. — Small trephine employed in making an osteoplastic flap. The open- ing made with this instrument may be used to introduce the Gigli saw, or a bone- cutting forceps such as the DeVilbiss may be used. (See Fig. 535.) of the bone flap are then made by cutting the skull with DeVilbiss forceps, beginning at the trephine openings. After the three sides are completed the base is broken and the flap turned back. The DeVilbiss cutting forceps may be used instead of the saw in con- necting the trephine openings, the bone having been previously separated from the underlying dura. Those skilled in the use of FRACTURES OF THE SKULL 449 the chisel and mallet divide the bone with considerable facility, though this procedure is not to be recommended because of the shock so commonly produced by the hammering. (For the course of the middle meningeal artery and common sites of meningf^al hemorrhage, see "Surgical Anatomy," page 396.) After the flap has been made and turned back the clot should be removed witli the least possible trauma to the underlying brain. The artery from which the hemorrhage occurred is to be secured and ligated. Subdural clots or bleeding may be present, necessitating the open- ing of the dura to reach the collection of blood. In closing the wound the dural edges should be carefully approximated witli fine suture material after all hemorrhage has been properly controlled. In cases of marked increased intracranial tension it may be im- possible to bring the edges of the dura together, or if such is done, the object of the operation is to some extent defeated, if it has been performed for decompression. In such instances the dural defect may be provided for by the transplantation of a section of fascia lata. This prevents adhesions between the brain and scalp and at the same time allows an increase in intracranial capacity Plastic sliding operations on the scalp may be performed when the osteoplastic flap cannot be brought back into accurate apposition because of extrusion of the brain and dura. Lumbar puncture will facilitate closure of the scalp and skull in an otherwise diffi- cult case and is attended by less danger if the skull is open at the time the cerebrospinal fluid is withdrawn. Gushing 's cross- bow incision may be employed in opening the posterior fossa, though the results of decompressive operations in this region have not been as satisfactory as one might wish. The positions of the sinuses in this part of the skull must be kept in mind when op- erating in this region. Prognosis.- — The prognosis of head injuries is as varied as the subject itself. The outlook will depend largely upon the damage sustained by the cranial contents at the time of the accident and, inasmuch as it is sometimes most difficult to determine the extent and severity of this damage, it will be proportionately hard to state just what the outcome may be. In addition to the traumatic elements we will have to consider the chances of infection and meningitis when the fracture is compound. It is next to impossi- ble to state in a given case whether or not the patient will in the future develop traumatic epilepsy, suffer from chronic headache. 450 FRACTURES AND DISLOCATIONS vertiiiO and otlici- late syiiiptoius. oi' that lie will or will not develop cerebral tumor, abscess, gumma or softening. In a general way it may be stated that the more severe the trauma, and the more pronounced tlu^ symptoms, the greater the danger of an early, fatal termination. The prognosis as to life is good in cases which survive the fir.st forty-eight hours following the injury. Rigidity of the pupils, especially in dilatation, is conunonly followed by death, rronounced disturbances in respiration, temperature and jnUse whether early or late in the case, render the prognosis grave. The mortality and the development of sequela; have been materi- ally reduced by operation in selected cases. Fracture of the base more often produces death than fracture of the vault. Of frac- tures of the base those involving the posterior fossa have the high- est mortality, those of the anterior fossa the lowest, while fracture.s of the middle fossa occupy an intermediate place. This difference in mortality is largely due to the positions of the important basal ganglia, and to the fact that hemorrhage into the anterior or mid- dle fossa^ usually makes its escape without difficulty through the mouth, nose or ears. IMeningitis more commonly follows fracture of the anterior and middle fossae, though the dangers from this complication by no means equal the deadly effect of pent-up hem- orrhage within the posterior fossa. The development of new and significant symptoms during the course of the case may so alter the general aspect in diagnosis, treatment and prognosis that it will be unwase for the surgeon to make any definite forecast early in the condition. A most valuable aid in prognosis will be found in a carefully kept and complete chart which points accurately to changes occurring in the case and shows whether the symptoms are increasing in severity, or, on the other hand, are becoming less pronounced. Late Symptoms and Sequelae Following Head Injuries. — The immediate recovery and the after-effects in fracture of the skull do not bear any constant relation to each other, nor are the late conditions developing in the course of the case necessarily propor- tionate to the extent and severity of the original damage. The symptoms of tumor, gumma or abscess of the brain may make their appearance months or even years after the original injury, following an interval of apparent recovery. In other in- stances the symptoms of the sequelae may develop before the pa- FRACTURES OF THE SKUI.L 451 tient has recovered from the acute condition of fracture of the skull. The unfortunate condition of some of these patients is known to those who have attended large clinics for any considerable period. The head pains, epileptic convulsions, subjective sensory disturbances, psychic changes or paresthesis often unfit the sufferer for the sociologic demands of his surroundings, and he haunts the clinics or passes from one surgeon to another with the persistent hope that some new operation or different type of surgical pro- cedure may afford him relief. The peculiar way in which these patients attempt to figure out the details of intracranial derange- ment and their fixed opinions concerning the manner in which the surgeon should correct the trouble, are often characteristic. Epi- lepsy following fracture of the skull is not uncommon and often assumes the Jacksonian type. When the convulsions are focal in character and have not been allowed to persist for a period of more than two years the .chances of recovery, as a result of op- erative intervention, are good if the causative cortical irritation is corrected or the area of the cortex in which the convulsion begins, is removed. When the non-focal form of epilepsy follows fracture of the skull it is not so easily controlled, the treatment being, as a rule, medical. Chronic headache often begins in, or is confined to, the region of the original injury and may be dependent upon cortical irri- tation. When such is the case, operations for its relief may be successful, as in focal epilepsy. In other instances the headache is general and the outlook for surgical relief is not so hopeful. Pain in the nerves of the scalp, which is sometimes produced by cicatricial contraction, or pain in some of the cranial nerves, as a result of injury, is not, strictly speaking, headache, and should be dealt with according to the peculiarities of the individual case. Chronic headaches following fracture of the skull deserve the most careful neurological study in order that the cause may be deter- mined, when possible, and relief afforded. Vomiting, vertigo, and disturbances in hearing are sometimes persistent and extremely distressing to the patient. Little in the way of radical treatment can be accomplished for these conditions ; sedatives, depressants and proper hygienic surroundings are about all that can be done for their relief, with the hope that they will 452 FRACTURES AND DISLOCATIONS ill tiiiif lessen in degree and finally disappear. When tliese symp- toms occur as a result of cerebral abscess, tumor or softiMiing, the treatment becomes that of the causative lesion. Psycliic ciianges are not infrequently observed following fractures of tlie skull, particulai'ly in injury to the frontal lo])es. The extent of the frontal lobes, however, and the variability in the proportion exist- ing between lesion and symptoms renders the subject of localiza- tion extremely difficult unless local symptoms exist pointing to the exact region of damage, and even in instances in which a visible depression on the forehead indicates the site of fracture and corti- cal displacement, the results of operation are by no means uni- formly satisfactory. The patient may show a simple weakness of intellect, the com- prehension being dull and slow, or he may present an irritability and temperamental change entirely foreign to his disposition prior to the accident. Lassitude and aversion to either physical or mental activity are common among the psychic changes. It not uncommonly happens that the patient is persistently possessed of abnormal fears and apprehensions regarding his physical welfare, domestic relations or business responsibilities. The fear of failure is sometimes such an obsession that the patient refuses to even attempt anything in the way of resuming his former occupation. It should not be understood that such fears are without any real foundation in fact, yet when they do exist it is usually noted that the real degree of unfitness is by no means proportionate to his own sense of incapacity. In rare instances insanity may follow. CHAPTER XXXII. FRACTURES OF THE STERNUM. Surgical Anatomy. — The sternum is rarely fractured. Firstly, because of the protection afforded by the arms in case of accident, and secondly, because of its situation and structure. It is composed of a soft, spongy tissue encased in a layer of compact bone, and is supported by the ribs and costal cartilages which act as a series of springs which absorb and modify shock. The sternum is usually ossified from six centers ; one each, for the manubrium and ensiform appendix, and four for the gladiolus. Fig. 537. — The sternum. M.. manubrium; X., xyphoid cartilage; C, clavicle. The costal cartilages are numbered in order. Considerable variation occurs in the ossification of this bone. The lower sections of the gladiolus are not uncommonly ossified by two centers for each segment, and in anomalous instances lack of fusion between these lateral centers may result in a foramen or fissure in the lower part of the second portion of the sternum, even in adult life. This condition might be mistaken for a fracture if one is not 453 454 FRACTURES A XI) DISLOCATIONS aeqiiaiiited Avitli the anomaly. 'Vhv centers of cssitieation in tlu' sternum make their appearance in order from above downward, the lirst being seenas early as tlie fifth fojtal month, while the center for the lower segment of the gladiolus is often not present until the second year. The center for the xyphoid cartilage may make its appearance anywhere between the second and eighteenth years. Fusion of the different segments of the sternum begins at about puberty in the lower end of the gladiolus, and proceeds upward until the process is completed at about the twenty-fifth year. The xyphoid joins the gladiolus at about forty. The period at which fusion occurs between the manubrium and gladiolus is vai-iable. They are usually continuous on the surface after middle life though the center of the articulation often remains soft even in the aged. The anterior mediastinum with its contents lies directly behind the sternum. The pectoralis major is attached to the anterior surface of the bone. The sternomastoid, sternothyroid and sternohyoid are at- tached to the upper end, while the abdominal muscles are attached either directly or through their aponeuroses to the lower end of the bone. The diaphragm and triangularis sterni find attachments to the lower portions of the posterior surface. The anterior mediastinum with its contents lies directly behind the sternum. The heart lies directly behind the lower two-thirds of the sternum (excepting the xyphoid cartilage). The pericardium is separated from the bone by the remains of the thymus gland above, and a small quantity of areolar tissue below. Tlie junction of the first and second pieces of the sternum may be felt as a transverse ridge on the bone, passing between the attachments of the second costal cartilages. Violent hyperextension, or overflexion of the spine, particularly the latter, may produce fracture of the sternum. The violent im- pact of the chin against the upper portion of the bone is said to have produced the condition. A blow^ on the chest may, in rare instances, produce fracture. Gunshot injuries of this bone are not uncommonly seen even in civil life. In the aged, when ossification invades the costal cartilages, and the chest as a whole is more rigid, f i-acture is more easily produced ; but, on the other hand, the occupation and mode of life of those advanced in years expose less to trauma. A number of irregular types of fracture have been reported in which the condition was diagnosed FRACTURES OP THE STERNUM 455 as compound, comminuted, multiple or longitudinal. These types of fracture, however, are extremely umisual in the sternutn, the great majority being simple and transverse at, or near, the junction of the first and second pieces of the bone. The next most common deformity is one in which the upper fragment is displaced forward and slightly overlaps the lower piece. The common deformity con- sists in a displacement of the lower end of the upper fragment behind the lower fragment. The deformity is so characteristic and pronounced that a diagnosis can usually be made by inspection alone. Fig. 538. — Fracture of the sternum. Arrow indicates position of fracture which is in perfect reduction. Case of Dr. N. A. Thompson. Sometimes, however, a simple transverse fracture may exist without displacement, when the condition can only be recognized by palpa- tion, pressure being made first on one fragment and then on the other. The next most common site of fracture is at or near the junction of the first and second pieces of the gladiolus and resembles closely the more usual fracture occurring at Ludwig's angle. Symptoms. — The close relation existing between the sternum and thoracic viscera frequently results in complications involving these structures. It is seldom that we find fracture of the sternum un- accompanied by other injuries, so that the symptom-complex fre- 456 FRACTURES AND DISLOCATIONS (|U('iitly includes coiidilioiis siicli as t'l'ai'turc of the I'ihs, t'l'acturc of the spine,, poiu't rat ill ii" wounds of the chest, clc lu fracture of tlie sternuin the patient usually assniiies a hollow -chested attitude which is cliai-acteristic both in the erect and reeumlient positions. liespira- tion is usually painful, rapid and su|)eilii-ial, reseinhlinii' that seen in fracture of the ribs. Inspection and ])alpatioii of llie chest usually reveals the charac- teristic deformity in the upper part of the sternuin. AVlien no deformity exists, crepitus is, as a i-ule, elicited without difficulty and in some instances may, by means of the stethoscope, be recog- nized with every respiration. Dislocations between the first and second portions of the sternum, in young persons, produce practically the same symptoms except that crepitus is more likely to be cartilaginous. The distinction between the two, however, is clinically of little importance. Cyanosis and dyspnoea may occur as the result of direct pressure from the displaced fragment. Treatment. — AVhen deformity is absent from the first, or if reduc- tion has taken place spontaneously as sometimes occurs in normal respiration or in coughing, the only indication in the treatment is immobilization, which is most satisfactorily accomplished by strap- ping the chest with adhesive plaster in a manner similar to that employed in fracture of the ribs. 'Direct pressure on either of the fragments may be obtained by a pad of gauze properly placed and held in position by adhesive plaster placed diagonally across the chest. A plaster cast ilicluding the chest and shoulders may be employed instead of the adhesive, although it does not accomplish the purposes of fixation any more satisfactorily. When deformity is present, it should be corrected before the chest is fixed. The reduction of displacement is accomplished in all instances by upward traction on the upper fragment, and downward traction on the lower. As a rule this is effected by posture, the traction and countertraction being applied indirectly through the muscles and other portions of the thorax. If the patient is placed on a table in the dorsal position with head and shoulders over the edge so that hyperextension of the spine is accomplished, reduction will usually follow without further manipu- lation of the fragments. Raising the arms above the head and direct pressure on the projecting fragment will facilitate correcting the deformity when simple liyi)erextension of the spine proves insuf- PRACTrTRES OP TITE STERN (J M 457 ficient. After the fragment has ))een brouglit into j)r'oi)er position the chest is fixed as previously described. Operative Treatment. — Various methods have been described for the open treatment of these deformities when simpler methods have failed to accomplish reduction, but it will be unnecessary to enter into the minutiaB of these sutgical procedures since they all are based Pig'. 539. — Melhol of conectin; tiefoimitv in overridin-;; fracture of sternum. Pig. 540. — The method shown in Pig. 539 has been supplemented by direct upward pressure on the inner ends of the clavicles with the finger tips. on the same principles of traction, counter traction and manipula- tion after the fragments have been exposed by incision. Elevation has been accomplished by means of screws inserted into the depressed fragment. As a rule it will not be a difficult matter to pry the depressed portion of the sternum back into position with some strong instrument such as a periosteal elevator. The greatest care should 458 FRACTURES AND DISLOCATIONS be exercised uot to insert tlie instrument too far or in any way, either by cutting or laceration of tlie tissues, to open the pleural or pericardial sacs. In oi)eratiny in this region wo should bear in mind the course of the internal inaiiuuary artery one-half inch external to, and parallel with the lateral border of the sternum. If the origin of the pectoralis major interferes with the operative manipulations the fibres should be cut away so that the fragments are properly exposed. AVhen reduction has been accomplished the incision is to be closed without drainage, and provision made in the fixation apparatus for the subsequent dressing of the wound during the after-treatment. After-Treatment. — Fixation of the chest should be maintained for from six to eight weeks following the accident and heavy work or violent exercise forbidden for another two or three weeks. Ditfer- ent types of steel braces and apparatus have been used with success to immobilize the chest and neck though they are seldom called for in a simple case. Prognosis. — The prognosis of simple, uncomplicated fracture of the sternum is good both as to life and function, but the frequency with Avhich this fracture is associated with severe crushing injuries, such as fractures of the spine and complications of the thoracic viscera, renders the outlook variable, since the prognosis in these i2:stances is that of the complication rather than the fracture itself. CHAPTER XXXIII. FRACTURES OF THE RIBS. Surgical Anatomy. — The surprising degree of trauma whieli the ribs are capable of withstanding is the result of their mobility and the natural spring which they possess. The first rib is the shortest, the seventh the longest. They are diagonally placed so that the posterior end of a given rib is at a considerably higher level than the anterior extremity. They increase in obliquity from above downAvard to the ninth rib, below which they become again more horizontal. The upper seven ribs are connected with the sternum through their own costal cartilages. The next three are attached through their cartilages to the ribs above, while the remaining two are floating. The first rib joins the sternum through its cartilage just below and behind the sterno-clavicular articulation. The sec- ond costal cartilage joins the sides of the sternum at Ludwig's angle. The lower border of the pectoralis major leads to the fifth rib, while the first visible digitation of the serratus magnus is attached to the sixth. . The lower border of the tenth rib forms, from a surgical standpoint, the lower border of the thorax. The inferior margin of each rib is grooved on its deep aspect for the corresponding intercostal vessels. The sixth and seventh ribs are the ones most frequently fractured. The upper two ribs are more or less protected by the clavicle, while the heavy muscles of the back and the unattached condition of the eleventh and twelfth renders these lower ribs even more capable of withstanding trauma. The ribs may be broken by direct or indirect violence. The former occurs when the rib is fractured and driven, inward at the point of impact ; the latter when breaking results from bending, as in forcible compression of the chest wall. The weakest point in the rib is just anterior to the angle, and it is here that fracture most often occurs when the result of indirect violence. The costal cartilages may be broken, a not uncommon site being at their junc- tion with the ribs. The close relations existing between the ribs and pleura account for the frequency of complications involving 459 460 FRACTURES AND DISLOCATIONS this inembi'aiu' and tlic uiidtTlyinii- lun^. especially in fractures produced liy indirect \iolence. When a sinj>le rib is fractured there is little tendency toward displacement, since both ends are fixed, and tlie intercostal mus- cles maintain its i-elations with the ribs above and below. When a number of ccnsecntive ribs are fractured thei-e is frroat(>r proba- f third, fourth, fifth nnd sixth ribs. bility of deformity, as is also the case when a single rib is broken in two or more places. Dislocation of the ribs may occur at either end, though their structure and the strength of their articulations render fracture by far the more common injury. Dislocation may occur at the vertebral ends of the ribs or at the mesial end of the first, second, eighth, ninth and tenth costal cartilages. FRACTIIUIOS OF TJIK RIBS 461 Symptoms. — Pain is a, coiistant ,syiii])1()iii, hcinn' well localizod in the region of the fracture. It is greatly increased by breathing, especially by deep inspiration. Coughing and sneezing render the suffering momentarily more intense. The patient usually stands or sits in an attitude cliaracteristic of the condition, willi the trunk Pig. 542. — Caving in of chest with fracture of a number of ribs, the result of direct violence. Note the flattened condition of the chest on the patient's right side. Case seen with Dr. H. R. McGraw. Fig. 543. — Fracture and displacement of a costal cartilage. bent slightly forward and toward the injured side. Respiration is shallow and rapid. The pectoral excursion on the injured side is usually less than that observed on the well side of the chest. Abnormal mobility is often present in the fractured rib near the site of the break. Crepitus may, or may not, be present accord- 462 FKAC'TCHKS AND DISLOCATION'S ing to tlio roliitiou of tlu' serrated ends of tlie fragments. Swell- ing of the parts is slight, if present at all. Ecchymosis may make its appearance- within the first twenty-four to forty-eight hours following the accident. The lung may be penetrated by one of the fractured ends. Bloody expectoration and subcutaneous emphysema are the most common indications of this complication. In pronounced cases the subcutaneous tissues of the chest, face, neck and arms may be extensively distended with air. Palpation gives a distinct sense of crepitation when air exists Mdthin the tis- sues. Traumatic pneumonia may follow if the lung is injured. Diagnosis. — The diagnosis is based on the symptoms just de- scribed, together with a careful and systematic examination of the chest. The ribs should be palpated in order, from above down- ward, for the purpose of recognizing crepitus and abnormal mo- bility. If pressure is made on a given rib, anteriorly (say the seventh), while the fingers of the opposite hand rest on the same rib in the posterior axillary line, the motion imparted to the rib, anteriorly, may be recognized by the opposite hand if the rib is intact between the points of palpation. If fracture is present, crepitus may be elicited in this manner, and dissolution of con- tinuity appreciated when present. As previously stated the ribs possess a certain amount of spring, which quality should be tested when examining for fracture. If the chest be gently compressed antero-posteriorl.y pain will be produced or increased at the seat of fracture, which is promptly recognized and indicated by the pa- tient. Crepitus, even with shallow respiration, may sometimes be determined by the stethoscope. Fractures of the posterior ex- tremities of the ribs are not infrequently extremely difficult to diag- nose because of their deep situation under the heavy muscles of the back. In such instances a radiogram will make the diagnosis possible. Treatment. — Fixation of the injured side of the chest is the first indication in fractures of the ribs. This is best accomplished by strapping the chest with zinc oxide adhesive plaster. The usual method of applying the adhesive straps or swathe to the back first, and then encircling the chest during expiration is contrary to the principles of surgical anatomy in this region. The anterior por- tion of the chest is the movable part, while the spinal portion is fixed. The strapping therefore should be done from before back- ward (see Fig. 54-4). When the injured side of the thorax is 1<^RACTIJRES OF THE RIBS 463 fixed, relief from suffering is prompt and pronoiincfid. The fact that the chest in respiration moves as a whole, renders it unneces- sary to always apply the strapping directly over the rib fractured. If the lower portion of the chest is fixed on the affected side, relief will follow, even though the fracture be situated in one of the upper ribs. In other words, if the lower four or five ribs are fixed on the affected side motion in the entire half of the chest will be restricted. In severe fractures of the ribs, or in those presenting symptoms of pulmonary complications the strapping should not be applied too tightly, lest additional injury be done to the lung by forcing a displaced fragment or spicule into its substance. If suft'ering is not sufficiently relieved by strapping, the use of opiates Fig. 544. — Adhesive plaster strapping for fracture of the ribs. may be necessary during the first day or two following the accident. In fleshy persons, especially in women with pendulous breasts, fixation of the thorax is more difficult. The amount of subcu- taneous tissue renders the skin more mobile and cutaneous irrita- tion seems to be more readily produced, accordingly strapping is less satisfactory. In these cases a swathe snugly surrounding the lower chest will usually answer the purpose better than strapping. Subcutaneous emphysema does not ordinarily call for special measures, yet should the condition become severe it may be re- lieved by multiple incisions. After-Treatment. — The fixation dressing should be maintained for a period of about three weeks. In the milder cases in which a single rib is fractured, the patient may be up and about immedi- 464 FRACTURES AND DISLOCATTONS ati'ly follow iii^i- the iiijurv. When the coiidition is more severe, as when a immbtT of ribs are fi-aeturecl, or tlie lung penetrated, treatment in reeumheney is demanded. If respiration is painful or dit'lii-iilt ill the dorsal position the patient may lind eomfort in tnrninu' on his side, or tlie l)aekrest may he used to raise him to a semi-sittinu' posture. It will often be neeessary to tighten or re- apiil\ the strapping if it licroines loosened, oi" if cutaneous irri- tation dexi'lojis. For these reasons tlie i)atient should be kept under close obsiu'vation especially during the early ]nirt of the aftei'-trcatiiu'iit. A linen swathe iiuiy l)e used about the chest if, for any i-eason, sti'api)ing seems inadvisable. Prognosis. — Fi-actures of single ril)s are aliiu)st invai'iably fol- lowed by complete restoration of function. Union with deformity is not likely to be followed by ill effects. The i)rognosis of severe crusliing injuries. i)enetrations of the lung, trauumtic pneumonia, etc., is that of the complication i-athei' than of the fracture itself. CHAPTER XXXIV. FRACTURE-DISLOCATIONS OF THE SPINE. Considerable useless distinction has been made between ''frac- ture" and ''dislocation" of the vertebrge. The use of the X-ray, of recent years, has demonstrated the fact that nearly all spinal fractures are complicated by at least some articular displacement, and that dislocations rarely occur without fracture of some por- tion of the vertebrge. This close association of the two conditions, therefore, renders the term "fracture-dislocation" the most satis- factory and accurate, and it will be understood in the subsequent discussion of injuries to the spine that one condition rarely occurs without the other. Dislocations, uncomplicated by fracture, are sometimes seen in the cervical spine but almost never in the lower portions of the column. The importance of fractures and dislocations of the spinal column lies not so much in the bony injury sustained by the vertebras, as in the damage which may be inflicted on the spinal cord contained Mdthin the spinal canal. In other words, the serious complica- tions which follow fracture of the spine are shown by the symp- toms of injury to the cord or spinal nerves rather than those of fracture of the spinal column. The diagnosis and treatment, therefore, come more properly under the head of neurology than of surgery. Since such is the case it will readily be seen that it is well for the surgeon, when possible, to have the counsel and cooperation of an experienced neurologist in dealing with fracture- dislocations of the spine. Surgical Anatomy. — The character of the hony structure of the vertebra is of importance in explaining the deformity which occurs in fracture-dislocations of the spine. The vertebral body is com- posed of a cancellous structure similar to that seen in the ends of the long bones. The surface is composed of a layer of com- pact tissue on which the strength of the body largely depends. In compression strains, little resistance remains after this bony capsule of compact tissue has been fractured; the internal can- 465 466 FRACTURES AND DISLOCATIONS I't'lloiis tissue cruslu's readily and the Ixidy collapses. The verte- bral arelu'H, though less in bulk, are eoini)osed of a heavy compact tissue with a CQinparatively small amount of enclosed cancellated structure. The result is that fracture of this portion of the verte- bra is more distinct and clean-cut in nature, witli little or no loss of bone through crushing or impaction of cancellous tissue. The difference in the types of fracture occurring in these two portions of a verte])ra may be likened to the difference existing between fracture taking ])laee in the shaft, as comjiared to that seen in the Fig. 545. — Fracture of the bodies of the second, third and fourth cervical vertebrae with kyphotic deformity. expanded upper extremity of a long bone, such as the humerus. The usual strain producing fracture of the spine is . that of hyperflexion, and the effect upon the spinal column as a whole is similar to that occurring when other materials are subjected to bending strain. The convex side of the rod or column is under tension, the concave side under compression, while the intermediate part is in a neutral condition until either the convex or concave side of the column breaks. With hypertiexion, therefore, the bodies of the vertebrae are under compression while the vertebral FRACTURE-DISLOCATIONS OF SPINE 467 arches and connecting ligaments are subjected to tension. In most instances the compression strength of the bodies is less than the tension strength of the posterior spinal ligaments. The usual re- sult therefore, when the strain becomes greater than the spine can withstand, consists of a crushing of one or more of the vertebral bodies with kyphosis as a consequent deformity. The planes of the articular surfaces in the cervical spine are more nearly parallel with the upper and lower surfaces of the bodies than in other portions of the spine. This less firm inter- Fig. 546. — Fracture of body of second cervical vertebra witli subluxation between bodies of second and third vertebras. Fracture of second and third vertebras near pedicles. locking in the cervical region accounts to some extent for the com- parative frequency of uncomplicated dislocations of the vertebrae in the neck. The upper portions of the spine normally carry less weight than the lower; hence the lighter structure in the cervical region. Accordingly the same degree of trauma wall more surely produce fracture or dislocation in the neck than in other regions of the spine. As already explained the usual deformity is ky- photic; yet we may see angular displacements in other directions, and the deformity may be overriding or rotary, as well as angular. 468 FRACTURES AND niSL( )('ATl()i\S In Pott's disease tlie vertebral body gives way uiulcr iiorinal strain as a result of diseased bony tissue; in fraeture of the spine, with kyphosis, tlie normal body eoHajJses because of excessive strain ; the deformity is similar in both instances. In the dorsal region, the articular surfaces change so they are more nearly at right angles with the jirticuhir planes between the bodies. This results in greater strength and lessened mobility, so that it is almost impossible to slide one vertebra on another (be- yond ligamentous limits) without producing fracture. In the Fig. 547. — Dislucatimi Ijflwuen tin displacement of the skull. lii'st iind setuiul cervical verlebrie with forward lumbar region the articular surfaces are also nearl\' at right angles with the articulations between the bodies although they correspond more closely witli tiie sagittal than with the coronal plane. The tips of the vertebral spines are subcutaneous and palpable from the sixth or seventh cervical to about the fourth sacral. The anterior surfaces of the bodies of the upper four cervical may be palpated through the pharynx; the lumbar bodies through the anterior abdominal wall, in thin persons; and the coec^yx and lower end of the sacrum through the rectum. Otherwise the heavy PRACTURE-DISI.OCATIONK OP SPINE 469 Fig. 548. — Fracture of the lower dorsal and upper lumbar vertebrte with lateral de- formity 470 FRACTURES AND DISLOCATIONS fascia? and erector spina? mass so conceal the deep portions of the vertebrte that it is impossible to accurately determine their con- dition and positions by palpation. The spinal cord lies within the spinal canal, extending down- ward from the foramen magnum to about the level of the inter- vertebral disc between the first and second lumbar vertebrge. The level of the lower end of the cord varies somewhat in different per- sons. It is said to extend to a relatively lower level in women than Fig. 549. Fig. 550. Fig. 551. Figs. 549, 550 and 551. — Posterior view, sagittal section and anterior view of an old fracture of the spine. Note the constriction of the spinal canal and crushing of the Cauda equina opposite the third lumbar verteVjra. in men, in short persons than in tall. This is explained by the growth of the individual. Early in fcetal life the cord occupies the entire spinal canal but the subsequent disproportion in growth between the spinal column and cord finds tlie conus terminal is on a level with the third lumbar vertebra at birth and later in life the cord terminates at the first or second lumbar according to the extent of longitudinal growth in the spinal column. In the early foetal arrangement the spinal nerves arise from the FRACTURE-DISLOCATIONS OK SI'INE 471 death. Fig. 553. — X-ray plate of case shown in Figs. 549, 550 and 551, some weeks before 472 FRACTURES AXD DISLOCATIONS cord opposite the iiil('rviTtt'l)i'al lor;iiiiina tlii'oiigli which tlu\y emerge. The fat-t. liowevcr, thai Ihe spine grows fastci- than the cord lowers the level of the si)inal exit for a given nerve, with relation to its spinal eord origin. All of the spinal nerves, there- fore, with the exception of the tirst two cervical, ha\t' a downward Fig. 5.5y. — Friicture of tlie liody of the fifth lumbar vertfljra at the point indicated by arrow. intraspinal course of greater or less extent, varying with the level of the nerve. The lower the nerve, the longer its intraspinal course. The spinal dura or "theca" forms a well, within the spinal canal extending from the foramen magnum to ahout the third sacral vertebra. The cord is susi)ended within this well and surrounded FRAOTrTRE-DTST/JCATIONR OF SPINE 473 by cerebrospinal fluid in sneh a manner that injury hy direct vio- lence is almost impossible if the spinal column remains intact. The denticulate ligament and spinal nerves steady the cord within the theca and serve to prevent its coming in contact with the walls of the canal. The tracts within the cord are composed of jnedullated aneurilem- matic axones, and when these fibres degenerate, following injury or disease, regeneration does not take place. Loss of function, therefore, is permanent. The spinal nerves, however, are both medullated and neurilemmatic and will regenerate under favorable conditions. This difference in structure and power of regeneration explains the invariable necessity for operative intervention to re- move pressure in injuries of the cauda equina. Symptoms. — The symptoms of fracture of the spine are, firstly, those of the bony lesion (the fracture itself) and secondly, those resulting from injury to the spinal cord or nerves. The symptoms of fracture of the spinal column are : 1. Local pain and spasm. 2. Abnormal mobility. 3. Crepitus. 4. Deformity. 5. Loss of function. The symptoms following injury to the cord and spinal nerves are : 6. Shock (and unconsciousness in cervical fracture). 7. Changes in pulse, temperature and respiration. 8. Motor disturbances. 9. Sensory disturbances. 10. Disturbances in reflexes. 11, Trophic changes. Symptoms of Fracture of the Spinal Column. — 1. Pain is usually present at the seat of fracture, and is similar in character to pain produced by fracture elsewhere.^ It is in- creased by motion and severe enough in some instances to produce syncope. 2. Abnormal mohility is usually present and can be recognized if the fracture has been at all severe. It is generally possible to 1 Reflex pain is not here considered. 474 FRACTURES AND DISLOCATIONS riox the spine beyond normal limits, but the (laii^cr of pi'Otlueinp: OT increasing' injury to the spinal cord should pi't'cludc any and all unnecessary manii>ulations. 3. Crepitus may or nuiy not be pceseid but any attempt to elicit same, sim])ly for diagnostic purposes, is abs()lu1el\- to be coiulennied on account of tlie i)ossibility of injury to the spinal cord or nerves. 4. Dc for mil II varies with the region of the spine injured and the nature and degree of the fracture. It is almost invariably present. If the back be thoroughly inspected and carefully pal])ated the surgeon will, as a rule, experience little dif^cult}^ in recognizing I'ig. 655. Figs. 554 and 555. — Fracture of the spines of the third, fourth and fifth cervical vertebrae and of the bodies of the fifth and sixth. The thumb is depressed into the hollow caused by the displacement of the fractured spines. the gravit}^ of the condition even though the details of the fracture cannot he ascertained without resorting to the use of the X-ray. The usual deformity consists of anterior angular displacement of that portion of the spine above the fracture, with resultant kyphosis. In unusual instances the loss of vertebral alignment may be rotary. In severe cases overriding as well as angular deformity of the spinal column may occur. Kyphosis is often sufficiently pro- nounced to be recognized by inspection alone. It is seldom that the important elements cannot be determined by palpation. Frac- ture of one or more of the spinous processes with loss of alignment in the tips of the spines may produce a slight deformity which can FRACTURE-DISLOCATIONS OF SPINE 475 Fig. 556. Fig. 557. Figs. 556 and 557. — Fracture of the spine in tlie lower dorsal region a few min- utes following the accident. Arrow in upper photograph indicates the visible irregu- larity in the spinous processes. In the lower plate (Fig. 557) the finger is pressed into the depression. 476 FRACTURES AND DISLOCATIONS be recognized Ity i)al])alion, if not by inspection alone. In isolated fracture of the spinous processes tlie deform ity is slij^ht and not aeeompanit'd by symptoms of fracture of the column itself, such as ang-nlation of the spine, shock, motor and sensory disturbances, loss of function, etc. Fi'acture of the arches may be accompanied by symptoms of cord injury if the fi-agments have been displaced foi'ward into the si)inal canal. 5. Loss of function is inevitable in fracture of the s|)iiial column, and will be more or less complete according- to the severity of the injui-y. Shock, pain, and cord injury may disable the patient, but aside from these conditions the mechanical disturbances pro- duced by the fracture are sufficient to prevent the patient from standing or sitting. Spasm of the nuiscles of the trunk, especially the erector spina? mass, will be present, and represents Nature's attempt at splinting the injured parts. Loss of function through isolated fracture of the spinous processes, is mainly the result of local pain, especially when the muscles attached to the involved spine are brought into action. Local swelling and ecchymosis are seldom pronounced, if they occur at all. The extravasated blood and fluids of inflammation are so bound down by the heavy dorsal fascia covering the erector spime mass, that they seldom reach the surface. Symptoms Followino Injury to the Cord and Spinal Nerves. — The symptoms following injury to the spinal cord or the nerves contained within the spinal canal vary with the complete- ness and region of the injury. The nature and degree of these sj'mptoms are explained by reverting to the anatomy of the spinal cord and the distribution of the spinal nerves. Slight pressure on the spinal cord, such as produced by hemorrhage (and in some instances slight bony displacement), is prone to produce irritation of the spinal centers which, if allowed to continue, is not uncom- monly followed by a degeneration of the affected cells and their axones. Destniction of spinal cord tissue is invariably accom- panied by prompt loss of function in the destroyed cells, and interruption of impulses in the damaged white tissue of the cord. If the damage to these cells has been at all severe, degeneration ensues regardless of relief of pressure. If, however, pressure is not removed pressure myelitis is almost sure to follow, the degen- erative process will be more extensive, and adjoining cells and tracts will be involved, which were primarily unaffected at the FRACTURE-DTRIiOOATTONS OF SI'INK 477 Fig. 558. — Fracture of the lower doisal spme home eight years following the in- jury. The cord was partially crushed and paralysis of the lower extremities with loss of bladder and bowel contiol followed. Note thechionic sore in the sacral region and the cord about the hips supporting a urinal. Fig. 559. — A case of Charcot's spine showing the same type of kyphotic deformity &s is sometimes seen in fractures of the lumbar spine. Paralysis of the lower extrem- ities and loss of sphiricteric control due to pressure on the spinal nerves within the canal. 478 FRACTURES AND DISLOCATIONS time of injury. Tlicrc arc none oL* the so-ealled silent areas within the cord simihir to those existing in the brain, and hence lesions of tlie coi"d. either partial or complete, ai'c always attcnchnl by dis- turhances in function. 6. SJiock, at least in a mihl degree, accompanies all uncomi)li- cated fractures of the spine and is greatly augmented when the cord is injured. Unconsciousness, however, i-arely occurs unless the injury is in the region of the upper four cervical vertebrge. 7. Except in injuries of the upper cervical region pronounced changes in temperature, respiration and pulse do not occur im- mediately following the accident. Shock may influence the tem- perature, pulse and respiration, but shock may occur in many con- ditions and is not characteristic of cord lesions. Later in the coiirse of the case pressure myelitis, meningeal complications or degenerative processes within the cord may cause a rise of tem- perature, with alterations in the pulse and respiration. 8. Motor (lifiiurhances at and below the seat of fracture, are the rule when the cord is injured and the character of these symptoms varies according to the nature, region and completeness of the lesion. In complete crushing of the cord paralysis will be found in the parts supplied by the damaged segments, and all the seg- ments below them will be thrown out of function. In partial in- jury to the cord the musculature supplied by the injured segments will show more or less complete flaccid paralysis, while the muscles supplied by lower segments will be spastic. The condition of the muscles will often be difficult to recognize immediately following the accident because of the accompanying shock and temporary loss of reflexes. The distribution of the thoracic nerves is simple and regular, and hence it is an easy matter to recognize the level of the spinal injury when the thoracic segments are involved. When, however, the injury is sustained by the cervical, lumbar or sacral segments it is necessary to understand the different plexus formations to appreciate the nerve distributions, and to be able to determine from the motor and sensory symptoms which spinal segments have been involved. In partial lesions of the cord the paralyses are often incomplete and asymmetrical. There may be weakness in certain muscles, Avith spasm, or complete loss of function in others. Irritative lesions commonly become paralytic as the case progresses. Paralysis of unstriped muscular tissue is seldom complete because FRACTURE-DISLOCATIONS OF SPINE 479 of the additional nerve supply which it receives from llic sympa- thetic system. Disturbances in the control of the hhuidcr and bowel will be considered under injuries of the lumbar enlargement. The motor areas of the cord are more easily injured than the sensory, and hence in partial lesions motor paralysis is often more extensive and complete than are the sensory disturbances. The symptoms of cord injury following bony displacement are almost always paralytic from the first and are not progressive in nature. But on the other hand, hemorrhage within or about the cord is often accompanied by irritative symptoms, such as spasm or tremor, and the intensity of these symptoms usually increases both in degree and extent. Hematomyelia (hemorrhage into the .sub- stance of the cord) and hematorrhachis (hemorrhage about the cord) are not uncommon complications of spinal cord injury. It is a peculiar fact that crushing injuries of the cord are frequently fol- lowed by hemorrhage into its substance a few segments above the site of the lesion. When this secondary traumatic hematomyelia above the lesion occurs, it usually develops within the first few days. Hematorrhachis is more properly a complication than a sequel, since its onset is prompt following injury to the spinal plexus of veins at the seat of injury. In either of these conditions the sj^mp- toms are, as a rule, progressive. The motor and sensory losses are not infrequently preceded by evidences of irritation in the spinal centers. In rare instances slight pressure upon the cord from bony displacement may produce symptoms simulating hemorrhage, provided the pressure is not sufficiently pronounced to produce immediate destruction of cord tissue. Under these conditions the symptoms may be irritative and occasionally slightly progressive. 9. Sensory disturbances are common in cases of spinal cord in- jury, though in partial lesions they are usually less pronounced and extensive than are the motor symptoms. In complete trans- verse cord injuries anesthesia develops immediately in the areas supplied by the injured portion of the cord, and in addition the sensory function of all Segments below the lesion is promptly, com- pletely and permanently lost. This area of anesthesia is soon followed by a girdle of hyperesthesia representing two or three spinal segments directly above the injured region of the cord. This area of hyperesthesia is the result of irritation of the spinal centers contained within the segments adjoining the lesion, and may be the only evidence of a hematomyelia which so commonly 480 FRACTURES AND DISLOCATIONS develops in the cord tissue near tlic injury. Great sutfering some- times occurs as the result of retlex shooting pains tlirougliout the hypei-estlu^tic area. This condition in ttie thoi-aeic ])07-tion of the cord produei's iiirillc pains; in the lunihar t'lihii'iii'iiicut , sliooting jiains in the lower extremities and genetalia ; while spinal irritation in tlie upper dorsal or lower cervical segments of the cord may produce pain in the upper extremities. Hyperesthesias following irritation of spinal centers will vary in degree and distrihution ac- cording to the region and severity of the cord lesion. 10. Distitrhances in- reflexes. — In complete cord lesions the re- flexes below the injury will be immediately, completely and perma- nently abolished. Shock, from any cause, may produce temporary loss of reflexes which return, however, as the patient recovers. Accordingly too much stress should not be laid on their absence immediately following the accident. In partial lesions the reflexes, dependent upon the damaged segments, will be lost or reduced, while those below the lesion are often absent immediately following the accident, though they return later and are often increased through lack of inhibition from the higher centers. When such is the case patellar and ankle clonus are present, together with Babinski's reflex, and other pathologic reflexes of the foot and ankle, indicating damage to the upper motor segment. The loss of reflex activity is often asymmetrical in, partial lesions, and cor- responds more or less accurately to the distribution of motor and sensory losses. If the reflex of a given segment is increased through spinal irritation, spasm, tremor or hyperesthesia will prob- ably be present in the corresponding area. 11. The trophic disturhances following injury to the cord are among the most serious and difficult to control of the complications with which we have to contend. JMost prominent among them are the bed .sores which develop where continued pressure is applied to subcutaneous bony prominences, especially in the region of the sacrum and heels. The sacral sores are often intractable, rapidly attaining such size and depth as to lay bare the lumbar and sacral vertebrae, and not infrequently a considerable part of the ossa innominata. When this type of sore develops the patient usually succumbs within a short time, either from exhaustion and a general septic condition or following involvement of the exposed spinal membranes. The musculature below the seat of injury atrophies until in extreme cases the outlines of the bones of the lower ex- FRACTURE-DISLOCATIONS OF SPINE 481 tremities are apparent on inspection. Contractures are common, especially in the feet, which are often depressed and in a condition resembling that seen in hydrocephalus. The bladder changes are due partly to the effects of retention following paralysis, and partly to the disturbed trophic supply of the viscus. Infection of the bladder, with urinary decomposition, develops sooner or later in spite of the most assiduous care. This infection not infrequently ascends to the kidneys, ultimately producing death. The symptoms accompanying fracture-dislocations of the spine show such variation in different levels that for practical purposes we will consider the symptoms peculiar to the different regions. Fracture-dislocations of the cervical spine are often immedi- ately fatal, especially when the injury involves the upper four vertebrge. Dislocations uncomplicated by fracture are more com- mon here than in other portions of the spinal column (see "Anat- omy," page 465). The usual deformity is kyphotic, though the dis- placement ioa.a.y, in unusual instances, be lateral, posterior, rotary or even overriding. Unilateral luxations are more common in the neck than in other portions of the spine, their usual seat being in the occipito-atlantal or in the atlo-axial articulations. If death does not follow the injury within a few hours motor and sensory disturbances develop in the regions supplied by the injured spinal segments and below the site of the lesion. Injuries at, or above, the fourth spinal segment destroy or interfere with the nerve sup- ply to the diaphragm, and the proximity of the important centers in the bulb, together with the close association between the pneu- mogastric and spinal-accessory nerves, renders fractures in this region especially dangerous. When death is not immediate pro- nounced variations are usually observed in the temperature, pulse and respiration. The temperature may rise to 105° or 106° or even higher, the pulse becoming rapid and arythmic. The more complete the loss of function in the phrenic, the more pronounced will be the action of the accessory muscles of respiration provided they are still capable of action. Fracture of the cervical region may involve the segments from which the nerves of the brachial are derived, and the muscles paralyzed in the upper extremity will vary according to the level of the lesion. AVhen the lesion in- volves the upper portion of the brachial plexus the upper extremi- ties will be held in a characteristic position with the elbows flexed, and the upper arm abducted and rotated outward. Injury to the 482 FRACTTRES AXO DISLOCATIONS lower portion of tlu' plexus produces a different attitude, with the arms not far from the side and the hands resting on the chest in pronation. The" reason for these differences in attitude is ex- plained by the formation and distribution of the brachial plexus. In complete lesions of the cervical cord death almost invariably occurs within a few hours, if not at the time of the accident. If the patient survives the immediate effects of the injury the usual motor and sensory paralyses develop below the site of the injury, including: loss of sphincteric control. If he lives a few weeks tropliie disturbances make their appearances, the most important of which is the bed sore. Fracture-dislocations of the thoracic region are more constant in their type of deformity than are corresponding injuries in either the cervical or lumbar spines. Kyphosis with crushing of the body of the vertebra is the rule. Fractures of the upper thoracic region do not commonly influence motion or sensation of the upper extremities, though the usual symptoms develop below the lesion according to the severity of cord injury. Loss of sphincteric con- trol with sensory and motor disturbances of the legs and lower trunk are present. Diminished or lost peristalsis sometimes results in severe tympanites and fecal impaction, through interference with the nerve supply of the intestines. Any or all of the ab- dominal viscera may show^ diminished function. The thoracic por- tion of the spinal cord extends from the level of the sixth cervical interspace to the ninth thoracic vertebra, and hence fractures of the spine below this level involve the lumbar enlargement or the Cauda equina rather than the dorsal segments. Injury to the lumbar enlargement, situated opposite the low^er three thoracic and first lumbar vertebrge, gives rise to flaccid pa- ralyses of the lower extremities, varying in degree Avith the sever- ity of the lesion. The centers controlling the bladder, bo^vel and genitalia are all situated in this portion of the cord, and hence dis- turbances in function occur in these parts when this portion of the cord is injured. Injuries below the first lumbar vertebra may damage the nerves forming the cauda ecpina ; the motor and sensory losses will vary according to the nerves injured. The reflexes in the lower ex- tremities will be lost if the nerves are crushed. Shock will be much less than that accompanying injury to the cord itself even Avhen all the nerves are crushed. PRACTURE-DTSLODATTONS OP SPINE 483 Diagnosis.— The diagnosis of fracture of the spine and its com- plications, is based on the symptoms previously desfribed. The alignment of the spine should be determined by inspection, and the tips of the spinous processes carefully palpated. Isolated frac- tures of the spines produce only local pain, abnormal mobility, and sometimes crepitus; the symptoms of fracture of the spine as a whole are absent. It is, as a rule, an easy matter to determine the presence of fracture in the spinal column, although an accu- rate appreciation of the details of the fracture is often only had by means of the X-ray or at autopsy. Unless the most careful examination is made in fractures without deformity the condition may be overlooked and subsequent displacement may produce in- jury to the cord which could have been prevented if proper fix- ation apparatus had been employed. The important element in fracture of the spine is that of cord injury, the degree and position of which determine the treatment. Complete transverse lesions produce immediate, total, permanent and symmetrical loss of mo- tion, sensation and reflexes below the lesion. Partial lesions are usually followed by irregular, incomplete and asymmetrical motor, sensory and reflex losses. The motor losses below the lesion are spastic, while the paralyses in the muscles supplied by the injured segments are flaccid. In complete lesions the motor losses, at and below the lesion, are all flaccid. In cord injuries, loss of motion in a single muscle, or group of muscles, never occurs. Such a condition means injury to one of the peripheral nerves rather than a spinal segment or nerve root. When a spinal nerve is crushed in one of the intervertebral foramina, the motor and sensory losses are conflned to the distribution of that single nerve root. The loss of reflexes, accompanying shock and unconscious- ness, often prevents the surgeon from making an early diagnosis. The degenerative and inflammatory changes within the cord, fol- lowing pressure, may begin within a few hours of the injurj^, and hence the value of an early diagnosis is apparent. The symptoms of bony pressure are prompt in onset, and usually not progressive, while pressure due to hemorrhage produces symptoms which in- crease in severity as the blood escapes into or about the cord. Pressure myelitis, however, gives rise to symptoms which are prac- tically identical with those of hemorrhage, and in a given case it is not infrequently impossible to difl^erentiate between the two. It is, also, extremely difficult in some instances to differentiate 484 FRACTURES AND DISLOCATIONS between a partial K'sion diu' to hoiiy prcssiire and that due to hemorrhage. Tlie ditifieulties of diagnoses in tliese cases are greatly increased by tlie manner in wliich shock and nneonsciousness sometimes ob- scure the symi)toins for a nuiuhcr of hours following the injury. Symptoms simuhiting (•oiu[)h4e lesions frequently change within the first twenty-four hours, being replaced by the symptoiu-cum- plex of a partial injury. The X-ray, especially in stereoscopic form, is sometimes of the greatest service in determining the ex- tent to which the lumen of the spinal canal has been encroached upon by bony displacement. The level of the cord lesion is de- termined by the level of the motor and sensory disturbances, par- ticularly the level of the hyperesthetie zone and the area of flaccid paralysis. Treatment. — The treatment of fractures of the spine is directed, firstly, towards the fixation of the injured portion of the column, and secondly, to the alleviation of complications and their symp- toms. With the exception of isolated fractures of the spinous or transverse processes fracture of the spinal column calls for a fixation in some form regardless of v^diether or not the cord has been injured. Fixation is most satisfactorily accomplished by means of a plaster cast, modified according to the region of the injury. In the cervical spine it should be so applied as to include the head, neck and shoulders, leaving the arms free. In the dorsal region, it will be necessary to include the chest and upper abdomen, together with the neck, if the fracture is high. AVhen the lower dorsal or lumbar vertebra? are fractured the east should extend from below the armpits to the hips, including the crests of the ilia. In whatever region the cast is applied, the deformity should be previously corrected as perfectly as possible, and the patient's position maintained unchanged until the plaster has become suffi- ciently set to properly splint the parts. Fractures of the cervical spine may be held in reduction by the hands of an assistant while the cast is being applied. In the dorsal and lumbar regions, correction of the deformity is much more difficult because of the weight and bulk of the parts handled. Reduction in these portions of the column may be accomplished in a number of ways, any of which is satisfactory if properly performed. The possibility of producing cord or nerve injury, or even death, while correcting the deformity should be constantly FRACTURE-DISLOCATIONS OP SPINE 485 kept in mind during these procedures. AH manipulations should be gradual, gentle, and guarded and the greatest care exercised in moving the patient to avoid strain or further displacement of the injured portions of the spine. If the patient is placed on two tables, face downward, and the tables so separated that the body sags downward between them, the deformity will not uncommonly be reduced without further ma- nipulation. Gentle pressure over the prominent spines may be necessary in addition to secure proper relations of the fragments. Two or three assistants will be necessary to securely hold the pa- tient at the shoulders and heels to prevent his slipping off the tables, and to maintain the proper degree of spinal curvature. In this position the surgeon may begin the application of the plas- ter bandages, the skin of the trunk having been previously pro- tected by means of a snug, soft woven shirt. Another method consists in suspending the patient in a hammock, and so regulating the tension at which the hammock is hung that the proper spinal curvature is obtained, and the deformity corrected. The Brad- ford-Lovett hammock frame is an excellent apparatus in the appli- cation of a cast of this kind. It matters little how the cast is applied provided the following essentials are observed : The deformity should be corrected ; the cast should be sufficiently heavy to withstand the subsequent strain; it should possess some non- irritating lining and should so secure the trunk that the spine is immobilized. A stomach pad consisting of two or three folded towels should be placed over the abdomen, before the plaster is applied and removed when the cast is completed. This allows room for comfortable respiration and eating during the after- treatment. It is essential that the cast remain exposed to the air (not covered with bed clothes) for twenty-four hours, or until the plaster has thoroughly set and dried. Immobilization of the spine may be accomplished in other ways besides the plaster cast, though probably not any more satisfactorily in the usual case. Steel braces, similar to those employed in the treatment of Pott's disease, may be used in fixing the spine. The water bed has been much used in the treatment of these eases, though the fixation of recumbency alone is by no means as efficient as that produced by the cast or brace. In the early treat- ment of fracture of the spine, extension and counter-extension may be employed by means of Buck's apparatus applied to both legs 486 FRACTURES AND DISLOCATIONS Avitli tile foot of the lied raised. Saiul bags about tlie body serve to steady, the parts, and a small, hard pillow under the small of the back will n>aiiitain the proper dorsal curvature. The Bradford frame uuiy be used to advantage when simple recumbency is the nu'thod of fixation. If the fracture is complicated by cord or nerve injury, liic indi- cations to be met in the treatment are much more complex. In addition to fixation of the spine, the relief of symptoms resulting from the complication is demanded as far as may be possible. This inay, or may not, require operation. When an absolute diag- nosis of complete crushing to the cord can be made, operation is contraindicated, since it can do no good. In partial lesions we should open the spinal canal at the seat of injury for the removal of such pressure as may be present. Fractures of the spine below the cord, with symptoms of injury to the cauda equina, call for operation. Operative Treatment. — The question of when to operate and when to treat the patient expectantly has been the subject of much discussion. At the present time, however, it is commonly agreed by most surgeons that complete crushing injury to the cord should not be operated because of the hopelessness of the condition. The difficulty in determining when, and when not, to operate in a given case arises from the difficulty of an accurate diagnosis of the con- dition of the cord. Partial lesions to the cord and injuries to the Cauda equina demand oi)erative intervention in almost all cases. The peculiarities of each individual case, however, must be consid- ered by themselves, and complicating conditions such as shock and injuries to other portions of the body, especially the skull, neces- sarily modify the indications for operation and the best time for its performance. Compound fractures of the spine invariably call for surgical measures. The objects for which operation is per- formed, are: the correction of deformity, decompression of the cord, suture of nerves, and the treatment of the wound in com- pound cases. The permanency of the sensory and motor losses determines the completeness of the cord injury, but when operation is delayed for a few days to establish the diagnosis, the prognosis in partial lesions is rendered much w^orse by the development of pressure myelitis, and other degenerative processes within the cord. For this reason some surgeons maintain that the spinal canal should FRACTURE-DISLOCATIONS OF<^ SPINE 487 be opened in practically all instances complicated by cord injury, for the sake of removing pressure in partial lesions which could not be otherwise differentiated from total crushes. If we follow this principle, we must, of necessity, submit many cases of com- plete crushing- to operation for the sake of relieving pressure in instances in which the lesion proves to be only partial. The ques- tion might then be asked, and not without reason, "What harm has been done by operating upon complete lesions when they are hopeless from the first?" Spinal decompression is by no means as successful as might be wished, yet if only a moderate degree of improvement results the operation is justified. The state of the patient, even though he be confined to a wheel chair is much more tolerable than when he is completely bedridden and unable to help himself. The spinal canal may be opened by simple laminectomy, or by means of an osteoplastic resection. In performing a laminectomy, a median incision four or five inches long is made in the region of the injury. The muscles are separated from the spines and laminae on either side, preferably by blunt dissection. If hemor- rhage proves troublesome one side should be packed with gauze, while the other is being worked upon. It is next determined how many sets of spines and laminae are to be removed to properly expose the region of injury. The supra- and inter-spinus liga- ments and ligamentum subflavum are then divided below the low- est spine to be removed and above the uppermost pair of laminse to be included in the resection. Care should be taken not to introduce the scalpel too far in dividing the ligaments lest injury be inflicted on the contents of the neural canal. The laminge are next divided near their junction with the transverse processes by means of a saw, chisel or heavy bone cutting forceps, after which the osteo-ligamentous section is removed, exposing the dura. The theca is then opened by immediate incision, and the cord and its nerves examined. Inspection and palpation will disclose the na- ture and degree of pressure on the cord, together with the second- ary changes which may have occurred. Pressure may be relieved in some instances, by simply correcting the deformity in the column, or it may necessitate the chiseling away of bony prominences or the removal of fragments. Hemorrhage about the cord is readily recognized when the dura is exposed and opened. Hemorrhage into the substance of the cord gives a distended, swollen appear- 488 KKACTIUKS AXI> DISLOCATIONS iiucv. ll is j)rol)al)ly wise to di'jiiii tlic (•(intents ol' liciiuitoinyclia, though this- proeeduiv has not liccn pcrfoi-iiu'd sufticiciitlN' often to l)ei"init of trust\Vorthy eonelu.sions. 'I'tie renio\al ol' .spines and lainiuas leaves a defieienc}' in the s|iinal coluinn. yet ilisturbances in function resulting from tliis loss are extremely rare. Laiui- nectoniy produces greater injury to the circulation than occurs in an osteoplastic resection, yet it has other advantages which more than make up for the difference. When the normal anatomic re- lations ai'e disturbed by fracture or dislocation, it is safer to expose the lamina? before dividing them ; there is less danger of injury Fig. 560. — Methods of wiring the processes togetlier sometimes employed in operating on fractures of the spine. to the contents of the canal if the bony landmarks are exposed and the deformity accomi^anying the fracture fully appreciated. In opening the spinal canal by the o-steoplastic method a U-shaped incision is made, the vertical arms of which are parallel to the spinous processes in the region of the injury. The soft tis- sues are divided by a deep incision, down to the laminae. The ligaments are then divided transversely between two vertebrae below the seat of the fracture as described in laminectomy. The laminte are then cut on either side near their junction with the pedicles, a sufficient number of arches being divided to turn four or five spines upward in the osteoiilastic flap. When this operation is done in the dorsal region, where the spines are imbricated, it may FRACTURE-DISLOCATIONS OP SPINE 489 be necessary to remove; the ti]) of the vertebral spine just aljove the base of the flap before the latter can be turned back. This is best accomplished through a short, median incision over the spine to be removed (see Fig. 561). After the deformity has been cor- rected, and the pressure, whether due to bone or blood, removed, the flap is sutured in position, with drainage in the lower angle. It is usually necessary to apply a cast to maintain reduction. When injuries to the cord exist nothing can be done which will be followed by regeneration in the destroyed cells or tracts, yet Fig. 561. — Lines indicating the incisions used in operations on the spine. A.-B., median incision employed in laminectomy. The loop CD. is used in an osteoplastic flap. Tlie incision E.-F. is made to divide the spinous process above tlie flap so the flap may be turned back. deformity should be corrected and pressure removed to avoid the subsequent development of secondary complications. If spinal nerves are divided they call for suture, in addition to the removal of pressure. There is no established technique or mode of procedure in oper- ating upon fractures of the spine. The findings in a given case will point out the indications. The operations just described are for the purposes of relieving cord and nerve injuries, and have little to do, primarily, with the correction and fixation of the de- formity. Operation for these purposes alone is only rarelj' found 490 FRACTURES AND DISLOCATIONS necessary. If an iiiie-oiuplicateil ItacluiL' of the spine exists, with ])ronounced tendency to the recurrence of deformity following re- duction, we may be justified in exposing the spines and laminae with a view to fixing tiiem by means of wire as described by Hadra. The essentials of the method consist in securing sound spines above tlie injury to those below the seat of fracture, by means of silver wire (see Fig. 560). After-Treatment. — The after-treatnicnt iu fractures of the spine is directcil firstly, to uuiintaining fixation of the fracture, and secondly, to the symptonuitic treatment of disturbances resulting from cord or nerve injury. The apparatus used for fixing the spine whether cast, brace, extension or other apparatus, should be carefully inspected from day to day to avoid irritation of the soft parts which so often results in the development of sluggish sores. This applies to any form of fixation appliance employed in the treatment of fracture, but especially in complicated fractures of the spine when anesthesia and the loss of the protective pain sense, together with disturbed trophic supply favors the development of sores and extensive sloughs without the patient realizing his con- dition. The buttocks and heels require especial care to prevent the development of bed sores. A pneumatic ring may be used to relieve the sacral region from pressure, and pads of cotton may be placed under the tendo-achillis to prevent the heel resting on the bed. These parts, especially, should be bathed in alcohol twice daily if the slightest evidence of skin irritation is present. The perineal and gluteal regions should be kept scrupulously clean to prevent irritation from urine and feces. One of the most discouraging conditions with which we have to contend is that of cystitis which almost invariably develops fol- lowing the repeated use of the catheter. It is needless to say that the most strict aseptic precautions should be observed if cathe- terization is found necessary. It is advisable, when possible, to rely on the bladder's emptying itself, even when a moderate de- gree of urinary distention is present. Gentle massage of the dis- tended viscus will often result in a fairly satisfactory evacuation of the bladder, and although this method is by no means ideal, yet it is far better to get along in this way than to resort to the catheter with its almost inevitable train of disastrous results fol- lowing infection of the genito-urinary tract. If the bladder be- comes infected during the after-treatment, it is often best to estab- FRACTURE-DISLOCATIONS OP SPINE 491 lish permanent drainage to control the condition. Suprapubic cystotomy may be performed and a suction af)paratus employed to keep the bladder empty. This is probably as satisfactory a method as any of dealing with infection of the bladder under these circumstances. "When analgesia is present in the hypogastric region, the operation may be performed without an anesthetic. The bladder should be washed at least once daily with a boric acid or potassium permanganate solution. Some surgeons prefer peri- neal drainage. Permanent catheterization has been employed with success, though the urethra will not tolerate the presence of a foreign body indefinitely. The intermittent use of hexamethylene- tetramine will be found of service in dealing with infection of the genito-urinary tract. Obstipation and fecal impaction sometimes accompany fracture of the spine, and must be dealt with by laxatives, enemata, mas- sage, and in some instances mechanical removal of the impacted material. The condition of some of these patients is so obviously hopeless that it is often wise to make them comfortable even though, in some respects, it may be at the expense of their physical welfare. Severe shooting pains in the hyperesthetic areas, when severe, call for the exhibition of opiates. Prognosis. — The outlook in uncomplicated fractures of the spine is good, especially when a fair reduction of the deformity has been accomplished. When, however, injuries to the spinal cord accom- pany the fracture, the prognosis is, at best, discouraging. There will be permanent loss of function, the degree varying with the extent of the injury, and the improvement which takes place in these cases is usually too trifling to be of real importance. Cases of partial injuries to the cord which survive the immediate effects of the accident, lead a life of invalidism varying from a few months to a few years. Cases of complete crushing of the cord seldom live more than a few months. Death usually follows as a result of some intercurrent condition, such as infection of the genito- urinary tract, meningitis, septic states, pneumonia, etc. The lower the injury in the spine, the better the prognosis. Operation is of no avail in complete crushing injuries, although it renders the prognosis much more favorable in partial lesions especially when done within a few hours of the injury. CHAPTER XXXV. KKACTrRES AND DISLOCATIONS OF THE PELVIS. Surgical Anatomy. TIr- pelvis is orid in fracture of the posterior portion of the pelvis. The bladder lies behind the pnbes and is more or less attached to the bones by tibrons tissue; it may be injured by compression wlieii the viscus is full, by the penetration of fragments or by the l)ull of tlie connective tissue when portions of the bone are dis- placed. 'J'he two layers of the triangular ligament, composed of heavy fibrous tissue, are firmly attached to the isehiopubie rami which form the subpubic arch. When this arch is fractured the ligament is usually torn and since the urethra passes through the ligament it may also suflfer injury. The rectum is situated in the posterior portion of the pelvis, follows the curve of the anterior surface of the sacrum and coccyx, and in this protected position is rarely injured. The nerves passing through the sacrum and in close relation to the coccyx may be injured when this region of the pelvis is fractured. Etiology. — Fracture of the pelvis is usually the result of great violence such as occurs when the patient is caught between two railroad cars or crushed beneath falling rock in mine accidents. Falls from heights may produce the condition, the force often being transmitted through the femora or tubera ischioinim. Fracture of the pelvis is comparatively a rare accident, constituting about one- half percent of all fractures. The flaring ilia are more frequently fractured than is the true pelvis because of their lighter structure and more exposed positions. Classification and Pathology. — The pelvis is a complex structure both ill its bony parts and its relation to viscera. The different portions of the pelvis should be studied individually, and then the pelvis as a whole is to be considered with reference to its various functions. Like the skull, the most important feature of fracture of the pelvis consists of the injury which may be sustained by adjacent soft tissues, in other words the complications occurring in fracture of the pelvis are far more serious than the fracture itself. Fracture of the pelvis may be divided clinically into complicated and nncompJicatrd cases. Uncomplicated fracture commonly oc- curs in isolated fracture of some one of the three bones forming FRACTURES AND DTSTjOCATIONS OF PF.LVIS 497 the OS innorainatum while the complicated type, is most commonly seen when the pelvic girdle is fractured. Uncomplicated fracture most frequently occurs in : 1. The upper expanded portion of the ilium. 2. The rim of the acetabulum. 3. The tuberosity of the ischium. 4. The coccyx and tip of the sacrum. The complicated type is represented by : 1. Separation of the symphysis pubis. 2. Fracture of the pubic and ischiopubic rami. 3. Vertical fracture of the lateral portions in the region of the acetabulum. 4. Separation of the sacro-iliac joints. 5. Transverse fracture of the sacrum. Considerable useless distinction has been made between fracture and dislocation of the pelvis. Probably the only real dislocation occurring in the pelvis is that of the coccyx. The so-called dislo- cations described as having taken place in the sacro-iliac synchon- drosis are at most only subluxations, usually complicated by frac- ture in the immediate neighborhood of the joint. In most of the reported cases of sacro-iliac dislocation fracture has been recog-. nized as a complication and in other instances the report would indicate that the presence of fracture had not been properly ex- cluded by X-ray examination. Separation of the symphysis may be considered as a dislocation though it is probably more in ac- cordance with the pathological facts to place it under the heading of fractures. Symptoms. — The symptoms of fracture of the pelvis will vary according to the region of the injury and the complications present. Isolated fracture of a small portion of the pelvis such as the anterior superior iliac spine will not, as a rule, give rise to more than local symptoms. There will be more or less localized pain which is increased when the patient moves about. On examination we find abnormal mobility, crepitus, tenderness, swelling, etc. But, on the other hand, when the pelvic girdle is fractured and complications are present, we have a very different clinical picture. Shock is a prominent symptom as evidenced by pallor, cold clammy skin, weak rapid pulse, etc. Collapse and unconsciousness may 498 FRACTURES AND DISLOCATIONS supervene in ]»i<)iiouiiee(l eases. If eoiiscioiis the patient suffers intense pain and deformity of the true pelvis is present to a greater or less degree.- It is often possible to elicit abnormal mobility and crepitus upon examination though the surgeon should exer- cise the greatest care to avoid further injury to the viscera by manipulation. Inability to walk may be due to pain, shock and visceral injury or it may be the result of mechanical disturbance in the weight-carrying function of the pelvis. If that portion of the pelvis bearing the acetabulum is displaced upward there will be shortening in the lower extremity of the same side. To these symptoms will be added those peculiar to the complications present. Of the uncomplicated fractures of the pelvis, isolated fracture of the upper expanded portion of the ilium is the most common, while fracture of the anterior portion of the pelvic ring is the most frequent representative of the complicated type. The symptoms occurring in the different types of uncomplicated fracture of the i)elvis are as follows : 1. Fracture of the upper expanded portion of the ilium will be accompanied by pain in the region of the injury, tenderness and often swelling. Ecchymosis frequently develops after the first twelve or twenty-four hours. Pain will be increased by any motion which calls into activity the muscles attached to the fragment or fragments. "When the course of the fracture is horizontal the crest may show marked upward displacement. The line of frac- ture will frequently be found running downward and forward from the middle of the crest, or less commonly downward and backward from the same point. The fracture is usually due to direct violence and accordingly bruises or abrasions are frequently seen in the skin over the region of injury. In rare instances the intestines lying in the hollow of the ilium may suffer injury, producing symp- toms of shock and peritonitis. When the fracture is confined to the region of the anterior superior iliac spine the fragment may be dis- placed forward and outw^ard due to the combined actions of the abdominal muscles, sartorius and tensor vaginae femoris. When the fragment includes only a small part of the crest and only a small portion of the abdominal muscles are attached, the action of the thigh muscles just mentioned will be practically unopposed, resulting in doAvnward displacement. Crepitus is usually present but is by no means constant, since the fragments are not alwa^-s in contact. Relaxation of the muscles FRACTURES AND DISUOfiATIONS OF PELVIS 499 of the abdomen and thigh will render palpation of the fragments easier and often enable the snrgeon to elicit crepitus which would otherwise be absent. This may be accomplished by placing pillows beneath the patient's shoulders and flexing the thighs. Fig. 566. rigs. 565 and 566. — Fracture of the left ilium with tearing away of the abdominal muscles from the iliac crest. Note the change in outline with the patient in the lateral recumbent position. (Atrophy of right thigh result of old amputation of right leg.) 2. Fracture of the rim of the acetabulum does not occur except as a complication of displacements of the head of the femur. The upper posterior part of the rim is the portion of the acetabular cir- 500 FRACTURES AND Dl.SlA)CATlOXS cuiiifeivnce most frtHiuently detached by the head of the femur as it leaves the cavity. Fracture of the rim of the acelabuhuu with displacement of the femoral head i-csults iu shortening of tlie liiiili of the affected side though the i)Ositioii assumed is not necessarily characteristic of dorsal dislocation of the hip. Slight manipulation of the thigh with traction is usually sufficient to bring the head of the femiu" back into place though the deformity recurs either innne- diately or within a few hours following reduction. It differs from dislocation of the hip in the ease with which i-ciluction is accom- plished and the tendency to recurrence of deformity. The condition however closely resend)les fracture of the neck of the femur, having frequently been mistaken for it. In fracture of the neck of the femur the arc described by the trochanter when the thigh is rotated is of shorter radius than normal. In fracture of the rim of the acetabulum this arc is normal as may be demonstrated by comparison with the opposite side. This differ- ence, however, is often slight and difficult to determine, so that the use of the X-ray will frequently be necessary to determine the pathology of the case. The fragment usually follows the head when the latter is returned to the acetabulum, and crepitus Avill be pro- duced as the fractured surfaces pass each other. This crepitus may be as pronounced as in fracture of the hip, or it may be exceedingly indistinct according to the position of the fragment. 3. Fracture of the tuberosity of the ischium is an exceedingly rare condition being the result of severe localized trauma. The condition is therefore likely to be accompanied by wounds of the soft parts which may reach to the bone, rendering the fracture com- pound. Abnormal mobility and crepitus may be elicited by palpa- tion through the rectum or vagina, while the opposite hand gives counter-pressure through the gluteal muscles. Local pain, tender- ness, etc., will be present. 4. The coccyx may he fractured or (Tislocatcd by direct violence acting either from without or within. It most often follows falls on the buttocks and may be displaced forward, laterally or back- ward, the latter being the result of forces acting from within the pelvis, such as the descending head of the child. The distinction between fracture and dislocation of this bone has been the subject of much discussion between certain writers, but for practically clinical ];ui'poses it matters little since the symptoms and treatment are identical. ^Piu' pain in fracture or dislocation of the coccyx may be P^RAGTURES AND DTSTjOCATIONS OK I'ELVIS 501 surprisingly severe considering the actual damage done. Before reduction is accomplished the patient usually presents the symptoms of agonizing pain which radiates up the back and down the dorsal aspect of the thighs from the seat of injury. Even after the suffer- ing has been relieved by correcting the displacement it will be many days before the patient can move about with any degree of comfort. The fracture may take place through the lower end of the sacrum so Fig. 567. — Lateral dislocation of the coccyx. The arrows point to the coccyx which has been outlined to accentuate its position. The lower arrow passes through the symphysis pubis. that a portion of this bone is displaced with the coccyx. The higher the fracture in the sacrum the greater the likelihood of injury to the nerves contained within the sacral canal and emerging through the sacral foramina. Injury to these nerves may produce pain, numb- ness, loss of function, etc., throughout the region of their distribu- tion, and in severe cases to trophic disturbances with sores or sloughs in the skin covering the coccyx and lower end of the sacrum. The coccyx and sacrum become one bone in the aged so that fracture of 502 FRACTURES AND DISLOCATIONS the tip of the sacrum is more likely to occur after tlie articuhition has been obliterated. The usual displacement of the coccyx is angular and forward so that the tip of the bone may be felt pointing forward when the examining linger is introduced into the rectum. This displacement encroaches upon the cavity of the rectum, rendering bowel move- ments extremely i)ainful. The lateral and posterior dis()lacetnents, which are extremely rare, do not tend to recur following reduction; the anterior displacement however does tend to recur as a result of the action of tlie attached nuiscles. Lateral displacements may be palpated tlirough the rectum; posterior displacements will be accompanied by an abnormal prominence in the lower part of the gluteal cleft. The symptoms occurring in complicated fracture of the pelvis M'ill depend on the region of the pelvis injured, together with the nature and extent of the injury sustained by the soft parts in the region of the fracture. When any portion of the pelvic girdle is fractured numerous complications may exist so that it will be best to consider the bone injuries first in the order previously set down, after which the complications will be taken up. The mechanism and pathology of fracture of the pelvic girdle are of secondary importance when compared to the complications commonly found accompanying this condition. 1. Separation of the symphysis pubis may be the result of indirect violence forcing the ossa innominata apart, due to the overaction of the adductor group of muscles while the thighs are in abduction, or to the spreading action of the foetus as it descends through the parturient canal. The separation of the pubes may be felt and in many instances seen. Separation of over one and a half inches is, as a rule, accompanied by rupture of the anterior sacro-iliac ligaments or fracture in some other portion of the pelvic ring. With separation of the symphysis the patient suffers considerable pain and the weight bearing function of the pelvis is interfered with as a result of the dissolution of the counter-arches. Rupture of the ligaments and loosening of one of the sacro-iliac joints will allow one os innominatum to be displaced, usuall}^ upward. Symphyseal separation may be associated with fracture of the pelvis or with loosening of one or both sacro-iliac joints. One pubic bone may be displaced behind the other and when such is FRACTURES AND DISLOCATIONS OF PELVIS 503 the case it is usually very difficult to reduce the deformity. The common complication is rupture of the urethra or bladder, the symptoms of which will be described later. 2. Fracture of the anterior portion of the pelvic ring occurs more frequently than any of the other fractures in this group. The details of the lines of fractures vary greatly. Both rami of the pubis are usually fractured, the upper one anterior to the ilio- pectineal eminence and the lower near the junction of the descend- ing pubic with the ischial ramus. The condition is not infre- quently bilateral. Deformity is usually present and can be de- tected by palpation. The condition may be the result of violence applied to the pelvis in the antero-posterior direction or it may be due to lateral squeezing. Fractures in the lateral or posterior portions of the pelvic ring are common as complications, and are seen in instances in which the causative trauma continues to act after the anterior portion has been fractured. The patient is unable to walk, pain is severe, and shock often pronounced, especially in the presence of visceral complications. Rupture of the bladder and injury to the urethra are common as complica- tions (see page 509). 3. Fracture of the lateral portions of the pelvis in the region of the acetabulum occurs in conjunction with fracture of the anterior portion of the ring as previously explained, and also as a result of trauma transmitted through the head and neck of the femur. The first named type of fracture is more or less vertical, passing from the crest of the ilium to the great sacro-sciatic foramen. The line of fracture frequently branches in its upper end. It may pass into or cross the sacro-iliac joint involving the sacrum: in other instances it comes out below the anterior inferior iliac spine. When it crosses the sacro-iliac joint it may follow more or less closely the line of the articulation, or it may follow the sacral foram- ina separating the lateral mass of the sacrum from the rest of the bone. The directions which the lines of fracture may take in the lateral portions of the pelvis are very variable and accordingly two cases will seldom show the same deformity. The fact that the femur articulates with this portion of the pelvis often gives rise to symptoms of importance. The lower extremity of the affected side usually lies helpless and is shorter than normal because of the displacement of the acetabulum. The muscles of the thigh are in spasm and any attempt at passive motion is seriously objected to 504 FRAPTT'RER AXD DTi^T-OfATTOXS hy the patient. Abnormal mobility aiul creijitus can. as a nib\ be elicited with ease by direct palpation or manipulation ol" Ihc tbiiili, and the pelvic deformity is often plainly visible. Injury 1o tlie acetabulum and adjoining pelvis resulting from trauma transmitted through the femur is rare, because wtieu violence is applied to the trochanter the neck of the femur is iiuk-Ii moi-c liable to fracture than is the pelvis. The condition, however, does occasionally occur anil a variety of fractures may result when the pelvis is injured in this manner: the acetabulum may be "bi-oken out," so to speak, of the rest of the pelvis with three lines of fracture, one from a point below the antero-infei-ior spine to the great sacro-sciatic notch, the second across the ascending ramus of the pubis and the third across the body of the ischium below the acetabulum ; another result is that the violence applied to the acetabulum pro- duces radiating fractures which, following the lines of least resist- ance, reach the sacro-sciatic notch, thyroid foramen and rim of the pelvis; in addition w^e may have injury of the bone at the bottom of the acetabular cavity without fracture of adjoining portions of the pelvis. A rare condition is sometimes seen in which the head of the femur is driven through the bottom of the acetabulum into the pelvic cavity. The symptoms of deformity and disturbance in function will vary with the pathology of the condition. When the acetabulum is fractured there is likely to be shortening of the lower extremity, abnormal mobility of the upper end of the femur and crepitus wdien the thigh is manipulated. When the head of the fenuir is driven through the acetabulum there will be abnormal fixation of the upper end of the femur, mesial displacement of the troclianter as palpated externally, and the patient will be able to bear the weight of the body on the limb of the affected side since the ring of the pelvis is not fractured and the weight is trans- mitted to the neck of the femur instead of to the head. The shock and pain, however, will usually be sufficient to prevent the patient attempting anything in the way of walking. Fracture of the pelvis by lateral compression is usually preceded by fi-acture of the "tie arches" composing the anterior part of the ring, so that the symptoms of fracture of both these portions of the pelvis will be present at the same time. 4. Separation of the sacro-iliac synchondrosis, as an isolated injury, is an extremely rare condition. Tt occurs sometimes in conjunction with fractui-e of tlie antei-ioi- poi-tion of the pelvic FRACTIIKKtt AND DTSr.OOATTONS OF 1'ET.VTS 505 ring or separation of the- symphysis pubis. Inward displacement of the lateral portions of the pelvis, such as occurs in transverse crushes, may result in rupture of the posterior ligaments behind the articular surfaces. Spreading of the pelvis throws the strain on the anterior sacro-iliac ligaments, which rupture, allowing the anterior aspect of the joint to gape. The strength of these liga- ments, however, is so great that fracture in the adjoining bone is more frequently produced than rupture of the ligament itself. Displacement in one or both sacro-iliac joints, or separation of all three pelvic articulations is known to have taken place, but such conditions are very rare. Laxity or rupture of the ligaments of the sacro-iliac joints will allow an upward and outward displace- ment of the ilium if the patient attempts to sit or stand. Disturb- ances in function following injury to the pelvic articulations will give rise to symptoms similar to those occurring in fracture of the same region. The sacro-iliac joints are not infrequently subject to sprains in falls and blows on the pelvis, and although the con- dition is by no means a dislocation, it deserves mention. There is more or less pain in the joint when the patient moves about, and pressure on the anterior superior spines produces pain in the region of the injury. The condition is usually not serious, being followed by prompt recovery with rest in bed for a few days. 5. Transverse fracture of the sacrum is the result of severe local- ized trauma and is fortunately a rare condition. A small portion of the sacrum may be displaced with the coccyx but this condition is described under fracture of the coccyx. The fragment in trans- verse fracture of the sacrum is usually displaced forward, project- ing into the cavity of the pelvis and is commonly accompanied by injury to the rectum and the nerves contained within the sacral canal. The displacement is easily detected by palpation. Severe pain, radiating up the back and down the thighs, may be present. Shock is often pronounced. Paralysis of the bladder and rectum, due to injury of the nerves supplying these structures as they pass through the sacrum, is not uncommon. Paralysis of the lower leg type has been noted in some cases. The displacement is produced by the original trauma and the action of the attached muscles. The deformity usually recurs promptly following reduction. Diagnosis. — When fracture of the pelvis is suspected the exam- ination should be conducted systematically in order that the full extent of the injury may be recognized. Moreover the examination 506 FRACTURES AND DISLOCATIONS sliould not be considered complete as soon as we find one line of fracture, since multiple fracture and visceral complications are common. The patient should be placed in a position wliich is accessible and convenient for the surgeon, preferably an operating table, and unless there are special contraindications it is advisable to administer a short anesthetic. The pelvic girdle is covered with a number of muscles and many of its parts are deeply situated, yet by proper palpation fracture and articular displacements can, as a rule, be determined without difficulty. liy insi)eetion alone it is often possible to detect asymmetry of the two si(h's of the pelvis, raising of one of the ossa innoniinata, or the median depression of symphyseal separation. The shortening and helphss attituch' in which the lower extremity may lie is indicative of fracture of tlie femur or pelvis. Palpation will usually elicit crepitus and ab- normal mobility in the presence of fracture or separation. With the patient in the dorsal position and the pelvis solidly supported, backward pressure is made Avith the palms of the hands on the antero-superior iliac spines, then the iliac crests are crowded together and finally antero-posterior pressure is exerted with one hand over the symphysis and the other on the sacrum. Pressure in these directions will usually elicit mobility and crepitus if the fracture has passed through the pelvic girdle. Due care should be exercised to avoid further injury to the viscera in manipulating the parts since the examination may thus infiiet more serious injury. The pubes and their ascending rami are near the surface and their outline may be followed throughout. The mesial borders of the ischio-pubic rami may be palpated at the lateral boundaries ff the perineum with the thighs abducted. The anterior superior iliac spines are subcutaneous and the iliac crests may be palpated throughout their extent, terminating posteriorly in the postero- superior iliac spines. The tuberosity of the ischium may be palpated with the fingertips of one hand resting in the lower part of the gluteal cleft while the opposite hand makes counter-pressure through the buttock. It may also be palpated through the rectum or vagina. The spines of the sacrum may be palpated throughout but the remainder of the posterior surface of the bone is obscured to touch by the heavy fascia covering the lower end of the erector spinie mass. If the finger be passed into the rectum and the thumb opposed posteriorly the coccyx may be thoroughly palpated, and the presence of abnormal mobility and crepitus determined when PRACTURK8 AND DISLOCATIONS OF PEFyVIS 507 present. The presence of fracture is, as a rule, easily reco^ized by palpation as above described, but it is often impossible to deter- mine the details without enii)loyrng the X-ray. Treatment. — The treatment of fracture of the pelvis aside from the complications is usually a simple matter. If the deformity is not great immobilization and rest in bed will be all that is required. In fracture of the crest of tli.e ilium a body swathe may be used or adhesive straps may be employed to steady the fragment. Too much pressure should be avoided, as it may displace the fragment inward, thus increasing the deformity. Rest in bed is necessary and the patient should be warned against undue use of the abdominal muscles. The bowels should be kept soft to avoid straining at stool. Moderate deformity does not mean impairment of function and seldom requires special measures for its correction. A flattened hip in a young woman, however, is often considered a serious matter and we may be called upon to secure the fragment by operation for the correction of deformity. Fracture of the rim of the acetabulum is to be treated similarly to fracture of the hip and will be considered with the treatment of fractures of the upper end of the femur. Fracture of the tuberosity of the ischium rarely shows great displacement and recovery with moderate deformity is followed by good function. Rest in bed and a pneumatic ring to relieve the region of fracture from pressure will constitute the essentials of treatment. If the tuberosity, however, shows enough inward displacement to encroach on the transverse diameter of the birth canal in a woman of the child-bearing period, it is best to cut down on the fragment before union commences and secure it in place with wire or some other form of suture material. Fracture or dislocation of the coccyx calls for immediate reduction to relieve the suffering and if necessary opiates should be used in addition. All of the displacements except the anterior show little or no tend- ency to recurrence and not much in the way of treatment will be required aside from reduction and relief of pain. The patient should be kept in bed for a week or so or until the extreme tender- ness has subsided. During this time the use of a pneumatic ring will add greatly to the patient's comfort. In fracture or disloca- tion with anterior displacement it is difficult to keep the fragment in reduction, because of the muscles attached to the coccyx. The condition has been treated by packing the rectum and the exhibition of opiates to produce constipation. If a large rubber tube, rolled in 508 FRACTURKS AXI> niSI.OCATIONS gauze, is introduced it will allow the escape of flatus and li(|iii(l feces witliout removing the dressing. AVhen this dressing is used the bowels slioukl l)e kept liquid by laxatives. In any case the rectal packing will liavf to be mainlaiiicd until the callus is suf- ficiently firm to i)revent the recuri-ence of deforniily. It should be renewed often enough during the after-treatment to keep the parts clean and avoid rectal irritation. Vaseline facilitates intro- duction and is less irritating to the mueosa than plain gauze. If these measures do not eontrol the tendency toward displacement or ])ain following the injury persists and defecation is i)ainful because of tile anterior displacement, excision of the coccyx is indicated and will be followed bv relief and no disturbance in function. ii_. .')i;>. — I'hi^iHi- ...1 L'nris fliuiWe spica of trunk and both thighs for the treat- ment ol' fracture of the pelvis. The thighs should be slightly flexed and abducted to allow proper care of the patient and use of the bed pan. In the above isolated fractures of the pelvis the patient may be made comparatively comfortable by rest in bed and proper nursing, but when the ring of the pelvis is fractured the condition is much more serious and difficult to treat. The element of importance in separation of the symphysis, fracture of the puhic and ischio-puhic rami, lateral fracture of the pelvis and separation of the sacro-iliac joints is the breaking of the pelvic girdle and the likelihood of visceral compljcations. The indications, therefore, in the treatment of these conditions will be to secure immobilization of the pelvic ring and provide for the complications as soon as they are recognized. The various visceral complications are not peculiar to any one form of fracture of the pelvic ring and because of this fact they will be considered under a separate heading (see page 509). A Bradford FRACTURES AND DISLOCATIONS OF PELVIS 509 bed-frame or some substitute is essential to prevent disturbing the fragments whenever the bed-pan is used and to keep the bed and patient properly clean. In place of the Bradford bed-frame we may employ a double plaster of Paris spica extending from the waist to the knees, and in this manner the pelvis is secured so that the patient may be rolled from side to side, the bed-pan used and the clothes changed without disturbing the parts or increasing the suffering. The cast should be applied with the thighs slightly abducted and with moderate flexion at the knees and hips, thus giving ready access to the anal region and the genitals, besides securing a more com- fortable position for the patient. Traction on the thigh may reduce deformity when the portion of the ring to which the femur is attached is driven in. By manipulation it is sometimes possible to correct some of the displacements. The treatment of fracture of the pelvic girdle consists mainly in the treatment of the complica- tions which accompany the condition. Complications. — Complications very rarely occur except in cases in which the pelvic girdle is fractured, but their presence in isolated fracture of some of the bones of the pelvis or even in cases of abdominal or perineal trauma without fracture should not be lost sight of. The visceral injuries accompanying fracture of the pelvic girdle are far more important than the fracture itself, being responsible for the high mortality following this fracture. Rupture of the urethra, rupture of the bladder, rupture of the bowel, injury to vessels (especially the external iliacs) and injury to nerves (especially the sacral and coccygeal) are among the complications most common in fracture of the pelvis. Renal injury sometimes occurs as an associated condition. The symptoms of rupture of the urethra will depend on the region of the canal injured. Injury is most frequently sustained in the membranous portion, as the canal emerges from the superficial layer of the triangular ligament. If the tear in the urethra is outside the cut-off muscle the hemorrhage from the meatus will be more or less continuous. There is often a dribbling of blood for some time following the accident, which grows less and finally stops only to begin again when urine is passed or micturition attempted. Pain and tenesmus are usually pronounced. Swelling of sudden onset, due to urinary accumulation, is seen in the perineum and if not relieved soon extensively infiltrates the surrounding tissues. The catheter usually meets obstruction when it encounters the site of 510 FRACTURES AND DISLOCATIONS rupture. If the floor of the urethra is torn catheterization may sometimes he accomplished ])y following the roof with a metal instru- ment. Complete tear almost always ivcjuires operative inlci-vention to enter the hladder. If tlie rupture is behind the cut-off muscle the blood will flow back into the bladder, appearing at the meatus only with micturition. If the rupture is complete, retention is the rule with occasional dribbling of bloody urine. "When retention is present the symptoms of distended bladder will supervene wdthin a few hours. The diagnosis of rupture of the urethra is made on the s.ymptoms enumerated aliove. In some instances the tear in the u)'('tlira nuiy be inspected by means of the urethrascope or posterior endoscope or l)etter still the cystourethrascope. Treatment of riipfKre of the urethra. — In rui)ture of tlic urethra the prime indication is for prompt, continuous and complete drain- age of the bladder. Cases in which the passage of the catheter has been possible have been successfully treated by means of continuous catheterization and suction apparatus. By far the safest method however consists in prompt external urethrotomy followed by direct drainage of the bladder through a rectal tube in the perineum connected by means of rubber tubing with a bottle beneath the bed. Perineal drainage instituted early will accomplish more in preventing urinary infiltration than anything else. When the tear is complete the roof of the urethra should be brought together and secured by suture during the operation. The most satisfactory catheter in these cases is the rectal tube. In some instances consid- erable difficulty is experienced in finding the proximal end of the torn urethra and in such cases it is better to enter the bladder supra- pubically and do a retrograde catheterization rather than to pro- long the search in the perineum with the patient already suffering considerable shock from the accident. During the treatment of this condition it is always advisable to determine the condition of the bladder to avoid overlooking complications of this viscus. Symptoms of rupture of the hladder. — Shock is always a prom- inent symptom aside from the shock occurring in fracture of the pelvis. Pain is pronounced and tenderness present. If the rupture is extraperitoneal the patient passes bloody urine which is not pre- ceded by blood as in urethral injury. Suprapubic swelling due to infiltration of urine into the space of Retzius makes its appearance a few hours following the injury. When the rupture is intra- peritoneal the urine passes from the bladder into the peritoneal FRACTURES AND DISLOCATIONS OF PELVIS 511 cavity and accordingly the viscus does not become distended. If sufficient nrine collects in the abdominal cavity, dullness on percus- sion may be noted in the flanks. The patient is unable to pass urine although tenesmus is present and frecjuent ])aiiifiil altempts at micturition are made. Diagnosis of rupture of the Madder will be followed by the symptoms peculiar to this injury as described above. In addi- tion we may test the walls of the bladder by introducing a measured quantity of sterile salt solution through a catheter and remeasuring it after it has been withdrawn. If the bladder has been ruptured intraperitoneally it will be impossible to fill the viscus, and the fluid when withdrawn will be much less than the quantity introduced. When the rupture is extraperitoneal the loss of fluid will often be too small to detect. The catheter should not be introduced further than is necessary to reach the bladder since in some cases of intraperitoneal rupture it may pass through the rent in the bladder into the peritoneal cavity, thus evacuating urine which has escaped from the bladder or salt solution which has been introduced for diagnostic purposes. This method is not ideal and has been condemned by some genito-urinary surgeons, yet it is the best we have and nothing is more fatal to the patient than the expectant plan of treatment followed because of ignorance of the conditions present. The questionable damage done by the passage of salt solution (previously sterilized) from the ruptured bladder into the abdominal cavity and followed by operation is more than outweighed by the benefit the patient derives from a positive diagnosis and prompt surgical treatment. The cystoscope is valueless in intraperitoneal rupture since the bladder cannot be distended. When the rupture is extraperitoneal it will sometimes be possible to inspect the injury by means of this instrument in competent hands. The hemorrhage, however, is usually sufficient to obscure the water with which the bladder is distended, so rapidly that vision is rendered unsatisfactory or impossible. Treatment of rupture of the bladder. — Rupture of the bladder calls for immediate operative intervention if we expect to save the patient. In the intraperitoneal form of rupture the rent must be closed through an abdominal incision and the bladder drained from below through a permanent perineal tube to prevent disten- tion of the viscus and tension on the sutures. In extraperitoneal rupture the tear is frequently situated in the lower anterior aspect 512 FRACTURES AND DISLOCATIONS of the bladder or the region of the trigone, and should be repaired with fine absorbable suture material. The situation, however, of these extraperitoneal tears is inaccessible and difficult to oi)erate upon and the condition of shock in whicli we find the patient often precludes any prolonged operation- or anesthetic. It is therefore best in many cases of extraperitoneal tear to establish free perineal drainage at once, leaving the rent to take care of itself. PART III. LOWER EXTREMITY. CHAPTER XXXVI. DISLOCATIONS OF THE HIP. Surgical Anatomy. — The hip-joint is a typical ball-and-socket articulation, and the depth of the acetabulum is such tliat the integrity of the joint is much less dependent upon the ligaments than is the case in the shoulder-joint. Numerous muscles are at- tached to the upper end of the femur and the great trochanter, all of which exert more or less of an upward or inward pull, their action being much more apparent in fracture of the neck of the femur than in dislocations of the hip. The muscle of greatest im- portance in this region is the obturator internus which is inserted into the digital fossa after having emerged from the pelvic cavity through the lesser sacro-sciatic notch. If the head of the bone passes under this tendon we have the sciatic form of dislocation. When it passes over the muscle we have the iliac type in which the head of the bone rests on the dorsum ilii. The hip has five liga- ments: ligamentum teres, the capsule, the cotyloid, transverse, and ilio-femoral. The ligamentum teres passes from the ovoid depres- sion on the head of the femur to the margins of the fossa acetabuli. The capsular ligament surrounds the joint, is attached at its inner end to the margins of the acetabulum, while the opposite end is attached to the femoral neck. The anterior portion of the capsule extends downward and outward as far as the spiral line of the femur, while the posterior portion of this ligament reaches to within a half inch of the posterior intertrochanteric line. The capsule is lined with synovial membrane and possesses a number of accessory thickenings along the lines of the greatest and most frequent strains. The upper and anterior portion of this tube- like ligament is the heaviest. The posterior inferior portion is comparatively thin, loose and lax. The cotyloid ligament is an intracapsular fibro-cartilaginous ring attached to the margins of the acetabulum; it serves to deepen the cavity and strengthen the joint. "Where it crosses the cotyloid notch, it is known as the transverse ligament. The above ligaments are all more or less 515 516 P^RACTIJRES AND DISLOCATIONS essential factors in tlic liip, ])iit the ligament of by far the greatest importance is the ilio-fitnortil or Y-ligament of Bigclow. This con- sists of an accessory thickening in the anterior portion of the cap- sule. Its lower extri'inity is attached lo tlic aiitei'ior intertro- chanteric line, while its ui){)er end is attached, with the straight head of the rectus, to the anterior inferior iliac spine. Tn exten- sion of tile thigh tills ligament is tense, and Hiiiils motion at the hip; in tlexion it is i-elaxed. in a jxM'son of average liuild it is Figr. 569. — The ilio-feiiioral nr Y-li(;aiiient of Bisrelow. a most ini|)oitiUit slriictui'e in dislocations of the hip. said to pos.sess a tensile strength of two hundred and fifty pounds or more, and thus it will be readily understood tiiat this ligament is rarely torn in dislocations of the hip. The head of the femur when displaced may lie anywhere about tlie acetabulum, depending on the manner in which violence was applied at the tiiiu- of the aceidtmt, and tlie subsecjuent action of tlie muscles and ligaments attaclied to the bone. Although the head may lie in almost any position around the acetabular ring, yet it almost invariably leaves tlie joint tlii'ough a rent in the lower DTRTiOOATIONR OF TITE HIP 517 portion of the capsule. After escaping -from the socket it usually rides upward either in front of, or behind the acetabulum. Ac- cordingly numerous classifications have been given of dislocations of the hip, all of them based on the position occupied by the dis- placed head. There are two main groups deserving of consider- ation, namely, anterior and posterior. The resultant attitude as- sumed by the lower extremity is purely a question of mechanics, depending upon the relations of the displaced head and the influ- ence of the Y-ligament. Whatever position the femoral head may find, the distance between the anterior inferior spine and the spiral line cannot exceed the length of the ilio-femoral ligament. The Fig. 570. — Iliac dislocation of the hip. The higher the head rests on the ilium the more pronounced will be the inward rotation of the thigh provided the Y-ligament is not ruptured. Fig. 571. — Sciatic dislocation of the hip. The head rests in the sciatic notch. action of this ligament, under these conditions, might be likened to that of a "toggle joint" or "shackle," which, though movable at one end, maintains a more or less fixed relation between the attached objects. If the head, therefore, is displaced outward and backward, the knee must of necessity come forward and inward, and in like manner the other characteristic deformities accom- panying the various dislocations of the hip, may be readily under- stood if one appreciates the anatomy, particularly the action of the ilio-femoral ligament. A second element in the production of deformity is the angle at which the femoral neck joins the shaft, and the consequent 518 FRACTHHRS AND niSL( )C.\'I'1()NS leverage exerted by the neck when the head of the bone is out of the socket. Thus, if the posterior aspect of the neck lies in con- tact with the- OS innoniinatuni, as in the anterior displacements, Ilio-pectineal dislocation of tlie hip. Pubic dislocation of the hip. Fig. Fig. 574. — Obturator or thyroid dislocation of the hip. Fig. 575. — Perineal dislocation; an e.xaggeration of the obturator type. outward rotation must be the result; when the reverse condition is true, the anterior surface of the neck lying in contact with the hip bone, as in posterior dislocations, inward rotation of the thigh will 1)6 present. The depth of the socket and the heavy ligaments DISLOCATIONS OF THE HIP 519 surrounding the joint account for the extreme rarity of disloca- tion of this articulation. If the antero-superior iliac s])ine be connected by a line with the most prominent portion of the tuber ischii, the acetabulum will be approximately bisected, the line passing just across the tip of the great trochanter. This is known as Nelaton's line and forms the dividing line between anterior and posterior luxations. Fig. 576. — High dorsal dislocation of the hip -with eversion or outward rotation which is only possible when the outer arm of the Y-ligament is ruptured. If the head lies posterior to this line the condition will be know^n as a posterior dislocation and the exact position at which the head comes to rest will determine the type of backward luxation present. In like manner anterior dislocations are subdivided according to the point at which the head comes to rest in front of Nelaton's line. The more usual dislocations occurring at the hip ma^^ be classified as follows : Posterior luxations Anterior luxations rlliac \Sciatic Ilio-peetineal Pubic Obturator -Perineal 520 FRACTURES AND DISLOCATIONS Extreme and unusual conditions sometimes occur l)ut for prac- tical purposes it is inadvisable to attempt their consideration in a elassilication. ' In eases of great violence, in wliicli the Y-ligament is torn, the head may lie anywhere in this region and the symp- toms accompanying the dislocation will be atypical. The condition may, in rare instances, be comitound or comi)licated by fracture. Etiology. — Dislocations of the hip constitute from one to two percent of all luxations. They occur most frequently between the fifteenth and forty-tifth years, altliough they may be seen at any age. Tlie increasing brittleness of the bones as age advances, ren- ders dislocation extremely uncommon in the aged. It occurs about eight times more often in males than in females. Of the various types of displacements, the dorsal iliac is by far the most common. Next in order of frequency is the obturator, a sul)division of the anterior. Symptoms. — Severe, sickening, localized pain, loss of function, and restricted mobility are symptoms which are common to all forms of dislocation of the hip. Deformity, however, will vary with the position occupied by the displaced femoral head. In the iliac type, the head of the bone lies above and behind the acetabulum, being prevented from occupying a higher position by the restraining action of the untorn ilio-femoral ligament. The thigli is slightly flexed, rotated inward, somewhat adducted, and apparently shortened to the extent of about two inches. The pa- tient's suffering is greatly increased and rigid resistance is felt when passive motion is attempted, especially abduction. A com- plication of this condition is occasionally observed wlien the upper posterior portion of the rim of the acetabulum is fractured, and the fragment displaced with the head. Under these circumstances, the head leaves the socket at the point of fracture instead of through the usual rent in the lower part of the capsule. Reduction may be possible by simple traction, since the obstructing portion of the acetabular rim is no longer intact. Crepitus may occur as the serrated surfaces pass, often rendering the condition extremely diiBeult to differentiate from fracture of the femoral neck. The condition might, more properly, be described as a fracture of the acetabulum, complicated by dislocation. In iliac luxation of the hip there is no tendency towards spontaneous recurrence of deformity following reduction, unless the condition is complicated by fracture of the acetabular rim. In simple dorsal dislocations, DISLOCATIONS OP THE HIP 521 passive flexion of the thigh meets with less resistance than motion in any other direction. Loss of function is complete. There are a few reported cases of dorsal dislocation with eversion of the thigh as a result of laceration of the anterior arm of the Y-ligament. The head of the hone may lie in the sciatic notch, instead of on the dorsum of the ilium, the condition then being known as the sciatic form of posterior dislocation. Under such circumstances, Fig. 577. Fig. 578. Fig. 5 77. — Attitude in dorsal luxation of tlie hip. Tliigli shortened, adducted and rotated inward. Fig. 578. — ^Attitude in anterior luxation of the hip. Thigh lengthened, abducted and rotated outward. flexion and adduction of the thigh will be more pronounced. We have practically the same dislocation whether the head lies in the sciatic notch, or on the dorsum ilii, the difference being one of degree only. As previously explained, the determining factor be- tween these two types of posterior dislocation, is the obturator internus. The symptoms in forward dislocation are the same as those just described as far as pain and loss of function are concerned. The 522 FRACTURES AND DISLOCATIONS deformity, however, is unlike that seen in posterior luxations be- cause of the difference in the positions occupied by the head. In the ilio-pcctineal luxation, the head rests on the horizontal ramus of the pubis, in the region of tlio ilio-pectineal eminence, in which position it may be palpated. Oiitwai'd rotation is marked, thougli abduction and flexion arc slight, if present at all. The capsular rent is in the lower or lower anterior j^ortion of the liga- ment. Numbness and pain may be present along the course of the anterior crural nerve if pressure has been exerted upon it by the displaced head. Pressure upon or injury to the femoral ves- Fig. 5 79. Figs. 579 and 580. — Old unreduced dorsal dislocation of left hip of thirty-five years' standing. Patient unable to fully extend thigh though able to get about by the aid of a built-up shoe and cane. Note the shortening, adduction and inward rotation of thigh. The shortening is more pronounced than is usual iu recent cases. (Toes of left foot lost through freezing. ) sels has been observed in some instances. Slight shortening of the lower extremity usually exists, and passive motion, especially in- ward rotation, meets with solid resistance. If the head of the bone continues further in its inward course, it may come to rest on the symphysis pubis or above the liorizontal ramus, the dislocation then being spoken of as symphyscal or supra- pubic. These two conditions are but exaggerated forms of the ilio-pectineal luxation, and accordingly the symptoms will be more pronounced and the danger to the anterior crural nerve and femoral vessels is greater. In either of these forms the head of the bone DISL0CATI0N8 OF THE HIP 523 may be felt as a slol)iilHr |))'Oiiii)ieiK'e somewhere along the hori- zontal ramus of the pubis. A few cases have been reported in which the head occupied an extremely high position, directly below the anterior superior iliac spine. This is !)ut a variation of the ilio-pectineal form, and is exceedingly rare. In the obturator dislocation, another form of anterior displace- ment, the head of the bone fails to ride upward after leaving the acetabulum but comes to rest in the obturator foramen. This form of dislocation is next, in point of frequency, to the iliac type. The limb is slightly flexed, abducted, and rotated outward, and the displaced head may be palpated without difficulty. A depres- sion is noted in the position formerly occupied by the trochanter, the thigh appears lengthened and full extension is not possible. The perineal luxation is simply an exaggeration of the obturator form of displacement, in which the symptoms (especially abduc- tion) are more pronounced. The condition is very unusual. The prominence produced by the head may be recognized both by in- spection and palpation. The ischio-pubic rami may be fractured as the head passes across this portion of the pelvis into the perineum. There is an extremely rare form of downward luxation known as the infra-cotyloid, which is analogous to the luxatio erecta oc- curring in the shoulder. The head of the bone is forced from the acetabulum while the thigh is in extreme flexion, and rests in dis- placement on the body of the ischium. The thigh is maintained in extreme flexion until the head is replaced. This condition can neither be classed with the anterior, nor with the posterior dislo- cations, since the head is crossed by Nelaton's line. This luxation is so extremely rare that it might better be considered as a surgical anomaly rather than to describe it as a type. Another very unusual displacement is known as central dislo- cation of the hip, in which the head is driven through the bottom of the acetabulum. This condition has already been described on page 504 under "Fractures of the Lateral Portions of the Pelvis." Diagnosis. — The diagnosis is based on the sjnnptoms just de- scribed. Recognition of the condition is seldom really difficult, although it is not uncommon to see a dislocation of the hip mis- taken for fracture of the femoral neck, or even confounded with some forms of pelvic fracture. The fact that the usual impacted fracture of the neck of the femur should not be broken up, renders 524 FRACTURES AND DISI.OCATIOXS it ossontial tliat the surgeon be at least reasonably sure of the existinji' conditioiis hcfoi-e an attempt is made at the reduction of a luxated hip. In fracture of the neek witli impaction, the lower extremity lies in a helpless attitude, shows some shortening and slight outward ]-otation. There is no abnormal fixation of the parts aside from that iJi'oduced b>- i-cflcx inusculai- spasm. Inward rotation is extremely rare in fracture of tlie femoral neck. The most connuon dislocation of the hip is the dorsal, in which adduc- tion and inwai'd rotation arc pronounced. The great majority of dislocations are on to the dorsum of the ilium or into the obturator foramen, and the characteristic de- formities a('comi);myiiig these displacements will suggest the con- dition when the case is first inspected. In dislocations it will usually be possible to palpate the femoral head, which is, of course, impossible in fractures of the neck. In dislocations, mobility at the hip is much restricted in contradistinction to the normal mo- bility seen in impacted fractures, and the increased mobility occur- ring in fractures of the unimpacted type. In dislocations crepitus is absent ; in fractures it can almost invariably be elicited. Dorsal dislocation with fracture of the acetabular rim, nuiy be quite diffi- cult to differentiate from fracture of the femoral neck. Crepitus may be present in either injury. In the former, motion is re- stricted as in all uncomplicated dislocations of the hip, while in the latter, it may be restricted or abnormally increased. Reduc- tion of a simple doj-sal dislocation is only accomplished by some system of manipulations, such as Bigelow's, while on the other hand, displacement accompanying fracture of the acetabular rim may be reduced without difficulty by simple traction and counter- traction, and there is a strong tendency towards spontaneous re- currence of deformity. In fractures it is almost always possible to rotate the thigh, and with the finger placed on the trochanter, the arc described by the femoral neck can be ascertained and compared with the uninjured side, and the surgeon can estimate whether or not the center of this arc is in the acetabulum. In dislocations the fixity of the thigh precludes anything but the slightest rotation. When doubt exists as to the nature of the injury the X-ray should be employed to clear up the diagnosis. Treatment. — The first indication of treatment is the reduction of the displaced head. The method of accomplishing this purpose DISLOCATIONS 01^ THE HIP 525 must, of necessity, vary with the type of dislocation present. The object in all instances is to cause the head to retrace the course taken by it in leaving the cavity. All manipulations must be performed with due appreciation of the strength and attachments of the ilio-fe moral ligament (see ''Anatomy," page 516). It should be distinctly understood that the common, dorsal dislocation can- not be dragged back into position by simple traction and counter- traction without the employment of excessive and unnecessary force and rupture of the ilio-femoral ligament. Reduction must be ac- complished by manipulation. Fig. 581. — Reduction of the common backward dislocation of the hip (see text). In Bigelow's method the thigh is tlexed to a right angle, adducted, rotated inward, lifted, circumducted outward and extended. The lifting of the thigh is the essential step in the reduction of backward dislocations and may be aided by counter-pressure with the unbooted foot as shown in this plate. In Bigelow's method of reducing an- terior luxations the thigh is flexed to a right angle (as shown in this illustration), abducted, rotated inward, adducted and extended. This modification is readily under- stood if the position of the head in anterior luxations is kept in mind. In reducing a dorsal dislocation, the first step consists in flexing the thigh to a right angle, which move relaxes the Y-ligament. Traction is then made in the line of the axis of the semi-flexed femur, which draws the head of the bone up on to and over the acetabular rim. Outward rotation is then performed, and the thigh allowed to gradually assume the horizontal, or extended position. The head of the bone should slip back into the socket as outward rotation is commenced, or during the first part of extension. The most essential part of this manipulation (Bigelow's method) con- sists in drawing the femoral head forward from the dorsum of the ilium over the acetabular rim. 526 FRACTURES AND DISLOCATIONS Fig. 582. — Stimson's inetliod of redufiiij; in>st(M'ior lu.xations. Tlie weight of the lower extremity pulls in the direction indicated by the arrow and this alone may be sufficient to effect reduction. Downward pressure, however, with the hand, as shown, will render the method more certain. (See text.) Fig. 583. — Author's modification of Bigclow's nietliod. The thigh is "lifted" (raised sky-ward) by the surgeon's shoulder while counter-pressure is exerted on tlie anterior- superior iliac spine. Tlie opposite liand exerts direct pressure on the trochanter and prevents it from riding around the rim of the acetabulum. (See text.) It has been the author's experience that difficult cases may be handled in this way after the nnmodified Bigelow's method has failed. An anesthetic is often essential to the reduction of dis- locations of the hip, especially in well-muscled persons. DISLOCATIONS OF THE HIP 527 The author has found the following original method of accom- plishing this result successful in instances in which the above ma- nipulation failed. With the hip and knee flexed at right angles the surgeon places his shoulder under the bend of the knee, one hand is placed on the anterior superior iliac spine, while the oppo- site hand grasps the trochanter, and exerts pressure in the desired direction. In this position forward traction is made by raising the shoulder, direct manipulation is had by the hand on the tro- chanter, while counter-traction is exerted through the hand resting on the iliac spine. During this manipulation an assistant should securely hold the patient's ankle, thus fixing the lower leg. Ac- cording to instructions issued by the surgeon to his assistant during manipulation the ankle may be carried away from, or toward the Fig. 584. — Allis' method of securing tlie pelvis to the floor while reducing luxa- tions of the hip. Three staples are driven into the floor and the pelvis secured as shown. median plane, thus producing inward or outward rotation of the thigh as desired. In this way the head may be controlled, and forced up on to the slope of the acetabulum, rather than allowing it to ride about the margins of the rim. (See Fig. 583.) No originality is claimed for the principles involved in this manipu- lation since it is only a modification of Bigelow's method. AYhen, however, difficulty is experienced in forcing the head of the femur over the rim of the acetabulum this manipulation will be found much more efficient than the regular Bigelow's method. Stimson's method is as follows: The patient is placed face downward on a table. The injured thigh is allowed to hang over the edge of the table at a right angle, while the uninjured extremity is maintained in the horizontal position by an assistant to steady 528 FRACTURES AND DISLOCATIONS the pelvis. The surgeon tlien flexes the knee, and the weight of the knee, with the muscles relaxed, is said to be sutidcient to ett'ect reduction. Slight rotation and downward traction will assist in accomplishing the return of the head to the acetabulum. This method works nicely in some cases, though it is by no means as efficient as Stimson's method of effecting reduction in dislocations of the shoulder. All of the above methods are based on the same principles: namely, bringing the head opposite the capsular rent by flexion and rotation of the thigh, and then forcing the head over the acetabular rim and through the capsular rent by traction in the line of the axis of the femur. Allis fully appreciated the value of fixation of the pelvis and advises having it secured to the floor by means of a sj^stem of screw eyes and bandages (see Fig. 584) or else by means of assistants. This however will not be necessary if the author's modification of Bigelow's method is employed. The reduction of anterior displacements is accomplished by the same principles as already described, although the difference in the position of the head will necessitate different manipulations to bring the head opposite the capsular rent. The ilio-pectineal dislocation and its variations along the hori- zontal ramus of the pubis are reduced as follows : extension is made to bring the head downward as far as possible so that flexion can be accomplished. The thigh is then flexed at a right angle with the body, while direct pressure is made upon the head to prevent its slipping upward. Inward rotation and traction in the line of the axis of the femur are then performed to return the head to the socket. The last step in this manipulation is similar to that already described under dorsal dislocations. The obturator dislocation and its exaggerated form, the perineal type, are reduced in much the same manner as dorsal dislocations after the head has been brought opposite the capsular rim. The steps are : flexion of the thigh to a right angle, traction in the line of the axis of the femur, and then, abduction and outward ro- tation. The limb is then extended. Central dislocations of the hip are reduced by outward traction on the upper end of the thigh while the knee is fixed. The condi- tion is more properly a fracture than a dislocation. Buck's exten- DISLOCATIONS OF THE HIP 529 sion is indicated for from six to eight weeks and direct outward traction on the upper portion of the thigh should he maintained, according to the Ruth-Maxwell method, to prevent the muscles attached to the upper femur from pulling the head through the acetabulum into the pelvis. (See "Ruth-Maxwell method," page 545.) The strength of the muscles and the pain accompanying manipu- lations renders an anesthetic essential in the reduction of hip dis- locations. Operative Treatment. — Nearly all dislocations of the hip can be reduced by proper manipulation under anesthesia, though occa- sionally it is impossible to return the head to the socket, unless recourse is had to operative methods. A vertical incision in the region of the trochanter can be so made as to expose the parts involved. When inward rotation is present the incision should be made a little behind the trochanter; when outward rotation is present the incision should be anterior to the trochanter to prop- erly expose the head and neck. A¥ith the parts opened, the cap- sular rent and the course taken by the head after leaving the cavity of the acetabulum may be readily recognized, and by the proper manipulation, the head may be made to retrace its course back to the socket. Obstructions to reduction are to be removed when present. With the head again in the acetabulum, the capsular rent should be sutured, muscular structures approximated and the skin incision closed. Old, unreduced dislocations are the ones most frequently de- manding operative reduction. When the head of the bone has been out of the socket for some time, fibrous tissue forms about it in such a manner that partial restoration of function results. The action of the thigh, however, is always more or less impaired be- cause, if for no other reason, the upper end of the femur is "off- center" with relation to the muscles of the hip. Partial or com- plete healing of the capsular rent often renders it impossible to accomplish reduction by simple manipulation. If some months have elapsed since the accident the acetabulum may become filled with fibrous tissue, which must be removed with a heavy curette or chisel before the head of the bone can be made to fit it. The joint is approached through a lateral, vertical incision, as already de- scribed, which varies somewhat with the type of dislocation present. 530 FRACTURES AND DISLOCATIONS Contractiiivs in tlic tliigli nmsclos soini^inios nocessitnti' tiaiisverse cutting of eitlifi- tciulous or niuscU's before tiie head of tlie bone ean be retui-ned to llie socket. After- Treatment. Following reduction of a recent dislocation llie pal lent .slioidd be kept at rest in bed for a period of from two to four weeks, according to the age of the individual and the sever- ity of the condition. JMassage and passive motion are of service in maintaining the muscular tone of the lower extremity. In the performance of passive motion, however, abduction should be avoided, since this is the jiosition in which the head probably left the cavity. Central dislocations and dorsal dislocations compli- cated by fracture of the acetabular ring require Buck's extension apparatus to maintain reduction. In addition central dislocation calls for lateral traction of the thigh. These appliances should be kept in use for a period of six weeks. During the after-treat- ment the weights employed in the traction apparatuses may be reduced as the muscular spasm grows less. The resumption of function should l)e gradual after the patient has recovered suffi- ciently to leave his bed. He should be instructed to particularly avoid any position of the thigh similar to the attitude in which dislocation occurred. Prognosis. — The outlook in uncomplicated dislocations of the hip is good if reduction is accomplished early and sufficient time allowed for the repair of the parts before function is resumed. Central dislocation of the hip is a much more serious condition, since it includes fracture of the pelvis and may be accompanied by injury to the pelvic viscera. Proper operative procedures are usually fol- lowed by improvement of function, though it is seldom possible to secure a perfect restoration, if the head of the bone has been out of the socket for any considerable length of time. CHAPTER XXXVII. FRACTURES OF TPIE UPPER END OF THE FEMUR. Surgical Anatomy. — The upper end of the femur has three accessory centers of ossification ; one for the head, one for the greater, and one for the lesser trochanter. They all join the diaphysis at about the eighteenth year. Epiphyseal separations, however, are extremely rare in the upper end of this bone, except as a chronic condition in children, which is known as coxa vara. (See "Injuries to the Femoral Neck in Children," page 555.) The structure of the upper end of the femur, including the relation of compact and cancellous tissue, is of importance in explaining many i'ig. 585. Figs. 535 and 586. — Coronal and nearly horizontal sections of the upper end of the femur showing the relative distribution of cancellous and compact tissue. H., head of femur. T., trochanter major. (Preston — Surg., Gynecol, and Obstet., Feb., 1914.) of the clinical conditions occurring in fractures (see Figs. 585 and 586). The upper end of the bone is composed of wide-meshed cancellated tissue, enclosed in a layer of compact structure which grows heavier as the shaft is approached. Closer examination of the cancellous tissue shows that it is disposed in two sets of planes, the socalled "tension planes" and "pressure planes." The former run upward from the outer portion of the shaft into the trochanter, and arch over into the neck and head ; the latter ascend from the 531 532 FRACTURES AND DISLOCATIONS inner side of the shaft and pass into the head, while othei*s arch over to the. great troelianter. These planes are simply an arrange- ment of the cancellous tissue whicli renders the same amount of bone more capable of withstanding the pressure and tension to which the femur is subjected by use. The calcar femorale is a thickening in the internal structure of the neck which strengthens the angle of junction between neck and shaft. The neck joins the shaft at an angle of about 127 degrees, al- though variations occur between the limits of 121 and 14-1 degrees. In children the angle is more obtuse, while in old age it approaches the right angle. The great trochanter is often traversed by a continuation of the compact tissue of the posterior surface of the neck, and although this tends to strengthen the posterior aspect of the neck, yet the arrangement is not as strong as that found anteriorly. Numerous muscles are attached to the upper end of this bone, which influence the relative positions of the fragments in the pres- ence of unimpacted fracture of the neck, liaising of the lower fragment or, in other words, shortening of the lower extremity, is brought about by the action of the ham-string muscles, the adductor group, the glutei, rectus, sartorius, ilio-psoas, tensor vaginae femoris, pectineus and gracilis. Eversion of the lower extremity is the result of the weight of the thigh, the center of gravity being ex- ternal to the articulation of the hip. Eversion, in impacted cases, is due to the manner in which the base of the neck is driven into the trochanter and the fact that the anterior portion of the femoral neck is stronger than the posterior. In addition to the action of the pectineus and the adductor muscles, it will be observed that all the glutei tend to i)roduce outward rotation. Fractures may occur in the neck, close to the head, midway be- tween the head and the great trochanter, or at the base of the neck where it joins the shaft. The last named position is by far the most common. In some instances the fracture may pass in such a manner that it involves the upper portion of the femoral shaft as well as the neck. Fractures have been divided anatomically ac- cording to the position of the break with relation to the capsule. Intra-capsular fractures show a much stronger tendency toward non-union than those outside the capsule. Surgically, however, this distinction is not of great value, since it is almost impossible in a given case to say whether the fracture is within or outside of FRACTURES OF UPPER END OP FEMUR 533 the ligament. Moreover, post-mortem findings have demonstrated the fact that in the majority of instances in which the neck is broken, the line of fracture is both intra- and extra-capsular ; that is, the fracture passes through the femoral attachment of the liga- ment. The more practical distinction is vv^hether or not the frac- ture is impacted. Impaction consists, as a rule, in the base of the neck being driven into the substance of the great trochanter. If the neck is viewed from above one reason for the frequency with which eversion accompanies impaction will be apparent. The an- terior surface of the neck is almost straight and flush with the front edge of the trochanter, thus offering solid support to the anterior portion of the trochanter in the presence of direct vio- lence. The posterior surface of the neck is much curved and does not come flush with the posterior margin of the trochanter. This results in the posterior portion of the trochanter being much more poorly supported than is the anterior, and when direct violence is applied in this region of the bone the posterior aspect of the neck will be more likely to give way than the anterior. The result is, manifestly, eversion when impaction of the femoral neck occurs. The continuation of the compact tissue of the posterior surface of the neck into the trochanter, previously mentioned, tends to strengthen this portion of the bone ; yet this bony tissue is variable and even when present is not sufficiently heavy to increase the strength of the posterior aspect of the femoral neck so that it equals that found in the anterior portion. When the ring of compact tissue surrounding the junction of the neck and shaft is fractured, the neck crushes into the cancellous tissue of the trochanter with comparatively little resistance. The surgeon should know the bony landmarks in this region to be able to properly diagnose and treat fractures of the femoral neck. The crest of the ilium is subcutaneous throughout, the great trochanter can be recognized both by inspection and palpation, and the tuberosity of the ischium can be readily felt. The rela- tive positions of the anterior superior iliac spine, tuber ischii and trochanter major should be known under normal conditions in order that the variations occurring in fractures may be recognized. If a tape is stretched between the anterior superior iliac spine and the tuberosity of the ischium it will correspond to Nelaton's line (see Fig. 587). Normally Nelaton's line about touches the top of the great trochanter. In fracture of the femoral neck with short- 534 FRACTURES AND DISLOCATIONS t'liiiio:, the to]) of till' trocliaiitcr rises above this lino. Tlie fascia lata, composed of heavy lihroiis tissue, is attacheii above to the outer lip of the. iliac crest, and below to the external tuberosity of the tibia. I'lidei- normal conditions this fascia is tense and otfers resistance when |)i('ssuri' is made between the iliac crest and tro- chanter: when IVactui-e or disease of tlu' femoral neck results in shoi'tenint:-. this portion of the fascia lata becomes lax, which con- dition may lie recognized by comparison with the opposite side. The rarifyinp: changes or osteoporosis occun-ing in old age affect the ciilii-e iiilei'iial sti'uctui'e o f the upper end of the femur, and tend to remove the calcar i'emorale, and the extension of the pos- terior surface of the neck which continues into the substance of the trochanter. In addition, the surface compact tissue becomes Fit;. 587. — Miipijin^;- mil uf J-!r> aiil'.s triangle ami Nc'lalon's li)U'. A line drawn from the anterior superior iliac spine to the tuberositj' of the ischium is known as Nelaton's line and should about touch the top of tlie great trochanter. (See Fig. 600.) A vertical line dropped from the anterior superior iliac spine to the table on which the patient lies and a vertical line extended upward from the top of the great trochanter form two sides of Bryant's triangle while the third side is formed by Nelaton's line. Bryant's triangle — X.Y.Z. In fractures of the femoral neck the distance Y.Z. is usually shortened. A.fi., the anterior superior iliac spine. S., Symphysis pubis. T.I., Tuber ischii. thinner and more brittle. These changes togetlier with the alter- ation in the angle at which the neck joins the shaft explain, at least partially, the frc(|uency of fracture of the femoral neck in the aged. Fracture of tlie head of the femur is an extremely unusual con- dition, only two or three cases having been reported. It is not an uncommon matter for fractures of the neck of the femur to involve the great trochanter, but isolated fractui'e of the trochanter is almost as rare as fracture of the head. The cases reported have been due either to direct violence or to muscular action. Isolated fracture of the lesser trochanter is also a rare condition. The re- ported cases seem to have been due to the action of the ilio-psoas. Etiology. — Fracture of the neck of the femur is essentially an accident of advanced life. Fractures of the femur constitute FRAOTITRTCS OF TTPPKR END OF FEMTTR 535 Fig. 588. 589. Fig. 588. — Impacted fracture of base of femoral neck. Fig. 589. — Old ununited fracture of middle of femoral neck with upward displace- ment of lower fragment. The upward displacement of the femur is plainly visible and the manner in which the fascia lata becomes lax between the trochanter and iliac crest is readily appreciated. Fig. 590. Fig. 591. Fig. 590. — Impacted fracture of neck of femur. Fig. 591. — Fracture of femoral neck with usual deformity- -raisiug of trochanter. 536 FRACrrRKS A\l> DISL(irATIONS Fig. 592. — Fracture of rim of acetabulum. Upper arrow points to line of fracture while the lower indicates the detached fragment. Deformity controlled by Buck's exten- sion. Fig. 593. — Fracture of a small portion of the great trochanter with separation of the fragment. Result of muscular action. A condition which might readily be over- looked and considered as a "sprain" if the Xray were not employed. Fig. 59 4. Fig. 595. Fig. 594. — Fracture through femoral neck about midway between head and tro- chanter. Deformity overcome by Buck's extension. Fig. 595. — Fracture through base of femoral neck with splitting off of lesser tro- chanter. FRACTURES OF UPPER END OP FEMUR 537 about six percent of all fractures, and fractures of the neck of the bone make up from one-third to one-fourth of all femoral frac- tures. More than half of the fractures of the neck occur after the sixtieth year. They are more common in women than in men. Symptoms. — The physical signs and symptoms in fracture of the femoral neck vary according to whether or not impaction exists. In the unimpacted form the patient is unable to stand on the in- jured member. In fact the lower extremity lies in an entirely helpless attitude. Pain is constant, and increased on motion. The limb is usually completely everted so that the outer surface of the foot rests flat on the bed. The great trochanter is raised above Nelaton's line, and the fascia lata between the trochanter and iliac crest is found relaxed when compared with the opposite side. In- version of the limb, though extremely rare, may be present, instead of eversion. Crepitus and mobility may be elicited, but all manip- ulation should be most gentle and guarded, lest impaction, if present, be broken up. Rotation is particularly likely to loosen the impaction. The limb is shortened, though seldom more than two inches. The shortening is usually less pronounced immedi- ately following the accident than it is at the end of twenty-four or forty-eight hours. Traction upon the foot lessens the shortening, though recurrence is prompt when the foot is released. A slight fullness in the upper portion of Scarpa's triangle is usually noted. When the fracture is impacted most of the above described symp- toms are present though less pronounced. Slight or moderate eversion is usually noted, and some shortening exists though it is by no means as great as is commonly seen in unimpacted cases. Crepitus is absent. Pain is usually present, though the degree is quite variable. Loss of function is by no means as constant and pronounced as in unimpacted fractures. In fact, a patient with a firmly impacted fracture of the femoral neck may be able to walk a considerable distance. This incomplete loss of function has not infrequently been the cause of incorrect diagnoses, the condition having been mistaken for a "sprain." Impaction of the fracture produces some shortening of the femoral neck, which may some- times be recognized in the shorter arc described by the trochanter when the thigh is rotated. This shortening, however, is often so slight that it is difficult of recognition, and since rotation is so likely to break up impaction it will usually be best to pass lightly over this symptom. The history given in the usual ease of frac- 538 FRACTURES AND DISLOCATIONS Kii;. ji)t). — liiipai-lcd riiiitiu inpseiit and cversion is diily r of Ihr lIKldclMll \'rrv sli-iil (Ir-n if sliorten- Fit;. 597. — Iiiip:u-ted I'ruituie of tlie neik of tlic fciiuir in an old man. The limb is helpless. Very slight eversion and shorteninK pre.sent. There is no appearance of twisting of the thigh as seen in Fig. 626, nor is there cany thickening of the thigh as seen in Fig. 598. Riintgenogram shows fractnre of the femoral neck. It is this type of case which is so often overlooked and diagnosed as a "sprain" esijecially if the pa- tient is able to walk. Fig. o'JS. — Fracture of riglit femur through great trochanter. Note thickening of the thigh in its upper part and the evsrsion of the lower extremity. Compare the levels of the two knees which are directly in front of the camera. Right thigh slightJy shorter. Picture taken a few minutes following the injury. Fig, 599. — Fracture just below the great trochanter. Note the eversion and shortening. PRACTTIRES OF UPPER END OF FEMUR 539 ture of the femoral neck in elderly persons is one of slight trauma, such as a misstep, a twist of the thigh, or a fall in walking across the room. It is sometimes difficult to ascertain whether the fall pro- duced the fracture, or whether the fracture was spontaneous and resulted in the fall. Diagnosis. — The deep position of the femoral neck, surrounded by heavy muscles and fasciae renders palpation of this portion of the bone extremely difficult. The diagnosis is based on the symp- toms just described, together M'ith a careful examination of the lower extremity including mensuration and comparison with the uninjured member. The X-ray is invaluable in diagnosticating Fig. 600. — Drawing a line lietween tlie anterior superior iliac spine and the tuberosity of the ischium to determine the relative level of the greater tuberosity. Nelaton's line. (See Fig. 587.) the presence of fracture ; in fact it is the only means of determining accurately the details of the injury. Nelaton's line and Bryant's triangle (see Fig. 587), should be mapped out and the position of the trochanter determined with relation to the bony landmarks of the pelvis. (See ''Anatomy," page 533.) The case should be carefully inspected for the purpose of recognizing deformity, and accurate measurements should be made before manipulation in any form is attempted. The distance from the anterior superior iliac spine to the tubercle of the femur, and then to the internal malleolus should be taken with a steel tape, and compared with the distances between the corresponding bony prominences of the opposite lower extremity. In taking these measurements the patient should be placed squarely in bed so that 540 FRACTURES AND DISLOCATIONS a line (li'awii through the aiitci'ior su])('i'ior iliac spines will l)e at I'iufht aiigk'.s to the .si)inal coluiiiii. In other words the pelvis slioukl not be "tipped' "at the time the measurements are being taken. Fracture of the femoral neck must be differentiated from dislo- cations of the hip, fi-aetui'e of the aeetabuluiii willi oi- without dis- i. r:^ Fig. 601 and 602. — Mea.suring the length (if the Tower e.xti'emity from the anterior supe- rior iliac .^pine to the tip of the internal mal- leolu.s. The legs should be parallel and the pelvis should not be tipped. In other words a line drawn through the anterior superior iliac spines should be at riglit angles with the median plane of the body. (See Pigs. 603 and 604.) placement of the head, fracture of the pelvis, and fracture of the femoral shaft. The characteristic attitude as- sumed in luxations of the femoral head, the restricted mobility and, in some instances, direct palpation of the displaced head, should serve to distinguish dislocations of the hip from fracture of the femoral neck. In fractures of the fem- oral shaft the position occupied by the great trochanter will be found normal and the point of preternatural mobility will be lo- cated below it. When the thigh is rotated the trochanter will fail to follow the shaft. Fracture of the acetabular ring and certain Fi^-. I, FRACTURES OP UPPER END OF FEMUR 541 pelvic fractures are occasionally difficult to differentiate from fracture of the femoral neck unless a Rontgenog:ram is made. In fact the X-ray should be emi)loyed in almost all injuries about the Fig. 603. Pig. 604. Fig. 603. — Measurements of the lower extremities talcen with the legs parallel and the pelvis up-tipped. Fig. 604. — Shows the effect of tipping the pelvis when these measurements are being taken. hip. Inspection, palpation and mensuration may enable one to determine the seat of the lesion but it is impossible to ascertain the exact details and nature of the fracture without the aid of an X-ray plate. Moreover one cannot be sure, prior to examination, Fig. 605. — Picture taken lo sliow liow the fascia lata becomes lax between the iliac crest and the trochanter when tlie latter is raised through fracture or disease. whether or not impaction exists, and it is much better to refrain from manipulation altogether, rather than to break up an impac- tion. The surgeon who is unaccustomed to dealing Avith these 542 FRACTURES AND DISLOCATIONS cases had better submit the patient to an X-ray examination before any extensive manipuhitiou is attempted. Treatment. — Tlie treatment of fracture of tlie neck of the fennir dei)ends, first on the age and conditiou of the patient, and next on wliether or not the fracture is impacted. As far as the fracture itself is concerned, recumbency is a prime requisite, but the fact that old persons are unable to stand prolonged confinement to bed, makes it necessary to adopt some form of anibulatoi-y treatment or one in "which the patient may be raised to the sitting position. AVhen the neek of tlie fcmnr is fractured in elderly persons the treatment is often more a question of the prevention of compli- cations, such as hypostatic pneumonia, than complete restoration of function in the injured member. There are at the present time four recognized methods of treat- ing fractures of the hip. They are: recunibency luith traction and counter-traction, the plaster cast, the ambulatory splint and open treatment. Each form of treatment has its modifications, and com- binations of these methods are not uncommon in the treatment of fractures of the femoral neck. None of them is ideal ; they all have their advantages and their drawbacks. Each case should be carefully considered and the method or combinations of methods best suited to the case in hand should be adopted. In selecting the mode of procedure to be followed the surgeon must consider his surroundings and the available facilities as well as the age and condition of the patient. If the patient is strong enough to remain in bed during the process of repair the fracture may be treated by Buck's extension and the long side splint. It is essential that the bed be firm and unsagging. If a fracture bed cannot be obtained tlie ordinary bed may be made more rigid by placing boards under the mattress to prevent sagging. Buck's extension is applied as shown in Figs. 606 and 607. The lower extremity is soaped, shaved, sponged with alcohol and thoroughly dried before the adhesive plaster is applied. The wooden spreader below the foot should be broad enough to keep the adhesive plaster from touching and irritating the ankles. The weights employed should be suffi- cient to control the muscular spasm and will vary with the build of the patient. Greater weight will be required during the first day or two than is necessary later when the muscles have been tired out by the continuous pull of the extension apparatus. From ten FRACTURES OP UPPER END OF FRMIJR 543 V\iX. GOr,. Sllnws on the lower extreinily (llicsivc lllMst.M- lipiilicd Buck's extt'iLsiuii. lo secure longitudinal traction Pig. 607. — Shows Buck's extension completed. The strips of adhesive have been fastened to the spreader, and rope puUey and weight attached. The spreader consists of a small square piece of light board with a hole drilled through its middle for the attachment of a light rope. Its purpose is to prevent the adhesive plaster from coming in contact with the skin over the malleoli and to act as an equalizer so that the pull will be the same on both strips of adhesive. (See page 542.) bed, Fig. 608. Fig. 609. Pig. 608. — A convenient form of weight to be used with Buck's extension. Fig, gp9.— A good adaptation of the pulley to be attaehecl to the foot of an iron 544 FRACTFRES AND DISLOCATIONS to twenty poiiiuls may l)e advisable during the first few days, but later in the treatment six or eight pounds will usually be all that is necessary tc steady tlie i)arts and overeome the increased mus- cular tone. The i)atient will be more comfortable with a proper Aveio-ht than with too much or too little. Counter-extension is ob- tained by raisinw the foot of the bed eight, ten or even fifteen inches, according to the weight used. AVith the extension apparatus J- A Fig. 610. Fig. 611. Fig. 610. — Long Tsplint used in the treatment of fractures of the neck or shaft of the femur. A strip of wood about one foot in length may be nailed in the angle of the splint to prevent the bed clothes resting on the foot. This will obviate the neces- sity of using a cradle. (See Fig. 708.) Fig. 611. — A. shows Bucks extension applied and T-splint in position with appro- priate padding. B. shows the padding bandaged to the splint and the latter secured in position by means of strips of adhesive and body swathe. in place a long side splint is applied, the upper end extends to the eighth or tenth rib and is secured to the trunk by means of a body swathe. The thigh and leg are secured to the splint by means of bandages or adhesive plaster. If a cross-piece is attached to the low'er end of the splint it will render the whole more steady and secure. In unimpacted cases particular care should be taken to correct eversion. This can be nicely accomplished by transverse strips of adhesive passing under the thigh and over the side splint FRACTURES OF UPPER END OK FEMUR 545 to which they are fastened. If the fracture is impacted, extension and counter-extension should be applied with caution lest the im- paction be broken up. Enough weight, however, should be used to control the muscular spasm which is capable, in some cases, of breaking up the impaction, if not counteracted by the extension apparatus. Sand bags on either side of the limb may be used to advantage instead of the splint, especially in impacted cases. Ex- tension and counter-extension is one of the oldest methods of treat- ing fracture of the hip. The fixation secured in this manner is not as perfect as that obtained by the plaster cast or by one of the metal splints to be described later ; yet excellent results have followed its use. This method is particularly serviceable during the first week or ten days following the accident. It is often advisable to substi- tute some other form of fixation (such as the brace or cast) after the acute inflammatory reaction at the site of fracture has subsided, and the shortening has been partially or completely overcome by the extension apparatus. During this initial period one can de- termine by palpation, mensuration and the X-ray the degree of reduction which has been accomplished by non-operative measures and the advisability of resorting to open treatment. The Ruth-Maxwell method is an elaboration of the above in which lateral traction is exerted on the upjDcr end of the femur in addition to longitudinal extension and counter-extension. The longitudinal traction is accomplished as already described. The outward trac- tion on the upi^er end of the femur is had by means of a sling passed about the thigh at the level of the perineum, and then by the use of a cord, pulley and weight ; outward and forward traction is exerted, as shown in Fig. 612. Counter-extension for this lateral traction is obtained by raising the same side of the bed a few inches. In unirapacted cases the lateral traction may be made to overcome the backward displacement of the upper end of the lower fragment. E version of the lower extremity can be corrected by placing most of the pull on the posterior arm of the sling about the thigh. AVhen used in this way the sling should be prevented from slipping about the thigh by securing it to the skin with ad- hesive. A number of advantages are claimed for this method: firstly, that the neck is maintained at a more nearly normal angle during the process of repair, secondly, that the patient may be raised to the sitting position without disturbing the fragments, and thirdly, that the use of the bed-pan is greatly facilitated. 546 FRACTt'RES AND DISLOCATIONS The advisability of employing this method is best determined in a given case, by ascertaining the degree of reduction which it ac- complishes as shown by palpation, mensuration and the X-ray. If in an unimpaeted case the apposition is improved by lateral trac- tion, this method is indicated. The plaster cast has been used with considerable satisfaction and may be varied to meet the needs of the case. It may be employed in a number of ways; the following three types of cast will be found the most important. Tilt' strai.uht cast is most often employed in middle aged pa- \ Fig. 612. Fis. 613. Fis. 612. — Diagram illustrating the principles employed in the treatment of frac- tures of the femoral neck according- to the Ruth-Maxwell method. Fig. 613. — Shows the proper distribution of sand bags to steady the lower extremity when the hip is fractured. tients; in old and feeble persons the cast is applied with the knee and hip flexed to about right angles so that the patient may be raised to the sitting position during the day ; and in children it may be applied with the thigh in extreme abduction according to the principles laid down by Whitman. The straight cast should extend from the waist to the toes and be properly lined wdth sheet cotton or some other material, to avoid irritation of the skin. If a union suit of soft, ribbed material is put on before the cast is applied we will have a very satisfactory form of lining. After the plaster has set and dried, the portion of the union suit not covered by the cast may be cut away. A FRACTURES OP UPPER END OF FEMUR 547 stomach pad should be placed between the cast and the abdomen the same as employed with casts of the trunk. Special recinforce- ments of plaster-soaked gauze, tin, or cypress wood should be used at the groin and behind the knee where the cast most frequently breaks. These reenforcements are best placed between the different layers of the plaster bandages as the cast is being applied. The knee should be in a position a little short of complete extension to avoid subsequent discomfort in the joint. The cast should be heav.y enough to stand the strain of the six or eight weeks of use to which it will be put during the after-treatment. This dressing Fig. 614, — Plaster cast for fracture of the hip applied witli the thigh in abduction. A strap passing from the body portion of the cast under the perineum will add to the security of the fixation. An even more secure form of cast is one which includes both extremities in abduction. accomplishes fixation very nicely whether recumbent or ambulatory treatment is employed. If used as an ambulatory splint the shoe of the opposite foot should have the sole built up as is commonly done with the Thomas splint. The ambulatory treatment should not be allowed in old persons unless the surgeon is satisfied that the patient is not too feeble to get about with crutches without the risk of further fall and injury. Old and feeble persons do not stand confinement in bed for a period sufficient to obtain union, on the other hand they are often unable to get about with the added en- 548 FKAt'TfUKS AND DlSl.OC'ATIOXS euinbrance of a hip splint or cast. In such cases the author has had considerahlc satisfaction witli the followinij,- original luctliod. The cdsl is appl'utl icilli IIk hlji (iikI Ihc knee flexed ul about right angles. In othei* wortls the injurinl nK'nil)er is encased in plaster in the attitude noi'uudly assumed when the jiatient is seated. Witli tlie lower t'xti'eunty in this position the patient can coiiit'oi'tably occupy an easy chair dui'iug the day and still rest well iu bed at night with the tiexed lower exti'eniity properly bolstered. If a Morris chair is employed in the treatment, the iiio\ahle l)ack may be raised during the day and the foot of tlie injured uicudjer prop- erly supported on a foot stool oi- i)illows. When night comes the Fig. 615. — Ciist of lower (■.\trcinit.\- and trunk applied witli tlu' tliijih and_ le^ flexed to right angles. This form of fast is of gi-eat advantage when the hip is frac- tured in elderly persons who are unable to stand the recumbent position. During the day the patient may be placed in the sitting position while at night he may lie on his back with the injured member properly bolstered. (See text.) back of the chair can be lowered so that the patient resumes the dorsal recumbent position, while the injured leg is raised and sup- ported by pillows, sand bags or some other arrangement. (See Fig. 615.) In this way he may enjoy good rest at night and still be in the sitting position during the day, thus avoiding the develop- ment of hypostatic pneumonia. If traction is made at the knee while the plaster is setting a fair degree of extension and counter- extension may be had during the after-treatment. This is made possible by the position of the leg which is at right angles Avith the thigh. The plaster cast man ^i<^ employed with tlie thigh in extreme ab- duction as practiced hy Whitinaii. This method is particularly FRACT[JRES OF UPl'ER END OP KKMIJR 549 applicable in children and is based on sound mechanical and ana- tomical principles. By abducting the thigh the lower portion of the capsular ligament is made tense and the fractured surfaces (if engaged at all) are thus forced firmly together. This position is maintained by means of a plaster of Paris spica of the thigh. In selected cases this method will be productive of excellent results and deserves a more extended trial in adults. It should never be taken for granted, in a given case, that good reduction has been accomplished because the thigh has been ab- ducted and fixed in this attitude. The position of the fragments should be verified by the X-ray. The reason that this method has met with such success in chil- dren is due firstly, to the fact that fractures of the femoral neck at this period of life are seldom complete, and secondly, that ab- duction with the fractured surfaces opposed and firmly engaged tends to prevent the subsequent lessening of the angle at which the neck joins the shaft. In other words, it prevents coxa vara. If the fractured surfaces are not engaged this method is valueless. The Thomas hip splint has been used with considerable success by some surgeons. The main drawback to this splint, and others employing the same materials and principles, consists in the cost and the difficulty of obtaining the services of some one competent to properly make and fit it to the patient at the time it is needed. The surgeon is not, as a rule, equipped for this work which should be done by an experienced blacksmith and leather-worker. In most of the larger cities there are makers of surgical instruments and orthopedic appliances who are thoroughly qualified to produce and fit a satisfactory splint, but in country practice it is often difficult to procure the desired apparatus on short notice. The splint is made of soft iron and consists of a main stem or bar of 3/16 by 5/8 inch material which extends from the chest to the ankle along the posterior aspect of the trunk and lower extrem- ity. To this main stem is attached a chest-band, a thigh-band and a calf -band as indicated in the accompanying diagram (Fig. 620). These bands are made of strips of soft iron % by one inch, on cross section, and are bent into position when the splint is applied. Different weights of material may be used according to the size and musculature of the patient, and the transverse encircling bands may be varied in position and number according to the nature of the case and the fixation desired. The main stem of the splint 550 FRArTTRES AND DTSLOCATTONS should follow tho c-urvt's of tlif Wndy mid lower extremity, and the points of juiH'tion between main slem and bands should be Hush, to avoid nndu.e local pressui-e and irritation. The entire splint should be well i)added and ])ound with leather and the anterior extremities of the horizontal bands connected by straps and buckles. By means of crutches and a built-up shoe for the opposite foot the l)atient, after some practice, is able to be up and aljnut. It often recpiires a number of trials before he becomes sufficiently sure- footed under these awkward circumstances, and the surgeon should see that he is properly attended to prevent falling. When ambulatory treatment is indicated, as is the case in old persons from the first, and in younger patients during the second half of the after-treatment, the Thomas splint has served well. If extension is required it may be had by means of adhesive strips applied in a manner similar to that shown in the use of Buck's extension (see page 543). The low-er ends of the longitudinal strij)s of adhesive are secured, under tension, to the calf bands of the splint. Fig. 616. — Authors screw plates iur internal fixation of fractures of the femoral neck. (See Figs. 617, 618 and 619.) The ambulatory pneumatic splint, as shown in Fig. 621, with the hip attachment, has the advantage of being adjustable, so that it can 1)6 used on ditferent cases, and is so constructed that it may be used for either hip. Extension is also provided for when needed (see Fig. 719). Operative Treatment. — The open method is indicated in non- impacted cases in which the fragments cannot otherwise be brought back into satisfactory apposition. Nailing and pegging the neck in place have been practiced for some years past but, because of the internal structure of the upper end of the femur, the end re- sults have not been as encouraging as might be desired. The cancellous tissue, through wdiicli the screw passes, crushes so readily that displacement following the operation is prone to occur. The FRACTURES OF UPPER END OF FEMUR 551 manner in which this takes place is indicated in Fig. 618. To avoid this result two screws or nails, placed at different angles have been used but the results following this method have been almost as uniformly inefficient as when a single screw is employed. A much more satisfactory method is that devised by the author in Fig. 619. Fig. 617. — Diagram of femur showing the common sites of fracture of the femoral neclj. {Surg., Oynecol. and Ohstet., Feb. 1914.) Fig. 613. — Diagram showing the manner in which the cancellous tissue crushes wlien the neck is subjected to the displacing action of the thigh and hip muscles, following operation with a simple screw or nail. (Surg., Gynecol, and Obstet., Feb., 1914.) Fig. 619. — Diagram showing the author's screw-plate in position. Angulation of the screw portion is prevented by the plate portion which secures a firm hold on the only available compact tissue in this region. (Surg., Gynecol, and Obstet., Feb., 1914.) which a modified Lane plate is employed, as shown in Fig. 619. By means of this screw-plate the compact tissue below the great trochanter is utilized to prevent the inner end of the screw portion of the appliance from being displaced downward. The head of the bone is thus hung on the end of the screw portion much as a hat is hung on a peg, the plate securing its hold on compact tissue. 552 FRACTURES AND DISLOCATIONS Before drilliiiir tlirony:li the troeliauter the surgeon should make sure of the i)roper alignment of the liead and neek. This can usually be accomplished by dull dissection along the neck outside the oai>sule. Following operation, external fixation apparatus sliould be employed to relieve the bone of as nuieh strain as pos- sible. Simple extension and counter-extension with the long side splint may be used, or the i)laster east applied. The east is, as a rule, preferable following operation on the hip or thigh and should be applied before the patient comes out of the anesthetic. Within forty-eight hours of the operation a window should be cut thi-ough the plaster to expose the region of incision. In operating on the neck of the femur the parts may be exposed by a vertical incision over the trochanter or an incision of the U-type may be employed. The best time for operation is at the end of a week or ten daj^s following the accident. When the open method is selected early in the condition because it offers better reduction and apposition of the fractured surfaces the results are usually satisfactory. When, however, operation is performed as a last resort when other methods have resulted in non-union or deformity the results are not nearly as good. In operating for non-union the fibrous tissue must be cut away and the fractured surfaces freshened and secured in apposition, preferably by the screw-plate just described. This procedure necessarily results in some loss of tissue and shortening of the neek. If the fracture is through the inner end of the neck, and the head is comminuted, it may be advisable to remove the fragments, round off the end of the femoral neck and rely on the formation of a new articular surface. Remarkably good results have followed resection of the femoral head. IMurphy has demon- strated the possibility of making a new femoral head and articular surface from a transplanted portion of the great trochanter, and of reestablishing the function of the joint following ankylosis. These operations, however, are rarely called for as a result of frac- ture of the femoral neck. Operative intervention offers little in the aged and is seldom called for in children. It offers most in the healthy adult, and is indicated in cases in which good reduction cannot otherwise be obtained, and in instances in which deformity or non-union with considerable loss of function has followed non- operative methods. After-Treatment. — The fact that the fragments have been placed in good apposition does not necessarily mean tliat they wdll remain FRACTURES OP UPPER END OP FEMUR 553 so and it should be the surgeon's greatest care during the after- treatment to see that the fixation apparatus employed is properly performing its function. Numerous adjustments will be needed during the process of repair. A weight of fifteen or twenty pounds may be necessary during the first few days but at the end of a week it may be entirely too much. If the patient is confined to bed the back and heels should be watched for signs of skin irrita- tion, and should they develop special care must be taken to keep the parts dry and relieved of pressure. The sheets should be clean, smooth and free from wrinkles and the patient should be frequently Fig. 620. — Diagrams illustrating the principles of the single and double Thomas hip splint. sponged and rubbed with alcohol especially in regions subjected to pressure. If a metal splint or cast is used the points of pressure should be similarly watched and treated if irritation develops. If the cast is employed it may be necessary to cut a window in it, if the patient complains of persistent cutaneous pain in a given region. The duration of the after-treatment depends on the progress of repair at the seat of fracture. It may be impossible to secure bony union in the aged and fixation may, in some cases, be prolonged indefinitely without result. In this type of case it is better to get the patient up and about after sufficient time has elapsed to give the fragments a fair chance to unite. Function will, of course, be 554 FRACTURES AND DISLOCATIONS imperfect but the i^atieiit will be better olf than if a prolonged, futile immobilization is carried out. The older the patient the less the probability of bony union and the slower it will be in forming, if it does occur. In ;i middle aged person union should be well advanced at the cutl of cii^ht or ten weeks but no wcij^fht should be Fig. 621. — "The Ambulatory Pneumatic Splint'' with hip attachment. borne on the injured member inside of thi-ee months. During the first eight weeks the hip should be immobilized, after this period gentle passive motion is advisable up to the third mouth, though all strain should be guarded against. Because of the varying rapidity in the process of repair seen at different ages and the different types of fracture encountered, no hard and fast rule can FRACTURES OF UPPER END OF FEMUR 555 be laid down regarding the length of fixation. ""I'lie most reliable information concerning the progress of union is to be obtained through the X-ray. Rontgenograms taken at the end of, say, eight, ten, and twelve weeks will show the condition of the fragments and the progress of repair, and will constitute the very best guide in the resumption of function. The patient's comfort during the after-treatment deserves much consideration, especially in elderly persons. The surroundings should be as bright and cheerful as possible. His friends should visit him frequently but should not be encouraged to stay long enough to weary him. Prognosis. — Fracture of the neck of the femur is a serious injury even under the most favorable circumstances. In the aged it is particularly dangerous because of the low vitality of the patient. They not infrequently suffer greatly from shock and confinement and are subject to complications which, in their asthenic state, may produce death. Bony union has for years been considered as de- pendent on whether or not the fracture was within the joint cavity. The correct conditions, however, are probably whether or not the fractured surfaces are in firm apposition. Under proper treatment union is to be expected in a healthy adult but in the aged it may or may not be obtained regardless of the treatment folloAved. Fibrous union means some impairment of function, yet a surprisingly useful hip may result even when there has been failure in bony union and some deformity exists. The surgeon, should never, even under seemingly favorable cir- cumstances, promise bony union. Injuries to the Femoral Neck in Children. — The epiphysis of the head joins the neck at about the eighteenth year, and the bony tissue of the neck is tougher and less brittle than in adult or ad- vanced life. These anatomical variations account for the clinical picture accompanying injury of the femoral neck in childhood. A green-stick fracture of the neck of the femur or an epiphyseal sepa- ration of the head of the bone (incomplete as it usually is) is pathologically and mechanically quite different from fracture of the femoral neck as seen in the adult or the patient advanced in years. Accordingly the symptoms and course of the ease are dif- ferent. In an incomplete fracture of the femoral neck the head of the bone is depressed and the neck approaches more nearly a right angle. This change in the angle of the neck increases the strain on it and further bending of the neck follows unless all weight- 556 FRACTURES AND DISLOCATIONS beariiijr, jar and strain are removed. In "starting" of the ep- iphysis the pathology is somewhat dift'erent, though the result is practically the. same. "When the epiphysis is ''started" it is dis- placed downward, and the fractured surface is only partially con- tacted with the end of the diaphysis. This downward displacement of the head is equivalent to a downward bending of the neck seen in green-stick fractures of tlie neck, and if the patient continues to use the member the result will be the same ; namely coxa vara. Either of these injuries usually follows severe trauma and after being con- fined for a short time in bed the patient is up and about although limping. The limp is thought little of at fii-st, but when this symptom increases instead of improving the surgeon's advice is sought. In some instances apparent immediate recovery takes Fig:. 622. — Diagrams to illustrate the development of coxa vara in a child following an injury to the hip in which the epiphysis is "started." A., normal hip in child about four years old. B.. same after injury which has startetl the epiphysis of the head and allows the trochanter to be displaced upward. C. change in angle of neck resulting from the altered position of the head. 7?., further change in the angle of the neck and raising of the trochanter, which result from the increased strain on the neck of the femur as it approaches the right angle. The elevation of the trochanter limits abduction by mechanical interference between the trochanter and the rim of the acetabulum. (After Whitman.) place, and months or even years later coxa vara develops with pro- gressive bending of the femoral neck and corresponding impairment of function. The immediate symptoms are slight, as a rule, and the condition may go unrecogTiized by the surgeon as well as the family. The apparent insignificance of the initial injury and the disastrous late consequences point out the necessity of the most careful ex- amination following injuries of the hip in children. If the lower extremities are carefully measured it will usually be found that the injured member is from one half to one inch shorter than its fellow, and there may be slight eversion of the thigli. The X-ray should be employed when there is a historv' of injury to the hip, even if only for the purpose of exclusion. If the case is seen soon after the initial injury it should be treated by rest in bed \rith Buck's extension applied and sand bags about the FRACTURES OP UPPER END OP PEMUR 557 injured member, or the long side splint employed. Tf deformity exists after the acute traumatic stage has passed the plaster cast should be employed with the lower extremity in abduction accord- ing to the principles laid down by Whitman. (See Fig. 614.) At the end of a month this dressing may be replaced by an ambulatory' hip splint with traction which is to be worn for a number of months, until union is solid and the danger of coxa vara passed. After this splint is removed the hip should be frequently examined by the X-ray to determine whether the strain incurred by use of the mem- ber is causing any change in the angle of the neck. If such is found to be the case the splint should be resumed with increased traction. If the case is seen only after the development of the secondary symptoms and coxa vara is present the traction am- bulatory splint should be employed and worn for a number of months. If the deformity and disturbance in function are pro- nounced it is well to consider the advisability of an osteotomy to restore the angle of the neck. CHAPTER XXXVIII. FRACTURES OF THE FEIMORAL SHAFT. Surgical Anatomy. — The shaft of tlie femur consists of a tube of heavy compact tissue which is capable of withstanding greater strain than the shafts of other long bones. The diameter of the shaft grows larger and the compact tissue thinner as the extremi- ties are approached. Ossification spreads from a single center which makes its appearance about the seventh week of foetal life. The shaft is slightly curved with the concavity backward. The linea aspera serves to strengthen the concave posterior aspect and affords attachment to the adductor muscles. In the upper third of the shaft this line divides into three ridges, while in the lower third of the bone it bifurcates to form the supracondylar ridges. The femoral vessels cross the internal supracondylar ridge under a fibrous arch in the adductor magnus and become the popliteal ves- sels. From the point where the artery pierces the adductor mag- nus to the knee joint, it lies in close relation to the posterior surface of the bone, and in fractures of this region the vessel may be injured by a displaced fragment. The nerve and vein lie more superficially in the popliteal space and are less subject to injury from the bone, than is the artery. The greater part of the three surfaces of the femoral shaft are taken up by the attachments of the three vasti muscles which, together with the rectus, make up the quadriceps extensor. Fracture of the shaft of the femur is usually attended by great shortening, which results from the con- traction of the powerful thigh muscles. The manner in which the fragments override will depend largely on the direction and nature of the break. In fractures of the upper third of the shaft, it is common to see the upper fragment displaced outward or outward and forward, while the lower fragment is drawn upward by the thigh muscles and displaced inward by the action of the adductor group. Outward rotation of the upper fragment not infrequently results from the pull of tlie ilio-psoas. A transverse fracture with the serrated surfaces engaged will, of course, allow only of angular 558 FRACTURES OP THE FEMORATi STfAKT 559 deformity as long as the fraetnred surfaces remain locked, but this condition is rare. Fractures in tl)e lower third of the shaft are Fig. 623 Figs. 623 and 624. — Anterior and posterior surfaces of tlie right femur with at- tached muscles. Ob. d G., Obturator internus and gemelli ; P., Pyriformis; G.Min., Gluteus minimus; Y.E., Vastus externus ; G.Med., Gluteus medius :" Q.F., Quadratus femoris; Ps., Psoas; Pe.. Pectineus; /., Iliacus; A.B., Adductor brevis ; A.M., Adductor magnus; V.I., Vastus internus; A.L., Adductor longus ; 0., Crureus or Vastus inter- medins; Bic, Biceps; S.C., Subcrureus ; (?., Gastrocnemius; PL, Plantaris. often accompanied by a backward displacement of the lower frag- ment as a result of the action of the gastrocnemius, the two heads of which are attached just above the condyles on the posterior 560 FRACTURES AND DISLOCATIONS aspect of tlio bone. The powerful action of the thi^rh muscles usually results in pronounced deforniit}^ and their l)ulk renders jialpation diflficult. Etiology.— Fractures of the femoral shaft constitute less than thiee jxreent of all fractures. Approximately one-fifth of the fractures of the femoral shaft occur in the upper third (not in- elu(lin?T the femoral neck), three-fiftlis occur in tlie middle third Fig. 625. — Traiisvt'i-se fracture ui the &hall ul the I'ciiuir witli uverriding and angular deformity. of the bone, while one-fifth is seen in the lower end. Fracture of the femoral shaft is the result of violence, direct and indirect and of muscular action, although the latter cause is probablj^ never responsible for fracture in a healthy bone. Twisting strains fre- quently produce the spiral or oblique fracture so commonly seen in the upper and middle thirds of the shaft, while direct violence more often results in transverse fracture of the lower third. All FRACTURES OF THE FEMORAL SHAFT 561 types of fracture, however, may be seen in any portion of the shaft. Symptoms. — Immediate and total loss of function is seen fol- lowing the accident, except in the green-stick type occurring in children. Pain is usually pronounced and the deformity is char- acteristic. The limb below the break is rolled, either inward or Fig. 626. — Fracture of right femur about twenty minutes after injury. Fracture caused by patient falling from first floor fire escape to the sidewalli. Violence trans- mitted through foot and leg. Note the shortening of the limb, the eversion of the foot and knee and the twisting of the muscles of the thigh. Fig. 627. — Case similar to the preceding about three and one-half months after injury. Fibrous union, deformity, loss of function. Fracture slightly oblique and about four inches below the great trochanter. Note the eversion, shortening, and wasting of the thigh muscles. Upper end of lower fragment is in contact with the lower surface of the femoral neck and united to it by fibrous tissue. Upper fragment abducted. Case operated. Incision on outer side of thigh, dense fibrous tissue broken up, ends of bone squared and wired together, most of the shortening and all of the eversion corrected. Function restored. Case first seen by author three and a half months after injury. outward (usually the latter), and the helplessness of the condition is typical. There is often considerable swelling at the site of frac- ture and in addition the thigh is actually thickened as a result of the overriding fragments and shortened muscles. The thigh is shortened according to the distance the fragments have overridden. The decrease in the length of the thigh can, as a rule, be recognized 562 FRACTURES AND DISLOCATIONS witliont tlie aid of the stool tape. Pain is greatly increased on manipulation. Abnormal mobility can nsnally be recognized as soon as the lower extremity is grasped and moved. Crepitus may be elicited if the fractured surfaces are in contact. The symptoms are, as a rule, ])i'onounccd and tlio shock coiisi(l(M-able. Spasm of the tliigh muscles is pi-eseiit and the result ing slioi'lening usually Fig. 628. — Fracture of left femur about one hour following injury. Lower end of upper fragment produces the prominence on the outer aspect of the thigh as indicated by the arrow. Patient assumes this position as a matter of choice. Leg much slu)rt- ened though this is difficult to determine in the picture as the opposite thigh is fle.xed. Fig. 629. — Fracture of the shaft of the femur at point indicated by arrow. Pro- nounced shortening with thickening of thigh at seat of fracture as a result of over- riding of fragments. Complete eversion below break. Flail-like condition recognized when the limb is manipulated. Upper fragment displaced anteriorly. Photograph taken ■within twenty minutes of injury. increases during the first twent^'-four or forty-eight hours, unless special preventive measures are employed in the treatment. Green-stick fracture sometimes occurs in children. In the pres- ence of this condition the s.ymptoms will be less pronounced, bowing of the femur will usually be apparent and lateral pressure on the thigh, in the direction of the bowing, will show an increased spring in the bone as compared with the uninjured femur. Diagnosis. — There is seldom any difficulty in recognizing fracture of the femoral shaft. The deformity, shortening, loss of function, abnormal mobility and crepitus render the diagnosis easy. The exact nature and position of the fracture, however, can only be FRACTURES OP THE FEMORAL SHAFT 563 learned by means of the X-ray or during opei-ation when the frag- ments are exjjosed. Even under anestliesia, |)ali)ation and jrianip- ulation aliord only an imperfect knowledge of the nature of the fracture. Fracture of the upper end of the femoral shaft miglit be confounded with fracture of the femoral neck, fracture of th(; rim of the acetabulum or fracture of the pelvis. The unaltered position of the great trochanter, its normal relation with Nelatoii 's line (see page 533) and the fact that it fails to rotate with the sliaft, will serve to differentiate fracture of the femoral shaft from the conditions just enumerated. Fracture of the shaft of the femur in the new-born is devoid of subjective symptoms and must be recog- nized by the physical signs. The less the thigh is manipulated the better : nearly all that can be learned by physical examination can be gathered by inspection alone, if the surgeon is observant. The deformity, helpless attitude of the limb, shortening, etc., and the history of the case should be sufficient evidence of the presence of fracture and its approximate location. Abnormal mobility and crepitus manifest themselves while the limb is being brought back into alignment incident to the application of Buck's extension and splints. If doubt exists, careful measurements of the two lower extrem- ities should be made and the same precautions are to be observed as already cited in fracture of the neck of the femur (page 539). The patient should lie straight in bed so that a line drawn through the two antero-superior iliac spines is at right angles to the median plane of the body and the lower extremities should be parallel. The usual deformity, however, with the lower extremity rolled out- ward, the thigh thickened and shortened and often angular dis- placement present, is, as a rule, too pronounced to require mensura- tion to establish a diagnosis. Moreover it will be most unwise to manipulate the thigh to bring it to a position which is parallel or symmetrical to its fellow, simply for the purpose of mensuration when the condition is already apparent through inspection alone. Treatment. — The treatment of fracture of the femoral shaft varies with the age and condition of the patient and the nature and position of the fracture. The emergency treatment and the care of the case during the first week are practically the same in all instances and will be considered first. The emergency treatment of these fractures is of importance in transporting the case from the scene of the accident to the 564 FRACTURES AND DISLOCATIONS hospital or lioinc. llospilnl facilities and suri'onndiiigs are of the greatest ndx'antiiL;!' in the |)i'()i)er treatnu'iit oL' fractures oi' the thigh aud the pnliciit slidiild I n ■ ;ul\ised of this fact at the earliest possible monicnl. Ill 1 raiispdi'l iii^ 1lic patient tlic tln^li and leg should be Fig. C30. — Diagram illustrating the manner in which lateral traction may be applied to bring the fragments into better position. Tlie appliances used in the treatment of fractures of the femoral shaft are similar to those employed in the treatment of frac- tures of the upper end of this bone. (See Figs. 606 to 612.) supported by some form of temporary splint to prevent further laceration of the soft tissues by the fragments. This may be accom- plished by means of a bed slat or some other similar piece of wood Fig. G31. — .\d,iust.il)h' inclined jilane \ised in the treatment of certain fractures of the femur. For otlier metliods of fixing the thigh in various degrees of flexion see Figs. 615, 632, 633, 650, 65], 652, 653, 654 and 706. which is bound or strapped to the lower extremity and trunk on the injured side. A blanket, sheet or towels may be used to secure the .splint in position. A short splint on the inner side of the thigh will increase the security of the dressing. A satisfactory emergency FRACTURES OF THE FEMORAL SHAFT 565 splint may be made with })roomsticks and a blanket. In moving the patient to or from tlie stretcher one; person should confine his entire attention to the injured member to prevent motion between the fragments, wliile assistants raise and move hiin. As soon as Figs. 632 and 633. — Showing the method of treating fracture of the shaft of the feniur in children by vertical extension. At the end of two weeks the extremity is low- ered to an inclined plane and treated in this position imtil union is complete. " The pa- tient IS secured to a Bradford frame by means of a band about the body. Fig. 634. — The Bradford frame. The frame is made of gas pipe and covered with canvas It is usually necessary to employ some means of securing the patient (especiallv a child) to the frame. (See Fig. 632.) » i- \ f . the patient is placed in bed a Buck's extension apparatus should be applied to control the spasm in the thigh muscles. Coaptation splints and a long side or T-splint should be employed in prepara- tion for the first week's treatment, during which time the traumatic reaction is to take place. 566 FRACTURES AND DISLOCATIONS Diiriiiuf tlio first week or ten days the usual ease of simple fracture of the tlii»rh is treated by means of Buek's extension, eoaptalion splints and the h)iit:- side splint, liiifk's extension and the long side or T-si)lint iiave already been desei-ibed under the treatment of fractures of the fenmral neck. ('oa})1ation splints are short, light splints suri'ounding lln' thiyli at the seat of fracture and ai'e often misusetl witii the idea of forcing the fragments together by means of lateral pressure. They serve a purpose in the treatment of these cases but their value has been greatly overestimated. They are fairly efficient in maintaining reduction after it has been accom- plished but have little or no effect in forcing displaced fragments back into position. If applied too tightly they are capable of doing considerable harm by interfering with the circulation or ))y forcing the nnisclcs against sharp fragments. The coaptation splints should be well padded and are best held in i)Osition by means of circular strips of adhesive ])laster. All the materials for the application of Buck's extension, together witii the side splint and coaptation splints should be at hand and ready for use before the parts are disturbed. It will usvially be best to have the patient anesthetized to relax the muscles. The thigh should be brought back into alignment with as little manipu- lation as possible. An attempt at accurate apposition of the frac- tured surfaces should be made at this time, yet reduction immedi- ately following the accident is usually only partially successful. This is because most fractures of the shaft are oblique or spiral, and although anesthesia relaxes the muscles, yet when the patient regains consciousness the spasm is almost sure to again displace the fragments, even though heavy extension is employed. As a rule the best that can be expected at this time will be an approximate reposition. Proper reduction can best be accomplished at the end of four or five days, or a week, when the extension apparatus has so exhausted the muscles that the displacing strain, resulting from local spasm, is practically negligible, when guarded by a heavy weight at the end of the extension cord. An accurate knowledge of the nature and position of the fracture is most valuable in attempting a iDermanent reduction, and for this reason an X-ray plate should be taken soon after the accident. By a study of the Rontgenogram and the symptoms of the case we are able to deter- mine whether ordinary treatment will give good results or whether operative intervention will be necessary to accomplish and main- FRACTURES OF THE FEMORAIj SHAFT 567 tain good reduction. In a simple transverse fracture it will often be possible to secure a satisfactory engagement without operation, but when the fracture is spiral or oblique, as is so frequently the case, it will usually be necessary to resort to the open method to obtain the best results. Non-operative treatment is reserved for those rare cases in which good reduction can be accomplished and maintained by manipulation and traction and immobilization, and in cases in which operation is contraindicated on constitutional grounds. If good reduction is possible without operation the case may be treated, until union takes place, with the apparatus just described : namely Buck 's extension, coaptation splints and the long side splint or the T-splint. After the traumatic reaction has sub- sided the cast may be employed instead of the above apparatus. The cast is usually applied with the lower extremity in the straight, extended position, but if the surgeon finds that some other position is more favorable to the retention of the fragments, he should employ whatever attitude is thus shown to be best adapted to the needs of the case. In any event the cast should extend from the waist to the foot and should be lined with sheet cotton to prevent irritation. The upper portion of the cast secures a firm hold on the pelvis while the lower portion immobilizes the thigh and leg. In fractures of the upper third of the shaft the upper fragment frequently shows a tendency to outward, or outward and forward, displacement and accordingly moderate flexion, or flexion with abduction, is often found to be the position favoring retention. This may be obtained by means of the double inclined plane, with extension from the knee in the line of the axis of the femoral shaft, or a cast may be applied with the hip slightly flexed, or flexed and abducted, with a corresponding position of flexion at the knee. In fractures in the lower third of the bone the lower fragment is often displaced backward by the action of the gastrocnemius, and when this occurs, flexion at the knee is the position in which the condition should be treated and the double inclined plane, or cast in flexion, are the appliances used. ( See Chapter XXXIX, ' ' Frac- tures of the Lower End of the Femur. ' ' ) These attitudes of fixation may favor the retention of fragments but are seldom really efficient in accomplishing good results. The fact that these positions are needed to favor reduction and retention 568 FRACTURES AND DISLOCATIONS usually means that the ease should be subjected to operation to aceoniplish really good apposition. In children under ten years of age, fractures of the femoral shaft are best treated by vertical suspension of the lower extremity, while the child rests on a Bradford frame in the recumbent position. A Buck's extension apparatus is applied as already described in the treatment of fractures of the hip, with this exception, the line of extension is vertical instead of horizontal. The cord passes through a pulley directly over the middle of the bed and on a vertical line with the hip. The lower extremity is thus maintained in a position perpendicular to the trunk. It is best to have the child secured to a Bradford frame, which greatly facilitates the after-care of the case and prevents the patient from moving about to the extent of disturbing the fixation. This position of vertical extension is maintained for about two weeks, after which the lower extremity is lowered to an inclined plane (about 40 degrees), and extension kept up in this position for another week. A plaster spica of the pelvis and lower extremity, or a hip brace, may then be applied and the patient allowed up and about with the aid of crutches and a high sole on the shoe of the opposite foot. The thigh should not be subjected to strain until the surgeon is sure of solid union, otherwise a bowing deformity may result. (See Fig. 632.) Fractures of the thigh in patients advanced in years present some of the same problems already described under the treatment of fractures of the hip in the aged (see page 547). Hypostatic pneumonia or bedsores and other complications may develop if the patient is long confined to bed. Accordingly some form of ambu- latory treatment should be adopted as soon as the shock and traumatic reaction have subsided. The Thomas hip splint, plaster cast, or "ambulatory pneumatic splint" with hip attachment may be used in getting the patient on his feet. In very old and feeble persons it is often best to employ the cast (see page 548) with the thigh and knee flexed so that they may sit in a chair during the day and rest in bed at night. In fractures of the femoral shaft in the new-born the thigh is best treated in complete flexion, being bound to the trunk in this position. The fcetal attitude is thus taken advantage of to secure immobilization. The thigh and abdomen are previously dried and powdered and a few layers of soft linen placed between them, before the thigh is fixed. FRACTURES OF THE FEMORATj .SHAFT 569 In fractures of the lower third with backward displacement of the lower fragment the double incline plane may be used instead of the plaster cast and is nuich more appropriate in the early part of the after-treatment, during the time the acute traumatic inflamma- tion is at its height. Operative Treatment. — A large proportion of fractures of the femoral shaft demand operative intervention if the best possible results are to be obtained. Fractures of the upper and middle thirds are usually of the spiral or oblique type and nothing, as a rule, will secure the fragments in accurate apposition except direct fixation following open reduction. In the lower third of the shaft it is more often possible to secure good reduction by non-operative treatment, yet fracture in this region often demands the open method. The shaft of the bone is usually best exposed through a longitudinal incision on the outer aspect of the thigh in the region of the fracture. With the fragments exposed, strong traction is made on the lower extremity and the serrated surfaces fitted Fig. 635. — The Nichols frame. An appliance of ^reat advantage in operating on fractures of the femoral shaft. A steady and powerful traction is maintained on the limb during the operation. together. They are then secured by means of wire or a heavy Lane plate. The Nichols extension frame is one of a number of appli- ances which are of value in exerting traction and countertraction during operation (see Fig. 635). Nowhere in the body is internal fixation subjected to greater stress than here in the shaft of the femur, and the material used should be strong enough to serve the purpose, pending the formation of bony callus. A good example of the fixation of a double spiral fracture of the middle of the femoral shaft with wire is shown in Figs. 636 and 637. ~Wlien wire is employed two points of fixation should be had to secure the proper leverage and to prevent angular deforrait}^ If the wire is passed circularly about the shaft it will often accomplish as much as if it were passed through drill holes in the bone. In encircling the shaft 570 FRACTURES AND DISLOCATIONS the instrument carrying the Avire should hug the bone closely to avoid injuring the femoral artery or one of its ])erforating branches uhieh, in the middle third of the shaft, lie in close relation with the internal hoi-dt-r of the bone. If a Liiuc ])late is used it should be heavy and long, ijrefcrably of the Sherman-lMerce type, and should be provided with six screw holes. When the fixation is completed UJU. Fig. 637. Fig. 636. — Double spiral fracture of femur with unattached fragment. X-ray p'.ate taken after everything in a non-operative way had been done to accomplish reduc- tion. Pig. 637. — Same case after operation. Fragments in accurate apposition with the result that the lower extremity shows no shortening. the thigh should be raised from the table and in this position it should be capable of sustaining the weight of the leg without giv- ing. The muscles should be brought together with a running suture of catgut and the skin closed with silk-worm gut or horse hair. A plaster cast should then be applied, after proper dressings have been placed on the wound and the lower extremity covered FRACTURES OF THE FEMORAIi SHAFT 571 with sheet cotton. The cast should extend from the waist to the foot, leaving the toes exposed, so that the condition of the circula- tion in the extremity may be watched during the after-treatment. Twenty-four to forty-eight hours following the operation a window should be cut in the cast, the wound inspected and gentle pressure Fig. 638 Fig. 639. Fig. 638. — Same case two j-ears following operation. Perfect restoration of func- tion. Fig. 639. — Same case six years after operation. Note the condition of the callus and wires, also the reopening of the medullary canal. made to express any dead blood which may have collected in the wound. In compound fractures of the thigh operative intervention is practically always indicated. The wound should be enlarged if necessary and all devitalized tissue trimmed away. When this has been done the wound should be washed with a few gallons of sterile salt solution and the muscles and skin accurately approx- 572 FRACTURES AND DISLOCATIONS iiuated (sec "Treatment of Coiiipoimd Fractures," page 789). After-Treatment. — Tlie duration ul' the after-treatment varies considerably with the accuracy of apposition and the age of the patient. Union will therefore take longer in non-operated cases tliau in eases which have been subjected to the open metliod (see "Ol)erative Treatment of Fractures," page 75-4). in a healthy adult, union will usuallj' have taken place in from six weeks to two months, although refracture may easily occur at this time if the limb is subjected to any considerable strain. In children union can usually l)e expected in from four to six weeks. In the aged union may be very much delayed and in some cases it may be impossible to obtain l)ony uiuon at all. No matter what line of treatment is followed the case should receive the most careful atten- tion during the after-treatment. The patient should be seen daily for the first few weeks. If the fracture is treated by extension and splints, frequent adjustments will be necessary to keep the patient comfortable and to maintain the fragments in proper position. During the first few days the weight should be heavy (usually about twenty-five pounds in the adult) to control the spasm in the thigh muscles which, at this time, is at its height. The w^eight should be graduallj" diminished as the muscles become exhausted and the spasm less active. Frequent measurements of the lower extremity should be made to determine the extent of the shortening and the influence of the extension apparatus in overcoming it. If the cast or ambulatory splint is used it will require adjustment from time to time and the parts with which it comes in contact should be care- fully watched for evidences of irritation. If, during the time the cast is being worn, the patient complains of persistent irritation in a given place, a window .should be made to determine the condition of the skin or to treat a sore if one has developed. Following oper- ative intervention the temperature chart should be watched for evidences of infection and the wound should be inspected within the first few days. Infection need not be expected, however, if the proper surgical technique has been followed out. If ambulatory treatment is not employed it is usuall}^ best to keep the patient in bed for a week or so following the removal of the splints. During this time massage and passive motion should be in.stituted. AVhen the patient is first allowed up no weight should l)e borne on the injured member until he is thoroughly adept with the crutches. The thigh should be inspected daily during the time FRACTURES OF THE FEMORAL SHAFT 573 he is beginning to bear weight on it and if the slightest evidences of bowing develop he should be again placed in bed and extension apparatus applied. It is advisable at this time to have an X-ray plate made to determine the condition of the callus. Prognosis. — Fracture of the femoral shaft is always a serious accident and the prognosis should be guarded. In unoperated cases shortening is the rule and angular or rotary deformity is not uncommon. If the shortening is less than an inch or an inch and a half, and the general alignment of the shaft is not changed, the result is said to be good. If the shortening is not greater than an inch and a half the tipping of the pelvis will compensate for the deficiency in the length of the lower extremity so that walking will be practically normal. Pain and weakness in the injured thigh are common following fracture of the femoral shaft and often persist for years. Little can be done to alleviate them. The more perfect the reduction the more complete and prompt will be the restoration of function. The results following the open treatment with internal fixation of the fragments are decidedly better than those following the non-operative method. It is often possible to secure union without shortening, even in spiral fractures, if recourse is had to operative intervention. If infection follows a compound fracture the outlook is often serious. With free drainage of the parts the danger is greatly reduced and bony union may follow. CHAPTER XXXIX. FRACTURES OF THE LOWER END OF THE FEMUR. ruder 1liis lu'adiiig are im-liKled the various fractures oeeurrinj^ in the lower end of the bone, some of which enter the joint cavity of the knee. Separation of the lower femoral epiphysis is also con- sidered under this heading instead of being taken up separately as is custoinai-y. Surgical Anatomy. — The lateral surfaces of the large expanded lower extremity of the femur are subcutaneous and can be palpated without difficulty. With the knee flexed the upper margin of the trochlear surface may be felt anteriorly. The two heads of the gastrocnemius are attached posteriorly just above the condyles. To the external surface of the outer condyle (outer tuberosity) is attached the tendon of the popliteus, and at the lower end of the external supracondylar ridge is the origin of the plantaris. In the notch between the condyles are attached the upper ends of the crucial ligaments. The popliteal artery lies in close relation with the posterior surface of the bone, from the point where it crosses the internal supracondylar ridge to the bottom of the intercondyloid notch. It may be injured in this position when fracture of the lower end of the bone occurs. The vessel is more often temporarily compressed than permanently injured, which fact accentuates the importance of early reduction. The popliteal nerve and vein lie more superficially than the artery, and accordingly are much less frequently injured by displaced fragments. The most common fracture of the lower end of the femur is trans- verse and a short distance above the condyles. Occasionally the lower fragment is split vertically, thus producing the typical T- or Y-fracture which enters the joint cavity. A more severe type of T-fracture is one in which the lower end of the shaft is driven into the lower fragment with considerable comminution and a vertical splitting into the intercondyloid notch. If it were not for the inter- condyloid notch the T-fracture would probably not occur. Either condyle may be broken off from the remainder of the bone. 574 FRACTURES OP LOWER END OF FEMUR 575 When force is applied to the knee in a lateral direction or when violence is transmitted longitudinally through the leg, the tuber- osities of the tibia play an important part in the pressure they may exert against the condyles of the femur. In like manner the pull of the lateral ligaments may result in fracture of a condyle when Fig. 640. Fig. 640. — Lateral view of tlie lower end of the femur. Fig. 641. — Coronal section of the lower end of the femur. the knee is subjected to lateral angmlar displacement. It is more common for the lateral ligaments to tear away only their bony attachments on the femoral tuberosities. This condition is usually represented by a portion of the surface compact tissue, together with, gome of the underlying cancellous bone, remaining attached to 576 FRACTURES AND DISLOCATIONS the ligament wliieli is torn away ami disijlaced from the tuberosity. This type of fraetui't^ is more i)roperly a complieation of siihluxa- tions or "sprains" of 1he knee, and will he considered under "Dis- locations of the Knee." \)i\ffe 613. The epiphyseal cartilage corresponds i-oughiy to a horizontal plane passing just above the condyles and througli tlie adductor tubercle. The top of the trochlear surface just touches this i)lane. The lower femoral epii)hysis is ossiiietl from a center which makes Fig. 642. — Kontgenogrum of the knee showing the locations of the epipliyseiil car- tilages. its appearance shortly after birth. Epiphj'seal separations cannot occur after the twentieth year since the epiphysis joins the shaft at this time. In fact they are rare after the sixteenth year. The injuries, then, to wdiich the lower end of the femur is subject are : supracondylar fracture, T-fracture, fracture of either condyle separating it from the remainder of the bone, epiphyseal separa- tion and avulsion of a portion of the surface of a tuberosity by the pull of the ligaments. In rare instances we may see a longitudinal splitting of the lower end of the shaft which extends through the FRACTURES OF LOWER END OF FEMUR 577 Fig. 643. Fig. 644. Fig. 643. — Fracture of the lower end of femur with anguhir deformity and cru.sli- ing of cancellous tissue in the lower fragment. Fig. 644. — Supracondylar fracture with pronounced overriding deformity. Fig. 645 Fig. 645. — Old displaced fracture with refracture through callus. Fig. 646. — ^Fracture of femur with lateral overriding deformity. 578 FRACTURES AND DISLOCATIONS lower end of tlie bone into the joint cavity. In some eases we may see a portion of the surface of the tuberosity driven inwai-d hy severe violence confined to a small area. Symptoms. — The symptoms vary with the age of the patient and the severity and nature of the injury. In supracondylar fracture, fracture of one of the condyles or epiphyseal separation, the loss of function is complete. Tlie patient is unable to stand on the injured member or to raise the foot from the bed. Deformity is usually present and varies with the position of the fracture. In the simple sui)racondylar type the lower fragment may be displaced in any Ki;;. 647. — Fracture of the lower third of the femoral shaft. Note llio shortoninsc, external rotation and thickening of the thigh. Lower fragment displaced posteriorly. Case first seen twenty-four hours after injury at which time this photograph was taken. Fig. 648. — L'(iiii]hiiiimI i-niniiiiniil(!. — CmIioI |i(islci-iijr wire .siilint licnt t(i lie nscil iis (IuuIjIc iiirliiird ])l:in( fact tliat the popliteal artery may he injured during reduction should never he lost sight of and accordingly manipulations should be most guarded. If reduction cannot be accomplished by traction and manipulation, tlie open method should be instituted at once, especially if there is the slightest indication that tlie popliteal artery is being compressed. In manipulating the fragments pressure should never be made in the i)opliteal space lest the arter}^ he driven FRACTURES OF IjOWER END OF FEMUR 581 against the end of one of the fragments. Pressure to force the lower end of the upper fragment forward should be made in the middle of the thigh posteriorly, where there will be no danger of injury to important soft tissues. In the presence of a T-fracture or a frac- ture of one of the condyles, an attempt should be made to force the Pig. 651. — Dupuy's adjustable splint used as a douljle inclined plane in a case of frnctuve of the femur. Extension in the long axis of the femur is employed to maintain reduction. Fig. 652. — Dupuy's adjustable metal splint for the treatment of fractures of the lower extremity. condyles together as reduction is being accomplished. This is an important matter since separation of the femoral condyles means loss of proper alignment between the femoral and tibial articular surfaces with subsequent disturbance in the function of the knee joint. If the fracture is near the knee and the lower end of the upper fragment is displaced forward the prominence thus produced 582 P^RACTURES AND DISLOCATIONS may interfere with the action of the patella and (luadriceps after union lias taken place. In separation of the epiphysis reduction should be accomplished at once and with the least possible manipulation. Gradual flexion ddnliU^ inclined piano, fracture box. of tile kncM' while ])n'.ssui'c is being- exerted on the epiphysis will aitl iiiatci ially in ctlVcting' reduction. If reduction cannot be ef- fected by traction, counter-traction, flexion and direct pressure on the epii)h>sis, it should be accomplished by operative intervention. Fig. 654. — Hodden's splfnt. This splint may be used as a double inclined plane. The manner in which the ropes are arranged affords traction as well as suspension. Repeated attempts at reduction of an epiphysis, with intervals of delay, are absolutely to be condemned. The sequel of such surgery is amputation. If the first attempt is unsuccessful, operation should be performed at once. Operative Treatment. — Operation is indicated when good reduc- tion cannot otherwise be accomplished. An incision along the inner border of the quadriceps extensor wall expose the fragments, and manipulation of the lower extremity may be aided by direct trac- tion on the displaced fragments, by means of bone hooks or forceps. Increasing the angular deformity may render reduction easy w'hich would otherwise have been difficult. After the serrated surfaces FRACTURES OF LOWER END OF FEMUR 583 have been engaged the angular deformity is corrected and tlie frag- ments brought back into good alignment. If the fracture is of the T-type it is often advisable to make two longitudinal incisions, one on the inner and the other on the outer aspect of the thigh opposite the lower end of the bone. With the parts thus exposed the condyles are forced together and back into position so that they properly fit the articular surfaces of the tibia. If a tendency toward recur- rence of deformity is noted they should be secured in proper rela- tion with each other by some means of internal fixation. If two holes are drilled transversely through the lower end of the bone above the condyles, a wire may be passed through the bone from one side to the other and back again, thus holding the fragments together. A Lane plate may be used on the anterior surface of the bone if the displacing strain is not too great. It should be remem- bered that the lower end of the femur is covered by a very thin layer of compact tissue while the interior of the bone is composed of a cancellous structure which offers an exceedingly poor foothold for screws, nails or pegs. The most secure fixation, therefore, is the transverse wiring just described. If transverse wiring is employed below the upper border of the trochlea care should be exercised to avoid drilling into the supracondyloid notch. The drill holes should, therefore, be placed well forward. (See "Anatomy of Lower End of Femur," page 574. The knee-joint should not be opened unless it is found that proper fixation cannot otherwise be obtained. "With reduction and fixation of the fragments accomplished the wound or wounds are closed and the lower extremity immobilized in whatever position shows the least tendency toward recurrence of deformity, as demon- strated during operation. Extension, semiflexion or flexion may be employed. As a rule, however, it will be found practicable to immobilize the lower extremity on a ham splint in a position just short of complete extension. "When the fracture is treated in this position a Buck's extension following operation is usually indi- cated to relieve the muscular spasm, steady the member and re- lieve the pressure between the articular surfaces of the tibia and femur. Padding of the splint for the purpose of exerting pres- sure in the popliteal space to effect or maintain reduction is not permissible. Tenotomy of the tendo Achillis to overcome backward displacement of the lower fragment has been advised and prac- 584 FRACTURES AND DISLOCATIONS tised but is proliably an luiwise measure. It is often imsiiccessful and by no means as satisfaetory as open treatment with direct fixation of the fragments. Tliere is usually little tendency toward recurrence of deformity following reduction of an epiphyseal separation, if the lower ex- tremity is treated in the semiflexed position. Should the excep- tion, however, be encountered and internal fixation prove necessary, absorbable suture material is the only material which should be used in holding the epiphysis in place. Loops of wire or a Lane plate should not be used across an epiphyseal cartilage. A light plaster cast extending from the groin to the ankle with the knee in semi-flexion will usually be found quite satisfactory in im- mobilizing the parts. It should not, however, be employed until after the traumatic reaction has subsided. If the cast is cut open before the plaster has dried it may be applied immediately fol- lowing the ojieration. After-Treatment. — Considerable traumatic reaction usually fol- lows the accident, and during the first week repeated adjustments will be necessary in making allowances for the onset and subsidence of swelling. Traumatic arthritis of the knee is the rule, especially in epiphyseal separations and fractures entering the joint cavity. The knee should be snugly bandaged and an ice cap should be kept in position most of the time during the first week. A long side splint such as used in fractures of the shaft of the bone, adds greatly to tlie security of immobilization when the fracture is treated in the extended position. If the lower fragment shows a tendency to posterior displacement not controlled by straight Buck's extension, a double incline plane should be employed or the lower extremity put up in a cast in a flexed or semi-flexed position. At the end of six or eight weeks the dressings should be removed and passive motion begun. In another week or ten days the pa- tient may be allowed out of bed and may begin the use of the member cautiously. He may bear a little weight on it while get- ting about with the aid of crutches and a moderately high sole on the opposite foot. In children union is much more rapid while in the aged it may be very much delaj^ed. The usual treatment of epiphyseal separations is with the knee in a position of semiflexion. At the end of three or four weeks the knee may be carefully brought to the extended position and FRACTURES OF LOWER END OF FEMUR 585 massage begun. Guarded passive motion sliould be instituted within the next few days. At the end of six weeks all dressings should be removed and the child allowed to lie unrestrained in bed Fig. 655. — Ambulatory pneumatic splint (adjustable), sliowino; application for all fractures but the hip, without any additional supports to the limb or hip-joint immobilizing attachment. for another two weeks. If the ambulatory pneumatic splint is used, or some other equally efficient appliance, the child may be up and about during this time. Function may be resumed grad- ually during the eighth and ninth weeks. At the end of two and 586 FRACTURES AND DISLOCATIONS a half moiitlis the patit'iil should lie hearing- his full wt'i<;lit on the lejr. It" at any time ihiriiiii,' the at'tfv-ti'eatineiit gaiijj;ri'ne or si'j)ti- cemia should develop as a result ol" destroyed cireulatiou or infec- tion, prompt amputation will usually be necessary to save the patient's life. ProgTiGsis. — Fracture of the lower end of the femur is at best a serious condition. Infection of the knee-joint or laceration of the popliteal artery are conditions which render the fracture itself only of secondary importance. Epiphyseal separation has a par- ticularly bad prognosis, especially when compound. Gangrene of the leg is not an uncommon sequel when the popliteal artery is injured and death has resulted in many instances from gangrene, infection, embolism, etc. Disturbances in the subsequent growth of the bone following epiphyseal separations are not common if recovery has taken place with the fragments in good reduction. The surgeon, however, should warn the parents of the untoward possibility so that he may not be unjustly blamed later on. Simple fracture of the lower end of the femur without arterial damage is usually followed by good function if the condyles do not unite in deformity. Joint adhesions may occur in the knee. Their severity is lessened by the proper use of Buck's extension during the height of the traumatic arthritis. A chronic villous arthritis is not uncommonly seen following fractures in this region. CHAPTER XL. FRACTURES AND LUXATIONS OP THE SEMILUNAR CARTILAGES. Surgical Anatomy. — The semilunar cartilages are two crescentie masses interposed between the articular surfaces of the tibia and femur and serve to deepen the articular surfaces on the head of the tibia. The superficial margins are thick, correspond roughly with the outline of the upper end of the tibia and are attached to the deep surface of the capsule of the knee-joint. The central margins of these cartilages are thin and lie free in the joint. Be- tween the articular surfaces of the tibia we have attached from before backward: the anterior end of the internal semilunar carti- lage, the anterior crucial ligament, the anterior end of the external cartilage, the posterior end of the same cartilage and, lastly, the posterior crucial ligament. It will be seen from this, that the two extremities of the external cartilage practically meet at the spine of the tibia while the extremities of the internal cartilage are separated by a considerable distance. The deep structure of these cartilages is fibrous while the surface is composed of hyaline carti- lage. They are triangular on cross-section. The circumference of each cartilage is bound to the borders of the tuberosities of the tibia by the capsule of the joint, which is continuous on the outer and inner aspects of the articulation with the lateral ligaments. The portion of the capsule thus attaching the cartilages to the tibia is known as the coronary ligaments, and fibres stretching between the anterior convexity of the two cartilages has been described as the transverse ligament. The knee-joint is of the hinge type with complimentary gliding and rotary motion. In extension, lateral motion is prevented by the lateral ligaments, but in flexion this function is performed by the crucial ligaments. The angle at which the tibia joins the femur in extension, normally throws greater strain on the internal lateral ligament than on the external. The internal cartilage is much more intimately attached to the in- ternal lateral ligament than is the external to the external lateral 587 588 FRACTURES AND DISLOCATIONS ligament. Kuiitnvc and displacement of llic iiitornal lateral M^ii- ment will therel'ore be much more likely to disturb the internal cartilage than- Avould be the case with the external cartilage if the external ligament were injured. The normal lateral angle of the knee is such that the longitudinal stress produced by th(> weight of the body tends to separate the articular surfaces on tlic inner side of the joint. The circumference of the cartilage is attached to the internal lateral ligament and when this structure is torn the carti- lage may be displaced inward and jammed between the articular surfaces. "When the femur is displaced laterally on the tibia the condyles ride upward on the semilunar cartilages and thus serve to bring the crucial ligaments to a tension. In si)rains of the knee the semilunar cartilages may be fractured or displaced. They may be found free in the joint or only partially detached. A portion of the cartilage may be fractured and partially or completely separated from the remainder. It may be folded upon itself and in cases of long standing various degenerative changes have been noted in the entire joint as well as in the cartilage. Cases are on record in which the cartilage from one side of the articulation has been found on the opposite side of the joint cavity. Symptoms. — In the typical case the clinical picture is quite characteristic. The patient gives a history of having been taken with severe pain in the knee (usually on the inner side) while the joint was partly flexed and under strain. The joint locked, so tlijit lie was unable to extend the leg, thougli it may have been l)Ossil)]e for him to hobble some distance with the knee in a position about half way between complete extension and semiflexion. By repeated, attempts at flexion and extension or Avith medical aid something was felt to give within the joint and the knee was again found to be free and capable of full extension. Following the accident evidences of traumatic arthritis develop and the patient is confined to the house for a period varying from a few days to a few weeks according to the severity of the reaction. It is during this time that the .surgeon usually first sees the case. If the patient gets about as soon as the swelling subsides recurrence of the accident is almost sure to occur when the knee is subjected to similar strain and position. The reaction following subsequent luxations is usually less severe than that attending the first dis- placement. In the atypical case there may be no history of the knee having locked. The patient may complain only of a sense of FRACTURES AND LUXATIONS OF SEMILUNAR fl.A HTII> AOKS 589 insecurity in the joint and of pfiin under strain, at times. In old cases the only evidences of tlie condition may be found in secondary changes such as chronic hypertropliic artht-itis. For a number of days following the accident it is the; rub; to find tenderness in the region of the cartilage, usually the internal, and in some instances Fig. 65G. — Subluxation of the knee with lateral dislocation of the patella. The in- ternal lateral ligaments are torn and the semilunar cartilage displaced toward the spine of the tibia. Fig. 657. — Another view of the same case showing how the iinger may be inserted between the tibia and femur. a gap between the bones may be produced by manipulation. Pain may be referred to the patella rather than the region of the carti- lage though the tenderness is always more pronounced at the site of the cartilage. The absence of physical signs, however, is char- acteristic following the traumatic reaction. Wlien the condition 590 FRACTURES AND DISLOCATIONS becomes recurrent it is not infrequently (luite disabling. The time consumed in recovering from the traunuitie reaction and the sense of insecurity which the patient experiences during the intervals are important sources of disability. The fact that the knee may be thrown out of function at any liiuc deters him from many ac- tivities. The degenerative changes which so often follow in the articulation are important. Diagnosis. — With the typical history of sudden pain and "lock- ing" of the joint, with complete release of the articulation when the cartilage is reduced, the diagnosis is easy. In atypical cases, however, without the characteristic symptoms of locking of the knee, it may be impossible to arrive at a diagnosis until the joint is explored. It might seem that a diagnosis should be made in all cases, yet experience will show that mistakes are common even among those most thoroughly versed in the internal derangements of the knee. "When the case is not typical the condition must be differentiated from : dislocations of the patella, synovial fringes, joint mice, lipomata and subluxations of the knee. If the patient is seen daring the acute disability there will be little difficulty in differentiating lesions of the semilunar cartilages from luxations of the patella. If, however, we are obliged to rely on the histor,y given by the patient it may become an extremely difficult matter to arrive at a diagnosis. If the patella has been dislocated the region of the knee cap will be tender for a few days following the displacement and it is often possible, especially under anesthesia, to displace the bone bej'ond its normal limits. ]\Iore- over the characteristic tenderness on the inner side of the knee at the site of the semilunar cartilage is absent. If the case is seen some wrecks or months following the accident it may be impos.sible to determine the conditions that existed, if the patient gives the usual imperfect history. When s.ynovial fringes are pinched, the locking is not as pronounced and solid as occurs in luxations of the semilunar cartilages. Moreover the point at which the motion of the knee is interfered with is not constant and the pain is usually more intense and acute than occurs when the semilunar is at fault. When joint mice are present it may be possible to palpate one or more of the loose bodies within the articulation, and the point at which the action of the knee is interfered with varies with different attacks. If the disturbance in function is due to lipomata the acute symptoms are less severe and the subsequent acute traumatic ar- FRACTURES AND LUXATIONS OF SEMILUNAR CARTILAGES 591 thritis is usually negligible. In addition a pepinanent puffiness is usually noted on either side of tlie patellar ligament wliieli repre- sents the enlarged fat pad beneath the ligament. In siibluxalions of the knee the history of trauma and the abnormal mobility will usually clear the diagnosis. The joint cavities have been injected with hydrogen and the X-ray used to determine the outlines of the semilunar cartilages but this method of diagnosis is seldom indi- cated in general practice. When it is employed the dangers of infecting the articulation should be kept in mind. In chronic dis- turbances of the knee the important points to be determined are whether or not the disturbance in function is sufficient to warrant opening the knee and whether or not good functional results can be obtained without operation. Treatment. — If the case is seen while the cartilage is luxated, reduction should be effected at once. Reduction of the displaced cartilage is usually easy though cases are occasionally encountered in which open incision is necessary. Reduction is effected by acute flexion of the knee, the leg is then rotated back and forth on its axis and laterally deviated from side to side and finally extended. In acute flexion of the knee the most convex portions of the femoral condyles are in contact with the articular surfaces of the tibia and accordingly there is more room for the cartilages than when the knee is extended. This accounts for the release of the pinched cartilage during acute flexion. The rocking and rotary motions just described also tend to free the cartilage. If the surgeon flexes the knee over his wrist, the latter acts as a fulcrum and aids ma- terially in separating the articular surfaces of the femur and tibia. If these manipulations have been successful and the cartilage has been freed, complete and active extension of the knee Avill be pos- sible and painless. If they have failed the knee will be blocked just short of full extension and the patient will be unable to hold the leg extended in the horizontal position. Moreover the attempt will be attended by pain. The proof of reduction is the free active extension of the joint unattended by pain. The patient will almost invariably be able to state when the cartilage is reduced. His con- duct reminds one of luxations of the shoulder in which the sufferer exclaims with satisfaction as the head of the bone slips back into the glenoid. The care of the case following reduction will be taken up in the after-treatment. Operative Treatment. — The indications for operative treatment 592 FRACTURK8 AND DISLOCATIONS vary with the social state of the patient and the nature of the lesion. . If this luxation occurs for the first time in a gentleman of leisure, who has ampk^ time for non-operative methods and can avoid subsequent strain to the joint, the condition may be treated expectantly. If on the other hand the patient is a laboring man, whose time and activity mean his living, the cartilage causing the trouble should be removed at once. The advisability of operating following the first luxation is a question. If reduction is accom- plished and the joint immobilized for a period sufficiently long to allow complete healing of the ligaments and cartilage, the condition may not recur. Cases of habitual luxation, with or without evi- dences of degenerative changes within the joint, call for operative intervention. Nothing can be expected from non-operative meth- ods under these circumstances. A vertical incision is made beginning about one inch behind the lateral border of the patella and a little above the horizontal plane of the articulation. This is carried downward across the articu- lation and continued backward in a curved direction as soon as the scalpel comes opposite the tuberosity of the tibia. After the skin incision is made the cutaneous edges are covered with gauze, whi-ch is held in position by tenaculfe. The tissues are then divided down to the capsule of the joint, which is incised with the least possible trauma. The half of the joint cavity to be operated upon is then open for inspection and the nature of the lesion may be determined. The most rigid asepsis shoukJ he observed; the gloved fingers should not be introduced within the articulation and instruments having come in contact with the hands should not enter the cavity. Sponges should be used but once. If the cartilage is fractured, detached (partially or completely), folded upon itself or degen- erated it should be removed. Anchoring of the cartilage to prevent luxation should not be attempted as the results are not satisfactory. Removal of the cartilage should be accomplished with as little trauma as possible. If other derangements are encountered within the articulation they should be corrected. Following operation the joint should be immo1)i]ized and an ice cap applied to the knee to control any traumatic arthritis which may develop. After-Treatment. — The care of the case following non-operative reduction consists in immobilizing the knee on a posterior splint in complete extension. Elevation of the lower extremity and the use of the ice cap will tend to control the traumatic reaction. If trau- FRACTURES AND LUXATIONS OP SEMILUNAR CARTILAGES 593 matic arthritis develops i^iiek's (extension sliould bo employed. Immobilization should be maintained for a period of thr(ie wcM.'ks and the resumption of function should be gradual. Strain to the knee in the flexed or semi-flexed position sliould be avoided for three or four months. If the inner side of the sole of the shoe is built up and the patient forms the habit of "toeing in" in walking, much of the strain will be removed from the internal lateral liga- ment and thus the chances of recurrent luxations of the internal semilunar will be reduced. Following operation and removal of the cartilage motion may be begun at the end of ten days and the patient may return to work within two weeks if there are no com- plications. Prognosis. — Fracture or dislocation of a semilunar cartilage may occur only once if proper immobilization has been carried out fol- lowing the accident. If on the other hand function is resumed immediately or as soon as the traumatic arthritis has subsided, re- currence is almost sure to follow. Restoration of function fol- lowing operation is prompt and complete. The patient is able to resume his original occupation or to follow the sport in which the injury was sustained. CHAPTER XLI. FRACTURES OP THE PATELLA. Surgical Anatomy. — The patella is a sesamoid bone developed in the tendon of the quadriceps extensor femoris. It is usually ossi- tiod from one center, which makes its appearance about the third year. In rare instances it is developed from two centers, laterally placed. The patella is attached to the tubercle of the tibia by the ligamentum patellae, which maintains the bone at a constant dis- tance from the tibia. The anterior surface is subcutaneous except for the prepatellar bursa which is interposed between the bone and the skin. The patella is covered on all sides, except the articular surface, by the tendon of the quadriceps which is spoken of below the bone as the ligamentum patellae. In extension of the knee the articular surface of the patella is in contact with the trochlear surface of the femur ; in flexion, with the condyles. The lower portion of the patella or apex has attached to it, both anteriorly and posteriorly, the fibres of the ligamentum patellas. The patella is situated in two fibrous planes; the superficial one is represented by the fascia lata covering the quadriceps extensor, the deep plane is the capsule of the knee-joint. When fracture occurs separation of the fragments does not take place unless the fascial planes, in which the bone is situated, are torn. The func- tion of the patella is to afford leverage to the tendon of the quadri- ceps, while acting across the flexed knee. The insertion of this muscle is chiefly into the patellar ligament, but it should not be taken for granted that the quadriceps acts only through the patella, since it finds a broad insertion into the upper end of the tibia through the fascia lata and capsule. In instances, therefore, in which the patella is fractured without tearing of the fasciae on either side of it, the patient still retains some power in extending the knee. The mechanism of fracture of the patella has been the subject of considerable discussion, and even at the present time differences of opinion exist concerning it. The bone may be broken by direct 594 FRACTURES OF THE PATELLA 595 violence, or by muscular action. When the former is the cause the fracture is often stellate or irregular and comminuted, depend- ing upon the nature, direction and degree of the trauma. In this type of fracture the lateral fasciae are seldom torn and the dis- placement is slight. Fracture produced in this way sometimes re- sults in injury to the underlying articular surface of the femur. When fracture results from muscular action it is caused by the violent action of the quadriceps extensor on the patella while the knee is flexed. In this way the patella is broken across the con- dyles of the femur, and if the muscle continues to act, the frag- ments are separated and the lateral fasciae torn. The mechanism of fracture of this bone, as a result of muscular action, may be illustrated by the facility with which a stick can be broken across the knee when it will be impossible to part this same stick by simple traction and counter-traction in its long axis. If a blow is sustained on the flexed knee (either by a moving object or in a fall) while the muscle is contracting, the fracturing effect of the muscular pull is greatly increased. The upper end of the bone is fixed by the quadriceps and the lower end by the liga- mentum patellae, while the middle of the posterior surface is the only part of the articular face in contact with the femur during flexion. The distribution of these three forces explains the man- ner in which the patella may be snapped. Fracture of the patella nearly always enters the knee-joint, but when confined to the lower portion of the apex of the bone, which is covered by the patellar tendon, the joint is not necessarily opened. Etiology. — Transverse fracture of the bone is most common, while the comminuted form is next in order of frequency. Over four- fifths of all fractures of the patella are in the lower half of the bone. This accident occurs more often between the ages of thirty and forty, and is three times as common in males. Muscular action is probably responsible for more cases than is direct violence, al- though a combination of these two elements is not at all uncommon. Symptoms. — Local pain is constant, with partial or complete loss of extension at the knee. The patient is sometimes able to walk backward by dragging the foot and keeping the knee hyperex- tended. If weight is put upon the leg, with the slightest degree of flexion at the knee, the lower extremity buckles and the patient falls. The condition is usually simple, although in severe crushing or cutting injuries the fracture may be compound and the joint 596 FRACTURES AND DISLOCATIONS exposed. Crepitus may be elicited in the absence of separation, or if the parted fragments are drawn toward each other and the Fig. 658. — Old t'l-iu-luri' ot' patelhi with siciKiriitiou ul' I'nigiufiits. liect-iil, t'lacture of the femoral neck, which accounts for the complete eversion of the entire lower e.vtrem- ity. The front of the knee looks outward instead of upward and the depression between tlie fragments of the patella is just above the point of the arrow. serrated surfaces rubbed together. Some degree of separation is usually present, which in many instances can be detected by in- spection alone if the ease is seen before the parts become exten- sively swollen. It is often possible to lay one or two fingers in the k'Viga^ Fig. 659. — Shows an unusual case of fracture with wide separation of both patellre. The fracture of the left patella is of three years' standing while that on the opposite side is two years old. Case treated by the expectant method which resulted in fibrous union with subsequent separation of the fragments. Case first seen by the author three years after the first fracture. depression existing between the fragments. Swelling and disten- tion of the joint follow rapidly, and obliterate the depression be- FRACTURES OF THE PATELLA 597 tween the fragments so that the condition cannot be recognized by inspection, although there is usually little difficulty in deterrninijjg the deformity by palpation. The development of ecehymosis witliin twelve or twenty-four hours of the injury is the rule. It is usually most pronounced on either side of the patella corresponding to tlie positions of the lateral fascial tears. The symptoms of acute traumatic arthritis generally supervene within a few hours of the injury. Swelling, redness, pain, tender- ness and distention of the joint are present. When the joint be- comes filled, the fluid reaches the surface between the fragments and produces a prominent swelling anterior to the patella. Dis- tention of the joint cavity causes the patient to assume a charac- teristic position of slight flexion of the knee and moderate eversion of the thigh. The later symptoms of fracture of the patella depend largely upon the line of treatment followed. Pain, swelling and tenderness are usually not severe at the end of a week or ten days, especially if measures have been instituted for their control. Bony union seldom occurs in cases which have been treated by non-operative methods and the amount of impairment in function will depend largely upon the length and strength of the fibrous union. This fibrous tissue tends to stretch with the subsequent use of the member, so that it is not uncommon for the patient to present himself for treatment at the end of a year or two because of pronounced and increasing loss of function. The separation between the fragments may be four or five inches or even more, so that the quadriceps extensor can be well contracted while the knee is still in a position of semiflexion. Secondary separation of the fragments is not prone to occur if the lateral . fascia were untorn at the time of injury. Fibrous adhesions or bony union between the articular surface of the patella and the femur, may so fix the knee cap that the thigh muscle cannot move it, thus producing loss of function of an entirely different character. Diagnosis. — The diagnosis is based on the history of injury to the knee followed by prompt loss of function and other symptoms just enumerated. Little difficulty should be experienced in recognizing the condition by inspection and palpation regardless of whether or not separation of the fragments exists. Even though the bone is superficial and easily palpated, nevertheless it is advisable to have an X-ray taken to accuratelj^ deteraiine and record the details of the fracture. 598 FRACTURES AND DISLOCATIONS Treatment. — The fact tliat reduction of tlie separated fragments is indieatcd in tlie treatment of fracture of the patella, is uniforndy conceded, hut. the proper method of attaining' iliis end has been, and is, the subject of nuich diseussion. Even at the present time few surgeons agree concerning the best method of procedure. Some are opposed to opening the knee-joint as long as there is a fair prospect of obtaining some kind of a functional result by non- operative methods. Others take the position that every fracture Fig. 660. — Shows tlie non-operative treatment, of fracture of the patella. A. shows the lower extremity fixed on a posterior splint with the knee in a position of slight flexion. The splint is a straight splint heavily padded opposite the knee. Two short splints are secured to the thigh on either side of the quadriceps to prevent contraction of this muscle. B. shows diagonal strips of adhesive applied above and below the patella to approximate the fragments. C. shows lateral splints applied. D. shows the lower extremity raised on pillows to relax the quadriceps. of the patella should be subjected to open treatment if the general condition of the patient will permit of operation. Personal ex- perience and observation have indicated that b}^ far the best results follow the more radical measures. It is a well known fact that ex- cellent functional results are sometimes seen in instances in which wide separation and heavy fibrous union are present. But on the other hand the highest percentage of functionally perfect results is seen in cases in which accurate anatomic reduction has been accom- plished. Conclusive deductions cannot, at the present time, be FRACTURES OF THE PATELLA 599 drawn from the statistics of operated cases because of the widely varying and sometimes imperfect technique which has been fol- lowed by different operators. In the author's opinion, non-oper- ative treatment is only indicated in old and feeble persons, or in cases in which separation does not exist. The lack of proper sur- gical facilities and skill or the presence of certain constitutional diseases, such as diabetes, will of course act as contraindications to the open treatment. The first indication in the treatment of fracture of the patella, in both the operative and non-operative methods, consists in putting the lower extremity at rest and in Fig. 661. — "Shaped" ham splint with padding applied to posterior aspect of lower extremity and held in position by three strips of adhesive plaster. instituting measures to control the traumatic arthritis. The lower extremity should be placed upon a jDOsterior splint, which is secured in position by bandages and strips of adhesive as shown in Fig. 660. A snug bandage should cover the knee to control the swell- ing, and an ice cap to the parts will be found of great service in relieving pain and modifying the inflammatory reaction. If the expectant method is to be followed adhesive straps above and below the patella are diagonally placed in such a manner as to draw the fragments together (see Fig. 660). It is useless, however, to at- tempt to approximate the fragments until the joint distention has 600 FRACTURES AND DISLOCATIONS subsided, which will not be sooner than one week following the injury. There is no method of applying these straps, even after the fluid has left the joint, which will accurately approximate the fragments if separation has existed, notwithstanding statements to the contrary. This fact may be conclusively demonstrated by the use of the X-ray in any given ease in which the fragments are supposed to have been reduced. In the rare instances in which fracture has occurred without separation of the fragments, as indi- cated by the X-ray, this method may be counted upon to give a good result. In most cases of fracture of the patella considerable separation will be found after everything which is possible in a non-operative way has been accomplished, and we therefore turn to the open treatment to secure reduction. Operative Treatment. — The open treatment of fracture of the patella is the ideal method, but should not be attempted unless one fully appreciates the untoward possibilities, and is thoroughly equipped to carry it through. If the cases, in which unsatisfactory Fig. 662. Fig. 663. Fig. 662. — Shows the method of placing the silver wire mattress suture in approxi- mating the fragments in a transverse fracture of the patella. Fig. 663. — Shows a horizontal section of the patella at the same level. Note the rela- . tive distribution of cancellous and compact tissue. results have followed the open treatment, are analyzed, they will be found to have resulted from one or more of three conditions, namely : infection, insecure fixation of the fragments and prolonged immobilization of the knee. Asepsis should be perfect in every detail as described under "Open Treatment of Fractures" on page 754. Infection follow- ing operations on the knee means not only failure in union, but involvement of the knee-joint which may result in loss of function in the articulation, if not amputation or death. It is common to find a clot of blood in the joint behind the fracture, which should FRACTURES OF THE PATEEIA 601 be removed before the fragments are brought together. It is dan- gerous to leave this dead blood where it may favor subsequent sup- puration (see ''Open Treatment of Fractures," page 754). The Fie 664 — Recent fracture of the patella with separation of fragments, near as the fragments could be brought together by non-operative methods. Fig. 665.— Same case after operation. A silver wire, mattress suture draws the fragments into apposition and holds them firmly against the displacing action ot the quadriceps. Ultimate result, complete restoration of function. fragments should be accurately and firmly approximated at the time of operation and so fixed that separation cannot take place during the after-treatment. Wire properly placed is the only 602 FRACTURES AND DISLOCATIONS iiKitcrial wliieli cau be counted on to seeiuv proper and permanent iiimiohilizatioii. Absorbable suture nuiterial has been strongly ad- vocated and i^ood I'esults may foUow its ('iui)loyiiient ; but the inse- curity resulting;- from its softening and absorption before the end of tile third week should condemn its use in fracture of the patella. It lias hccii used ill suturing the fascia? covering the patella and in the repair of latci'al fascial tears as well as in direct suturing of tlie bones through drill holes. Separation of the fragments is likely to occur during the second or third weeks, which can only mean failure in bony union with the possibility of further separation through stretcliing of the fibrous tissue. Even if chromicised cat- gut or other absorl)al)l(' material could be counted on to maintain reduction until bony callus relieved it of strain, we could not rely on the sutured fascia to withstand the pull of the quadriceps dur- ing this period. It is apparent, therefore, that wire, securing a tirm hold directly on the bony fragments, is the most satisfactory method of fixation. The structure of the patella should be remem- bered while securing the fragments. The wire should be so placed that it obtains its hold on the compact shell, rather than on the internal cancellated tissue, which is likely to give way under strain and allow the loop of wire to tear out. This is best accomplished by a mattress suture of wire as described later on. The more se- cure the internal fixation, the safer is the early employment of passive motion; and early passive motion is most essential in re- establishing the function of the joint. Its proper use will be de- scribed in the after-treatment. Loss of function and "painful joint" sometimes occur in cases in which proper reduction and bony union have follow^ed the injury. These conditions are almost entirely due to the lack of early passive motion. The joint should be moved not later than two weeks from the time of operation, but passive motion has its risk, if fixation of the fragments is not solid, and should not be attempted without properly guarding the patella from the action of the quadriceps. The following technique in operating on fractures of the patella has proven the most satisfactory in the author's hands and may be considered the procedure of preference in most cases. An in- cision is made exposing the fragments ; it may be longitudinal and directly over the fracture or of the U-shape commonly employed in operations on the knee. With the fragments exposed and sepa- rated the clot Avhich is usually found behind the fragments is re- FRACTURES OF THE PATEELA (m moved with thumb forceps. Bony contact is essential and if fascia is found covering one of the fractured surfaces (usually the lower) it should be carefully removed before the fragments are brought together. In transverse fracture of the patella holes are drilled in each fragment so that the drill enters the anterior face of the patella and comes out on the fractured surface. Two such parallel holes are drilled in each fragment so that the openings on the Fig. 666. Fig. 667. Fig. 666. — Wired fracture of the patella three years after injury. Function as good as before accident. Note silver wire which crosses line of fracture twice but does not enter joint. Accident in 1905; wire in place at the present time. Fig. 667. — Wired fracture of the patella two years following accident. Patient failed to follow instructions, got out of bed and walked about shortly after operation with the result that the wire was broken. It held, however, snfficientlv well to secure a functionally perfect result. This case demonstrates the advisability of using heavy wire which is as well tolerated by the tissues as lighter material. Compare this case with the on© shown in Figs. 665 and note the size of the wire. fractured surfaces are opposite the corresponding openings of the holes on the other fragment. A heavy silver wire is then threaded through these holes so that the two ends are above the line of frac- ture (see Fig. 662). The fragments are then drawn together until they are in firm apposition and then the ends of the wire are twisted together, cut off, and turned in toward the bone. This mattress suture will securely hold the fragments in simple transverse 604 FRACTURES AND DISLOCATIONS frat'tnre of the patella and in addition may be made to work well when three fragments are i)resent instead ol' two. In the presence of- eomminntion it may be impossible to make tlie mattress sutnre hold beeanse of the breaking up of the eom])aet tissne, and wbeji such is the ease a circular wire surrounding the eonnniiiiitcd hoiic may serve the purpose. A speeiallj' formed Lane plate has been devised to be used on the patella but the nature of the bone and the difficulty of making the screws hold, results in wire being the material of choice in the open treatment of this fracture. AVhen the wire is placed there should l)e no motion in the fragments nor in the wire : in other words the fixation should be as secure as possible, to obtain the best results. The knee should be flexed and extended before the wound is closed to see that the action of the joint does not disturb the fixation. The skin incision is then closed and a few strands of silk-worm are left in the lower angle of the wound to allow the escape of fluids following operation. If the vertical incision is employed directly over the fracture, a subcutaneous running suture should be so placed that it will bring as much of the soft tissues between the fracture and the skin as possible. Fracture of the i:>atella is sometimes compound from the first, with the joint exposed and infected at the time of the accident. AVhen such is the case, the condition of greatest importance is in- fection of the knee-joint. This is a serious matter and if not prop- erly controlled iiuiy necessitate amputation, or may even result in death from a general sei)sis. The opeuing of tiie joint should be increased in size if not already sufficiently large, and the edges of the wound should be trimmed away until all ti-aees of crushed and devitalized tissue are removed. The joint should then be irrigated with a few gallons of warm physiologic salt solution. In iriigat- inti the wound a soft rubl)er catheter should be used, and carried to the innermost recesses of the articulation so that the flow will be directed from the interior of the joint to the surface. After the articulation has been thoroughly washed out, the soft tissue should be accurately approximated and the joint closed as tightly as pos- sible with the idea of preventing subsequent leakage. The cavity of the knee is then injected with Murphy's Formalin Glycerine solution, the patient put to bed, the lower extremity elevated. Buck's extension applied and an ice cap kept on the knee. Sub- sequent injections of the formalin glycerine solution are made FRACTURES OF THE PATELLA 605 according to the amount of leakage througli the incision and the reaction occurring in the articulation. This method of treating infected joints, devised by Murphy, is productive of. such vastly better results that no other form of treatment should be considered until after this has been tried. If suppuration of the joint can be avoided in this way, suturing the patella may be done at the end of two or two and a half weeks when the dangers of articular infection have passed. Suturing of the patella immediately following the accident should not be done in compound cases. The joint infection should be treated first and the fracture reduced in a secondary operation. If infection of the joint cannot be controlled by the initial irriga- tion and subsequent injection, it should be opened and freely drained, and under such circumstances approximation of the patella will be of little importance, since ankylosis of the knee-joint will, in all probability, be the result. If the accident occurs in a region of the country in which tetanus prevails, the patient should receive a prophylactic dose of anti-tetanic serum. When operation is done for the secondary separation which sometimes follows fibrous union the method of procedure is similar to that already described. The fibrous tissue between the frag- ments should be excised and the fractured surfaces freshened and approximated. It may occasionally be necessary to lengthen the quadriceps above the patella to bring the fragments together. When the patella is attached to the trochlear surface by adhesions it may be possible to free it by forced passive motion under anes- thesia. If the adhesions are too firm to be broken up in this man- ner it may be necessary to open the joint and divide them with the scalpel. If the adhesions are extensive and show a tendency to reform, a transplanted layer of fascia lata may be sutured in position to cover the articular surface of the patella. Early passive motion, repeated at regular intervals, will then', as a rule, result in a freely movable patella and good articular function. After-Treatment. — The length of the after-treatment will vary according to whether or not the open method has been employed. If expectant treatment has been followed immobilization of the knee is required for from six weeks to two months, after which guarded passive motion is indicated. During the use of the splint the dressings should be carefully watched and tightened to keep them in proper position. The diagonal straps Avhich tend to pull 606 FRACTrRES AND DISLOCATIONS the fragments together are likt'ly to beeoiue hix, especially as the joint distention subsides. During the first two or three weeks, pads should be kei)t on either side of the quadrieeps and lirmly l);indaged in position to prevent contraetion of this muscle. Dui'ing the stage of artifiiliii' iiiHjiiiiniation the local ajjplication of the ice-cap will be found of service in controlling the reaction. The lower extremity should be elevated on an inclined plane to favor the cir- culation of the i^arts and relax the extensor thigh muscles. Accu- rate approximation of tlie fragments is practically impossible in the non-oj-xM-ativc treatment, as pi-eviously stated, and during the Fig. (568. — Method of performing passive motion in the treatment of fracture of the patella. The left hand bears down on the ankle thus fle.xing the knee while the right hand pushes downward on the patella to relieve the fracture of the pull of the quad- riceps. time the joint is distended it will be useless to even attempt dimin- ishing the degree of separation; when the fluid has left the joint the distance between them may be somewhat decreased by the proper application of straps. At the end of two months the splint may be discarded and the patient allowed to get about on crutches with some more convenient form of joint immobilization. A cast of the leg may be made, split up the front before thoroughly dried and removed. After the plaster is set the cast may be covered with some durable material and strips of leather with hooks, applied to the edges on either side of the opening. In this way the cast may FRACTURES OF THE PATELLA 607 be removed at night for the purpose of massage and motion of the joint. During the day it is worn and when snugly laced immo- bilizes the knee and protects the patella from strain. Motion of the knee involving strain, such as walking without splint or cast, should be prohibited inside of from six to eight months. Excep- tional muscular strain should be avoided for a year. If fibrous union is heavy and short, the time may be considerably shortened. If it is weak and shows a tendency to stretch, the period of fixation and protection of the knee should be increased. The period of disability following the open treatment is strik- ingly shorter than that just described. The limb should be kept on a posterior splint as described in the after-treatment of un- operated cases. The dressings should be removed at the end of two weeks from the time of operation, and passive motion insti- tuted, provided the internal fixation was properly and securely accomplished at the time the joint was opened. The manner of performing passive motion is of considerable im- portance : the knee may be so flexed that the entire strain of the thigh muscles is thrown on the patella, or it may be so accomplished that the fracture is entirely relieved of the pull of the quadriceps. When the knee-joint has been fixed for a period of two or three weeks and the joint has suffered the inflammatory reaction incident to traumatic arthritis, it will be impossible to accomplish passive motion without producing spasm in the quadriceps, and it is this spasm which should be guarded against. If the surgeon places the lower extremity across his knee while one hand grasps the ankle and the opposite index finger and thumb are pressed into the thigh just above the upper border of the patella, he will be in a position to perform passive motion and still protect the patella from the spasmodic action of the quadriceps (see Fig. 668). As the ankle is depressed, thus flexing the knee, the opposite hand forces the patella downward towards the knee and takes up the strain of the contracting extensors of the thigh. This is the only way in which early passive motion can be performed without risk. Slight, snapping sensations are sometimes felt by the hand which forces the patella downward, but there is no cause for alarm since they are produced by the breaking up of adhesions in the joint which at this time are too imperfectly organized to act as serious obstacles to motion. At the end of eight or ten weeks, the patient is allowed to get 608 FRACTURES AND DISLOCATIONS about without any fixation apparatus. It is well for him to carry a eaue, and favor the injuivd knee for another two or three weeks, and he should be especially cautioned against unusual and excessive strains until four or tive months have elapsed from the time of the injury. It is well to have another X-ray taken at the end of three months to determine the presence of bony union. The heavier the union, the less caution is necessary. Prognosis. — Tlie restoration of function following fracture of the l)atella is a variable (juantity. Fibrous union, even to the extent of two or three inches, does not necessarily indicate that the pa- tient may not enjoy most excellent function. On the other hand, accurate reduction and firm union does not necessarily indicate that the knee will be restored to its original usefulness. The percentage of functionally perfect results, however, is much higher in cases in which bony union is present. In the ordinary fractured patella we can hardly expect complete restoration of function with any form of non-operative treatment. The power of extension is likely to be decreased, and the action of the joint impaired, although it is not uncommon to find complete flexion possible. "Wlien fibrous union occurs, it will be impossible to state whether this union will be heavj', strong and efficient, or, on the other hand, thin, weak and permitting- of subsequent separation of the fragments. Weak- ness and painful joint are common secpielffi. The results following the open treatment are vastly better, pro- vided the three requisites previously mentioned, are observed, namely : avoidance of infection, secure internal fixation of the frag- ments and early and persistent passive motion. Under such cir- cumstances the usual result is complete and permanent restoration of function, together with absence of pain in the articulation. CHAPTER XLII. DISLOCATIONS OF THE PATELLA. Surgical Anatomy. — There are a few anatomical facts bearing directly on dislocations of the patella, to be taken up at this time without entering into the details of the knee-joint, which were considered under fractures of the patella. The pull of the quadri- ceps is upward and in a direction parallel with the long axis of the femur. The ligamentum patellae lies in the long axis of the tibia and since the axis of the tibia is not the same as that of the femur it will be apparent that the pull of the quadriceps (with the leg extended), is not in line with the long axis of the ligamentum patellae. It is evident, therefore, that when the quadriceps eon- tracts it not only pulls the patella upward but also tends to displace it outward. This tendency toward outward displacement of the patella is normally counteracted by the outer lip of the troch- lear surface of the femur and the attachments of the capsule and fascia lata. When the capsule and fascia lata internal to the patella are lax, or when the outer lip of the trochlea is not sufficiently prominent, the bone may be displaced outward on vio- lent contraction of the extensors of the thigh. The angle at which the tibia joins the femur varies considerably in different persons. It is usually greater in women because of the proportionately broader pelvis and greater divergence of the femora. The angle is greater in short stocky persons than in those of tall and slender stature. If the knee be fully extended and the quadriceps relaxed the patella will be found quite freely movable from side to side as well as vertically. If the lower extremity be kept in the same position and the thigh muscles tightened the patella immediatel.y becomes fixed. This is due largely to the vertical groove in the trochlea and the corresponding ridge on the articular surface of the patella. It will thus be seen that although the quadriceps has a lateral displacing action on the patella, yet the contraction of this muscle also tends to prevent lateral displacement (if the fascial attachments and trochlea are normal) by forcing the patella into 609 610 FRACTURES AM) DISLOCATIONS the groove on the troehlea. Tlie imiseles and fascia^ attached to the bone often tend to Hx it in disj)laeenient after dislocation has oc- curred. The patella may be dislocated in any direction and is not nnconinionly found rotated on its axis. If the patella is displaced laterally until it clears the trochlear surface, or the bone is com- pletely rotated on its axis so that the articular face looks forward, the dislocation is said to be complete. If portions of the articular surfaces remain op])osed or if the bone stands on edge tlie condition is incomplete and is spoken of as a subluxation. These distinctions are of degree only, and are more academic than practical. The same may be said of the classifications based on the details of the possible positions occupied liy the patella during displacement. F d F Fig. t)70. Fig. 671. Fig. 669. — Normal relations between patella and lower end of femur. Fig. 670. — Patella luxated outward. Most common type. Fig. 671. — Represents patella displaced outward and "on edge." Also rotation of patella so that the posterior surface looks forward. Etiology. — Luxations of the patella constitute less than one percent of all dislocations. Displacement may be in any direction although the external lateral type is by far the most common. The condition may be partial or complete. It is more common in women than in men ; in short persons than in tall. ]\Iuscular action is often responsible for this luxation, although it may be caused by direct violence. A combination of these two elements is not un- common. Symptoms. — Sharp pain occurs at the time the bone is pulled or driven out of place, and unless spontaneous reduction occurs (which is not uncommon) there will be immediate loss of function with deformity which can be readily recognized both by inspection and palpation. Following the accident symptoms of acute traumatic arthritis develop although they are seldom as severe as those accom- panying fracture of the patella. The deformity varies with the type of displacement. Kecurrence of luxations of the patella are not uncommon and may constitute a most annoying and disabling DISLOCATIONS OF THE PATELLA 611 condition. In many cases the patient will know just what [)0,sition of the knee or what form of strain is productive of the displace- ment, and is always on his guard to avoid the condition while using the lower extremity. Diagnosis. — If the surgeon sees the condition prior to reduction, he may recognize the displacement by the characteristic deformity. Palpation of the parts will readily determine, not only the fact that the patella is displaced but also, the type of luxation present. In instances in which the dislocation has been corrected or spon- taneous reduction has taken place, it may be difficult to differenti- ate the condition from a fractured or luxated semilunar cartilage. A careful history and examination of the parts will usually result in determining which of the two conditions has occurred. Treatment. — As a rule, little difficulty is experienced in returning the patella to its proper position. The knee should be maintained in complete extension, while the thigh is flexed on the abdomen to relax the quadriceps extensor. If the patella does not then slip back into place of itself, slight manipulation will usually suffice to reduce the luxation. Before manipulation is attempted the sur- geon should have learned the relations of the displaced bone by palpation, so that he may cause it to retrace the course taken at the time of the accident. "When the patella is found rotated on its vertical axis it is particularly necessary that the surgeon know in which direction rotation has taken place. This is readily deter- mined by palpation of the muscle above, and the ligamentum pa- tellse below. It is extremely rare to encounter difficulty in reduc- tion if the above manipulations be followed out, but should such occur, complete relaxation of the quadriceps may be had under anesthesia. In old, unreduced dislocations of the patella reduction may be impossible by ordinary methods, and under such circum- stances it may be necessary to resort to open treatment. Operative Treatment. — Reduction of recent dislocations of the patella by the open method is rarely necessary. In old luxations and in instances of recurrent dislocations operative treatment is often the only method which will give satisfactory results. In either of these conditions the bone may be exposed by a vertical incision or by the usual U-shaped incision. In old luxations it may be necessary to break up old adhesions and cut through scar tissue before the bone can be returned to its original position. A number of methods have been advised and employed for the 612 FRACTURES AND DISLOCATIONS correction of recurrent dislocations. The tubercle of the tibia, with its attached liiranu'iitiim patclUi', may ))e chiseled oft' and re- attached to the til)ia, internal to its original position, so that the pull of the (juadriceps is straightened, and the nniscle thus loses its outward displacing action on the patella. Another method con- sists in ])Ucation of the internal portion of the capsule or in the repair of a rent, if one exists, thus securing the inner border of the patella so that it cannot be displaced outAvard by the pull of the cpiadriceps. Still another method consists in increasing the prominence of the outer lip of the trochlea by dividing it from the fenuir and displacing it forward. The first two methods are to be preferred to the last. In any of these operations the most strict asepsis is demanded, especially if the joint is opened. After-Treatment. — Following reduction, the knee should be put at rest on a ham splint, and measures instituted for the control of the traumatic arthritis. Snug bandaging, and the use of the ice cap will usually be followed by subsidence of swelling within a few days. When the inflammatory reaction has passed, the knee should be strapped with surgeon's plaster to steady the patella, and the patient should be cautioned to avoid unnecessary strains. The position of the knee in which the luxation occurred is particu- larly dangerous. Prognosis. — Dislocations, resulting from direct violence are likely to be followed by complete restoration of function, unless the trauma was severe and resulted in injury to the joint greater than that occurring in the ordinary patellar luxation. Dislocations re- sulting from muscular action are likely to recur at some later date. Recurrent dislocations are usually followed by good results if ap- propriately operated. In old unreduced dislocations restoration of function may be delayed or incomplete as a result of articular changes occurring while tlie bone was displaced. CHAPTER XLIII. DISLOCATIONS OF THE KNEE. Surgical Anatomy. — In some of the lower animals the knee is composed of three distinct articulations. One between the outer tuberosity and the outer femoral condyle, another between the inner tibial tuberosity and the inner condyle of the femur and the third between the patella and the femur. In the human knee we have the analogues of these three joints although they are all merged into one. The crucial ligament attached to the inner con- dyle corresponds to the external lateral ligament of the inner articu- lation, and the crucial ligament attached to the outer condyle is analogous to the internal lateral ligament of the outer articulation. The knee-joint is the largest and one of the most complicated in the body. The proper apposition of the articular surfaces depends almost entirely on the ligaments holding the bones together, and when these structures are lacerated it will be necessary to allow sufBlcient time for them to become completely and firmly healed before the joint is subjected to any strain whatever. The liga- ments binding the tibia to the femur are the posterior ligament, the internal lateral, the external lateral (divided into two parts), the capsule and the crucial ligaments. The two lateral ligaments limit lateral motion when the knee is in the extended position but are much less effective in this respect when the knee is flexed. In the flexed position the crucials perform this function. The pos- terior ligament limits extension of the knee. The anterior liga- ment, however, does not limit the flexion of the joint since it has no attachment on the femur. It serves simply as the insertion of the quadriceps, the tonic action of which muscle, acting through the tendon, helps to keep the articular surfaces opposed in what- ever position the joint may be. The semilunar cartilages, and their ligaments (the coronary and transverse) are described under the heading of "Fracture and Dislocations of the Semilunar Carti- lages, ' ' page 587. The ligamentum mucosum and alaria are simply reduplications in the synovial membrane and together with the 613 G14 FRACXrRES AXn DlST,(irATT()XS crucials represent llic division of the joint into two lateral halves, ])revioiisly referred to. The bones entering into the formation of the knee-joint are long, and hence the leverage exerted against the ligaments of the joint is considerable. The articular surfaces of the ti])ia and fenmi- eoiifonn to each other only poorly and the Fi-. OT-J Fijr. 072. — LiKuinents of the knee. J.L.. Intenial lateral ligament; E.L., External lateral ligament; i'., Femur; T., Tibia; F. (below), Fibula; Con., Condyles. Between the two condyles may be seen the crucial ligaments. Fig. 673. — Ligaments of the knee. P., Patella; T., Tibia; V., Fibula; L.P., Liga- mentum Pat-ellse; T.T., Tibial Tubercle; C, Caiisule. burden of hob ling these surfacCvS together rests entirely with the ligaments. The strength of these ligaments, however, is such that dislocations of the knee are extremely rare. It is more common for unusual strain to produce fracture than to tear the ligaments. Fracture produced in this way most often consists in the avulsion DISLOCATIONS OF THE KNEE 615 of a small scale of bone corresponding to the insertion of the liga- ments onto the tuberosity of the femur or tibia. In some instances, however, an entire condyle may be broken off by the pull of the ligament. With the knees extended and the heels together, the legs are parallel, while the femora diverge to include the pelvis between them at their upper ends. It is apparent therefore that the axes of the tibia and femur are not in the same straight line. This lateral angle at the knee results in greater strain being thrown on the internal lateral ligament, when longitudinal compression stress is brought to bear on the lower extremity. Accordingly rup- ture of this ligament is more common than rupture of the external lateral ligament. If the ligament is torn between the femur and the semilunar cartilage, the cartilage will remain attached to the tibia, which it will follow in displacement. If the tear is below the cartilage the reverse will be true. The most common dislocation occurring at the knee is so slight as to scarcely deserve the term of subluxation. It consists in a tearing of the internal lateral ligament so that the leg may be deviated outward and the inner condyle and tibial tuberosity may be separated a slight distance. Dislocations of the knee are classi- fied according to the direction taken by the tibia. Accordingly there are anterior, posterior, internal and external luxations of the knee. In addition there is another type of dislocation in which the tibia is rotated on the femur. The relation of the popliteal artery directly behind the articu- lation is of importance as already described under "Fractures of the Lower End of the Femur." The popliteal nerve situated somewhat more superficially in the popliteal space, and the pero- neal nerve passing from behind the knee to the outer side of the leg where it winds around the head of the fibula, are sometimes injured in dislocations of the knee as evidenced by sensory and motor disturbances throughout their areas of distribution. The most important motion in the knee-joint is that of the hinge type. In addition to this there is a slight gliding action between the femoral condyles and the tibia, and when the knee is flexed there is a slight rotary motion between the two bones. The hinge action takes place between the femoral condyles and the semilunar cartilages, while the gliding and rotary motion is between these cartilages and the tibia. The antero-posterior luxations are more often incomplete than 616 FRACTURES AND DISLOCATIONS eoiiipleti*. Complete lateral luxations of the knee are extremely rare. The most common luxation is forward, and thru in order of frequency, backward, outward, inward and rotary. Great violence is necessary to produce luxation of the knee. I'robably the most eouHuon injury to the knee-joint consists in rupture of the internal lateral ligament with temporary separation of the articular sur- faces on the inner side of the articulation. Symptoms. — Tlie accident is almost invariably the result of severe trauma and if tlie history of the case is elicited an idea of the deg'i-ec of violence applied to the lower extremity at the time of the accident can usually be had. Pain, shock and loss of function are usually pronounced. Any of the luxations occurring at the knee may be complete or incomplete, simple or compound and compli- cated or uncomplieated l)y injury to vessels and nerves. The symptoms will vary according to the details of the case. Abnormal mobility is present. In complete luxations the action at the knee is usually tiail-like and the percentage of cases in which the con- dition is compound is high. In a complete forward dislocation of the knee treated by the author amputation was necessitated by the complete severance of the popliteal artery, and following the oper- ation the knee-joint was partially dissected for the purpose of ascer- taining the condition of the injured structures. The two lateral ligaments, the posterior ligament and the crucials were completely ruptured. The inner head of the gastrocnemius and the popliteus were torn across. The femoral condyles projected through a large rent in the popliteal space and their lower surfaces were about two and a half to three inches below the level of the tibial articular surfaces. The popliteal artery was completely torn across and the ends separated shortly above the popliteal notch. The popliteal and peroneal nerves w'cre also completely divided. The semilunar cartilages remained with the tibia. This type of case is extreme and denumds immediate amputation aliove the knee. It is more common to see an incomi)lete dislocation in which a portion of the femoral condyles remains in contact with the tibial articular surfaces. The loss of alignment in the axes of the femur and tibia is apparent. The forward displacement of the tibia is seen at a glance. The patella is less i)rominent than normal be- cause of the forward displacement of the tibia. If the artery is compressed or divided, loss of pulse and lowering of temperature below the knee will be noted. If the artery is simply compressed, DISLOCATIONS OF THE KNEE fil 7 but not otherwise injured, the pulse will return with reduction of the luxation. Pain may he intense if the nerves are stretched or compressed; if divided, sensory and motor paralyses will he ])resent. In compound eases with laceration of the artery, hemorrliHge is usually not profuse, strange as it may seem. In backward luxations the relations of the tibia and fciinur at the knee, are reversed. The lower end of the femur is prominent anteriorly while the posterior edge of the upper end of the tibia may be palpated posteriorly. If the luxation is complete the bones override in a manner similar to that described in the anterior form of luxation. The condition is uuich more likely to be compound when the luxation is complete. The femur may penetrate the skin anteriorly or the upper end of the til)ia may be found projecting through a rent in the popliteal space. The lateral luxations usually consist of either inward or outward incomplete displacement of the tibia. Complete lateral luxation of the knee is quite rare and the complications accompanying the condition are usually less important than those occurring in the antero-posterior types. In the rotary form of luxation, which is extremely uncommon, the tibia is seen to have rotated on its axis so that the normal re- lations between the articular surfaces are disturbed. The rotation is seldom more than forty-five degrees and is more often outward than inward. The axis of rotation may pass through the outer or inner tuberosity or in the region of the tibial spine. The liga- mentous structures ruptured will depend largely on the axis of rotation. In the different luxations occurring at the knee any or all of the ligaments binding the tibia to the fibula may be ruptured or one of their attachments avulsed, according to the nature and degree of the dislocation. Avulsion of the tibial spine has occurred in lieu of rupture of the crucials. Traumatic reaction is usually pronounced during the first week or ten days following the accident. Function is completely lost in all forms of complete luxations of the knee. Active motion of the leg is sometimes only partially lost when the luxation is incomplete. Treatment. — Traction in the long axis of the lower extremity with coaptation pressure on the displaced articular ends will usually suffice to reduce the luxation. A fragment of bone such as that 618 FRAPTrRES AND DISLOCATIONS l^rodueod by avulsion of the iiisoi-tioii of one of tlie lateral liga- ments, may lieconic iiitcrposeil between the ai'tieular surfaces or a displaced sriuilunai' cartilage may act a.s an oljstaeU' to reduction. Continuous ti-action as exerted by Huek's extension may control a tendency toward recurrence of deformity and is otherwise of service if the traumatic arthritis proves severe. Operative Treatment. — Operation is often indicated in cases in which tile luxation is complete. If the circulation below the knee is destroyed amputation sliould be performed at once. One should be absolutely ])Ositive, however, that such is the case, before remov- ing the leg. Simple compression of the artery will stop tlie pulse and circulation in the leg but with reduction and removal of pres- sure will be accompanied by the return of the pulse in the dorsalis pedis. It may be possible in some of the compound cases to directly examine the popliteal artery through the wound while the patient is on the operating table. When the artery is divided it is usually much lacerated and the ends retracted. In com])ound cases in which the circulation is not destroyed the wound sliould be thoroughly cleansed, the devitalized tissues trimmed away and divided structures approximated. Reduction of compound cases without these precautions is much more likel}^ to be followed by infection and suppuration. (See "Treatment of Compound Frac- tures and Dislocations," page 789.) Open incision is sometimes called for to remove an obstructing fragment of l^one or a displaced semilunar cartilage which interferes with reduction. The possi- bility of operative repair of ligaments should be given careful con- sideration in instances of recovery with loss of lateral stability of the knee-joint. The lateral ligaments are easily exposed through lateral incisions, but operation on the crucials is a much more dif- ficult matter. The crucial ligaments are best exposed through a U-shaped incision dividing the ligamentum patellae. The flap thus made is reflected and the knee ilexed, so that the ligaments may be seen in the popliteal notch. Plastic operations may be needed to bring the ends of the ligaments together and considerable ditificulty may be experienced in placing the mattress sutures because of the narrow^ limits of the popliteal notch. A small full-curved needle should be used. A needle may be heated in a flame and bent while hot to make the curve sufficiently sharp to meet the requirements. After repair of the crucial ligaments the knee should be protected from lateral strain for many months by wearing a brace. DISLOCATIONS OF THE KNEE 6H) After-Treatment. — Following reduction of a disloeation or sub- luxation of the knee the lower extremity should be immobilized on a posterior splint, the leg elevated on a pillow and carefully watched for evidences of stasis. If at any time during the after- treatment it is positively determined that the circulation has been destroyed the leg should be amputated. The general condition of the patient will often require careful attention during the first few days following the accident. If shock is great appropriate stimu- lants should be exhibited and when accompanied by much pain opiates may be necessary. The joint should remain fixed for a period of three months or more according to the extent of liga- mentary laceration. Early use of the knee will usually be followed by instability of the joint and much loss of function. The repair of ligaments is often surprisingly complete if the proper time is allowed before the joint is subjected to strain. Massage, when the splint is removed and during the time the knee is immobilized is of great service in maintaining the tonicity of the thigh and calf muscles. Prognosis. — The outlook in complete dislocations of the knee is not good especially if the condition is compound. The prognosis depends chiefly on the complications, the most important of which are injuries to the artery and nerves and the exposure of the joint to infection in compound luxations. If the case is incomplete and uncomplicated good restoration of function is the rule, provided sufficient time is allowed for the proper healing of the ligaments. Imperfect and incomplete healing of the ligaments may result in loss of lateral stability, sufficiently pronounced to require the use of a jointed knee brace. Surprisingly good function has been reported in a few cases of old unreduced luxations of the knee. If the knee-joint becomes infected following a compound luxation the prognosis will be that of a septic arthritis. In severe compound cases death may ensue from shock, thrombosis, embolism, sep- ticemia, etc., unless prompt and radical surgical measures are insti- tuted. CHAPTER XLIV. IX.IIKMKS .irsT ISF.LOW TIIH KXEK— FRACTURES OF THE T1I51A AM) EllU'LA (UPPER ENDS). The injuries occurring in this region of the leg and to be con- sidered under this heading are: fracture of the upper end of the tibia (either into or below the knee-joint), separation of the upper tibial epiphysis, fracture of the upper end of the fibula, separation of the upper tibial epiphysis and dislocations of the upper tibio- fibular articulation. Surgical Anatomy. — The broad, expanded, upper extremity of the til)ia which tonus tlie tuberosities, is largely subcutaneous and can be readily palpated just below the plane of the knee-joint. The inner tuberosity presents a horizontal groove on its posterior aspect for the insertion of a portion of the semimembranosus. The cir- cumference of the tuberosity is taken up by the attachment of the capsule and the intei'ual lateral ligament. In like manner the circumference of the outer tuberosity is taken up by the capsule on the outer side of the joint, Init the external lateral ligameiits of the knee are not attached to this Ijone but to the head of the fibula. The posterior asi)ect of the outer tuberosity articulates with the upper end of the fibula, and half-way between the tibial tubercle and th(^ tibulai- head is inserted the lower end of the ilio-tibial band. The upper end of the tibia is composed of cancellous tissue which is encased in a thin layer of compact bone. The heavy comi)act tissue of the shaft grows rapidly thinner as the upper end of the bone is approached. Fractui'c of tlie ujjper end of the tibia is the result of direct or indirect vioh-nce, usually tlie former. The line of fracture may be vertical, entei-ing the joint cavity, or it may be transver.se and below the articulation. Transverse fracture of the upper end of the tibia is usually the result of dii'ect violence and tlie displace- ment is, as a rule, not gi-eat. The superficial position of the bone accounts for the frequency of compound fractures in this region, especially when produced by direct violence. AVhen the fracture 620 INJURIES .JUST m-AA)W THE KNEE 621 enters the joint it is usually the result of violent adduetion or abduction of the leg. T-fractures however are usually the result of violence transmitted to the upper end of the bone in the long axis of the tibia. When this mechanism obtains in the i)roduction of fracture of the upper end of the tibia the shaft is driven upward into the upper fragment and usually splits it into two or more pieces. The upper fragment is sometimes extensively comminuted. This type of fracture is most frequently the result of a fall from Fig. 674. — Lateral view of the knee before the epiphyses have joined the shaft. Note how the wpper epiphysis of the tibia extends downward anteriorly to include the tubercle of the tibia. This formation is spoken of as the "lipping" of the upper tibial epiphysis. a height in which the patient lands on the foot. In rare instances the shaft may be driven upward into the upper fragment without splitting the latter and the result is likely to he impaction with shortening of the leg, but no abnormal mobility, crepitus, etc. Most of the fractures of the upper end of the tibia entering the joint cavity are accompanied by spreading of the tuberosities. The action of the lateral ligaments in producing fracture of the tuber- osities or of the femoral condyles has been described under ' ' Dislo- cations of the Knee," and again under "Fractures of the Lower 622 FHACTTRES AM) DISLOCATIONS End of the Femur." Fracture and avulsion of the spine of the tibia due to the ])ull of tlie crueials is a eoniplication of disloca- tions of 1lu' knee, and has been mentioned under Ihat heading. The upper epiphysis of the tibia is ossified from a single center which makes its apiicarance soon after birth and joins the shaft at about the Iwciitictti year. The epiphyseal cartilage corresponds roughlx' 1() a hdi'izoiital i>!aii(' about one inch below the top of the bone. Anteriorly liowcxcr it clii)s downward as it approaches the anterior liorder, to pass under the tibial tubercle. A not uncom- mon anetnaly is for the tibial tuliei-ele to be ossified l)y a separate Fig. 675. Fig. 676. Figs. 675 and 676. — An anomaly in the ossification of the upper end of the libia which is likely to be mistaken for fracture of the tibia. A close examination of an X-ray plate (not print) will show the supposed fragment to be surrounded by a layer of compact tissue and the contour of ossicle does not correspond to the portion of the tibia from which it is supposed to have been broken off. Moreover this type of anomaly is almost invariably bilateral. center. This downw^ard extension of the epiphysis to include the tibial tubercle is of importance clinically. The quadriceps extensor is attached to the tubercle through the ligamentum patellae, and with violent contraction of this muscle the anterior part of the epiphysis (the tubercle of the tibia) may be partially or completely separated from the diaphysis. Complete separation of the tibial epiphysis is an extremely rare condition but a starting of the tubercle with a corresponding partial detachment of the epiphysis is not uncommon in youth. The upper extremity of the tiljula does not enter into the forma- INJURIES JUST BET.OW THE KNEE 62:{ Fig. 677. Fig. 677. — Vertical fracture of upper end of tibia. Fig. 678. — Vertical fracture of upper end of tibia. Fig. 679. — Fracture of upper end of tibia involving the external articular surface. Fig. 680. — Splitting of upper end of tibia. Vertical fractures of the upper end of the tibia such as those shown on tliis page are not uncommon, and if not accurately reduced considerable disturbance in joint function may result. Operative measures are frequently indicated to obtain the best results. 624 I'HACTrKKS AND 1)1SI.(K 'ATIOXS tion of the kiuH'-JDiiit, though thi- two external lateral liwaments of the knee are attaehetl to it. The lon^' head of the hieeps (outer luiiiisli'iii^- luusele) is inserted around the base of tlie styloid j)roeess, and the attaehnients of tlie soh'us. i)eroneus lon.i^rus and extensor longus di,uitoi'uin are eontiimed ni)\\ai'd from the shaft onto the ui)|)er cxtri'iuity of the bone. 'I'his epiph.ysis of the fibula l)egins to os.sify about the foui-th yeai- and joins the shaft at about the twenty-tifth. A'iolent eontraction of tlie bleeps is known to ha\(' caused fraetuiT of the ui)per end of llie libiila. oi' sepai'ation of the epipliysis, and atlduetion of the leg has [)iH)tluced tlie same result tlirough the pull of the external lateral ligaments. Fracture of the upper end of tlie liluda just bt'low the head of the bone is usually the result of direct violence. Occasionally it aeconi))anies fracture of the upper end of the tibia. The upper tibio-libular articulation is a simple arthrodial joint with very limited motion. The articular surfaces entering into its formation are flat and the integrity of the joint depends entirely on tlie strength of tlie ligaments holding the two bones together. Tliis joint possesses an anterior and a posterior ligament which are thickenings in the capsule surrounding the articulation. Anterior and posterior displacements are prevented as long as the force is not sufficient to rupture these ligaments. Upward displacement is prevented not only by these ligaments but by the interosseous memliraiie and tlie lower tibio-fibular articulation. The importance of dis])lacements of the upper end of the fibula depends mainly on the fact that the peroneal nerve winds around the neck of the bone and may be injured with direct violence to the outer side of the leg, or when the head of the fibula is luxated. This nerve can be felt beneath the skin behind the tendon of the biceps. It passes between the tendon of the biceps and the outer head of the gastrocnemius and then winds around the neck of the fibula. It passes forward to join the anterior tibial artery and gives off branches, as it passes down the front of the leg, to supply the extensors of the foot. Injury to this nerve is accompanied by foot drop. Etiology, — Fi'actures of llie upper ends of the tibia and fibula are usually due to direct violence. Forcible adduction or abduction of the leg may result in fracture of the tuberosities. Violence transmitted in the axis of the leg may produce fracture of the upper end of the tibia and fibula, although all forms of indirect INJIJKIES .MIST 15Ely()W TJIE KNEE 625 violence are more likely to produce fracture below the middle of the shaft. Symptoms. — Because of the' variety of fractures which occur in this region, the symptoms seen in different cases vary considerably. The swelling and deformity which accompany simple transverse fracture of the upper end of the tibia may be remarkably slight. I have seen a number of cases suffering from this type of fracture in which the patient was able to bear weight on the leg. The dis- ability, however, is usually complete. Abnormal mobility is almost invariably present although impaction of the lower, into the upper fragment, may result in the leg being quite firm. AVhen the frac- ture is of the T-type or in instances in which one of the tuberosities Fig. 681. — Fracture of upper end of tibia. Note thickening at point indicated by arrow. is broken off, articular distention" and traumatic arthritis develop rapidly. Under these circumstances the lateral stability of the knee is usually lost and abnormal lateral mobility is apparent as soon as the parts are manipulated. The leg may be adducted or abducted to an abnormal degree and this maneuver usually pro- duces crepitus. In T-fracture of the upper end of the tibia or in fracture of one of the tuberosities, the tuberosities may be spread to such an extent that the condition is readily recognized by inspection alone. (See Figs. 681 and 682.) The parts below the knee are tender and painful. Fracture in this region, due to direct 626 FKACTrRES AXn DISI.OCWTIOXS violence, is often oomjiound and il' tlu- lino of fracture enters the joint it may be followed by suitpurative arthritis. Avulsion of tlic tubercle of the tibia is accompanied by a more or less upward displaeeinent of the patella accordino; to the extent of teariuii- in the latei'al expansions of the aponeurosis of the (puidri- ceps extensoi-. Tlic loose detached fragment can be palpated without ditificulty unless the swelling is intense. Tlie liganientum patella' is abnornudly lax. Kupture of the patellar ligament gives Fig. 682. — Longitudiiinl fracture of the upper end of the right tibia. Tuberosities spread so that finger may be pressed into external articuUir cavity just above prominence indicated by arrow. Such a fracture will interfere with the use of the knee joint unless the fragments are brought together and held in place. Operation is usually necessary in this type of case to secure the best results. a similar symptom-complex except for the absence of the detached fragment of the tubercle. Separation of the upper tibial epiphysis is attended by symptoms similar to fracture in this region. The epiphysis may be displaced in any direction. The crepitus produced by manipulation is soft and cartilaginous. The condition is extremely rare. Fracture or epiphyseal separation of the upper end of the fibula is accompanied by local tenderness and pain especially when the leg is used. It is often possible to move the head of the bone about. Crepitus is usually elicited without difficulty. If the fracture is INJURIES JUST BELOW THE KNEE 627 through the tibio-fi})ular articulation or below it, pressure on the shaft of the bone, in the middle of the leg', will produce pain at the seat of fracture. Injury to the peroneal nerve will b(^ productive of characteristic symptoms in motion and sensation throughout the distribution of the nerve. In luxations of the fibular head the upper end of the bone is more prominent than normal and its dis- placement either forward or backward is, as a rule, easily recog- nized. Injuries to vessels and nerves are not as common in this region of the leg as they are in fractures of the lower end of the femur but when they do occur the same train of symptoms will become mani- fest. Diagnosis. — There is, as a rule, little difficulty in recognizing fracture in this region. A simple transverse break, however, just below the tibial tuberosities, may, in rare instances, be difficult to determine without the aid of the X-ray. In the exceptional cases in which the shaft is impacted into the upper fragment with- out splitting the latter, abnormal mobility may be absent, but the condition should be recognized by the shortening of the leg, and in some instances there will be sufficient angular deformity to indi- cate the nature of the lesion. The X-ray is of the greatest value in determining the nature of the injury in the exceptional cases in which the physical signs are indefinite. When the upper end of the fibula alone is fractured the patient may be able to get about, though the use of the member entails more or less swelling and pain. This fracture has not infrequently been overlooked in spite of the fact that pressure in the middle of the shaft is productive of pain at the site of the lesion, if the fracture is below or through the upper tibio-fibular articulation. If the frac- ture is above this level it should be recognized by direct palpation. Treatment. — The desiderata in the treatment of these fractures are: reduction of deformity, immobilization of the fragments and restoration of function after the fragments have united. The details of treatment will vary with the type and severity of the fracture. In a simple transverse fracture of the upper end of the tibia, deformity is often slight and reduction easy. Strong traction on the leg with direct pressure over the displaced frag- ment will usually effect reduction. The fragments, however, are often so well apposed that nothing in the way of treatment is indi- cated aside from fixation. The lower extremitv should be immo- 628 FRAPTURES AND DlSIiOCATIONS bilizml on a lony posterior splint extcndinp; from jusi nbovo the lit'cl to a ])oint a short distance below the biittoek. 'I'lie re<;ulation ham sjjliiit iua\' I'e used or cue may he iiuuh' ot" plaster. 'The knee sliould be tixed in a i)ositii)n just short of complete extension and the padding einpU)yed shouM lie so disposed as to eveidy and tirndy support the lower exti'emity throughout the length of the splint. If there is any tendency for the foot to be rotated inward or out- ward the si)lint should include the foot. Tins may be accomi)lislied by a posterioi- plaster splint extendini^- downward to include the heel and sole of the foot. The same result uuiy be hail by means of a long plaster stirrup extending well up onto the thigh, or the long side T-splint, similar to that used in fractures of the hip, may be employed. AVhichever splint is used the means of securing it in position will be found in adhesive strips and bandages. In cases in which the traumatic reaction is severe, and rapid in onset, it may be advisable to postpone manipulation of the parts until it has subsided. This is }>articularly true when the fracture has entered the knee-joint with the development of a traumatic arthritis. When the fracture enters the joint cavity the correction of deform- ity and maintenance of the fragments in proper reduction is usually nuicli more difficult than in simple transverse fracture. In a T-fracture, or breaking off of one of the tuberosities, an attempt should be made to force the fractured surfaces together so that the articular surfaces on the head of the tibia will be in proper relation with the condyles of the femur. This is often a difficult matter and requires skillful manipulation. If one of the tuber- osities has been broken off, lateral deviation of the leg to the opposite side will often facilitate reduction of the displaced frag- ment. If the fracture is of the T-type with separation of the tuberosities, adduction or abduction of the leg will accomplish nothing. Under these circumstances strong traction in the axis of the tibia will lie necessary while the tuberosities are forced together by lateral pres.sure. In some cases it will be impossible to approximate the tuberosities in this manner, and in other instances the tendency to recurrence of deformity may be so great that the tuberosities separate as soon as traction and lateral pressure are removed. Under these circumstances open reduction either with or without internal fixation is indicated. Not infrequently a loose fragment of bone between the tuberosities acts as an obstacle to reduction and will require removal before the fragments can INJURIES .IITST BELOW TIIK KNKE 629 be brought into proper position. Tn instances in wiiich the shaft, has been driven into the ui)per end of the tibia with extensive comniinution, the destruction of bone may be so great that it is impossible to restore the original contour of the upper extremity of the bone. In this type of case continuous traction by means of Buck's extension will often accomplish more than any other method. AVhen extension is employed for this purpose the lower extremity should be so fixed to the splint that the traction does not pull the axes of the tibia and fibula into the same straight line, otherwise the normal lateral angle of the knee will be obliterated. What has been said of the treatment of fracture of the upper end of the tibia applies equally well in separation of the upper tibial epiphysis. Avulsion of the tibial tubercle in the adult usually calls for operative treatment to secure the fragment in proper position. Straps of adhesive above the patella to prevent upward displace- ment, and bandages about the upper part of the leg to force the fragment home are, as a rule, only partially successful. If there has been little or no upward displacement of the fragment non- operative measures will probably produce the desired result. Starting of the tubercle as an epiphysis is usually not attended by much displacement and the treatmeiit will consist of fixation and rest until the loosened portion of the epiphysis has become firmly fixed again. In luxations of the head of the fibula, pads may be so placed, and held in position by straps of adhesive plaster, as to prevent recur- rence of deformity. The lower extremity should be immobilized for three or four weeks, and in backward luxations the condition should be treated with the knee semiflexed to relax the pull of the biceps. If these measures are not effective in maintaining reduc- tion, or if evidences of nerve laceration are present, operation is indicated. Operation is also indicated in fractures of the fibular head with upward displacement of the fragment. Operative Treatment. — In cases of simple transverse fracture of the tibia below the knee, with good reduction, operative interven- tion oft'ers nothing, but when the fracture enters the joint cavity it may become necessary to cut down on the fragments to restore the articular surfaces of the knee-joint to their normal relations. Cases in which the tuberosities cannot otherwise be brought back into proper relation, or in w^hich recurrence of deformity takes 630 FRACTURES AND DTSLOCATTONS place, should be operated upon. If two longitudinal incisions are made, one on the inner and the otlicr on tlic oultM- side of the joint, the fraijnient.s ni;iy he directly niaiii|)ul;i1e(l and reduction effected.' If a solid engairement can be obtained between tlieni, tlie incisions may be closed and splints ai>plied. If a tendency toward tlie recurrence of deformity is manifest the fragments should be secured by some method of internal fixation. Non-absorbable materials should not be used if the fracture is compound. In a number of cases of T-fractures the author has found the following procedure satisfactory : two holes are drilled transversely tlirough the tuberosities after they have been forced together, and a lieavy silver wire is threaded through the holes and the ends tightly twisted together, tlnis maintaining the fragments in proper position and restoring the intra-articular surfaces in their normal relations. Tliis method is equally efficient in instances in which one of the condyles is broken oflp and displaced. The principle is the same as that already described as "transverse wiring" under the heading of "Operative Treatment of the Lower End of the Femur." Nails, screws, and the Lane plate are at a discount in this region because of the internal structure of the upper end of the tibia which is composed of a loose cancellous tissue. Compound fractures of the upper end of the tibia should be treated according to the principles laid down under the heading of "The Treatment of Compound Fractures" on page 789. Avulsion of the tibial tubercle with displacement of the frag- ment can seldom be reduced and maintained in proper position without operation. The fragment may be secured in place by means of a small nail or it may be sutured to the adjacent peri- osteum and surrounding soft tissues with absorbable suture material. Prol)ably the best method in the adult, is to secure it to the shaft by means of a loop of silver wire. The scale of bone torn away may be too small to fix in this manner, or instead of an avulsion there may be a rupture of the patellar ligament, and when either of these conditions is encountered, the operation must consist of suturing of the soft tissues to properly anchor the ligament. When the tubercle is avulsed as an epiphysis it sliould not be sutured in position witli anything except absorbable material. An occasion calling for open reduction of a complete separation of the upper tibial epiphysis almost never arises. In fractures or dislocations of the upper end of the fibula, the condition most often INJURIES JUST BELOW THE KNEE 631 rendering operation necessary, is injury to tlie peroneal nerve as it winds around the neck of the bone. When a portion of the fibular head has been displaced upward by the pull of the biceps, the fragment should be exposed, replaced and sutured in position. Non-operative methods of correcting this displacement are usually not successful. In dislocations of the head of the fibula the most prompt recovery and complete restoration of function follow open reduction, with fixation of the head in proper position against the external tibial tuberosity. This may be accomplished by suturing the soft tissues about the head or by means of a single loop of wire passed through the adjacent portion of the tuberosity. After-Treatment.— The first portion of the after-treatment will depend largely on the intensity of the traumatic reaction following the injury and whether or not the knee-joint is involved. When the reaction is severe it is often best to postpone manipulation of the parts until it has subsided. The lower extremity should be treated on a pillow-splint and the member elevated to favor circu- lation. The ice cap will aid materially in controlling the swelling. Undue constriction of the member should be avoided. With the subsidence of swelling, reduction should be accomplished by non- operative methods, if possible, or with operation if necessary. At the end of ten days or two weeks a permanent dressing should be applied. The plaster cast or plaster splints will be found quite satisfactory in this respect. If the plaster cast is used it should be split up the front before the plaster has set so that it may be removed during the after-treatment for inspection, massage and passive motion of the leg. Repeated adjustments will be found necessary during the after-treatment to keep the patient comfort- able. Frequent inspection of the leg is necessary to recognize and treat pressure points on the skin, should they develop. In the healthy adult union is to be expected in an uncomplicated case at the end of six weeks, but the callus at this time is too soft to with- stand any considerable strain. The full weight should not be borne on the leg for another month. Gratifying results have been obtained by use of the ambulatory pneumatic splint in simple frac- tures of this region. When this splint is employed it is often possible to begin the ambulatory treatment as .soon as the acute swelling has subsided. In compound fractures of the upper end of the tibia recovery maj" be much delayed b}^ the development of 632 FRACTURES AND DISLOCATIONS iK'(_Totic boiU' or arthritis of tlic knee, rersistnit diseliarging sinuses call for operation to remove the dead bone. Early guarded passive motion will accomplish a great deal in the prevention of permanent adhesions within the joint cavity. Anesthesia and forcible passive motion may be indicated to break up organized adhesions within the knee. Even arthrotomy may be called for in instances in which the adhesions are unusuall.>' strong. Early passive motion is called for to restore the function of the knee but the greatest care should be exercised to avoid refracture during the time the callus is friable. If a firm grasp be taken of the upper end of the tibia, force may be applied with much less risk than is the case when the leg is moved by the usual grip above the ankle. The lower the leg is grasped, in performing passive motion, the less the surgeon appreciates the leverage he is exerting against the upper end of the bone and the articulation. The dress- ing should be renewed from time to time to accommodate the changes which occur with the onset and subsidence of swelling. The older the patient the longer the time required for firm union to take place and the more imperfect recovery will be in the end. In avulsion of the tubercle of the tibia union may be expected within six weeks and the member may be actively used at the end of two and a half months. If the condition has been treated by non-operative methods the parts should be frequently inspected to see that the strappings are properly performing their function in holding the fragment in reduction. In separation of the upper tibial epiphysis the knee should be immobilized for a period of six weeks during the latter half of which time passive motion should be performed at intervals of four or five days. In dislocations of the upper end of the fibula retentive apparatus should be kept in place for about a month, provided the luxation has not been secured in position by operation and internal fixation. During this time undue strain should be avoided, especially activ- ities which involve forceful contraction of the flexors of the leg of which the biceps is one. Prognosis. — The prognosis of fractures of the upper end of the tibia is very variable according to the extent and severity of the lesion. Simple fractures not produced by severe trauma are usually followed by complete restoration of function. On the other hand, a severe compound fracture entering the knee-joint may be INJURIES JUST BELOW THE KNEE 633 followed by infection of the knee-joint with .septicemia and death. Restoration of function in severe cases is usually prolonged and seldom complete. The development of septic arthritis renders the fracture itself only of secondary importance. The prognosis fol- lowing operative cases is better than those treated by non-operative methods. Union often takes place with permanent thickening below the knee and the motion in the articulation is not infrequently restricted. The prognosis of avulsion of the tubercle of the tibia in the adult is good with proper treatment; when separated as an epiphysis the prognosis is equally good. The prognosis of fractures and dislocations of the upper end of the fibula is good, aside from the injuries sustained by the peroneal nerve. "When the nerve is injured the outlook varies with the degree of the injury and the completeness of repair which is pos- sible at operation. CHAPTEK XLV. FRACTURES OF THE SHAFTS OF THE BONES OF THE LEO. The division of fractures of the leg into: Fractures of the upper ends. Fractures of the shafts and Fractures of the lower ends, is not a scientific classification of these injuries, yet it forms a work- ing basis for their consideration. There is no hard and fast line to be drawn l)etween fractures of the shaft and fractures of the extremities. The nearer the break is located to the end of the bone the more it assumes the characteristics of a typical fracture of the extremity. Surgical Anatomy. — The shafts of the bones of the leg are each ossified from centers which make their appearances during the seventh and eighth weeks of fcetal life. That for the tibial shaft delevops first. The shaft of the tibia constitutes the main strength of the leg. It is distinctly triangular in cross-section and shows three surfaces separated from each other by three prominent borders. The anterior border is subcutaneous and may be palpated from the tibial tubercle to the internal malleolus. The lower third of this border, however, is much less prominent, and is more or less obscured by the tendon of the tibialis anticus. The external border is directed toward the fibula and has attached to it the heavy interosseous membrane. The internal border may be palpated throughout, though in Avell developed persons the middle portion is more or less encroached upon by the bellies of the flexor muscles of the foot. The internal surface of the bone is subcutaneous except for the insertions of the gracilis, semitendonosus and sartorius, which are attached to the upper end, a short distance below the inner tuberosity. AVith the intense swelling, which so frequentlj' develops following fracture, it is hard to realize that this portion of the bone is subcutaneous. The thickening is often sufficient to obscure the outline and render palpation difficult, but it should be remembered that this infiltration is in the subcutaneous tissues and that gentle, firm and continued pressure, with the finger tips, o:i4 FRACTURES OF .SHAFTS OF THE BONES OF LEG 635 will SO displace these fluids that the condition of the hone may he recognized. The weakest part of the tibial shaft is at, and just below, tlie junction of the middle and lower thirds, and it is here that fracture most frequently occurs. The shaft is composed of a tid)e of lieavj' compact tissue and the fractures occurring in this region are clean cut and show no impaction or crushing of bone tissue. Comminu- tion is not infrequently seen and the fracture may be multiple; but the fragments are hard and the edges clean cut, and screws find a firm foothold when the Lane plate is employed to secure reduc- tion and immobilization. The shaft of the tibia normally bows slightly forward while the fibula bows a little in the opposite direc- tion. The shaft of the fibula is almost entirely surrounded by muscles which act as cushions in the presence of direct violence. The upper extremity and external malleolus are the onl}^ portions of the fibula which can be satisfactorily palpated. The lower third or fourth of the external surface of the bone may be felt between the peroneus tertius anteriorly and the peroneus longus and brevis posteriorl5^ The shaft of the fibula is long and slender and nor- mally possesses a certain degree of spring when compressed against the tibia. This fact is of importance clinically since lateral pres- sure, in the presence of fracture, will detect an increase or loss of this spring as compared with the opposite fibula, even though the bone cannot be directly palpated. The shafts of the bones of the leg are usually both broken, though isolated fracture of either bone may occur. The fibula is more frequently fractured than the tibia. AA^hen both bones are broken the lesion in the fibula is usually at the higher level. The fracture in the tibia may be transverse, oblique, spiral, or longi- tudinal. Spiral and oblique fractures are quite common below the middle of the shaft and are usually the result of indirect violence. Transverse fractures are more common above the middle of the shaft and are usually due to direct violence. The upper posterior portions of the shafts of the bones of the leg are covered and protected by the heavy calf muscles, and the tendo Achillis in the lower part of the leg is capable of breaking the force of a blow, when direct violence is sustained from behind. Anteriorly the tibia has no such protection but receives the full force of direct violence applied to the shin. 636 P^RACTURES AND DISLOCATIDXS Fig. 683. — Compound tiM.iuii' .ii Imtli Imiws of the leg. Note the eversion of the foot and comi)are it with tlie patella which is directed upward. Fig. G8.5. — Compound fracture (jf Ijoth bonc-.s uf the leg with sliurtening and ever- sion. Result of direct violence. Note the position of the patella which looks directly upward while the foot is decidedly everted. Lower end of upper fragment penetrated the skin where the wound is seen at "x." FRACTURES OP SHAFTS OF THE BONES OF LEG 637 The subcutaneous position of the anterior border and internal surface of the tibia accounts for the large proportion of compound fractures in this region, especially when caused by direct violence. The direction of the oblique or spiral fracture is usually from above, downward and forward. Etiology. — Fracture of the shafts of the bones of the leg is rather a common accident and results from either direct or indirect Fig. 686. Figs. 686 and 687. — Show a simple fracture of both bones of the leg in their lower thirds. Note the inward falling of the foot, while the position of the knee is normal. Photographs taken a few minutes following injury. violence. It is often caused by a twist of the leg, a fall from a height, a direct blow on the shin, or a crushing force, such as being run over by a wagon. Fractures of the fibula alone are usually the result of direct violence. Fracture of the tibia alone is almost always the result of direct violence. Fracture of the shafts of these bones occurs most frequently during the fourth, fifth and sixth decades. This accident is the most frequent, occurring in the 638 FRACTIKKS WD DISLOCATIONS lowtT oxtri'iiiity. nnd constitutes jipin'oxitiiatcly six jxTi't'iit of all fractuiH's. Symptoms.-^— liiiiiic(li;itc ami lota! loss of fiiiictioii is the rule. Fig. 688. Fig. 689. ■Figs. 6.SS and fiSO.^ — Friictiire of botli hones of tlie leg near ,iuniick"s t'xiciision, in frae- tures ol" tilt' hip. Adlifsixc j)histci' when applied lo Ihe foot and aiikli' is liki'ly to irritate the skin, l)ecause of the small area to wliicli it eaii be attached. The antlior has round the following method very satist'actoi-y in instances in whicli extension was found necessary. Tlie patient's slioc is cut so that the "'upper" is divided Pig. 714. Fig. 713. — .interior and ixisterior jjla-ster splints apiilied to leg and held in posi- tion by encircling straps of adhe.sive plaster. Pig. 714. — Plaster stirrup. The two side splints are made of one continuous piece of gauze which passes under foot. As a permanent dressing this sjilint is probably the most efficient and satisfactory in fractures of the leg. from the sole. Slits are then cut in the sides of the "upper" and adhesive straps passed through them to he carried below the foot to a spreader, the same as employed in Buck's extension. The upper is then placed on the foot, the lacings tightened and a weight attached to the cord after it has been passed through a pulley se- cured to the foot of the bed. Six, eight or ten pounds will usually FRACTURES OF SHAFTS OF THE BONES OF LEG 649 suffice in correcting the deformity hut the amount of weight em- ployed should he governed entirely hy the degree of nmscular spasm to be overcome. Extension can be exerted in this way without irritating the foot and ankle during the time it is fixed on the temporary splint; counter-extension is had by raising the lower extremity on an incline plane or by raising the foot of the bed. Instead of splints, sand l)ags may be placed on either side of the leg and will serve the purpose well in steadying the parts. It is often impossible to forecast the degree of traumatic reaction which will follow in a given case and it is therefore best to post- pone the application of a permanent splint until this reaction has passed. The tension produced by the swelling, the internal lacer- ation of soft tissues by the fragments at the time of injury, and the not infrequent venous thrombosis about the site of the fracture are conditions tending to impede circulation and demand dressings which do not constrict the leg. The plaster cast has been exten- sively used in the early treatment of fractures of the leg and good results have attended its use, yet the author feels that it is an unsafe appliance and is inferior in every way to the plaster stirrup or plaster splints. With either plaster splints or the plaster stirrup the dressings may be tightened or loosened as the occasion demands and during the entire course of the case a strip of skin, extending the length of the leg, is open to inspection. The plaster cast is much safer during the later half of the after-treatment and forms a good method of fixation for ambulatory treatment. Isolated fractures of the tibia are rarely followed by much swell- ing, and fracture of the tibia alone is usually productive of a much milder traumatic reaction than occurs when both bones of the leg are fractured. The surgeon is usually able to estimate, with more or less accuracy, the degree of traumatic reaction to follow in a given case. Occasionally, however, cases are encountered which promise little in the way of swelling when first seen, and yet a few days later show the most marked symptoms. If such a case is wearing a permanent dressing of the nature of a plaster cast, great damage may be done to the leg before either the surgeon or the patient realizes the condition. Numerous modifications of splints (such as the Desault and plas- ter traction splints) have been devised to maintain reduction by means of extension and counter-extension until the fragments have become firmly enough united to prevent displacement. These ap- 650 FRACTURES AND DISLOCATIONS })liaiioes are well enough as a ]>enuanent dressing, in instances in which operation is contraiiulicated hecause ot" disease, ag(> or lack of surgical I'arilities, liul under ordinary cii-cniiistanees tliey are to he considered as ohsoh'te and to be disearded in favoi- ol' operative methods with direct tixation of the fi-agnients. The treatment of compound fractiii-es of the l)ones of tlie leg is essentially oi)erative, at tlie present time, and witli tlie vastly better results obtained in this way, there can be nothing but censure for non-operative metliods, [jrovided there are no constitutional con- traindications and surgical facilities are available. (See "Opera- tive Treatment," below.) A conunon and serious mistake in tlie treatment of compound fractures in this region is to ett'ect an inune- diate reduction as soon as the case is seen, often on the street or in the factory. This i)i'ocedure has probably been resi)onsible for the loss of numy legs which could otherwise have been saved. The ends of the fragnuMits projecting through the skin nuist be considered in- fected and if an iunnediate reduction is performed the patient will be fortunate, to say the least, if the entire tract does not become septic, with the usual disastrous train of symptoms following. Instead of attempting immediate reduction, the wound and exposed bone should be covered with a sterile dressing and the patient re- moved to surroundings in which proper surgical procedures can be carried out. (See "Treatment of Compound Fractures," page 789.) Operative Treatment. — There are four sets of circumstances which commonly call for operative treatment. First, to accom- plish and maintain reduction in recent cases in which non-operative methods have failed ; second, in the treatment of compound frac- tures; third, when non-union is present, and fourth, for the correc- tion of old fracture deformities. A large proportion of closed fractures of the leg demand operative intervention to secure the best results. The best time for operation in simple cases is after the traumatic reaction has subsided, which will be at the end of a week or ten days. The most aseptic tech- nique should be followed and other precautions observed such as are mentioned on i)age 754 under the heading of "Open Treatment of Fractures." A longitudinal incision should be made, preferably to the outer side of the midplane of the leg, so that the external surface of the bone will be exposed. It is not advisable to make the incision opposite the internal surface of the FRACTURES OP SHAFTS OF THE BONES OF LEG 651 tibia, since this face of the shaft is subcutaneous. In difficult cases two incisions may be made, one as already described and the other opposite the internal border of the bone on the inner aspect of the leg. Traction and direct manipulation of the fragments will ac- complish reduction and occasionally it may be possible to obtain a solid engagement of the serrated surfaces, thus obviating the ne- cessity of direct fixation. In most instances, however, in which operation is indicated, it will be found necessary to resort to some form of internal fixation to prevent recurrence of deformity. A very satisfactory method of securing the fragments, and one which Fig. 715. Fig. 716. Figs. 715 aud 716. — Lateral and anteroposterior views of comminuted fracture of tibia. Transverse fracture of fibula. will serve the purpose in most oblique and spiral fractures, is shown in Fig. 717. This consists in passing two wires about the shaft of the bone. The distance between them should be at least an inch, to secure the proper leverage. In some instances the Lane plate can be used to advantage. Transverse fractures can often be en- gaged in such a manner that no internal fixation is necessary. If a plate is used it is preferable to place it on the external surface of the shaft so that it will not be subcutaneous. In knotting or twisting wire, the twists or knots should be placed on this same surface. With the wires or plate in position the strength of the fixation should be gently tested to see that the fragments are solidly enough held. It should be possible to raise the foot by the 652 FRACTURES AND DISLOCATIONS heel witliout disturbing tlic i-rlative positions of the fragments. AVlu-n the internal fixation has been eonipleted and tested the wound sliould ])e closed and a small drain of silkwoi'm ^rut placed Fig. 717. Fig. 718. !■ ig. 717. — Same case as slinwn in Figs. 71.'^ and 71(1. X-ray plate made three weeks after operation in w'nicli tlie Ijoncs were wiri'd in two iilnces. Aseptic healing and ultimately perfect function. Fig. 718. — Same leg shown on posterior plaster splint. The anterior splint lias been removed to di-ess wounds. (See Fig. 7i:!.) in position to allow Ibc cscajx' of blood and scniiii during the first twenty-four or forty-eight houi's. A heavy plaster stirrup sliould be applied before the patient comes out of the anesthetic. A quick drying plaster sliould be used so that the stirrup may be well set FRACTURES OF SHAFTS OF THE HONES Ol"^ \jK(i 65.'^ before the patient leaves the operating room. If a sheet, rinrrovvly folded lengthwise, is passed once around the thigh just above the knee, and the ends secured to the side rails of the bed, it will pre- vent the patient moving the lower extremity while coming out of the anesthetic, and will be of valuable assistance to the attendant during this time. The leg should not be covered with the bed clothes during the first twenty-four hours following operation, so that the plaster may become thoroughly hardened and dried out. Failure to observe this precaution will probably necessitate the reapplica^ion of the dressing, to say nothing of the possibility of damage to the limb through lack of support. In compound cases the patient should be taken to the operating room as soon following the accident as possible. An anesthetic should be given, the skin surrounding the wound painted with five percent iodine and the incision enlarged if necessary. The wound should be irrigated with a few gallons of sterile salt solu- tion. Completely detached fragments of bone should be removed and the main fragments brought into as good alignment as possible. Devitalized tissue should be trimmed away and oozing controlled by hot salt solution. Active bleeding from small arteries should be stopped by torsion, if possible, rather than by ligature. Internal fixation of the fragments at this time is contraindicated regardless of the material used. The freshened surfaces of the wound should be approximated and a small drain of silkworm gut left in position to allow the escape of blood and serum. Dressings are then ap- plied to the wound, the leg covered with a layer of sheet cotton and a plaster stirrup employed as already described. "When the patient is transferred to the bed the leg should be w^ell elevated and an ice cap (one that does not leak) is placed on the anterior aspect of the leg in the region of the fracture. An attempt should be made during the operation to secure as accurate reduction as possible, yet it should be remembered, in these cases, that accurate reduction at this time is not the essential. The most important factor is to obtain healing of the wound which renders the frac- ture compound. If the position of the fragments is bad, a second operation may be done at some later date, after the wound has healed and the surgeon is free to work in an aseptic field. This can usually be done at the end of ten days or two weeks. If sup- puration and infection follow, in spite of the measures just ad- vised, the fracture must be treated along general surgical lines 654 FRACTURES AND DISLOCATIONS Avith free drainage, etc. The nuniber of infected cases, however, followincr this line of procedure will be sur])risingly small as com- pared with the cases in which local aiiplications of hichloi-id of mei'cury and other useless antiscplics are the agents dcpciidcd niton to prevent infection. Operation may be indicated to coricct old Iratdnrc dcfofnuties in whieli the pooi- alignment of fi'agmeids is accomj)anit'd by pro- nounced disturi)ance in function. In a case of this type the sur- geon should not be overanxious to operate if the patient is showing any improvement whatever. The restoration of function ma\- be greatly delayed and still the patient nuiy ultimately obtain a serv- iceable member without surgical intervention. When oi)eration is necessary the procedure is similar to that already described, with the addition of appropriate osteotomy to bring the fragments back into proper position. When operation is called for because of non-union the tirst indica- tion is to seek the cause of the failure in union. (See Chapter LXI.) After-Treatment. — A great deal of care and attention is called for in the after-treatment to keep the patient comfortable and to see that the dressings are performing their proper function. Eepeated adjustments will be necessary, especially during the time the leg is changing in size, with the onset and passing oft" of swelling. During the first week or ten days the leg should be inspected at least dail}' and readjustments made. Blebs should be opened after they have fully formed and the denuded surfaces dusted with boric acid or some other efficient dusting powder. These surfaces should receive the most careful attention and it nuist not be for- gotten that the member may become infected through such an atrium, especially in the presence of low resistance in the surround- ing tissues. The sooner ambulatory treatment is instituted, following the subsidence of traumatic reaction, the better for the patient in gen- eral and the fracture in particular. In non-operative cases the patient may be gotten up on crutches within five or six days of the application of a permanent splint. When open treatment has been employed to accomplish reduction, a week should elapse following the operation, before the patient is allowed up. In compound cases the wound should be well healed and the fragments in good position for a week or more before ambulatory treatment is insti- tuted. Complicated cases should remain in bed until the outlook FRACTUKIOS OK SHAFTS OF 'I'llE I'.ONKS OK IjKG 655 is favorable and convalescence well established. The patient sliouhl be allowed up for only a few minutes during the first day. The time should be increased the second day, and so on during the fol- lowing week until the limb can be held in the dependent position without undue swelling and pain. During this time he will gain control of the crutches, and the annoying sensations in the leg, attendant upon the erect position, will gradually grow less and finally disappear. At the end of nine or ten weeks the foot may be placed on the floor as the patient walks with crutches. During the following three or four weeks weight bearing should be grad- ually resumed. During this time the surgeon should wateh the leg Fig. 719. — Ambulatory pneumatic splint as used iu fractures of the leg extension mechanism at the end of the splint. Note the carefully for signs of a weak callus. The slightest bowing or short- ening of the leg demands immediate cessation of weight bearing. Swelling is often persistent and pronounced and should be treated by daily massage and immersion of the leg in hot Avater once or twice a day. An elastic stocking Avorn during the day will aid materially in controlling this swelling. The older the patient the longer the time necessary for the formation of firm weight bearing callus. In the very aged it may be impossible to obtain union at any time. In the exceptional case in which the surgeon maj^ be in doubt as to the best time for the resumption of function, an X-ray plate will afford the desired information concerning the con- dition and progress of callus formation. 656 FRACTIRES AND niSI,(M'ATl(1N:^ Fig. 720. — Old fi'a;-ture of the tibiu and fibula with discluirgin? .sinus eight years later. The condition has been an intermittent source of trouble during the entire eight years. This is a good example of a type of ease requiring operation for the removal of necrotic bone. Fig. 721. — Picture taken to sliow the swelling which so fretiuentlv persists follow- ing fractures of the l)ones of the leg especially with patients past middle life. Picture taken some months following the accident. The ring about the leg corresponds to the upper end of the elastic stocking. f^RACTTIRES OF SHAP^TS OF THE BONES OF IjEC, 657 Prognosis. — The prognosis in fractures of the l(;g is extremely variable and depends largely on the associated injuries to the soft tissues and whether or not a compound fracture becomes infected. Persistent swelling is common and may last for years. It is de- pendent on the damage done to the circulation at the time of the injury and on the development of venous thrombosis following the accident. The more severe these conditions, the more pronounced and persistent will be the swelling when function is resumccl. Pain in the leg may persist for months or even years following the acci- dent. Considerable disturbance in function usually follows vicious union of the fragments and is due to the mechanical strain imposed Fig. 722. Fig. 723. Fig. 72.5. Figs. 722, 723, 724 and 72.5. — Show tlie mechanical disturbances which follow union with deformity. When the leg diverges from the weight-bearing line the leg will be mechanically "off" and as a result there will be more or less permanent disturbance in function. on both muscle and bone by this faulty position. The more per- fect the apposition of the fragments and the less the damage to soft tissues at the time of the accident, the less pronounced will these annoying sequelae be. The percentage of cases in which perfect and prompt restoration of function occurs, has greatly increased since the advent of open treatment for the accurate correction of deformity. In compound infected eases, sinuses may persist until the necrotic bone from which they lead is removed by operation. Kefracture of the bones of the leg may occur if sufficient strain is sustained before the callus becomes thoroughly hardened. Kefrac- ture is through the callus and not the fragments. About one-half 658 FKACTl'RES AND DISLOCATIONS to two-thirds the time required for union in th(> ori^nnal break is necessary for union in a fraetured rallus. Hnil)olisiii from a de- tached portion of thrond)us or a fat cniholus may ])i'odu{'e immedi- ate deatli. Infection in compound cases may result in the loss of the leg, or if severe, even death. Desti-uetion of tlte eii-cidation in severe crushing injuries calls for iiiiiniMJi.-ite jimpulation. CHAPTER XL VI. POTT'S FRACTURE. Pott's fracture is both a fracture and a dislocation, and although it is usually included under the heading of fractures, yet it is probably more in accordance with the pathology of the condition to consider it as a dislocation complicated by fracture. Aside from fracture of the fibula. Pott's fracture is the most common injury of importance occurring in this region, and be- cause of this frequency and the poor results so often seen following its improper treatment, it will be taken up under a special heading. Surgical Anatomy. — There are three bones entering into the formation of the ankle joint ; the tibia, fibula and astragalus, and the disposition of these three bones is of great importance surgically. The trochlear surface of the astragalus fits the articular surface of the lower end of the tibia and is held in place laterally b}- the malleoli. Lateral motion between the astragalus and tibia is pre- vented by the tight, firm, mortise-like formation of the tibia and fibula. The two latter bones are held together by the lower tibio- fibular ligaments, the most important of which is the inferior in- terosseus, which passes between the contiguous rough surfaces of the tibia and fibula. These ligaments are so strong that separation of the two bones rarely takes place without fracture of either the tibia or fibula. The lateral ligaments are also of great strength and are more likely to tear away their attachments than to suffer rupture. They bind the astragalus and calcaneum to the lower end of the tibia but have little to do with the limitation of normal flexion and extension. The anterior and posterior ligaments are thin, loose and lax, and are not brought to a tension until the ankle either comes to extreme flexion or extension. When the foot is depressed to its limit of motion the anterior ligament becomes taut and in like manner the posterior ligament is brought to a tension when the ankle is dorsally flexed. Distention of the joint is first noted in the bend of the ankle w^here the thin anterior ligament is pushed forward by the fluids within the articular cavity. The 659 660 FRACTURES AND DISLOCATIONS outer malleolus is longer and extends to a lower level than the inner nuiUe'olus. 11' the nornuil alignment of the hones of the leg with tiie astragalus and calcaneum is observed it will be noted that tlie heel rests on the ground outside of tiie median i)lane of the leg (see Figs. 726 and 727). It will he readily seen, therefore, that violenee ap|)li('d in a longitudinal dirt'i-tion, such as is sus- tained in a fall from a height in winch tlie patient lands squarely on tiie foot, will tend to displace the foot outward as well as up- Fi;;. 72G. — Shows the movtise foj'med by the tibia and fibula into which the astragalus fits. E.M., External Malleolus; I.M., Internal Malleolus; A., Astragalus; E.A., Head of Astragalus. Fig. 727. — Same view of ankle with calcaneum in position. A line drawn through the long axis of the tibia falls to the inner side of the heel, hence the frequency of talipes valgus in injuries of this region. E.M., External malleolus; I.M., Internal malleolus; A., Astragalus; H.A., Head of Astragalus; C, Calcaneum. wai'd. It is ai)parent that this disi)laeement cannot take place without producing fracture and ligamentous rupture. The points of least resistance M'ill be found in the fibula just above the lower tibio-fibular articulation and in the internal lateral ligament of the ankle joint or its attachment to the inner malleolus. When these conditions prevail we have the typical Pott's fracture as shown in Figs. 729 to 731. Compare the positions of the bones as indicated in Fig. 729 with the clinical appearance of the deformity as shown POTT S FRACTURE 661 in Figs. 740 to 745. Outward rotatifjn of tlic loot, on u juore or less vertical axis passing through the astragalus, i)robably plays a part in the production of many Pott's fractures, by prying the malleoli apart. When this type of strain enters into the causative trauma the fibular fracture is usually spiral instead of transverse. In addition to the lesions just mentioned we may find either the Fig. 728. — Normal ankle showing the epiphyses at thirteen years of age. anterior or posterior margins of the lower tibial surface broken off and displaced. The constant element in Pott's fracture consists of a- fracture of the fibula within two or three inches of the lower tibio-fibular articulation. The variable element is at the inner malleolus, where either the deltoid ligament is ruptured or the tip of the inner malleolus torn away. Numerous descriptions have been given of the exact manner in which a Pott's fracture is produced and the order in which the different lesions take place ; as a matter of fact 662 FRACTURES AND DISLOCATIONS .&1EL Fig. 729. Fig. 730. Fig. 729. — Pott's fracture with tlie usual (iu(\\:(itl disijliiccincnt. Note the space between tlie inner malleohis and tlio astrasahis. Fi^. 730. — Variant of Pott'.s fracture. Tncoiiiplrd' fracture of iiliuhi witli avulsion of portion of til)ia, corresi)on(liiiK to insertion of lower titiio-til)ular liuauuMit. Fig. 733. Fig. 731. — Pott's fracture. Comminution of fibula ami fracture of inner malleolus. Fig. 732. — Pott's fracture. Comminution of fibula and fracture of inner malleolus. Fig. 733. — Variant of Pott's fracture. Fracture of inner malleolus and diastasis of lower tibio-fibular joint. The separation previously existing between the lower ends of the tibia and fibula has been corrected at the time of reduction, and hence the diastasis is not apparent in the Rontgenogram. POTT S FRACTURE 66;i it is difficult to state whether the internal lateral ligament ruptures before; the fibula breaks, or whether tlie bone breaks before the Fig. 736. Fig. 734. — Pott's fracture. Fracture of inner m:\lIeolus. Fig. 73.5, — Pott's fracture. Fracture of inner malleolus. Pig. 73G. — Pott's fracture with fracture of inner malleolus. Fig. 737. — Pott's fracture. Comminution of filnila and fracture of inner malleolus. Fig. 738. — Old Pott's fracture. Incomplete reduction. Fig. 739. — Lateral view of old Pott's fracture. Note old fracture in fibula. ligament ruptures. Probably the latter mechanism obtains in most cases. Instances of Pott's fracture liy inversion of the foot have 664 FRACTT'RES AND DISLOCATIONS been reported in wliidi llu- sliai't ol' tlu' lihiila was i'ractui'etl by the inward pull on the external nuilleoliis, and tlu' inner malleolus fractured by direct pressure of the astrapdus. The i)roduetion of Pott 's fracture by this nieehanisni is v|i('i' Icii^lli and aliout lour inches in width. If a t went \'-ti\(' \ai'd holt of uau/.c, sndi as is fonnd in Figs. 747 and 748. — Htinison's phistor si)liiits a])i)lied to a Fott'.s fracture and held in position by strips of adhesive ijlaster. Note how the foot has been inverted and brought forward until the relations are normal. Resiilts in this case were complete restoration of funftion and absence of deformitv. the usual hospital supplies is available, the desired amount may be cut from it without Maste and each splint is thus made of one piece. Each splint should he from twelve to eighteen ply, according to the size and musculature of the patient. These stri{)s of gauze are soaked in plaster cream, w'rung out and placed in proper posi- tion on the leg. The posterior splint is applied first and then the pott's FRACTURE 671 lateral splint. The lower end of tlie lateral splint, encircling- the foot, should he overlapped by the straight portion on 1lic onlcr aspect of the ankle (see Fig. 748). Tlic splints arc placed in posi- tion and brought (piickly into snug position by a roller bandfige. The surgeon then takes his phice at the foot of tlu^ table and forces the foot forward and into adduction while the f)laster is still wet. This attitude is maintained until the plaster lias set sufficiently to maintain the proper reduction. During this time the weight of the foot and lower extremity rests on the heel in the surgeon's hand thus forcing the foot forward and correcting the usual backward displacement. Some cases may require more force than is exerted by the weight of the limb in overcoming this posterior deformity. A quick-setting plaster should be used, otherwise the holding of the foot in inversion will be unduly tedious. If the condition is compound the lateral splint may be applied to the inner side of the leg with equal efficiency. If gauze is not at hand the splints may be made of four-inch plaster bandages soaked in water and run back and forth on a table until the proper thickness has been attained. It should be remembered in reducing an ordinary Pott's frac- ture that the deformity cannot be over-corrected. An anesthetic is always advisable in reducing the deformity and in the application of a permanent dressing, unless some constitu- tional condition exists to act as a contraindication. Following reduction a Rontgenogram should be taken to verify the position of the fragments. The usual Pott's fracture can be reduced wdthout difficulty as just described ; occasionally complications exist such as the interpo- sition of a fragment between the astragalus and the inner malleolus, which render reduction without operation impossible. Operative Treatment. — The open method is indicated when good reduction cannot be accomplished by non-operative methods or when the fracture is compound from the first. If reduction has been attempted and failed, the X-ray will usually reveal the cause of the failure, if it has not already been learned through palpa- tion and inspection. If, after complete inversion has been accom- plished, the upper end of the fibular fragment remains displaced inward against the tibia and there is undue space between the ex- ternal malleolus and astragalus, it will be advisable to make an incision over the fibular fracture, engage the fractured surfaces 672 FRACTURES AND DISLOCATIONS and secure the fibula in proper alignment. If internal fixation is found necessary to maintain reduction a Lane plate or wire may be us(_'d. If .this inward displacement of the upper end of the lower fibular fragment is allowed to persist it means a widening of the mortise by outward displacement of the external nudleolus, and a weak ankle will I'csult. The interposition of a fragment be- tween the inner malleolus and astragalus calls for removal of the obstructing material. This is best accomplished through a longi- tudinal incision below the inner malleolus. With the parts exposed tlir iitiici- lateral ligament should be sutured before the incision is closed. Operation is sometimes called for because of loss of function and painful joint following an imperfectly reduced Pott's fracture. When a patient presents himself for treatment under these circum- stances the case should be carefully studied by the usual examina- tion and the X-ray before an opinion or advice is given. The exact cause of the disturbed function should be accurately ascer- tained, and then, if surgical intervention offers relief, the parts should be opened. The usual causes of loss of function are trau- matic flat-foot and backward displacement of the foot. Both of these conditions can, as a rule, be corrected by osteotomies or read- justment of the articular surfaces. The joint is best approached through two longitudinal incisions over the malleoli. Through the iiuier incision obstructing materials such as bone or periosteum may be removed from between the astragalus and inner malleolus. Through the outer incision the position of the external malleolus may lie corrected, if in deformity, and an osteotomy of the fibula above the tibio-fibular ligaments may be performed if found neces- sary to bring the malleolus back into position. Obstructing fibrous tissue should be removed if present. The common method of cor- recting an old Pott's fracture deformity is by a double osteotomy of the tibia and fibula above the ankle. By this means the foot and ankle are brought back into proper alignment with the leg and both the outward and the backward displacements are corrected. If the fracture is compound the lacerated edges should be ex- cised, the wound and joint cavity thoroughly washed with a few gallons of physiological sterile salt solution and the parts closed. If infection follows in spite of this treatment the joint should be injected with IMurphy's glycerine-formaline solution and the con- dition treated according to the principles laid down under the head- pott's FRACTURE 673 ing of "Compound Dislocations " on page 789. If tiie case is seen early and the treatment just mentioned followed it will usually be possible to obtain aseptic healing even though the fracture is badly compounded. Following operation splints should be applied as already described. After-Treatment. — In the usual case of simple Pott's fracture the ankle should be maintained in adduction for a period of six weeks. No weight should be borne on the injured foot within two months of the time of the fracture. Massage of the leg, especially the calf muscles, is of advantage after the first week but it is best not to remove the splints early in the after-treatment lest recurrence of deformity take place. There is a marked tendency to the development of flat-foot fol- lowing Pott's fracture and it is due to incomplete reduction of the displacement or the too early use of the foot in bearing the weight of the body. Two months is a longer period than is usually ad- vised before weight is borne on the foot, yet the author has found that if this length of time is allowed before the parts are subjected to strain, the patient does not develop flat-foot. The use of arch supports in the late after-treatment is an admission in itself that weight is being borne on the foot too soon. Passive motion of the foot, however, should be begun early but must be guarded lest out- ward strain be placed on the ankle. The foot should be carried through dorsal and plantar flexion but eversion must not be made. By means of massage, hot applications and passive motion the func- tion of the joint should be well restored before the patient is al- lowed to bear his weight on the member in walking. Passive mo- tion should be applied to the joints of the tarsus as well as to the ankle-joint proper, so that the full flexibility and usefulness of the foot may be restored. Prognosis. — If proper reduction is accomplished and sufficient time is allowed for the solid repair of bone and ligament, in a healthy adult, the joint should be practically as useful and strong as before the injury. The older the patient, the longer the conva- lescence and the more incomplete the restoration of function. A certain amount of restriction of motion is common following this fracture and seems to be unavoidable. Cases in which accurate reduction has been accomplished and early passive motion insti- tuted, show the greatest freedom of motion when recovery is com- plete. Extreme dorsal flexion is the motion most commonl}^ re- 674 FKACTIRKS AND DISLOC.VTIDNS strieted and the one least essential in the nse of the foot. Traumatic flat-foot followiuET T*ott*s fraetuiv is a serious, cripplino: deformity and shows a tendrncy to ^row worsi- wlicii oiicc cstaljlishcd. Con- sitii'rahle relief may he had hy the use of oi'thojicdic ai)i)lianees such as used in the treatment of flat-foot I'lom other causes. Steel or felt arches to support the inner side of the foot and a hiiildinf? \^^ of the inner side of the sole, may enable the patient to get aboul with more or less ease if the defoi-mity is not too great. Considerable improvement will usually take place during the fii'st two or three months of active use and weight bearing. Loss of lateral nu)tion in the foot may be productive of lame- ness and constitute a serious disability. Lateral niolion is not one of the noiMual actions of the ankle-joint but is accomplished by the articulations in the tarsus. It is evident therefore that this condi- tion is not the I'esidt of the injury sustained by the tibio-fibular articulation but follows luolonged iunuobilization of the foot with- out the necessary earl}^ passive motion to the tarsus. CHAPTER XLVII. FRACTURES OF THE LOWER ENDS OF THE TIBIA AND FIBULA. Surgical Anatomy. — The surgical anatouiy of the lower ends of the tibia and tibnla is similar to that already given under the head- ing of "Pott's fracture" on page 659. Symptoms. — When both bones are fractured above the ankle, pain, loss of function, crepitus, abnormal mobility and swelling are usually present and well marked. The traumatic reaction is often less pronounced than that accompanying the usual fracture of the 749. Fig. 750. 749. — Splitting of lower end of tibia. 750. — Splitting of lower end of tibia. shaft and the mobility is, as a rule, not so completely flail-like. The line of fracture in the lower end of the tibia is cpiite variable and accordingly the deformity is not characteristic. The frac- ture may be transverse, spiral, comminuted or longitudinal. Longi- 675 676 FRACT^RE^^ AND DISLOCATIONS Fis. 75 1 Fig. 751. — Fracfui-e of tip of intern ill malleolus. Fig. 752. — Fracture of internal malleolus at higher level. Fig. 753. — Fracture of internal malleolus at still higher level. Fig. 754. — EpiphvM-ul supination of lower tnil ul liliiii cuniplicated b.v friicture of tibial diaphysis. Also fracture of tiljula. The result of violence similar to that pro- ducing Pott's fracture. FRACTURES OP LOWER ENDS OF TIBTA AN[~) FIBULA 677 tudinal splitting of the lower end of the tibia ciitei-iiif^- llic joint cavity is not at all uneoininon and is nsualiy aecoiiipMiiied l)y trans- verse thickening of the ankle. Tlie line of fraeture may extend from the inner surface of th(; bone into tlie joint cavity so that the inner malleolus is displaced inward or it may extend from the outer surface of the hone into the articulation and allow the frag- Fig. 756. Figs. 755 and 756. — Fracture of both bones of tlie leg just above the ankle. Arrows indicate the levels of the two fractures. ment and lower end of the fibula to be displaced outward. Diastasis of the lower tibio-fibular articulation with separation of the lower ends of the bones of the leg is occasionally seen and has been classi- fied as a complication of upward dislocation of the ankle when the astragalus is displaced upward between the ends of the bones. Supra-malleolar fracture of the tibia is usually accompanied by fracture of the lower end of the fibula. Fracture of the inner HTS FRAOTITRES AND DISLOCATTONS malleolus usually occurs as a i)ai't of Pott's fracture, but even as au isolated injury it is not uncoimnon. A'arious types of fracture of the lower ends of the tibia and iibula occur as complications of dislocations of the ankle and of Pott's fracture, but will not be considered undei* this heading. It is not at all uncommon to see cue of the tibial fragments projecting through the .skin. The de- ymmmmm^/tiiki!iiii:iiaf. Pigs. 757 iind 758. — Supraiuiilleolav fracture of both bones witli inward displace- ment of the foot. Compare the two ankles. Arrows indicate the levels of the two frac- tures. formity may be pronounced and in cases resulting from direct vio- lence the fragments may remain in the position in which they were driven at the time of the accident. Fracture of the lower end of the fibula is often attended by remarkably slight loss of function especially if the line of fracture is into the lower tibio-fibular ar- ticulation. The patient may be able to walk with such a fracture although use of the member entails pain. FRACTURES OP LOWER ENDS OP TIBIA AND FIBULA 679 Diagnosis. — There should, as a rule, be liit](i (lifficully in recog- nizing fractures in this region but the details of the break are often difficult or impossible to recognize without the aid of the Fiff. 759. Figs. 759 and 760. — Fracture of both bones of the leg just above the ankle with pronounced inward displacement of the foot. The photographs were taken about twenty minutes following injury and show an unusual displacement. I. indicates the upper end of the lower fragment of the fibula. II. indicates the displaced external malleolus. III. indicates the internal malleolus. Injury the result of direct violence. X-ray. Fracture of the fibula may be mistaken for a sprain unless the examination is carefully made. When the fracture is supra- malleolar the two malleoli will remain in proper relation to each other but will move with the foot and not the leg. "When the frac- 680 FRACTFRES AXP DISLOCATIONS ture entiM-s the joint cavity it will usually he possibK' to elicit ab- noi'iual mobility of one of tlie malleoli (tlie one detached). The symptoms in sei)aration of the lower epiphyses are praetieally the same as in fractui-es of this i-ewion except for the crepitus which is Fig. 762. Figs. 761 and 762. — Splitting of the lower end of the tibia with broadening of the iinklf. Both malleoli prominent. Type of case requiring operation to secure the best results. cartilaginous and not bony. If the fracture in the fibula is above the lower tibio-fibular ligaments pressure in the middle of the shaft will produce pain at the seat of the fracture. If the fracture is through the ligaments or below them direct pressure at the site FRACTURES OP liOWER ENDS OP TIBIA AND PIRTJLA 681 of the lesion will be necessary to produce pain. When the fibula alone is fractured there is usually little loss of siren gtli in the ankle. Treatment. — In fracture of both bones above the ankle or in epiphyseal separations the indications in treatment are similar to those cases just described in which the fracture is at the usual site (the junction of the middle and lower thirds of the shafts). The necessity for temporary treatment is not as great in this region since the traumatic reaction is seldom as severe as in fracture of the shafts. It is best, however, to place the leg in a fracture-box or pillow splint for the first few days, until the amount of swelling to follow can be determined. During this time the ice cap locally and intermittently applied is of great value. A plaster stirrup as Pig. 763. — Old case of fracture of both bones of the leg above the malleoli. PatieiU presents himself for treatment because of inability to use limb. Pen outline on skin indicates palpation of fibula. This case is a good example of delayed restoration of function due to incomijlete reduction of fragments. already described in "Fractures of the Shaft" will in most cases be found thoroughly efficient in maintaining reduction. A quick drying plaster should be used and the surgeon should hold the ankle in reduction, while the splint is setting. The best position for the ankle, in a given case, is the one in which the tendency to recurrence of deformity is least. It is preferable to fix the foot in a position of slight plantar flexion rather than at a right angle. The proper position for the foot, aside from the prevention of deformity, is one in which the flexor and extensor muscles are at an equal tension and balance each other. In instances in which the lower end of the tibia is split longitudinally it will often be 682 FRACTURES AND DISLOCATIONS uecessaiy to force the fraguieuts together, by hiteral pressure, while the plaster is drying, in order that union may not take place with transverse thickening of the ankle and widening of the mortise. If the posterior portion of the articular surface of the tibia is broken off the foot should be more or less dorsally flexed to favor reduction and prevent recurrence. When a fragment is broken oft' of the articular surface anteriorly the foot should be immobilized in the opposite position for the same reasons. The foot should be covered with a layer or two of sheet cotton before the stirrup is applied. The bony prominences about the ankle are subcutaneous and if the splint is not properly padded undue pressure may pro- duce sloughing of the skin. Fracture of the fibula alone does not require as solid immobilization as is the case in isolated fracture of the lower end of the tibia or when both bones are broken. When an outward displacement of the external malleolus exists as a result of fracture of the fibula, whether the break is above, below or through the lower tibio-fibular ligaments, the deformity should be corrected and held in position by the dressing. Strong adduction of the ankle, as in the treatment of Pott's fracture, will usually correct this displacement if the internal malleolus is intact. Operative Treatment. — Open treatment is not as frequently indicated in fractures of the lower ends of the tibia as it is when the shafts of these bones are broken. It is most commonly called for when there is a longitudinal splitting of the lower end of the tibia in which difficult}'^ is experienced in approximating the frag- ments. Even a slight spreading of the malleoli means a widening of the mortise in which the trochlear surface of the astragalus rests and this condition, if not corrected, is followed b}^ a pro- tracted recovery if not permanent disability. If two longitudinal incisions are made, one on the inner and the other on the outer aspect of the lower part of the leg, the fragments can be replaced by direct manipulation and transverse holes drilled through the approximated fragments at the most advantageous points. Heavy wire is then threaded through these holes and the ends securely twisted to maintain proper reduction. In some instances passing wire around the fragments may be all that is required but this point can seldom be determined until the fragments are exposed. In supra-malleolar fractures open incision ma}^ be necessary to effect reduction but it is seldom necessary to employ internal fixation. FRACTURES OF LOWER ENDS OF TIBIA AND FIBULA 683 After- Treatment. — If the traumatic reaction is great the leg should be treated on a pillow splint or in the fracture-hox during the first few days. The swelling is usually less than that seen when the fracture is higher, and it will seldom be necessary to wait more than four or five days before placing the leg in a permanent splint. As previously stated, the plaster stirrup is the most efficient form of permanent dressing in which to treat fractures in this region. Union may be expected in the healthy adult in six weeks but the callus is not sufficiently strong at this time to permit of weight bearing. Massage and gentle passive motion should be instituted at the end of the second week. During the eighth and ninth weeks weight bearing should be gradually increased until the patient is able to walk at the end of two and a half months. The time should be prolonged in cases in which the fracture involves the articular surfaces and when passive motion is employed due regard should be had for the tendency to displacement, if such exists. It is best for the patient to walk with a cane for some time following the removal of all dressings. Persistent swelling of the ankle should be met with massage and hot applications and, if pronounced, gi^eat relief, may be had by the use of an elastic stocking during the day. Isolated fracture of the fibula without displacement may, as a rule, begin weight bearing at the end of three or four weeks. Prognosis. — The more accurate the reduction the more complete and prompt is recovery. Some limitation of motion in the ankle, especially dorsal flexion, is common, following fractures in this region, particularly so when the line of fracture involves the ar- ticular surface. Fractures of the fibula alone are usually followed by complete restoration of function. The prognosis in other re- spects is similar to that already given in "Fractures of the Shafts of the Bones of the Leg," page 657. CaiAPTER XIA'lir. DISLOCATIONS OF 'IIIH ANKLH. Surgical Anatomy, — 'I'lic Ijoiics ('ii1t'i'iii<;' into tlic foi-iiuition of the ankle-joint and the liyanipnts liokling these bones in ap{)Osition, have already been ineiitioiuHl in the .sur^jical anatomy of "Pott's fracture," on page 65!). The niaimci' in wliidi \\\r iiialh'oli are placed on cither side of the botly of the asli-agalus explains the freipieney with which fracture complicates dislocations of this ar- ticulation. Xcai-ly all the luxations of the ankle are accompanied by fracture of either the tibia, fibula or astragalus. One or both malleoli may be broken otif and displaced with the foot. The bones of the ankle are not deeply situated and it is not uncommon to see compound luxations of the ankle. When severe and direct violence is applied to the ankle, the foot may be torn away from the tibia and libula and displaced in any direction. The greater the violence producing the injury the greater the probability of the condition being compound and complicated by fracture of the malleoli or astragalus. In severe cases the bones of the foot may be entirely toi'u from the lowei- cud ol' the leg with onl}' the soft tissues connecting the two, ami a large rent in the skin. In such instances the character of the deformity is not typical of any of the forms of ankle luxation to be described. The typical luxations of the ankle in their order of fi'ccpiency are: outward, inward, backward, forward, and upward. It should be remembered, however, that a given luxation may present a dis- placement resembling two forms of dislocation. Thus the foot may be displaced forward and inM-ard so that the defonnity shows some of the characteristics of both the forward and inward types of dislocation. In many of these luxations (especially the lateral types) there may be a rotary element present in Avhieh the foot is turned either inward or outward on a more or less vertical axis. This form of displacement has been described as a separate form of luxation, and may occur as such, but is almost always secondary to one of the other dislocations just mentioned. 684 DISLOCATIONS OK THE ANKLE 685 Fie 764 View of ligaments of foot from flbuhir side. E.M., External malleolus; A., Astragalus; N.. Navicular; CM., Middle cuneiform; C.E., External cuneiform; CaL, Ca'lcaneum; Cub., Cuboid. Fig 765 — View of ligaments of foot from tibial side. Cun.I., Internal Cuneiform: A' Navicular; A., Astragalus; J., Tibia; CaL, Calcaneum; T.P., Tendon of tibialis posticus; G., Groove for the passage of the tendon of the tibialis posticus. 686 FKACTl/RES AND 1)ISI,( (CATIONS In outward hi.nifiona the lesions ai-e soniewhat variable. The less severe forms of this dislocation are the same as Pott's fracture, which has already been described. AVhen the force which pro- duces Pott's fracture continues to act, the lower tibio-fibular liga- ments are either ruptured, or tear aAvay their til)ial attachment, including a fragment of bone, and llic astragalus continues in its outward course. If the displacement is great enough to allow the trochlear surface to clear the tibial articular surface, the astragalus will be displaced upward as well as outward and is described as one of the upward luxations of the ankle (Dupuytren's disloca- tion). The more ])ronoui)ced the lateral displacement of the ankle (until it clears tlic til)ia ) tlie greater the tendency of the astragalus to rotate on a more or less horizontal antero-posterior axis. When this rotation occurs the foot corresponds to the position assumed by the astragalus. The outer side of the foot is raised and the sole looks downward and outward. The surgical anatomy of this fracture luxation is the same as Pott's fracture (see page 659). In inward luxations of the ankle ("inverted" or "reversed" Pott's fracture) the filmla is usually fractured at the level of the joint and the inner malleolus is broken off at its base. The line of fracture in the tibia is usually oblique, extending upward and inward from the junction of the horizontal and vertical portions of the lower tibial articular surface. The usual position of the fracture is well illustrated in Fig. 753. The astragalus commonly show^s more or less rotation in a direction opposite to that usually seen in Pott's fracture. The foot is displaced inward according to the degree of causative violence. Inward rotation of the foot is particularly common in this form of luxation. Backward luxations are extremely rare and almost invariabh' accompanied by fracture. They may result from extreme plantar flexion of the foot or from a force which drives the foot backward when the leg is fixed. The reverse mechanism may obtain in which the lower end of the leg is driven forward while the foot is fixed. When this type of luxation is the result of extreme plantar flexion the posterior margin of the tibia is almost invariably broken off. It is common for one or both of the malleoli to be broken off and displaced backward with the foot. The lower end of the tibia rests on the scaphoid and cuneiform bones while the astragalus is dis- placed backward. The ligaments of the joint suffer extensive laceration. If one malleolus and its corresponding lateral ligament DISLOCATIONS OP THE ANKLE 687 remain intact the backward displacement will be accompanied by more or less of a rotary deformity with the sound malleolus as the center of the arc described. Forward luxations are extremely rare and almost invariably accompanied by fracture of the malleoli or the anterior edge of the tibia. This type of dislocation of the ankle is produced by a force which drives the lower end of the leg backward while the foot is fixed, or the same result may follow a blow on the heel which drives the foot forward while the leg is fixed. Extreme dorsal flexion, alone or combined with an antero-posterior force, may be responsible for the luxation. When caused by flexion the anterior edge of the lower end of the tibia is almost always broken off. The reported cases of this luxation are very few, being less than fifteen in all and have usually been accompanied by fracture. Most of the uncomplicated cases were reported before the X-ray came into use and some writers question the occurrence of this luxation un- accompanied by fracture. The case shown in Fig. 768, however, is a pure luxation, as demonstrated by the X-ray plate which was taken following reduction and which showed no fracture. Upward luxations of the ankle are extremely rare. Two forms are described. The first is simply an exaggerated Pott's fracture with diastasis of the lower tibio-fibular articulation and an upward displacement of the astragalus between the lower ends of the tibia and fibula. This luxation has already been described with out- ward dislocations of the ankle and is known as Dupuj^tren's lux- ation. The second form of upward dislocation is one in which the astragalus is displaced upward between the lower ends of the tibia and fibula following a diastasis of the tibio-fibular joint, without the usual complicating fracture of the fibula. Symptoms. — In all forms of ankle luxations the pain, tenderness, loss of function and swelling are usually pronounced. Ecchymosis often develops within twelve to tw^enty-four hours and is much more constant if the condition is accompanied by fracture. The deformity varies wdth the type of luxation. In outivard luxations the appearance of the ankle is usually typical of Pott's fracture and the exaggerations of this deformity just described. In inward luxations of the ankle, the foot is usually markedly inverted with more or less adduction. The inner side of the foot is higher than normal while the outer edge of the sole is depressed. 688 FKACTl'KKS AND 1)ISI,( )CATIONS 'riif (Irt'oniiity is syimiu't rically opposito to that .seen in I'ott's frac- tuir. W'licii rotai-y deformity accompanies the condition it is usually inward, and may be as much as ninety degrees, so the toes point directly toward the 0]iposite foot. Jmu Fills. 7(i(i iiiiil 7()7. — Inward fractiirc-liixiitinn nl' l\\r .-mkle :i few iiiiinitcs follow- ing tlie in.iury. Inner malleolus broken off and displaced with tlie foot. The external malleolus remains intact. Note the prominence of the external malleolus and the way the skin is stretched between it and the foot. Reduction accomplished without difficulty. Fig. 768. — Anterior dislocation of ankle. The entire nnsns is (lisiihiccd lorward at the tibio-astragaloid articulation. Note the prominence of the internal malleolus in its backward displacement. In.iury sustained in automobile accident. Dislocation caused by VjIow on posterior aspect of heel. Trauma of vulnerant body was sufficiently great to penetrate counter of shoe, without, liowever. injuring skin on heel. Reduction easily accomplished by pressure in bend of ankle accompanied by traction on the foot. Picture taken about two hours following accident. X-ray plate taken following reduction showed no fracture. In haclxivard dislocations the dorsum of the foot is shorter than normal and the heel is unduly prominent. The foot is usually held in a position of more or less pronounced plantar flexion as a result of the increased leverage of the muscles attached to the DISLOCATION« OP TJIE ANKLE 689 teiido Achillis. A transverse ridge is felt anteriorly, in tlie IjcihI of the ankle, and the extensor tendons may be palpated passing across it from the leg to the foot. If the malleoli are not frac- tured they will be found displaced forward with the leg. In forward luxations the appearance of the foot and aiikh' is the reverse of that just described. The dorsum of the foot is lengthened and the heel shortened. The malleoli are both dis- placed backward unless broken off. The trochlear surface of the astragalus can, as a rule, be felt in the bend of the ankle, and when the usual fracture is present it may be possible to palpate the de- tached tibial fragment. In upward luxations accompanied by fracture of the fibula the clinical picture is that of an exaggerated Pott's fracture. Abnor- mal lateral mobility, broadening of the malleoli, more or less ever- sion and crepitus are usually present on examination. The con- dition is often compound. When upward luxation exists without fracture of the fibula abnormal lateral mobility may be absent. The malleoli are lowered (nearer the sole of the foot) and widely separated. The leg above the ankle is broader than normal. Diagnosis. — With a knowledge of the anatomy of the parts it is not difficult to recognize the different tjq^es of luxation which occur at the ankle. The presence of complicating fracture, how- ever, is often not easy to determine without the aid of the X-ray. If the case is not seen until some hours have elapsed following the injury the swelling may be so intense that palpation is quite diffi- cult. The disturbance in the alignment of the foot and leg, as viewed from the side and antero-posteriorly, should be recognized by inspection even if the swelling is pronounced. Motion of the foot will usually reveal the nature of the injury. An X-ray exam- ination of these conditions cannot be considered complete unless two plates at right angles to each other are made. Treatment. — The nature of the injury should be appreciated by the surgeon before an attempt at reduction is made. There is usually little difficulty in returning the articular surfaces to their normal relations but when fracture complicates the condition, as it frequently does, some trouble may be experienced in maintaining reduction. A short plaster stirrup, as already described in the treatment of fractures of the tibia and fibula, is the most satisfac- tory method of treating these luxations but the application of this dressing should be delaj'-ed until the SAvelling (if pronounced) has 690 FRACTURES AND DISLOCATIONS snlisidt'd. Dui-in^ tliis time the anklo may bo treated in the ])illow splint Of fraeture-box with the foot elevated and the ice cap ap- plied. If no fracture exists the most comfortable position for the foot is at an aniile of about 100 decrees with the leg. In other words the foot should be immobilized in a position a little more than a right angle. If the anterior edge of the tibia has been frac- tured the foot should be fixed in plantar tlexion, if the posterior edge is broken off it should be placed in dorsal flexion. In fracture of the malleoli there is usually little tendency to the recurrence of deformity if good reduction has been accomplished. In the treatment of Pott's fracture the foot is inverted as far as possible and there is no danger of overcorrecting the deformity, but in inward luxations of the ankle the reverse is not true. The deform- ity can be overcorrected and if the foot is put up in extreme ever- sion the result will be recovery with pronounced deformity. The reasons for this are apparent if we note the lines of fracture in an inward luxation as compared with a Pott's fracture. In an inward luxation the foot should be brought back into alignment with the bones of the leg and fixed with a plaster stirrup. Operative Treatment. — Operative treatment is usually not called for except in compound luxations and in instances in which com- plicating fractures cannot be satisfactorily reduced by non-oper- ative methods. The fragment of a fractured malleolus may become displaced and wedged between the astragalus and end of the tibia, requiring removal before proper reduction can be effected. If one of the malleoli or a portion of the lower end of the tibia re- mains displaced, in spite of attempts at reduction, it may be ad- visable to fix it in position through an open incision. Compound dislocations of the ankle should be treated along the lines laid down in the treatment of "Compound Luxations" on page 789. The cavity of the articulation should be irrigated with a few gallons of sterile salt solution, devitalized tissue trimmed away and the wound closed. PVagments should not be wired at this time. If internal fixation is found necessary it should be per- formed at a later date after the primary wound has healed. If severe infection develops ami^utation may be necessary, especially if the patient is old and feeble. Amputation, however, is rarely called for, even in compound cases, if proper surgical measures are carried out. After-Treatment. — The care of these cases following reduction DISLOCATIONS OF THE ANKLE 691 varies greatly with the complications. In simple dislocations of the ankle without fracture, ligamentous union wili he firm at the end of about three weeks. Function should be resumed gradually. Gentle passive motion should be begun at the end of ten days. When the condition is complicated by fracture of the lower ends of either the tibia or fibula the after-treatment will be practically the same as that already given for "Pott's fracture" (page 673) and in "Fracture of the Lower Ends of the Tibia and Fibula." Prognosis. — In simple luxations the prognosis is good but when fracture complicates the dislocation (as it almost invariably does) the outlook varies with the nature of the break. The prognosis is essentially that of the complicating fracture and may be considered the same as set down under "Fractures of the Lower Ends of the Tibia and Fibula," page 683, and under "Pott's Fracture," page 673. CHAPTER XLiX. FRACTURES AND DISLOCATIONS OF THE ASTKACALUS. Wlieu the astragalus is luxated from the iia\i('ular or the eal- caneuin, but reinaius in its normal relation witli tlie bones of the leg, the condition comes under the heading of Subastragalar and ]Medio-tarsal Dislocations (pages 699 and 709). When the as- tragalus is dislocated from the tibia and fibula, but remains at- tached to the tarsal bones, the condition is known as a dislocation of the ankle. Complete luxations, therefore, are the only displace- ments of this bone considered under this heading. These may be in any direction but are most comiiioiil\' forward, or forward and outward. Surgical Anatomy. — The astragalus is composed of soft cancellous bone covered by a layer of compact tissue. The greater part of the surface of the bone is taken up by the articular surfaces which Figs. 7H9 ;nul 770. — Lateral and antero-postorior views of a fracture-luxation of- the astragalus. Fracture passes through neck of bone, the anterior fragment being dis- placed laterally. enter into the formation of the calcaneo-astragalar, astragalo- navicular and tibio-tarsal joints. Above, it articulates with the tibia and laterally the two malleoli extend downward and em- ti!l2 FRACTURES AND DISLOCATIONS OP ASTRAGALUS 69.3 brace it, thus forming the firm compact mortise of the tibio-as- tragalar articulation which allows of motion in only one plane. Below, the astragalus presents two articular surfaces which entf;r into the formation of the calcaneo-astragalar joint. These two facets are separated by a deep groove for the attachment of the heavy interosseous ligament which holds the calcaneum and as- Fig. 771. — Antero posterior view of outward luxation of astragalus. The bone is rotated on aii antero-posterior axis as well as being displaced laterally. tragalus together. The anterior surface of the astragalus (the head) projects forward, inward and downward and articulates with the navicular. The astragalus is held in position by the conformation of the bones surrounding it and the heavy ligaments which bind it to the tibia, fibula, calcaneum and navicular. There are no muscular attachments on this bone. Gi)4 FRACTURES AND DISLOCATIONS la ialls on llic loot tlie astragalus may bu crushed between the tibia and calcaueuni and is not infrequently associated with frac- ture of the latter bono. This type of violence, however, is much more likely to produce fracture of the shafts of the bones of the leg or fracture of the os calcis. In fractures of the body of the astragalus the nature of the break is not constant ; it may be transverse, longitudinal, or stellate, or the entire body may be extensively crushed and comminuted, with a decrease in the distance between the calcaneum and bones of the leg. Fracture of the neck of the astragalus is the most common break occurring in this bone and usually results from extreme dorsal flexion of the foot. Fractures of the neck of the bone are usually transverse and the head is seldom much displaced. Lateral lux- ations may occur with fracture of the malleoli, and backward dis- location of the body of the bone accompanied by fracture of the neck is a condition which occurs, but is extremely rare. The soft tissues surrounding the ankle are scant, and in the usual forward, or forward and outward luxation there is scarcely room within the skin to accommodate the bulk of the displaced bone. Accordingly luxations of the astragalus are often compound. In simple cases the skin covering the displaced bone is rendered so tense that slovighing is likely to follow if the displacement is allowed to remain unreduced. The ligamentous damage accompanying luxations of the astragalus is usually extensive. The displacement of this bone throws the foot out of alignment, and the deformity will depend largely on the position occupied by the astragalus. The displaced bone may be rotated in various directions depending largely on the trauma which produced the luxation. Fracture and dislocation may both be present in the same case. In such instances there is usually a fracture of the neck with luxation of either the head or body. Symptoms. — The symptoms accompanying fractures and disloca- tions of the astragalus vary greatly with the nature and degree of the injury. Fractures of this bone, especially of the body, have frequently been mistaken for sprains of the ankle and treated ac- cordingly. In fractures of the body, pain, swelling and disability are pronounced. JMotion of the ankle and attempts at weight bear- ing greatly increase the sutfering. Crepitus may, or may not, be present. It is usually best elicited by palpation in the bend of FRACTURES AND DJSLO(JATJONS Oh' ASTRAGALUS 695 the ankle while the foot is being passively flexed and extended. Fracture of the neck of the astragalus is usually attended by symp- toms a little more pronounced than is the case in fractures of the body. Pain, loss of function, swelling and local tenderness are generally severe and crepitus is, as a rule, easily elicited by lateral motion of the foot. Deformity, if present at all, is usually very slight in either fracture of the body or neck. In luxations of the bone loss of function, pain, swelling and local tenderness are equally as pronounced as in fracture, and the deformity is usually extreme. In any of the forward displace- ments the bone may be felt as a prominent mass in the bend of the ankle, the foot is more or less depressed and the malleoli are lowered. When the astragalus is displaced forward and outward the foot will be inverted. When the bone is luxated forward and inward the foot will be everted. In backward luxations of the bone (practically always associated with fracture of the neck) the body may be felt between the lower end of the tibia and the tendo Achillis, and an abnormal hollow will be noted anteriorly, below the lower end of the tibia. Lateral luxations are associated with fractures of one or both malleoli, are usually incomplete and re- semble lateral dislocations of the ankle. Diagnosis. — The diagnosis of these different lesions is based on the symptoms just given. Fractures of the astragalus are often difficult to determine unless crepitus can be elicited and even then the surgeon's appreciation of the condition is likely to be vague if the case is not examined with the X-ray. The deformity in lux- ations is usually sufficiently pronounced to permit of recognition of the condition. The association of fractures of the different bones of this region is so frequent that the X-ray should be em- ployed whenever available. By its use complicating lesions are often shown to exist, which would otherwise be overlooked. Treatment. — The traumatic reaction is often severe during the first few days or week in fractures of this bone and during this time it is advisable to treat the leg in the pillow splint, in the ele- vated position and with the intermittent use of the ice cap. When the swelling has subsided the foot and ankle may be fixed in a short plaster stirrup after the parts have been properly covered with sheet cotton to provide the necessary padding. The best reduction is usually had in a position of slight plantar flexion, which position is preferable in most cases to the academic "right 696 FRACTURES AND DISLOCATIONS angle," so insistently and nselessly deniandod in most text-books. If tile eondition is aceonipanied hy otlicr fi-aelui-es in the foot a more complete fixation may Ijc rtMniii'cd. and is liad li\' means of a short iH)sterior plaster splint. This splint is applieil before tiie stirrni> and extends down tlie leg and nndei- the foot to a point just beyond llic loes. Il is the same as usvil in fractures of the metatarsals. In disloeations of the astragalus i-educlion sliould be effected at the earliest possible moment, unless the condition is compound. The necessary manipulations will depend entirely upon the posi- tion occupied by the displaced bone. The oljject is to return the trochlear surface of the astragalus to its proper relation in the moitise formed by the tibia and fibula. This may be a difficult matter especially if rotation of the bone has occurred. The fact that no tendons are inserted into the astragalus increases the diffi- culty of reduction. In forward displacements of the bone, direct backward pressure on the prominent trochlear surface will usually effect reduction. Plantar flexion before the bone is "started," and dorsal flexion in the latter part of the manipulation may aid materially in reduction. In the forward and outward type of luxation similar maneuvers are employed. The common outward rotation of the bone is often difficult to correct, and until it is, it will usually be impossible to effect reposition. Strong traction on the foot and sometimes an accentuation of the inversion will render the direct pressure more efficient. In inward and forward luxations the opposite manipulations are necessary to return the bone to its normal position. In backward luxations with the usual fracture of the neck, strong traction with direct forward pressure on either side of the ankle in front of the tendo Achillis, will usually be sufficient to accom- plish reduction. Plantar flexion of the foot while traction is being made, will increase the distance between the calcaneum and the tibio-fibular mortise posteriorly and may thus facilitate reduction. If I'eduction cannot be accomplished by manipulation, open incision under proper surgical surroundings should be resorted to at once. This is particularly true of any of the anterior luxations, since the pressure exerted by the displaced bone may produce sloughing of the integument and render the condition compound. The fact that the trochlear surface is slightly broader anteriorly accounts FRACTURES AND DISLOCATIONS OF ASTRAGALUS 697 for the frequency of complicating fractures of the inalk;oli in back- ward luxations. When either of the malleoli are broken they de- serve special consideration in the treatment (see "Pott's Frac- ture," page 668, and "Dislocations of the Ankle," page 689. The treatment of lateral dislocations with fracture of the malleoli is similar to that already given for lateral luxations of the ankle. When either fracture or luxation of the astragalus is compound, immediate operative intervention is demanded. Operative Treatment. — Operation is seldom indicated in the treatment of simple, uncomplicated fractures of the astragalus. It is called for in compound cases and in instances in which lux- ations of the bone cannot l)e innnediately corrected by manipula- tion. In compound cases no attempt at reduction should be made until the patient is in the operating room. The skin should be painted with a five percent tincture of iodine, lacerated and de- vitalized tissue should be trimmed away from the margin of the wound and the cavity irrigated with a few gallons of sterile salt solution. The surgeon then determines what the individual needs Fig. 772. — Deformed astragalus removed to restore function. Old fracture with union in deformity. of the case may be. Fractures usually require nothing in the way of reduction, and internal fixation of the fragments is not feasible. In luxations the bone is to be returned to its normal position by direct manipulation while traction, flexion, extension or other needed maneuvers of the foot are carried out. Care should be exercised to avoid injury to the articular surfaces while grasping the bone with forceps. The best place to grasp the astragalus and one in which the teeth of the forceps will do no damage, is at the neck. The wound is then closed wdth interrupted sutures. If diffi- culty is experienced in bringing the edges of the wound together, after the devitalized tissue has been removed, it may be necessary to perform some plastic, skin-sliding operation. It is imperative 698 FRACTURES AND DISLOCATIONS that the wound be closed at tliis time, evtMi at the expense of leaving some adjoining area deniulcd. It' .suppuration occurs in spite of this treatment (and it rarely docs) drainage will lie necessary. Excision of the bone in difficult cases was the usual treatment a few years ago but at the present time there seems to be no excuse for this procedure, except in the most extreme cases. In old un- reduced luxations, and in recent cases in which necrosis develops in the astragalus it may be necessary to excise the bone, either en- tirely or in part. In instances in which ankylosis of the tibio- tarsal articulation follows suppuration surprisingly good function may be restored by a s[)ontaneous increase in the range of motion in the medio-tarsal articulation. After-Treatment. — In fractures of the astragalus due time should be allowed for proper union of the fragments. It should be re- membered in this respect that the strain entailed in ordinary walk- ing is considerable, and unless the callus is well ossified and solid, deformity may follow. The foot should be protected from weight bearing until two months or more have elapsed from the time of the injurj^ and even then function should be only gradually re- sumed. IMassage and early passive motion, however, are essential in preventing joint adhesions, and if properly employed, subject the parts to very slight strain. The resumi^tion of function may be begun at the end of four or five weeks in simple luxations. Complicating fractures of ad- joining bones modify the after-treatment according to the nature of the lesion. Prognosis. — In simple luxations of the astragalus, with proper and prompt reduction, we may look for practically complete res- toration of function. The outlook in fractures depends on the severity of the lesion and is not generally as favorable as is the case in simple dislocations. Recovery is slower and ultimately some restriction in motion may exist. Simple transverse fracture of the neck is usually followed by better results than is usual with fractures of the body. In instances in which luxations have been allowed to go un- treated the loss of function and deformity are usually pronounced. Surprisingly good function, however, frequently follows complete removal of the bone. CHAPTER L. SUBASTRAGALAR LUXATIONS. Surgical Anatomy. — The astragalus rests upon, and articulates with, the calcaneum by two facets which are divided by a deep groove for the attachment of the heavy interosseous ligament. The calcaneum and astragalus are directly bound together by the internal, external and posterior calcaneo-astragaloid ligaments and by the interosseous ligament. Both the internal and external lateral ligaments of the ankle-joint are attached below to the cal- caneum as well as the astragalus, and in subastragalar luxations either of the malleoli may be broken by the direct pull of these ligaments. The relatively low position of the external malleolus exposes it to fracture by direct pressure of the calcaneum when the luxation is outward. The only ligament passing between the as- tragalus and navicular is the superior astragalo-navicular which is thin and weak. The place of the lower ligament is taken by the calcaneo-navicular ligament. This ligament, by binding the cal- caneum to the navicular, maintains the head of the astragalus in apposition with the navicular. In subastragalar dislocations the calcaneum may be displaced inward, outward, backward or forward. The astragalus remains in position in the tibio-fibular mortise while the bones of the tarsus below it are displaced as a whole. The most common luxation is lateral, oblique, incomplete and often compound. The displace- ment is usually more complete in the posterior subastragalar joint than in the anterior. The head of the astragalus is, as a rule, com- pletely separated from the navicular. There is often slight back- ward displacement accompanying either the inward or outward luxation. Forward luxations are extremely rare, resembling in this respect forward dislocations of the ankle-joint. The articula- tion between the head of the astragalus and the navicular is almost invariably broken up in subastragalar luxations regardless of the direction in which the foot is displaced. The usual subastragalar luxation is the result of forcible inver- sion or eversion of the foot and not infrequently occurs in falls 699 TOO FRACTl'RKS A.\|) DISLOCATIONS Oil the foot. This type of violence is imicli more likely to produce fracture-luxations of the ankle Ihan dislocations of the suhastraga- lai' articulation. P'l'aclui'c of the neck of IIk^ astragalus is a coin- plicalion wliidi lias been reeordt'd in a uuinber of eases. Symptoms. — In outward luxations the sole of the foot looks down- ward and outward and llic whole fool is dispjacfd lalcrally. 'riie Figs. 773 and 774. — Case of backward dislocation of the calcaneum and scaphoid on the astragalus. (Backward subastragalar luxation.) The calcaneo-astragalar .loint has been dislocated and the articulation between the astragalus and navicular has been entirely broken up. The head of the astragalus is seen presenting in the wound with the tendon of the tibialis anticus lying internal to it. Result of falling down an elevator shaft. The foot below the astragalus is displaced backward. Note the prominence of the heel. inner malleolus is abnormally prominent and the head of the as- tragalus may be palpated. The malleoli are in normal relation with each other and with the astragalus, which is not displaced with the foot. The external malleolus is less prominent than nor- SUBASTRAGALAR LUXATIONS 701 mal. If backward displacement of the foot exists, as well as lateral, there will be an undue prominence of the heel and a corresponding shortening of the dorsum of the foot. In inward luxations the reverse deformity is seen. The sole of the foot looks downward and inward. The inner border is raised and more concave than normal. The external malleolus is unduly prominent. The head of the astragalus may be palpated and the scaphoid may be felt near the inner malleolus. The whole foot is displaced inward. Antero-posterior luxations resemble disloca- tions of the ankle in the same plane. The fact that the astragalus, however, remains in its normal relation with the bones of the leg causes the deformity to be at an obviously lower level than that seen in dislocations of the ankle. In posterior luxations the dorsum of the foot is shortened and the heel abnormally prominent. The head of the astragalus pro- jects into the bend of the ankle and may be readily recognized in this position. The condition may be compound as shown in Figs. 773 and 774. Anterior luxations are extremely rare. The heel is shortened and the dorsum of the foot lengthened. Palpation reveals the astragalus in its tibio-fibular mortise. Diagnosis. — The diagnosis of these luxations is based on the characteristic deformities just described. If the swelling is in- tense it may be difficult to recognize the exact nature of the de- formity. An X-ray is of the greatest value in ascertaining the details of the injury. Treatment. — There is seldom much difficulty in reducing the deformity. In the lateral luxations the surgeon secures a firm grasp of the heel with one hand and the dorsum of the foot with the other, and by strong traction the foot is brought back into position. Counter-traction will usually be needed and should be made by an assistant, above the ankle. In backward luxations for- ward traction should be exerted on the heel while the leg is fixed. The reverse manipulation is performed to correct anterior lux- ations. The parts should be fixed in a plaster cast extending from the middle of the leg to the toes and cut open before the plaster has dried. Operative Treatment. — If reduction cannot be performed by manipulation, open incision with direct reposition of the displaced bones should be performed. 702 FRACTURES AX[i niSLOC'ATIONS After-Treatment. Finn union of llic liR'rratrd ligaments will be present at the end of two and a linlt' to three weeks. Passive motion should be begun at the end of ten days hut the patient should not be allowed to bear his weight on the foot inside of three weeks from the time of the accident. Prognosis. — The loss of function following this accident is very trivial it' proi>er reduction of the displacement has been accom- plished following the injury. Like dislocations in other joints, the too cjirlx- use of the parts is likely to be followed by recurrence of the luxation wliidi nun* even become habitual. CHAPTER LI. FRACTURES AND DISLOCATIONS OF THE CALCANEUM. Surgical Anatomy. — Fracture of the os calcis is a fairly common accident but isolated luxations of this bone are extremely rare. The internal structure of the bone is cancellated while the surface is composed, for the most part, of a thin layer of compact tissue. The surface layer is heavier on the external, lateral surface of the bone than elsewhere. The os calcis articulates above with the astragalus by two facets, which are divided by a deep groove for the attachment of the heavy interosseous ligament binding these two bones together. The anterior extremity of the calcaneum ar- ticulates with the cuboid which in turn supports the fourth and fifth metatarsal bones. The os calcis is connected by ligaments with the astragalus, cuboid, navicular and to the second, third and fourth metatarsal bones. A number of the intrinsic muscles of the foot, as well as one of the secondary insertions of the tibialis posticus, are attached to the calcaneum but the muscles of surgical importance finding attachment on this bone are the gastrocnemius and soleus. These muscles are inserted through their common tendon, the tendo Achillis, into the lower part of the posterior surface of the bone. The fact that this tendon is inserted into the lower and not the upper part of the posterior surface accounts for the peculiar displacement of the fragment when fracture results from muscular action. A small anomalous bone (the trigonum) is sometimes present just behind the posterior subastragalar joint, and if one is not familiar with its appearance it may be mistaken for a fracture, in interpreting an X-ray plate (see Fig. 776). The os calcis is ossi- fied by two centers : one for the main portion of the bone, and the other for the epiphysis. That for the body makes its appearance during the sixth foetal month. The center for the epiphysis is first seen during the tenth year and joins the body of the bone soon after puberty. It should not be mistaken, during this period, for a fracture of the posterior portion of the bone. 703 704 FRACTURES AND DISLOCATIONS I'^i-actuTo of tli(^ cnlcancnin )iia\' I'i'siilt rroiii falls on the foot, lioiii iiiusciilai- i-oiiti'at'liou and t'roiii fofcililc twisting of the foot. The fracture may be transverse, or longitudinal, and not infre- quently extensive eoniniinution of the lione exists. Anj' portion of tlie bone may be broken and tlie posterior part is often displaced Fig. 776. Fig. 775. — Fracture of calcaneum. Fig. 776. — Anomalous bone present (the trigonum) wiiich mi.?ht readily be mistaken for a fracture. Fig. 777. — Fracture of calcaneum. Fig. 778. — Fracture of calcanenm. outward as well as upward. The usual break is produced by a fall from a height in which the patient lands on the foot. There is usually more or less comminution and crushing of the bone below and behind the astragalus, and not infrequently the line of frac- ture enters the posterior subastragalar articulation. This com- FRACTURES AND DISLOCATIONS OF CALCANEUM 705 miniition results in an increase in th(! width of the bone. 'I'vvisting of the foot and falls on the foot while inverted are said to be |)ro- ductive of fractures of the sustentaculum tali. When fracture results from a twist of the foot the line of the break is more clean cut and the deformity is, as a rule, slight. When fracture occurs as the result of overaction of the calf muscles the line of the break and the deformity are usually charac- teristic. A small fragment is detached from the posterior portion of the bone and displaced upward by the pull of the tendo Achillis. The upper end of the fragment commonly remains in contact with the body of the calcaneum while the lower end describes an arc upward and backward. Isolated dislocation of the calcaneum is an extremely rare con- dition and is essentially the same as an incomplete subastragalar luxation. The bone is torn away from its attachments to the astragalus and cuboid and is most often displaced outward. The symptoms and treatment are practically the same as that given under the heading of "Subastragalar Luxations," page 700. Symptoms. — The patient complains of pain in the region of the injury particularly when an attempt is made to stand on the foot. If weight is placed on the heel the direct pressure produces suf- fering. If the weight is placed on the ball of the foot the action of the calf muscles will pull upward on the calcaneum and the at- tempt will be equally painful. Swelling usually develops promptly following the accident and is noted on either side of the foot below the ankle, especially to the inner side. The foot often gives the appearance of flat-foot. The heel is broadened, elevated and often displaced outward. If there has been much comminution of the calcaneum its width will be increased and the outward displace- ment of the external wall may be recognized by palpation below the external malleolus. Flexion and extension of the ankle will be free but lateral motions of the foot involving the tarsal joints will be restricted, especially if the fracture has entered the pos- terior subastragalar articulation as it so frequently does. Crepitus can usually be elicited by manipulating the heel but it is never sharp and pronounced. This is explained by the small amount of compact tissue in the calcaneum. In luxations of the calcaneum the heel is displaced as a whole, either inward or outward. There is abnormal mobility, no crepitus and no upward displacement as in fracture. 706 FR.VCTrRES AND DISLOCATIONS Diagnosis. — The diagnosis is based on the preceding syraptons but should be confirmed by the X-ray. This renders the diagnosis certain, informs the surgeon of the exact nature of the fracture and discloses complicating injuries of adjoining bones when they occur. Notwithstanding the great differences in the symptoms of the two conditions, fracture of the os ealcis has been mistaken for Pott's fracture, in a number of instances of wliidi the author knows. The normal positions and relations of the malleoli and the position of the astragalus in the tibio-fibulai- moitise should serve to diflferentiate this condition from lesions higher up. Im- pacted fracture of the os ealcis may be quite difficult to recog- nize without the aid of the X-ray, If a stereoscopic Riintgenogram is made it will aid the surgeon materially in appreciating the de- formity. There is considerable variation in the normal contours of different calcanea and it is therefore advisable to have a plate made of the opposite foot for the sake of comparison. Treatment, — The treatment of fracture of the os ealcis is to imnio])ilize the foot in a position which will correct the deformity. Complete plantar flexion of the foot relieves, to a large extent, the displacing pull of the calf muscles inserted through the tendo Achillis. Fixation is usually best accomplished by means of a short, well padded, plaster stirrup. While the plaster is setting the surgeon should hold the bone in reduction ; this can be done In- grasping the heel and pulling it down\vard and slightly inward. The stirrup is moulded tightly about the tendo Achillis at the back of the ankle and when the plaster is firmly set prevents upward displacement of the posterior end of the calcaneum. The portion of the stirrup passing under the foot should be so moulded that it supports the arch of the foot. Reduction and fixation can, as a rule, be satisfactorily accomplished in this way. If, however, the pull of the calf muscles proves greater than can be overcome by this dressing a tenotomy of the tendo Achillis may be required to prevent recurrence of deformity. When considerable broadening of the calcaneum exists as a result of crushing of the bone it may be necessary to force the sides of the bone toward each other by lateral pressure beneath the malleoli. If the surgeon has a power- ful grip this ma.y be accomplished manually. An anesthetic should be employed to correct the deformity and apply the plaster stirrup. Operative Treatment. — Aside from tenotomy (which is rarely needed) operation is called for in compound cases, and in instances FRACTURES AND DISLOCATIONS OP CALCANEUM 707 in which the fragment has been detached and displaced upward by the pull of the calf muscles. Compound fracture of the calcaneuin is to be treated according to the principles laid down on page 789. In severe crushing injuries, with destruction of the soft tissues covering the calcaneum, plastic operations and skin grafting may be called for to cover the bone. Necrosis may require sequestrot- omy. If a fragment, displaced by the tendo Achillis, is not readily held in position by pads (and it seldom is), operation with direct fixation of the fragment is indicated. Nailing of the fragment is not advisable because of the soft cancellous tissue in which the nail must be placed. A small mattress suture, preferably of silver wire, is probably the best method of securing the fragment in position. Outward displacement of the external surface of the bone may give rise to an extremely tender point below the outer malleolus, when the patient resumes the use of the foot. This may call for removal, by chiseling, of the portion of bone impinging against the inner side of the malleolus. The formation of excessive callus in this region may produce the same symptoms and calls for similar treatment. A fragment or spicule of bone projecting into the sole may render walking excessively painful and calls for removal of the offending portion of bone after the diagnosis has been con- firmed by the X-ray. Union with extreme deformity may be fol- lowed by such pronounced disturbances in function that operation is demanded for the relief of the condition. A transverse oste- otomy of the calcaneum just behind its articulation with the astragalus, with correction of the deformity, should be done. Operative treatment is not indicated in uncomplicated luxations of the calcaneum. After-Treatment. — Union takes place rapidly in the calcaneum but it should be remembered that the strain imposed on the bone in walking is great, and unless the callus is solidly ossified sec- ondary deformity may develop. By means of a properly applied plaster stirimp the foot is im- mobilized for a period of from four to six weeks. Passive motion and gentle massage should be instituted at the end of two weeks. No weight should be borne on the injured foot within two or two and a half months and the resumption of function should be grad- ual. If the fracture has been a severe one this time may be 708 FRACrrKES AXU niSLOCATlONS increased. Secondary upward displacenieiit of tlie lieel and the development of static tiat-foot arc the i-csnlts of too early use of the foot in vvalking. Free active and [)assi\c motion are of advan- tajre in the treatment of the case many weeks before it is safe to allow the fidl weijjlit to he borne on the injured mend)ei'. In cases in wliicJ! the t-alcaneinn has united in deformitx' a pad may be worn in the shoe beneath the heel and will often alt'ord ^reat com- fort. In instances in which ti-anmatic tiat-foot occui-s arches may be worn within the shoe to suppoi't the inner side of the foot. These measures, however, are ])Oor substitutes for union with the fragments in proper position, and will seldom be needed if the deformity has been properly coi'i-cctcd and held in rcd\ic1ion fol- lowing- the injur.w Prognosis. — With proper treatment uncomplicated fracture of the OS calcis should be followed by fair restoration of function. The most important secpielffi are: tiat-foot, restriction of motion in the subastragalar articulation, metatarsalgia, pain beneath the outer malleolus, and painful heel caused by a projecting fragment. The more perfectly the deformity is corrected following the acci- dent the less the probability of these annoying and disabling sequelae. Occasionally, however, a case is seen in which the most perfect reduction and painstaking after-treatment have been car- ried out and yet there is considerable disturbance in function as a result of one or more of these conditions. Flat-foot may be treated by means of arches within the shoe or if severe an osteotomy of the caleaneura may be performed and is usually followed by pro- nounced improvement. The motion in the subastragalar articu- lation may be increased by forcible passive motion under anesthesia, which may be repeated many times if necessary. IMetatarsalgia is a result of flat-foot and wall pass off wdth removal of the cause. Pain beneath the outer malleolus is relieved by removing the por- tion of bone causing the pressure. Removal of spurs on the under surface of the calcaneum will be followed by prompt and complete relief. Considering the causes of disturbed function and the pos- sibility of relief the prognosis is not so bad provided the patient is willing to submit to the necessary corrective measures. CHAPTER LII. MEDIO-TARSAL LUXATIONS. Surgical Anatomy. — Luxations sometimes, though rarely, occur at the medio-tarsal joint, the anterior portion of the foot being more or less completely displaced from the posterior. The bones entering into the articulation are proximally the astragalus and ealcaneum, and distally the navicular and cuboid. The ligaments connecting these bones are very powerful and tlie articulation is seldom broken up except in crushes of the foot. The inner portion of this joint is a part of the anterior subastragalar articulation. The outer part of the joint (the calcaneo-cuboid) has a separate synovial cavity. The pliability of the foot depends mainly on the subastragalar and medio-tarsal articulations. Luxations of the medio-tarsal articulation have been so confounded with subastraga- lar luxations that only a few of the reported cases can be con- sidered sufficiently dependable to deserve consideration. Disloca- tion, uncomplicated by fracture, rarely if ever occurs. The displacement may be inward, downward or outward. Upward luxation of the bones probably occurs only as a secondary element in outward luxations. In most of the cases the deformity has resembled that of an inward subastragalar luxation. The anterior portion of the foot is shortened, the inner border raised and more concave than normal. The calcaneum is not deviated as in sub- astragalar luxations. Crepitus is usually present as a result of complicating fracture. The anterior portion of the foot is abnor- mally mobile. The anterior ends of the calcaneum and astragalus produce a distinct ridge on the dorsum of the foot. In outward luxations the foot is pronated and the scaphoid and cuboid slightly raised. Treatment, — The treatment consists in reducing the luxation and immobilizing the parts sufficiently long to allow healing of the liga- ments. Reduction should be accomplished by open incision if non- operative measur(;s fail. The treatment, operative treatment, after- treatment and prognosis are similar to those given under ''Sub- astragalar Luxations," page 699. 709 CHAPTER LIII. FRACTURES AND LUXATIONS OF THE CUBOID, SCAPHOID AND CUNEIFORMS. Surgical Anatomy. — The cuboid articulates with the calcaneum posteriorly and to the iuner side with the external cuneiform. It supports the outei- two metatarsals and is sei'iii-(4\- ludd in position by heavy ligaments connecting it with the adjoining hones. Frac- ture of the cuboid is not an uncommon lesion, especially in crushing injuries of the foot, but isolated luxation of this bone is hardly more than a surgical anomaly. Fracture usually results from di- rect violence to the dorsum of the foot and since the bone is prac- tically subcutaneous the condition is often compound. The three cuneiforms are firmly bound together and to the surrounding bones by heavy ligaments and like the cuboid are rarely luxated. Frac- ture of these bones is usually the result of direct violence. Cases of partial displacements of the navicular and cuneiforms have been reported but the mechanism is not clear. It should be remembered that the tibialis anticus and tibialis posticus, two powerful mus- cles, find their main insertions on the cuneiforms and navicular. The cuboid, navicular and cuneiforms are all composed of can- cellous tissue internally, while the surface is made up of a thin layer of compact bone. They are firmly bound together by heavy ligaments and are usually fractured by direct violence to the dorsum of the foot. The soft tissues covering the dorsum of the foot are scant and the lesion is often compound. When the frac- ture is not compound from the first, it often becomes so later, as a result of sloughing of the integument on the dorsum of the foot. A crushing of the tarsal or metatarsal bones is an accident not uncommonly seen among railroad employees. The foot is caught beneath the wheels of a car and more or less severely crushed. If the train is moving with much speed the foot is crushed and ampu- tated. If the rate at which the train is moving is slow the foot may be pushed aside and only partially crushed. Treatment. — In fractures of the anterior bones of the tarsus, 710 FRACTURES AND LUXATIONS OF (UfBOID AND SCAPHOID 711 whatever deformity is present should be corrected and the foot immobilized on a plaster sole as shown in Fig. 787. This splint should extend from the middle of the leg to a point beyond the toes. A plaster cast should not be used since secondary sloughing is not uncommon and the skin dn the dorsum of the foot should be Fig. 780. Figs. 779 and 780. — Crushing injuries of feet sustained beneath car-wheels. Crash- ing disarticulation through tarso-metatarsal joint. In the upper plate (Fig. 779) the lower portion of the foot is not completely severed though the tissues are so thoroughly mangled that the circulation is destroyed and amputation is necessary. In the lower plate (Fig. 780) the lower portion of the foot was completely severed at the time of the accident. open to inspection during the after-treatment. The damage to the soft tissues is often more important than the fracture. If slough- ing occurs the parts should be frequently dressed and the sloughing area kept as aseptic as possible. Granulations should be cultivated and stimulated by balsam of Peru and in removing the dressings the surgeon should avoid injury to these delicate granulations. 712 FRACTURES AND DISLOCATIONS Tlu' use of antiseptics siieli as bichlorid of mercury will do more harm than good. AVliile liealint;- and union are taking place the surgeon should see to it that the plaster soh' properly maintains tile ai'eh of llie foot. Operative Treatment. -( )itei'ali(»ii is riMMjiiently indicated because the I'l'acture is conipduiid Iml rarely to accniii|)lisli i-ediict ion. The treatment of eompountl eases is the same in fractures of these bones as has already been indicated under the heading of ''The Treat- ment of Compound Fractures" on page 7S!). In severe crushes of tlie foot iniiiiediate amputation is not infre(iuently denumded. After-Treatment. — The length of tlu' period of immobilization varies greatly with the severity of the fraetui'e and whether or not it is compound. If the arch of the foot has been involved, by the fracture or luxation, weight should not be borne on the injured mend)er inside of six weeks. In instances in which this has not occurred the patient may begin the gradual resumption of func- tion at the end of three or four weeks. If sloughing of the tissues on the dorsum of the foot takes place union is usually delayed and the period of fixation should be prolonged accordingly. Prognosis. — In severe crushes of the foot amputation may be necessary. In instances in which the trauma has not been severe, with little displacement, and no sloughing of the soft tissues, com- plete restoration of function is the rule. Surprisingly good func- tion not infrequently follows even in compound cases and in instances in which the soft tissues have sloughed. CHAPTER LIV. TARSO-METATARSAL LUXATIONS. Surg-ical Anatomy. — The articulation between the distal tarsals (three cuneiforms and cuboid) and the bases of the five metatar- sals is firmly supported by heavy ligaments, and luxations are rare. Displacements of the bases of the metatarsals may occur, but the causative trauma is more likely to produce fracture in this region. The anterior end of the long plantar ligament is attached to the bases of the second, third and fourth metatarsals. All five metatarsals may be luxated as a row, or the base of any one may be dislocated alone. The displacement is almost invariably dorsal, so that the base of the metatarsal may be palpated on the dorsum of the foot. Luxation of the first metatarsal alone is the most common single luxation. The dorsum of the foot is slightly short- ened. Divergent luxations have been noted in which the bases of the outer metatarsals are displaced outward, while the inner bones of this row are displaced inward. Symptoms. — The dorsum of the foot is slightly shortened, and a little more prominent than normal. Pain is experienced in walk- ing and when pressure is made on the ball of the foot by the sur- geon. Crepitus is absent unless the luxation is accompanied by fracture, which is not uncommon. If the foot is carefully com- pared with the opposite foot the deformity will be noted at the level of the tarso-metatarsal articulation. Pressure on the ball of the foot may increase the deformity on the dorsum, as the corre- sponding metatarsal is displaced upward and backward. Diagnosis. — If swelling is pronounced it may be difficult to differ- entiate between luxations of this joint and fractures of the ad- joining bones, without the aid of the X-ray. AVhen the traumatic reaction is not great the landmarks on the foot will serve to dis- close the nature and position of the lesion. Treatment. — Traction on the foot will accomplish reduction. The foot should be fixed for a period sufficiently long to allow healing of the ligaments. The treatment of luxations at this joint is simi- lar to other dislocations in the tarsus. 713 CHAPTER LV. FRACTTTRES OF THE IMETATARSALS. Surgical Anatomy. — The metatarsal bones are classed among the long bones. The extremities are composed largely of cancellous tissue encased in a thin layer of compaet bone. The shafts consist of a heavy tube of compact tissue. Accordingly, the nature of the fracture varies with the region of the bone broken. The outer four metatarsals are ossitied by two cent'ers, one for the shaft and one for the head (the distal end). That for the shaft appears about the seventh week, while the epiphyseal center is first seen during the third year. Ossification of the epiphyseal cartilage occurs be- tween the eighteenth and twentieth years. The first metatarsal is diflferent from the other four. The liead and shaft are ossified from one center which makes its appearance in the seventh week. The base is the epiphysis and its center is first seen during the fifth year. Fusion occurs between the eighteenth and twentieth years. Not uncommonly there is also an epiphysis for the head of the bone. When the first metatarsal shows two epiphyses it re- sembles both metatarsal and phalanx. These facts concerning the ossification of the metatarsals are of importance in examining Rontgenograms of this region in persons under twenty years of age. The bases of the metatarsals are firmly bound to the distal tar- sals and to each other by heavy ligaments, and like the tarsals are seldom luxated. The long plantar ligament is attached to the ventral aspect of the bases of the second, third and fourth meta- tarsals. The distal ends of the metatarsals do not articulate with each other but are held in position by the transverse metatarsal ligament. This ligament tends to prevent overriding deformity of the shaft in the presence of fracture of one of the metatarsals. Aside from the tendons of the long extensors playing over the dorsum of the foot the metatarsals are practically subcutaneous. The scant, soft tissues covering the bones in this region offer little protection from direct violence when applied to the dorsum of the foot. 714 FRACTURES OF THE METATARSALS 715 Fractures of the metatarsals are almost invariably the result of direct blows and are frequently seen in crushes of the foot. Frac- ture from indirect violence does, however, occasionally occur, espe- cially of the first and fifth. A misstep or twist of the foot may Fis. 781. Fig. 782. Figs. 781 and 782. — Show fractures of the ba.ses of the fifth metatarsals. produce fracture of one of the metatarsals. The injury has been noted in soldiers at the end of long, forced marches. The base of the fifth metatarsal is prominent, and falls on the foot, with the member inverted, not uncommonly result in fracture of the 716 FRACTURES AND ])|SI ,(iCAT10NS l)i'oximiil jiortioii of this hone. Fracture of the metatarsals is not, as a rule, acconipaiiii'd by impaction and (lispjaccincnt, as is the cast' wlicn tlu' iiictacarpals ai'c lu'okcii. Fig:. 7.S FiiC. ■7.S4. Fig. 783. — Oblique frjictuio of tlie shaft of tlic tiftli nietatiiisal. Fia;. 784. — Fracture of the h'asr- of the fiftli metatarsal. Fig. 785. — Compound crushinroximal fragment. Diagnosis. — There is usual!}' little difficulty in recognizing a frac- ture of one or more of these bones. Their dorsal surfaces are practically subcutaneous, and if the case is seen early much can be learned by direct palpation. If the swelling and traumatic reaction are well advanced before the surgeon is called, the parts may be exciuisitel.y tender, and under such circumstances it is preferable to determine the presence of fracture by tlie use of the X-ray, rather than to administer an anesthetic and establish the diagnosis by palpation and manipulation. If pressure is made on the ball of the foot (between the toes and the ball) and toward the base of the bone (that is, in the direction of the axis of the metatarsal) pain may be produced at the seat of fracture in the corresponding bone. Pressure should be made in this way over the head of each metatarsal. Treatment. — The foot should be placed on a plaster sole which is moulded so that it properly supports the arch of the foot. This splint should extend from the middle of the leg to a point beyond the toes. Traumatic reaction should be controlled by the inter- mittent application of the ice cap, and by keeping the foot in the elevated position. If deformity exists it should be corrected be- fore the plaster sole is applied. Operative Treatment. — Compound cases are common and the operative treatment in these cases is practically the same as that given on page 712 under "Fractures and Dislocations of the Cuboid, Scaphoid and Cuneiforms." Open treatment to correct deformity in simple cases is practically never indicated. After-Treatment. — Union takes place in simple cases in three to four weeks. Weight bearing should be only gradually resumed, since ventral bowing may occur if the first metatarsal alone or more than one of the other metatarsals has been broken, and the PRACTIIKKS OF Till': METATARSALS 739 patient walks too soon. Hot applications, passive motion and mas- sage will hasten the time when the patient will be able to enjoy free use of the foot. Prognosis. — The seventy of these lesions varies gi-eatly, and ac- cordingly the outlook will depend on the amount of damage done. Simple, uncomplicated injuries should be followed by complete restoration of function. Severe crushing injuries may require im- mediate amputation. CHAPTER LVI. FRACTURES AND LUXATIONS OF THE PHALANGES. Surgical Anatomy. — The structure of the bones of the toes is similar to that found in the tinkers. Tlie toes may be broken in crushes of the foot, and resemble the eondition as occurring in the metatarsals. The toes are practically always broken by direct vio- lence. The accident is common among laborers and results from heavy objects being dropped on the foot. A not uncommon form of injury is one in which the toes are caught in a moving elevator. The great toe usually suffers most and the crushiug of the parts is severe when produced in this way. Stubbing of the toes against some projecting object, while the patient is barefooted, is fre- quently responsible for fracture of one or more of the phalanges, especially that of the little toe. Luxations of the toes are rare and resemble those seen in the fingers. Symptoms.— The amount of disability is almost entirely de- pendent on the severity of the causative trauma. In simple frac- ture of the little toe the patient is usually able to get about with little difficulty although pain may be severe immediately following the accident. On the other hand severe crushing injuries, such as sustained in the usual elevator accident, completely disable the pa- tient. Crepitus, pain and swelling are present. Crepitus may be difficult to elicit if the fracture is in the distal phalanx, because of the splinting effect of the nail. Treatment. — The parts should be immobilized on a plantar splint. The displacement is usually moderate and can be corrected without difftculty. In fractures of the great toe the patient should be pre- vented from bearing weight on the foot until union is solid. In fracture of the smaller toes the patient may be allowed about as soon as the traumatic reaction has subsided. The great toe is an important factor in walking but the lesser toes have little to do with the usefulness of the foot. If fibrous union takes place in one of the smaller toes there will be no subsequent disturbance in function. When the little toe alone is fractured it will usually 720 FRACTURES AND LUXATIONS OF PHALANGES 721 not he necessary to employ a splint in the treatment of the (condi- tion. If cotton is placed between the little toe and the adjoining digit, and the injured toe strapped in position with adhesive, the necessary immobilization will have been accomplished. In com- pound, crushing injuries the important element is the damage done to the soft tissues, and the case must be treated accordingly. Gan- grene may develop in one or more of the toes if the crushing has been severe, and amputation may be necessary. Prognosis. — In simple uncomplicated cases the prognosis is good. If the accident results in the loss of the great toe there may be a limp, more or less noticeable in the patient's gait. PART IV. SPECIAL SUBJECTS. CHAPTER LVII. TERMS AND DEFINITIONS. Fracture. — No better definition can be given than the meaning of the Latin word {f ranger e, to break) from which the term is de- rived. A breaking of bone or cartilage. Dislocation or Luxation. — Is a condition in which the articular surfaces are completely displaced from each other. These terms are often loosely used, and in many instances an incomplete dis- placement of the articular surfaces is spoken of as a dislocation when it should be designated as a subluxation. Subluxations are dislocations in which the articular surfaces re- main partly in contact with each other. Complete and incomplete are terms used to indicate the degree of fracture or luxation. In incomplete fractures the line of frac- ture only partially separates the fragments. Congenital fractures and luxations are conditions which exist at birth. In many instances it is difficult to state whether or not the lesion was intra-uterine. Congenital fractures and luxations may be the result of prenatal disease, defective development or of trauma at birth, or of a combination of these causes. Spontaneous fractures and dislocations occur as a result of dis- ease or paralysis. In some instances, notably fracture of the hip, the bone may break under normal strain as a result of the absorp- tion and rarefication of bone which takes place in the aged. Pathologic fractures are caused by diseases of the bone such as osteo-sarcoma, carcinoma, osteo-myelitis, etc. Pathologic luxations result from diseases which cause degener- ation of the ligaments or alterations of the articular surfaces. Recurrent or habitual luxations are conditions in which the same dislocation takes place repeatedly, following incomplete healing of the ligaments after the initial lesion. Recurrent luxations are com- mon in the shoulder joint following improper treatment of the first displacement. Diastasis and distraction are terms used to indicate a condition 725 726 FRACTURES AMI DISLCXWTIONS in Avliich the joint surfaces are forcibly torn from each other and remain separated without overriding deformity. A good example of diastasis is sometimes seen in the lower tibio-fibular articulation Fig. 788. Fig. 789. Fig. 788. — Example of a simple trimsverse fracture. Fig. 789. — E.\ample of multiple fracture of the shaft. when the ligaments are torn and the lower ends of the tibia and fibula separated. The term compound or open is used when the fracture or lux- ation is connected with the outside air by means of a wound. The wound may be made by the vulnerant body penetrating to the TKRMS AND DKKINITIONS 727 bone, or the end of the fragment or articular surface of the bone may penetrate the skin from witliin. The term closed is used in contradistinction to open or com- pound. Fig. 790. Fig. 791. Figs. 790 and 791. — Surface form and section of fracture united in deformity. Old fractured tibia sawed in tlie coronal plane. Note how the rough fractured surfaces not originally in apposition have been absorbed, filled in and rounded off, as the middle of the callus became more dense. When union takes place with deformity, as in this case, the callus is of necessity heavier and more dense than when good reduction has been accomplished. This specimen was obtained from the dissecting room and is probably many years old yet the medullary canal has not reopened. In fractures of the shafts of long bones the medullary canal reopens some years following the injury provided the reduction is good. In this case the deformity is pronoimced and the medullary canal remains occluded by the internal callus. A good example of the reopening of the canal is seen in the X-ray plates (Pigs. 636 to 639). The term simple is used in contradistinction to both compound and complicated. The term complicated is rather indefinite in its meaning. It is used when the fracture is compound or open and is also employed 728 FRACTURES AND DISLOCATIONS to indicate asjsot'iatLtl injury to arteries, veins, nerves or muscles. It is also used when the fracture is infected. A green-stick fracture is one in which the line of fracture re- sembles that seen when a green-stick is broken. The bone is bent Fig. 792. — Carcinoma of the humerus with spontaneous fracture. Fig. 793. — Carcinoma of the humerus with spontaneous fracture. and the fracture involves only the convex side of the shaft. Many fractures are called green-stick which are in reality of the sub- periosteal type. Suhperiosieal fracture. — This term is used when the fracture is TERMS AND DEFINITIONS 729 Fig. 794. — Carcinoma of the lower end of the femur with extensive destruction of f30 FRACTURES AND DISLOCATION'S Fig. 795. — Syphilitic dactylitis with siioiilancdus fracture. Fig. 796. — Spontaneous fracture following osteosarcoma. TERMS AND DEFINITIONS 731 not accompanied by appreciable tearing of the periosteum or dis- placement of the fragments. It occurs in children and is the result of bending force applied to the bone. When this type of violence Fig. 797. — Osteocarciiioma with spontaneous fracture. Much destruction of bone. is applied to a young bone (young bones are tough rather than brittle) the convex side of the shaft is under tension strain while the concave side is under compression strain. Fracture may 732 FRACTURES AND DISLOCATIONS "^9 TERMS AND DEFINITIONS 733 Fig. 799. Pig. 800. Fig. 799. — Same case as shown in Fig. 798. Note fraoture of femur. Fig. 800. — ^Same case. Note fracture of femur. Fig. 801. Fig. SO 2. Fig. 801. — Same case. Note bowing of tibia and point in shaft which is ready to break with the slightest strain. Fig. 802. — Same case. Same condition as seen in tibia of opposite leg in Fig. 801. 7o4 FRACTrRES AXU DISLOCATIONS occur on tlie convex side from tension or on the concave side from compression. Wlien the former type of fracture occurs and is incomplete we luive tlie lypical ,ureen-stiek fracture. AVhen the latter type occurs we have tlie suh])eriosteal form of fracture. Tlie ditference is well illustrated hy the manner in which different forms of iron hrcak. \Vi'(Miiili1 ii'on -, " wliiU' steel girders break on the convex side with clean fradui-e. The more brittle the material the more likely the fracture is to begin on the convex side of the column and to be conij>lete. The more rapid the liending the greater the proba- bility of a complete fracture and of the l)reak lieginning on the convex side. Various terms are used to indicate the nature of the fracture, the character of the deformity and the line of the break. Such commonly used terms as: comminuted, multij)le. transverse, oblique, spiral, overriding, angular, depressed, etc., are self-explanatory. CHAPTER LVIII. THE USE OP THE X-RAY. BY H. G. STOVER, M.D. After the lapse of some eighteen years since Rontgen's discovery, it ought not to be required, in a work upon fractures and disloca- tions, to insist upon the absolute necessity for the routine use of this indispensable diagnostic means in every instance of possible bone or joint injury. Yet even in this day, when the benefits of Rontgenology are avail- able in so many localities, the use of this agent is far from as general as it should be. In the early days of the Rontgen ray there was some excuse for the surgeon who did not rely upon it : the users of the ray were not in possession of efficient apparatus ; exposures were long, and often resulted in harm ; and, owing to imperfect technique and small experience, the information afforded by a Rontgenologic examina- tion was in many instances incomplete, and at times misleading. These excuses do not hold now ; in every center of population there are installations capable of giving useful Rontgenograms, and men who are competent to make the examinations skillfully and without danger to the patients. The advantages of the Rontgenologic examination are many and vital. The Rontgen examination does away with the need for manipu- lation of injured parts in the attempt to elicit pain, crepitus and preternatural mobility; it not only affords all the information of value to be gained from the ordinary methods of examination, but it brings forth facts impossible to be elicited in any other waj': certain fractures without displacement ; certain impacted fractures ; certain incomplete fractures; certain fractures, which, by their very nature cannot give the usual clinical signs ; it reveals the inter- position of small fragments between the ends of fractured bones; and avoids the bruising and laceration of tissues which must occur in some instances if there be a prolonged manipulative examination. 735 736 J^RACTURES AND DISLOCATIONS It has been argued by some that a surgeon ought not allow his manual dexterity to suffer the atrophy of disuse, by relying upon the Rontgen ray ; one might as well say that an internist ought not use the microscope to look for plasmodia in the blood, but ought rather nurse his skill in eliciting subjective and objective clinical synijitoins upon which to formulate his diagnosis. At the same time, it must be insisted that the Rontgen examination is not to supplant the clinical methods; rather nuist it supplement them. The skilled hand of the surgeon has done its wonders through the ages ; it cannot be neglected now ; the practised eye discovers ex- ternal signs of internal conditions in a marvelous way as evidenced by the photographs in this book. The time is coming when failure to make appropriate use of Rontgenology, when accessible, will be counted as negligence, and this not only in surgery, but in many departments of internal medicine. Even the laity are coming now to criticise their attend- ants for delay or neglect in this matter. After attempted reposition of fracture or dislocation, the Rontgen examination affords a means of ascertaining if position is correct without disturbing retentive dressings or apparatus, enables one to watch the course of healing, and to know the final anatomical result. In many of the fractures met with, a clinical diagnosis sufficiently accurate for preliminary treatment can be made ; in these cases the Rontgen examination should be made after reposition in order to check up the clinical diagnosis and to make certain that satisfactory reposition has been accomplished. But there are not a few in- stances in which the Rontgen examination should be made before anything else is done ; in this class are many of the injuries about the elbow^, hip, and pelvis, and those severe traumata in which there is suspicion of grave damage to vital soft tissues, and further injurj'^ through manipulation might result in gangrene, or other detri- mental sequelae. As the Rontgen ray produces no sensory impression upon the retina, it is necessary to use intermediate means to transform the results of its energy into visible records. There are three physical factors which render this possible : First: all substances absorb the Rontgen ray practically in rela- tive amounts corresponding directly to the ratio existing between their atomic weights. Second : the Rontgen ray causes certain substances to fluoresce. THE USE OF THE X-RAY 737 Third : the Rontgen ray has the power of producing a paralyzing effect, or a latent, developable image, upon the chemicals used in the sensitive emulsion of photographic plates and certain photo- graphic papers. If a substance is so placed that it will intercept rays directed toward a screen coated with fluorescent material, or a photographic plate, the absorption which occurs leaves areas on the screen or emulsion, which are not affected ; these areas on the fluorescent screen are dark; in the emulsion of the plate no latent image is produced ; if the substance 'under examination is made up of areas of various densities, the amount of fluorescence upon the screen or of alteration in the silver salt of the emulsion of a plate, in corre- sponding areas, varies in an inverse proportion to the densities of these areas, or in direct ratio to the amount of rays which these areas permit to pass. At the present time the fluoroscope is not used in this branch of surgical Rontgenology, except for roughly and quickly estimating the approximate location of a foreign body, or obtaining some general facts regarding a bone injury; the screen image is not so rich in detail as is that upon the plate ; it can be studied during only a short period of time ; it is not a permanent record ; its fre- quent use is dangerous to the operator; long or repeated exposure may lead to injury of the patient's skin, as for example, when the operator, the attending physician, perhaps a consulting surgeon, and probably from one to a dozen relatives and friends, must all ' ' have a look. ' ' On the other hand the sensitive plate gives all the details; it can be studied as long or as often as needed and at any time ; it is a permanent record of the condition ; it is demonstrable evidence that such an examination has been made ; in addition to this, the accumulation of a large library of plates furnishes rich material for scientific study and for the writing of papers. The great part of Rontgen diagnosis in medicine and surgery must be done by specialists in this line, and indeed before long there will be subspecialties in Rontgenologj^, so great is the field and so complicated the technical details of diagnosis-making. jNIost physicians and surgeons will find it impracticable to make their own Rontgen examinations. A complete equipment is costly in apparatus and space and its maintenance expensive. One's own patients will not contribute as liberally to this for these examina- tions as they will do when referred to a specialist for the purpose, TAS FKACTIRKS AND DISLUCATIUXS and men cainiot irivc tiinc iVoiu a busy prnctico' to carry out the woi-k. The i)liy.si('ian who docs not have reasonably ready access to a competent Hiintgenologist nia\- wdl. howevei-, pi'ep.-ii-e and ccpiip luinsclf to examine fi'actnres and dislocations by this nu'thod. lie will not need the jiowerfnl wencratinsi' machines, tlie com])licated auxiliary ap|)aratiis or the costly tubes nccessai-y I'oi- instantaneous Rontgenoi'ra{)hy ot the luniis and stomach, ^'ct lei not such an Fig. 803. — The Kose i)(irtiililc coil. one imagine that he is taking up a simple problem! For this man the author would advise the Rose Portable Coil (Fig. 803). It may be used on either direct or alternating current; it is of the compact "suit-case" type and can be carried in the hand for short distances without overfatigue, so it may be used either in the office or at the beside where electric current is available. In Fig. 804 is shown a larger apparatus of the same type. It is more powerful but is THE TISK OF Tlir-: X-RAY 739 more weighty and heavier fuses must \h' phieed in house eii-euits in which it is used. Another box for carrying the Crooke's tube and the plate-holders is a convenience. The apparatus requires a special type of Clrooke's tube, calculated to suppress inv(!r.se current (Fig. 805). Fig. 804. — This apparatus is similar to tliat sliown in preceding figure. It is. liow- ever, more powerful and more weighty. Heavier fuses must be placed in the house circuits on which it is used. The Cramer, the Forbes, or the "Agfa" X-ray plates will be found quite satisfactory, permitting of some latitude in exposure time. These plates are to be enclosed in the black and yellow envelopes. r40 FRACTURES AND DISLOCATIONS Opaque to ordinary actinic light, wliicli may be procured from the plate makers. Always put the plate in the black envelope (in the dark-room, of course) so that the film of the plate is next to the smooth side "of the envelope; then put the black envelope into the yellow one so that their smooth and unprinted sides are together; Fij. 805. — Special type of Crookes tube, calculated to suppress inverse current. this is important, as in this way one is always certain as to which side of the package carries the film side of the plate. If Rontgeno- grams are made with the tilm side of the plate down in some examinations and up in others, when using envelopes, there might he no way of knowing, in a subsequent study of the plate, whether l''ig. 806. — Metallic numbers for marking X-ray plates. the right or left side of the body had been examined, a point which it is quite necessary to know when making reports to insurance companies, or when the physician is called to the witness stand. It is a very good plan to mark the plates, at the time of making the exposure, by means of leaden letters "L" and "R. " THE USE OF THE X-RAY 741 For several reasons it is quite important that plates be carefully so marked that their future identification is always positive. Metal- lic numbers (Fig. 806) may be placed on the plate at the time of the exposure, thus obtaining a Rontgenogram of the number as a part of the image produced; if this is not practicable the number of the plate or the patient's name, should be written upon the film side of the plate, in the dark-room, with a lead pencil, immediately before developing it. When the Rontgenogram has been made, the following points should be noted upon the envelope, for a record : name of patient ; address ; occupation ; if a minor or a dependent, the name and address of the financially responsible party ; the date ; the part examined; the nature of the view — whether antero-posterior, postero-anterior, lateral, etc.; the condition suspected; the diagno- sis ; and other facts may be added if desired, such as, history of the injury; description of the dressings applied, etc. The plates should be filed away in a safe place in such a way that they will be readily accessible for future reference. Filing may be done according to number, or in groups of "parts of body," or in groups of "lesions found." An index of such a nature that plates may be found easily, should also be kept. Do not permit patients or others to carry away your plates ; you may want them badly yourself some day. The plate is the most important part of your record of your work ; it may be needed for study of the progress of a case ; it may be needed in court ; in time your plates form a valuable library as already stated. The author does not permit his plates to be introduced in evi- dence as "exhibits" in medico-legal cases; when the author is on the stand and is asked to show his plates to the jury, he says to the Judge, "May it please your Honor, these plates are a part of my professional records; they are necessary to me as such, and as material for scientific study ; I therefore do not desire to introduce them into evidence as exhibits, but simply to use them as diagrams, by means of which to demonstrate the opinion I am here to give." This has always been allowed without question by the Court. Prints, if they are of such a nature that they will show the con- ditions according to the opinion of the expert, may be introduced as exhibits. Personally the author does not think plates or prints ought to be made exhibits in evidence. The Rontgenologist is not 742 KUACrrRKS AND DISl.t ICA'PIONS in court as a ])liotoc!:raph('r. but as a in(Mlico-l('«ral expert wliose oplniou is beiiij? given. The Rontgen ray is a form of energy proceeding in divergent lines from its source. This most important fact nuist be borne in mind when i)Osing patients for examination and wlien reading the negatives obtained. On .Mceount of this divergence, we have this fact to remeiiiher: otlier things being ecpial, the quantity of Rontgen ray falling upon a surface varies inversely with the square of the distance of that surface from the source of energy. Suppose a surface (Fig. 807) one foot s(|uare exi)osed to the Rontgen ray at a distance of one foot from the target of the tube; let ^4 be the target of the tube: let lU'DK tie tile surface exposed: then this s(|uai-e Fig. 807. Fig. 808. foot of surface is receiving a pyramid of rays included in AB, AC, AD, AE ; now extend these lines until they reach a plane at a dis- tance of two feet from the target (Fig. 807), and they include the surface FGHJ, which will be found to contain four square feet ; therefore the same pyramid of rays at one foot distance covering one square foot of surface, at two feet distance covers four square feet. Another important factor in posing is now to be brought out (Fig. 808). Suppose the target of the tube at .4, the object to be examined X-Y. If a plate is placed at B-C, the image of X-Y is somewhat but very little magnified on B-C ; but if now the plate is moved to B'-C, leaving the object X-Y close to the target as before, THE USE OF THE X-RAY 743 the shadow of X-Y takes on the length B'-C, a very great distortion. If, however (P'ig. 80!)), both plate and objeet (Examined are moved far fi-oni the target, the image of X-Y on phite H-(] is A Fig. 809. M N Fig. 810. much more nearly the actual size of the object than when both were close to the target. Further, pose, for our ''object," a sphere containing in its center a smaller and denser spherical mass, so that the plate and the object Fig. 811. are near each other, but at a good distance from the target A, yet in such a position that the line PA (representing the principal axis of rays, those falling perpendicularly upon the plate) pass far from 744 FRACTl'KES AND DISLOCATIONS the center of the object, as in Fij?. 810. The Klinttiviiogi-ain result- ing from tliis ])Ose, shown in Fig. 811, iiives a distorted image of tiie object. The outline of the image is far from being eii'cular in form, aiul the image of the smaller sphere is not at tlie ceiitei- of the image of the large sphere. From these facts Ave ma\ deduce a general rule for so posing as to avoid distortion : The object and the plate sliould be as ch)se together as possible; they should be as far as possible from the target (consistent with securing sufficient (luantity of ray) ; the rays falling from the target perpendicularl\- upon the plate should pass through the center of the object. A distance of from eighteen to twenty-four inches between tube and plate is usually used. Now this cannot be an absolute rule ; it nuist be infringed upon in respect of the relation of the principal axis of rays and the center of the object, at times. For example : a patient with a suspected fracture of the neck of the femur, exhibiting considerable eversion of the lower extremity ; as the patient lies on his back, the plane of the neck of the femur is not parallel with the surface of the plate placed underneath ; rays passed through the neck of the femur and falling perpendicularly upon the plate, would give a foreshortened image of the neck, largely covered by the superimposed shadow of the greater trochanter ; therefore the exposure to show a fracture of the neck of the femur in such a case as this must be made with the target of the tube outside of a perpendicular from the plate passing up through the neck ; this oblique direction of the rays will show the full length of the neck. In making a Rontgenogram of the ankle-joint, antero-posterior view, with the toe pointing directly upward, perpendicularly to the plate beneath, the target should be placed a little to the outside of the perpendicular, in order not to superimpose the shadows of the lower ends of the tibia and fibula. The rays proceeding from ditferent (Jrookes tubes are not always the same in quality ; the quality of ray from any given tube will vary from time to time. There is a variation in quantity depend- ing upon the exciting current ; beside this, there are all degrees of variation in penetrating power, dependent largely, apparently, upon the nature of the vacuum in the tube, other things being equal. THE USE OP THE X-RAY 745 In general we speak of tlie rays as being "soft," "meflium," or "hard," and we use tlie same terms in desei-ihiug tlie tubes. The soft ray comes from a "soft" tube, of low (comparative) vacuum; these rays are emitted in large ({uantity, have a consider- able chemical action, but are of low penetrating power. These are the rays which quickly lead to dermatitis if permitted to act too long on the tissues. They produce very contrasty Rontgenograins of thin parts. It is worse than useless to attempt the production of a Rontgeno- gram of a thick part with a soft tube by unduly prolonging the exposure ; this simply over-doses the tissues with rays which are all absorbed, and the only result will be a "burn." The hard rays come from a "hard" tube, one of high vacuum; they are emitted in relatively less ciuantity, have less chemical action, but are very penetrating. The medium rays come in large quantity from a tube of (com- parative) medium vacuum, and are best for general purposes, giv- ing good bone-structure and contrast between bone and soft tissue. For bone work in very thick parts a harder ray is better. If too hard a tube is used, the extremely penetrating rays being so little absorbed by the bony tissue, give a flat negative without contrast between bone and soft tissue. The user of the Rontgen ray should be very careful to protect himself from its deleterious effects. This is a matter of the utmost gravity ; repeated exposures are bound to produce the specific results upon the tissues ; the Rontgen ray is not a plaything. A serious dermatitis results invariably in carcinoma with a strong metastatic tendency, and the death roll of Rontgenologists, with several yet living whose names will soon be added to it, is already too large. In addition to the fact of the danger to life from incautious ex- posure, is the fact that the ray affects the reproductive organs in such a way as to produce sterility (not impotentia). Fluoroscopes are now provided with lead glass for protection, and opaque gloves, aprons, gowns, etc., may be procured. There are shields of heavy lead glass, white oxide of lead, or rubber compound which may be placed directly about the tube, and which are quite opaque to the ray. In estimating the time of exposure for different parts, one should consider: the thickness or density of the part; the distance of the 746 FRACTTTRES AXD DTST^OCATTOXR tubt'; the penetrating powcf. oi- liiirdiicssof the ray used ; the anionnt of fUffi'iit pasvsinw tliroiiiili llif liilir; tlic kind of phite nsed (some are imu-li more rapid tluiii olhci-si. 'IMic use of an intensifying Fig. 812. — Kacliii-rhvdnomett'r. screen ents down the time from one-fifth to one-tenth, bnt it also cuts down in the same proportion the allowance of latitude for error in calculation. There are scales for measuring the penetrating power of the Pig. 813. — The Bauer qualiineter. ray; the best of these is the Benoist radio-chronometer (Fig. 812) ; with this, when viewed through the fluoroscope, or its image studied upon the plate, a comparison is made of the color produced by rays THE USE OP THE X-RAY 747 which have passed through pieces of aluminuTii of different thiek- ness, with that produced by rays which have passed through a piece of silver of a standard thickness. The hardness of the rays may be measured by means of the Bauer Qualimeter, a sort of electro-static torsion balance (Fig. 813). A special milliamperemeter is used for measuring the quantity of high voltage current passing through the tube. Thus quite an accurate technique may be built up. Experience soon teaches how to estimate the values of the various factors so that the calculation with these becomes automatic with the experienced operator. With small apparatus, such as has been recommended for the Fig. 814. — Linear fracture of upper end of tibia. amateur Rontgenologist, it is necessary to make rather long ex- posures in order to produce good plates of the thicker parts ; thus the quiet of the part may be disturbed by respiratory movements, or muscular twitchings may occur, or nervous patients may find it impossible to remain quiet. The exposure time may be shortened by the use of intensifying screens as has already been said. Such a screen consists usually of a sheet of cardboard upon which has been laid a smooth coat of some substance which fluoresces when exposed to the Rontgen ray. This fluorescent light is much more active actinically than is the Rontgen ray itself. In use, the chemical side of the screen is placed in very perfectly intimate contact with the film of the plate (a special plate-holder is necessary) ; this 748 FRACTURES AND DIST.OCATIONS jilato-lioldor is placed under tlie part to be examined, preferably with the glass side of the ])late toward the patient and tube; the exposure is then made, and \ery much shorter llian when the sereen is not used: in the dark room the holder is opened, the screen quiekly removed and placed in its container and the plate developed. Uidess a fine sei'ecn is usi d and great cai'e 1;iken that the exposure Fig. 815. Fig. 816. Fig. 81.5. — .\ntero-posferim- view of fracture of the radius. Fis. 81(i. — Jjiitcral view of sauie case. ifs ]ieither too long nor too short by a very small margin, the result will not be satisfactory; if there is even a slight overexposure the image will be ^'grainy" and the lines of bone-structure will not be shar]) and clcai'. The t(M'lini('al difficulties are multiplied by the screen, but its use will he of value wdien examining thick parts with small apparatus. The Rontgenogram (Fig. 814) produced is not a photograph; it THE USE OP TJJE X-RAY 749 is a record of the combined, superimposed images of the various densities contained in an almost infinite number of planes in the object examined, through which the ray has passed. Fig. 818. Fig. 817. — Fracture of the femoral sliaft whicli cannot be detected because the ravs do not pass through the plane of the fracture. Fig. 818. — Another plate of the same case. No evidence of fracture. A single view of a fractured bone is seldom or never sufficient for the diagnosis; exposures should be made from at least two points of view, generally at right angles to each other, and sometimes more 50 KK'ACTIHKS AM) niSl.OCATIOXS aro necessary lo I)!*!!!*; out ohsciirc points, since the IxrxMitprenofxi'nm is in a wnv a sillinnette oi' slnulow imaue. Fi FiK. ^: Fig. 819. — .\nother plate of the case shown in Figs. 817 and 818. The outlines seen in the middle of the shaft miglit lead one to su.speft fracture hut are hardly sufficient to establish a diagnosis. Fig. 820. — Another view of the same case showing tlic fracture ((uile distinctly. This plate and Figs. 817, 818 and 81'.! demonstrate the possibility of overlooking a fracture if the case is examined only \n one plane. Fig. 815 shows an antero-i)Osterior view of an old fracture of the radius; the lateral view shown in Fig. 816 demonstrates very strik- iiifflv the need of more than one view. THE TTSK OF THE X-FIAY 751 Figs. 817, 818, 819 and 820 are all views of the same reiiiiir fdiild j taken from different viewpoints. In certain parts of the body (the shoidder, for example) it is impossible to obtain two views at right angles to each other; here the stereoscopic method is of special importance. In this method two views are made from slightly different viewpoints, bnt bearing a mathematical relation to each other. For the first view the target of the tube is placed one and one-quarter inches to one side of a perpendicular from the plate passing through the center of the object; the second plate is made after moving the target an equal Fig. 821. Fig. 822. Figs. 821 and 822. — Stereoscopic Rontgenogram of a low subcoracoid dislocation of the shoulder. distance to the other side of the perpendicular. Stereoscopic plates are observed by means of a plane prism stereoscope (not the usual parlor instrument), and a perspective view results, enabling one to get all the relations between the parts of the image (Figs. 821 and 822, subcoracoid dislocation of humerus). This stereoscopic view may be studied by means of a trick of visual accommodation if one has not a stereoscope handy ; direct the gaze to a point midway be- tween the two plates, then focus upon an imaginary oliject some dis- tance beyond ; this will cause the appearance of three images ; study the middle one, disregarding the two outside. One should do his own developing, instead of referring it to a 752 FRACTURES AND 11ISL(1CATI0NS pliotograi)lu'r ; tlic j)hotoy:i'a])h('r may Itc a better teelniieian at tlio outset, hut he is rarely sut^eieiitl>' ac(|iiaiiite(l with anatomy ami ]iathology so that he will know at what stage of (leveU)])ment to arrest the process. The dark-room must a])solute]y exelude all dayliglit or artilieial light save that from the red him]). The red light should he tested by exposing small plates to it and de\-ehipiug them, in order to make sure it is a "safe light.'' If possible it is well to begin the develop- ment of plate in total darkness. Put the plate, lilm up, in the tray and quickly swirl the developer over it, then continuously rock the tray, slowly ; hold the plate up to the red light after a time, and from time to time, in order to observe the progress of development, but do not do this too often, no matter how "safe" the light is. Develop until by reflected red light the back of the plate .shows some dark- ening, or until the inuige seen by red light transmitted tlirongh the plate, begins to fade. A good developer is that known as the Cole developer, used by Dr. L. Gregory Cole of New York : Distilled water 32 ounces ^Metol 40 grains Hydroquinone 6 drams Sodium Sulphite (dry) 2 ounces Sodium Carbonate fdry) 2 ounces Potass. Bromide 40 to 60 grains A fault of a good many developers recommended for Rontgen work is that they do not contain enough l)ronnde. The temperature of the develoi)er should not be above sixty-five degrees Fahrenheit. After development, rinse the plate carefully for a real minute in running water, put it into one or another of the hyposulphite of soda fixing solutions in order to dissolve out the unexposed silver salt from the emulsion ; after about twenty minutes, or at lea.st ten minutes after the foggy white color has gone from the back of the plate, put it in running water for one hour; then take out and set on edge to dry in a room of even temperature, where dust will not fall upon the soft emulsion. Be cleanly in the dark-room. Have trays for each special pur- pose, use them for no other, and keep them clean. AVear thin rubber gloves when developing; metol is veiy poisonous to the skin of some people. Rinse the hands carefully every time they have THE USE OF THE X-RAY 753 been near a solution. If a very little hypo is carried into your developer you will find your plates displaying some very peculiar appearances. Plates which are not quite perfect in certain respects may be improved by intensification or reduction, as indicated by the quality of the density, but really in order to obtain a correct plate the exposure must have been very nearly correct in the first place ; after- manipulations will not make a good plate out of a bad one. In studying plates, put them in a window against a clear sky, north light preferred. A box fronted with ground glass and con- taining electric lamps is a convenience as it may be used at any time. Make plenty of experimental plates of normal parts in order to have a standard. It is well, in injury cases, to examine the corre- sponding normal part until one becomes familiar with normal Rontgenologic anatomy, and has a collection of normal plates. There are no "high lights" in Rontgenograms ; these are impor- tant in camera photography ; the corresponding condition in a Ront- genogram is the black part of the plate outside the field of the image ; in Rontgenography we are dealing with what photographers call "shadow detail." In studying plates, look out for the appearances (artefacts) caused by air bubbles adhering to the plate during development, finger marks, scratches, light-struck spots due to holes in the envelopes, and chemical stain and fog. Look out for confusing lines where the shadows of two or more bones are superimposed. Do not be deceived by the heavy (white) shadow of a ridge for muscular attachment, which at times may appear to be the margin of a fracture shadow. Remember that epiphyses unite at varying periods in the develop- ment of the individual. Do not mistake a normal center of ossification of a condyle for a displaced fragment of bone. Remember that a patient may have more than one fracture. Remember that a fracture may be located at some distance from the seat of pain. Remember that a functionally perfect result may appear very far from being an anatomically perfect result. Just because your plates show good apposition in a fracture located near a joint, do not be over-optimistic in your prognosis. CHAPTER LIX. TTTE OPEN TREAT:\IENT OF FRACTURES. The use of the X-ray and operative treatment have, of recent years, greatly improved the results in certain fractures and disloca- tions. Open treatment is particularly adai)ted to the correction of deformity in instances in whieh simpler methods cannot accomplish reduction or fail in preventino' subsequent displacement during the after-treatment. Cases in which operation is performed may be divided into two groups: the first includes cases in whicli this method has been chosen soon after the injury because of the im- proved results which it may offer; the second includes cases which are operated iipon as a last resort after non-operative methods have been tried and proven unsuccessful, or in which operation was demanded because the condition was compound from the first. The results of these two groups of cases are quite different and should not be confounded when deliberating upon the advantages of opera- tive treatment. Consideration at this time is only given to cases in Avhicli operation is performed as an initial measure because it offers better results than non-operative procedures. Operation done in compound fractures will be taken up under the headings of "Treat- ment of Compound Fractures and Dislocations," page 789. All forms of treatment give a higher proportion of functionally perfect results in children, and hence the difference between opera- tive and non-operative results is less marked before puberty. With advancing years the proportion of eases in which a better result can be obtained by operation increases. Mechanical means for the direct or internal fixation of the fragments have been known and employed for many years, but it is only recently that improved technique, both as to appliance and asepsis, have demonstrated the real value of the operative method. Wire, nails, screws, pegs, clamps, ferrules, and absorbable suture materials, have all been used, and even now have their appropriate places. But the develop- ment of the Lane plate has proven, undoubtedly, the greatest stride in the open treatment of fractures. It is a well known fact that 754 THE OPEN TREATMENT OF FRACTURES 755 perfect anatomic reduction is not always essential to the complete restoration of function, yet the more cases in which absolutely exact reduction is obtained, the greater will be the dec^reasc in the per- centage of cases showing loss of function. We shouh], tli(;rci'ore, endeavor in each and every case to secure as accurate an anatomic result as is possible. Proper operative treatment not only accom- plishes more perfect apposition and fixation of the fragments hut shortens the period of disability, gives better functional results and lessens the suffering of the patient. Probably the best time for operation is from seven to ten days following the accident. This allows the tissues to recover from the initial shock and gives time for the development of local resistance. In operating on simple fractures the surgeon should fully appreciate that he is rendering the condition compound, and that infection following open treat- ment is often productive of much worse results than would be the case if surgical measures had not been instituted. For this reason the most strictly aseptic surroundings are demanded and the oper- ator should be skilled in this particular branch of surgery. Those unaccustomed to bone work should not attempt these cases. The surgeon should possess a mechanical sense peculiar to this particular type of work, and an appreciation of the relative strengths of the materials operated upon and employed. This mechanical sense, referred to, is easier to illustrate than to define. For example : if we observe an experienced mechanic at work, we never see him tighten a nut until the threads strip or the shaft of the bolt twists in two, and yet he tightens nuts of all sizes and threads, each one requiring a different degree of force to properly seat it. In like manner the expert cabinet maker saws and shapes his wood to fit the desired places and yet a nail is never driven without due consid- eration for the strength and nature of the material through which it passes and the function which it is to perform, nor is a screw driven home so that the last turn strips the thread, breaks the shaft or causes the wood to split. On the other hand, if we watch the apprentice learning his trade, the lack of mechanical sense is ap- parent in the frequency with which he spoils materials and ruins his tools. Any one who has seen the last screw of a Lane plate split the shaft of a bone, or a bone graft broken just as it is being brought into position will appreciate the value of this mechanical sense and see what can be learned by the surgeon from the artisan. One 756 FRACTURES AND DISLOCATIONS desirous of inereasino: liis ])rofi('ien('y in this particular branch of surgery shoukl obtain fresh bones from the Ijutclicr and then with chisel, saw, nail and screw determine to his own ])ractical satisfac- tion the relative strentrth of bone, and just what it will, and will not stand. Later on fresh specimens from the dissecting room siiould be procured and the same experiments conducted. In addition the various t^'pes of fixation may be tried out on difVerent portions of the bone and the security of the fixation tested. The difference between cancellous and compact tissue may be appreciated in this way and in no other, outside the operating room. When this experience has been gained further obstacles to progress ma}- be minimized by assisting or observing some surgeon of experience in bone work, until a satisfactory technique is obtained. The question of when, and when not to operate in a given case depends upon the general condition of the patient and the degree of reduction which is pos.sible by non-operative methods. Diseased states, such as diabetes, erysipelas, advanced nephritis, etc., otfer contraindications to operation, in the open treatment of fractures, the same as they do in other fields of surgery. If the general health of the patient allows of an operation, the question then arises: "Can an equally good result be obtained by the non- operative method as is possible with open treatment ? ' ' and secondly, "Are the proper surgical surroundings and skill available?" In conclusion, then, we might state that with the proper health of the patient and available surgical facilities, all cases of fracture should be operated, in which an equally good result cannot other- wise be expected. The site of the operation should be carefully shaved, and painted with a three and a half percent solution of iodine (half strength tr. iodi) the day preceding the operation. The i)arts are then covered with sterile dressings until the time of operation. The parts are again painted wdth tincture of iodine (five percent) before the incision is made. As soon as the skin is divided the cutaneous edges should be covered with gauze or towels which are secured in position by small tenacula2, thus preventing infection of the deeper struc- tures from the cut edges of the skin. Ivul)ber gloves are demanded, the hands should be kept out of the wound, as far as possible, and instruments having come in contact with the gloves should not enter the wound. In other words, the most strict aseptic precautions should be observed in every detail, gloves should be worn and then. THE OPEN TREATMENT OP FRACTURES 757 while operating, the surgeon slionld consider his gloved hands capable of infecting the wound. The danger in tliis particular work lies largely in the fact that a glove may be torn b\' one of the serrated fragments while attempting reduction, and when this occurs the pent-up perspiration from the hand is poured out into the wound. A pin-hole in the glove may cause leakage onto the field of operation during the entire procedure. The details of the operation and the exact form of internal fixa- tion which will best meet the requirements of the case in hand are often only determined after the bone has been exposed. The exact nature of the fracture, with the fragments exposed, frequently appears different from the conditions anticipated, even though care- ful examination has been previously made and the X-ray employed. The surgeon should, therefore, have a number of appliances ready that he may choose from among them to more perfectly meet the requirements of the conditions encountered. If an internal fixation appliance is employed it should secure the fragments as solidly as may be, even to the extent of sustaining the weight of the extremity. In the subsequent treatment, however, splints should be employed in such a manner as to relieve the internal fixation appliance from as much strain as possible. In other words, internal fixation should never be called upon to do the work of splints or other forms of external fixation. The fact that internal fixation is so often used in the open treatment of fractures does not necessarily indicate that the objects of operation may not sometimes be attained without its employment. In some instances accurate engagement of the ser- rated ends of the fragments during operation, will be sufficient to prevent lateral or overriding deformity, and the proper application of appropriate splints may be relied upon to prevent angular dis- placement. Reduction of deformity and fixation are thus obtained by operation, but without the use of any type of internal or direct fixation. It is essential that the anatomy of the parts operated upon be understood so that important structures, such as nerves and vessels, may be avoided and the displacing action of the muscles attached to the fragments may be appreciated. The internal structure of the bone should be understood as well as its surface form, since so much depends on the nature of the portion of the bone operated. Irrigation of the wound, just before closure, with a gallon or so of hot sterile physiological salt solution will promote hemostasis and 758 FKACTrUKS AND DISLOCATIONS tend to remove any infection wliicli nii«>;ht liave gained entrance (lnrini>: tlie ojxTation. The nse of the so-called antiseptic solutions within the w.ound are not only useless, hut tend 1o daiiiaii'e the tissues. .When possible a ruiunnij: suture of catgut shoidd approxi- mate tlie muscles before the skin is closed. Deep through and through sutures are most objectionable. The large majority of operations done on fractures jniss through heavy nniscidar tissue which is highly vascular. Extravasation of blood into the wound is almost sure to follow, even though hemostasis seems perfect at the time of closure. Living blood within the vessels possesses distinct bactericidal activity, but wiien extravasated this quality soon disappears, the result being that collections of dead blood within a wound act as most excellent culture media, at body tem- perature, thus favoring subsequent suppuration. It is evident, therefore, that fluids forming within the wound following closure should be allowed to escape at the earliest possible moment. If a few strands of silkworm-gut be so placed within the wound that they act as drains, this most important requisite will have been ful- filled. The field of operation .should be inspected within twenty- four or forty-eight hours and gentle pressure exerted in such a manner that any fluids which may have collected in the meantime will be expressed. c^ii!i^g> ic^Biii^ji ic ^Enai^ 823. — Jh'thdds of usiiiic win- in tlu- intornal ti.Niition of friuUirt The Use of Wire has been largely supplanted by the Lane plate, though it still i-etains its i)lace of ])reference in certain fractures, notably those of the olecranon and patella, and in some cases of fractures in the extremities of the long bones. The difit'erent ways in which wire may be used are shown in the accompanying plates (Fig. 828). In fractures near the expanded extremities of the long bones a single looj) of wire properly i)laced may be sufficient to prevent displacement (see Fig. 825). In wiring the shafts of THE Oi'EN TREATMENT OF FltACTUKES 759 the long bones it is almost essential that two points of fixation be employed to secure proper leverage (see Fig. 638). The circular wire has the advantage of not entering the medullary cavity, and of not requiring the destruction of bone tissue l)y drilling. In most instances the firmest hold is obtained by having the wire pass perpendicularly through the plane of fracture whether spiral, oblique or transverse. If the fracture approaches the transverse type or the serrations are coarse enough to permit of firm engagement a single loop of wire may be sufficient to prevent lateral displacement, angular deformity being prevented by the proper use of splints. Figs. 824 and 825. — -An examiDle of how a single loop of wire can be made to hold the end of a bone in position. The essentials in the use of wire are firstly, that the material be heavy enough to withstand the strain to which it is subjected, and secondly, that it be firmly placed and secure proper leverage on the fragments. These points are best appreciated by referring to the accompanying diagrams. Heavy wire is as well tolerated by the tissues as if the material used were light and inadequate. Virgin silver wire has for years been considered the best, but recently bronze-aluminum wire has been preferred by many, be- cause of its greater torsion strength. Nails, Pegs, Screws and Staples have all been used to secure the fragments in position, but at the present time the development of 760 FRACTURES AND DISLOCATIONS more perfect ajipliances lias rendered tlieir use more limited. They are ouly now employed i"or the ])urpos(' of securino: a small, dis- placed fragment such as a fcactin'cd coiKlylc luhcrclc or tuber- Fig. 826. — Iiistninionts ^\lli(•ll h;ive liccn for ml of considci-jilik' service in operating on fractures. On the left is shown ;i lion-.iawecl bone f()r(ei)s with ratchet in the handle. By means of this instrument it is often ijossible to liold the frasnients in reduction while applying internal fixation apparatus. The instruments to the right are ordinary retractors with the handle ends shaped and drill(Hl so tliat they ma.v he used in passing wire about the shafts of long bones. osity. A good example of the appropriate use of a nail is shown in Fiof. 219. In this case the external condvli^ of the huinerns was Fig. 827. — The linne bone drill. broken off and so displaced that the elbow would have remained useless if operation had not been performed. The nail has been driven at right angles to the displacing pull of "the muscles attached THE OPEN TREATMENT OP FRACTURES 761 to the fragment, and in this position securely holds the condyle against the recurrence of deformity. In the use of nails the hole drilled in the bone should be only a trifle smaller than the size of the nail to be used, otherwise the bone may be split when the nail is driven home. The same holds true in the use of screws, pegs and staples. Screws and nails have been used with some success in the treat- ment of fractures of the femoral neck, the nail or screw being Pis. 828. — Bone forceps. driven through the great trochanter to enter the neck parallel to its long axis. The reason that success has not been more constant in operating on this portion of the femur is because of the soft, cancellous tissue of which the internal structure of the upper end of the femur is composed. Screws, nails and pegs depend for their hold mainly on compact tissue, and in regions of the skeleton in which cancellated structure predominates, little reliance can be placed upon them if the displacing action is considerable. Thus when a nail is driven into the extremitv of one of the long bones it 762 FRACTURES AND DISLOCATIONS will usually be found possible to tear it out witb the fingers; but if the shaft is selected as the site of the cxixM-iniont the nail will be found as solidly seated as it' (lii\rn into wood. This dilt'erenee is entirely dependent upon the (lis[)ositiou of the compact tissue, and it is evident, therefore, tiiat before a surgeon operates on a given region he should be acquainted with the internal structure as wt'll as the surface form of tlu' jiortion of the bone fractured. If a luiil Of screw once gives in cancellous tissue tlie seeuritv of tixa- Fig. 830. — Gerster's turn-lnu-kles fur reducing diflicult fractures, e.specially of the long, large bones sucli as the femur and lunnerus. They may be u.sed to advantage in some cases though it is seldom that proper angulation of the fragments and manipulation fail in accomplishing reduction in the open method. Great force can be e.\erted bv this mechanism and it should not be used witliout due regard for the damage it may inflict. tion is lost, but on the other hand a loop of wire never releases the fragments until entirely torn out even though some displacement may occur. Screws, like nails, depend on the compact tissue for their hold, and it is apparent that tlieir value decreases as the epiphyses are approached. The thread of any screw used in bone work should continue to the head and the screw itself should be of the type used in woodwork. Sherman has devised a screw of the machine type with a shaft of uniform thickness throughout. The end of the screw is made like a tap so that it cuts its own thread as THE OPEN TREATMENT OP FRACTURES 763 it sinks into the bone. Tlie ])i-iiicipl(; is good and the screw should be efficient, though the author lias had no cxi)erience with it. "When a screw is driven home it should not be too tightly fixed lest it strip the threads cut in the bone or cause the subsequent absorp- tion of compact tissue through too great stress. Ivory pegs are practically unused at the present time. Nails and screws should be made of steel and either nickel or silver plated. Fig. 831. — Appliance for holding plate in position while screws are being also holds fracture in reduction. placed. It The Four-post Clamp. — Numerous modifications of the four-post clamp have been devised and used with more or less success though they have been almost entirely superseded, in the last few years, by the Lane plate. Notable among the variations of the four-post clamp is the one devised by Parkhill in which the fragments are held in alignment by four long, threaded, steel rods. These rods are screwed into drill holes, two on either side of the fracture, and held together at their superficial ends by a special locking device (see Figs. 832 and 833). The four posts must be in the same plane and parallel to each other in order that this particular locking device may securely hold them ; it will readily be seen that this type of appliance is difficult of application. Some other modifications of the four-post clamp do not require that all the posts should be parallel, although it is necessary in all types that they be in the same plane. Excellent results have been secured by using the four-post clamp, and it will be found at the 76i FRACTURES AND DISLOCATIONS present time the most sntisfaetoi-y method, next to the Lane plate, of securing some forms of fracture. If the mechanics of the clamp be studied, and compared ^vith the ])late, its inferiority will be apparent. In tracing the fixation through the clamp from one fragment to the other it will be seen that there are twice as many points of possible motion as compared with the plate. Thus a four- Fig. s:',i'. — Slu.ws a ((iniijdiincl fviwture (if tiliia and lilmla. Noti' limv \Ur iiiippr end of both luwer l■l•asm^.-llt^s project tUrout;h tlu> sUiu. Thv anulc at wiiiili tlic li-g is held shows the flail-like condition. Picture tiikon a few liours followintc injury. Case seen with Drs. Lyman and Thompson. Fig. 833. — Same case as showji in Fiii. ^^i- after ieductioji and securing of the frag- ments by means of Freeman's modification of the four-jiost clamp. post clamp has eight points of possible motion, whereas a four-screw plate has only four. In addition to this the four-post clamp is at a disadvantage because of the distance of the locking device from the bone, which means so much leverage against fixation. Besides the mechanical inferiority of the four-post clamp, it will be ob- served that four tracts must be left open from the bone to the skin when the posts are in position, which can only mean increased risk THE OPEN TREATMENT OP FRACTURES 765 of infection during the after-treatment. It has been claimed by some that the four-post clamp possesses a distinct advantage in that no foreign body is ultimately left within the tissues. This argument may seem sound theoretically, but practice has proven rig. 834. — Set of Sherman's modification of Lane's plate manufactured by Harvey Pierce & Co. of Philadelphia. Made of Vanadium steel. beyond a doubt that certain foreign materials properly placed within the tissues are tolerated without the slightest disturbances. In the presence of infection all appliances are alike failures, whether four-post clamp, plate, nail, screw or wire. It will readily be seen, therefox^e, that the difi&culty of application, mechanical in- 766 FRACTURES AND DISLOCATIONS feriority and increased risk of iiifcclion I'ciidcr tlie four-post clamp a inncli nioi-c imperfeet api)li;iiii-i' tlian is llic Lane plalc. The Lane Plate. — -Lane's mctliod ol' intmial lixalion oL' the frag- ments is aceomi)lislied I)\ iiifaiis of cold-rolled steel plates and screws as shown in Fig'. S'.'A. Tlic most I'iuid asepsis is observed Fig. 835. — Comparison of the wood screw ordinarily used with the Lane plate, and Sherman's "tap-screw." (After Sherman in Surg., Gynecol. <6 Obstet.) Screwdriver; special construction to fit tap screws. Center point fixes screw and insures vertical and direct driving. 3/8 IN. 5/q in. Vanadium steel self-tapping (fluted) screws. Three flutes are provided at end of each screw, thus combininf a tap and screw. Fig. 8:!6. — (.\fter Sherniiin in Surf/., Gynecol. (£• Obstet.) during the entire procedure. As soon as the incision is made, the skin edges are protected and other precautions taken to prevent infection as previously described on page 756. ^Fhe incision is carried down to the bone and the fragments exposed, brought back into alignment and held in apposition b}^ means of a heavy clamp of special design. A plate of appropriate size is then placed and THE OPEN TREATMENT OF FRACTURES 767 held against the bone by the ehitrip. Holes, slightly smaller than the screws to be used, are drilled in the; botu; eorresponrling in position to the openings in tlu; plate. Scr'cws arc then (lfi\c>i Fig. 837. — Examples of broken Lane plates of the ordinary type. Note the point at which the break usually takes place, (xiftor Sherman in Surg., Gynecol, d Obstet., June, 1912.) Fig. 838. Fie. 840. Fig. 838. — A. P. view of fracture of both bones of leg. Fig. 839. — Lateral view of same case. Fig. 840. — ^Same case two years later. Fig. 841. — Another view of same case at time Fig. 840 was taken. home, securing the plate to the bone which in turn immobilizes the fragments. The deep structures are then approximated by catgut and the skin incisiori is closed. Drainage by means of silkworm- 768 FKACTLKES AND DISLOCATIONS gut should 1)0 establislied for the first twenty-four or forty-eight hours to allow the escape of fluids which may eoUect within the wound. The plate should be accurately shaped to the surface of the bone before being screwed into position. It should be so bent as to come in contact with the bone througliout its entire extent witliout special stress at any given point. If the plate lias been securely fixed and the pro})er aseptic precautions observed through- out the operation, it will remain in position indeHnitely witliout giving rise to trouble. In the cxtreiiiitics of the long bones the plate is not as efficient because of the thinness of the compact tissue on which the screws depend for their holds. A simple wire loop, properly placed, will often hold the fi-acturt'd extremity of one of the long bones in i)Osition more securely than the plate. The Lane plate should never cross an ei;)iphyseal cartilage because of the possibility of disturbing the subsequent gi-owth of the bone. A screw should never be placed closer than one-fourth of an inch from the end of a fragment ; the nearer the screws are placed to the line of fracture the greater the danger of splitting tlie bone. Plates of various sizes, shapes and weights have been designed by Lane to meet the rec(uirements in different portions of the skeleton and may be secured from the instrument dealer. Absorbable Suture Material is employed and strongly advocated by some surgeons for certain fractures in which the displacing strain is not pronounced. Excellent results have followed its use in many cases, in other instances, however, the nature of the material has been responsible for a repetition of the operation because of the recurrence of deformity. The nature of tlie fixation required is so different from that to be fulfilled in the approxima- tion of soft tissues that one should not employ absorbable material lightly and without due consideration for its shortcomings as well as its one advantage of being absorbable. It should be remembered that the most important time for fixation does not commence until eight or ten days after the operation when the bony callus begins to form. It is just about this time that absorbable material is beginning to lose its strength, and if it releases its hold within the first two or three weeks another operation may be necessary. The edges of the drill holes may cut the suture material before the callus is sufficiently strong to hold the fragments in position. The so-called "ten day" and "twenty day" chromicized catgut does not always correspond to the label, in the time which it takes THE OPEN TREATMENT OF FRACTURES 769 for the material to be removed by absorption. Ten to twenty days is more than ample for the processes of healing in soft tissues under aseptic conditions. Bone, however, requires a longer period in which to unite. If the suture material becomes soft and lax Fig. 842. — Tibia from which Lane plate has heen removed because of infection. Non-union present in spite of heavy callus seen in plate. Note the absorption of bone where the screws were placed. within a week or two, motion may occur between the fragments and delayed or non-union may follow. The surgeon, in the meantime, is laboring under the false impression that the fragments were securely and permanently fixed at the time of operation. In addi- 770 FRACTURES AND Dlf^LUCATIONS tion it uuiiht he stated tliat chromie ^iit is not as easy of steriliza- tion as are niotallic .sn])staiu'es, siieli as wire, and the Lane plate. Absorbable suliii'c in.itcriiil is more coimiionl)- used in repair of the ]iatella and olecranon tlian in other rcfjcioiis. Tlie purpose is accom- plislh'd in either of these two parts hy suturing the torn fasciae attached to the fragments rathei- than hy direct suture of the bone. In conclusion it might be stated that absorbable suture has the advantage of being entirely removed after it has accomplished its purjiose, but it is so insecure that it had better be discarded, in most cases, in favor of some metallic, mechanical material. The subject of tlie ojjcn treatment of fractures cannot be con- sidered com])h'tt' without cntci-ing into the uses and indications of bone transi>lan1ati()ii. It is not improbable that many of the estab- lisiied methods in opei'ating on fractures will, in the near future, be revised or e\'eii discarded when the possibilities and uses of bone grafting become better known and further developed. Bone transplantation will be taken up in the following chapter. CHAPTER LX. BONE TRANSPLANTATION. One of the most important developments of surgery in recent years is the transplantation of bone to fill in deficiencies in the skeleton which have resulted from injury or disease. As a sur- gical procedure it has become well established in spite of the fact that the fundamental underlying principles are as yet by no means established. The three theories which have had the greatest fol- lowing are those of Axhausen, Macewen and Murphy, and the very diversity of these theories points unmistakably to the fact that the subject has yet to be explored and the actual facts determined. 'Axhausen maintains that the bone composing the graft invariably dies, and is absorbed and replaced by new bone formed from the periosteum surrounding the transplant. According to this theory the periosteum is all that remains of the original transplant, and the success of the operation depends entirely on this membrane. Macewen of Glasgow is of the opinion that the graft is repro- duced entirely from the osteoblasts within the transplant, and that the periosteum has nothing to do with regeneration of bone, but acts only as a limiting membrane preventing the osteoblasts from penetrating the surrounding tissue. Murphy of Chicago states that the graft acts only as a scaffold- ing for the production of new bone by the osteogenetic elements which pass from the living bone into the transplant at the points of contact. In other words, he maintains that the graft is not osteogenetic but only osteoconductive, and that therefore the solid contacting of the graft with living bone is the important point, and not the activity of the periosteum. It is probable that each of these theories contains some truth but that no one of them is entirely correct. Since the setting forth of these theories much experimental work has been done on the subject, and although much valuable, practical information has been gained in this way yet the ultimate fate of the graft has not been conclusively de- termined. From a practical standpoint we are not so much in- 771 772 FRACTURES AND DISLOCATIONS terestod in the theories as we are in knowing the eonditions under wliieli bone may ])e sueeessfnlly trans[)hnited to iill in defeets in the skeleton.. Moreover it is not sufficient to know that under cer- tain conditions the operation maif he successfully ix'rt'ornied but we nuist know just wliich methods will give the hij^'hest percentage of success, and just what conditions ai-e most likely to interfere with the "taking'' of the graft. In order that we may develop the practical side of the subject we must examine into the results obtained in some of the more recent experimental work and consider these facts together with the theories just refei-red to and what we know of the embryonic development of bone and the repair of fractures. Following frac- ture certain tissues, as far as we can determine, resume their em- bryonic function and produce bone to repair the lesion. In the embryo the bone-forming tissues seem to be the periosteum and the osteoblast, but whether or not the l)one-forming properties of the periosteum are inherent to this membrane or are dependent on the osteoblast cannot be stated. The bone cell is developed from the osteoblast, and in the presence of fracture it is not improbable that the bone cell reverts to its embryonic role and produces bone provided circulation is not destroyed. It would therefore seem that in the repair of a fracture ossification of the soft callus emanates from three sources: namely, the periosteum, the endos- teiim, and from the osteoblasts within the bone near the frac- tured surfaces of the fragments. If the bone-forming properties of th€ periosteum and endosteum depend on the osteoblasts then the process of ossification resolves itself into one word, viz., osteo- blast. A transplant might be considered as an ordinary fragment if it were not for the fact that its circulation has been disturbed by being removed from its original position. This is a most im- portant matter since the life of the bone cell, and hence of the bone itself, depends on an adeciuate circulation. It is an established fact that if a section of periosteum be stripped up from the bone and transplanted into other tissue (muscle for example), it is capable of living and producing bone. Now a normal bone receives its circulation from three sources : the periosteum, endosteum and the direct ramifications of the nutrient vessel or vessels. In remov- ing a graft the branches of the nutrient artery are of course put out of function, but if the periosteum, when transplanted, can continue to live and reestablish its circulation, it is capable, to a BONE TRANSPLANTATION 773 greater or less extent, of taking care of the attached bone and its contained bone cells. In considering the circulation of the graft and its periosteum it should be remembered that the function of circulation (namely, the supply of oxygen and nutrition and the removal of waste products) can, to some extent be directly ac- complished by diffusion, osmosis, dialysis and infiltration within the fluids surrounding and pervading the transplant. A graft stripped of its periosteum may live, when transplanted, but the chances of its doing so are much less than when the membrane is left attached. A periosteum-free transplant is more likely to survive if broken up into small pieces, since the fluids thus obtain freer access to the bone cells. On the other hand it is well known that under favorable circumstances dead bone (sterilized by boil- ing and hence killed) has been successfully grafted into defects in the skeleton and what would seem still more remarkable inorganic materials, such as bars of magnesium, have been placed between the fragments and been replaced by strong living bone. The chances of transplanted bone living, whether periosteum-covered or not, are increased when it is firmly contacted with living bone. These facts would seem to indicate that Murphy's theory is cor- rect, in as far as ossification may take place from osteogenetic ele- ments passing from the ends of the fragments into the substance of the graft. Magnesium as a graft, however, has had only fair success even in regions of greatest vascularity, such as the face. It would seem apparent therefore that the periosteum, endosteum and the osteoblast (whether situated in the graft or in the frag- ments) are each capable of producing bone under favorable cir- cumstances and that therefore the technique most favorable to the activity of all of these elements, will show the highest percentage of success. The transplant does not need to be as heavy as the section of bone which it is to replace. If the operation is successful and the transplant lives, it will increase in diameter until it is capable of properly withstanding the full strain to which the bone is normally subjected. This increase in size, however, is more or less depend- ent on the use of the member after the graft has solidly united. In other words, if the member into which the graft is placed is kept at rest and not subjected to strain after union of the trans- plant, the volume of the graft cannot be expected to increase in size to properly take up its function. This means, therefore, that 774 FRACTURES AND DlSlA)CATIONS after union has takon jilacc tlu> nicnilioi' should be gradually sub- jected \o increasing sti'ain unlil the transverse diameter of the graft has augmented sufficiently to take up its full function. The progress of this growth is best determined by Rontgenograms taken at intervals during the after-care of the case. In obtaining a graft oidy a portion of llie diameter of the shaft from which it is taken should be removed, since if a section of bone including the entire diameter with its periosteum is removed, re- jniir of tlie defect with Ixjiiy tissue cannot l)c expected. When a section of bone is taken from the tihia as shown in Figs. 846, 847 and 848, the space left in the crest of the shin is entirely repaired and filled in with living bone. Exi)crience has demonstrated that the i)rocedure is most suc- cessful when the graft is taken from the same i)crson. If this is not possible the nearest lilood relative should be chosen. The pros- pect of failure is so great when the graft is taken from one of the lower animals that this source has been entirely discarded. In order that we may arrive at a i)rai'tical working knowledge of the subject we must review the established facts as determined by clinical experience and experimental work and apply them ac- cording to the principles of modern aseptic surgery, so that in a given case the most favorable conditions for the operation may be obtained. The most favorable conditions may be summed up as follows: 1. Absolute asepsis. The most rigid asepsis should be observed throughout, in exposing the fragments, in obtaining the graft and finally in placing it in position to fill in the defect. The graft should not come in contact with the gloved hand and the gloved hand should not be introduced within the wound if possible to avoid it. The subject of asepsis has been considered under the heading of "The Open Treatment of Fractures" (Chapter LIX, page 758). One should never attempt bone grafting in the pres- ence of a discharging sinus or infection of any kind. After the sinus or diseased area has healed the operation may be attempted. 2. The use of an autoplastic periosteum-covered transplant. '•]. The solid contacting of transplant with living bone; at both ends if possible. 4. It is essential that the transplant be covered with viable soft tissue. The thicker the edges of the incision the more soft tissue there will be to close over graft. BONE 'J'ltANSPL.ANTATION U ■) 5. The avoidance, as Far as possible, of iion-absorl)a1)le material in fixing' the graft in place. We cannot cxpcA-t a graft to show as much resistance as is possessed by a fragment with intact circ^iia- tion. 6. The graft should have a function to perform as previously explained. A graft v^ill not develop or may even be absorbed if not subjected to some strain after union has taken place. 7. In obtaining the graft the entire diameter of a shaft should not, as a rule, be removed. It interferes with regeneration of the defect thus made. Indications. — The conditions in which bone grafting is indicated are numerous and the future will probably disclose additional uses for this procedure. There are three classes of conditions which most frequently call for bone grafting. 1. To till in defects in the skeleton. 2. To produce union between fragments where non-union has existed. 3. For the immobilization of joints and the support diseased parts. 1. The types of skeletal defects are numerous and are classified according- to the etiologic element. They may be the result of con- genital defects, destructive infections, tumor formations and trauma. From the standpoint of fractures and dislocations we are interested only in bony defects resulting from trauma. In severe compound comminuted fractures a large section of a bone, more commonly its shaft, may be destroyed and if the parts become infected (as they so frequently do, seeing that the injury is sus- tained under septic conditions) additional bony tissue may be destroyed. The end to be attained in such cases is to clear up the infection and obtain healing of the wound. If necrotic bone is present it should be removed. (See following chapter on the treatment of compound fractures and luxations.) When the parts are thoroughly healed an attempt should be made to fill the bony defect by bone grafting. The most satisfactory technique will usually be found to be the medullary graft or the inlay graft as described by Albee. 2. Non-union is a condition which in many cases can only be corrected by bone grafting. After non-union has existed for some time the ends of the fragments become sclerosed and often ebur- nated and seem to lose their power of forming bone or at least 77U FRACTURES AND DISLOCATIONS are too di'iise to allow tlie peiictfation of lioiit'-foniiiiiii' clciiicnts. I'lKlcr siicli conditions hone «:rafliiiii' is tlic onl\' way in wliich union can !)(' obtained. The niedullai'v and inla\' ural'ts are the most satisfactory methods of transplaidin*;" hone to correct non-union. Tlie iiday irraft seems to he uainiiiii; favor over the medullai'y trans- phiiit in this type of work, although the techniiiue is more difficult and requires more special apparatus. 3. For the purposes of sui)port and arthrodesis bone transplan- tation is rarely called for in tlie treatment of fractures and dis- locations. Instability of the knee .joint following- injury can, as a rule, he corrected by rei)air of the ci'ucial and latei'al ligaments. Technique. — Bone grafting is by no means a new subject but it is only within the last few years that it has been widely employed and this is because of the improved results obtained by the more recent technique. It is apparent that in the evolution of a subject such as this a great variety of methods are evolved and discarded before a satisfactory technique is finally develojjed. A detailed description of some of the older methods, therefore, would be of in- terest from an historical standpoint only. Among those which have been most prominent might be mentioned the following: 1. The transplantation of living bone chips to fill in defects. As much of the periosteum as possible should be left attached to each chip. This method is deficient in that it does not afford fixation and the manner of contacting between the chips and frag- ments is more or less haphazard. The failures accompanying this method are much greater than when more recent technique (to be discussed later) is employed. It is now obsolete. 2. The transplantation of dead bone, either as chips or in one large fragment. This method does not give as high a percentage of success as the transplanting of living bone chips and is not em- ployed at the present time. 3. The transplantation of bone or periosteum by means of the flap method in which the graft is raised from one region, turned on its pedicle and inserted into the bone in which the defect is to be filled in. This technique is difficult, limited in application and shows no advantage over the use of the free, periosteum-cov- ered transplant. It is for the most part discarded at the present time although there are certain conditions in which it may be used to advantage. Prominent among these is the filling in of defects in the tibia bv using the fibula of the same leg and in filling in BONE TRANSPTvANTATION 777 defects in one oi" tlic bones ol' the torciarm l)y a ^^ral't taken from the other bone. This will he discussed Inter nnder "Rcfi:ional Teclniique." 4. The grafting of foreign materials into defects. Some remark- able work has lieen done along these lines. Magnesium has been grafted into the defect and been absorbed and replaced by living bone. A silver framework has been made to replace a large sec- tion of the lower jaw and after being placed in position has been surrounded by bone, but such a result cannot be expected in any but the most vascular regions such as the face and even then failure is likely to result. Absorbable and non-absorbable materials have been discarded in favor of the living periosteum-covered trans- plant. We are warranted in employing only the methods which are known to produce the highest percentage of success. At the pres- ent time the transplantation of a large, free, periosteum-covered transplant is the method which produces the best results. The manner in which this may be accomplished has varied in the hands of different surgeons and according to the region involved. The technique of modern bone transplantation in the treatment of frac- tures may be considered under the following headings : 1. The medullary graft or dowel method. 2. The inlay graft. 3. Regional or special technique in which the procedure is adapted to certain regions. 1. The Medullary Graft or Dotvel Method. — It would seem un- necessary to repeat that first class operating room facilities should be available and that the surgeon be experienced in bone work. These conditions and the observance of the most rigid asepsis are essential. The fragments are exposed and the ends freshened with saw, chisel, burr, gigli saw or motor saw according to the preference of the surgeon. The older the fracture the more important is this freshening of the ends of the fragments. If the ends are much sclerosed it may be advisable to remove considerable bony tissue. If overriding deformity exists it should be corrected, when possible, by traction on the limb. In old cases it may be impossible to bring the member back to its original length and in such instances enough bone should be removed from the ends of the fragments 778 FRACTURES ANH DISLOCATIONS to allow tho overriildi'ii fragmonts to be brought baek into align- iiiciil. Till' lucduUary cavity of each fragment is then reamed out with a hm-r or drill to reeeive the ends of tiie transplant. IMnrphy has dcvisrd special hiin's I'm* this ])nrpos(' but the authoi- has found I'iK. 84 Fig. 845. Fig. 84.T. — Old ununited fracture of tibial shaft with rounding of ends of frag- ments and interposition of fibrous tissue. Fig.' 844.- — Same, after ends of fragments are squared off and medullary cavity in fragments reamed out to receive the graft. Fig. 845. — Same, after medullary dowel graft has been placed in position. that the work may be quite satisfactorily done with an ordinary machinist's breast drill. Tire wound is then lightly packed witli gauze, Avhich has been wrung out of physiologic salt solution, and is thus protected while the graft is being obtained. The graft may be taken from the fibula, crest of ilium, upi)er third of ])ostcrior border of ulna. RONK TKANSI'LANTATION 779 clavicle, etc., hut the crest of the tihia is the favorite site and unless there is some special contraindication the ti'ans|)hiiit should be taken from this l)one. Tlic libiji is exposed and the tibialis jiiiticus Fig. S4() 84S. Fig. 846. — Mailing saw cuts in obtaining medullarj' graft. Tlie distance between the saw caits represents tlie lengtli of the desired graft. Fig. 847. — Removing medullary graft with chisel. Grooves are cut with tlie chisel and deepened until the medullary cavity is entered. The grooves should be deeply cut before an attempt is made to remove the graft, as otherwise it may be split. Fig. 848. — Removing medullary graft with rotary motor saw. (See Fig. 851.) The saw should be kept under a stream of sterile salt solution to prevent heating and devitalization of bone tissue. cut away from that portion of the external surface which is to be included in the graft. Two transverse saw cuts are made in the crest of the bone, the distance between them being the length of the 780 FRACTITRKS AND OlSLOCATIONS desired ji;raft. (See Fi^. 840.) jMeelianie's dividers or enlipers tire siM'vieeable in traiisren-inj; llie iiieasiirciiu'iit fi'oiii llic injured iiiciiilifr to I lie site from whidi the graft is to be lakcii. Tlie uraft should Ik- lon^j onon«>h lo bi-id^c tlie defect and t-xlend into the uK'dullary cavity oi' each fratiment sni'liciently to obtain proper IcNfrauc Two grooves are next made on eitlier side of the crest ol' the tibia and api)roxiniately parallel to it. The cuds oi" the saw cuts aiv thus connected. A carpenter's chisel (without the wooden handle^ makes a very satisfactory instrument for cutting these iji'ooves as shown in Fig. 847. Care should he exercised in making thes(> gi'ooves, not to split the graft; they should be deeply cut before an attem])t is made to drive the chisel into the medullary cavity and thus raise the graft and sepai'ate it from the rest of the bone. The graft should be about the size of the index finger if it in to he transplanted into one of the lai-ger hones, and correspond- ingly smaller if it is to he iised in one of the smaller long hones. The graft thus removed is trihedral, two of its sides are covered with periosteum while the third corres])onds to the medullary cav- ity and is covered with endosteum. The ends are then cut with bone cutting forceps so that they will he slightly tapered, thus facilitating their introduction into the medullary cavities of the fragments and insuring a good tit and solid contacting between the graft and the fragments. The transplant should be handled only with instruments and should be shaped and placed in jDOsition as rapidly as possible. Washing the graft in salt solution is not advisable. After the graft is removed the wound made in securing it is lightly packed with moist gauze, and after the ends have been shai)ed one end of the transplant is driven into the reamed out medullary cavity of one of the fragments until solidly seated. The opposite end is then driven into the medullary cavity of the other fragment. When seated the graft should afford considerable support to the extremity. If the operation is done because of non-union and there is very little loss of bony tissue the fragments may come in contact over the graft and entirely cover it. If, however, grafting is indicated because of loss of tissue in a shaft as well as non-union, it will he best to shape the graft so that the fi-agments will solidly engage with it before they come together. (See Fig. 84;").) The graft is thus made to bridge the defect and overcome shoi-leuing of the member. If the shaping of the graft is not carefully done one or both ends may slip into the medullary BONE TRANSPLANTATION 781 cavity Further than desired and affoi'd only n l()os(^ seatirif^ and allow shortening of the bone. This trouble chii l)e correeted, to some extent, by using nails, pegs, sutures, (!tc., but there is nolhing which will take the place of a solid contacting at th(; [)roper points. If the graft enters a fragment too far a hoh; may be drilled transversely through the fragment and graft, and a nail driven in place thus holding the graft in the desired position. Instead of the nail a heavy strand of kangaroo tendon may be passed through the hole and tied about the end of the fragment. What will answer the purpose still better, especially if Albee's doweling machine is at hand, will be to ' secure additional bone from the site from which the graft was taken and make from it a peg of bone of proper size to be driven into the hole passing through the end of the fragment and transplant. Foreign ma- terial, especially that which is non-absorbable, should be avoided as far as possible in fixing the graft in position since the resistance of the transplant is lessened by the circulatory disturbance re- sulting from its removal. Excellent results have been obtained even when the ends of the graft have been secured in position by nails or wire but, as previously stated in this chapter, it is incumbent on us to follow the methods affording the highest per- centage of success and the use of foreign non-absorbable materials in fixing the graft is more likely to be followed by trouble or failure than when such material is not employed. In obtaining the graft the work may be a little more rapidly and neatly done if a circular motor driven saw is used. In instances in which there is considerable loss of bone and the graft must be depended upon to maintain the length of the mem- ber without the ends of the fragments coming in contact, the medul- lary graft is probably superior to other methods. AVhere there is not great less of bony tissue and the element of non-union is the important factor better results are claimed for the inlay graft. 2. Tlie Inlay Graft. — (Albee's technique.) The fragments are exposed and the ends freshened as already described in preparing the fragments for the medullary graft. It is an extremely diffi- cult matter to carry out this technique without the twin motor saw as used by Albee and if such is not available one had better employ the medullary graft. A longitudinal incision is made through the periosteum and the edges turned back to expose the cortex of the bone in Avhich the 782 truttcr is to III- FRACTURKS AND DISLOCATIONS •lit to i'('i'ci\i' tlic Lirat'l. Two loiiuit iidiiial parallel saw cuts arc iiiadc witii the twin saws acfoss the |)laiK' of frac- ture and extendiiiij into cadi ria'^mciit for a distance of two and a half to throe inches. These cuts pass ttu-ouiiii the coi'tex into the W^i V Fig. 849. Fig'. 849.— Inlay graft in place. Albee's tefhiiique in cases of non-union. 'I'lio twin motor saws are almost essential in cutting the gutter to receive the graft aiul in obtaining the graft from the tibia. Fig. 850. — Method of securing inlay graft in place with kangaroo Iciulon as advo- cated by Albee. medullary cavity of the fragments. Care sliould lie exercised in using the saws to see that they follow straight lines as otherwise the fitter will show a lateral curvature which will Iw ditficult to tit with the graft. Albee advises that the saws be adjusted to a dis- tance of •)i(; to %(; of an inch from each other according to the size of the bone operated upon. In cutting the groove the saw^s should be kept under a stream of salt solution to prevent heating of the bone which tends to devitalize it. The bone is finally re- moved from the groove by cutting the ends with a small osteotome so as to make a tongue and groove. (See Fig. 849.) Either two BONE TRANSIT^ANTyVTION 783 or four holes (according to the needs of the case) are llicii diago- nally drilled through the cortex on both sides of the groove and in both fragments. These holes are drilled in i)airs op|)Osite each other, as shown in Fig. 849, and through each pair of holes is passed a double strand of heavy kangaroo tendon. The fragments are now ready for the graft. The wound is then lightly packed with Fig. 851. — Motor saw equipment including twin saws. Fig. 852. — Doweling machine. moist gauze and the surgeon turns his attention to securing the graft to fill the gutter. The internal surface of the tibia is next exposed and the dimen- sions of the desired graft are mapped out on the periosteum with a scalpel. The twin saws are then employed (without changing their adjustment) and a strip of bone, the same size as the gutter prepared in the fragments, is removed. The ends of this graft are then pointed with the saw to conform to the ends of the groove in the fragments. The graft is next transferred and the wound filled with a moist pack. One strand of kangaroo tendon is then 784 FRACTURES AND DISLOCATIONS pulk'd uj) Trom tlie m(_-duUary cavity Ix-twoeii each pair of lioles previously ilrilled in the fragments and the graft placed under these raised strands. The ends of the sutures i)rojecting from the drill holes are tied and the graft thus secured in place. (See Pigs. 849 and 850.) Tiie tongue and groove effect at the ends of the graft causes the ends of the ti'ansplant to become firmly engaged when extension is removed and the muscles of the extremity con- Fig. 853. Pig. 854. Fig. 855. Fig. 853. — Fir.st step in Albee'a technique in recent fractures. Superficial cuts are made with the twin saws and then each cut is finished with a single rotary saw so that the section of bone removed will be wedge-shaped. Fig. 854. — Second step. Short piece is removed to be cut up longitudinally to be used in making bone pegs with the doweling machine. A. shows short piece removed. Fig. 855. — Third step. Long piece has been slid to opposite end of gutter so that it crosses the line of fracture and is held in place by means of obliquely driven bone pegs. B. is a cross-section showing manner in which oblique pegs hold graft. tact, while the kangaroo tendon sutures maintain the fragments and graft in alignment. The older the case of non-union and the more sclerosed or eburnated the ends of the fragments, the longer the graft should be, thus insuring bone-forming activity by extend- ing well into the substance of each fragment. It is claimed that this method gives better results in old cases of non-union because BONE TRANSPLANTATION 785 of the greater surface of contact between graft and fragments. On the other hand it is certain that the inlay graft does not occupy as good a position from a mechanical standpoint as does tin; medul- lary transplant, and when heavy muscular contraction and shorten- ing are to be overcome (as in fracture of tiie femur) the latter will be found the safer technique. It is probal)]y not wise to attempt the inlay method unless the motor saw (^(|uipm(Mit is avail- able. Albee's Technique in Recent Fracture. — Albee employs a modi- fied inlay graft in the operative treatment of recent fractures. The twin motor saw and the doweling machine are essential to this technique. The fragments are exposed and approximated. With the twin motor saw (the blades being adjusted to about Y-iQ of an inch apart) two longitudinal superficial cuts are made crossing the line of fracture as shown in Fig. 853. The saws should follow straight lines and the cuts should extend about twice as far on one side of the plane of fracture as on the other. A single motor saw is then used to complete the cuts into the medullary cavity. The cuts are not made in parallel planes but are so placed that the periosteal surface of the graft is about one-fourth of an inch wider than is the endosteal surface. Thus by making a wedge of the graft it will be impossible for it to be displaced into the medul- lary cavity. The short piece of the graft is removed and the long piece slipped to the opposite end of the groove so that it crosses the line of fracture. (Fig. 855.) The short piece of the graft is then cut up with the motor saw and converted into pegs with the doweling machine. Oblique holes are next drilled into the fragments on each side of the graft and the bone pegs driven home so that their ends project over the graft. (See Fig. 855.) Good fixation is thus afforded if the technique is properly carried out and the great claim for this method is that no foreign material is left imbedded in the wound. Albee recommends this method as a substitute for the Lane plate. 3. Regional or Special Technique. — The methods just described will meet the indications in practically all of the fracture cases in which bone grafting is indicated. The various modifications which have been employed in different regions of the skeleton have in almost all cases been devised to correct conditions resulting from disease or defective development, and hence cannot be properly considered as coming within the scope of this work. If the sur- 786 FRACTURES AND DISLOCATIONS .k't'on api)ret'iat('s the })riiu'iples involved in bone grafting- and tlie techni(|ue of the dowel and inlay grafts lie will he able to modify his Icchiuciue to meet the exi'e[)tional case. Some of tiie more eoni- iiion variations may be mentioned. The entire upper fiid of tlie huiiierus has been rei)laeed with the upper eiul of the fibula. A longitudinal in- cision exi)Oses the region previously occupied by the u[)per end of the humerus. The end of the rragmeiit is fresliened and its metluUary cavity reametl out. The upper end of the fibula is next exposed and the length of the desired graft marked on its shaft. It is then cut across and the cut end inserted into the reamed out medullary cavity of the humenis while the ligaments and muscles of the shoulder are sutured about the upper end of the bone when placed in the glenoid cavity. In a similar maimer the lower end of the radius has been replaced by transplanting the upper end of the fibula. The shaft of the tibia may be replaced by the shaft of the fibula without completely detaching the fibular shaft from its surrounding soft tissue. The operation is usually done in two stages though it may be done in one. The lower end of the upper tibial fragment is ex- posed, the end freshened and the medullary cav- ity reamed out. The upper end of the fibula is then divided and carried across to be inserted into the upper tibial fragment and the wound closed. The second step of the operation consists in trans- planting the lower divided end of the fibula into the lower tibial fragment. The entire tibia has been replaced in congenital ab- sence of this bone by using the fibula. The upper end of the fibula is placed against the femoral condyles while the lower end of the bone is placed against the astragalus. In loss of bony tissue in one of the bones of the forearm (e.g., the shaft of the radius) a section of the shaft has been raised from the ulna and grafted into the radial defect without severing the pedicle attached to the trans- plant. In an operation of this kind only a portion of the shaft of the ulna should be removed. In old ununited fracture of the neck Fig. 856. — Dia- gram, showing man- ner in whicli upper end of humerus may be replaced by grafting of upper end of fibula. Sel- dom called for in the treatment of fractures but illus- trates one of the adaptations of bone grafting. BONE TRANSPLANTATION 787 of the femur excellent results have been obtained by driving a graft taken from the tibial crest through the trochanter and neck of the bone. The principles involved are the same as described in Fig. 857. Fig. 858. Fig. SoE Fig. 857. — Loss of tibial shaft. Fig. 858. — First step in replacing tibial shaft by shaft of fibula. The fibular shaft is divided and implanted into the upper tibial fragment. Fig. 859. — Completion of operation. The lower end of fibular shaft has been im- planted into lower tibial fragment. the "Operative Treatment" of "Fractures of the Upper End of the Femur" (page 550), except that a graft is used instead of a screw or "screw-plate." The knee has been replaced by the same joint taken from a freshly amputated leg and the metatarso- phalangeal joint has been excised and grafted into an ankylosed elbow of the same patient. 788 FRACTFRES AND DISLOCATIONS It is manifestly iiuiiracticablc at llu' present time to enter into all the possible variations of hone "grafting and a consideration of the conditions in which it may be indicated. If the principles of this procedure are iniderstood and the conditions under which it is most likely to be successful are fully appreciated the surgeon's mechanical sense and ingenuity should be sutificient to enable him to modify his techni(|ue to meet the requirements in a given case of exceptional needs. CHAPTER LXI. TREATMENT OF COMPOUND FRACTURES AND DISLOCATIONS. The advent of asepsis and the improved technique of recent years has greatly reduced the percentage of bad results, previously so high, following compound fractures and luxations. Compound fractures are common, but it is unusual to see a dislocation which exposes the joint except in luxations of the fingers. The more com- mon luxations are almost invariably closed. The principles involved in treatment are practically the same whether the condition be a fracture or dislocation, and accordingly the two conditions will be considered together. Immediate reduc- tion is the natural tendency as soon as the case is seen but in many instances nothing more detrimental could be done. The exposed fragment or articular surface must be considered infected, and if immediately replaced is almost sure to be followed by sup- puration of the tissues with which it has come in contact. ]\Iany compound fractures and dislocations are produced by penetration from without, and in these cases we do not have to deal with a projecting fragment or articular end. When a compound fracture or luxation is first seen the wound should be covered with a sterile dressing and the patient removed to surroundings in which proper surgical procedures can be carried out. Sterile surgical dressings may not be at hand, in some in- stances, and in lieu of these a towel fresh from the laundry is a safe substitute to use in covering the wound. The heat of ironing sterilizes the towel fairly well, especially as done in the modern steam laundry, and if the towel is unfolded so that a fresh surface comes in contact with the wound there will be little danger of infec- tion from the dressing, and the wound will be properly protected during transportation. An anesthetic is advisable in most cases. With the patient in the operating room the dressings are removed and the skin sur- rounding the wound painted with a five percent tincture of iodine. The edges of the wound are then inspected, and if lacerated and 789 IW FKACTrRES AND DISLOCATIONS devitalized tissue is present it should lie triinined away until the margins present healthy viabU' tissue. If a fragment or the artic- ular end of (lm-in'4 disloi-a- tions, of hi|), o'iS Aniliiilatory ])n('uniatic s]>lint. for fractuii' of liip. .■)o4 for frai'turc of lc>r, (ia.") for fracturi' of tliigli, oS.") Anatomical nwk of Imnicrus. frai-- turo of, S:? An!)() diaf»nosis, (iS!) in'oiinosis, (iOl siirjiical anatomy, 684 s\nii>toms, 6S7 treatment. ()8!) after-treatment, (590 o|ierative treatment, (i'lO Anomalies of carpus, 2S3 Anomalous ossification of ii])iier end of tibia, 622 A])o])lectiform attacks, difYerent'ated from unconsciousness in fracture of skull, 44,") Asche nasal splints, 320 A])0])lexy differentiated from uncon- sciousness in fracture of skull, 440 Astrasialus, fractures and disloca- tions of, 602 after-care, 608 diagnosis, 605 ]iro2nosis, 608 surgical anatomy, 602 s\mptoms, 604 treatment, 605 after-treatment, 605 operative treatment. 607 Atlas {see Fractiu-e-dislocations of spine. 465) Author's method of reducin'f disloca- tions of hi]), 526 nasal sulint, ^M) screw-jjlate, 550, 551 Avulsion of ui))ier e.\tremit\", 6,3 Axillary pad. 08 Axis {see Fracture-dislocations of spine, 465) Bandage, four tailed, for fracture of jaw, 358 bandage, — eovVd. Mohr's tigure-of-eiizlit. 25 Stiinson's, for dislocation of clav- icle, 35 N'ellieau's, 25 in fracture of clavicle, Barton's fracture, 251 l?ase-hall linger, 300 Hase of skull {see Skull, fracture of, 301) Battle's sign, 420 Bauer's (|ualinn'ter, 746 l?edsores, in fractures of s]iine, 400 Bennett's fracture, 200 Beiioist, radio-clironometer, 746 I'igelow's metliod of reduciii'^ dislo- cation of hip, 526 ^' -ligament of, 516 Blebs, in fracture near elbow, 120 in fracture of leg, 640 Bodv swathe, in fracture of liiimerus, 101, 114 in fracture, of pelvis, 507 of ribs, 463 used with T-si^lint. 544 Bone drill. Lane's, 760 Bone forceps, 761 Bone grafting {see Bone transplan- tation, 771) Bone plates, Lane's, 766 Sherman's modification of, 765 Boiu\ structure of, in clavicle, 12 in femur, 531, 575 in Inunerus, 83 in radius, 204 in tibia, 727 in ulna, 204 B(mes of carpus, iniur.ies to, 277 anomalies of, 282 Boiu' transi)lantation, 771 techni(|ue of, 776 Albee's metliod, for nonun'on in recent fractures, 78:'> nu'dullarv graft, 775, 777 theories of, 771 I^race. Tavlor's. for fractured clavi- ' cle, 27 Brain, anatomv of i srr Skull, frac- ture of, 302) abscess of brain, symutoms of. 443 differential diagnosis of, 450 coini)ression of. 410 concussion of, 407 coTitusion of, 408 inJTU'>' to, 411 laceration of, 400 membranes of. 305 Bryant's triangle, 534 Buck's extension, 542 INDEX 795 Cabot's wire splint, as double inclined plane, 580 in fracture of thigh, 580 of leg, 040 in Pott s fracture, 609 Calcaneum, fractures and disloca- tions of, 703 after-care, 707 diagnosis, 700 prognosis, 708 surgical anatomy, 703 symptoms, 705 treatment, 700 after-treatment, 707 operative treatment, 706 Carcinoma, cause of fracture, 728, 729, 731 Carpal bones (see Carpus, 277) Carpo-metacarpal dislocations, 294 after-care, 296 diagnosis, 295 prognosis, 296 surgical anatomy, 294 symptoms, 295 treatment, 296 after-treatment, 296 operative treatment, 296 Carpus, injuries to, 277 after-care, 292 diagnosis, 290 prognosis, 293 surgical anatomy, 277 symptoms, 287 treatment, 291 after-treatment, 292 operative treatment, 292 Carrying angle, loss of, 128 Cartilages, semilunar, fractures and dislocations of, 587 Cast, plaster, for fracture of hip, 546 in fracture of leg, 649 in fracture of pelvis, 509 in fracture of spine, 484 with arm in abduction, 103 with thigh in abduction, 548 with thigh in semiflexion, 548 Cerebrospinal fluid, escape of, in frac- ture of skull, 417 Chest, injuries to, (see Fractures of ribs, 459) (see Sternum, 453) Clamp, four-post, 763 Clavicle, dislocation of inner end, 5 after-care, 10 diagnosis, 7 prognosis, 10 surgical anatomy, 5 symptoms, 6 Clavich; — cont'd. treatment, 7 after-treatment, 1 operative! treatment, 9 dislocation of outer end, 30 after-care, 30 diagnosis, 33 prognosis, 36 surgical anatomy, 30 symptoms, 32 treatment, 34 after-treatment, 36 operative treatment, 36 fracture of, 11 after-care, 28 diagnosis, 22 prognosis, 29 surgical anatomy, 11 symptoms, 15 treatment, 22 after-treatment, 2i8 operative treatment, 26 Coaptation splints, for fracture, of humerus, 115 of femoral shaft, 567 Cobb's nasal splint, 330 Coccyx, fracture-dislocations of, 500 treatment, 507 CoUes' fracture (see Radius, fracture of lower end, 242 ) Coma, in head injuries, 420 from alcohol, 433 from asphyxia, 435 belladonna and its alkaloids, 436 chloral, 435 hyocyamus and its alkaloids, 436 lead poisoning, 436 morphine, 434 opium, 434 phenol, 434 reflex causes, 438 in abscess of brain, 443 acute exanthemata, 438 apoplexy, 440 cerebral anemia, 432 cerebral congestion, 432 cerebral embolism, 440 cerebral hemorrhage, 441 cerebral meningitis, 443 cerebral syphilis, 442 cerebral thrombosis, 441 diabetes, 437 epilepsy, 439 feigning, 438 hysteria, 438 pneumonia, 438 ptomaine poisoning, 435 shock, 431 syncope, 431 tumor of brain, 443 796 INDEX Coma, in — cnnViJ. typlioiil. 4:{S Complications in t'raiturc nt ju'lv is. • 509 rupture, of bhuld.r. :)l(i, .")11, :^\-l of urethra, 50!», Tilt) Compound fractures and dislocations. 7«9 treatment of, 7 Sit Comiirt'ssion of luain, 4 In Concussion of lirain, 407 Contracture following. Colics" frac- ture, 27;') dislocation of shoulder, 7() injury to brachial plexus, 76 injury to nuisculo-spiral, 140 Volkniaiui's paralysis, 231 Contusion of brain, 408 Coracoid process {see Scapula, frac- ture of, 37 ) Coronoid process (see Ulna, fracture of upper end, 188) fracture of, complicating disloca- tions of elbow, 166, 167 Coxa vara, 556, 557 Cradle, 646 Cranial nerves, passage through skull, 344 symptoms of injury to, 425 Crepitus {see Symptoms of region in question ) Crookes tube, 740 Crushes of carpus {see Carpus, inju- ries to, 287) of tarsus, 710 Cubitus, valgus {see Humerus, frac- tures of lower end, 142) varus {see Hinnerus, fractures of lower end, 142) Cul)oid, fractures and dislocations of, 710 Cuneiform (see Carpus, injuries to, 281, 286, 289) Cuneiforms of tarsus, fractures and dislocations of, 710 Davison's method for fracture of fe- mur in children, 565 Diagnosis of, dislocations of, ankle, 689 astragalus, 695 calcaneum, 706 carpometacarpal joint, 295 clavicle, inner end, 7 outer end, 33 elbow, 163 fingers, 315 hip, 523 Diagnosis of, dislocations — cont'd. OS calcis, 706 patella, 611 l>clvis, 505 [ilialangi's of hand, 315 radius, head of, 180 semihniar cartilages, 590 slioulder. 64 spin.'. 4S:i subastragalar joint. 7lU subcoracoid, of shoulder, (i4 suliglenoid, of shoulder, 64 tarso-mefatarsal joint, 713 ulna, lower end, 239 wrist, 290 fractin-e of, astragalus, 695 calcaneum, 706 car])us, 290 clavicle, 22 coccyx, 506 femur, lower end, 579 shaft, 562 upper end, 539 tibula, lower end, 666, 679, 689 shaft, 642 upper end, 627 fingers, 310 hip, 539 humerus, lower end, 136 shaft. 111 upper end, 95 inferior maxilla, 356 jaw, lower, 356 upper, 345 metacarpals, 300 metatarsals, 718 malar, 338 maxilla, inferior, 356 superior, 345 nasal bones, 327 olecranon, 190 pattdla, 597 l)elvis, 505 ])halanges of hand, 310 radial and ulnar shafts, 219 radius, lower end, 260 shaft, 219 upper end, 200 ribs, 462 scapula, 41 semi-lunar cartilages, 590 spine, 483 superior maxilla, 345 tibia and fibiila, lower ends, 666, 679, 689 shafts, 642 upper ends, 627 ulna, lower end, 234 shaft, 219 INDEX 797 Fibula, ulna — cont'd. upper end, li)0 zygomatic arcli, 3i88 in Colles' fracture, 200 in injuries to carpus, 200 in Pott's fracture, 660 Definitions and terms, 725 Deformity (see Symptoms, under fractures and dislocations of various bones and joints) Deformity, garden-spade, 244 gunstock, 135, 138, 142, 158, 201 in Barton's fracture, 257 in Bennett's fracture, 229, 230 in Colles' fracture, 252-262 in dislocation of wrist, 262, 287 in Pott's fracture, 664, 665, 666, 667 in Volkmann's contracture, 230 Madelung's, 239 silver-fork, 247, 252-262 Desault splint, 645 DeVilbiss forceps, 448 Dislocatio erecta, 60 Dislocation of, acromioclavicular joint, 30 ankle, 684 {see Ankle) astragalus, 692 (see Astragalus) calcaneum, 703 (see Calcaneum) carpal bones, 277 (see Carpus) carpo-metacarpal joint, 294 cervical vertebrae, 465 (see Spine) clavicle (see Clavicle) inner end, 5 outer end, 30 coccyx, 500 (see Pelvis) costal cartilages, 460 (see Ribs) cuboid, 710 cuneiforms, 710 elbow, 154 (see Elbow) fingers, 314 (see Fingers) head of humerus, 44 (see Shoul- der) head of radius, 177 (see Radius) hip, 515 (see Hip) inferior maxilla, 376 (see Maxilla, inferior ) jaw, 376 (see Maxilla, inferior) knee, 613 (see Knee) medio-tarsal joint, 709 OS calcis, 703 (see Calcaneum) patella, 609 (see Patella) pelvis, 492 (see Pelvis) phalanges of foot, 720 (see Toes) radius (see Radius) upper end, 177 radius and ulna, divergent, 154 (see Elbow) scaphoid, 710 Dislocation of— cont'd. semilunar cartilages, 587 (see Sfimilunar (tartilagcs) shoulder, 44 (see Sliouidcr) spine, 465 (see Spine) subastragalar joint, 099 sternal end of clavicle, 5 thumb, 314 ulna, lower end, 237 upper end, 175 wrist, 277 (see Carpus) Drainage, in operative treatment of fractures, 758 in treatment of compound fractures and luxations, 790 Dupuy's splint for fracture of lower extremity, 581 Dupuytren's splint, 668 E Ecchymosis, in fracture of clavicle, 21 humerus, 89, 96 leg, 640 olecranon, 190 skull, 418, 420 Edmund's forceps, 364 Elbow, dislocations of, 154 after-care, 171 diagnosis, 163 fracture complicating, 156 prognosis, 174 surgical anatomy, 154 symptoms, 156 treatment, 167 after-treatment, 171 operative treatment, 170 Embolism, fat, 642 Emergency treatment, of fracture of leg, 642 of thigh, 563 Emphysema, in fracture of, malar and superior maxilla, 338, 344 nasal bones, 326 ribs, 462 Epilepsy, as a cause of unconscious- ness, 439 following fracture of skull, 451 treatment of, 45 1 Epileptic unconsciousness, differen- tiated from coma accom- panying head injuries, 439 Epiphyseal separations, considered under fracture of bone in question ( see Fracture ) Epiphysis of, acromion, 37 clavicle, 11 798 INDEX Epiphysis of — cont'd. loraooid, 38 femur, lower end, .")70 upper end, ">:U humerus, U)\yer end, 125 upper end, 88 nu'tiu'iu] iu I. ones, 2!I7 metatarsal bones, 714 pelvis, 4!)2 phalanges of fingers, 307 radius, lower end, 251 upper end, 1D8 seapula, 37 tibia and liliula, lower ends, 076 upper ends, 1)22 ulna, lower end, 232 upper end, 180 Erect dislocation of shoulder, GO Etiology of, dislocation, of hip, 520 inferior maxilla, 377 patella, 010 fracture of, femoral shaft, 560 U])iier end, 534 liunurus, upper end, 89 inferior maxilla, 350 malar, 330 nasal bones, 325 patella, 595 pelvis, 496 tibia and fibula, shafts, 637 upper ends, 624 Everted dorsal dislocations of hip, 519 Examination {see Diagnosis) Eacc, fracture T of bones of, malar, 334 maxilla, inferior, 348 superior, 343 nasal, 323 Facial, artery, injury to, 350 nerve, injury to, 350 Fat embolism, 042 Feeding after fracture of inferior maxilla, 375 Femur, dislocation of lower end, 613 {see Knee ) UDoer end, 515 {see Hip) fracture of, lower end, 574 after-care, 584 diagnosis, 579 prognosis, 586 surgical anatomy, 574 symptoms, 578 treatment, 580 after-treatment, 584 operative treatment, 582 shaft, 558 after-care, 572 I'cimir. sliaft — iniit'd. diagnosis, 562 .•tiology, 560 in cliildren, 508 in ncw-lxirn, 5li8 prognosis, 573 surgical anatomy, 558 symptoms, 501 trt'atnu'nt, 503 after-treatment, 572 operative treatment, 569 u|)p«'r end, 531 after-care, 552 diagnosis, 539 in <'hildren, 555 ])rognosis, 555 surgical anatomy, 531 symi)toms, 537 treatment, 542 after-treatment, 552 operative treatment, 550 Fingers, base-ball, 309 Fingers, dislocation of, 314 after-care, 318 diagnosis, 315 prognosis, 319 surgical anatomy, 314 symi)toms, 317 treatment, 3 1 7 after-treatment, 318 ()I)erative treatment, 318 fractures of, 307 after-care, 312 diagnosis, 310 prognosis, 313 surgical anatomy, 307 svmptoms, 308 treatment, 310 after-treatment, 312 operative treatment, 311 Fissure of Rolando, 401 Flap, osteoplastic of, skull, 447 of si)ine, 488 Flat-foot, traumatic, 673, 70^ Forceps, DeVilbiss, 448 Edmund's, 364 Forearm, fracture of shafts of bonea of, 204 {see Radial and Ulnar shafts) Four-])ost clamp, 763 Freeman's, 764 Fourtailed bandage, 358 Fracture of, acetabulum, 499 {see Pelvis) complicating luxation of hip, 582 acromion process, 40 {see Scapula) accompanying upward luxation of shoulder, 51 anatomical neck of humerus, 90 astragalus, 692 INDEX 799 Fracture of, astragalus — cont'd. after-care, 6i)8 diagnosis, ()i)5 prognosis, ()i)8 surgical anatomy, 692 symptoms, 6i)4 treatment, 605 after-treatment, 6!)8 operative treatment, 607 Barton's, 251 Bennett's, 299 calcaneum, 703 after-care, 707 diagnosis, 706 prognosis, 708 surgical anatomy, 703 symptoms, 705 treatment, 706 after-treatment, 707 operative treatment, 706 carpal bones, 277 after-care, 292 diagnosis, 290 prognosis, 293 surgical anatomy, 277 symptoms, 287 treatment, 291 after-treatment, 292 operative treatment, 292 clavicle, 1 1 after-care, 28 diagnosis, 22 prognosis, 29 surgical anatomy, 11 symptoms, 15 treatment, 22 after-treatment, 22 operative treatment, 26 coccyx, 500 {see Pelvis) treatment, 507 coracoid process, 38 {see Scapula) cuboid, 710 after-care, 712 . prognosis, 712 surgical anatomy, 710 treatment, 710 after-treatment, 712 operative treatment, 712 cuneiforms, 710 treatment, 710 femur, lower end, 574 after-care, 584 diagnosis, 579 prognosis, 586 surgical anatomy, 574 symptoms, 578 treatment, 580 after-treatment, 584 operative treatment, 582 shaft, 558 J^Yacture of, fc^iiinr, shaft — cont'd. after-care, 572 diagnosis, 562 etiology, 560 in children, 568 in the nevv-I)orn, 56i8 ]jrognosis, 573 surgical anatomy, 558 symptoms, 5(51 treatment, 5()3 after-treatment, 572 operative treatment, 560 upper end, 531 after-care, 552 diagnosis, 539 etiology, 534 in children, 555 prognosis, 555 surgical anatomy, 531 symptoms, 537 treatment, 542 after-treatment, 552 operative treatment, 550 fibula {see Tibia and Fibula) lower end, 675 shaft, 634 upper end, 620 fingers, 307 after-care, 312 diagnosis, 310 prognosis, 313 surgical anatomy, 307 symptoms, 308 treatment, 310 after-treatment, 312 operative treatment, 311 forearm, bones of, 184 {see Radius and Ulna) hip, 531 {see Femur) humerus, anatomical neck of, 90 lower end, 120 after-care, 151 diagnosis, 136 prognosis, 152 surgical anatomy, 120 symptoms, 128 treatment, 143 after-treatment, 151 operative treatment, 148 shaft, 108 after-care, 119 diagnosis, 111 prognosis, 119 surgical anatomy, 108 symptoms, 110 treatment, 113 after-treatment, 119 operative treatment, 116 upper end, 82 after-care, 106 800 INDEX Kraftuii' of. huiiu-nis, upper t'lul — COtlt'll. diajrnosis, 95 pni'inosis. 107 suruiial anatomy, 82 symi)toms, S!t tri'atiiu'ut. !17 aftiT-trcatiiuiit. KMI oi)(.'rati\ (■ trcatiiifiit. MM isc'liium, r>(t(i malar, H:M aftor-iarf, 342 cliafiuosis, ;i^8 etiology, •VM't prognosis, 342 suryiral aiiatt)my. 3.34 svmptoms, 33(( treatment. 331) after-treatment, 342 ujierative treatment, 340 maxilla, inferior, 348 after-care, 375 diajinosis, 35t> etiology, 350 |irognt)sis, 375 surgieal anatomy, 348 symptoms, 351 treatment, 357 after-treatment, 375 oi)erative treatment, 373 superior, 343 after-care, 346 diagnosis, 345 prognosis, 347 surgical anatomy, 343 symiJtonis. 344 treatment, 345 after-treatment, 346 operative treatment, 346 metacarpals, 207 after-care, 306 diagnosis, 300 prognosis, 306 surgical anatomy, 397 symi>t()ms, 2!M) treatment. 301 after-treatment, 306 operative treatment, 305 metatarsals, 714 after-care, 718 diagnosis, 718 prognosis, 710 surgical anatomy, 714 sym])toms, 716 treatment. 718 after-treatment, 718 operative treatment, 718 nasal hones, 323 after-care, 332 diagnosis, 327 I'racture of. nasal hones — cout'd. etiology, 325 prognosis, 333 surgical anatomy, 323 svniptoms, 325 treatment, 320 after-treatnu'iit. 332 o|ierative treatment, 331 iia\icular. 71i' treatnH'ut. 7 U' nose, 323 (see Nasal hones) olecranon, 185 OS calcis, 703 (sec Calcaiieum) patella. 504 after-care. 605 diagnosis. 507 .tiniugy. 505 ])rognosis. tiOS sui'gical anatomy. 504 symjitoms. 505 ti'catment, 508 after-treatment, 605 oi)erative treatment, 600 pelvis, 402 (•nmi)lications, 500 injury to, hladder, 510 pelvic viscera, 509 urethra, 509 vessels, 509 diagnosis, 505 etiology, 496 pathology, 496 surgical anatomy, 492 symptoms, 497 treatment, 507 of comjjlications, 510, 511 ])lialanges of foot, 720 ])rognosis, 721 surgical anatomy, 720 symjjtoms, 720 treatment, 720 ])]ialanges of hand, 307 after-care, 312 diagnosis, 310 prognosis. 313 surgical anatomy, 307 symptoms, 308 treatment, 310 after-treatment. 312 operative treatment, 311 radius, lower end, 242 after-care, 271 Colles' fracture, 242 diagnosis. 260 ])rognosis, 273 surgical anatomy, 242 symptoms, 252 treatment, 264 after-treatment, 271 operative treatment, 269 INDEX 801 Fracture of — cont'd. shaft, 204 aftor-care, 228 diagnosis, 219 prognosis, 229 surgical anatomy, 204 symptoms, 200 treatment, 220 after-treatment, 228 operative treatment, 225 upper end, 197 after-care, 202 diagnosis, 200 prognosis, 203 surgical anatomy, 197 symptoms, 199 treatment, 200 after-treatment, 202 operative treatment, 202 ribs, 459 after-care, 463 diagnosis, 462 emphysema in, 462 prognosis, 464 surgical anatomy, 459 symptoms, 461 treatment, 462 after-treatment, 463 scaphoid, 710 scapula, 37 acromion process, 40 after-care, 43 coracoid process, 40 diagnosis, 41 prognosis, 43 surgical anatomy, 37 symptoms, 40 treatment, 42 after-treatment, 43 semilunar {see Carpus) semilunar cartilages, 587 after-care, 592 diagnosis, 590 prognosis, 593 surgical anatomy, 587 symptoms, 588 treatment, 591 after-treatment, 592 operative treatment, 591 skull, 391 (see Skull, fractures of) diagnosis, 427 differential, 429 prognosis, 449 surgical anatomy, 392 symptoms, 411 treatment, 444 operative treatment, 447 spine, 465 after-care, 490 Fracture of, spine, — cont'd. diagnosis, 483 ])rogno8i8, 491 surgical anatomy, 465 symptoms, 473 cervical region, 481 lumliar region, 482 tlioracic region, 482 treatment, 484 after-treatment, 490 operative treatment, 486 sternum, 453 after-care, 458 prognosis, 458 surgical anatomy, 453 treatment, 456 after-treatment, 458 operative treatment, 457 tibia and fibula, lower ends, 675 after-care, 683 diagnosis, 679 prognosis, 683 surgical anatomy, 675 symptoms, 675 treatment, 681 after-treatment, 683 operative treatment, 682 shafts, 634 after-care, 654 diagnosis, 642 etiology, 637 prognosis, 657 surgical anatomy, 634 symptoms, 638 treatment, 642 after-treatment, 654 operative treatment, 650 iipper ends, 620 after-care, 631 diagnosis, 627 etiology, 624 prognosis, 633 surgical anatomy, 620 symptoms, 625 treatment, 627 after-treatment, 631 operative treatment, 629 ulna, lower end, 232 after-care, 235 diagnosis, 234 prognosis, 236 surgical anatomy, 232 symptoms, 234 treatment, 235 after-treatment, 235 operative treatment, 235 shaft, 204 after-care, 228 diagnosis, 219 802 INDEX Fnu-turi' of, ulna, sliaft— tonis, "itXi tii-atnu-nt, -i-iO afti'i-tioatnu-nt, 22S operativi' treatment, 22') u])|)i'r iiul (oli'i-ranon I . IS.") aftiT-eari', !!•.') diagnosis, VM) [irognosis, l!Mi surgieal anatomy, 185 symptoms, ISS treatment, MX) after-treatment, 1 05 operative treatment, I'-'l zygomatic areli, :VA-i {sec Malar) Fraeture-box, t)43 as double inclined plane, r)S2 use of, t)-44 Fractures, compound, treatment of. 7sn open treatment of, 7o4 absorbable suture material, 768 asepsis in, 7.ib cautions in closing wound, 758 drainage, 758 the four-post clamp, 763 the Lane plate, 700 use of screws, nails, etc., 759 Freeman's clamp, 704 G German base line, 400 Gerster's turn buckle, 702 Glycosuria following head injuries, 429 Goldthwaite's splint, 311 Grafting of bone, 771 Gun-stock deformity, in dislocation of elbow, 158 in fracture below elbow, 201 in fracture of humerus, 12:8 H Hammond's %vire splint, 372 Head injuries, 391 {see Skull, frac- ture of) compression, 410 concussion, 407 contusion, 408 laceration, 409 Heath splint, for fracture of man- dible, 363 Heel, fracture of, 703 (see Calca- neum ) Hematoma of scalp, 382 Hematomvelia, in fracture of spine, 479 llcniatnrrliarlus. in tracturt' of spine, 47'.l Ibiiiatvuia. in fract\ire of pelvis, 509, .-)ll ll.'inorrliage. beneath skin (see Ec- chymosis | into sjiinal cord, 479 intracranial, 397 meningeal, of cord, 579 subdural, 397 Hip, dislocation of. 515 after-care, 530 diagnosis, 523 etiology, 520 prognosis, 530 surgical anatomy. 515 symptoms, 520 treatment, 524 after-treatment, 530 operative treatment, 529 types, 519 fracture of, 531 {see Neck of fe- mur ) after-care, 552 diagnosis, 539 etiology, 534 injuries to femoral neck in chil- dren, 555 prognosis, 555 surgical anatomy, 531 symptoms, 537 treatment, 542 after-treatment, 552 operative treatment, 550 Hodgen's si)lint, 582 Hook, ^IcBurney's, 72 Humerus, dislocation of, 44 (see Shoulder, dislocation of) fracture of, lower end, 120 after-care, 151 crescentic fracture, 121, 123 diagnosis, 130 external condyle, 130 external epicondyle, 129 internal condyle, 131 internal epicondyle, 131 ])rognosis, 152 surgical anatomy, 120 svmi)toms, 12S T-fracture, 134 transverse fracture, 131 treatment, 143 after-treatment, 151 operative treatment, 148 shaft, 108 after-care, 119 diagnosis. 111 nnisculo-spiral nerve in, 108, 117, 119 prognosis, 119 INDEX 803 Humerus, fracture of shaft — cont'd. aurfiical anatomy, 108 symptoms, 110 treatment, 113 after-treatment, 11!) operative treatment, 1 1 6 upper end, 82 after-care, 106 anatomical neck, 83 diagnosis, 95 dislocation of humeral head complicating, 72-76 etiology, 89 fractvire of tuberosities, 85 prognosis, 107 separation of epiphysis, 88 surgical anatomy, 82 surgical neck, 87 symptoms, 89 treatment, 97 after-treatment, 106 operative treatment, 104 Hysterical unconsciousness, 438 Iliac dislocation of hip, 517 everted, 519 Iliopectineal dislocation of hip, 518 Ilium, fracture of, 498 (see Pelvis) Inclined plane, double, 580, 581, 582 in fracture of thigh, 564 Internal right-angle splint, 146 with traction, 146 Intracranial sinuses, 399 Ischium, fracture of, 500 (see Pelvis) Jaw, lower (see Maxilla, inferior) dislocation of, 376 fracture of, 348 upper, fracture of, 343 K Kingsley's splint, 361 Kocher's method of reducing disloca- tions of shoulder, 66, 67 Knee, dislocation of, 613 prognosis, 619 surgical anatomy, 613 symptoms, 616 treatment, 617 after-treatment, 619 operative treatment, 618 Laceration of brain, 409 Laminectomy, 487 Lane's l)one drill, 760 ))one plates, 766 Sherman's modilication of, 765 Leg, fractures of bones of, lower ends, 675 (see also Pott's fracture and ankli;) after-care, (i83 diagnosis, 679 prognosis, 683 surgical anatomy, ()75 symptoms, 675 treatment, 681 after-treatment, 683 operative treatment, 682 shafts of, 634 after-care, 654 etiology, 637 diagnosis, 642 prognosis, 657 surgical anatomy, 634 symptoms, 638 treatment, 642 after-treatment, 654 operative treatment, 650 upper ends of, 620 after-care, 631 diagnosis, 627 etiology, 624 prognosis, 633 surgical anatomy, 620 symptoms, 625 treatment, 627 after-treatment, 631 operative treatment, 629 Ligaments, acromio-clavicular, 30 capsular, of hip, 515 of shoulder, 44 of ankle, 685 of clavicle, inner end, 5 outer end, 30 of elbow, 154 of hip, 515 of knee, 613, 614 of shoulder, 44 radioulnar, lower, 237 upper, 177 Y-ligament of Bigelow, 516 Lothrop's operation in fractures of malar, 340 Lumbar puncture in fracture of skull, 449 Lung, puncture of, in fracture of ribs, 462 Liixatio ereeta, 61 Luxations (see Dislocations) M Madelung's deformity, 239 804 INDEX ^lalar bone, fractiiro of, 334 after-care, 342 (lia>;nosis, 33S etiolopv, 33(i proiiiio'sis. 34-2 sin\i:ii-al anatomy, 334 syiiiptoms. 33t) tn-atiiiciit. 33!) a ftcr-treatment, 342 oiH'rative treatment, 340 Mandilile {sec Maxilla, inferior) ^lassage (see After-treatment) Matas splint, 3(12 Maxilla, inferior. dislocation of, 37(i etiolo-y, 377 iu'diznosis. 37S siir<:ieal anatomy, 37t) symjitoms, 377 treatment, 377 after-treatment, 378 fracture of, 348 after-care, 375 diagnosis, 3o0 ]>rogTiosis, 375 surgical anatomy, 348 symptoms, 3.51 treatment, 357 after-treatment, 375 operative treatment, 373 sui)erior, fracture of, 343 after-care, 34(5 diagnosis, 345 prognosis, 347 surgical anatomy, 343 sym])toms, 344 treatment, 345 after-treatment, 346 operative treatment, 346 McBurney's hook, 72 Measurements in {see Diagnosis) fracture of femur, 539 of humerus, 0(i Medio-tarsal joint, dislocations of, 70!) surgical anatomy, 7ii'.) treatment, 70!) Meninges, of brain, 3!)5 vessels of, 306 -Meningitis, differentiated from frac- ture of skull, 443 ^letacarpal bones, dislocations of, 204 {see Carjio-metacar- pal luxations) fractures of, 207 after-care, 306 diagnosis, 300 ]n-ognosis, 306 surgical anatomy, 297 symptoms, 299 Metacarpal bones, frai'tures of — cont'd. treatnu-nt, 301 after-treatment, 306 operative treatment, 305 Metal numbers for marking X-ray plates, 704 Metatarsal bones, dislocations of, 713 (see Tarsometatarsal luxations) fractures of, 714 after-care, 7 1 8 diagnosis, 718 prognosis, 71!) surgical anatomy. 714 symptoms. 716 treatment, 718 after-treatment, 718 oi)erative treatment, 718 ]Middledorf triangle, 102 Mohr's tigure-of-eight bandage, 25 Musculo-si)iral nerve in fractures of liumerus. 108, 117, 119 N Nasal bones, fractures of, 323 after-care, 332 diagnosis, 327 etiology, 325 prognosis, 333 surgical anatomy, 323 sym])toms, 325 tr(>atment, 329 after-treatment, 332 operative treatment, 331 Navicular of tarsus, 710 prognosis, 712 surgical anatomy, 710 treatment, 710 after-treatment, 712 operative treatment, 712 Neck, anatomical, of humerus, 83 (see Humerus) of femur, 532, 537 {see Femur) of sca])ula, 40 {see Scapula) surgical, of humerus, 87, 02 {see Humerus) Neck, fractures of. 465 {see Spine, fracture-dislocations of) Nelaton's line, 533, 534. 539 Nerves, cranial, in fracture of skull, 394 exists through l)ase, 394 s>'m])toms of injury to, 425 Nichols traction ap])aratus, 569 Nose, fracture of, 323 (see Nasal bones) Olecranon, fracture of, 185 (see Ulna) INDEX 805 Olecranon, fracture of — cont'd. after-care, l!t5 complicating luxations of elbow, 16G diagnosis, 100 prognosis, 196 surgical anatomy, 185 symptoms, 188 treatment, 190 after-treatment, 195 operative treatment, 191 Oliver's method of wiring jaws to- gether, 366 Operative treatment of compound fractures and (Lsloca- tions, 7^9 Operative treatment, of dislocations of ankle, 690 astragalus, 697 caleaneum, 706 carpal bones, 292 carpometacarpal joint, 296 clavicle, inner end, 9 outer end, 36 elbow, 170 fingers, 318 hip, 529 OS calcis, 706 patella, 611 phalanges of hand, 318 radius, head of, 181 scmihmar cartilages, 591 shoulder, 71 spine, 486 (see Spine) subastragalar joint, 701 ulna, lower end, 240 upper end, 176 wrist, 292 in fractvire of, astragalus, 697 caleaneum, 706 carpus, 292 clavicle, 26 coccyx, 508 cuboid, 712 cuneiforms, 712 femur, lower end, 562 shaft, 569 upper end, 550 fibula, lower end, 651, 682, 690 shaft, 650 upper end, 629 fingers, 311 hip, 550 humerus, lower end, 148 shaft, 116 upper end, 104 jaw, lower, 373 upper, 346 malar, 340 maxillfi, inferior, 373 ( >|)erative treatment, in fracture of — cont'tl. sui)erior, 346 metacai'iials, 305 metatarsals, 718 nasal bones, 331 olecranon, 191 OS calcis, 706 ])atella, 600 phalanges of hand, 310 radial and ulnar shafts, 225 radius, lower end, '^69 shaft, 225 Ujijjer end, 202 scaphoid, 712 semilunar cartilages, 591 skull, 447 spine, 486 sternum, 457 tibia and fibula, lower ends, 682 shafts, 650 upper ends, 629 ulna, lower end, 235 shaft, 225 upper end, 191 zygomatic arch, 340 in Colles' fracture, 269 in Pott's fracture, 671 Os calcis, fractures and dislocations of, 703 after-care, 707 diagnosis, 706 prognosis, 70S surgical anatomy, 703 symptoms, 705 treatment, 706 after-treatment, 707 operative treatment, 706 Osgood-Penhallow splint, 102 Os magnum, fractures and disloca- tions of, 277 (see Carpus) Osteitis of carpus following Colics' fracture, 274 Osteogenesis imperfecta, 732, 733 Packing of nasal cavities in fracture of nose, 329 Pad, axillarv in fracture of humerus, 98, 99, 101, 114 Passive motion after (see After- treatment ) Colles' fracture. 272 dislocation of, elbow, 172 fingers, 381 shovilder, 79 thiunb, 381 fracture of, clavicle, 29 olecranon, 195 patella, 606 806 INDEX Passive motion after — cont'd. injuries to earpus, 2!>2 Pott's fnutnrc. ()73 Patella. disl.H-atipn of. (iOO after-iare. y\\l diagnosis. (11 1 etiolojiy, (ilO prognosis, 1)12 surgical anatomy. (J09 sym])tonis, 010 treatment. Oil after-treatment. 612 operative treatment, Oil fracture of, .)!t4 after-eare. 005 diagnosis, iiOT etiology, ;>!15 prognosis, 608 surgical anatomy, 504 symptoms, 505 treatment, 508 after-treatment. 005 operative treatment, 600 PatholoLnf fractures. 72S-7.'?:{ Pelvis, fracture-dislocations of, 492 diagnosis, 505 etiology, 400 patholoijy, 406 surgical anatomy, 402 symptoms, 407 treatment, 507 of complications, 510, 511 of rupture of bladder, 511 of rujiture of urethra, 510 Penliallow, Osgood-Penhallow splint. 102 Perineal dislocation of hip, 518 Phalanges, of foot, 72f) {see Toes) of hand {see Fingers) dislocations of, 314 fracture of, 307 Plate, Lane's, 700 Plaster of Paris, use of in fractures of femur, 546, 508 of hip, 546 of humerus, 100, 103, 147 of leg, 64S of metacarpals, 305 of metatarsals, 718 of pelvis, 508 of spine, 484 Pneumonia following fractures of hip, 542 of rihs. 404 Pott's fracture. 050 after-care, 673 diagnosis, 060 ]iroernosis, 073 surgical anatomy, 659 symptoms, 664 Pott's fracturi^ — cont'd. treatnu-nt. 008 after-treatment. 073 ojierative treatment, 671 Prognosis, in dislocations of, ankle, 001 astragalus, 608 calcaneum, 708 carjial hones, 203 cari)o-metacar|)al joint, 206 clavicle, inner end, 10 outer end, 36 cuboid, 712 elbow, 174 fingers, 310 hip, 530 jaw, 378 knee. (ilO mandible. 378 maxilla, 378 OS calcis. 708 l^atella. 612 phalaniies of foot. 721 of hand. 310 radius, head of. 183 semilunar cartilages, 503 shoulder. 80 spine. 401 subastragalar joint. 702 ulna, lower end. 241 \il)])er end, 176 fracture of. astragalus, 60S calcaneum. 708 carpus. 203 clavicle, 29 cuboid. 712 cuneiforms. 712 femur, lower end. 580 shaft, 573 upper end, 555 fibula, lower end. 673, ()83. 001 shaft. 057 upper end. 033 fingers. 313 hip. 555 Imnierus. lower end. 152 shaft. 110 ujiper end. 107 inferior maxilla, 375 jaw, lower, 375 upper, 347 malar. 342 maxilla, inferior. 375 superior. 347 metacarpals. 300 metatarsals, 719 nasal bones. 333 olecranon. 196 OS calcis. 708 patella, 608 INDEX 807 Prognosis, fracture of — cont'd. phalanges of foot, 721 of hand, 312 radial and ulnar shafts, 22f) radius, lower end, 2.']6 shaft, 229 upper end, 203 ribs, 464 scaphoid, 712 scapula, 43 semilunar cartilages, 593 spine, 491 sternum, 458 superior maxilla, 347 tibia and fibula, lower ends, 6S3 shafts, 657 upper ends, 633 ulna, lower end, 236 shaft, 229 upper end, 196 zygomatic arch, 342 of Colles' fracture, 236 of Pott's fracture, 673 Pubic dislocation of hip, 573 Pulse, in fracture of skull, 422 Puncture, lumbar, in fracture of skull, 449 Punctvire of lung in fracture of ribs, 462 Pupils, reaction of, in fracture of skull, 423 in various types of coma {see Dif- ferential diaonosis in frac- ture of skull, 429) Q Qualimeter, Bauer's, 746 E, Rachitis as cause of fracture, 732, 733 Padio-chronometer, 746 Padio-ulnar ligaments, lower, 237 upper, 177 Padius, dislocation of upper end, 177 after-care, 182 diagnosis, 180 prognosis, 183 surgical anatomy, 177 symptoms, 178 treatment, 180 after-treatment, 182 operative treatment, 181 fracture of, lower end, 242 after-care, 271 diagnosis, 260 prognosis, 273 surgical anatomy, 242 symptoms, 252 Padius, fracture of— cont'd. treatment, 264 after-treatment, 271 operative treatment, 269 of shaft, 204 after-care, 228 diagnosis, 219 prognosis, 229 surgical anatomy, 204 symptoms, 206 treatment, 220 after-treatment, 228 operative treatment, 225 of upper end, 197 after-care, 202 diagnosis, 200 prognosis, 203 surgical anatomy, 197 symptoms, 199 treatment, 200 after-treatment, 202 operative treatment, 202 Heduction of (see Treatment) Reflexes in {see Symptoms) coma from various causes, 429 {see Differential diagnosis of fracture of skull) fracture of skull, 423 of spine, 480 Respiration in coma, from various causes, 429 in fracture of ribs, 461 of skull, 422 of sternum, 426 Reversed Colles' fracture, 244 Reversed Pott's fracture, 664 Ribs, fractures of, 459 after-care, 463 diagTiosis, 462 prognosis, 464 surgical anatomy, 459 symptoms, 461 treatment, 462 after-treatment, 463 Rolando, fissure of, 401 Rijntgen ray in diagnosis and treat- ment of fractures and luxations, 735 Rose portable coil, 738, 739 Ruth-Maxwell method in fracture of hip, 545 S Racro-iliac synchondrosis, 504 Sarcoma as cause of fracture. 730 Sayre's dressing (modified) in dislo- cations of clavicle, 9 in fracture of clavicle, 24 in fracture of scapula, 42 808 INDEX Scalp wounds, .S7!1 aftiT raif, :?!)() coinplicatioiis. ;iS4 |iatlii>l()>;y, ."JS-i ri'(.-oj:iutioii <>f coinplications, .SS!1 seqiU'hv, .SS4 surgical anatomy. :57'.' syiniitonis, :iS2 treatment, SSf) closure of wound, 389 control of lu-niorrhage, 385 lirevention of infection, 388 varieties. 3S:?, 384 Sea|ilioid of carpus, dislocations of, •2Sti "divided." 283 fracture of, 280 Scai)ula. fracture of, 37 after-cari', 43 diagnosis, 41 ])rouiiosis, 43 surgical anatomy, 37 symptcmis, 40 treatment, 42 after-treatment, 43 Sciatic dislocation of hip, 517 Screw-])lato, Author's, 550, 551 Semihuiar, fracture of {see Carpus) Seniihuiar cartilages, fractures and dislocations of, 587 after-care, 502 diagnosis, 500 prognosis, 503 surgical anatomy, 597 symptoms, 588 treatment, 501 after-treatment, 502 operative treatment, 501 Separations, ejiiphyseal, considered inider fracture of lione in (jiu'stion {sec Fractinc) Slieriiian's modilication of Lane's ])late. 7()5, 7()(t tap-screw. 7()() Shoulder, dislocation of, 44 after-care. 70 diagnosis. (>4 etiology, 51 tiiuture complicating, 72 old dislocations, 77 ])rognosis, 80 recurrent dislocations, 77 surgical anatomy, 44 sym])toms, 52 treatment. (56 after-treatment. 70 horizontal traction in, 60 Koclier's method in, Gfi, 67 operative treatment, 71 Stimson's method in, 69 Shoulder, dislocation of — cotit'd. tyi.es. 40 Silver fork deformity. 252-259 Skull, fractiu-es of. 301 diagnosis. 427 (lilVerential from. abscess of hrain. 443 ah'oliolic coma, 433 aiio])lectiform and epilcidit'orm convulsions. 443 ai)oi)lexy, 440 aspliyxia from gas. 435 cerebral anemia. 432 cerebral congestion, 432 cerebral embolism, 440 cerebral hemorrluige, 441 cerel)ral sypliilis, 442 cerebral thrombosis, 441 coma of acute infections. 438 diabetic coma, 437 ei>i]epsy. 430 epileptiform attacks, 443 feigning, 438 hysteria, 438 poisoning bv, belladonna, 431) alcohol, 433 chloral, 435 hvocyamus, 436 lead," 436 opiixm, 434 phenol. 434 ptomaines, 435 shock, 431 syncope, 431 tumor of brain. 443 uremic coma, 436 etiology, 404 mechanism and pathology, 405 fracture by, hending, 405 bursting, 405 contre coup, 40i; giuishot fractures. 407 ]irognosis, 440 surgical aiuvtomv, 302 l)ones of skull, 302 cortical centers, 399 formation of, base, 303 vault, 302 membranes of brain, 305 vessels of, 306 meningeal vessels, 396 sinuses, intracranial, 390 symptoms, 411 aphasias, 424 classification of, 412 compression. 410 concvission, 407 contusion. 408 cranial nerve symptoms, 425 depressions in hone, 413 INDKX 809 8kiill, frai'tnrcH of, syin|)t()ms — cont'd. (IcnMations in eyes, 422 clistvirht'd psychic function, 42 4 cccliyniosis, 4 IS empliyscina, 420 escapt' of Mood and brain, 417 general llaccidity, 421 headache, 421 laceration, 40!) late symptoms and secpiela-, 4r)n ciironic headache, 451 disturbances in hcarin<>-, 4.')1 e])ilepsy, 451 psychic changes, 452 vertigo, 451 vomiting, 451 weakness of intellect, 452 localizing, 423 mobility and crepitus, 413 pain in region of fracture, 413 pulse in, 422 pupillary reactions, 423 rellexes, deep, of two sides, 423 respiration, 422 temperature, 422 of two sides, 424 unconsciousness, 420 vomiting, 420 vertigo, 421 treatment, 444 catheterization. 445 electric heat blanket, 444 hot water bottles, 444 dangers of, 444 nasal and oral cavities, 446 operative treatment, 447 elevation of fragments, 447 osteoplastic flap, 448 sedatives, 445 stimulation, 445 the ear, 446 Smith, R. E., splint, 646 Spine, fracture-dislocations of, 465 after-care, 4!)0 diagnosis, 483 prognosis, 401 surgical anatomy, 465 symptoms, 473 treatment, 484 after-treatment, 400 operative treatment, 486 Splints, ambulatorv pneumatic, 554, 585, 655 Cabot wire splint, 580, 646 Cobb's nasal, 330 T)esault, 645 ^^ Dupuv's, 581 for C'olles' fracture, 223, 265, 266. 267 Splints — ('ont'd. for fractures of lingers, :iir,), 3 10, 31 1 for frai'turcs of furearm, 223 lor fractui'e of metacarpals, 304 for fracture of patella, 508, 500 for I'ott's fracture, 668, 6(i0 l)u])uytren'a, 668 Stimson's, 660 (ioldthwaite's, 311 Ham, 500 Hammond's wire, 372 lleatli's, 363 llogden's, 582 Kingslev's, 361 Mata's', ' 362 Osgood-Penhallow's, 1 02 plaster, for fractures of humerus, 147 for fracture of leg, 648 right-angle, 146 Smith's, 646 straight, in fracture of olecranon, 101 T-splint, 544 Thomas' hip, 540 Walker's, 266 Stereoscopic X-ray plates, 74, 751 Sternum, fracture of, 453 after-care, 458 prognosis, 458 surgical anatomy, 453 treatment, 456 after-treatment, 458 operative treatment, 457 Stimson's dressing for dislocations of outer end of clavicle, 35 method of reducing dislocations of hip, 526 method of reducing dislocations of shoulder, 60 sjilints, 660 Strapping, of chest, for fracture of ribs, 463 of scapula, 402 Stromeyer cushion, 1 14 Striicture of, clavicle, 12 femur, lower end, 575 shaft, 575 upper end, 531 humerus, upper end, 83 patella, 600 St>loid of ulna, fracture of, 232 vSubastragalar joint, dislocation of, 600 after-care, 702 diagnosis, 701 prognosis, 702 surgical anatomy, 600 810 INDEX Sulnistragalar joint, dislinatioii of — co»t' (Hiter einl. 30 nilMiid. 71(1 ell)o\v. ]:^A fingers, 314 hip, 515 jaw, 370 knee, (513 mandilile. 37(5 maxilla. 370 mediotarsal joint, 701) OS calcis, 703 patella. 00!) pelvis, 402 phalanges of foot, 720 of hand, 314 radius, head of, 177 scapula, 37 semilunar cartilages, 587 shoulder, 44 spine, 4G5 subastragalar joint, OilO tarsometatarsal jo'ut, 713 ulna, lower end. 237 upper end. 175 wrist, 277 fracture of, astragalus. 002 calcaneum. 70:5 carpus, 277 clavicle, 1 1 cuboid, 710 cuneiforms, 710 femur, lower end, 574 shaft, 558 upper end, 531 fibula, lower end, 675 shaft, 634 upyjer end, 620 fingers. 307 hip, 531 humerus, lower end, 120 shaft, 108 upper end, 82 Surgical anatomy of, fractvu'e of — cont'd. inferior maxilla, 348 jaw, lower, 348 ui)per, 343 malar. 334 maxilla, inferior, 348 superior. 343 metacarpals. 207 metatai'sals, 714 nasal bones, 323 olecranon, 185 OS calcis. 703 l.atella. 504 pelvis. 402 phalanges of foot. 720 of iiand. 3(t7 radial and uliuir shafts. 204 radius, lower end, 242 shaft, 204 U]>per end, 107 ribs, 450 scaphoid, 710 scapula, 37 semilunar cartilages, 587 skull, 392 spine, 465 sternum, 453 su])erior maxilla, 343 tibia and fibula, lower ends, 675 shafts, 634 upjier ends, 620 ulna, lower end, 232 shaft, 204 u])]ier end, 185 /.ygomatic arch, 334 of Colles' fracture, 242 of Pott's fracture, 650 of seal]) wounds, 370 Surgical neck, of humerus, fracture of, 87 complicating' dislocations of slioulder, 72 relations of. to circumflex nerve, 105 of sca])ula, fracture of, 40 Sutui-e of fragments {see Open treat- ment of fractures) Sutiuc materials in treatment of fractures, 768 Suturing of fascia in fracture of ])a- tella, 602 Swathe, in fracture of, huinerus, 101. 104 ]i('l\'is. 507 ribs, 404 with long side splint, 544 Symptoms, of dislocations of, ankle, 687 astragalus, 694 INDEX 811 Symptoms, of dislocations of — cont'd. caleaiK'um, 705 carpo-metacarpal joint, 2!)5 clavicle, inner end, (i outer end, 32 elbow, 150 lingers, 317 hip, 520 jaw, 377 knee, 616 mandible, 377 maxilla, 377 OS calcis, 705 patella, 610 pelvis, 497 phalanges of foot, 720 of hand, 317 radius, head of, 178 semilunar cartilages, 588 shoulder, 52 spine, 473 subastragalar joint, 700 tarso-metatarsal joint, 713 ulna, lower end, 238 upper end, 175 fractures of, astragalus, 694 calcaneum, 705 carpus, 287 clavicle, 15 coccyx, 500 femur, lower end, 578 shaft, 561 upper end, 537 fibula, lower end, 675 shaft, 638 upper end, 625 fingers, 308 hip, 537 humerus, lower end, 128 shaft, 110 upper end, 89 inferior maxilla, 351 jaw, lower, 351 upper, 344 malar, 366 maxilla, inferior, 351 superior, 344 metacarpals, 299 metatarsals, 716 nasal bones, 325 olecranon, 188 OS calcis, 705 patella, 595 pelvis, 497 phalanges of foot, 720 of hand, 308 radial and ulnar shafts, 206 radius, lower end, 252 shaft, 206 upper end, 199 SyniptoniH, frac'turcs of — cont'd. ribs, 461 scai)ula, 40 semilunar cartilages, 5HS skull, 411 spine, 473 su})erior maxilla, 344 tibia and filnila, lower ends, 075 shafts, 63S upper ends, ()25 ulna, lower end, 234 shaft, 206 upper end, 188 zygomatic arch, 366 of Colles' fracture, 252 of Pott's fracture, 664 of scalp wounds, 382 Symphysis pul)is, separation of, 502 Syphilis as a cause of fracture, 730 Syphilitic deformity of nasal bones, 327, 328 T-splint, 544 Tarso-metatarsal joint, dislocation of, 713 diagnosis, 713 surgical anatomy, 713 symptoms, 713 treatment, 713 Taylor brace for fracture of clavicle, 27 Teeth, loss of alignment in, fracture of inferior maxilla, 351- 356 fracture of superior maxilla, 345 Temperature, in fracture of skull, 422 in various forms of unconscious- ness, 429 Terms, 725 Thomas hip splint, 549 Tibia and fibula, fracture of, lower ends, 675 after-care, 683 diagnosis, 679 prognosis, 683 surgical anatomy, 675 symptoms, 675 treatment, 681 after-treatment, 683 operative treatment, 682 shafts, 634 after-care, 654 diagnosis, 642 etiology, 637 prognosis. 657 surgical anatomy, 634 symptoms, 638 812 INDEX Tiliiii anil lilmhi, sliafts — iont'd. trcatimiit, tl4-2 aftt r-trfutiiu'iit, l>.")4 iipt'iativc trcatiiU'iit, (ioO uppiT ends, (')20 aftiT-iaic, (ilJl (liajiiiosis, t>27 i'tiolo<;y. t)24 suijiiral anatouiy. (i'iO syniptonis. (>2.> tn-atmcnt. 027 aftfi-tn atnu'iit. ti:?l (•]ifrati\f tnatnu-nt, 0"i!) 'liliial tiiluMilf, aiHiinaltiiis (issilua tii)ii of. (>-J-J iiijiiiy to. (•-- "lippinji" of. &1\ Toi-s, fraftun-disliu-atioiis of. 7"2(J prognosis. 721 siirgifal anatt)niy. 7'i(i synii)tonis. 720 tifatniciit. 7"2n Transplantation of liont', 771 I raiiniatic tlat-foot, iil'-i, 7t)S 'I r( atnicnt of compound fraeturi,s and luxations, 78!t I ri'atnu'iit of, dislocation of, ankle, t)S<) astragalus, G!)5 caleancuni, 70t; cari)al honi's. 2'.M carpo-nu'tacarpal joint. 2iUJ clavicle, inner end, 7 outer end, 34 elbow, 1()7 lingers, 317 hip, 524 inferior maxilla. :!77 knee, (il7 maxilla, inferior, 377 mediotarsal joint, 70!) OS calcis, 70(5 patella, 611 ])elvis, 507 ])lialanges of foot, 720 of hand, 317 semilunar cartilages, 591 shoukU'r, 00 spine, 484 subastragalar joint. 7ol tarso-metatarsal joint. 713 thinuli, 317 ulna, lower end, 230 upper end, 176 wrist, 291 fracture of, acetabulum, 507, 530 acromion, 42 astragalus, 0!t5 bones of forearm, shafts, 220 Trcatnicnt of, fracture of — vont'd. calcancum, 70(i I arjial bones. 2".i 1 clavicle, 22 iiilioid, 710 cuneiforms, 710 femur, lower end, 5S0 shaft, 563 upper end, 542 liliula, lower i-nd, 65.S, tiSl, 68!t shaft. 642 upper end, t)27 lingers, 310 Inniicrus. lower end. 143 shaft, 113 up|ier end, !t7 malar, 330 maxilla, infi-rior, 357 supciioi', 345 metacarpal l)ones, 301 nu'tatarsal bones, 718 nasal i)om's, 32!) olecranon, l!tO OS calcis, 7t)6 patella, 598 pelvis, 507 phalanges of foot, 720 of hand, 310 radial and ulnar shafts, 220 radius, lower end, 264 shaft. 220 ui>])er end. 220 ribs. 462 scaphoid, 710 scajiula, 42 semilunar cartilages, 5!)1 skull, 444 spine, 484 sternum, 456 til)ia and fibula, lower ends, 681 shafts, 642 ui)]ier ends, 627 ulna, lower end, 235 shaft, 220 u])per end, 190 zygomatic arch, 339 of iJarton's fracture, 269 of Bennett's fracture, 305 of Colics" fracture, 264 of Potfs fracture, iSiS^ of scal|) wounds, 385 recuml)ent, of fracturi'd clavicle, 25 Ti-iangulare, 27!* Trigonvnn. 703 Tuberosities of hunierus. fracture of, 85 Turn buckles, Gerster's, 762 U L Ina, dislocations of lower end, 237 after-care, 240 INDEX 813 Ulna, dislocations of lower end — cont'd. diagnosis, 231) prognosis, 241 surgical anatomy, 237 symptoms, 238 treatment, 239 after-treatment, 240 operative treatment, 240 upper end, 175 after-care, 176 prognosis, 176 surgical anatomy, 175 ■ symptoms, 175 treatment, 176 after-treatment, 176 operative treatment, 176 fracture of lower end, 232 after-care, 235 diagnosis, 234 prognosis, 236 surgical anatomy, 232 symptoms, 234 treatment, 235 after-treatment, 235 operative treatment, 235 of shaft, 204 after-care, 228 diagnosis, 219 prognosis, 229 surgical anatomy, 204 symptoms, 206 treatment, 220 after-treatment, 228 operative treatment, 225 upper end (olecranon), 185 after-care, 195 diagnosis, 190 prognosis, 196 surgical anatomy, 185 symptoms, 188 treatment, 190 after-treatment, 195 operative treatment, 191 Unciform {see Carpus) Unconsciousness from fracture of skull, differential diagno- sis of, 429 Union of fragments, time necessary {see Prognosis of various chapters ) Uremic coma, 436 Tretlira, injury to, and rupture of, in fracture of pelvis, 509 Use of, four-jjost clamp, 763 Lane ])late, 76(5 nails, scr<'\vs and jjeg, 759 wire, 758 X-ray, 735 Velpeau's l)andage, 25 in dislocation of clavicle, 9 Vertebrae, fracture of {see Spine) Vertical suspension in fracture of femur in cliildren, 565 Vertigo in fracture of skull, 421 Vessels, meningeal, 396 Visceral lesions in fracture of pelvis, 509 Volkmann's contracture, 231 Vomiting in head iniuries, 420 W Walker's splint for Colles', 226 Whitman, treatment of fracture of femoral neck in children, 557 Wire nails, 754 Wire, use of, in fractures, 758 Wounds of compound fractures, 789 Woxmds of scalp, 379 Wrist {see Carpus) X X-ray, use of, 735 Y-ligament of Bigelow, 516 Zygomatic arch, fracture of, 334 {see Malar) COLUMBIA UNIVERSITY LIBRARIES This book is due on tne d^te indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE otc^ ',f,,A?f' Hu' • \('\ < C2a(ll40)M100 V'^ u COLUMBIA UNIVERSITY LIBRARIES (hsi.stx) RD101P92C.1 Fractures anri fiisinrniiMns 2002102587 0^ '^/