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 I 1/ 
 
 TRAUMATIC SEPARATION 
 
 OF 
 
 THE EPIPHYSES 
 
Bij the same AutJior. 
 
 THE SKIAGHAPHIC ATLAS. 
 
 Showing the Development of the BONES of the WRIST 
 
 and HAND, for the Use of Students 
 
 and others. 
 
 WITH 19 SKIAGRAMS. 
 Eoval 8vo. 5s. 
 
 London: S3IITH, ELDEE, & CO., 15 Waterloo Place. 
 
TEAUMATIG SEPARATION 
 
 OF 
 
 THE EPIPHYSES 
 
 BY 
 
 JOHN POLAND, F.R.C.S. 
 
 WITH THREE HUNDRED AND THIRTY-SEVEN ILLUSTRATIONS 
 
 AND SKIAGRAMS 
 
 LONDON 
 SMITH, ELDEE, & CO., 15 WATEELOO PLACE 
 
 1898 
 
 [All rights reservedj 
 


 (?5 
 
 
 TO MY FATHEK 
 EICHAED HENEY POLAND 
 
 I DEDICATE THIS WORK 
 
 JOHN POLAND 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/traumaticseparatOOpola 
 
PEEFACE 
 
 I VENTUEE to trust that this volume will prove of assist- 
 ance in elucidating a large class of injuries which up to the 
 present, time have not been properly understood. 
 
 My warmest thanks are due to my friend Mr. Hugh A. 
 Webster, Librarian of the University of Edinburgh, for the 
 great labour entailed in revising the proof-sheets, and for 
 many valuable suggestions. To Messrs. Churchill I am 
 indebted for two blocks from Mr. T. Bryant's 'Art and 
 Practice of Surgery,' and to Messrs. Longmans & Co. 
 for one from Messrs. Ashby and Wright's ' Diseases of 
 Children ' ; and I take this opportunity of thanking the 
 pubhshers, Messrs. Smith, Elder, & Co., and the printers, 
 Messrs. Spottiswoode & Co., for the way in which all my 
 wishes have been carried out. 
 
 Most of the illustrations have been made for me by 
 Dr. C. W. Hogarth and Mr. John Burman, while the 
 engraver, Mr. T. P. Collings, has done much to enhance 
 their value. 
 
viii PREFACE 
 
 The kindly help of my brothers, Messrs. Charles and 
 Ernest Poland, T\-ho hare respectively assisted me Avith the 
 German literature and proof-sheets, has saved me much 
 labour. 
 
 To my old friend Mr. \\Tlliam "Webster, one of the chief 
 exponents of the Piontgen ray process in this country, I 
 owe a debt of gratitude for his valuable series of skiagrams 
 showing the normal epiphyses of the hand. 
 
 Finally, I thank the many kind friends, especially those 
 in the profession both at home and abroad, who have con- 
 duced so much, by their interesting contributions of cases 
 and photographs, to the completeness of the book. 
 
 J. P, 
 
INTRODUCTION 
 
 While most of the standard works on surgery mention epiphysial 
 separations, very few give any cases or enter into any detail either 
 as to their diagnosis or treatment. This may account for the 
 fact that these lesions do not sufficiently occupy the attention 
 of practitioners. 
 
 Epiphysial separations are still continually mistaken for ordi- 
 nary fractures or dislocations, and in many cases suitable treatment 
 is not adopted. 
 
 Numerous specimens of such separations now exist in museums, 
 and clinical cases not unfrequently afford accurate data upon which 
 an exact diagnosis may be made, 
 
 Though the literature of the subject is most extensive, it is very 
 scattered. It has cost me some years of labour to bring together 
 and summarise the records hitherto published. Almost all references 
 have been verified, and, in a great number of instances, corrections 
 have been made in the dates as well as in the pages. 
 
 My interest in the subject was first aroused when, sixteen j^ears 
 ago, I held for two and a half years the post of Eegistrar at the 
 North-Eastern Hospital for Children, and for a time took the 
 duties of the Acting- Surgeon, I then came across more than one 
 complicated injury to the joints in children whicii perplexed me 
 very much. 
 
 Most of the anatomical details were worked out during the years 
 I acted as Demonstrator and Senior Demonstrator of Anatomy in 
 the Guy's Hospital Medical School. Many are not to be found 
 in any anatomical or surgical text-book ; they are now published 
 for the first time. 
 
 For permission to make use of the cHnical cases at Guy's 
 Hospital up to the year 1884, collected when I was Surgical 
 Eegistrar to the Hospital, I am greatly indebted to the members 
 of the surgical staff. 
 
X INTEODUCTIOls 
 
 A very large number of cases have been under my own observa- 
 tion and care, more especially at the City Orthopaedic Hospital and 
 at the Miller Hospital, Greenwich, 
 
 Separation of the epiphyses, with their symptoms, mechanism, 
 causes, pathological anatomy, treatment, and prognosis, will be 
 considered first in general. 
 
 The symptoms, treatment, &c., special to each variety of separa- 
 tion will then be described in their appropriate chapters. 
 
 All separations verified by direct examination have been placed 
 under the head of ' Pathological Anatomy,' which has also been 
 made to include nearly all compound separations ; and throughout 
 it has been my endeavour to place the subject upon a sound 
 anatomical and pathological basis. 
 
 The total number of cases I have here collected is over seven 
 hundred, though a large number of published reports have been 
 rejected on account of their obscure nature. 
 
 I hope this work may induce hospital surgeons to publish the 
 cases under their observation, which are numerous, if we may judge 
 by the annual statistical reports of many of the hospitals. 
 
DEFINITIONS 
 
 Epiphysis, from eV/, upon ; (pvais, growth, from (j}va>, to grow. An accretion ; 
 something that grows to another. 
 
 Synonyms. — Diductio epiphysium. Diastasis, disjtinctio, divulsio, discessio 
 epiphysium. Traumatische Epiphysentrennung, Absprengung der Epiphysen, 
 Trennung der Epiphysen. Divulsion, disjonction, decollement tranmatique des 
 epiphyses, separation des epiphyses. Disjonction diaphysaire (Oilier). Decolle- 
 ment juxta-epiphysaire. Fracture juxta-epiphysaire. Desepiphysation. Distacco 
 delle epifisi. 
 
 Various names have been applied in this country to these injuries, such as dis- 
 junction, divulsion, epiphysial detachment or separation, juxta-epiphysial fracture 
 and separation, epiphysial diastasis. 
 
 Juxta-epiphysial separation or fracture would limit the solution of continuity to 
 the juxta-epiphysial region, which has been called the bulb of the bone (bulbe 
 de Z'os) by Lannelongue, and which is a short distance from the epiphysial 
 cartilage. 
 
 The name of diaphysial separation {decollement diaphysaire) has been proposed 
 by M. Oilier, and with considerable accuracy, for in a typical epiphysial separation 
 it is the diaphysis which is separated from the epiphysial cartilage, and not the 
 epiphysis. The term 'epiphysial separation' would then be reserved for those very 
 rare cases where the epiphysis is detached from the epiphysial cartilage. 
 
 But there would be little advantage in changing a title with wliich all are now 
 so familiar. 
 
CONTENTS 
 
 PAET I 
 
 TRAUMATIC SEPARATION OF THE EPIPHYSES 
 IN GENERAL 
 
 CHAPTER PAGE 
 
 I. HISTORICAL 1-15 
 
 II. ANATOMY 
 
 Diaphysis — Epiphysis, its development — Epiphysial or conjugal 
 cartilage, its function — Juxta-epiphysial region — -Periosteum, 
 its function — Articular cartilage — Eelation of synovial mem- 
 brane to conjugal cartilage — Apophyses .... 16-37 
 
 III. ETIOLOGY 
 
 Pathological separations — Indirect violence — Traction on limb — 
 Forcible torsion — Direct violence — Muscular violence. 
 
 AGE 
 
 Intra-uterine separation — Epiphysial separation during childbirth 
 — Periods of age — Chronological table of ossification of 
 epiphyses— Times of union of epiphyses to the diaphyses of 
 long bones. 
 
 SEX 
 
 Statistics of sex in the three most frequent separations — Sex in 
 the different epiphysial injuries — ^Sex in the different periods 
 of age 38-50 
 
 IV. FREQUENCY OF THE VARIOUS SEPARATIONS 
 
 Date of ossification of the chief epiphyses of the long bones — 
 Published statistics of cases of traumatic separation of the 
 epiphyses — Author's statistics of separations of the epiphyses 
 of the long bones . . . . . . . . 51-57 
 
 V. EXPERIMENTS IN PATHOLOGICAL ANATOMY AND THEIR 
 HISTOLOGICAL ANATOMY 
 Detachment of periosteum. 
 
 MECHANISM AND EXPERIMENTS 
 
 Indirect violence — Traction in axis of limb — Forcible hyper- 
 riexion and hyper-extension of joint — Forcible abduction and 
 adduction — Torsion — Direct violence .... 58-69 
 
xiv CONTENTS 
 
 CHAPTER PAGE 
 
 VI. PATHOLOGICAL ANATOMY 
 
 Site of separation — ^Separations at birth — -Pure separations — 
 Partial separation with fracture of diaphysis — Foucher's clas- 
 sification — Juxta-epiphj'sial separations — Transverse fracture 
 of diaphysis close to epiphysial line — Incomplete separations 
 ■ — Juxta-epiphysial sprains — Incomplete and complete dis- 
 placement of epiphysis or diaphysis — Complications — Fracture 
 of diaphysis — Detachment of periosteum — Fracture of epiphy- 
 sis — Multiple separation — Separation with dislocation — Injury 
 to joints — Occlusion of vessels — Injiury to nerve trunks — 
 Disease caused by separation — Separations from disease — 
 Compound separations . . . . . . . 70 87 
 
 VII. SYMPTOMS 
 
 Separation with displacement — Separation without displacement 
 —Epiphysial sprains in infancy. 
 
 DIFFEEENTIAL DIAGNOSIS 
 
 Fracture — Dislocation — Compound dislocation . . . 88-97 
 
 VIIL PROGNOSIS AND RESULTS 
 
 Union — Non-union — Deformity — Impaired movements of joint 
 and ankylosis — Atrophy of limb from disuse— Exuberant 
 callus — Paralysis of nerve — Arrest of growth, causes of, 
 partial and complete — -Consequent deformity — Arrest of 
 growth from ostitis — Lengthening of bone — Suppuration 
 from ostitis — Periostitis — Necrosis of shaft and necrosis of 
 epiphysis — Aneurism — Disease due to partial separation— 
 Pj'semia — Prognosis in other severe lesions — Prognosis in 
 compound cases — Gangrene 98-122 
 
 IX. TREATMENT 
 
 Description by Roux in 1822 — Separation without displacement 
 — Juxta-epiphysial sprain in infancy — Separation with dis- 
 placement — Massage — Immediate massage — Passive move- 
 ment — Suppuration — Compound separations — Ligature of 
 veins for thrombosis — Primary operations for irreducibility 
 — Secondary amputation — Refracturing for recent deformity — • 
 Resection in old separations — Operations for deformity from 
 arrest of growth — Conjugal chondrotomy — Conjugal chon- 
 drectomy . . . ■ ■ • • • • • 123-134 
 
 PAET II 
 
 TBAUMATIC SEPARATION OF THE EPIPHYSES OF 
 THE UPPER EXTREMITY 
 
 I. SEPARATION OF THE EPIPHYSIS OF THE CLAVICLE 
 
 Normal anatomy of epiphysis— Etiology— Age— Pathological 
 
 anatomy — Symptoms — Diagnosis — Prognosis— Treatment 135-143 
 
 II. SEPARATION OF THE EPIPHYSES OF THE SCAPULA 
 
 Separation of the Glenoid and Coracoid Cartilage — Separa- 
 tion OF THE EPIPHYSIS OF THE BASE OF THE SCAPULA, 
 SUPRA- SCAPULAR EPIPHYSIS — SEPARATION OF THE EPIPHYSIS 
 
 OF THE coracoid PROCESS : — Anatomy — Etiology— Age — 
 
CONTENTS 
 
 XV 
 
 Pathological anatomy — Symptoms — • Complications — Treat- 
 ment — Separation of the epiphysis of the acromion 
 PROCESS : — Anatomy — Etiology — Pathological anatomy — 
 Symptoms — Diagnosis — Prognosis — Treatment — Separation 
 
 OF THE apical EPIPHYSIS OF THE CORACOID . . . 144-162 
 
 III. SEPARATION OF THE UPPEE EPIPHYSIS OF THE 
 
 HUMERUS 
 Anatomy — Age — Sex — Etiology — Statistics — Pathological 
 anatomy — Pure separations — Pure separation with displace- 
 ment — Complete and incomplete displacement of diaphysis 
 — Juxta-epiphysial separation — Complications — Separation 
 without displacement — Symptoms — Displacement subsequent 
 to accident — Differential diagnosis — Sub-coracoid dislocation 
 ■ — Fracture of surgical neck — Shoulder sprains — Treatment — 
 Complete and incomplete displacement — Primary operations 
 in recent cases — Resection of diaphysis in old cases — - 
 Excision of head — Compound separations — Separation with 
 dislocation of epiphysis — Massage — Prognosis — Deformity — 
 Non-union — Arrest of growth — Arrest of growth from inflam- 
 mation — Gangrene 163-261 
 
 IV. SEPARATION OF THE LOWER END OF THE HUMERUS 
 
 BEFORE PUBERTY 
 
 Anatomy — Age — Sex — Etiology — Statistics — Pathological 
 anatomy — Pure separation — Separation with fracture of 
 epiphysis — Partial separation with fracture of diaphj'sis — 
 Compound separations — Displacement backwards of epiphysis 
 — Displacement forwards of epiphysis — Displacement inwards 
 and outwards of epiphysis — Complications — Symptoms- 
 Separation without displacement — Separation with displace- 
 ment — Differential diagnosis — Dislocation of elbow — Con- 
 tusion of elbow — Fracture above condyles — Prognosis — 
 Union — Deformity — Ankylosis of elbow — Implication of 
 nerves — Gangrene — Arrest of growth — Treatment — Simple 
 cases — Croft's splints — Separation with displacement — Ex- 
 tended position — Flexed position — No fixation^Passive 
 motion — Primary and secondary amputation — Operations for 
 deformity 262-332 
 
 V. SEPARATION OF THE LOWER EPIPHYSIS OF THE 
 
 HUMERUS IN YOUTHS 
 
 Anatomy — Age — Pathological anatomy— Etiology — Symptoms 
 
 — Displacement of epiphysis backwards — Displacement of 
 
 epiphysis forwards — Differential diagnosis — Prognosis — 
 
 Treatment 833-345 
 
 VI. SEPARATION OF THE INTERNAL EPICONDYLE OF THE 
 HUMERUS 
 Anatomy — Etiology — Age — Statistics — Sex — Pathological 
 anatomy — Complications — Articular lesions — Injury to 
 iihiar nerve- -Dislocation of elbow — Symptoms— Separation 
 without displacement — Displacement of epiphysis — .Disloca- 
 tion of ulna — Fracture of olecranon — Differential diagnosis 
 — Prognosis — Union — Deformity — Atrophy of epicondylar 
 muscles — Treatment — Passive motion — Primary operation for 
 displacement — Excision of epicondyle .... 346-391 
 
xvi CONTENTS 
 
 CHAPTEB PAGE 
 
 VII. SEPARATION OF THE EXTERNAL EPICONDYLE OF THE 
 
 HUMERUS 
 Anatomy^ Age — Etiology — Pathological anatomy — Symptoms 
 — Detachment without displacement — ^Complications — Dislo- 
 cation of radius — Prognosis — Treatment— Primary resection 
 — Passive movement — Operative treatment . . . 392-404 
 
 VIII. SEPARATION OF THE TROCHLEA WITH INTERNAL 
 EPICONDYLE (EPICONDYLO-TROCHLEAR SEPARATION) 
 AND SEPARATION OF THE TROCHLEA WITH FRAC- 
 TURE OF INTERNAL CONDYLE (CONDYLO-TROCH- 
 LEAR FRACTURE) 
 
 Etiology — Age — Pathological anatomy — Symptoms — Complica- 
 tions — Injury to ulnar nerve — Rupture of brachial artery — 
 Diagnosis — Prognosis — Deformity — Arrest of growth — Flexed 
 and extended positions in treatment — Passive motion — Com- 
 IDlications — Recent irreducibility of fragment — Resection of 
 elbow-joint — Compound separations .... 405-420 
 
 IX. SEPARATION OF THE CAPITELLAR AND EXTERNAL 
 EPICONDYLAR EPIPHYSES (EPICONDYLO-CAPITELLAR 
 AND CONDYLO-CAPITELLAR FRACTURES) 
 Anatomy — Etiology — Age — Pathological anatomy — Cubitus 
 valgus from displacement — Complications — Dislocation of 
 elbow — Dislocation of radius — Symptoms — Separation with- 
 out displacement — Separation with displacement — Differen- 
 tial diagnosis — Prognosis — Deformitj' — Articular lesions — 
 Flexed and extended positions in treatment — Passive motion 
 — Resection of elbow-joint — Primary operations — Partial 
 resection in old cases 421-447 
 
 X. SEPARATION OF THE TROCHLEA 
 
 Anatomy — Age — Pathological anatomy — Complications — 
 Etiology — Symptoms — Diagnosis — Treatment. 
 
 SEPARATION OF THE CAPITELLUM 
 
 Anatomy — Age — Pathological anatomy — Etiology — -Symptoms — 
 Complications — Prognosis — Treatment. 
 
 SEPx\RATION OF THE CAPITELLAR AND TROCHLEAR 
 
 EPIPHYSES 448-456 
 
 XI. SEPARATION OF THE OLECRANON EPIPHYSIS AND OF 
 THE CARTILAGINOUS UPPER END OF THE ULNA 
 Anatomy — Pathological anatomy — Age— Etiology — Symptoms- 
 Separation with and without displacement — Differential dia- 
 grams — Fracture of olecranon — Prognosis — Articular lesions 
 — Treatment — Passive motion — Extra-articular suture — 
 Wiring of fragments — Compound separations. 
 
 SEPARATION OF THE UPPER EPIPHYSIS (HEAD) OF 
 THE RADIUS 
 
 Anatomy — Etiology — Age— Pathological anatomy — Symptoms — 
 Separation with and without displacement — Prognosis— 
 Differential diagnosis — Treatment. 
 
 Separation of the Bicipital Epiphysis of the Radius . 457-477 
 
CONTENTS xvii 
 
 CHAPTER PAGE 
 
 XII. SEPAEATION OF THE LOWER EPIPHYSIS OF THE 
 EADIUS 
 
 Aiiatomy — Etiology — Age — Sex — Statistics — Pathological ana- 
 tomy — Separation without displacement — Displacement of 
 epiphysis backwards — Displacement of epiphysis forwards — 
 Separation with fracture of diaphysis — Complications — 
 Separation with fracture of epiphysis — Separation with 
 fracture of styloid process of ulna — Separation with fracture 
 of ulnar shaft — Compound separations — Articular lesions 
 — Separation with separation of ulnar epiphysis— Other 
 severe lesions — Later complications — Gangrene of hand 
 — Tetaniis — Suppuration — Periostitis — Symptoms — De- 
 formity — Injury to radial artery — Differential diagnosis — • 
 Dislocation of wrist — Colles's fracture — Fractiire of lower 
 end of radius with anterior displacement — Separation with 
 forward displacement — Prognosis — Non-union — Arrest of 
 growth and subsequent deformity — Treatment — Complete 
 displacements — Passive motion — Secondary amputation — 
 Operating in old cases and for deformity . . . 478-579 
 
 XIII. SEPARATION OF THE LOWER EPIPHYSIS OF THE 
 
 ULNA 
 Anatomy — Pathological anatomy — Complications — Etiology — 
 Age — Symptoms — Prognosis — Arrest of growth — Treat- 
 ment .... 580-587 
 
 XIV. SEPARATION OF THE EPIPHYSIS OF THE METACARPAL 
 
 BONE OF THE THUMB 
 Anatomy — Etiology — Age — Pathological anatomy — Symptoms 
 — Complications — Diagnosis — Treatment — Compound separa- 
 tions. 
 
 SEPARATION OF THE EPIPHYSES OF THE TRUE (FOUR 
 INNER) METACARPAL BONES 
 
 Anatomy— Etiology — Age — Pathological anatomy — Symptoms 
 — Displacement forwards — Displacement backwards — -Dis- 
 placement outwards — Diagnosis — Prognosis — Treatment. 
 
 SEPARATION OF THE EPIPHYSIS OF THE PHALANGES 
 OF THE DIGITS 
 
 Anatomy — Pathological anatomy — Symptoms — Diagnosis — 
 
 Prognosis — Treatment 588-602 
 
xviii CONTENTS 
 
 PAKT III 
 
 TRAUMATIC 8EPAEATI0N OF THE EPIPHYSES OF 
 THE LOWEB EXTBEMITY 
 
 I. SEPARATION OF THE EPIPHYSES OF THE OS INNOMI- 
 NATUM 
 
 Separation of the epiphysial parts of the acetabulum — 
 Separation of the epiphysis of the iliac crest and 
 
 ANTERIOR and POSTERIOR SUPERIOR ILIAC SPINES — SEPARATION 
 OF THE EPIPHYSIS OF THE ANTERIOR INFERIOR SPINE OF THE 
 
 ILIUM — Separation of the epiphysis of the symphysis 
 PUBES — Separation of the epiphysis of the spine of the 
 PUBES — -Separation of the epiphysis of the sciatic spine — 
 Separation of the epiphysis of the tuber ischii . 603-614 
 
 II. SEPARATION OF THE EPIPHYSIAL HEAD OF THE 
 FEMUR 
 Anatomy — Age — Statistics — Etiology — -Patliological anatomy — 
 Incomplete separation — Symptoms — Separation with dis- 
 placement — Differential diagnosis — Fracture of neck of 
 femur — Dislocation of hip— Hip disease — Separation with- 
 out displacement — Prognosis — Non-union — Arrest of growth 
 • — -Treatment — Passive flexion — Excision of epiphysial head 
 — Primary operation for displacement .... 615-660 
 
 III. SEPARATION OF THE EPIPHYSIS OF THE GREAT TRO- 
 
 CHANTER 
 
 Anatomy — Age — Etiology — Pathological anatomy — Pure separa- 
 tion^ — Separation with fracture — Symptoms — Separation 
 without displacement — Separation with displacement — 
 Pyaemia — Differential diagnosis — Prognosis — Complications 
 ■ — Treatment. 
 
 SEPARATION OF THE EPIPHYSIS OF THE LESSER 
 TROCHANTER 
 
 Anatomy^ — Etiology — Pathological anatomy — Symptorns. 
 
 SEPARATION OF THE EPIPHYSIS OF THE THIRD 
 
 TROCHANTER 661-677 
 
 IV. SEPARATION OF THE LOWER EPIPHYSIS OF THE 
 
 FEMUR 
 
 Anatomy- -Age —Statistics — Sex — Etiology — Pathological ana- 
 tomy — Separation in infancy— Pure separations — Compound 
 separations — Separation without displacement — Separation 
 with fracture of diaphysis — Separation with intercondyloid 
 fracture — Displacement of epiphysis forwards — Displace- 
 ment of epiphysis backwards— Displacement of epiphysis 
 laterally — Partial separation with fracture — Complications — 
 
CONTENTS xix 
 
 CHAPTEE p^GE 
 
 Injury to popliteal vessels and nerves — Detachment of 
 periosteum— Gangrene of limb— Primary and secondary 
 haemorrhage — Articular lesions — Acute periostitis and 
 necrosis — Pyaemia — Aneurism — ■ Prognosis — Union — De- 
 formity after separation — ^Arrest of growth — Symptoms — 
 Displacement subsequent to accident — Differential diagnosis 
 — Dislocation of knee — Supra-condyloid fracture — Treat- 
 ment — Flexed position — Passive movement — Primary opera- 
 tion for replacement — Primary and secondary amputation^ 
 Osteotomy for deformity ....... 678 797 
 
 V. SEPARATION OF THE UPPER EPIPHYSIS OF THE 
 TIBIA 
 
 Anatomy— Etiology— Age— Statistics— Sex— Pathological ana- 
 tomy — Pure separations — Displacement of epiphysis for- 
 wards—Displacement of epiphysis backwards — Displace- 
 ment of epiphysis laterally — Separation with fracture of 
 diaphysis — Articular lesions — Prognosis — Union — Deformity 
 after separation— Arrest of growth — Symptoms — Diagnosis — 
 Dislocation of knee — Treatment — ^Primary and secondary 
 amputation 798-815 
 
 VI. SEPARATION OF THE EPIPHYSIS OF THE TUBERCLE 
 OF THE TIBIA 
 
 Anatomy — Etiology — Age — Pathological anatomy — Articular 
 
 lesions — Sjanptoms — Diagnosis — Prognosis — ^Treatment . 816-823 
 
 VII. SEPARATION OF THE LOWER EPIPHYSIS OF THE 
 TIBIA 
 
 Anatomy— Age — Statistics — Sex — Etiology — Pathological ana- 
 tomy — Separation with fracture of diaphysis — Compound 
 separations — Pure separations — Separation with fracture of 
 fibula — Separation of lower epiphyses of tibia and fibula — 
 Displacement outwards of epiphysis — Displacement inwards 
 of epiphysis — Displacement backwards of epiphysis — Ar- 
 ticular lesions — Injury to tibial vessels and nerves — Com- 
 plications — Acute periostitis — G angrene — Symptoms — De- 
 formity — Separation without deformity — Diagnosis — Dis- 
 location of ankle — Pott's fracture — Prognosis — Arrest of 
 growth — Treatment — Operation for deformity — Conjugal 
 chondrectomy 824-855 
 
 VIII. SEPARATION OF THE UPPER EPIPHYSIS (HEAD) OF THE 
 FIBULA 
 
 Anatomy — Etiology — Age — Pathological anatomy — Symptoms 
 — Treatment. 
 
 SEPARATION OF THE LOWER EPIPHYSIS (EXTERNAL 
 MALLEOLUS) OF THE FIBULA 
 Anatomy — Etiology — • Age — Pathological anatomy — • Com- 
 pound separations — Suppuration — Arrest of growth — Sym- 
 ptoms — Displacement of epiphysis — Treatment — Conjugal 
 chondrectomy 856 866 
 
XX CONTENTS 
 
 CHAPTEK PAGE 
 
 IX. SEPAEATION OF THE EPIPHYSES OF THE BONES OF 
 THE FOOT 
 Separation of the epiphysis of the os calcis — Separation of 
 
 THE occasional EPIPHYSIS OF THE ASTRAGALUS — SEPARATION 
 OF THE EPIPHYSIS OF THE FIRST METATARSAL BONE SEPARA- 
 TION OF THE EPIPHYSES OF THE FOUR OUTER METATARSAL 
 
 BONES — Separation of the epiphysis of the phalanges of 
 THE toes 867-871 
 
 PAET IV 
 
 I. TBAUMATIC SEPARATION OF THE EPIPHYSES OF 
 THE VEUTEBR^ AND BIBS 
 
 SEPARATION OF THE EPIPHYSES OF THE VERTEBRA 
 
 GENERALLY 873-875 
 
 SEPARATION OF THE EPIPHYSES OF THE DIFFERENT 
 VERTEBRA 
 
 Separation of the epiphyses of the cervical vertebra — • 
 Sepajration of the epiphysial parts of the atlas — Se- 
 paration of the epiphyses of the axis — Separation of 
 the epiphyses of the lumbar vertebrae . . . 876-878 
 
 SEPARATION OF THE EPIPHYSES OF THE SACRUM . . .879 
 
 SEPARATION OF THE EPIPHYSES OF THE RIBS 
 
 Separation of the epiphysis of the head of the rib — Se- 
 paration OF the epiphysis of the tuberosity of the rib 880 
 
 APPENDIX 881-882 
 
 INDEX OF NAMES ' 883-904 
 
 INDEX OF SUBJECTS 905-926 
 
LIST OF ILLUSTEATIONS 
 
 SKIAGEAMS 
 
 with 
 
 sis of 
 
 To face p, 28 
 
 Series to Illustrate the Development of the Epiphyses of the Hand and Wrist 
 
 Female Infant aged Twelve Months (First Child of Parents) ^^ 
 
 Child aged Two Years (Third Child of Parents) 
 
 Child aged Three Years (Eighth Child of Parents) 
 
 Male Child aged Four and a Half Years 
 
 Child aged Five Years (Second Child of Parents) 
 
 Child aged Five Years (Thirteenth Child of Parents) 
 
 Male Child aged Sis l^ears . 
 
 Male Child aged Seven Years 
 
 Male Child aged Eight Years 
 
 Boy aged Eight Years and Five Months 
 
 Male Child agred Nine Years 
 
 Boy aged Ten Years 
 
 Boy aged Eleven Years 
 
 Boy aged Twelve Years . 
 
 Boy aged Thirteen Years . 
 
 Boy aged Fourteen Years 
 
 Boy aged Fifteen Years 
 
 Boy aged Sixteen Years 
 
 Boy aged Seventeen Years . 
 
 Displacement forwards of Lower Epiphysis of Humerus 
 
 Displacement backwards of Lower Epiphysis of Humerus 
 Fracture of Diaph^'sis ... 
 
 Separation of Lower Epiphysis of Humerus 
 
 Separation and Displacement backwards of Lower Epiphys 
 Humerus ..... 
 
 Simple Separation of Lower Epiphysis of Humerus with com- 
 plete Displacement backwards. Wiring for Irreducibility 
 
 Cubitus Valgus with ununited Condylo-capitellar Fracture 
 
 Cubitus Varus. Separation of Capitellum and External Epi- 
 condyle with Displacement downwards and inwards 
 
 Fracture of Neck of Radius with Dislocation of Elbow backwards 
 
 The same case after reduction of the Dislocation of Elbow 
 
 Separation of Lower Epiphysis of Radius with Displacement 
 backwards and outwards ...... 
 
 Separation of Lower Epiphysis of right Radius with Displace 
 ment 
 
 / 
 
 29B 
 
 800 
 
 304 
 
 304 
 
 356 
 
 428 
 
 440 
 476 
 476 
 
 492 
 
 534 
 
xxii LIST OF ILLUSTEATIOKS 
 
 Separation of Lower Epiphysis of left Eadius without Displace- 
 ment To face p. 534 
 
 Separation of Lower Epiphysis of left Radius without Displace- 
 ment (Fourth Week) „ 534 
 
 Separation of Lower Epiphysis of right Eadius. Fracture of 
 
 Styloid Process of Ulna (Fourth Week) „ 534 
 
 Separ ition of Lower Epiphysis of Radius (Early Rontgen 
 
 Picture) „ 548 
 
 Arrest of Growth of Eadius Twelve Months after Injury . . „ 570 
 
 Arrest of Development of Ulna ....... ,, 586 
 
 Displacement forwards of Epiphysis of Metacarpal Bone of 
 
 Index Finger .......... „ 592 
 
 Displacement outwards of Epiphysis of Metacarpal Bone of 
 
 Index Finger ......... „ 594 
 
 Dislocation of Metacarpo-phalangeal Joint, with Fracture of 
 
 Epiphysis of Metacarpal Bone of Index Finger ... „ 596 
 
 Fracture of Neck of Femur in a Lad ,, 644 
 
 Fracture of Neck of Femur in a Girl ...... ,, 648 
 
 Arrest of Growth of Femur after injury to lower end. Lateral 
 
 view ,, 758 
 
 Arrest of Growth of Femur after injury to lower end. Antero- 
 posterior view ......... „ 758 
 
 Normal Left Knee of same case ...... ,, 758 
 
 Normal Epiphyses of Ankle and Foot at Seven Years ... ,, 868 
 
 ILLUSTEATIONS IN TEXT 
 
 FlO. PAGE 
 
 1. Longitudinal (Microscopical) section of Epiphysis of the Femur of a 
 
 Human Fcetus {Burdon- Sanderson) ....... 21 
 
 2. Microscopical section of Epiphysis through Line of gi'owing Bone and 
 
 Periosteum (Macnaniara) .......... 30 
 
 3. Microscopical section of Epiphj'sial Separation in a newly born Infant 
 
 {Curtillet) 61 
 
 4.. Microscopical section of Traumatic Separation of an Epiphysis in a 
 
 Child Three Years of Age {CurtiUef) . . . . \ . . 62 
 
 5. Lesions produced by forcible Abduction of the Femur in a Child aged 
 
 Twenty-two Months {Oilier) 78 
 
 6, 7, 8, 9. Diagrams of the common Forms of Epiphysial Separation . . 80 
 
 10. Valgus Position of Hand produced by Arrest of Growth of the Radius 
 
 {Nicoladoni) ............ 115 
 
 11. Deformity following Traumatic Separation of the Lower Epiphysis of the 
 
 Ulna, with Suppuration and Necrosis {Curtillet) . . ... 118 
 
 12. Suppurative Periostitis and commencing Necrosis after Epiphysial 
 
 Separation ............ 120 
 
 13. Lower Epiphj^sis of the Femur united with great Displacement upwards; 
 
 the pi'ojecting Diaphysis produced an Aneurj'sni of the Popliteal 
 Artery (after Charles Bell) 122 
 
 14. Deviation of the Hand, the result of Arrest of Growth following Juxtar 
 
 epiphysial Ostitis of the lower end of the Radius ..... 134 
 
 15. Appearance of the Hand after Excision of the Conjugal Cartilage of the 
 
 Ulna {after Oilier) 134 
 
LIST OV ILLUSTEATIONS xxiii 
 
 16. Clavicle at the Nineteenth Year 135 
 
 17. Separation of the cartilaginous outer part of the Scapula 
 
 18. Scapula about the Seventeenth Year, shovi'ing two Centres of Ossification 
 
 for Acromion process {after Rambaud and Renault) 
 
 19. Epiphysis of the Acromion extending to the Spine of the Scapula 
 20 and 21. Symmetrical separate Acromion Process .... 
 
 22. Ossification of Coracoid Process, Sub-coracoid Bone, and Glenoid Cavity 
 
 (Rambaud and Renault) ........ 
 
 23. Scapula seen from above, showing the two Coracoid Epiphyses and the 
 
 more extended form of Acromial Epiphysis between the Eighteenth 
 and Nineteenth Years . . . . . . 
 
 24. Scapula of a subject aged Seventeen {after Ramhawd and Renault) 
 
 25. Humerus at the Third Year (after Rambaud and Renault) 
 
 26. Vertical section of upper and lower ends of Humerus at the Third Year 
 
 (after Rambaud and Renault) ........ 
 
 27. Vertical section of the upper end of Humerus at the Age of Seve3ateen 
 
 showing the Cancellous Structure of the Epiphysis and Diaphysis . 
 
 28. Upper end of Humerus at the Eighteenth Year ..... 
 
 29. Bones forming the Shoulder-joint at the Twentieth Year. Kelationship 
 
 of Epiphysial Junction of upper end of Humerus 
 
 30. Frontal section of the right Shoulder -joint of a Female Infant set. If Years 
 
 {A. V. Brunn) .......... 
 
 31. Upper Epiphysis of the Humerus at the Nineteenth Year 
 
 32. Section of Right Shoulder-joint in a Subject set. Sixteen (Brunn) 
 
 33. Frontal section of the upper end of Humerus at Birth (after Kiistner) 
 
 34. Champion's Specimen of Separation of the Upper Epiphysis of the Hiimerus 
 
 {Malgaigne) ........... 
 
 35. Incomplete Displacement backwards of Humeral Diaphysis . 
 
 36. Specimen of Traumatic Separation of the Upper Epiphysis of the 
 
 Humerus {after ThudicJium) ....... 
 
 37. Sxiecimen of Pm-e Separation of the Upper Epiphysis of the Humerus 
 
 with complete Displacement backwards of the Diaphysis . 
 
 38. Specimen of Separation of the Upper Epiphysis with Fracture of the 
 
 Great Tuberosity {after Gurlt) ....... 
 
 39. Diagram of Separation of the Upper Epiphysis of the Humerus, with very 
 
 little spac3 between the Fragments and no Displacement . 
 
 40. Diagram of Separation of the Upper Epiphysis of the Humerus at the 
 
 Eighteenth Year .......... 
 
 41. Diagram of Separation, with Locking of Lower into Upper Fragment 
 
 42. Incomplete Displacement forwards of Diaphysis of Humerus (after 
 
 Bardenheuer) .......... 
 
 43. Displacement of the Diaphysial End of Humerus seen from the Postero 
 
 lateral Aspect ((i/^er if eZ/e?-^'/;) . ....... 
 
 44. Separation of Upper Epiphysis of the Humerus. Complete Displacement 
 
 inwards of Diaphysis (after Bruns) ...... 
 
 45. Diagram of complete Displacement inwards of Diaphysis beneath Coracoid 
 
 Process ........... 
 
 46. Diagram of situation of Separation and Fracture of the upper end of the 
 
 Humerus in Children ......... 
 
 47. Pattern of Plaster-of- Paris Shoulder Cap for a Child of Eight Years 
 
 48. Method of applying Plaster-of- Paris Si^lint to Trunk and Upper Extremity 
 
 49. Plaster-of- Paris Splint for Shoulder, &c., removed . . . • 
 
 144 
 
 146 
 147 
 153 
 
 156 
 
 156 
 157 
 1G4 
 
 164 
 
 166 
 166 
 
 167 
 
 167 
 168 
 168 
 176 
 
 179 
 179 
 
 180 
 
 181 
 
 184 
 
 189 
 
 leo 
 
 194 
 201 
 201 
 
 207 
 
 208 
 
 217 
 219 
 220 
 £20 
 
xxiv LIST OF ILLUSTKATIONS 
 
 50. Method of applying Bandage after the Diaphysis has been restored to its 
 
 normal position ............ 222 
 
 51. Middeldorpf s Triangle, consisting of a Double IncUned Plane framed out 
 
 of three boards {after EsmarcK) 223 
 
 52. Shoulder without Deformity after Operation for Epiphysial Separation 
 
 (Lejars) 236 
 
 53. The same Patient, the Arms completely elevated (Lejars) .... 286 
 
 54. Specimen of old Fracture of the Humerus throiigh the Line of the Epi- 
 
 physis united by Bone {B. W. Smith) 249 
 
 55. Specimen of Disjunction of the Upper Epiphysis of the Humerus, united 
 
 with locking of the upper end of the Diaphysis in the Epiphysis {after 
 Duplay and Beclus) 252 
 
 56. Section of same Specimen {after Duplay and Beclus) 252 
 
 57. Arrest of Growth of Humerus after Injury to its Upper Epiphysis {after 
 
 HelfericJi) ' . 257 
 
 58. Uninjured right Humerus .... ..... 260 
 
 59. Arrest of Growtli of left Humerus 260 
 
 60. Vertical section of the upper and lower ends of the Humerus in a Child 
 
 aged Two Years and Nine Months 262 
 
 61. Frontal section of lower end of Humerus at the Age of Six and a Half 
 
 Years 263 
 
 62. Lower end of the Humerus, about the Eleventh Year, showing the Carti- 
 
 laginous Epiphysis detached {after Bamiaud and Benault) . . . 263 
 
 63. Sagittal section of the Elbow-joint; Humero-ulnar Articulation in a Youth 
 
 aged Fifteen and a Half Years 267 
 
 64. Frontal section of Bones forming the left Elbow-joint of a Child Fourteen 
 
 Years Nine Months old 268 
 
 65. Diagram of Separation of the lower end of the Humerus before Puberty 270 
 
 66. Specimen of pure Separation of lower end of Humerus before Puberty . 272 
 
 67. Specimen of complete Separation of the lower end of the Humerus at 
 
 about Four Years of Age ......... 272 
 
 68. Specimen of partial Separation, with Fracture of the Diaphysis . . . 274 
 
 69. Specimen of partial Separation of Epiphysis, with Fissure and Transverse 
 
 Fracture of the Shaft {after HelfericJi) 275 
 
 70. Separation of the Olecranon Epiphysis, with Longitudinal Fracture of 
 
 Shaft {after Helferich) . . ' 275 
 
 71. Specimen of Fracture of Diaphysis directly above Epiphysis. Displace- 
 
 me]it of lilpiphysis forwards. Separation of Olecranon Epiphysis . . 281 
 
 72. Antero posterior vertical section of same specimen 282 
 
 73. Frontal vertical section of the Humeral Part of same Specimen . . 282 
 
 74. Chesterman's Steel Calliper Gauge for measuring Height and Width of 
 
 the Epiphyses at the various ages ........ 292 
 
 75. Displacement of Lower Epiphysis of Humerus outwards, with Injury 
 
 to Median Nerve. Amount of Extension at the Elbow-joint Three 
 Months after the Accident 297 
 
 76. Partial Separation, with extensive oblique Fracture of the Diaphj^sis of 
 
 the Humerus ............ 299 
 
 77. Hyper-extension of Elbow after Displacement forwards of Diaphysis of 
 
 Humerus ............ 307 
 
 78. Pattern for Inner Pieces of Lateral Splints with Elbow at right angles. 
 
 For a Boy of Fifteen Years . . ...... 314 
 
 79. Pattern for Outer Pieces of Lateral Splints with Elbow at right angles. 
 
 For a Boy of Fifteen Years ......... 314 
 
 80. Semi-diagrammatic View of Ci'oft's Lateral Splints of Plaster-of-Paris 
 
 applied to Arm and Forearm 315 
 
LIST OF ILLUSTKATIONS xxv 
 
 ^'"' PA(iE 
 
 81. The same with Outer Sphnt laid aside by cutting the MusHn Bandage along 
 
 the whole of gap in front and by cutting gap behind in the Forearm 
 Portion ............. 315 
 
 82. Pattern of Pasteboard Splint for Elbow 316 
 
 83. Winchester's Tin Splint . 317 
 
 84. Author's Anterior Kectangular Splint for the left Elbow , • . . 325 
 
 85. Jones's Posterior Trough Splint of Tin, with interruption for compound 
 
 Injuries at the Elbow-joint 329 
 
 86. Epiphyses about the left Elbow -joint at Fifteen Years of Age. View from 
 
 the inner side ............ 333 
 
 87. Epiphyses about the left Elbow-joint at Fifteen Years of Age. View from 
 
 the outer side 333 
 
 88. Lower Epiphysis (properly so called) of the Humerus at Sixteen and a 
 
 Half Years of Age. Separated by Maceration 334 
 
 89. Coronal section of the lower end of the Humerus at Fourteen and a Half 
 
 Years of Age ............ 337 
 
 90. Diagram of Separation of the Lower Epiphysis of the Humerus at the Age 
 
 of Fifteen and a Half Years 341 
 
 91. Diagrammatic View (from the outer side) of Separation of the Lower Epi- 
 
 physis of the Humerus at the Age of Fifteen and a Half Years. Dis- 
 placement of Diaphysis forwards ........ 343 
 
 92. Epiphysis of the Internal Epicondyle at Seventeen and a Half Years of 
 
 Age " 347 
 
 93. Specimen of Detachment and Displacement downwards of Internal Epi- 
 
 condyle ............. 354 
 
 94. Separation of Internal Epicondyle, with Displacement backwards and 
 
 Pressure upon Ulnar Nerve. Diagram of Area of Loss of Sensation 
 before Operation ........... 356 
 
 95. Specimen of Internal Epicondyle of Humerus removed by Operation . 357 
 
 96. Diagram of relation of Ulnar Nerve to Internal Epicondyle . . , . 366 
 
 97. Diagram of Dislocation of Elbow outwards, with Separation of the Internal 
 
 Epicondyle (HelfericJi) 369 
 
 98. Dislocation outwards of Elbow accompanying Separation of the Internal 
 
 Epicondyle (Hclferich) 370 
 
 93. Flexible Metal Splint for Separated Internal Epicondyle or other Milder 
 
 Cases of Injurj' near the Elbow-joint . . . . * . . 385 
 
 100. Wrenches used at the City Orthopaedic Hospital 385 
 
 101. Method of applying Wrenches for bending Metal Splints of all kinds to 
 
 fit accurately the shape of the Joints in any position .... 385 
 
 102. Epiphyses of Capitellnra, Trochlea, Internal and External Epicondyles, 
 
 at the end of the Fourteenth Year after Maceration ..... 393 
 
 103. Fracture of the External Epicondyle and a small part of Capitellum 
 
 {after Sir Astley Cooper) 396 
 
 104. Internal Eectangular Splint of Wood hollowed for Right Elbow . . . 404 
 
 105. Specimen of Fracture of the Internal Condyle and Trochlea ; Displace- 
 
 ment upwards of Fragment {after Ourlt) ...... 406 
 
 100. Cubitus Varus following Separation of the Trochlear Epiphysis of the 
 
 Humerus {Avhhy and Wright) ......... 413 
 
 107. Author's Posterior Rectangular and Hollowed Splint for Left Elbow . 414 
 
 108. Author's Anterior Rectangular Splint for Left Elbow 416 
 
 109. Author's Lateral External Tin Splint for Right Elbow . . . .417 
 
 110. Sagittal section through the outer portion of the Elbow-joint, showing 
 
 the relation of the Synovial Membrane to the Epiphysial Lines of the 
 Bones (Radio-Humeral Articulation), in a Youth aged Fifteen and a 
 Half Years 421 
 
xxvi LIST OF ILLUSTEATIONS 
 
 FEG. VAnv, 
 
 111. Detacliment of the Capitellar and External Epicondylar Epiphyses pro- 
 
 duced by Maceration at the Fifteenth Year ...... 421 
 
 112. Vertical Antero-posterior section of the flexed Huniero-radial Articula- 
 
 tion at the Age of Thirteen Year a {after Farabeuf) ... . . 422 
 
 113. Specimen of Separation of Epiphyses of Capitellum and External Epi- 
 
 cond^'le 424 
 
 114. Specimen of lower end of Eight Htimerus ; m:iinjured .... 427 
 
 115. Specimen of Displacement of the Capitellar and External Epicondylar 
 
 Epiphysis of Left Humerus, with Fracture of small part of Diaphysis. 
 United. From a Lad aged Eighteen Years ...... 427 
 
 116. Cubitus Valgus, with ununited Condylo-capitellar Fracture . . . 428 
 
 117. Semi-diagrammatic view of Specimen of partial Dislocation inwards of 
 
 Eadius and Ulna, with Separation and outward Rotation of Capitellar 
 Portion of Epiphysis .......... 430 
 
 118. 119, 120, 121. Diagrams of the more common forms of Fracture on the 
 
 outer side of the lower end of the Humerus ...... 433 
 
 122. Fracture of the outer Condyloid (Capitellar) portion of the Humerus. 
 
 J] nniiited {after Sir Astley Cooper) . , . . . . . 436 
 
 123. Diagram of Natural Carrying Angle of Elbow. 170° outwards . . . 488 
 
 124. Diagram of Cubitus Valgus following Fracture into Elbow -joint. Excess 
 
 of Carrying Angle 438 
 
 125. Diagram of Cubitus Varus. An angle of 170° inwards . . . . 439 
 
 126. Diagram showing the natural Deviation of the Left Forearm outwards 
 
 and the relation of Axis of Elbow -joint to Axis of Humerus . • . 440 
 
 127. Pattern for posterior pieces of Antero-posterior Splints ^Croft's) with 
 
 Elbow at a right angle. For a Boy of Fifteen Years . . . . 442 
 
 128. Pattern for anterior pieces of Antero-posterior Splints .... 442 
 
 129. Croft's Antero-posterior Splints of Plaster-of-Paris applied to Left 
 
 Forearna ............. 443 
 
 130. The same, with the anterior piece laid to the outer side after cutting 
 
 through the Muslin along the whole of the Gap on the inner side and 
 through part of the Gap on the outer side ...... 444 
 
 131. Sagittal section of upper end of Ulna at the Age of Seven Years . . . 457 
 
 132. Upper end of Ulna at about the Twelfth Year {after Eambaud and 
 
 Henault) 458 
 
 133. Ossification of Olecranon Epiphysis almost complete, at the Fourteenth 
 
 Year 458 
 
 134. Specimen of Complete Separation of the whole Cartilaginous upper end 
 
 of the Ulna in a Child aged Three Years . . . . . . 459 
 
 135. Straight Anterior Splint (Gooch's Splinting) from Shoulder to Wrist for 
 
 Separation of the Olecranon {after Silence) . . . . . . 466 
 
 136. Upper end of Eadius at the Sixth Year — mostly Cartilaginous . . 470 
 
 137. Upper end of Radius at the Sixteenth Year {after Rambaud and 
 
 Renault) " 471 
 
 138. Section of lower end of Radius and Ulna at the Eighteenth Year, 
 
 showing Cancellous Structure of the Bones ...... 479 
 
 139. Frontal section through the Bones of the Wrist and Hand in a Youth 
 
 aged Eighteen Years . . . . . . . . . . • 481 
 
 140. Specimen of Pure Separation of Lower Epiphysis of Radius with slight 
 
 Displacement backwards {Anger) 489 
 
 141. Specimen showing Lower Epiphysis of Radius from outer side displaced 
 
 backwards with Periosteum ......... 493 
 
 142. Dissection of Traumatic Separation of the Lower Epiphysis of the 
 
 Radius, and Dislocation of the Ulna. Anterior view .... 495 
 
 143. The same. Lateral view {Be Paoli) 495 
 
LIST OF ILLUSTKATIONS xxvii 
 
 vxci, pagf; 
 
 144. Recent Traumatic Separation of the Lower Epiphysis of the Radius, and 
 
 Separation with Fracture of the Lower Epiphysis of the Ulna 
 [after De Paoli) . , . . . . . . . . .497 
 
 145. Author's Dissection of Specimen of Separation of Lower Radial Epi- 
 
 physis in Guy's Hospital Museum. From a Lad aged Twelve Years . 502 
 
 146. Compound Separation of Lower Epiphysis of Radius, with Fracture of 
 
 Styloid Process of Ulna . ......... 508 
 
 147. Specimen of Compound Separation of the Lower Epiphyses of Radius 
 
 and Ulna 505 
 
 148. Separation of Lower Epiphysis of Radius, with Fracture of Ulna. Before 
 
 dissection {after B. W. Smith) . . . . • . . .510 
 
 149. Specimen from same case {after B. W. Smith) . . . . . . 510 
 
 150. The same. Outer side {after B. W. Smith) 510 
 
 151. Compound Separation of the Lower Epiphysis of the Radius, with Frac- 
 
 ture of the Ulna. . Palmar aspect {after B. W. Smith) . . . . 511 
 
 152. The same. Dorsal aspect {after B. W. Smith) 511 
 
 153. Probable Epiphysial Fracture with moderate Displacement forwards 
 
 {after Boberts) ............ 523 
 
 154. Separation of Lower Epiphysis of Right Radius with Displacement back- 
 
 wards halfway off the Diaphysis and Fracture of Styloid Process of 
 Ulna 533 
 
 155. The same Case seen from its Postero-internal Aspect . .... 533 
 
 156. Separation of the Lower Epiphysis of the Left Radius without Displace- 
 
 ment ............. 534 
 
 157. Complete Dorsal Displacement of Carpal Epiphysis of Radius 
 
 {Hutchinson) ............ 542 
 
 158. James Hossack's Case of backward Dislocation of the Carpus . . 545 
 
 159. Fracture of the lower end of the Radius in the vicinity of the Conjugal 
 
 Cartilage {after De Paoli) 548 
 
 160. Traumatic Separation of the Lower Epiphysis of the Radius united in 
 
 bad position. Sagittal section {after De Paoli) . . . . . 557 
 
 161. The same viewed laterally .......... 557 
 
 162. Deformity following Separation of Lower Ra lial Epiphysis . . . 558 
 
 163. The same Case, showing nearly complete Absence of Deformity, Two 
 
 Years after the Accident .......... 559 
 
 164. Specimen of Arrest of Growth of Radius ....... 566 
 
 165. Deformity of Hand and Forearm from Arrest of Growth of Radius due to 
 
 Epiphysial Injury ........... 569 
 
 166. Method of applying Anterior Wooden Splint to Forearm and Hand . 573 
 
 167. Pattern for Anterior and Posterior Pieces of Antero-posterior Splints 
 
 (Croft's), for the Hand and Wrist and Forearm of a Boy of Fifteen 
 Years 574 
 
 168. Croft's Antero-posterior Splints of Plaster-of-Paris applied to the Right 
 
 Forearm and Hand .......... 575 
 
 169. The same, with Dorsal Portion laid aside after cutting through the Muslin 
 
 along Gap on outer side .......... 575 
 
 170. Stout Knife employed by Author for removing soiled portions of the 
 
 Diaphysis in Compound Epiphysial Separations ..... 577 
 
 171. Specimen of Separation of Lower Epiphysis of Ulna, and Fracture of 
 
 Radius ............. 581 
 
 172. Varus position of Hand and Elbow, the result of Arrest of Growth of Ulna 
 
 following Injury {Nicoladoni) ........ 586 
 
 173. Epiphyses of the Metacarpus and Phalanges at the Age of Fifteen and a 
 
 Half Years 589 
 
 174. Epiphyses of the Phalanges and Metacarpal Bone at Sixteenth Year 
 
 {after Bamhand and Benaidt) ........ 591 
 
xxviii LIST OF ILLUSTBATIONS 
 
 175. Frontal section of the Little Finger of the Left Hand of a Boy aged Eight 
 
 Years, showing relation of Synovial Membranes to the Epiphysial 
 Lines {v. Brunn) . , , , . , , , ... 592 
 
 176. Separation of the Head of the Metacarpal Bone of the Index Finger, 
 
 with Displacement forwards ....,,,,. 594 
 
 177. Dislocation at Metacarpo-phalangeal Joint of Lidex Finger with slight 
 
 Fracture of the Head of Metacarpal Bone 596 
 
 178. The same. Lateral view . . . 596 
 
 179. Epiphyses of the Phalanges of the Digits at the Sixteenth Year {after 
 
 Bamhaud and Benault) . . 599 
 
 180. Sagittal section through Middle Finger— Ulnar Surface of Section, 
 
 shoAving relation of Synovial Membranes to the various Epiphyses 
 [after Brunn) ' . 600 
 
 181. Tin Finger Splint for injury to the Phalanges 602 
 
 182. Os Lniominatum at the Twelfth Year [Bamhaud and Beyiault) . . 604 
 
 183. Specimen of Separation of the Os Innominatum into its origmal parts . 605 
 
 184. Os Innominatiun at the end of the Eighteenth Year .... 610 
 
 ] 85. Upper and lower ends of the Femur a few Weeks before Birth. Anterior 
 
 view [after Bamhaud and Benault) 615 
 
 186. The same. Posterior view 615 
 
 187. Coronal section through upper end of Femur before Birth, carried 
 
 through the Lig. Teres and Trochanter Major [Kilstner) . . . . 015 
 
 188. Femrn: at the end of the Second Year [after Bamhaud and Benault) . 616 
 
 ] 89. .interior view of upper end of Femur, showing the Epiphyses of Head 
 
 and Great Trochanter at Seventeen and a Half Years . " . . . 617 
 
 190. Posterior view of the upper end of Femur, showing the Epiphyses of the 
 
 Head, Great and Lesser Trochanters, between the Seventeenth and 
 Eighteenth Years 617 
 
 191. Frontal section of Left Hip-joint of a Lad aged Seventeen and a Half 
 
 Years, showing relation of Synovial Membrane to Epiphysial Lines . 019 
 
 192. Specimen of Traumatic Separation of Epiphysial Head of Femur [after 
 
 Bousseau) . . . . . . " , . . , . . 02G 
 
 193. Specimen of piure Separation of Head of Femur 628 
 
 194. Traumatic Separation of the Epiphysial Head of the Femur. Appear- 
 
 ance of the Limb Two Years after the Accident 629 
 
 195. Specimen of portion of Head and Neck of Femur excised for Displace 
 
 meat forwards of the latter following Epiphj'sial Separation. Posterior 
 view of Divided Surfaces 630 
 
 196. Fracture of Neck of Femiir close to Epiphysial Junction of Head . . 645 
 
 197. Diagrams of Injuries to the Neck of Femur (i?02/aZ Tl/7i i^»za.n) . . . 647 
 
 198. Thomas's Hip Splint, with broad Pelvic Band 657 
 
 199. Pattern of Plaster-of-Paris Splint for Hip, encircling Pelvis and Lower 
 
 Extremity. For a Child of Eight Years 658 
 
 200. Plaster-of-Paris Splint applied to Eight Hip, Pelvis, and Lower Ex- 
 
 tremity ........ 659 
 
 201. Plaster-of-Paris Hip Splint removed . 659 
 
 202. Anterior view of Epiphyses at upper end of Femur at about the Fifteenth 
 
 Year 662 
 
 203. Vertical section of upper end of Femur at Sixteen and a Half Years. 
 
 Posterior half of section, showing Cancellous Structure of the Epiphyses 662 
 
 204. Specimen of pure Separation of Great Trochanter 667 
 
 205. Separation of the Epiphysis of the Great Trochanter [T. Bryant) . . 669 
 
 206. Long External Splint with Interruption at Hip permitting Abduction of 
 
 Lower Extremitv 673 
 
LIST OF ILLUSTKATIONS xxix 
 
 207. Posterior view of Epiphyses at upper end of Femur at about the Fifteenth 
 
 Year 675 
 
 208. Specimen of Separation of the Lesser Trochanter, Posterior view . . 676 
 2C9. Tlie same. External view 676 
 
 210. Posterior aspect of Femur of Adult Male, showing Third Trochanter 
 
 {after Houze) ............ 677 
 
 211. Epiphyses at the Knee-joint at the Nineteenth Year. Outer side . . 680 
 
 212. Frontal section of Bones forming the Knee-joint between the Seventeenth 
 
 and Eighteenth Years of Life, showing Cancellous Structure of the 
 Epiphyses 681 
 
 213. Sagittal section of Bones forming the Knee-joint and showing 
 
 Cancellous Structure of Epiphj'ses ........ 681 
 
 214. Median sagittal section of the lower end of the Femur, from a Girl ao-ed 
 
 Fourteen Years, showing lelations of Synovia] Membrane . . . 682 
 
 215. Sagittal section of the Left Knee-joint through the Outer Condyle of the 
 
 Femur in the flexed position, showing relations of Synovial Membrane. 
 Outer surface of section. From a Girl aged Fourteen Years . . 683 
 
 216. Sagittal section through Internal Condyle of Femur and Inner Tuberosity 
 
 of Tibia in the same case to show relations of Synovial Membrane . . 683 
 
 217. Specimen of pure Separation of Lower Femoral Epiphysis . . . 693 
 
 218. Specimen of Separation of Lower Epiphysis of Femur with slight Dis- 
 
 placement ............. 702 
 
 219. Specimen of Separation of Lower Epiphysis of Femur with Fracture of 
 
 the Diaphysis ........... 703 
 
 220. Specimen of Separation of Lower Epiphysis of Femur with extensive 
 
 Fracture of the Diaphysis .......... 704 
 
 221. Specimen of partial Separation of Lower Femoral Epiphysis, with in- 
 
 complete Fracture of Diaphysis {after Bruns) ..... 705 
 
 222. Professor J. L. Little's Case of Compound Separation of Lower Epi- 
 
 physis of Femur with Displacement inwards of the Epiphysis . . . 706 
 228. The same after Amputation, showing slight Fracture of the Diaphysis . 706 
 
 224. Specimen of Separation of Lower Epiphysis of Femur with Intercon- 
 
 dyloid Fracture . . . . . . . . , . .712 
 
 225. Specimen of Incomplete Displacement of Lower Epiphysis of Femur 
 
 forwards off the Diaphysis .......... 715 
 
 226. Specimen of Separation and Displacement forwards of the Lower Epi- 
 
 physis of the Femur united and followed by Suppuration . . . 744 
 
 227. Arrett of Growth of the Femur and Tibia with Contraction of Knee 
 
 following Injury to the Lower Epiphysis of the Femur and Upper 
 Epiphysis of the Tibia Nine Years previously {after Nicoladoni) . . 756 
 
 228. Attitude of Patient from Arrest of Growth of Lower Extremity foUowin"' 
 
 Injury to Lower Epiphysis of Femur ....... 757 
 
 229. The same Patient with Limb elevated Four Inches 758 
 
 230. The same Patient, showing Position of Limb when the Inner Tuberosity 
 
 of Tibia was placed in contact with the Internal Condyle of Femur . 759 
 
 231. Diagram of Normal Epiphyses of the Knee-joint at the Nineteenth Year, 
 
 showing commencing Displacement forwards of the lower Femoral 
 Epiph;ysis 761 
 
 232. Diagram of Complete Displacement of the lower Femoral Epiphysis 
 
 forwards and Rotation on its Transverse Axis ..... 764 
 
 233. Displacement of lower Femoral Epiphysis forwards {Ashbi/ and Wright) 764 
 
 234. Diagram to show incomplete Displacement of Lower Epijihysis of 
 
 Femur backwards ........... 765 
 
 235. Diagram of Displaceniont of Lower Epiphysis oi Femur and Leg 
 
 directly outwards before Abduction takes place , . , , , 769 
 
XXX LIST OF ILLUSTKATIONS 
 
 Vm. PAGE 
 
 236. Diagram showing Displacement directly inwards at the Age of Seventeen 
 
 and a Half Years . . . . . . . . . . . 773 
 
 237. Lower Extremities, showing Displacement inwards and Rotation of 
 
 Lower Epiphysis of right Femur (T. Bryant) . . . . . . 774 
 
 238. Lower Extremities, showing Displacement forwards and inwards of Lower 
 
 Epiphysis of left Femur ......... 776 
 
 239. Doiible-inclined Plane with Extension on Leg for separation of lower 
 
 Epiphysis of Femur ........... 784 
 
 240. Diagram of complete Displacement forwards of Epiphysis and Pressure 
 
 upon Popliteal Vessels .......... 791 
 
 241. Diagram of the same after Reduction . . . . . ... 791 
 
 242. Upper Epiphysis of the Tibia at the Sixteenth Year . , . . 7t8 
 
 243. Antero-lateral view of the fully foi'med Epiphyses of the Tibia and Fibula 
 
 at the Nineteenth Year .......... 799 
 
 244. Epiphyses of the Knee-joint at the Nineteenth Year. Inner side . . 799 
 
 245. Diagram of frontal section of Knee-joint, showing relation of Synovial 
 
 Membrane to the Epiphysial Lines at the Eighteenth Year. Posterior 
 half of section ............ 801 
 
 246. Median Sagittal section of Tibia in a Boy aged Thirteen and a Half 
 
 Years, showing relations of Synovial Membrane ..... 801 
 
 247. Frank Marsh's Specimen of pure Separation and Displacement forwards 
 
 of Upper Epiphysis of Tibia . . . . • . . . . 806 
 
 248. Specimen of Lateral Displacement of Upper Epiphysis of Tibia. Posterior 
 
 view {after Aslihurst) .......... 807 
 
 249. The same Specimen. Anterior view {after Ashliurst) 807 
 
 250. Specimen of Separation of the Upper Epiphysis of the Tibia, with 
 
 Fractiu-es of the Diaphysis ......... 807 
 
 251. Specimen of Displacement forwards of Upper Epiphysis of Tibia. 
 
 United at the Eleventh Week {after Fischer and Hirschfeld) . . . 809 
 
 252. Arrest of Growth of Tibia Two Years after Injury to Upper Epiphysis 
 
 {Bryant) 811 
 
 253. Pattern of Lateral Splints for Knee (Croft's). For a Boy of Fifteen 
 
 Years 814 
 
 254. Croft's Lateral Splints applied to Knee 814 
 
 255. The same with Outer Piece laid aside after cutting through Gap in front 814 
 
 256. Posterior and Lateral Splint for Thigh and Leg with Foot-piece and 
 
 Hinge at Knee 815 
 
 257. Vertical section of the upper end -of the Tibia between the Fourteenth 
 
 and Fifteenth Years {after Ramhaud and Renault) .... 816 
 
 258. Frontal section through the lower end of Tibia and Fibula before Birth 
 
 {after Kiistner) 824 
 
 259. Lower Epiphysis of the Tibia at the Sixteenth Year .... 824 
 
 260. Frontal section through the Bones of the Ankle-joint at Seventeen and 
 
 a Half Years, showing the Cancellous Structure of the Epiphyses . . 825 
 
 261. Sagittal section through Bones of the Ankle-joint at Sixteen Y^ears . . 825 
 
 262. Juxta-epiphysial Lesions produced by forcible Adduction of the Foot. 
 
 From a shghtly Rachitic Subject Eight Months old {after Oilier) . . 829 
 
 263. Lesions of the Tibia produced by forcible Abduction of the Foot. Oblique 
 
 section. From an Infant Two Years old {after Oilier) . . . 829 
 
 264. Experimental Specimen of Fracture above Lower Epiphysis of Femur . 830 
 
 265. Experimental Specimen of partial Separation and Fracture of lower 
 
 Epiphysis of Tibia Sc^O 
 
 266. Specimen of partial Separation of Lower Epiphysis of Tibia and Fracture 
 
 of Diaphysis {after Bruns) 831 
 
 267. Partial Separation of the Lower Epiphysis of the Tibia with Fracture of 
 
 the Diaphysis. Separation of the Lower Epiphysis of the Fibula (after 
 Anger) ^^2 
 
LIST OF ILLUSTKATIONS xxxi 
 
 FIG. PA(JF 
 
 268. Arrest of Growth of Tibia and Deformity of Foot and Leg Five Years 
 
 after Injury to the Lower Tib.al Epiphysis ...... 848 
 
 269. Pattern of Lateral Splints (Croft's) for Leg and Ankle with Foot at a 
 
 right angle. For a Boy of Fifteen Years ....... 851 
 
 270. Croft's Lateral Splint applied to Leg and Foot 852 
 
 271. The same with outer piece laid aside by cutting through the Gap along 
 
 the Foot and Front of Leg ......... 852 
 
 272. Posterior and Lateral Leg Splints with Rectangular Foot-pieces as used 
 
 at Guy's Hospital ........... 853 
 
 273. The same applied to Leg .......... 853 
 
 274. Plaster- of- Paris Splint with Interruption at Ankle for Compound Separa- 
 
 tions 854 
 
 275. Steel Leg-iron with Foot and T-strap for spurious Talipes Varus, the 
 
 result of Arrest of Growth of the Tibia, after Epiphysial Separation . 855 
 
 276. Posterior aspect of the fully formed Epiphyses of the Tibia and Fibula, 
 
 showing the Fibular Facet on the outer Tibial Tuberosity . . . 857 
 
 277. Epiphysis of the Head of Fibula at the Nineteenth Year, showing the 
 
 Facet for the outer Tuberosity of the Tibia . . . . . . 857 
 
 278. Section through Superior Tibio-fibular Articulation, showing relation of its 
 
 Synovial Cavity to the Conjugal Cartilages of the Tibia and Fibula and 
 the small amount of Tissue intervening between it and the Articulation 
 of the Knee. From a Boy aged Thirteen and a Half Years . . . 858 
 
 279. Normal relation of the Epiphysial Lines of the Tibia and Fibula to the 
 
 Ankle-joint. From a Subject aged Eighteen Years 860 
 
 280. Frontal section through Bones forming the Ankle-joint at the Age of 
 
 Seventeen and a Half Years, showing the Cancellous Structure of the 
 Epiphyses .861 
 
 281. Author's Specimen of Traumatic Separation of the Lower Epiphysis of 
 
 the Left Fibula with Displacement of the Foot inwards . . . . 863 
 
 282. Dupuytren's Splint for Fracture of the External Malleolus . . . 865 
 
 283. Eight Foot seen from the outer side, showing Epiphyses of Os Calcis, 
 
 Metatarsus, and Phalanges at the Age of Fifteen and a Half Years . . 867 
 
 284. Under surface of Astragalus, showing occasional Epiphysis or Os 
 
 Trigonum 868 
 
 285. Median Sagittal section through Great Toe and inner row of Tarsal Bones 
 
 in a Boy aged Fourteen Years, showing relations of Synovial Mem- 
 branes to Epi]3hysial Junctions ......... 869 
 
 286. Lumbar Vertebra about the Nineteenth Year. Vertical section {Bavibaud 
 
 and Renault) ............ 874 
 
 287. Anterior view of Lumbar Vertebra {Bambaud and Renault) . . . 874 
 
 288. A Cervical Vertebra {after Bambaud and Benault) ..... 876 
 
 289. Atlas at the end of the First Year of Life, the Centres of Ossification 
 
 already greatly developed {after Bambaud and Benault) . . . 877 
 
 290. Axis towards the Middle of the Second Year. Vertical section through 
 
 Odontoid Process, exposing Five Cartilaginous Lines {Bambaud and 
 Benault) 878 
 
 291. Anterior surface of the Sacrum at the Twenty-third Year {Bambaud and 
 
 Benault) 879 
 
 292. Last Two Cervical and First Dorsal Vertebrte, with the first Ribs show- 
 
 ing their Epiphyses, between the Eighteenth and Nineteenth Years 
 {Bambaud aiid Benault) . . . . . . . . . 880 
 
PAET I 
 
 TBAUMATIC 8EPABATI0N OF THE EPIPHYSES 
 IN GENERAL 
 
 CHAPTER I 
 HISTORICAL 
 
 An often quoted fable attributes to the Amazons the custom of 
 separating the epiphyses of their male children, with the design of 
 assuring to the female the supremacy of strength and beauty. 
 
 Among ancient writers Hippocrates has often been referred to as 
 the first to make any allusion to separation of the epiphyses. An 
 equivocal quotation from a passage where he treats of dislocations of 
 the wrist has led to some discussion on the subject : sart 8' ots kuI 
 Tf s7ri(f}v<TLs sKivrjOr}. ' Quandoque autem et epiphysis emota est ' {Hipp, 
 de articuUs, 27, Littre's ed. vol. iv. p. 138). It would be useless to 
 attempt any precise explanation of the phrase, for Hippocrates 
 appears to have used the term epiphysis in a very indefinite manner. 
 With the same uncertainty he alludes to abruption of the epiphysis 
 or trochlea of the humerus as being a much milder form of accident 
 than other injuries at the elbow joint. 
 
 Many centuries appear to have elapsed without any mention of 
 this kind of injury. 
 
 Bealdus Colombus {De re anatomica, Venetiis 1559, lib. i. p. 6), 
 in the sixteenth century, clearly pointed out the possibility of the 
 occurrence of epiphysial separation, alluding to it in the following 
 passage : ' Quam luxationem nunquam, aut summa quidem certe 
 cum difficultate, curari posse crediderim propter sinuum tuberculorum 
 multitudinem, quibus utraque pars tam appendicis quam ossis cui 
 adnascitur abundat & eorundem mutuum ingressum postulat.' He 
 was the first to point out the existence of separation of the epiphyses 
 in newly born infants. 
 
 Morgagni quotes {De sedihus et causis inorhorum,~EA^Am. a) another 
 passage from Colombus in the following words : ' Si les os tendres 
 des enfants sont manies trop fortement par les mains d'un medecin 
 inhabile, les ligaments s'etendent jusqu'a entrainer les appendices 
 (ei^iphyses) avec eux.' 
 
 /^ B 
 
2 TKAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 Eognetta (Joe. cit. infra) and others have on insufficient grounds 
 considered a case to be one of separation of the great trochanter 
 which Ingrassias describes in his commentaries on the works of 
 Galen (ch. xx.), but it does not appear that Ingrassias was cognisant 
 of epiphysial injuries (J. P. Ingrassias, In Galeni lihrinn de ossib^ls 
 doctissima et expectatissima commentaria, Panormi 1603), It was 
 the case of a young man who, whilst fencing with a halberd, had 
 torn off the trochanteric process by a violent movement. 
 
 Coming to 1614 we find Ambrose Pare noticing, in two places at 
 least in his works, the probable occurrence of epiphysial separation. 
 In one of them he expresses himself thus : ' Nous avons vu une autre 
 sorte de luxation qui se fait, principalement en os des jeunes, par une 
 separation des epiphyses, comme la tete de I'os adjutoire (humerus) 
 et femoris, et autres iointures, et cela se cognoist en ce qu'on voit 
 separation des os avec crepitation et impotece de la partie.' Again, 
 with reference to dislocations, the following quotation is from Thomas 
 Johnson's translation of the Chirurgical works of Ambrose Parey 
 (London, 1634, p. 596) : * Also that dislocation is uncurable, when- 
 as the ligaments, steeped and swollen up with an excrementitious 
 humiditie, are so much shortened and contracted in their length, as 
 they have acquired in their breadth ; and thus they draw away and 
 plucke off the appendices of the bones from whence they arise, and 
 by reason the bone and the appendix doe enter arid receive each 
 other by manie cavities and prominences, therefore they cannot, by 
 how skilfull hand soever they may be handled, be again fitly placed 
 and put together.' Pare quotes Hippocrates as calling the upper 
 appendix (epiphysis) of the tibia the diaphysis. He has only recorded 
 one case of detachment of an epiphysis, that of the pelvic end of the 
 femur, which at first had been mistaken for a dislocation of this bone. 
 
 Poupart and others about this time observed cases following 
 small-pox and scurvy, and denied that separation could take place 
 without some pathological condition. 
 
 Euysch is said to have made some experiments on new-born 
 children. 
 
 In 1632 a Neapolitan surgeon, Marcus Aurelius Severinus, drew 
 attention {De ahscessuum recondita naturalih., degihhis, valg. etvar., 
 Lugd. Bat. 1724, cap. vii. p. 428) to separation of the upper and 
 lower epiphyses of the tibia as w^ell as to the deformities of the 
 knee and foot which result from such separation. 
 
 Towards the middle of the same century, Ej^sson specially studied 
 diseases of the bones in children, and particularly treated of separa- 
 tion of the epiphyses (H. Eyssonius, De ossihus infantis, 1625 ; also 
 V. Goiter, 1659). Eognetta states that the work of Eyssonius 
 {Tractatus anatomicus et medicus de ossihus infantis cognoscendis, 
 conservandis et curandis, Groningse, 1659, vol. i.) was in 1834 
 exceedingly scarce in Paris. 
 
 Fabrice de Hilden about the middle of the seventeenth century 
 
HISTOEICAL 3 
 
 (Fabricius Hildanus, Francofurti, 1646), and Jean B. Verduc towards 
 the end of the same century, 1696 {Bandages et fractures, 1696), 
 also vaguely alluded to the separation of the upper epiphysis of the 
 femur. 
 
 It was not, however, until the beginning of the eighteenth 
 century that any real work on this subject appeared. 
 
 Both J. L. Petit {Maladies des os, Paris, 1705 ; also Description 
 exacte des os, Ley den, 1709) and G. J. Duverney {Maladies des os, 
 Paris, torn. i. 1751 ; also trans, by Sam. Ingham, Lond. 1762) allude 
 to this injury in connection with fractures of the neck of the femur. 
 While the former associated it with fractures themselves, the latter 
 did not believe in its existence without some morbid condition of the 
 bone (scurvy, &c.). 
 
 J. M. Schwartz mentioned the subject in his thesis {Disputatio 
 de ossium epiphysibus, Lipsise, 1736). 
 
 Although, as we have seen, separations of the epiphyses were 
 admitted as possible by so many writers from the earliest times, but 
 little practical interest or importance can be attached to the published 
 records before Eeichel's special treatise in 1759, one hundred and 
 thirty-seven years ago (M. Geo. Christian Keichel, Dissertatio de 
 epiphysium ah ossium diaphysi diductione, Thesis, Lipsise, April 27, 
 1759 ; Edwardus Sandifort, Thesau7'us Dissertatio7ium. vol. i. 
 Koterdami, 1768-78). He was the first author who had made a 
 special study of these lesions and insisted upon their reality. The 
 pathological specimens, however, brought forward by him appear 
 to have been fractures which occurred in persons of very advanced 
 years, for the three figures given by him as united epiphysial 
 lesions are probably united fractures — two specimens of separation or 
 fracture of the neck of the humerus, and one a spontaneous separation 
 of the lower epiphysis of the femur. He was, nevertheless, the first 
 to correctly distinguish traumatic separations from those due to 
 disease (or spontaneous). From an examination of Eeichel's plates, 
 Delpech {Chirurgie clinique, 1823, tom. i. p. 246) doubted the real 
 occurrence of epiphysial separation in these instances. 
 
 Keichel also described a case of separation of the upper 
 epiphysis of the femur. 
 
 We then come down to Ambrosio Bertrandi of Turin, who, in an 
 article in 1787, ' Delia Separazione delle Epifisi delle ossa ' {Opere 
 anatomiche et cerusiche : Malattie delle ossa, Turin, 1787, tom. v, 
 cap. XV. p. 156), noted one or two cases which he had established by 
 dissection in infants ; but the data he gives are not very accurate, and 
 cannot be relied upon as at all certain. He endeavoured to draw 
 up a general description of these lesions, and was the first to direct 
 attention to disjunction of the humeral epiphysis during delivery. 
 He mentions instances at the upper extremities of the humerus 
 and tibia, and at the lower extremity of the femur and ulna. 
 
 Bognetta and others also allude to another Italian surgeon, 
 
 B 2 
 
4 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 Monteggiaof Milan (Monteggia, Instit. de cliirurgie,iovii. iv., Milano, 
 1814), as having given some attention to this subject. Monteggia 
 refers to cases at the upper extremity of the tibia and the lower 
 extremity of the humerus. 
 
 J. B. Palletta, also an Italian surgeon {Exercitationes ana- 
 tomicce, Mediolani, 1820), likewise added a few new cases in support 
 of the occurrence of this lesion. 
 
 Portal (in his Anatomie medicale, Paris, 1803, tom. i. p. 31) says 
 the epiphyses are sometimes detached from the body of the bones, 
 especially in children. He believed that the upper extremity of the 
 . radius and the neck of the femur were the most frequent subjects 
 of these disunions ; and that, as they were often mistaken for dis- 
 locations of these bones, errors in their treatment look place. 
 De la Motte also mentions some cases of the same injury. 
 Petit-Eadel {Cliir. encycloped. art. ' Epiphyses,' tom. i. p. 433), like 
 Bertrandi, added but little to the knowledge of the subject ; while 
 his article in ' L'Encyclopedie Methodique ' is merely a translation 
 of Bertrandi's work. 
 
 In 1816 M. J. Delpech, with much reason, seeing the un- 
 certainty felt in the minds of surgeons by these first attempts at 
 descriptions of these injuries, doubted the existence of the occur- 
 rence of detachment of the epiphyses. But some years later, in 
 1823 {Chiriirgie clinique de Montpellier, tom. i. 1823), he was con- 
 vinced of their occurrence after seeing the pathological specimens of 
 separation of the lower epiphyses of the femur and of the radius 
 described and recorded by M. Eoux. In this volume Delpech describes 
 the specimen of separation of the lower epiphysis of the femur pub- 
 lished by M. Coural, and at that time in his possession (the first of 
 Eoux's specimens). 
 
 Boyer, about the year 1815, and likewise Dupuytren, dismissed 
 the subject in a few words. The former only mentions {Chir. tom. iii. 
 4™® edit. p. 211) the possibility of these lesions at the upper end of 
 the femur and humerus, and asserts that they usually take the place 
 of fractures. 
 
 In 1817 Champion (Bull, de la Fac. et de la Soc. de Med., Paris 
 1817) made careful observation of several cases, which he proved 
 anatomically by examination after death (see also Champion, ' De- 
 collement des epiphyses des os longs,' Journal complem. dii diet. 
 d. so. niSd., Paris, 1818). 
 
 Laurent, in his article ' Observations pour servir a I'histoire du 
 Decollement des epiphyses des os longs ' {Journal complem. du 
 diet. d. sc. med. Paris, 1818, tom. i. pp. 317-26), was unable to throw 
 any fresh light upon the subject. 
 
 In England James Wilson (Lectures on Diseases of the Bones and 
 Joints, London, 1820) added a few facts with regard to the 
 mechanical production of these injuries ; but he gives no descrip- 
 tion, and indeed makes no mention, of epiphysial separation as 
 
HISTOKICAL 5 
 
 met with in the hving subject. We shall allude to this again 
 later on. 
 
 Epiphysial separations were described nearly at the same time 
 by MM. Eoux and Gueretin. 
 
 M. Eoux de Brignolle wrote his thesis at Montpellier entitled 
 Dissertation sur la disjonction des epiphyses, February 8, 1822. 
 It contained a description of two specimens obtained by ampu- 
 tation : (1) Coural's case of separation of the lower epiphysis of the 
 femur, which had occurred in 1816 ; and (2) a very remarkable case 
 of disjunction of the lower epiphysis of the radius, the styloid 
 epiphysis of the ulna, and the upper epiphysis of the first phalanges 
 of the thumb, index, and middle fingers. This occurred in 182] . 
 Both these cases are fully described in their proper chapters. 
 
 Boux says that his thesis was written to prove to some sceptical 
 minds the possibility of such a lesion of the osseous system after 
 the first few years of life. He insisted upon, ' first, the danger of 
 ignoring epiphysial separation when its reduction ought to be 
 possible ; secondly, the progress of the phenomena which result 
 from such an error of judgment ; thirdly, the possibility of separa- 
 tion of the epiphyses occurring up to the eighteenth year ; fourthly, 
 the possibility of such separation taking place on the largest 
 cylindrical bones, as well as on the medium-sized and smallest.' 
 
 Writing in 1825 {loc. cit. infra), Jarjavay says: 'Aussi en 
 clinique, il est bien difficile, sinon impossible dans certains cas, de 
 determiner si la lesion est un decoUement plutot qu'une fracture. 
 II ne faut pas perdre de vue, si Ton cherche a arriver a ce 
 diagnostic, ce fait anatomique, a savoir, que les epiphyses ne com- 
 prennent generalement que les deux tiers seulement des extremites 
 des OS longs, et que la diaphyse fournit I'autre tiers.' 
 
 Goyrand in 1836 published his first observations on separation of 
 the lower epiphysis of the radius. 
 
 Gueretin' s valuable work, ' Recherches sur le DecoUement spon- 
 tane et traumatique des Epiphyses ' {La Presse Medicale, 10 Mai, 
 13 Mai, 17 Mai, 1837, i. No. 7, &c. pp. 290, 297, 305), was pubhshed 
 in 1837, and added some important facts. This author collected a 
 number of cases (forty-five) published up to this date. Many of these 
 were fractures in adults, some were separations through disease. 
 He also endeavoured by numerous experiments on the dead body, as 
 well as by careful examination of clinical cases, to clear up the many 
 obscure points with which the subject was then surrounded. But 
 from want of sufficient material his descriptions were very incom- 
 plete, and many points of interest were not even mentioned. 
 
 Nearly a century after Eeichel's thesis, M. Rognetta (' Memoire 
 sur la Divulsion traumatique des Epiphyses,' Gazette Medicale, Paris, 
 1834, p. 433) published an elaborate memoir upon traumatic separa- 
 tion of the epiphyses. To this interesting memoir we are indebted 
 for much valuable information, and in it we find brought together 
 
6 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 everything bearing upon the subject that had been previously 
 pubhshed. M. Eognetta has collected some instances of epiphysial 
 separations met with in the trunk as well as in the long bones. His 
 work is unfortunately too full of theories to the neglect of direct 
 anatoinical research, and he appears to believe in a simple separation 
 of the epiphysial cartilage from the bone in most cases without any 
 portion of the latter ever being dragged away. 
 
 M. Eoux, fifteen years after the publication of his first work, 
 states (' Sur le Decollement epiphysaire,' La Presse Medicale, Paris, 
 1837, tom. i. No. 55, July 12, 436-438) that on August 30, 1836, he 
 communicated a memoir to I'Academie Eoyale de Medecine contain- 
 ing several (4) new cases of epiphysial separation occurring in his 
 practice, but only one of these was verified by direct examination. 
 
 Sir Astley Coo]per in England, in his Fractures and Dislocations 
 (new edition by Bransby B. Cooper, 1842), was one of the first to 
 clearly point out that epiphysial separations are mostly mistaken for 
 dislocations rather than for fractures. He especially so alludes to 
 this lesion at the lower end of the humerus. He has added one or 
 two interesting cases. 
 
 In 1840 M. Piscart, in his inaugural thesis (These de Paris, 
 1840, No. 219), indicated the occurrence of traumatic separation 
 during delivery and after birth. Champmas' thesis in the same year 
 (These de Paris, 1840, No. 139) furnished no further facts for the 
 elucidation of these injuries beyond those of his predecessors 
 (especially Eognetta). 
 
 The distinguished Nelaton, in his JEUnients de patliologie 
 chirurgicale (tom. i. p. 678, sec. 3 : ' Divulsion traumatique des 
 Epiphyses '), treats the subject in the following manner : 
 
 ' Bien que les decoUements des epiphyses se trouvent indiques 
 dans les livres hippocratiques, et que depuis Ambroise Pare un 
 grand nombre d'auteurs aient parle de cette lesion, on pent cepen- 
 dant affirmer que nous manquons de documents necessaires pour 
 faire un expose dogmatique de cette affection. En effet, presque tout 
 ce que nous possedons sur ce sujet se reduit a des assertions sans 
 preuves et a quelques observations sans valeur, a cause de I'absence 
 complete des details.' However, he quoted some valuable examples 
 which were known at that time. 
 
 Voillemier, in 1842, made a special study of the mechanism of 
 separation of the lower epiphysis of the radius. 
 
 M. Salmon's doctoral thesis on traumatic solutions of continuity 
 of the bones during youth (P. A. Salmon, Bes solutions de continnite 
 traumatiques des os dans le jeune clge, These de Paris, 1845) con- 
 tains out of 129 cases a description of sixty-eight experiments on the 
 upper extremity, in which he detached the epiphyses by extension 
 of the fore-arm on the arm. They are mostly (64) of the lower 
 end of the humerus, one of the internal epicondyle, two of the upper 
 end of the ulna, and one of the upper end of the radius. This series 
 
HISTOEICAL 7 
 
 of experiments contributed some details as to the anatomical cha- 
 racter of separations. Salmon was the first to prove that when the 
 periosteum is lacerated, the separation is accompanied by displace- 
 ment. He also noted the frequency of separation, and the easy mode 
 of its production at the upper end of the femur in newly born infants 
 (ten out of eleven being in infants less than a month old), but he 
 was unable to detach the upper epiphysis of the humerus. Those of 
 the upper end of the femur were, as he describes, a detachment of the 
 whole cartilaginous end of the bone, to which he alludes in an earlier 
 part of his thesis. Salmon's thesis is, however, entirely without 
 clinical cases. 
 
 Detachment of the cartilaginous ends of the bones during 
 delivery was especially investigated by M. Pajot in his thesis 
 Des lesions traumatiques que le foetus ijeut ejgrouver 'pendant 
 V accouchement, Paris 1853. 
 
 Prof. E. W. Smith, of Dublin, showed {Treatise on Fractures in 
 the Vicinity of Joints, Dublin, 1847) a very clear conception of one 
 or two of these lesions, and paid considerable attention to the 
 subject. His accounts of certain forms of separation of the upper 
 and lower epiphyses of the humerus and of that of the lower end of 
 the radius are still regarded as most trustworthy descriptions (see 
 also, Dublin Quarterly Journal of Med. Science, vol. ix. New Series, 
 1850, p. 63). 
 
 Cruveilhier, vn:iting in 1849 {Traite d'anatomie pathologique, 
 Paris, tom. i. p. 101), says of the thirty-eight cases of traumatic 
 epiphysial separation then known to science, that there was but 
 little reliance to be placed on them. 
 
 E. E. Klein devoted a thesis to this subject {Be epiphys. dissolu- 
 tione, Diss, inaug., Gryphise, 1854 ; see also C. E. Zuehlke, De 
 diastasi epiphysium et ossium diaphysi. Halis Sax. 1859). 
 
 Dr. J. Ludw. Thudichum appears (' Die Absprengung der 
 Epiphysen,' Miinchener illustrirte medicin. Zeitung, 1855, Bd. iii. 
 s. 188) to have given some attention to fracture of the epiphyses, and 
 furnishes a brief account of epiphysial separation of most of the long 
 bones. Thudichum also wrote ' Ueber die am oberen Ende des 
 Humerus vorkommenden Ejiochenbriiche,' Giessen, 1851. 
 
 Malgaigne admitted {Traite des fractures, 1855) the occurrence of 
 epiphysial separations as proved by dissection at both ends of the 
 humerus, femur, and tibia, and at the lower end of the radius, and 
 ranked them among fractures because they have ' the same causes, 
 present the same symptoms, call for the same treatment, and, lastly, 
 cannot always be exactly distinguished from fractures properly so 
 called.' He therefore did not attach much importance to distinguish- 
 ing between them. He considered, and rightly so, that in the majority 
 of cases there is a more or less considerable detachment of the 
 osseous end of the shaft. Malgaigne attributed the first distinct 
 and satisfactory notice of separation of the epiphysis to Bertrandi 
 
8 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 towards the close of the last century. He quoted several cases, and 
 also added that he knew of no instance occurring in a female. 
 
 These lesions were also especially alluded to by Gurlt {Hand- 
 huch der Lehre von den Knochenbrilchen, Berlin, 1862). This 
 author carefully collected the literature of the subject up to this 
 date, and after the examination of anatomical specimens, experiments, 
 and clinical cases, came to the conclusion that epiphysial separations 
 were very rare injuries. He thought that this was to be accounted 
 for by the fact that the epiphyses, being in relation to the dia- 
 physes larger in infants than at a later period, were less frequently 
 the subject of injury, and that infants were less exposed to external 
 injury than children at puberty, when epiphysial separation very 
 unfrequently occurred. Gurlt collected eighteen cases verified by 
 dissection. 
 
 Bardeleben, in his 'Handbook of Surgery,' agreed with Gurlt's 
 decision. 
 
 Another French surgeon, M. Foucher, in 1860 (' Recherches 
 sur la disjonction traumatique des epiphyses,' Monit. des Sciences med. 
 et pharm. No. 90, 1860 ; Annales du Congres medical de Mouen, 1863), 
 added some valuable experimental knowledge of the subject, gave a 
 clear description of the pathology of the lesion, indicated several 
 varieties of separation, and drew up a classification which is even 
 now more or less adhered to. Hi§ experimental work is still the best 
 on the subject, and he summed up in a very complete manner all 
 that was known up to that time as to the mechanism of these lesions. 
 Nevertheless this author states that separation is effected with 
 great difficulty even in infants. In 1863 Foucher collected a number 
 of cases (' De la Divulsion des Epiphyses,' Cong. med. de France, 
 Paris, 1863, torn. i. pp. 63-72). 
 
 Prof. E. W. Smith, writing in 1865 and 1867 {British Medical 
 Journal, August 17, 1867), believed them to be very frequent and 
 common. This view was also held by Broca and Uffelman. Smith 
 has described many interesting specimens and cases which still 
 maintain their value to the practical surgeon. 
 
 Dr. A. Coulon, in 1861 {Traite des fractures cliez les enfants, 
 Paris, 1861) , totally denied the existence of these injuries, notwith- 
 standing the writings of M. Gueretin and Eognetta. He came to 
 this conclusion after many years' experience at children's hospitals, 
 and quotes (Eichet, Anatomic chiriirgicale, p. 64) M. Eichet's decision 
 in the following words : ' A I'etat normal, I'union est si intime entre 
 le cartilage de conjugaison et le tissu osseux en voie de formation, 
 qu'on pent les regarder comme un seul organe, les vaisseaux sanguins 
 se portant sans interruption de la diaphyse dans I'epiphyse. Howship, 
 qui avait etudie avec le plus grand soin ce point d'anatomie, a dit, 
 avec raison, que le cartilage epiphysaire etait continu et non pas 
 contif^u a I'os. C'est done une erreur de dire que le cartilage de con- 
 jugaison et I'os se touchentpar deux surfaces, I'une osseuse et I'autre 
 
HISTOKICAL 9 
 
 cartilagineuse, onduleuses et anfractueuses, se recevant reciproque- 
 ment ; ce n'est qu'apres maceration qu'on trouve cette disposition, car, 
 a I'etat sain et frais, le cartilage et I'os ne font qu'un, il y a fusion 
 intime, continuite en un mot. 
 
 ' Cette remarque conduit a rejeter le decollement des epiphyses 
 admis par quelques chirurgiens, puisque la diaphyse et I'epiphyse 
 ne sont pas accolees, mais bien reunies par I'intermediaire de leur 
 cartilage de conjugaison ; et quand, par suite de violences exterieures, 
 il y a separation en ce point, c'est une veritable fracture comme 
 celles qui s'operent dans la continuite des os. M. Gueretin {loc. ' 
 cit.), MM. Cruveilhier et Bonamy {TraiU d'anatomie pathologique, 
 tom. i.), qui, dans le but d'eclaircir cette question, se sont livres a 
 une serie d'experiences et de recherches, ont vu a peu pres con- 
 st amment que I'epiphyse, en se separant, entrainait toujours avec elle 
 une lamelle plus ou moins considerable du tissu osseux ; et les 
 faits de disjonction des epiphyses observes sur le vivant ont 
 presente le meme phenomene. A la rigueur, cependant, on con9oit 
 que le cartilage de conjugaison puisse se rompre precisement au 
 niveau de sa fusion avec le tissu osseux, et les faits observes par h 
 Bertrandi sur la tete du femur et celle de I'humerus, par MM. m 
 J. Cloquet et Rognetta sur I'extremite inferieure du radius, tendent 
 a prouver que la brisure pent quelquefois avoir lieu dans ce point 
 meme et sans solution de continuite du tissu osseux ; mais, dans ce 
 cas encore, c'est a une fracture et non a un decollement simple que 
 Ton a affaire, puisque I'inspection anatomique a prouve qu'il y avait 
 fusion des deux tissus. 
 
 ' Ce n'est la d'ailleurs, il faut bien en convenir, qu'une discussion 
 sans importance pratique, pi;iisque le pronostic et le traitement de 
 ces pretendus decollements epiphysaires sont identiques avec ceux 
 des fractures des extremites articulaires completement ossifiees.' 
 
 M. Coulon, after quoting Malgaigne's v^^ords, sums up the matter 
 by saying that traumatic separation of the epiphyses is extremely 
 rare, that it is recognised by the same signs as fracture in the 
 neighbourhood of the joints, that its gravity is the same, and that it 
 demands the same treatment. 
 
 In Russia these injuries have been studied by Michniowsky, 
 especially by means of experiments (' Untersuchungen liber den 
 Heilungsvorgang bei gewaltsamer Epiphysenlosung,' Militdi-drztl. 
 Journal (Russisch), 1864 ; Petersb. Med. Zeitschr. 1866, Bd. x. s. 300). 
 
 Richet, denying the existence of true separation, considered, from 
 the anatomical evidence which could then be produced, that the 
 cases brought forward by Bertrandi, Cloquet, and Rognetta of solu- 
 tion at the site of the epiphysial junction were really fractures. 
 
 Guersant (Chirurgie des enfants), during twenty years' service at 
 the Children's Hospital, met with very few instances. 
 
 The injuries were the subject of a special discussion at the 
 Societe de Chirurgie de Paris in 1865, by many able surgeons, on 
 
10 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 M. Dolbeau presenting before the society two specimens of separa- 
 tion of the lower epiphysis of the radius {Gazette des Hopitaux, 
 1865, No. 145, 147 ; Extract in New Sydenham Society's Betro- 
 spect, 1865-6, p. 248). M. MarjoHn beheved separations of the 
 epiphyses to be so extremely rare that their existence might almost 
 be denied, and produced in proof of this opinion some details of frac- 
 tures at the Hopital Ste. Eugenie which showed, at any rate, that 
 they had been very rarely diagnosed at the hospital from which his 
 statistics were drawn. Out of 600 fractures in children, he found no 
 cases of separation of the epiphyses. He added Malgaigne's opinion 
 that this lesion was rarely perfect, being almost always accompanied 
 by a fracture of the diaphysis which adhered to the epiphysis. M. 
 Guersant also said that he had never been able to diagnose the 
 injury with certainty, nor had he ever had occasion to verify it 
 anatomically, but spoke in favour of its occurrence. M. Chas- 
 saignac expressed his opinion that true separation of the epiphyses 
 hardly ever occurred ; that a small portion of the shaft almost 
 always adhered to the epiphysial cartilage, and that it was impossible 
 to make a special diagnosis. M. Trelat maintained that an epiphysial 
 separation, from a surgical point of view, in symptoms and cure, in 
 contradistinction to a fracture, was not to be accepted. M. Broca, 
 however, reminded the Society that the injury could easily be pro- 
 duced in the dead subject, and therefore was very probably more 
 frequent in the living than was supposed. In experiments on the dead 
 subject, the cartilage was usually found attached to the epiphysis. 
 M. Richet and M. Blot spoke in the same sense. 
 
 M. A. T. Cosseret's doctoral thesis. Be la clivulsion des 
 epipJujses (These de doctorat, Paris, 1866, No. 141), was sug- 
 gested by Foucher's work in 1860 {loc. cit. supra), but contains 
 little of importance in addition to what had been previously written. 
 He adhered to the opinion of Malgaigne, Marjolin, Coulon, and 
 others by placing these lesions amongst fractures. 
 
 Bouchut describes {Traite des maladies des enfants, 1867) separa- 
 tion of the epiphyses in young children in his article on fractures, 
 but gives no examples. He states that in this solution of continuity 
 of the bone there is no rupture of the osseous tissue, and that the 
 injuries are generally produced by a considerable strain on the 
 articulation, and are not as a rule the result of a direct blow. He 
 also says that besides the pain and swelling, there is preternatural 
 mobility, and often a dull grating crepitus, very different from the 
 crepitus of bone. 
 
 The labours of Professor Oilier did much to put epiphysial 
 separations on a well merited footing. By his researches on the 
 regeneration of bones {Traite de la regeneration des os, tom. i. 1867), 
 on the unequal growth of the two extremities of the long bones, and 
 on the physiology, anatomy, and pathology of the diaphyso-epiphysial 
 region, a complete study has been permitted of these interesting 
 
HISTOEICAL 11 
 
 lesions. He calls these lesions diaphysial separations because the 
 separation almost always takes place between the diaphysis and the 
 cartilage, and not between the latter and the epiphysis. 
 
 Professor Poncet, of Lyons (' Des Deformations produites par 
 I'arret d'accroissement d'un des Os de I'avant-bras,' Lyon Medical, 
 1872), has also given some valuable remarks upon the arrest of 
 development following lesions of the epiphysial cartilages, and upon 
 the deformities which result from them, in the parallel bones of the 
 forearm and leg. 
 
 Epiphysial separation was the subject of M. Jules Colignon's 
 thesis (De la disjonction traumatique des ejnjjhyses, These de Paris, 
 1868, No. 226), especially as regards the lower epiphysis of the 
 radius. Some interesting experiments on the dead body were 
 included, and the number of published cases was brought up 
 to seventy-nine ; many, however, of these were very incomplete. 
 This thesis was based upon those of Gueretin and Foucher, the 
 former of which was one of the best memoirs then published. 
 
 Even up to that date the possibility of these injuries on the 
 living subject was still doubted by certain authors. M. Colignon 
 brought some exact clinical observations to bear upon the question, 
 the study of which by means of post-mortem experiments had now 
 been fairly well carried out. 
 
 From this time the pathological and clinical observations of many 
 authors began to place the study of the lesions upon a firmer basis. 
 
 Mr. Timothy Holmes, in his Diseases of Children, 1868, attached 
 some importance to these injuries, and drew some conclusions from a 
 study of the museum specimens then existing in the London 
 hospitals. His inquiries, he says, were due to his desire of testing 
 the relative accuracy of M. Chassaignac's and Professor Smith's 
 opinions on this subject. He thought the precise line of solution of 
 continuity was the chief point of importance in the probability of 
 suspension of growth after such injuries. ' Thus it is seen that out 
 of the preparations from the lower end of the femur, three are un- 
 comphcated with visible fracture — one in early infancy, the other 
 two in late puberty ; and that these are the only genuine specimens 
 of epiphysiary disjunction which our museums contain ; the two of 
 the fibula at St. George's being somewhat doubtful, and that of the 
 upper end of the ulna in infancy rather a fracture of the cartilaginous 
 extremity of the bone than a separation of its epiphysis, which 
 at that early age can hardly be said to exist, at any rate has not 
 begun to ossify.' 
 
 Emile Barbarin, in his thesis (Contribution a V etude des fractures 
 chez les enfants, 1873), while admitting the occurrence of epiphysial 
 disjunctions, thought, nevertheless, that they were rare in practice. 
 
 M. Alfred Leblois {Contribution a V etude des fractures chez les 
 enfants et de leur traitement, Paris, 1894) alludes to them in a 
 cursory manner. 
 
12 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 Manquat, in his essay ' Sur les Decollements epipliysaires trauma- 
 tiques ' (These de Paris, 1877), cohected 130 cases of epiphysial separa- 
 tion — all of which had been previously published. Even at this period 
 he believed they were rare accidents. He classed ' toute solution de 
 continuite brusque survenant par le fait d'un traumatisme entre la 
 diaphyse et I'epiphyse d'un os au niveau du cartilage epiphysaire ' as 
 traumatic epiphysial separation. 
 
 In the same year Professor Novaro {Gazzetta delle cliniche, 1877), 
 whilst referring to a clinical case of separation of the upper 
 epiphysis of the humerus, briefly expounded traumatic separation 
 of the epiphyses in general. 
 
 Writing in 1878 M. E, Pingaud {Diet, encycl. des Sciences 
 medicales, I™^ sec. torn. xxi. p. 627) thought that all cases should be 
 considered as true fractures. He says : ' Et d'ailleurs, comment une 
 semblable separation pourrait-elle avoir lieu, quand on considere 
 combien est intime, a I'etat physiologique, I'union qui existe entre le 
 cartilage de conjugaison et le tissu osseux en voie de formation ? 
 Car il n'y a pas simplement juxtaposition entre ces deux parties de 
 I'os, mais fusion complete, continuite absolue de tissu ; a I'etat frais, 
 I'os et le cartilage ne font qu'un, et les vaisseaux sanguins se portent 
 sans interruption de I'un a I'autre. Le perioste enfin, tres dense et 
 tres adherent au niveau de la ligne de conjugaison, ajoute encore a la 
 solidite de I'union de I'epiphyse avec la diaphyse. Quand done une 
 violence exterieure parait diviser un os au niveau de la ligne de con- 
 jugaison dia-epiphysaire, il y a toujours une veritable fracture, le 
 cartilage, en raison de son elasticite et de sa tenacite, arrachant 
 toujours, plutot que de ceder, une lamelle plus ou moins considerable 
 de tissu osseux. II su£&t d'ailleurs de considerer la forme du segment 
 detache pour voir de suite qu'il n'est pas uniquement constitue par 
 I'epiphyse, et que la calotte diaphysaire qui le penetre a ete arrachee 
 en meme temps que lui.' 
 
 Professor Syme, in 1842, wrote on diastasis or separation of the 
 epiphyses thus : ' The symptoms resemble those which would result 
 from fracture in the same situation, and the treatment does not in 
 any respect require to be different ' (Principles of Surgery, p. 179, 
 1842). 
 
 Sir William Fergusson also wrote (System of Practical Surgery, 
 1846, p. 123) : ' No particular allusions will be made to separation 
 of the epiphyses — diastasis, as the accident is called — a kind of 
 injury which is occasionally met with in the young subject ; and 
 the reason for this is, that I know of no difference of treatment 
 which such cases may require, whilst every anatomist must be 
 aware that a solution of continuity is as likely to occur in such 
 a situation as elsewhere. If they deserve especial comment, it is 
 that crepitus will probably be less distinct ; and also with reference 
 to the proximity of the injury to the joint ; but on the latter point, 
 the principles of treatment for ordinary fractures are equally appli- 
 
HISTOEICAL 13 
 
 cable, whilst if the symptoms are so obscure as to make crepitus 
 essential to the diagnosis, it is evident that if there be a fracture at 
 all, it must certainly be one of a most simple character.' 
 
 Joseph Amesbury, in his work on ' Fractures of the Trunk and 
 Extremities,' does not even allude to the possibility of epiphysial 
 injury. 
 
 In 1862 Gurlt was able to collect only eighteen cases of separation 
 of the epiphyses during life, in which the diagnosis was verified by 
 dissection ; of these, five were of the humerus (four being of the 
 upper and one of the lower end), four of the lower end of the radius, 
 five of the lower end of the femur, and three of the tibia. Gurlt was 
 of opinion that separation was a rare form of accident. 
 
 Writing in 1863, Stimson says that his experience of these 
 injuries was limited to two cases, both compound, one of the proxi- 
 mal phalanx of the great toe and the other of the upper end of 
 the fibula. 
 
 In a later edition of his work, Syme, in 1866 {Principles of 
 Surgery, 4th edit. 1866, p. 170), dismissed the subject in the 
 following words : ' Before the epiphyses are united to their respective 
 shafts, they are apt to suffer separation from them by such violence 
 as, in the adult, would occasion fracture of the bones concerned, or 
 dislocation of their articulating extremities.' 
 
 Holmes says, in 1869 : ' The conclusion to which my experience 
 of this injury would lead me is, that fracture occurs not very rarely 
 at or in the immediate neighbourhood of the epiphysial line ; that 
 the line of fracture coincides in these cases partially with that of the 
 epiphysial cartilage, but seldom completely ; that the general symp- 
 toms are therefore the same as those of fracture, while the special 
 symptoms must be sought for from the anatomy of each joint.' 
 
 It is thus only during the last twenty years that traumatic 
 separations of the epiphyses began to be generally admitted, and 
 described with any accuracy. But there can now be no doubt of 
 their frequent occurrence ; and in this country their importance has 
 been often alluded to for many years by Mr. Jonathan Hutchinson, 
 Professor Sir George Humphry, and others. 
 
 Their chief exponent is Mr. Jonathan Hutchinson, who has 
 from time to time since the forties published a number of cases 
 and specimens bearing out the reality of these lesions, and also 
 the not infrequent result of loss of growth in length of the bone 
 affected. 
 
 Mr. Hilton and his surgical colleagues at Guy's Hospital were 
 also amongst the first to point out many important details respecting 
 these injuries. 
 
 Mr. T. Bryant, in his Practice of Surgery and elsewhere, has 
 published numerous cases of separation of the various epiphyses, 
 many of them of great value and many showing arrest of growth. 
 
 The London hospital is indebted to Mr. Nathaniel Ward for many 
 
14 TEAUMATIC SEPARATION OF THE EPIPHYSES 
 
 specimens in its museum, and others have been added by Mr. 
 Hutchinson. 
 
 As to our current works on surgery, we find these injuries are 
 still scarcely mentioned in many of them, while only a few give any 
 information with reference to them. Though not so common as 
 fractures, the number of separations now recorded leads to a more 
 careful investigation of their clinical signs. 
 
 We find, even as late as 1884, Hamilton, in his Fractures and 
 Dislocations, 7th edit. p. 37, stating : ' Epiphysial separations we 
 shall not hesitate to class with fractures, and to submit them to 
 the same rules of nomenclature. These accidents rarely occur after 
 the twentieth year of life ; since after this period, and in the case of 
 some bones at a much earlier period, the epiphyses are usually united 
 to the diaphyses by bone.' However, he gave a distinct heading to 
 many of these injuries, and in a few cases considered their diagnosis 
 from fractures. He published a number of new cases from his own 
 observation. 
 
 Even at the present day we see that there are very contradictory 
 opinions with regard to these injuries ; one surgeon detects them very 
 frequently while another never does so, or only admits that they are 
 rarely met with. This difference of opinion has been due in part 
 to the absence hitherto of direct examination in a large proportion of 
 cases, and in part to the ease with which epiphysial separation may 
 be confused with dislocation or fracture of the end of the diaphysis. 
 
 Numerous cases followed by an autopsy or by amputation, 
 others in which the presence of a w^ound has permitted a direct 
 examination of the separated fragments, and many instances in which 
 an open operation has been undertaken in simple cases for replace- 
 ment of fragments, have now clearly and definitely established the 
 frequent occurrence of epiphysial separation. 
 
 Germany has furnished us with two important monographs 
 on the subject by P. Vogt and Paul Bruns, both of which appeared 
 in Langenbeck's Archiv {Archiv filr hlin. Chirurg. 1878 and 1882), 
 and proved that these injuries are by no means so rare as had 
 been previously held by some. Vogt believed that separation 
 without displacement was common in early life. Paul Bruns 
 has published a large series of cases (verified by an autopsy) for 
 statistical purposes, and in order to throw some light upon their 
 history and after consequences. He collected eighty-one such cases 
 and added three from his clinic at Tubingen. He believed the 
 injury to be not at all an uncommon one, and that if he had included 
 simple cases the number collected would have been much greater. 
 
 Some other French writers have contributed special articles on 
 one or other of the epiphyses (Delens, Archives generales de Med. 
 1884, p. 272 ; Farabeuf, Bull, et Mem. de la Societe de Chir., Paris, 
 torn, xii., 1886, p. 692 ; Berges, These de Paris, 1890). 
 
 In 1882 Dr. Erasmo De Paoli published {Del distacco traiimatico 
 
HISTOPJCAL 15 
 
 delle epifisi, Torino, 1882) a concise account of these injuries, adding 
 some new cases and experiments of his own, 
 
 G. Mazziotti has also furnished some articles (' Del distacco delle 
 epifisi, e sue differenze dalla frattura,' Giorn. mternaz. d. sc. med., 
 Napoli, 1880, ii. p. 957 ; ibid. 1882, new series, iv. p. 371 ; also Ann. 
 din. d. osp. incu7\, Napoli, 1882, viii. p. 162). 
 
 * The diagnosis of traumatic separation of the epiphyses ' formed 
 the subject of a paper read by the author before the West Kent 
 Medico-Chirurgical Society in April 1886.* In this paper attention 
 was drawn to the frequent occurrence of separation toitliout displace- 
 ment, especially at the lower end of the femur, and to the common 
 escape from injury of the neighbouring joint in many of the more 
 simple separations, e.g. at the lower end of the racius. Allusion 
 was also made for the first time to the gradual displacement of 
 the diaphysis or epiphysis subsequent to the accident in instances 
 .in which the lesion had been overlooked or not diagnosed. This 
 want of recognition the author believed to be due to the absence of dis- 
 placement at the time of the accident. Permanent deformity and pres- 
 sure upon important structures, leading to disastrous consequences, 
 resulted in several cases. After examination of the specimens in 
 the hospital museums of London and other cities, and after collecting 
 statistics, the fact was noted that the epiphyses of certain bones, 
 from their anatomical peculiarities, were more liable to be broken' 
 off at particular ages than at others. 
 
 The thesis of Dittmayer deals with arrest of growth in length 
 following traumatic separation of the epiphyses, and that of AVilhelm 
 -Stehr with arrest of growth of the radius following epiphysial separa- 
 tion (Dittmayer, These de Wurtzbourg, 1887 ; "Wilhelm Stehr, These 
 de Tubingen, 1889). 
 
 M. Joseph Curtillet has given {Du decollement traumatique des 
 epiphyses, Lyon, 1891, pp. 107) the proportion of cases of epiphysial 
 separation to those of ordinary fracture met wdth in children as 
 twenty to a hundred. His figures were taken from cases under the 
 care of M. Vincent of Lyons. 
 
 In 1891 Mr. Jonathan Hutchinson, jun., was awarded the 
 Jacksonian Prize at the Eoyal College of Surgeons for his essay upon 
 ' Injuries to the Epiphyses of Long Bones,' and he has supplemented 
 much of his father's work in this direction. 
 
 He embodied this work in his lectures in 1893 on ' Injuries to the 
 Epiphyses and their Ptesults,' delivered at the Eoyal College of 
 Surgeons. 
 
 * (Printed in Pediatrics, New York and London. Vol. iv. No. 2 July 15, 1897, p. 40). 
 
16 TRAUMATIC SEPARATION OF THE EPIPHYSES 
 
 CHAPTER II 
 
 ANATOMY 
 
 DiAPHYsis — Epiphysis, its developement — Epiphysial or Conjugal Cartilage, 
 its function — juxta-epiphysial region — periosteum, its function — 
 Apophyses. 
 
 A KNOWLEDGE of the bones is imperfect without an accurate and 
 complete acquaintance with the anatomy and connections of the 
 epiphyses. 
 
 In his address on surgery at the British Medical Association 
 (loc. cit. infra) Professor R. W. Smith said : ' When the surgeon is 
 called upon for his opinion respecting the nature of injuries occurring 
 in the vicinity of the larger joints in early life, he will find a know- 
 ledge of the anatomy of the epiphyses of the greatest importance.' 
 This instruction, however, is seldom afforded to students during their 
 anatomical course. 
 
 Very false conceptions as to the parts included in the epiphyses 
 and diaphyses have led to many errors in diagnosis, and in many 
 cases, it might be added, to improper treatment. 
 
 "We find during the development of the bones that the boundary 
 line between the epiphysis and the diaphysis alters its relationship 
 very considerably with regard both to those parts, to the neighbouring 
 joint, and to other surrounding structures. Marked examples of this 
 may be seen at the lower end of the humerus and the upper end of the 
 femur. In the latter the whole upper extremity in infancy comprises 
 the head, neck, and greater and lesser trochanters in one cartilaginous 
 mass, but, as age advances, the head and trochanters form separate 
 epiphyses by the upward growth of the neck from the diaphysis. 
 
 Not only do the individual epiphyses alter their relationship with 
 the corresponding diaphyses during the different stages of their 
 development, but the same epiphysis will have a very different 
 anatomical appearance at different periods — e.g. during infancy and 
 during adolescence — at one time forming a relatively large portion of 
 the end of the bone, and at another time a small one, as at the upper 
 end of the humerus. 
 
 Diaphysis. — The long bones have a large epiphysis at each end 
 of the diaphysis, with the exception of the clavicle, the metacarpus, 
 the metatarsus, and the phalanges of the hand and foot, which have 
 only one. 
 
ANATOMY 17 
 
 It will be seen later on that the epiphyses of the long bones 
 in children do not comprise the whole of the end of the bone as 
 seen in the adult, but only about two-thirds, the remaining third 
 (e.g. the lower end of the humerus) being formed by the diaphysis 
 (Cruveilhier) . 
 
 At birth the epiphyses are almost entirely cartilaginous, with the 
 exception of the lower epiphysis of the femur and the upper epiphysis 
 of the tibia, and are somewhat larger in proportion to the diaphysis 
 than they are when their ossification is complete. , By the process 
 of ossification advancing into the epiphysial cartilage from the 
 diaphysial end the epiphysis becomes, as a rule, relatively smaller 
 towards its diaphysial surface. This may be readily seen on com- 
 paring the upper end of the humerus in infancy and at puberty. In 
 the case of the long bones the whole diaphyses are ossified at 
 birth. The bones, at first entirely cartilaginous, are invested with 
 a perichondrium which is comparable to the periosteum of later 
 years and wdiich similarly consists of a superficial and a deep layer. 
 The superficial layer, like that of the periosteum, passes over the 
 articulations as its capsule, and the deep layer unites with the 
 cartilaginous end of the bone, blending with it at the level which 
 marks later on the union of the epiphysis and the diaphysis. 
 
 The long bones increase in length rather than in thickness from 
 the time of birth up to the sixth or seventh year by the process of 
 ectochondral ossification, precisely similar to that of a centre of 
 ossification. The growth and ossification of the cartilage take place 
 on the diaphysial aspect only — in fact, according to Busch, the ex- 
 clusive function of this cartilage is the ossification of the shaft. 
 John Hunter proved experimentally on animals that the increase in 
 length of long bone took place at the epiphysis. His experiments 
 were adopted and corroborated by Beclard. 
 
 The unequal growth of the two ends of the diaphysis has also 
 been conclusively proved experimentally by Hales, Oilier (De 
 VinegaliU d' accroissement des deux extremites des os longs chez 
 riiomme, Paris, 1863 ; Memoires de la Societe des Sciences Medi- 
 cates de Lyon), Duhamel (Histoire de VAcademie des Sciences, 1743), 
 Leser (Langenbeck's Archiv f. klin. Chirurg., Bd. xxxvii. 1880), 
 Flourens (P. Flourens, Theorie experimentale de la formation 
 des OS, 1847; ' Sur le developpement des os en longueur,' Gaz. 
 des Hop., Paris, 1861, xxxiv. p. 74 ; also Ann. de la Chir. franc^. et 
 etrang., Paris, 1844, xii. p. 170; and ibid., 1845, xv. 230-39; also, 
 Becherclies sur le developpement des os et des dents, Paris, 1842) ; and 
 others have fully confirmed the experimental results obtained by 
 these authors. 
 
 In every long bone ossification proceeds more rapidly in one 
 direction than another ; hence increase in length takes place by the 
 growth of the cartilage continuing at the opposite end. While the 
 elongation of the long bones is chiefly the result of addition to the 
 
 c 
 
18 TEAUMATIC SEPAKATION OF THE EPIPHYSES 
 
 shaft at the epiphysial junctions, the growth takes place more rapidly 
 and is continued longer at the end where the epiphysis is last united. 
 The oblique direction of the vascular canals is due to this inequality 
 of growth, which causes a shifting of the periosteum investing the 
 greater part of the shaft, and so draws the proximal portion of the 
 medullary artery towards the more rapidly growing end, and gives 
 rise to its canal. 
 
 The newly formed bone in contact with the diaphysial side of 
 the conjugal cartilage is exceedingly vascular. The medullary canals, 
 therefore, ran in the direction of the end in which ossification is 
 progressing most rapidly and away from the end in which increase 
 in length takes place. As Humphry points out, this is in order to 
 maintain the proper relative position of the soft parts which exists 
 during the period of growth. After piercing the shaft the nutrient 
 artery, as seen in the cartilaginous state of the diaphysis, divides 
 into two chief branches which extend upwards and downwards 
 towards either end of the bone. Other branches are given off from 
 these which finally reach the epiphyses. 
 
 In his excellent description of the nutrient canals and the growth 
 of the long bones, Schwalbe, in 1876, has given a true account of the 
 position of the nutrient canal in relation to the ends of the bones. 
 
 While the two ends of the diaphysis take an unequal share in 
 the increase in length, there is a difference for each particular bone. 
 Thus in the tibia and humerus the upper ends, in the femur and 
 bones of the forearm the lower ends, are in this respect the most 
 active. 
 
 Individuality plays so important a part in the rate of growth in 
 length in the long bones and in the union of the shaft with the ends, 
 that it has been found extremely difficult to give precise figures. Ac- 
 cording to Topinard, individual variations are numerous, and doubt- 
 less both race and sex influence the time of union of the epiphysis 
 and diaphysis ; the state of health or disease also must modify the 
 process, seeing that the growth of bone is only the expression of the 
 rate of ossification and renewal of calcareous material, which must 
 be considerably influenced by a good or bad nutritive process. 
 This increase of the diaphysis at the extremities will be found to be 
 almost entirely due to that part of the conjugal cartilage, or disc, 
 which is in contact with the diaphysis. Excision of the epiphysis 
 itself, leaving this cartilage, was found by OHier to lead only to a 
 temporary checking of nutrition and arrest of growth of the bone. 
 The conjugal cartilage still proliferated and produced new osseous 
 material. 
 
 Duhamel in 1743, as regards the tibia, recognised that the upper 
 end increased more than the lower ; this was also seen by Flourens 
 a hundred years later in 1847. The difference in the growth of 
 the long bones according to their ends was established in 1852 
 by the researches of Broca who was one of the first to make 
 
ANATOMY 19 
 
 experiments on this subject ; and by Oilier and Humphry in 1861 
 (Med. Chirurg. Transactions, vol. xlv. 1862). 
 
 The difference in the increase in length of the ends of the long 
 bones is manifested from birth, and does not depend upon the early 
 or late period of union of the epiphysis with the diaphysis, although 
 there is a relationship between these two, for it is the epiphysis 
 which joins on last that grows the most ; but they do not depend 
 one on another — they are both the expression of a general condition 
 (Oilier). Furthermore, experimental researches, clinical and post- 
 mortem experience have proved conclusively that the value of each 
 epiphysis of the long bones for the growth in length is very different 
 in the various periods of young life. 
 
 Besides this increase in length of the long bones from their ends, 
 it has been asserted recently by some German authors that a certain 
 amount of increase may be met with interstitially ; for in the adult 
 an increase in length of the long bones has been noted in more than 
 one specimen, even long after the disappearance of the epiphysial 
 cartilage. These cases must be regarded as belonging rather to 
 pathological than normal anatomy. 
 
 Epiphysis. Structure. — The epiphyses are either for the forma- 
 tion of the joints, for the attachment of tendons or ligaments, 
 or for the development in length of the bone, but more frequently 
 they fulfil all these functions at the same time. They have a 
 sort of independent existence from the rest of the bone, being 
 supplementary processes designed to protect the functions of 
 the part whilst the diaphysial ossification is extending. In certain 
 bones, therefore — the outer end of the clavicle, the metacarpus 
 and metatarsus, for example — we see the diaphysial ossification 
 extending to the end of the bone. The epiphyses are, proportionately 
 to the diaphyses, larger in early infancy than later on, and at first 
 sight this relatively large size of the joints in infancy would appear 
 to be more favourable to receive external violence and predispose to 
 epiphysial separation. Yet this is not borne out by facts. About 
 the second or third year the epiphyses become less bulky and the 
 periosteum begins to diminish in thickness, while at the tenth and 
 on to the fifteenth year they have very much diminished in size 
 relatively to their diaphyses. 
 
 The epiphyses, when fully formed, are somewhat similar in 
 structure to the short bones of the body, being composed of spongy 
 cancellous tissue, arranged in a definite and distinct mechanical 
 manner and surrounded by a thin layer of compact bone. Their 
 diaphysial surface is not smooth but covered with small mamillary 
 projections and pits which accurately fit corresponding depressions 
 and ridges on the end of the diaphysis, strengthening the union 
 between the epiphysis and diaphysis. On the diaphysial ends of 
 some of the long bones, as at the lower end of the tibia, these lidges 
 and elevations are arranged in a very definite manner. 
 
 c 2 
 
20 TRAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 The epiphj'ses at the two ends of the cliaphysis of the long bones 
 at the period of maturity freely communicate by means of openings 
 into the medullary canal, the alveoli of the spongy epiphysial tissue 
 at this period passing into those of the dia^Dhysis. 
 
 It is only in rickets and some other pathological conditions that 
 the cartilaginous line is penetrated by blood vessels ; the epiphysial 
 cartilage, small though it may be, will in the normal state com- 
 pletely shut 0&. the alveolar spaces of the epiphysis from those of 
 the diaphysis. 
 
 The epiphj^ses obtain their blood supply from the periosteal net- 
 work of arteries, large branches of which perforate the thin layer of 
 compact tissue on their exterior, and are distributed throughout 
 the spongy cancellous tissue. Kearly the whole of the blood 
 supply is therefore independent of the diaphysis. Only one or two 
 minute arteries pass into the epiphyses from the diaphyses through 
 the conjugal cartilage. This accounts for the comparatively 
 infrequent occurrence of necrosis of the epiphysis in traumatic 
 separation of the epiphysis even when the diaphysis is more or less 
 completely displaced from off the epiphysis. 
 
 According to many observers, the veins are enclosed in distinct 
 channels formed of thin plates of bone, and have very thin walls. 
 
 Ossification. — In the ossification (endochondral) of the cartila- 
 ginous ends of the bones the cells are collected into columns, which 
 are usually in a direction parallel to the long axis of the bone, 
 separated by the cartilaginous matrix, which becomes granular, 
 calcifies, and forms between the altered cartilage cells areolse or 
 meshes. In this calcified matrix the osteoblastic material is very 
 soon deposited and blood vessels form. This material breaks 
 the meshes up by absorption (chiefly through the medium of the 
 osteoblasts) and forms secondary areolae. These areolae contain 
 the osteoblasts and some giant cells. The vessels shoot from 
 the periphery towards the centre point of the cartilaginous end. 
 The osteoblasts become separated from one another by an inter- 
 cellular matrix entering into a calcareous condition and surrounding 
 the osteoblasts, which now become the bone corpuscles and com- 
 municate with one another by means of the canaliculi. Ossification 
 takes place from the centre of the epiphysis towards the periphery. 
 It commences in the cartilaginous epiphysis by one or more 
 central points or nuclei, and extends by the same process of intra- 
 cartilaginous ossification peripherally until all the epiphysis is 
 invaded and occupied by osseous material except a narrow line 
 of cartilage usually called the epiphysial cartilage or disc at the 
 junction with the shaft. 
 
 For instance, in the lower end of the humerus there are four such 
 centres, in the upper end two, at each end of the femur only one. 
 
 The principal osseous centres appear gradually in the epiphyses 
 of the long bones up to about the eighth year, each epiphysis having 
 
ANATOMY 
 
 21 
 
 its own special time for appearance, subject to some variation 
 according to the individual, &c. The centres for the lower epiphysis 
 of the femur and the upper epiphysis of the tibia are the first to 
 appear. 
 
 Fig. 1.— longitudinal section of epiphysis of the femur of a human fcetus 
 (bukdon-sandeeson) 
 A and B, pure hyaline cartilage of the joint ; c, layers in which the cartilage capsules 
 are distinctly enlarged, i.e. where the intercellular substance is diminished ; at d, the cell 
 elements (derived from the cartilage cell of the cartilage capsule) begin to place themselves 
 in regular order peripherally ; the intercellular substance still further diminishes and 
 passes over into bony trabeculas — the embryonal bony tissue of the layer e ; in this layer 
 he cell elements of the spaces, which answer to the cartilage capsules of the previous 
 layer d, have precisely the position of osteoblasts. 
 
22 TKAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 M. Arthaud says that the epiphyses corresponding to ginglymoid 
 joints ossify much earlier than those of orbicular joints ; but this 
 rule is far from a universal one — e.g. the upper end of the humerus, 
 corresponding to the orbicular shoulder joint, ossifies sooner than 
 the lower end. 
 
 From a series of experiments, J. B. Sutton {Journal of 
 Anatomy and Physiology, xvii. p. 479) was induced to formulate 
 the following new and general rule : ' The centres of ossification 
 appear earliest for those epiphyses which bear the largest relative 
 proportion to the shafts of the bones to which they belong.' His 
 intention was to show that the ratio of a terminal cartilage to the 
 diaphysis being given, on referring to the table (which he arranged) 
 the date of appearance of its ossific centre might be inferred with a 
 tolerable amount of accuracy. 
 
 The epiphysis ossifies first at the end where the greatest increase 
 in length takes place, but the epiphysis joins the shaft first towards 
 the end where ossification of the shaft progresses most rapidly — that 
 is, the end towards which the nutrient canal slants or is directed. 
 Growth of the long bones, therefore, takes place more rapidly, and is 
 continued longer, at the end where the epiphysis is last united to 
 the shaft. But the direction of the nutrient canal has of itself no 
 importance as regards the increase in length of the bone — it is only 
 a curious coincidence in man which is not found in other animals 
 (Oilier). Berard, in a memoir {ArcJdves gen. de med., fevr. 1837) on 
 the relationship which exists between the direction of the medullary 
 canals of the long bones and the order in which the epiphyses join, 
 was the first to enunciate the law that of the two ends of a long hone, 
 it is always that toioards lohich the nutrient canal is directed which 
 joins first with the shaft of the hone. 
 
 Berard also thought that this arrangement might have some 
 influence on the consolidation of fractures, and believed that the 
 formation of callus frequently failed in fractures of the portion of 
 the diaphysis opposite to the direction of the nutrient canal ; but 
 this does not appear to have been borne out by the cases collected by 
 M. Gueretin {Presse medicate, 1837, p. 45) and by Varris, quoted 
 by Malgaigne {Anatom. chirurg. tom. i. p. 201), of non-union after 
 fracture, which they found to be as numerous at one end as at the 
 other. In the long bones, where there is only one epiphysis, 
 the nutrient canal is directed towards the end which has no 
 epiphysis, e.g. outwards in the clavicle, towards the distal end of 
 the metacarpal bone of the thumb and great toe, and upwards 
 towards the proximal end of the rest of the metacarpal and metatarsal 
 bones. 
 
 Berard and Flourens appear to think that the precocious union 
 is due to a greater activity in the formative function of the 
 epiphysial cartilage, an increased blood supply being directed towards 
 it by the nutrient artery. But Oilier has proved that the earlier 
 
ANATOMY 23 
 
 junction of an epiphysis with the diaphysis is the index of an 
 exhausted nutrition, that the epiphysis joins on first where the 
 increase in growth has almost entirely ceased, and that the end 
 which joins on last is that which has the greatest activity in pro- 
 liferation ; this difference between the two ends of a bone being 
 manifested from the time of birth and, it may be, before any of the 
 epiphyses are joined on. Therefore, as will be seen later on, 
 the unequal growth of the two ends is due to the unequal value of the 
 epiphysial cartilages, and is manifested from the time of birth quite 
 independently of the union of the epiphyses. Humphry was the 
 first to point out, from his experiments on animals, that the increase 
 in length of the end of the shaft in each bone where the epiphysis is 
 last ossified is twice as great as that of the other end, or even more. 
 As Oilier gives it : ' Ce sont la deux faits correlates ; quand 
 I'accroissement cesse par epuisement des materiaux d'ossification, 
 I'epiphyse se sonde ; mais la soudure est plutot I'effet que la cause 
 de I'inegalite d'accroissement.' 
 
 There is really less physiological activity in the cartilage at the 
 end of the bone which joins on first and sooner completes its 
 evolution. This is a very different explanation from that of Berard. 
 
 In the bones of the forearm and arm the medullary canals are 
 directed towards the elbow, and in the bones of the leg and thigh 
 away from the knee. In the femur, ulna, radius, and metacarpal 
 bones of the thumb and great toe and the phalanges, the medullary 
 canal is directed towards the proximal end, whereas in the humerus, 
 tibia, and other metacarpal and metatarsal bones the direction is 
 towards the distal end. Therefore in the increase in length of the 
 arm and forearm, the epiphyses at the elbow will play a much smaller 
 part than the epiphyses at the shoulder and wrist ; whereas in the 
 lower limb the epiphyses of the femur and tibia at the knee joint 
 are of more importance in this respect. 
 
 In bones having only one epiphysis — i.e. clavicle, metacarpus, 
 metatarsus, phalanges — the growth in length of course takes place at 
 this end only. In other irregular bones, such as the ilium, growth 
 occurs chiefly in the vicinity of their epiphyses. 
 
 It is the lower end of the fibula which grows most, and hence 
 it is the lower epiphysis of this bone which commences to ossify 
 earlier and consolidates before that of the upper, which is in a 
 rudimentary condition. 
 
 M. Oilier {Traite de la regeneration des os, 1867, tom. i. p. 358) 
 puts it in the following manner : the analogous bones in the 
 upper and lower extremity are in an inverse relation in this 
 respect, for the femur increases by its lower extremity inversely 
 to the humerus, and the radius and ulna inversely to the tibia and 
 fibula. As regards the forearm and arm, the ends of the bones at 
 a distance from the elbow increase the most, whilst in the lower 
 extremity the ends of the bones of the leg and thigh at a distance 
 
24 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 from the knee increase the least, thereby constituting a sort of 
 opposition between the elbow and knee; or, in other w^ords, in the 
 bones of the same hmb the same inverse relationship exists, the 
 humerus increasing mostly by its upper end, the femur by its lower, 
 the radius and ulna by their lower, whilst the tibia does so by its 
 upper end.^ 
 
 Sappey says that the last epiphyses to join on are the lower end 
 of the tibia, the lower end of the femur, the upper end of the 
 humerus, and then the lower end of the radius. By this arrange- 
 ment the upper limb arrives at maturity before the lower limb. 
 
 The foUo"vsang table gives the times of appearance of the centres 
 of ossification in the various bones. 
 
 Date of Appearance of the Cextees of Ossification 
 OF the Chief Epiphyses of the Loxg Boxes 
 
 Clavicle 
 Humerus 
 
 Upper Extremitij 
 
 18th vear 
 
 upper epiphysis (head) . 
 /capitellum 
 lower ,, trochlea 
 
 about 15 months after birth. 
 2nd to 3rd year. 
 11th year. 
 
 external 
 epicondyle .13th year 
 
 Eadius 
 
 Ulna 
 
 Metacarpus 
 Phalano-es . 
 
 Femur 
 
 internal epicondyle 
 upper epiphysis 
 lower ,, 
 upper 
 lower 
 
 5th year (at times earlier). 
 at the end of 5th year, 
 towards end of 2nd year. 
 10th year. 
 4th to 5th 5'ear. 
 2^ to 5th year. 
 3rd to 5th year (1st, 2nd, and 
 3rd row successively). 
 
 Lower Extremitij 
 
 upper epiphysis (head) 
 
 lower ,, 
 
 trochanter, great 
 ,, lesser 
 
 Tibia . . upper epiphysis 
 
 lower ,, 
 Fibula . upper epiphysis 
 
 lower ,, 
 
 Metatarsus 1st (proximal epiphysis) 
 
 ,, 4 outer (distal epiphyses) 
 
 Phalansfes ...... 
 
 10th month after birth. 
 
 2nd or 3rd week before birth. 
 
 4th year. 
 
 13th 3^ear. 
 
 2nd week after birth. 
 
 at 18th month after birth. 
 
 4th year. 
 
 2nd year. 
 
 3rd year. 
 
 about 4th or 5th to 8th year. 
 
 4th to 8th year. 
 
 ' ' Au membre superieur, pour les os cTu bras et de I'avant-bras, c'est Testremite con- 
 courant a former le coude qui s'accroit le nioins. 
 
ANATOMY 25 
 
 The period and order in which the consolidation of the epiphyses 
 with the shaft takes place vary considerably in the different bones, 
 in different individuals, and in the sexes. As Topinard remarks, 
 the times of union have, unfortunately for comparative anthropology, 
 been most studied among European races. They no doubt vary in 
 other races, and are important from an anthropological point of view. 
 The time of union of the epiphysis to the diaphysis proceeds in an 
 inverse order to the time of commencement of their ossification. 
 Thus at the upper end of the femur, the lesser trochanter, whose 
 ossification appears last, joins on first, then the great trochanter, next 
 the head. 
 
 The first to appear of all the epiphyses of the long bones is that 
 of the lower end of the femur, while the upper epiphysis of the 
 radius is one of the last, and it is not a little interesting to note that 
 the latter unites with the shaft almost the first, but the femur, as a 
 rule, the very last. The union between the epiphysial cartilage 
 and the diaphysis appears to be even and uniform, but the surface 
 of union is strengthened by small interlacing prominences or pro- 
 jections, so that portions of the diaphysis or scales towards the peri- 
 phery may be broken off in epiphysial separations. Generally, the 
 consolidation between the epiphyses and the shaft is completed at or 
 soon after puberty, i.e. the sixteenth to seventeenth year (Topinard). 
 In some instances, however, the union is not perfect till a consider- 
 ably later period — up to the twentieth year, and often till the twenty- 
 fifth in the irregular bones of the body, a thin layer of cartilage existing 
 between the epiphysis and the body of the bone even at this late period 
 of life. In females the union takes place a little earlier than in males. 
 Otto found none of the epiphyses united at the ages of twenty-two and 
 twenty-three, and noted the same in the case of a man aged twenty- 
 seven. Topinard believed that, generally speaking, the process was 
 completed earlier in the lower than in the upper extremity. He gives 
 (Anthropologie generale, 1885, p. 416) twenty-six jesbYS as the ter- 
 mination of this process in the male. 
 
 At the elbow-joint, injuries cannot be complicated with epiphysial 
 separation after the eighteenth year, while in the case of the knee 
 epiphysial separation of the tibia is possible up to the twentieth 
 or twenty-first year. 
 
 From some observations made upon the skeleton, Dwight has 
 come to the conclusion (' The Kange and Significance of Variation 
 in the Human Skeleton,' Boston Medical and Surgical Journal, 
 August 2, 1894, p. 97) that the union of distinct parts occurs 
 
 ' Au membre inferieur, pour les os de la cuisse et de la jambe, c'est I'extremite con- 
 courant a former le genou qui s'accroit le plus. 
 
 ' Les deux segments principaux d'un meme membre se trouvent par cela meme dans 
 un rapport inverse entre eux ; les os du membre sup6rieur sont aussi dans un rapport 
 inverse relativement aux os analogues du membre inferieur.' — Oilier. 
 
 These rules are of vast importance when the operations for resection of joints are 
 considered, as well as those for the injuries we are now concerned with. 
 
26 TEAUMATIC SEPAKATION OF THE EPIPHYSES 
 
 earlier than accords with the general teaching, to the speedy dis- 
 appearance of the epiphysial lines. 
 
 The site previously occupied by the epiphysial cartilage is 
 indicated for many years after complete ossification by a thin line of 
 osseous material. 
 
 The following table gives the 
 
 Times of Union of the Chief Epiphyses to the 
 
 DiAPHYSES OF THE LONG BoNES 
 
 upper Extremity 
 
 Clavicle .... 
 Humerus . upper epiphysis 
 
 . lower 
 „ . internal epicondyle 
 
 Eadius . upper epiphysis 
 
 . lower 
 Ulna . upper epiphysis 
 
 . lower 
 Metacarpus 
 Phalanges .... 
 
 22nd to 25th year. 
 18th to 22nd year. 
 17th year, 
 about 18th year, 
 about 16th year. 
 19th to 23rd year. 
 16th to 17th year. 
 18th to 20th year. 
 20th year. 
 18th, 19th, or 20th year. 
 
 Loiuer Extremity 
 
 Femur , upper epiphysis (head) 
 
 . lower 
 
 „ . trochanter, great 
 
 Tibia . upper epiphysis 
 
 . lower 
 
 Fibula . upper epiphysis 
 
 . lower 
 
 Metatarsus 1st (proximal epiphysis) 
 
 ,, 4 outer (distal epiphyses 
 
 Phalanges . (posterior epiphyses) 
 
 19th year. 
 
 20th to 23rd year. 
 
 18th to 19th year. 
 
 18th year. 
 
 21st to 22nd year. 
 
 18th year. 
 
 20th to 22nd year. 
 
 19th to 21st year. 
 
 19th year. 
 
 20th year. 
 
 17th to 20th year. 
 
 Topinard gives {Antliropologie generate, 1885, p. 1028) the 
 following table of individual variations of the times of union of the 
 epiphyses. It shows the extreme variations noted by this author, 
 and is interesting anthropologically. 
 
ANATOMY 
 
 27 
 
 Times of Union of the Epiphyses with the Body 
 OF THE Bone 
 
 Individual Vay'iations 
 
 Humerus 
 
 Bodies of vertebrae, upper and lower 
 
 epiphyses, dorso-lumbar . 
 
 Clavicle, inner end .... 
 
 /coracoid . . . . 
 
 „ , acromion .... 
 bcapula . i 1 . , . 
 
 ^ lower and posterior mar- 
 
 V ginal epiphyses 
 ''upper epiphysis 
 
 , Condyle (capitel- 
 
 lum), trochlea, 
 
 and outer tube- 
 
 ower^ rosity (epicon- 
 
 epiphysis^ dyle) . . 
 
 Inner tuberosity 
 (internal epi- 
 ^ condyle) . 
 j upper end .... 
 (lower end .... 
 j upper end .... 
 (lower end .... 
 /union of the three primary 
 
 ^ . portions .... 
 
 Us mno- ■ 1 
 
 minatuml^^^'^^® supplementary cen- 
 tres .... 
 'upper marginal epiphysis . 
 
 ^ (upper end .... 
 
 ±1 emur . 1 1 ■. 
 
 I lower end .... 
 
 „., . (upper end . . . . 
 
 Tibia .1 T 
 
 i lower end .... 
 
 „., , (upper end .... 
 Fibula . / ^ -, 
 
 i lower end .... 
 
 Os calcis ...... 
 
 Radius 
 
 Ulna 
 
 22nd to 26th year. 
 20th to 25th year. 
 14th to 17th year. 
 17th to 18th year. 
 
 22nd to 24th year. 
 21st to 25th year. 
 
 15th to 16th year. 
 
 16th to 17th year. 
 12th to 19th year. 
 18th to 25th year. 
 14th to 19th year. 
 21st to 24th year. 
 
 15th to 18th year. 
 
 14th 
 15th 
 16th 
 20th 
 18th 
 16th 
 18th 
 18th 
 16th 
 
 to 28th year, 
 to 16th year, 
 to 22nd year, 
 to 25th year, 
 to 24th year. 
 to 18th year, 
 to 22nd year, 
 to 19th year, 
 year. 
 
 Dwight gives {loc. cit. supra) the following table of the times of 
 union of the epiphyses of the long bones, but adds that the dates are 
 somewhat too late. It is here quoted, although in several particulars 
 the times are not quite accurate. 
 
 ' From sixteen to eighteen, lower epiphyses of the humerus 
 (except internal condyle), upper ends of radius and ulna, lesser 
 trochanter of femur. At eighteen, internal condyle of humerus, 
 great trochanter. 
 
23 TEAUMATIC SEPASATIOX OF THE EPIPHYSES 
 
 ' From eighteen to nineteen, head of femur, lower end of tibia. 
 From twenty to twenty-one or twenty-two, head of humerus, lower 
 end of radius and ulna, condyles of femur, lower end of fibula, u^^per 
 end of tibia. From twenty-two to twenty-four, upper end of 
 fibula. 
 
 Dwight's observations offer the following as a provisional chart 
 for seventeen years onwards : 
 
 ' At seventeen years things are much as described from sixteen to 
 eighteen, but perhaps a little more advanced. The lower end of the 
 humerus is joined, excepting possibly the inner condyle. Subse- 
 quently the process is more rapid, so that the epiphyses of the long 
 bones are usually firmly joined to the shaft at nineteen. At this age 
 the lines of union about the elbow, hip, and ankle are nearly gone. 
 At twenty all are indistinct or quite vv"anting. The epiphyses of the 
 crests of the ilia and of the posterior border and inferior angle of the 
 scapula are among the last to unite. They probably join at about 
 twenty-one, but the lines of the crests of the ilia may be seen in parts 
 for some years.' 
 
 Up to the present time the order of union of the epiphyses has 
 been investigated by Beclard, Cruveilhier, Humphry, Kambaud, 
 Renault, Sappey, &c., only in the case of Europeans; but, as Topinard 
 says, there is probably considerable variation in different races. 
 
 The new skiagraph}^ by Eontgen's process will undoubtedly in 
 the near future furnish us with very exact information as to the 
 appearance of the centres of ossification of the epiphyses, their 
 position and form at dilTerent ages, and, lastly, as to the time of 
 union of the epiphyses to the diaphyses. 
 
 As to the reason for the separate centres of ossification forming 
 the additional epiphyses or processes (apophyses), it is still a matter of 
 speculation. These do not contribute to the increase in length of the 
 shaft. 
 
 The . epiphysial or conjugal cartilage {cartilage de conjugaison), 
 cartilage of conjunction, or disc of cartilage is a very important struc- 
 ture. It is the cartilaginous layer or disc left by the ossification of 
 the epiphysis between it and the diaphysis. 
 
 The epiphysial line of junction is more or less transverse in 
 infancy, but as age advances the under surface of the epiphysis in 
 many of the long bones becomes cup-shaped, especially projecting 
 laterally, as at the lower end of the humerus, or anteriorly, as at the 
 upper end of the tibia. During adolescence and almost up to the 
 time of union of the epiphysis with the diaphysis it maintains a fairly 
 uniform thickness. It then disappears by its complete ossification. 
 Broca, in 1852 {Bulletins de la SocietS Anatomique, 1852), 
 though recognising that the different long bones increased in length 
 more by one extremity than the other, appeared to think that this was 
 due to the greater thickness of the chondroid layer {couclie cliondro'ide) 
 of the conjugal cartilage and to the relative height of the nutrient 
 
FEMALE INFANT AGED TWELVE MONTHS. 
 
 MR. T. P. COLLINGS'S GRANDCHILD. FIRST CHILD OF PARENTS. 
 
 ' Suap-shot ' exposure. Taken by Mr. Wm. WEBsraR. 
 
CHILD AGED TWO YEARS. THIRD CHILD. 
 
 Ossification in some respects more advanced than in the following skiagram. 
 
 Taken by Mr. Wm. Webster. 
 
CHILD AGED THEEE YEA.BS. EIGHTH CHILD. 
 Taken by Mr. Wm. "Webster. 
 
MALE CHILD AaEB FOUR AND A HALF YEARS. 
 2^ second exposure. Taken by Mr. Wm. Webster. 
 
CHILD AGED PIVE YEARS. SECOND CHILD OF PARENTS. 
 Taken by Mr. Wm. Webster. 
 
CHILD AGED FIVE YEARS. THIRTEENTH CHILD OF PARENTS. 
 
 Ossification not so advanced as in the followins sliiagram of a child of same ajre (second child), 
 
 and in some respects no further advanced than in skiagram of child of three years. 
 
 Taken by Mr. Wii. Webster. 
 
MALE CHILD AGED SIX YEARS. 
 
 jL second exposure. 
 
 Taken by Mr. Wm. "Webster. 
 
MALE CHILD AGED SEVEN YEARS. 
 I second exposure. Taken by Mr. Wm. W 
 
1 second exposure. 
 
 MALE CHILD AGED EIGHT YEARS. 
 
 Taken by Mr. W M. WKBSTKli. 
 
AUTHORS SON (R D. r.), AGFD EIGHT YEARS AND FIVE MONTHS. 
 Skiagiam of Hard takeu in Aiiril 1896 by Mr. C. S^yI^•TO^^ 
 
MALE CHILD AGED NINE YEAES. 
 
 1 second exposure. 
 
 Taken by Mr. Wji. Webster. 
 
1 second exposure. 
 
 BOY AGED TEN YBAKS. 
 
 Taken by Mr. Wm. Webster. 
 
1 second exposure. 
 
 BOY AGED ELEVEN YEAES. 
 
 Taken by Mr. Wm. Webster. 
 
i:p.(i_'i'"^^ 
 
 1 second exposure. 
 
 BOY AGED TWELVE YEARS. 
 
 Taken bv ilr. Wm. Webster. 
 
3 seconds exposure. 
 
 BOY AGED THIETEEN TEARS. Taken by Mr. Wm. Webstee. 
 
2 seconds exposure. 
 
 BOY AGED POUBTEBN YEARS. Taken by Mr. Wm. Webster. 
 
3 seconds exposure. 
 
 BOY AaED FIFTEEN YEARS. 
 
 Taken by Mr. Wm. Websieb. 
 
BOY AGED SIXTEEN YEAES. MK. T. P. COLLINGS'S YOrKGEST SOX (SIXTH CHILD). 
 4 seconds exposure. Taken by Mr. Wm. Webster. 
 
1 second exposure. 
 
 BOY AGED SEVENTEEN YEAES. Taken by Mr. Wm. Wf.BSTEH. 
 
ANATOMY 09 
 
 canal at the different ages. He laid considerable stress upon the 
 fact that the thickness of the chondroid layer is proportionate to the 
 activity of the local growth. 
 
 Oilier agrees in a general way with Broca in his theory that 
 ' I'activite de I'ossification est proportionnelle a I'epaisseur de cette 
 couche chondroide.' This is verified by his experiments on animals. 
 
 According to Oilier, fourteen-fifteenths of the length of a bone is 
 due to the activity of the diaphysial sm^face of the epiphysial discs. 
 This diaphysial surface has an osteogenic power twelve times greater 
 than that of the epiphysial surface, the ratio of growth being therefore 
 as twelve to one. The growth in length of a long bone takes place 
 in this layer of cartilage between the end of the shaft and the 
 epiphyses by the proliferation and successive ossification of the la^^ers 
 of the cartilage at their diaphysial surface. Physiological activity 
 is greatest in this situation, the epiphyses taking a very small part 
 in this process, so that we may say that the growth in length of the 
 long bones is the exclusive function of the epiphysial line of cartilage. 
 
 The layer — disc or bar — of cartilage -between the epiphysis and 
 the shaft varies with the age of the patient. As youth advances, 
 the epiphysial or conjugal layer of blue hyaline cartilage becomes 
 thinner, while in infancy there is a considerable mass of carti- 
 lage intervening between the ossifying centre or centres of the 
 epiphysis and the shaft. As its surface, however, is encroached upon 
 by its undergoing ossification in the part nearest to the diaphysis, 
 an interstitial fresh zone of cartilage is produced by proliferation of 
 the pre-existing cartilage, and a constant cycle of changes goes on 
 uninterruptedly so long as the growth of the bones continues — the 
 growth of the epiphysial cartilage always being, so to speak, in ad- 
 vance of the ossifying process. 
 
 The circumference or peripheral margin of the conjugal cartilage 
 projects over the outer aspect of the end of the diaphysis, and becomes 
 blended with and forms the deep or under layer of the periosteum. 
 
 This overlapping of the circumference of the conjugal cartilage 
 more or less accounts for the cup-shaped appearance of many of the 
 epiphyses into which the diaphysis is received at the age of puberty, 
 when the conjugal cartilage is fully formed. 
 
 The increase in length at the diaphysial ends of the same bone 
 is, as stated above, very unequal, so that all extremities of the long- 
 bones have not the same importance. 
 
 Oilier {TraiU de la regeneration des os, tom. i. and torn. ii. 1867) 
 has fully discussed the increase of the long bones generally, the 
 relationship of the unequal growth with the order of union of the 
 epiphysis, and with the direction of the nutrient canals. He has 
 investigated this unequal growth with reference especially to the 
 unequal thickness of the chondroid layer of the conjugal cartilage, at 
 the same time giving in detail many experiments. (See also ' De la 
 part proportionnelle qui revient a chaque extremite dcs os dcs membres 
 
30 TEAUMATIC SEPAKATIOX OF THE EPIPHYSES 
 
 dans leur accroissement en longueur,' Oilier, Journal de laphysiologie 
 cle Broion-Sequard, 1861 ; ' Eecherclies experimentales sur la mode 
 d'accroissement des os,' Oilier, Archives de physiologie, 1873 ; 
 ' De I'accroisseinent normal et pathologique des os,' Oilier, ' Congres 
 de I'Association fran9aise pour I'Avancement des Sciences, Session de 
 Lyon, 1S73 ' &c.) 
 
 iiki^nm 
 
 ^^^i/.^^-'-s 
 
 
 
 n 
 
 
 ''^ ( 
 
 -27 
 
 
 "1 U 
 
 < 1 
 
 1^'' 
 
 
 n 
 
 Fig. 2.— secticx of epiphysis through line of growing bone and periosteum 
 
 (macxajiaea) 
 
 A A, cartilage cells : some of them are seen to be undergoing fibroid changes; b b, 
 cartilage cells rapidly proliferating and becoming arranged into rows continuous 
 with the medullary spaces in the newly formed bone ; d d, nuclei of cartilage 
 cells passing into the medullary spaces of the bone. Along the sides of these 
 spaces some of the round cells are seen to be transformed into bone corpuscles. 
 c c, cartilage cells passing into and forming the deep layers of the periosteum. 
 Some of these cells are undergoing changes into bone corpuscles ; e e, the inner 
 layers of the periosteum ; g g, the outer layers of the periosteum. 
 
 It is conclusively shown by this observer and others that when 
 two metal nails are inserted — at a given distance apart, but nearer to 
 the upper epiphysis than to the lower — into the diaphysis of the long 
 bone of an animal, the distance between the nails is the same after 
 the bone has grown, but that the upper nail is now further from the 
 upper epiphysis than the lower nail is from the lower epiphysis, 
 
ANATOMY 31 
 
 thus proving conclusively that the chief growth in length of the bone 
 is at the upper epiphysis. 
 
 Flourens erroneously supposed that all long bones increased more 
 by their upper than by their lower epiphyses. 
 
 The difference in the various epiphyses as regards the growth in 
 length of the bones has also been investigated by Kolliker, Vogt, 
 Humphry, Schwalbe (' Ueber die Ernahrungskanale der Knochen 
 und des Knochen wachsthums,' Zeitschrift filr Anatomie unci Ent- 
 luicklimgsgeschichte,' 1876, i. s. 307), Strelzoff, and others. 
 
 The rate of growth, as well as the value, of each of the epiphysial 
 cartilages of the long bones is very exact on the opposite sides, 
 although so unequal at each end of the same bone. All this is more 
 fully alluded to under the head of ' Epiphysis.' 
 
 What we know of the function of the epiphysial cartilage from 
 experiments is corroborated by pathological as well as clinical 
 experience. Conical stumps are continually found in the arm and 
 leg, after amputation, from continued growth at the upper epiphysial 
 lines of the humerus, fibula, and tibia. The radius, ulna, and femur 
 mainly depending upon their lower epiphyses for increase in length, 
 such stumps in the forearm and thigh from this cause are seldom 
 found in children. See discussion at the Societe de Chirurgie in 
 1858 {Bulletin de la Societe de Chirurgie, 1859). 
 
 Humphry has also made experiments on the limbs of animals 
 and proved the same thing {Medico-chiritrg. Transactions, 1861, xliv. 
 p. 117), but, as he truly states, this elongation frequently fails short 
 of the proper amount and is not in precise proportion to the corre- 
 sponding bone of the opposite healthy limb. Again, the indirect 
 irritation of a long-continued osteo-myelitis or chronic endostitis 
 may stimulate the conjugal cartilage to increased growth and 
 increased length of the bone. Excessive elongation from such a 
 cause must therefore not be looked upon as a healthy growth. 
 
 Mr. Bryant {Practice of Surgery, vol. viii.) describes the case of 
 a boy aged seven years, whose leg was amputated. Subsequently, 
 on two occasions, at intervals of three years, it became necessary 
 to remove a piece of the tibia an inch long ; the tibia grew faster 
 than the fibula, so that at the second operation the fibula required no 
 shortening. Mr. Bland Sutton, in a lecture on ' Amputation Stumps ' 
 {Lancet, December 8, 1888), alludes to a similar case in a girl aged 
 thirteen years under his care at the Middlesex Hospital. She had had 
 amputation of the leg performed, for injury, at the age of two years. 
 
 It is a question whether it would not be justifiable intentionally to 
 destroy the central layer of the epiphysial cartilage, and so arrest 
 the growth at the epiphysial line at the time of amputation. 
 
 The cartilaginous line between the epiphysis and the shaft is 
 more or less transverse, but is much altered in its direction by pro- 
 C3sses of the epiphysis in certain directions ; e.g. in the upjDer end 
 of the tibia there is a tongue-shaped process extending from the 
 
32 TEAUMATIC SEPAKATION OF THE EPIPHYSES 
 
 epiphysis downwards in front, forming a part of the anterior tubercle ; 
 and in the lower end of the humerus, on the inner and outer side, a 
 bending upwards (up to a certain period) to form the inner and after- 
 wards the outer epicondyle. It is more often concavo-convex on its 
 surface and sinuous, as is well seen in the case of the lower end of the 
 femur {very marked in the lower animals), and affords a remarkable 
 reciprocal socket between the epiphysial cartilage and the diaphysis. 
 
 This sinuous appearance is but little marked at birth, when the 
 surface of the epiphysis is more distinctly cnp-shaped, but is more 
 and miore characteristic as the time of union of the epiphysis with 
 the diaphysis is approached. 
 
 Although by reason of its softness the conjugal cartilage predis- 
 poses to epiphysial separation, and to certain inflammatory diseases 
 
 viz. acute epiphysitis, ulceration, &c. — yet it must not be forgotten, 
 
 as Sir George Humphry says {A Treatise on tJie Human Skeleton, 
 1858, p. 42), ' that advantages, more than outweighing these incon- 
 veniences, accrue to the young subject from this subdivision of its 
 skeleton and the interposition of cartilaginous plates between its 
 segments. Besides the greater facilities for growth thus afforded, 
 its flexibility is thereby greatly increased, and its escape from injury 
 durino- the many falls incidental to this time of life is, in no small 
 degree, attributable to this cause.' 
 
 The epiphysial discs also act as barriers to the articulation and for 
 a time prevent inflammation of the diaphysis and medulla spreading 
 to and invading the joints. All round their circumference they are, hke 
 the epiphyses, intimately connected and blended with the periosteum. 
 On the side next the epiphysis continual proliferation takes place, 
 while on the diaphysial side there is a production of osseous material 
 wdiich is permanent, the process of ossification being identical with 
 that of the cartilage of the epiphyses themselves. 
 
 To the naked eye the division between the diaphysis and epiphysis — • 
 viz. the passage of the cartilage into the osseous tissue — appears very 
 abrupt, but on closer examination it looks less so. In infancy the 
 separation between the diaphysis and epiphysis is more decided and 
 abrupt than in adolescence, when it becomes a Httle less distinct. 
 In reality the gradation of cartilage into bone is imperceptible. 
 Broca was one of the first to distinguish two layers or zones in this 
 region, and his description has been generally accepted by histolo- 
 gists, such as Todd and Bowman, Eanvier and Eobin. 
 
 The first zone or proliferating layer {couche chondro'ide, Broca) 
 is composed of the normal cartilage, and is of a light bluish colour 
 and translucent. Its thickness varies from one to two mihimetres. 
 The cells have lost their angular foetal shape, and have become 
 enlaro-ed, more numerous, rounded, and arranged in columns or 
 linear series which are less regular as the unossified part is reached 
 (cartilage seriS). These columns are separated by longitudinal 
 intervals. 
 
ANATOMY 33 
 
 This chondroid zone is said to be more distinct in some bones 
 than in others ; it is very distinct at both ends of the tibia, the 
 upper end of the humerus, the lower end of the fibula, and the lower 
 ends of the bones of the forearm ; very thin at the upper end of the 
 femur and at the lower end of the humerus, and almost completely 
 absent at the upper end of the fibula, ulna, and radius. 
 
 The second zone or osteoid layer of Eanvier {couclie ostCoide; couchs 
 spongoide, Broca) is of a yellowish grey colour, granular, and opaque. 
 Here there is a simple calcareous deposit which without any formation 
 of true osseous tissue takes on an appearance somewhat resembling 
 it. In this manner a reticulated calcified cartilage is produced 
 {cartilage calcifie, Gegenbauer ; la zone granuleuse, Eobin). The 
 cartilage cells are still present. The areolse are more delicate 
 than those of the ordinary spongy osseous tissue and are more 
 friable. 
 
 The blood vessels are dilated and form loops or sinuses springing 
 from the already formed medullary cavities of the bone, which invade 
 and cause absorption of the calcified cartilage. The rows of cells 
 disappear towards the osseous tissue and the cartilage cells become 
 dissociated. 
 
 It is into these meshes of the calcified substance that the 
 osteoblastic tissue penetrates. These last procedures constitute the 
 commencement of true ossification. 
 
 The osseous layer (couche osseuse, Eanvier) is that portion 
 beyond, where some osseous cells are found deposited in the carti- 
 laginous arches separating the first medullary spaces, and is therefore 
 composed of temporary and brittle bone. 
 
 From the fact of a partial absorption of the cartilage, and the weak 
 and dilated condition of the vessels in a part where the true osseous 
 tissue is not found, we can fully realise the comparatively weak 
 nature of this region. 
 
 The important physiological rd/e of this cartilage will be found 
 under Peognosis, but we can readily see that the irritation or 
 destruction (partial or complete) of this structure will very materially 
 modify this function. 
 
 It is unnecessary here to reproduce the experiments of Oilier 
 upon animals ; the reader must refer to his work De la regenera- 
 tion des OS, Paris, 1867, pp. 394-396 ; also fig. 27, p. 395. He found 
 that simple incision of the conjugal ca.rtilage retards the growth, 
 whilst lesion of the same produces complete want of development 
 of the bone. In Germany the subject has been studied by Bergniann, 
 Billroth, Langenbeck (1869), Weinlechner and Schott (1869). 
 
 The direction of the conjugal line of cartilage, its relation to 
 the neighbouring joint, audits precise distance from the interarticular 
 line can be best studied on the living subject by means of the new 
 skiagraphy. By this method the position of the lines of cartilage of 
 the various epiphyses at different ages can be determined ; and it will 
 
 D 
 
34 TEAUMATIC SEPAEATIOX OF THE EPIPHYSES 
 
 doubtless supplement the information here given in onr several 
 chapters. 
 
 The jttxta-epipliysial region of Oilier at the end of the diaphj^sis 
 is the soft sjDongy layer of the bone uniting this latter with the 
 conjugal cartilage, and in it the most active processes take place. 
 The epiphysial line is here of a reddish colour and very vascular. 
 
 This region is the weakest part of the bone, and the one which 
 gives way first to external violence, so that, as M. RoUet remarks, 
 the lesions under consideration are not strictly epiphysial but juxta- 
 epiphysial. The layers of new bone adjoining the cai-tilaginous layer 
 are soft and spongy. Oilier, in his experimental researches on the 
 growth of bones, has clearly demonstrated the importance of the juxta- 
 epiphj^sial region (Oilier, Encydojy. internationale de chirurgie : 
 ' Maladie des os,' tom. iv. 1885 ; Traite des resections, tom. i. and ii., 
 Paris, 1885 and 1888). 
 
 Tlie periosteum in young subjects is a thick, vascular, greyish-white, 
 fibrous structure, and forms the external covering of the diaphysis, 
 except where the tendons and aponeuroses are attached. It becomes 
 continuous with the periarticular ligaments at the articular ends or 
 epix^hyses, and forms one of the principal bonds of union between 
 the epiphysis and the diaphysis. Many experimentalists have found 
 that if the periosteum be removed the epiphysis may be very readily 
 detached from the diaphj^sis. It is a most important structure 
 owing to the x^art which it takes in reproducing osseous tissue, and 
 contains vascular plexuses which, together with some delicate fibrous 
 tissue, enter the foramina on the surface of the bones and help to 
 bind the periosteum to the bone. But in young subjects it can be 
 readily separated from the diaphysis. It is composed of tico layers, 
 the one consisting of connective and elastic fibres, with adipose 
 tissue, in which the vessels and nerves ramify, the other of osteo- 
 genic tissue. The outer layer is a fibrous membrane, in which the 
 elastic fibres become more nmnerous as the inner part is reached. 
 The imier layer in contact with the bone comprises a network of 
 very fine elastic fibres, in the meshes of which are found cells which 
 form bone during the active time of development, and add to their 
 thickness externally. This is known as the osteogenetic layer. The 
 cells of which it is composed are osteoblastic. 
 
 Epiphysial separations are of less frequent occurrence than 
 they might be, not so much on account of the firmness with 
 which the epiphysis adheres to the shaft, as in consequence of the 
 great support given at the epiphysial lines of junction by the 
 periosteum. At this part the periosteum is very thick and strong, 
 becoming thinner and more loosely attached to the bone as it passes 
 along the shaft. The periosteum is tougher and more resisting 
 during the first few years of life than later on. At this early period 
 it forms the chief bond of connection between the epiphysis and 
 diaphysis. The great cartilaginous mass of an epiphysis is intimately 
 
ANATOMY 35 
 
 connected with the periosteum and appears to be, as it were, a 
 massive expansion of the periosteum of the diaphysis on which it is 
 placed and grows. Duhamel, indeed, regarded the epiphyses as 
 formed by such an expansion or enlargement of the periosteum, on 
 account of this intimate connection of the periosteum with the 
 conjugal cartilage and cartilaginous ends of the bones. The 
 periosteum proper does not reach beyond the cartilage ; it has there- 
 fore no part in the ossification of the epiphysis. This function of 
 the periosteum, serving to unite the epiphysis with the diaphysis, is 
 well illustrated in Wilson's experiments, in which the epiphysis was 
 much more readily detached from the diaphysis after the removal of 
 the periosteum. 
 
 As we shall see hereafter, the tough periosteum by its intimate 
 connection with the epiphysis will very frequently prevent any dis- 
 placement when epiphysial separation has occurred, and will often 
 (by its swelling &c.) effectually mask the nature of the lesion even 
 when sUght displacement has occurred. 
 
 During adolescence the periostemn becomes thinner and more 
 adherent. It is then more likely to be lacerated, and to a less 
 extent stripped off the diaphysis in traumatic epiphysial separations. 
 
 In some situations, as over the great trochanter, the olecranon 
 process of the ulna, and part of the acromial process of the scapula, 
 the periosteum becomes very thin, if not entirely deficient. The dense 
 tendinous fibres which are present in these instances are almost 
 directly attached to the osseous tissue itself. 
 
 In such instances the periostemn is more likely to be torn across 
 in epiphysial detachments if the violence be sufficiently great to 
 lacerate the powerful tendinous fibres covering these processes and 
 to allow of displacement. 
 
 The periosteum is also the principal factor in the production of 
 callus for the union of the fragments after epiphysial separation. 
 
 From the second or third year onwards the periosteum begins to 
 diminish in thickness ; by the tenth to fifteenth it is so much 
 thinner that many of the older writers believed that the periosteum 
 at this later age was more liable to be lacerated than to separate off 
 from the diaphysis, as usually occurred in younger life. After the 
 union of the epiphysis with the diaphysis, and therefore after the 
 growth in length of the bone is complete, the growth in thickness is 
 still carried on by the periosteum. 
 
 Oilier has proved that if the whole surface of a periosteal layer 
 is scraped after being detached, new osseous material will not be 
 reproduced under the portion so treated. His experiments on 
 animals have recently (1892) been entirely confirmed by Matchin- 
 sky's observations on the human subject. 
 
 The nerves and vessels and lymphatics ramify in the periosteal 
 membrane before entering the diaphysis, which they do by the 
 large orifices freely scattered over its surface. 
 
36 TEAUMATIC SEPAEATIOX OF THE EPIPHYSES 
 
 The nerves mostlj^ belong to the sympathetic system, and are 
 not very abundant in number. 
 
 The articular cartilage capping the layer of compact tissue at 
 the extremity of the epiphysis is composed of hyaline cartilage with 
 its characteristic cells, or chondroblasts, and its homogeneous inter- 
 cellular substance. This permanent articular cartilage is the 
 remains of the original cartilage forming the epiphysis, so that the 
 ossification of the epiphyses may be said to be never completely 
 accomplished. 
 
 The s}Tiovial membrane extends for a short distance over the 
 caii;ilage to which it is strongly adherent, but is absent where the 
 articular cartilage is in apposition with its articular fellow. 
 
 In the encrusting or articular cartilage of the epiphyses the 
 cartilage cells are arranged at their deeper parts in columns at right 
 angles to the surface of the bone, while the superficial ones He 
 parallel to its surface. 
 
 It is sufiicient to allude to this point in Prof. Sir George 
 Humphry's words (A Treatise on the Human Skeleton, 1858, p. 41) : 
 
 ' It is remarkable that, although the cartilage of an epiphysis 
 presents throughout the same characters, ossification takes place in a 
 part of it only ; a thin portion next the surface of the joint remains 
 unossified, and forms the articular cartilage. This becomes in course 
 of time somewhat more opaque and more dense ; but I am not aware 
 that it has ever been known to be converted into true bone, even in 
 morbid states or in old age.' 
 
 In its deeper portion, however, near the bone, this cartilage 
 frequently calcifies in old age. Oilier, Busch, Ogston, and others 
 think that in later years, besides their mechanical function, the 
 articular cartilages are connected to a slight extent with the x^ro- 
 duction of new bone, repairing the constant loss of this tissue from 
 pressure at the articulation. 
 
 Relation of articular capsule to conjugal cartilage. — Another 
 most interesting anatomical condition is the exact relationship or 
 attachment of the capsule of the joint with regard to the limit of 
 the epiphysis. If the capsule be attached beyond this boundary, a 
 separation of the epiphysis ^dll be an intra-capsular one, and the 
 synovial membrane of the joint will probably be opened. 
 
 The relation of the capsule to the epiphysial cartilage in manj^ 
 instances alters with the age of the individual. 
 
 Relation of synovial membrane to conjugal cartilage will be discussed 
 along -with each individual epiphysis. It is of great importance 
 in certain epiphyses which may be considered as intra-articular. 
 During infancy the osseous centre of the cartilaginous epiphysis of 
 several of the long bones is wholly surrounded by the synovial 
 membrane. This relationship has been the subject of some investi- 
 gations by Schwegel in 1858, who has written a work on the develop- 
 ment of the epiphyses {Die EntwicJxelungRfjcschichte der Knochen 
 
ANATOMY 37 
 
 des Stammes mit Bilcksicht auf Cliiritrgie, dx. ; Wien, 1858), by Sesary 
 (' Eecherches sur les synoviales considerees dans leurs rapports avec 
 les extremites des os longs,' Lyo7i Medical, 1870, p. 227 ; and Bull. 
 SoG. Anat de Paris (1870), 1874, xlv. pp. 104-9), by J. Uffelmann 
 (Anato7?iisch-chirurg. Studien oder Beitrdge z. d. Lehre von den 
 K7ioGhen jugendlicher Individuen, Hameln, 1865), and by Dr. A. 
 V. Brunn {Das Verhdltniss der Geleiikkajjsehi zu den Epiphyseal, 
 Leipzig, 1881). 
 
 Projecting processes which have special nuclei forming separate 
 epiphyses have little to do with the increase in length of the bone. 
 They are intended rather for the greater strength and the firmer and 
 more extensive attachment of the powerful tendons, muscles, or 
 ligaments with which they are connected, e.g. great and lesser 
 trochanters of femur, inferior angle of scapula, iliac crests, &c. 
 
 The exact size, form, and situation of these are important details 
 to the surgeon. 
 
38 TEAUMATIC SEPAKATION OF THE EPIPHYSES 
 
 CHAPTEE HI 
 ETIOLO&Y, AGE, SEX 
 
 ETIOLOGY. — GuELT thought the rareness of these traumatic 
 separations was due to the fact that children are seldom exposed to 
 sufficient violence to produce them. In the eighteen cases he 
 was able to collect it was clear that the violence was much greater 
 than that which is the usual cause of fracture at the corresponding 
 periods of life. 
 
 He believed that, with the exception of the cases produced on 
 infants during delivery, the amount of force required was very 
 considerable. Thus in three of the cases the fracture was produced 
 during the delivery of the child by traction upon the foot, arm, or 
 axilla ; in seven, it was the result of severe falls ; in five the limb 
 was caught by machinery or between the spokes of a waggon wheel ; 
 and in one, separation of the upper epiphysis of the humerus was 
 produced in a child three years old by jerking its arm. 
 
 Boyer says ' que, dans les jeunes sujets, les causes capables de 
 produire la fracture du col de I'humerus peuvent donner lieu a la 
 separation de I'epiphyse superieure d'avec le corps de I'os ' (Boyer, 
 TraiU des maladies chirurgicales, tom. iii. p. 211, 4''™^ ed.). 
 
 Taken as a whole the causes which produce these lesions are the 
 same as those of fracture, but as a rule they are more severe. This 
 is especially true as regards such severe forms of separation as have 
 been examined anatomically (see under PATHOLOGiCAii anatomy). 
 There are, however, differences according to the epiphysis involved, 
 and in many of these cases the violence is less than what would 
 produce fracture of the same bone — e.g. hyperextension at the knee. 
 
 The precise mechanism of these lesions has also now been pretty 
 well established by numerous experiments on the dead subject. 
 
 An injury which would be sufficient to produce a dislocation in 
 an adult will in the child produce a separation of the epiphysis ; 
 epiphysial separation in the child may indeed be called the analogue 
 of dislocation in the adult. 
 
 Children at the age of puberty are more exposed to injuries by 
 reason of the games they play, and of their erratic tendency and 
 generally thoughtless doings ; in this way some have attempted to 
 prove the greater frequency of epiphysial separation in them than in 
 children during the first few years of life, when they are more under 
 protection and guidance. 
 
ETIOLOGY, AGE, SEX 39 
 
 Pathological separations. — A slight violence applied to an epiphysis 
 in a young subject with some constitutional affection is often 
 sufficient to cause its separation, without producing any displace- 
 ment. (See Separation of epiphysis of head of femur.) 
 
 Eickets so alters the normal condition of the end of the diaphysis 
 and the epiphysial structure that separation under these conditions 
 is entirely different from that occurring in healthy subjects. 
 According to M. Oilier, it is not, in rachitic children, that the cartilage 
 has a greater tendency to separate from the diaphysis (for it is, on 
 the contrary, more adherent than in healthy children) ; but that 
 bending and solution of continuity take place in the bulbar region 
 of the bone {region hulhaire, Lannelongue) between the limit of the 
 medullary canal and the spongy layer. The weak spongoid material 
 produced from the epiphysial cartilage, though irregularly formed and 
 with wide meshes, is true osseous tissue. 
 
 Other conditions, such as starvation, septicaemia, pyaemia, tubercle 
 (Maisonneuve) , scurvy, congenital syphilis, prolonged mercurial treat- 
 ment (Lobstein), &c., which produce more or less grave alterations 
 in the skeleton, must be placed in the same category as rickets. 
 
 Iscovesco describes (Congres frangais de chirurgie, tom. v., Paris, 
 1891, p. 696) four cases of epiphysial fracture produced by forcible 
 attempts at straightening for white swelling of the hip and knee. 
 
 In certain cases, then, it is exceedingly difficult at first sight to 
 express a very decided opinion as to the separation. The diseased 
 or unhealthy condition of the child may have been entirely over- 
 looked by the parents, or a previous illness been intentionally kept 
 from the notice of the surgeon. In snch cases the slight degree of 
 violence causing the injury is always a suspicious factor. Where 
 the violence appears to be inadequate for the production of separa- 
 tion, a careful examination of the general condition of the child 
 should be made in order to determine the existence of any of the 
 above-mentioned conditions. 
 
 Suppuration of a single epiphysis causing separation is frequently 
 detected, and distinguished from a true traumatic separation by 
 the presence of a fistula. This must not be confounded with 
 suppuration due to traumatism ; the former is usually more acute, 
 the latter chronic. 
 
 At first sight it might be supposed that on limbs affected with 
 infantile paralysis or paralysis from cerebral disease, separation of 
 the epiphyses would occur from slight violence, but in the author's 
 experience such is not the case. Separation may take place in a 
 child so affected but not more easily than in one in a healthy con- 
 dition. This seems strange, but nevertheless it is a fact. 
 
 Indirect violence is the most frequent cause of detachment of the 
 true or osseous epiphysis, and it is generally of a severe character. In 
 this respect these injuries are much more like dislocations than 
 fractures — being occasioned by such violence as a fall from a height 
 
40 TKAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 (as, for example, out of a second or third story window, or from a mast- 
 head to a ship's deck or into the hold ; from a tree, or from crags) or by 
 a fall whilst running— such falls being on to the extremity of the limb, 
 which transmits the shock to the epiphyses. Or again, a child may 
 have fallen with one of its joints doubled beneath it, the joint being 
 thus fixed in position and receiving the weight of the body. 
 Another frequent cause is the entanglement of the limb in the re- 
 volving wheel of a vehicle, in the revolving wheel or strap of 
 machinery, or in a ship's rope ; or the patient may have been rolled 
 round by the band of a machine. All these are examples of the 
 greatest indirect violence to which a limb can be exposed, and combine 
 traction vv^ith torsion. Violently lifting the child by its limbs is also 
 a not infrequent cause. Keichel believed this to be a very common 
 mode of injury, resulting in the separation of the humeral head. 
 
 In other cases the limb, or part of the limb, may be fixed and the 
 rest of the body violently thrown in one or other direction : in climb- 
 ing over a fence, for instance, the foot may be caught in the rails at 
 the top and the child fall to the opposite side ; or the leg may be 
 caught in a hole or between the joists of a floor, or otherwise fixed, 
 and the child fall forwards ; or the toe may be pushed under a door, 
 and an attempt be made to withdraw it. 
 
 The less severe forms of epiphysial separation, in which the 
 displacement is not complete and which are diagnosed clinically as 
 belonging to this class of injury, are found to be caused by a pro- 
 portionately smaller amount of violence. A fall from a short height — • 
 for example, off a tree a few feet high — is sufficient to separate the 
 upper epiphysis of the humerus, but not to completely displace the 
 fragments. Or a fall on the palm of the hand whilst walking may 
 suffice to separate the lower epiphysis of the radius. 
 
 In infancy the cartilaginous and elastic condition of the epi- 
 physes assists materially in preventing separation. 
 
 Direct traction on the axis of the limb. — Violent traction of the 
 limbs at birth has frequently produced separation, but many of these 
 cases may have been associated with disease and cannot be con- 
 sidered as authentic ; moreover, they were doubtless combined 
 with some torsion of the limb. It is certain that direct traction, 
 however forcible, will less readily detach an epiphysis than force 
 applied obliquely or at right angles to the axis of the bone. Thus 
 M. Champion in 1810 observed {Journal Complement aire, tom. i. 
 p. 817) separation of the lower epiphysis of the left tibia in a child 
 at birth by violent pulling on the foot. 
 
 Madame Lachapelle gives {Pratique des Accouchements, tom. ii. 
 p. 225, and tom. iii. p. 180) a similar case from a like cause ; and 
 another in which the traction on the foot separated at the same time 
 the inferior epiphysis of the femur and the superior epiphysis of the 
 tibia. In both these instances, as well as in that quoted by Bertrandi 
 of separation of the humerus, the children were born dead. 
 
ETIOLOGY, AGE, SEX 41 
 
 A similar separation was observed by Chapelain Durocher {These 
 l7iaugurale, Paris, 8 Frimaire, an xii.) in a child which survived 
 fourteen months ; the midwife caused it by hooking her finger in 
 the attempt to assist the delivery. Obstetric physicians have from 
 time to time noted cases of separation of the epiphysis of the femur 
 and tibia from traction on the lower limbs during pelvic version or 
 in delivery by the breech. 
 
 Bailly {Nouveau Dictionnaire de Medecineet de CJiirurgie pratique, 
 1872, XV. p. 33) briefly notes the possibility of these injuries. 
 
 Dr. Carl Kuge has also {Zeitschriftfilr Geburtshillfe und Frauen- 
 kranhlieiten, Berlin, 1876, s. 86) alluded to the same amongst the fre- 
 quent and unsuspected injuries to the foetus produced during delivery. 
 Pajot thought that epiphysial separations, as a consequence of 
 obstetrical manipulations, were more frequently met with than 
 fractures or dislocations. 
 
 Dr. Sam. E. Milliken, of New York, records {Archives of Pedia- 
 trics, vol. xii. 1895, p. 611) a case of separation of both ends of the 
 humerus during delivery. The labour had been a tedious one. The 
 separation of both epiphyses was complete. 
 
 Forcible torsion. — M. Chan:irpion {he. cit. supra) has given two 
 remarkable examples du€ to twisting in boys from eleven to thirteen 
 years old. One had his arm caught in the spokes of a wheel, and 
 the other had his forearm entangled in a carding machine. In the 
 former there resulted separation of the superior, and in the latter of 
 the inferior, epiphysis of the humerus. 
 
 M. Bicard has recorded (S. Duplay et P. Beclus, Traite de 
 chirurgie, tom. ii. 1890, p. 346) a very clear case in a lad aged nineteen 
 years, who had the upper epiphysis of the left humerus separated by 
 his arm being seized and violently twisted. 
 
 Beichel mentions forcible rotation of the upper extremity as a 
 cause of disjunction of the upper epiphysis of the humerus. 
 
 Direct violence. — Direct violence, such as the passage of a cart- 
 wheel over the limb, or severe violence applied directly to the 
 epiphysis (or in the situation of the epiphysial cartilage), as from the 
 fall of a wall or heavy weight upon the part, is the common cause 
 of separation of the epiphyses at all periods as well as of detachments 
 of the cartilaginous ends of the bones in infancy. Ordinary direct 
 blows and injuries, however, do not so frequently give rise to separa- 
 tions of the epiphyses as they do to fractures. The rarity of injuries 
 I)roduced by direct violence is dependent upon the small size of many 
 of the epiphyses. 
 
 Malgaigne expresses the opinion that epiphysial separation could 
 only be due to indirect causes, and states that there are no examples 
 of such results from direct blows. The number of cases of un- 
 doubted separation of the upper end of the humerus from blows or 
 falls on the shoulder nowadays conclusively refutes such a statement. 
 Violence applied in the neighbourhood of a joint in children is 
 
42 TRAUMATIC SEPARATION OF THE EPIPHYSES 
 
 miTcli more likely to be followed by an epiphysial separation than a 
 fracture, although it may be only partial or complete, with or without 
 displacement of fragments. 
 
 Compression separations of the epiphyses are a constant accom- 
 paniment of severe crushings of the limbs in the neighbourhood of 
 joints in children, and they often occur in hospital practice. 
 
 Muscular violsnc3. — Grross {Si/stem of Surgery, vol. i. p. 935, 5th 
 edit. Philadelphia) asserts that there is no example in which 
 muscular action alone has ever determined the detachment of any 
 epiphysis ; and Nelaton expresses a doubt on this point {Traite de 
 pathologie ext. tom. ii. p. 235, 1867) ; yet many instances are now 
 recorded of epiphysial separation by muscular action, and several 
 have been verified by an autopsy. Van Swieten attributed separa- 
 tion of the femoral head to the muscular action of a child in arms 
 throwing itself violently backwards. The cases described by 
 Ingrassias (great trochanter) and Eoucher (upper end of humerus), 
 which have been often quoted, are very doubtful. The latter case 
 of Bouchut's was probably one of acute epiphysial osteomyelitis. 
 A girl, aged thirteen, on taking an embroidery frame down from a 
 wall, felt a crackling and acute pain in the left shoulder. Suppura- 
 tion and signs of acute infective fever supervened, followed by death 
 at the end of the sixth week (see Uppee epiphysis of the humeeus). 
 
 A case is related by Mr. Christox3her Heath {loc. cit. infra) of a 
 boy who separated the epiphysis of his clavicle whilst raising his 
 arm violently to bowl at cricket. 
 
 The lesser trochanter of the femur, the anterior iliac spine, and 
 anterior inferior spinous processes have been detached by muscular 
 violence. Strong action of the biceps has occasionally torn off the 
 upper fibular epiphysis. (Stanley Boyd, Treves' System of Surgery, 
 vol. i. 1895, p. 734.) 
 
 Violent movements, acting directly upon an articulation or upon 
 the contiguous bones themselves, which in an adult produce stretch- 
 ing and laceration of the ligaments, or even detachment of portions 
 of bone into which these are inserted, produce in young children 
 lesions of the spongy juxta-epiphysial region of the diaphysis. The 
 bulbous portion is the most yielding and least consistent part of the 
 bone, and gives way rather more easily than the ligaments or the 
 cartilaginous epiphyses, which escape injury by reason of their 
 elasticity. This yielding of the bulbous region (Lannelongue) of the 
 diaphysis, giving rise to ecchymosis, crushing, and laceration of its 
 substance, is of common occurrence in infancy, and very frequent 
 in rachitic children. The epiphysial cartilage being relatively more 
 adherent to the diaphysis in them than in healthy children, the 
 slightest force only is sufficient to lacerate the soft tissues at the 
 juxta-epiphysial line. Injuries of the juxta-epiphysial region present 
 various lesions of the spongy and compact peripheral layer of the 
 bone, and are grouped by Oilier {Bevue de Chirurgie, 1881) under 
 
ETIOLOGY, AGE, SEX 43 
 
 the name of juxta-ejjiplujsial sprains \i'entorse jiixta-epiphysaire). 
 Although not apparent from the outside, they are yet important 
 lesions, since they are the immediate or remote cause of various 
 inflammations of the bone or joints. Sach lesions are of especial 
 importance in children predisposed to tubercle, or who have suffered 
 from septic poisoning. Many of the pains called ' grov^ing pains ' 
 are due to juxta-epiphysial sprains or injury. A juxta-epiphysial 
 sprain is often nothing but the first degree of an epiphysial separa- 
 tion, in the same way that an articular sprain is nothing but the 
 first degree of dislocation. 
 
 AGrE. Intra-uterine separation of an epiphysis. — The occurrence of 
 this injury apart from disease appears to the author to be extremely 
 doubtful. M. Piscart was one of the earliest authors who considered 
 intra-uterine separations possible. Eognetta says that a fall upon the 
 abdomen in the ninth month of pregnancy, or a violent blow can 
 give rise to this injury. Gueretin doubted the reality of such cases. 
 There is no authentic case recorded in this country, such cases as 
 that described by Carus {Archives gen. de medecine, tom. xvi. p. 288) 
 in a six-months-old foetus, where the lower epiphysis of the tibia was 
 found separated, and the projecting bone necrosed at the delivery at 
 full term, being extremely rare. The mother had fallen from a height 
 upon the abdomen ; she immediately felt the foetus violently move, 
 but soon these movements ceased. Reduction was unsuccessfully 
 tried, and the child died on the thirteenth day. Other instances have 
 been described by Velpeau (Lancette frangaise, tom. v. p. 368), Mon- 
 teggia, Kognetta, and Cliaussier (Journal de Medecine, No. 43). 
 
 Devergie relates the case of a woman who had struck herself 
 against the corner of a table at the sixth month of pregnancy and 
 gave birth to a child having a separation of the lower epiphysis of 
 the tibia, the upper fragment projecting through a wound. 
 
 Epiphysial separation during childbirth. — Many cases are recorded 
 by Bertrandi (upper epiphysis of the humerus and femur from 
 traction on the arms or feet by the midwife), also by Bitot, Volk- 
 mann, Moldenhauer, De la Motte (upper epiphysis of the humerus), 
 Champion (lower end of the tibia), Dubroca (upper epiphysis of the 
 humerus), and others, as occurring during childbirth from excessive 
 or awkward traction by the accoucheur ; but it is questionable 
 whether many, if not all, were not due to a diseased, or at any rate 
 an altered, condition of the bones. 
 
 Cruveilhier, in 1849, declared with much veracity that these were 
 due to putrefactive changes following the death of the child before 
 birth. In Bitot's case {Gaz. Medicale de Paris, 1860, p. 361) the infant 
 lived twelve days, and on section the epiphysis appeared to be uniting 
 to the diaphysis by soft, spongy bone. 
 
 It is true that attempts to produce dislocations, as at the liip, by 
 traction on the limbs of the foetus only separate the cartilaginous 
 ends of the bones. 
 
44 TEAUMATIC SEPAKATION OF THE EPIPHYSES 
 
 Gueretin and Champmas were never able to produce dislocations 
 in the newly born. 
 
 The case of separation of the lower epiphysis of the tibia related 
 by M. Champion in 1816, caused by the violent tractions of a midwife, 
 is open to great doubt, inasmuch as the infant was dead before 
 delivery. The foot was displaced forward with the epiphysis, and 
 parallel with the leg. 
 
 Many of the cases of separation of the cartilaginous ends of the 
 bones which have been recorded as occurring in the first few years 
 of infancy have been due to disease. Some are less doubtful but still 
 open to criticism, as in the case of a male infant, thirteen months 
 old, who fell out of the cradle and was believed by Hamilton to have 
 separated the upper epiphysis of the humerus. It is unlikely that 
 a separation of the healthy cartilaginous end in infancy will readily 
 take place from indirect violence. 
 
 The cartilaginous epiphyses at this early age may readily be 
 crushed off by severe direct violence — as by the passage of a cart- 
 wheel over the limb. 
 
 Hutchinson mentions a separation of the lower epiphysis of the 
 femur in a child aged eighteen months, who had been run over in 
 the street. 
 
 The force of violent traction upon the limbs during delivery, or a 
 few days after birth, will be expended rather upon the epiphysis than 
 upon the articulation itself, the resistance of the uniting material 
 between the cartilage and the bone being much less than that of the 
 ligaments and articular capsule. 
 
 Periods of age. — Up to the time of Roux's dissertation in 
 1822, epiphysial separations were very generally beheved to occur 
 only in infancy or the first few years of childhood. Malgaigne 
 states that separation had been observed mainly during the period 
 from birth up to fifteen years of age, and that, although separation 
 might be possible up to twenty-five years of age in subjects in whom 
 the epiphyses were as yet unconsolidated, he knew of no instance 
 of its occurrence above the age of fifteen. 
 
 Although the possibility of separation of the epijphyses of bones 
 after the first few years of hfe was doubted by many eminent surgeons, 
 M. Eoux, in 1837, related {La Presse Medicale, No. 55, July 12, 
 1837 ; extract in British and Foreign Medical Beview, vol. v., 
 January 1838, p. 250) a number of cases which proved that it may 
 occur as late as the eighteenth year. 
 
 He relates an instance of separation of the condyles of the femur 
 in a boy of eleven years ; of the inferior extremity of the radius, the 
 styloid process of the ulna, the head of the first phalanx of the 
 thumb, and of the fore and middle fingers of the left hand in a boy 
 of eighteen years of age ; of the humerus in a boy of twelve years ; 
 of the lower extremity of both radh in a boy of seventeen ; of the 
 head of the humerus in a boy of fifteen ; and of the lower extremity 
 
ETIOLOGY, AGE, SEX 45 
 
 of the radius in a man of twenty-two years of age. None of these, 
 however, appear to have been clearly established. 
 
 According to Colignon's estimate, the majority of traumatic 
 epiphysial separations occurred between the ages of twelve and 
 thirteen years. 
 
 This is greatly at variance with the results arrived at by many 
 experimentalists on the dead subject. Gueretin found experimentally 
 that at the age of nine months separation was produced in about 
 one case out of four, the other three being true fractures ; from two 
 to seven years of age, one separation out of nine cases, the others 
 resulting in fractures or dislocations ; from seven to fourteen years 
 out of ten attempts not a single epiphysial separation was produced, 
 but fractures or dislocations in every case. In many recent works 
 the first decade of life is still given as the usual period. Thus M. A. 
 Leblois, in 1894, says {Des fractures cliez les enfants et leur traitc- 
 ment, Paris, 1894, p. 17) that the first years of life up to the age of 
 ten are the times when epiphysial separations most frequently oscur, 
 and that the nearer the time of birth the more easily is this lesion 
 produced. Eicard {Traite de chirurgie, Duplay and Eeclus, tom. ii. 
 1890, p. 343) also says that separations are almost always met with 
 in the first few years of life, before the twelth or fifteenth year, 
 and that the younger the subject the more easy it is to separate its 
 epiphysial ends experimentally. 
 
 From statistics the author has given in each chapter it is clearly 
 proved that these accidents are less common in early childhood than 
 after the age of eleven or twelve. This is contrary to what has com- 
 monly been conjectured by former writers and those just mentioned — 
 viz. that young children are the most frequently affected with traumatic 
 epiphysial separations. The belief probably arose from the fact that 
 the epiphyses at this early age are considerably larger in proportion to 
 the diaphyses and less strongly united to them than they are at a later 
 period. In reality, the period of eleven or twelve to eighteen jea.va 
 of age is the one in which these injuries are most likely to be met 
 with, which fact is largely due to the circumstance that children at 
 this age are more exposed to severe injuries, such as are likely to 
 cause epiphysial separations. 
 
 Knowing that the osseous union of the epiphysis to the 
 diaphysis may be delayed beyond the twenty-first year, we may 
 expect to find occasionally an epiphysial separation at a more 
 advanced age than that just given. Voillemier experimentally 
 separated the lower epiphysis of the radius in a powerful muscular 
 male subject aged twenty-four years. 
 
 The precise age of the child is therefore one of the most important 
 points in the consideration of separations, for not only are particular 
 bones more liable to be separated at a certain period of life, but the 
 separations are also more likely to 'be purer in character at the same 
 period. 
 
46 TEAUMATIC SEPAEATION OF THE EPIPHi^SES 
 
 Again, many of the epiphysial processes — for instance, these at the 
 lower end of the humerus, internal and external epicond5des, &c. — are 
 only distinct epiphyses from the rest of the lower end of the humerus 
 at a particular period, and often for only a few years. A pure separa- 
 tion of such processes can, therefore, only occur at this particular 
 period of childhood. Age has, consequently, a very marked influence 
 in determining the anatomical character or variety of the separation. 
 We may now state that the various epiphyses have certaia 
 periods in which they are most liable to separation, although there 
 is still great discrepancy among authors as to the comparative liability 
 to separation of the various epiphyses at the different ages. Allow- 
 ance must also be made for the diversity in the period of 
 coalescence of the epiphysis with the diaphysis which is found to 
 exist in individuals. 
 
 Another difficulty experienced in detecting these lesions is the 
 want of precision in fixing the exact date of union of the individual 
 epiphyses. The same epiphysis may have some years' difference in 
 different subjects before it is finally blended into the diaphysis. 
 
 Uffelmann states {Deutsche KliniTi, 1864, p. 183) that he found the 
 epiphyses still dis-united in subjects beyond thirty years of age, 
 CHEONOLOGICAL TAELE OF THE 
 DATES OF APPEARANCE OF THE CENTRES OF OSSIFICATION 
 OF THE EPIPHYSES 
 At Birth . . The centre of ossification of the Lower epiphysis of the femur al- 
 ready exists. 
 At the 1st year . „ „ Up)per epiphysis of the tibia ap- 
 
 pears, and Upper epiphysis [head) 
 of the femur. 
 At the 15th month „ „ Upper epiphysis (head) of the 
 
 Mimeriis. 
 At the ISth month „ „ Lower epiphysis of the tibia. 
 
 At the 2nd year . „ „ Loiver epiphysis of the radius, Loioer 
 
 epiphysis of the fibula, and 
 Capitellar portion of lower end of 
 humerus. 
 Betzoeen 2^ and 5 years „ „ Epiphysial heads of the metacarpus. 
 
 At the 3rd year . „ „ Great and sviall tuberosity of the 
 
 upper end of the humerus. Epi- 
 physis of the first metatarsal bone, 
 Epiphysis of first metacarpal bone, 
 and Great trochanter of femur. 
 Between the Brd and 5th „ „ Epiphijses of phalanges of the fingers. 
 
 years 
 At the itli year . „ „ hiternal epicondyle of humerus. 
 
 Betioeeji the ith and „ „ Up>per epiphysis of the fibula and 
 
 5th years Lower epiphysis of the iilna. 
 
 Between the 5th and Gth „ „ Head of the radius and Four outer 
 
 years metatarsals. 
 
 About the 1th year „ „ Epiphyses of phalanges of the toes. 
 
 About the 10th year „ „ Olecranon epiphysis. 
 
 At the 11th year . „ „ Trochlea of the humerus. 
 
 At the 13fh year . „ „ ■ Lesser trochanter of the femtir and 
 
 External e2ncondyle of the humerus. 
 At the ISth year . „ „ Epiphysis (sternal) of the clavicle. 
 
ETIOLOGY, AGE, SEX 
 
 47 
 
 The union of the epiphyses to the diaphyses commences during 
 the period of puberty. The last to unite are the lower epiphysis of 
 the femur and the upper epiphysis of the tibia in the lower extremity, 
 and the upper epiphysis of the humerus and the lower epiphysis of 
 the radius in the upper extremity ; those of the lower extremity, as 
 a rule, unite before the upper, the tibia before the femur, the humerus 
 before the radius. 
 
 THE TIMES OF THE UNION OF THE EPIPHYSES TO THE DIAPHYSES 
 OF THE LONG BONES 
 
 At the l&th year 
 
 Betioeen the \.Qtli and 11th years 
 
 At the nth year 
 
 At the 18th year 
 
 Betioeen the nth and 20th years 
 
 Between the 18th and 20th years 
 
 About the 20th year . 
 
 Between the 18th and 22nd years 
 
 Betioeen the 19th and 23rd years 
 
 Between the 22nd and 25t]i years 
 
 At the 18th year 
 
 Between the 18th and 19th years 
 
 Between the 19th and 20th years 
 
 At the 19th year 
 
 Betioeen the 18th and 19th years 
 
 Between the 19th and 21st years 
 
 Betioeen the 20th and 22nd years 
 
 Between the 21st and 22nd years 
 
 Between the 20th and 2'drd years 
 
 The upper epiphysis of the radius. 
 
 The olecranon epiphysis of the ulna. 
 
 The lower epiphysis of the humerus. 
 
 The internal epicondyle of the liumcrus. 
 
 The epiphyses of phalanges of toes. 
 
 The epiphyses of ph%langes of fingers, and lower 
 
 epiphysis of ulna. 
 The metacarpal epiphyses. 
 The upper epiphysis of the humerus. 
 Tlie lower epiphysis of the radius. 
 The epiphysis of the clavicle. 
 The lesser trochanter. 
 The great trochanter. 
 The metatarsal epiphyses. 
 The epiphysial head, of the femur. 
 The lower epiphysis of the tibia. 
 The lower epiphysis of the fibula. 
 The upper epiphysis of the fibula. 
 The upper epiphysis of the tibia. 
 The lower epiphysis of the femur. 
 
 In the female the union takes place, as a rule, a little earlier than 
 in the male ; in the former about the twenty-second year, in the 
 latter at the twenty-third, or even as late as the twenty-fifth. 
 
 The frequency of each separation varies considerably according 
 to the age of the patient in whom it is produced. 
 
 M. Curtillet gives the following statistics of twenty-one cases of 
 epiphysial separation occurring in children from one to ten years 
 of age, in the practice of M. Vincent : 
 
 Humerus 
 
 Upper epiphysis 
 Lower epiphysis 
 
 Radius, lower epiphysis 
 
 Eemur, lower epiphysis 
 
 Epitrochlea . 
 
 Epicondyle . 
 
 2 
 
 11 
 
 2 
 
 2 (doubtful) 
 3 
 1 
 
 Separations of the femur and radius, usually considered amongst 
 the most frequent, are here in the minority, and M. Curtillet 
 explains this preference for epiphysial separations of the lower 
 extremity of the humerus by the assumption that these very young 
 children, being as yet unacquainted with protective movements such 
 
48 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 as carrying the hands forward during a fall, come to the ground 
 in a clumsy manner, fracturing the elbow or the two bones of the 
 forearm, instead of falling on the hand and injuring the wrist 
 
 He remarks that, from a large collection, the most common 
 injuries of the upper extremity in quite young children were fractures 
 of both bones of the forearm, somewhere in the shaft, and fracture 
 or epiphysial separation of the lower end of the humerus. 
 
 It is probable that the comparative immunity from these injuries 
 in early childhood is due to the fact that these very young children 
 are less exposed to the various sources of injuries which produce 
 separations in older children — such as falls, games, and other violent 
 exercises ; at the same time, the muscular system is much less 
 developed. 
 
 Colignon rightly recognised that epiphysial separations were more 
 frequent during adolescence than in the first years of life. 
 
 Among Gurlt's collected cases (1862) verified by dissection, with 
 the exception of the three newly born children, only one of the 
 patients was less than nine years old ; the oldest was eighteen. 
 
 In Bruns' statistics the frequency of epiphysial separations based 
 on anatomical grounds in the different periods of childhood and 
 youth is tabulated as follows. 
 
 The most frequent period noticed was between the ages of ten 
 and nineteen years, for in sixty-one cases in which the age was known 
 forty-four belonged to this period. The greatest frequency observed 
 w^as between the sixteenth and seventeenth years (fourteen cases), 
 twelfth to fourteenth years (fifteen cases), eighteenth to twentieth 
 years (nine cases), and tenth to eleventh (six cases). The least 
 frequent period was from one to nine, with a record of. only eight 
 cases. 
 
 Out of seventeen cases verified by an autopsy which Gurlt col- 
 lected in 186'2, with the exception of three in the newly born infant, 
 only one of the patients was less than nine years old. The oldest 
 was eighteen (the lower end of the radius) ; all the others were below 
 the age of 16^, the majority occurring between nine and fifteen j^ears 
 of age. Gurlt knew of no case of pure separation, confirmed anatomi- 
 cally, after the twentieth year. 
 
 Separation may, however, occur in certain individuals after the 
 twentieth year.- 
 
 Dr. Jetter records two cases of separation of the upper epiphysis 
 of the humerus (verified by operation) in a woman in her twenty-third 
 year, and in a man in his twenty-first year. 
 
 In an old separation of the upper epiphysis of the humerus, 
 operated upon by P. Bruns for great loss of power and utility of the 
 limb, the age of the patient was twenty-four, so that, as he says, the 
 limit of the age up to which these injuries may occur must be 
 extended beyond the twentieth year. 
 
 As a rule, epiphysial separation can only occur before the 
 
ETIOLOGY, AGE, SEX 49 
 
 twentieth to twenty-first year, the time of osseous union of the 
 epiphysis with the shaft, or body of the bone. Several cases have 
 been recorded of separation at the twentieth year, but their true 
 nature is somewhat doubtful. 
 
 It must be remembered, however, that in certain epiphyses con- 
 solidation is not complete until the twenty-fifth year, or even later. 
 
 Gurlt quotes Platner (J. M. Schwartz, Diss, cle ossiitvi epiijliysihiis, 
 Lips. 1786, and J. Z. Platner, Ojnoscula, tom. i., Lips. 1788, 4, 
 p. 174) as being able to show the skeleton of a big fully grown man 
 in which most of the epiphyses were still attached by cartilage to the 
 diaphyses. Nanula (of Naples), according to Eognetta, had pos- 
 session of a skeleton of a man, aged 26^ years, in whom most of the 
 epiphyses were still visible. 
 
 Twenty-four or twenty-five must be the extreme limit of age at 
 which these exceptional cases can occur, although the usual highest 
 limit for the epiphysial junction is, according to Sappey, from the 
 eighteenth to twentieth year. 
 
 SEX. — In all the cases diagnosed during life, and also in those 
 verified by an autopsy, which were known to Malgaigne, the lesions 
 were all in male subjects. 
 
 The author's statistics, showing the enormous difference in 
 frequency of occurrence between the male and the female sex, are as 
 follows. 
 
 Total number of separations occurring in the three most frequent 
 situations, viz. : 
 
 Loioer epiphysis of femur. — Out of 114 cases, the sex is stated in 
 96 — 83 males and 13 females, all the latter below fourteen years of age. 
 
 Lower epiphysis of the radius. — Out of 112, the sex is given in 
 89, as 79 in males and 10 in females ; the whole of the latter being 
 at or below fourteen years of age. 
 
 Tipper epiphysis of the humerus. — Out of 119, the sex is given in 
 104. Of these, 85 were males and 19 females (16 being at thirteen 
 years and below, three above). 
 
 Cases verified anatomically. Lower epiphysis of femur. — Out of 80 
 (age stated in 68) the sex is given in 55 as 46 in males and 9 in females. 
 All the latter were from fourteen years of age downwards, none above. 
 
 Lower epiphysis of the radius. — Out of 60 cases, the sex is given 
 in 45 — viz. 41 males and 4 females ; all the females at or below five 
 years of age. 
 
 Upper epiphysis of the humerus. — Out of 21 the sex is stated in 
 12— all males. 
 
 Simple cases. Loioer ejnphysis of femur. — 34 cases ; sex stated 
 in 32, as 28 males and 4 females ; all the latter were from thirteen 
 years downwards. 
 
 Loioer epiphysis of the radius. — 52 cases ; sex stated in 44, as 
 38 males and 6 females ; all females were below fourteen years. 
 
 U'pp)er epiphysis of tJie liumerus. — Out of 98 cases, tbn sex is 
 
 E 
 
50 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 stated in 92 ; 19 only of these of the female sex (16 at thirteen years 
 and below, 1 at fifteen, 1 at sixteen, and 1 at twenty-three). 
 
 In 231 cases of the upper extremity represented by the lower epi- 
 physis of radius and upper epiphysis of humerus, the sex is given in 
 193 as 164 males and 29 females ; all the females except 3 were at 
 or below fourteen years of age. 
 
 Out of the total number of cases (345), the sex is stated in 289 as 
 247 males and 42 females ; all except three of the latter being at or 
 below the age of puberty. 
 
 Sex in the different epiphysial injuries. — Delens states, as regards 
 the lower epiphysis of the femur, that the injury has almost always 
 been observed in boys. Out of 23 cases where the sex of the patient 
 had been noted, 20 were boys and only 3 girls. In the lower and 
 upper extremity the percentage of males and females is very similar. 
 
 In the lower extremity, as represented by the lower epiphysis of 
 the femur, 86'44 per cent, of the cases were in males, and 13' 52 per 
 cent, in females ; all the females were at or below fourteen years of age. 
 
 In the upper extremity, represented by the upper epiphysis of the 
 humerus, 81-76 per cent, were in males, 18-28 per cent, in females; 
 and by the lower epiphysis of the radius, 88-6 per cent, were in 
 males, 11-2 per cent, in females. Tiiis makes a total percentage of 
 84-8 in males and 15-5 in females. 
 
 Sex in the different periods of age. — Before puberty the vast excess 
 of males over females is somewhat less than after this period ; this 
 is particularly marked in the earlier years of childhood. Under the 
 conditions of external surroundings, in their games, &c., girls are 
 exposed to injury almost equally with boj^s, whereas in later years 
 they isolate themselves more and are not exposed by their occupa- 
 tion to severe injuries. 
 
 As we have just seen, out of 289 instances only 42 were in 
 females, and with three exceptions all occurred at or below the age 
 of puberty. 
 
 The so-called equality of the sexes, and the modern tendency 
 for females to undertake the work of the male sex and imitate their 
 habits, may in the remote future considerably modify the statistics 
 of the past and present. 
 
51 
 
 CHAPTEE IV 
 FREQUENCY OF THE VARIOUS SEPARATIONS 
 
 The frequency of epiphysial separations varies not only with the 
 different ages but also with the various epiphyses involved. The 
 epiphyses of the long bones are far more frequently detached than 
 those of other bones — e.g. iliac crest, tuberosity of os calcis, or of 
 ischium. 
 
 It is probable that in infancy many cases of separation without 
 displacement, and juxta-epiphysial sprains are often overlooked. 
 
 The true osseous epiphyses are more frequently separated than 
 the unossified cartilaginous epiphyses, or cartilaginous ends of the 
 diaphyses. 
 
 Date of Ossification of the Chief Epiphyses 
 OF THE Long Bones 
 
 At birth . 
 
 At 1 year 
 
 At li years 
 
 At 2 years 
 
 At 3 years 
 
 At 4 years 
 
 From 5 to 6 years 
 
 At 8 years 
 
 j Lower end of the femur 
 ^ Upper end of the tibia 
 f Upper end of the femur 
 ( Upper end of the humerus 
 (Lower end of the tibia 
 (Lower end of the humerus 
 j Lower end of the radius 
 (Lower end of the fibula 
 j Great trochanter of femur 
 ( Great tuberosity of humerus 
 f Upper end of the ulna 
 (Upper end of the fibula 
 Upper end of the radius 
 Lower end of the ulna 
 Lesser trochanter of femur 
 
 The epiphyses of certain bones appear to have never been 
 detached during life. 
 
 The epiphyses of some of the long bones are found to be much 
 more frequently affected than others, which is explicable to a great 
 extent on anatomical grounds, but partly also by physiological as 
 well as mechanical reasons. Thus the lower end of a femur, which 
 
 E 2 
 
52 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 ossifies at the same time as the upper end of the tibia, will 
 give way rather than the epiphysis of the tibia in a fall upon 
 the knee. 
 
 It might be supposed from the longer period in which separation 
 is possible that the epiphyses of the long bones which joined on later 
 to the diaphyses — and which, as a rule, begin to ossify first — would be 
 the most commonly affected, and it has been pointed out that this 
 agrees with the order of frequency of separations given by previous 
 surgeons. 
 
 This, however, according to the large number of cases collected by 
 the present writer, is not strictly accurate. It would seem that a Joint 
 which has very free mobility with a large unprotected epiphysis will be 
 more frequently the seat of separation than one whose epiphysis is 
 small and well protected. Again, the lower ends of the radius, femur, 
 and humerus are, from their situation, most liable to be affected by 
 injury. 
 
 The cause of the frequency of separation of particular epiphyses 
 will be considered under the head of each epiphysis. 
 
 Many French and German writers have collected cases of epiphysial 
 separation, but they lack the importance which is attached to Bruns' 
 cases from the fact that the greater proportion were very doubtful, 
 and only a few verified by direct inspection. 
 
 Thus Manquat in 1877 {Essai sur les decollements epiphijsaires 
 trcmviatiques, These de doctorat. Paris, 1877) collected 130 cases, the 
 majority of which were of the lower epiphysis of the radius (twenty- 
 three) and of the lower epiphysis of the femur (twenty-three) ; while 
 the upper (thirteen) and lower ends (eighteen) of the humerus were 
 the next most frequent ; the upper end of the femur following with 
 ten, and the upper and lower ends of the tibia with seven each. 
 
 To these P. Bruns added, in 1886 {Deutsche CJiirurgie, Billroth 
 and Luecke, 1886 ; ' Die Lehre von den Knochenbrlichen,' p. 119), 
 ten cases, mostly of the lower epiphysis of the radius and of the 
 upper epiphysis of the humerus. 
 
 C. 0. Weber also published a number of cases in 1859. 
 
 Again, with regard to the lower epij)hysis of the radius, some 
 writers regard the injury as very common, while others believe it to 
 be quite exceptional. 
 
 Malgaigne claimed that as fractures of the lower end of the 
 radius were the most common, so separation of the corresponding 
 ex^iphysis was most frequently met with, in children. 
 
 Gurlt's tables show a vast preponderance of fractures at the lower 
 end of the humerus over those at the upper in the first two decades 
 of life ; indeed, he foand that up to the tenth year the lower portion 
 of this bone was considerably more than twice as often fractured as 
 the upper end and shaft together. It can readily be understood that 
 a o-reat number of these cases were probably epiph}' sial separations of 
 one or other variety. 
 
FBEQUENCY OF THE VAEIOUS SEPAEATIONS 53 
 
 Other surgeons (Eeeve, &c.) consider separation of the lower 
 epiphysis of the humerus to be the most frequent. 
 
 Packard says that ' the epiphyses of the humerus are far more 
 often separated by violence than those of the femur.' 
 
 Professor E. de' Paoli, of Perugia, states {Communicaz. dclla 
 Clinica Gliir. Propedeutica delV Univ. di Perugia, 1891, p. 52) that out 
 of 105 cases of epiphysial separation proved by anatomical examina- 
 tion, fourteen were of the upper end of the humerus. 
 
 Such complications as gangrene and haemorrhage from injury to 
 the vessels or the presence of a wound, especially noticeable in separa- 
 tion of the lower epiphysis of the femur, have necessitated surgical 
 interference and led to a complete examination of the injury. We 
 see, therefore, that separation of the lower epiphysis of the femur 
 has been most frequently confirmed by direct examination of the 
 fragments. 
 
 Other epiphysial separations are usually less complicated and 
 less liable to secondary complications, or to complications which call 
 for surgical interference, so permitting an inspection of the fractured 
 surfaces. Probably, also, in many situations such separations are 
 often overlooked. 
 
 Pick says {Fractures and Dislocations, 1885, p. 14) that ' separa- 
 tion of the epiphysis appears to occur more commonly in the lower 
 end of the femur than in any other situation. After this the lower 
 end of the radius, the lower end of the tibia, and the extremities of 
 the humerus are the bones most frequently affected.' 
 
 As regards the lower end of the femur, M. Delens has written 
 {Arcliiv. gen. de mod. 1884) a very complete monograph on this form 
 of epiphysial separation. 
 
 Champmas {Thesis, Paris, 1840) gives the following order : 
 
 Divulsion of the upper epiphysis of the humerus . 12 cases 
 
 ,, inferior ,, radius . . 7 cases 
 
 ,, upper „ femur . . 5 cases 
 
 ,, inferior ,, humerus . 4 cases 
 
 ,, inferior ,, femur . . 3 cases 
 
 In Colignon's figures, of fifty-nine cases of traumatic separation 
 of the epiphyses of the long bones, thirty-five were of the upper 
 and twenty-four of the lower extremity ; of these, twelve were of the 
 upper end of the humerus, fifteen of the lower end of the radius, 
 ten of the upper, and seven of the lower end of the femur. From 
 his experiments and collected cases, Colignon believed that the lower 
 epiphysis of the radius separated most easily and most frequently, 
 next the upper epiphyses of the humerus and the femur, and lastly 
 the lower epiphyses of these two latter bones. 
 
 Gucretin gives, out of thirty-seven cases, ten of the upper end of 
 the humerus, four of the lower end of the radius, live of the u^^per, 
 and three of tlie lower end of the femur. 
 
54 TEAUMATIC SEPAEATIOX OF THE EPIPHYSES 
 
 Gurlt, in 1862, only collected eighteen cases verified by autopsy. 
 
 ' ^pper epiphysis . , . .4 cases 
 
 ' Lower epiphysis . 
 
 Lower epiphysis . 
 
 ( Great trochanter . 
 
 i Lower epiphysis . 
 
 Upper epiphysis . 
 
 .Lower epiphysis . 
 
 Humerus 
 
 Eadius 
 
 Femur 
 
 Tibia 
 
 
 
 1 
 
 case 
 
 
 
 4 
 
 cases 
 
 
 
 1 
 
 case 
 
 
 
 5 
 
 cases 
 
 
 
 1 
 
 case 
 
 
 
 2 
 
 cases 
 
 Bruns collected in 1882 {Archiv fiir Minische Chirurgie, Langen- 
 beck, Bd. xxvii. 1882, S. 240j seventy-eight published cases, and three 
 of his own from his Tiibingen clinic, in which the diagnosis had been 
 confirmed by dhect examination of the seat of injur}', either through 
 an accompanying wound, or after amputation or death. In eleven 
 instances the injury was double or multiple (2 to 4), the total being 
 101. 
 
 The division of cases was as follows : 
 
 Humerus 
 
 Ulna 
 
 Badius 
 
 Ossa pubis 
 
 Femur 
 
 Tibia 
 
 Fibula 
 
 (Upper ej^iphysis . 
 (Lower epiphysis . 
 ' Fpper epiphysis . 
 ' Lower epiphysis . 
 Lower epiphysis . 
 
 Ux^per epiphysis . 
 I Lower epiphysis . 
 jUpx^er epiphysis . 
 (Lower epiphysis . 
 ! L'pper epiphysis . 
 I Lower epiphysis . 
 
 ^Metatarsus 
 
 Total 
 
 11 
 4 
 
 1 
 2 
 
 25 
 3 
 
 3 
 
 28 
 4 
 
 11 
 3 
 4 
 2_ 
 lOf 
 
 Bruns says that, although it had hitherto been customary to 
 believe that separation of the upper epiphysis of the humerus was the 
 most frequent, his statistics proved that the lower epiphysis of the 
 femur stands first in order of frequency, then the lower epiphysis of 
 the radius, and, thirdly, the upper epiphysis of the humerus. The 
 first two mentioned together comprised more than half of all the 
 cases. 
 
 He accounts for this frequency by the large size of the lower 
 epiphysis of the femur, its late union, and the great strain which is 
 thrown upon the conjugal cartilage by the powerful leverage 
 cf the leg ; V^ut at the same time he is of opinion that probably sepa- 
 ration of the lower epiphysis of the radius will be found to be as 
 frequent, or even more so, when we consider how often these 
 separations are without compHcation, and unite vithout any direct 
 examination of the lesion having been made. 
 
FEEQUENCY OF THE VAKIOUS SEPAEATIONS 55 
 
 Several other writers have endorsed Bruns' statement. 
 
 For instance, in 1892, Dr. Joseph Prochnow {Pest. Med. Chir. 
 Presse, Budapest, 1893, xxix. S. 389) states that separation of the 
 lower end of the femur takes the first place in regard to frequency. 
 
 Coming to the latest paper by Dr. C. A. Sturrock {Edinburgh 
 Plospital Beports, vol. h. 1894), we find the same statement 
 (p. 598) : ' As regards the relative frequency of epiphysial injury in 
 different situations, separations seem to occur most often at the lower 
 extremity of the femur, and at the lower and upper extremities of the 
 humerus.' And this is repeated by Mr. D'Arcy Power {The Surgi- 
 cal Diseases of Children, 1895, p. 163) when he says that 'it occurs 
 most frequently at the lower end of the femur, next at the upper 
 and lower ends of the humerus, at the lower end of the radius, and 
 at the lower end of the tibia.' 
 
 Putting the statistics of previous writers together, the order of 
 frequency with regard to the long bones would be as follows : 
 (1) Lower epiphysis of femur ; (2) lower epiphysis of the radius ; 
 (3) upper epiphysis of the humerus; (4) lower epiphysis of the 
 humerus ; (5) lower epiphysis of the tibia ; (6) upper epiphysis of 
 the tibia. 
 
 Although the cases verified by direct examination afford the best 
 data for statistical purposes, the many hundreds of chnical cases 
 cannot be ignored ; yet here also a large number are even at the 
 present time often overlooked or mistaken for dislocations. 
 
 Nevertheless in Bruns' 100 cases, verified by autopsy, the upper 
 end of the humerus only took the third place (11 per cent, of the 
 cases) ; indeed it must be placed first if we include, as we should, 
 the many clinical cases which have of late years been so accurately 
 recorded. 
 
 Dr. G. Jetter states the order of frequency from cases observed 
 at the Tubingen clinic {Beitrdge zur hlinischen Chirurgie, 1892, 
 S. 362) during ten years : First, the upper epiphysis of the humerus ; 
 secondly, the lower epiphysis of the radius ; and thirdly, the lower 
 epiphysis of the femur, which in Bruns' statistics is placed first 
 (28 per cent.). 
 
 With reference to the relative frequency of the different varieties 
 of fractures or separations about the elbow-joint, M. Guedeney has 
 collected sixty cases from the clinic of M. Vincent at Lyons {Du 
 traitement des fractures du coude chez Venfant, dec, Lyon, 1893) ex- 
 tending over a period of about seven years. Twenty-seven are classed 
 under the heads of juxta-epiphysial disjunctions, fractures of the lower 
 extremity of the humerus, fractura disjunctiva humeri (Hueter), 
 supra-condyloid fractures (Malgaigne), &c. Amongst these, T- ^ and 
 Y-shaped fractures were perfectly made out seven or eight times. 
 Fourteen were fractures of the epicondyle (external epicondyle) , but 
 two were accompanied by detachment of the capitellum (condyle), six 
 were fractures of the epitrochlea (internal epicondyle) , five of the 
 
56 TRAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 olecranon, and four fractures of the upper part of bones of the 
 forearm, mostly accompanied by dislocation backwards of the elbow ; 
 two of the latter being diagnosed as separation of the upper epiphysis 
 of the radius. 
 
 From practical experience one is led to the belief that 
 separations of the lower end of th6 humerus in their various com- 
 plicated forms are perhaps the most frequent. 
 
 The epiphyses of the upper Hmbs are much more often involved 
 than those of the lower. The author's figures are 423 in the upper 
 extremity and 253 in the lower extremity. 
 
 Mr. Hutchinson, junr.'s, collection consists of about 350 cases, of 
 which nearly 150 were not previously published {British Medical 
 Journal, July 8, 1893, p. 53, &c.) : 
 
 Clavicle . . . . 
 Upper epiphysis of humerus 
 Lower epiphysis of humerus 
 Internal epicondyle 
 Upper epiphysis of ulna 
 Lower epiphysis of ulna 
 Upper epiphysis of radius 
 Lower epiphysis of radius 
 Epiphyses of phalanges and 
 metacarpal bones 
 
 3 Upper epiphysis of femur . 26 
 
 66 Epiphysis of lesser tro- 
 
 52 chanter .... 1 
 
 38 Lower epiphysis of femur . 75 
 
 2 Great trochanter of femur . 11 
 
 6 Upper epiphysis of tibia . 10 
 
 2 Epiphysis of tubercle of tibia 6 
 
 54 Lower epiphysis of tibia . 27 
 
 Upper epiphj^sis of fibula . 4 
 
 10 Lower epiphysis of fibula . 2 
 
 The author's statistics of separations of the epiphyses of the 
 long bones are as follows : 
 
 UPPEE EXTEEMITY 
 
 
 Pathological 
 anatomy 
 
 Compound 
 cases 
 
 Simple 
 
 Tota 
 
 Clavicle .... 
 
 1 
 
 1 
 
 3 
 
 5 
 
 IIuMEKUS, upper epiphysis . 
 
 1 
 
 33 
 
 7 
 
 30 (including 
 nine opiera- 
 tion cases) 
 
 120 
 
 ,, lower end (before 
 
 13 
 
 18 
 
 44 
 
 75 
 
 puberty) 
 
 
 
 
 
 „ lower epiphysis (at 
 
 1 
 
 1 
 
 4 
 
 6 
 
 and after puberty) 
 
 
 
 
 
 ,, internal epicondyle 
 
 5 
 
 
 
 56 (including 
 five opera- 
 tion cases) 
 
 61 
 
 ,, external epicondyle 
 
 3 
 
 — 
 
 6 
 
 9 
 
 Kadius, upper epiiDhysis . 
 
 2 
 
 — 
 
 5 
 
 7 
 
 „ lower epiphysis 
 
 46 
 
 14 
 
 52 
 
 112 
 
 Ulna, upper epiphysis . 
 
 4 
 
 2 
 
 3 
 
 9 
 
 ,, lower epiphysis . 
 
 6 
 
 — 
 
 5 
 
 11 
 
 Phalanges of Fingers 
 
 1 
 
 — 
 
 2 
 
 3 
 
 Metacarpus .... 
 Total .... 
 
 — 
 
 
 8 
 
 8 
 
 115 
 
 43 
 
 268 
 
 426 
 
FEEQUENCY OF THE VAEIOUS SEPAEATIONS 57 
 
 LOWEE EXTEEMITY 
 
 
 Pathological 
 anatomy 
 
 Compound 
 cases 
 
 Simple 
 
 Tota 
 
 Femue, epiphysis of head 
 
 4 
 
 — 
 
 31 (including 
 two ox^era- 
 tion cases) 
 
 35 
 
 „ great trochanter 
 
 11 
 
 1 
 
 2 
 
 14 
 
 ,, lesser trochanter 
 
 1 
 
 
 
 • — ■ 
 
 1 
 
 „ lower epiphysis 
 
 72 (including 
 many com- 
 pound, wliicli 
 were ampu- 
 tated) 
 
 12 (terminat- 
 ing in re- 
 covery) 
 
 41 
 
 125 
 
 Tibia, upper epiphysis 
 
 12 
 
 1 
 
 11 
 
 24 
 
 „ epiphysis of tubercle 
 
 — 
 
 
 
 10 (including 
 two opera- 
 tion cases) 
 
 10 
 
 ,, lower epiphysis 
 
 11 
 
 11 
 
 24 
 
 46 
 
 Fibula, upper epiphysis 
 
 3 
 
 — 
 
 — 
 
 3 
 
 ,, lower epiphysis . 
 
 3 
 
 2 
 
 — 
 
 5 
 
 Phalanges of Toes 
 
 — 
 
 1 
 
 1 
 
 2 
 
 Metatabsus .... 
 Total .... 
 
 — 
 
 — 
 
 o 
 
 ^ - 
 
 2 
 
 117 
 
 28 
 
 122 
 
 267 
 
 From the total number, 426, of separations in the upper 
 extremity, and the total 267 in the lower extremity, a grand total 
 of 693 ^ exists. 
 
 After the lower epiphysis of the femur, the lower epiphysis of 
 the radius stands next in order of frequency in the number of 
 specimens which pathological anatomy can show, wdiereas at the 
 upper end of the humerus there are few specimens compared with 
 clinical cases. The fallacy lies in the fact that in the lower end 
 of the femur the injury is more frequently followed by serious 
 complications, amputation, or death. 
 
 The grand total has been considerably increased since these figures were drawn up. 
 
58 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 CHAPTEE V 
 
 EXPEEIMENTS IN PATHOLOGICAL ANATOMY AND THEIR 
 HISTOLOGICAL ANATOMY. MECHANISM 
 
 Experiments in pathological anatomy and their histology. — Oilier 
 found that pure epiphysial separations could only be effected with 
 difficulty in animals on account of the periosteum, which is 
 intimately blended with the conjugal cartilage ; but if the perios- 
 teum were divided round the cartilage, separation was readily 
 effected. Many experiments on the human subject have given the 
 same results. 
 
 Wilson, in some experiments on the bodies of infants in 
 1820 {0)1 the Bones and Joints, London, 1820), found in one 
 instance that it required the weight of 550 lbs. to detach an 
 epiphysis from a growing bone from which the periosteum was not 
 removed ; whereas when the periosteum was removed from the 
 corresponding bone of the other side, 119 lbs. detached the epi- 
 physis, showing the great strength of the periosteum in binding 
 the epiphysis to the diaphysis. 
 
 The true osseous epiphyses {osteo-epiphyses, P. Vogt) are far more 
 readily separated in experiments on the dead subject than those 
 epiphyses {chondro-ejnjjJiyses) which are still entirely cartilaginous. 
 This is due to the elasticity of the latter, which presents less resis- 
 tance to the force of the violence acting upon them. . Pure separa- 
 tions were the rule in the latter case, whereas in the former they 
 were usually accompanied by fracture of the diaphysis in the imme- 
 diate neighbourhood. 
 
 Eoucher believed that, if the separation did not take place in the 
 spongy bone itself, it sometimes occurred between the chondroid 
 and spongy layers, and sometimes between the spongy layers and 
 the spongy bone. 
 
 Michniowsky, in his experiments on living animals, by forcibly 
 separating the epiphyses by means of hyper-extension found that 
 the separation never took place in the epiphysial cartilage itself, but 
 always between its calcareous layer and the most recently formed 
 osseous layer of the diaphysis. 
 
 Similar experiments by Oilier gave the same result, so that he 
 termed these lesions ' juxta-epiphysial.' 
 
 Gurlt, in his experiments on newly born children and infants a 
 
EXPEEIMENTS IN PATHOLOGICAL ANATOMY 59 
 
 few months old, found that epiphysial separations were at the same 
 time accompanied by a tearing away of pieces of the diaphysis, notably 
 in the case of the epiphyses of the larger bones. On the contrary, 
 in Colignon's experiments on the bodies of newly born infants the 
 cleanly separated surface of the epiphyses of the femur, tibia, and 
 bones of the upper extremity presented no osseous particles to the 
 eye or touch; it was exactly at the level of the conjugal cartilage. 
 Experiments on animals led to similar results. 
 
 The more recent experiments of Barbarin on the bodies of 
 children one to twelve years of age gave the same results at the 
 lower end of the femur. 
 
 Lateral flexion at the knee-joint, as in straightening for knock- 
 knee, has produced the same effects. 
 
 Oilier found separation through the epiphysial cartilage to be 
 frequent in his experiments on the bodies of children, a portion of 
 the cartilage remaining with the diaphysis. This agrees with the 
 actual condition found at times in the living subject. 
 
 Vogt finds on microscopical examination of the separated 
 epiphysial cartilage, in true epiphysial separations, numerous pieces 
 of already ossified epiphysial flakes, separated by well-marked 
 intervals, clinging to the cartilaginous area. 
 
 Salmon's experiments in 1845 were principally on the elbow- 
 joints of children's bodies. He divided them into (1) complete, 
 and (2) incomplete separations of the epiphysis, and (3) incomplete 
 separations both with and without simultaneous fracture. 
 
 Most of his experiments were undertaken on children under three 
 years. At the elbow-joint in 129 cases he found that a clean and 
 smooth separation of the cartilage from the osseous end of the 
 diaphysis is very uncommon, while perfect separations of the epi- 
 physis are combined with partial detachment of the osseous 
 substance, traces of which were perceptible on the cartilaginous 
 epiphysis. He also found that it was still rarer for fragments of 
 the cartilage to partially cling to the rough end of the diaphysis. 
 
 In Gueretin's experiments on bodies of children from one to 
 fourteen years of age, he only once obtained a pure separation of the 
 epiphysis in four instances of children one year old. In subjects of 
 two to seven years old the comparison was one to nine of fracture of 
 the diaphysis at a distance from the epiphysial cartilage. In ten 
 cases between the ages of seven and fourteen years not one case 
 of pure epiphysial separation occurred, but in nearly all there was 
 dislocation or fracture at a short distance from the epiphysis. 
 
 M. Cruveilhier, in 1849, considered that the subject of epi- 
 physial separations should be studied afresh, and at his request 
 MM. Jarjavay and Bonamy made some experiments on five 
 subjects from eight to ten years of age, but they were able to separate 
 only the lower epiphysis of the radius — and once only the lower epi- 
 physis of the femur and the olecranon epiphysis. MM. Cruveilhier, 
 
60 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 Jarjavay, and Bonamj^ {TraitS cVanato7me patJiologique, 1849, torn, i.) 
 also found in their extensive experiments that the epiphysis ahnost 
 always dragged away a more or less considerable layer of the 
 osseous tissue. These last observers do not mention the various 
 means employed by them to effect the separations. 
 
 M. Broca, in his experiments on the dead body, always found 
 that the epiphysial cartilage remained adherent to the epiphysis. 
 
 Eichet, in similar investigations, ascertained that the cartilage 
 was frequently attached to the epiphysis {Gazette des Hopitaitx, 
 1865, p. 147). 
 
 Menard always found separation of the periosteum on one side 
 of the diaphysis in his post-mortem experiments on the bodies of 
 children from two to sixteen years of age. In complete separations 
 it was torn through 2 to 4 centimetres distant from the conjugal 
 cartilage. 
 
 M. Foucher, in his ' Eecherches sur la disjonction traumatique 
 des epiphyses,' 1860 {Moniteur des Sciences Med. et Pharm. 1860, 
 July 31, p. 743), relates in detail the results of his numerous 
 experiments on the dead body. He says that these separations can 
 be produced ' with difficulty ; ' but one of the conclusions he came 
 to— viz. that ' separation never takes place in the middle of the car- 
 tilaginous layer ' — is certainly erroneous and not confirmed by later 
 experience. 
 
 Most of his experiments were undertaken to ascertain the 
 mechanism by which epiphysial separations were produced. Direct 
 traction and forcible movement at the articulations were carefully 
 studied by him, and his experimental researches are doubtless 
 some of the best which have been made on the subject. This, 
 author termed it an epiphysial fracture when the epiphysis dragged 
 away with it a finely granular layer. 
 
 MM. J. Bret and J. Curtillet (' Du decoUement traumatique des 
 epiphyses,' La Province Medicale, Jan. 23, 1892 ; No. 4, p. 40) have 
 worked out the histological features of epiphysial separations which 
 up to that time had only been examined macroscopically. * 
 
 In microscopical sections of the epiphyses detached experimen- 
 tally in a foetus immediately after death at full term, M. Curtillet 
 graphically describes {Du decoUement traumatique des Epiphyses, 
 Lyon, 1891) the appearance of the articular cartilage succeeded 
 by the thick layer of foetal cartilage with its angular cells. Lower 
 down, these are seen flattened and arranged in columns, separated 
 by the formative substance which also intervenes between them ; 
 still lower, these cells become rounded. Below, the cartilage 
 abruptly ends in the osseous substance, osteoid layer {couche osteo'idc), 
 where the detachment always occurred. This layer without car- 
 tilage cells appears to be implanted on the cartilage {cartilage serie) 
 by a number of perpendicular tooth-like processes, and in direct 
 continuation with the formative material between the columns of 
 
EXPERIMENTS IN PATHOLOGICAL ANATOMY 61 
 
 cartilage cells. The layer is not true bone, for no osteoblasts exist 
 at any part, but it is pervaded throughout by blood vessels (blood 
 globules). The trabeculas are here thin. This layer is, on the one 
 hand, less resistent than the compact cartilage, and, on the other, 
 more fragile than the bone which is more calcified. Sometimes 
 the separation in these experiments was effected a little lower, just at 
 the junction of the spongoid [couche sjjongo'ide) and spongy (couche 
 spongieuse) layer; but the long, needle-like processes which project 
 from the conjugal cartilage contained no osteoblasts at their borders, 
 which are festooned, and have their ends large and toothed, indicating 
 the site of rupture. In one case of the lower end of the humerus 
 the separation took place even in the midst of the spongy tissu§, 
 where the osteoblasts exist. 
 
 Cartilage witli 
 cells ammgeil 
 in rows (oliou- 
 droid layer) 
 
 iSTormal 
 
 spongoid tissue 
 vJW^-^gi^ i (osteoid laj er; 
 
 Fig. 3. — epiphysial sepaiution in a newly eoen infant 
 (cdktillet) 
 
 Specimens such as these are very much the same as those 
 obtained in infants where separation has been due to disease or 
 ante- or post-mortem maceration. 
 
 In similar sections taken from a separation in a child three years 
 old, M. Cur.tillet found the appearance absolutely different. The sepa- 
 ration, when viewed under the microscope, had taken place in the 
 midst of the osseous tissue. To the cartilage {cartilage serie) there 
 succeeded a very thin but uniform layer, which, on account of its 
 thinness at this period (in the foetus it is of a considerable thick- 
 ness), is probably often overlooked by the naked e5^e. This is the 
 osteoid layer destitute of osteoblasts {couche osteo'ide, Ranvier). It 
 appears like a series of gaping spaces below the cartilage filled with 
 blood globules, and limited by trabeculae of a homogeneous refracting 
 substance destitute of osteoblasts ; and on this are placed a few fine 
 medullary spaces. 
 
 This latter osseous layer {couche osseuse), which is dragged 
 away by the epiphysis, is vcr}^ thick in comparison with the former 
 layer, forming the true intermediary zone between the cartilage 
 
62 T.KAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 and the true bone, presenting a form of osseous tissue in an im- 
 perfectly constructed and transitional state. The trabeculse limiting 
 the medullary spaces show a clear yellow colour in the centre 
 and are bordered by an edge containing a large number of osteo- 
 blasts. The spaces between the trabeculse are filled with blood 
 globules and embryonic cells. The layer is consequently less resis- 
 tent to injury than the completely formed bone of the diaphysis. 
 The spaces here are larger, the trabeculse more slender, and the 
 embryonic cells less numerous than one finds lower down in the 
 diaphysis. In the latter the osteoblasts are numerous, with long, 
 slender prolongations ; but in the former angular in outline, or 
 slightly star-shaped, with feebly developed prolongations. 
 
 Fcetal 
 cartilage 
 
 Clionrlroitl 
 layer 
 
 Osteoid U3er 
 
 Spongy 
 osseous 
 tissue 
 
 ilarrow cells 
 
 Fig. 4.— teaumatic separation of an epiphysis in a child theee years of age 
 
 (curtillet) 
 
 The separation has taken place further off the epiphysial 
 cartilage than in the foetus, and beyond the thin osteoid layer in 
 the true intermediary zone between the cartilage {cartilage serU) 
 and the perfectly formed spongy tissue of the diaphysis ; in the 
 specimen the edge of the layer is formed by a number of irregular 
 fractures of its small osseous lamellse, detached from the trabeculae 
 and filling up the medullary spaces. The osteoid layer of Eanvier 
 at this period is very insignificant, but, on the contrary, in the 
 foetus it is of considerable thickness. 
 
 In two children, aged thirteen and sixteen years, M. Curtillet 
 detached almost all the epiphyses and found that the lesions presented 
 to the naked eye appearances precisely similar to those just described. 
 So that from the histological (or microscopical) point of view pure 
 separation does not exist according to M. Curtillet. Although in 
 the foetus the epiphysial cartilage appears to the naked eye to be 
 
EXPEEIMENTS IN PATHOLOGICAL ANATOMY 63 
 
 destitute of any osseous layer, there is a minute layer over its 
 surface which, while it is not bone, as it does not contain osteoblasts, 
 is not cartilage ; for it has blood-vessels and on the surface of its 
 trabeculse some osseous formative material. In older children the 
 separation does not pass, as Foucher believed, through the spongoid 
 zone, which is now extremely thin, but through true osseous tissue, 
 and it may therefore be definitely considered as a true fracture when 
 viewed by the microscope, and not merely macroscopically. 
 
 But Curtillet thinks that for other reasons these separations 
 should not be classed with ordinary fractures — viz. from the fact of 
 their close relation with the line of ossification, the special signs which 
 they present, the consequences which may follow from the develop- 
 mental aspect, and lastly from the special treatment which is often 
 called for ; and he therefore places under the heading of traumatic 
 epiphysial separation ' all fractures occurring between the conjugal 
 cartilage and the bulbar region of the diaphysis.' 
 
 Detachment of the periosteum. — The detachment of the periosteum 
 from the diaphysis, which occurs to a variable extent, will be 
 discussed under the head of pathological anatomy. The periosteum 
 remains connected with the epiphysis and epiphysial cartilage. 
 
 On its under aspect, especially in very young children, there is 
 to be seen a portion of its osteogenic layer, in which the process of 
 ossification has already commenced. It is therefore very similar to 
 the conjugal cartilage, which has clinging to it some of the ossifying 
 tissue of the diaphysis (couche spongo'ide) . 
 
 Salmon, in his experiments on the dead subject, came to the 
 conclusion that the periosteum might or might not be lacerated, 
 but, if it were, displacement was generally present — that is, no dis- 
 placement could occur without laceration of the periosteum, and 
 displacement was in the same direction as laceration. 
 
 Besides the constant occurrence of separation of the periosteum 
 which Colignon noted in his experiments on infants' bodies, he also 
 carefully remarks upon the frequent laceration existing at one part 
 or other of its extent, and explained in this way some of the dis- 
 placements which he had observed. 
 
 The periosteum is more or less extensively stripped from the 
 diaphysis, especially when displacement has been effected ; in the 
 latter case it is also lacerated to a greater or less extent, while it 
 remains untorn when there is little or no displacement. These 
 results agree with the anatomical conditions found in the post- 
 mortem experience of recorded cases. 
 
 Mechanism and experiments.^ — In the first place it must be re- 
 membered that all violent movements of the joints in young children 
 do not usually produce appreciable articular lesions, but expend 
 themselves upon the bones, or rather the weakest part of them, the 
 immediate neighbourhood of the conjugal cartilage, or the juxta- 
 epiphysial region of the French writers. This portion of the bone 
 
64 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 is, as we have now seen, the one least able to resist twists, great pres- 
 sure, or violent movements. 
 
 A natural question is : Are epiphysial separations more readily 
 produced by some forms. of violence than others? 
 
 Numerous experiments have been made to ascertain the degree 
 and direction of the force requisite to produce epiphysial separations. 
 Hitherto the scanty clinical data have added but little to their patho- 
 logy. They contrast very forcibly with dislocations, which are very 
 difficult to produce experimentally at this age ; but this is easily 
 understood when the comparatively weak conjugal neighbourhood 
 in these young subjects is fully appreciated. The violence producing 
 the two forms of injury — epiphysial separation in children and dis- 
 location in the adnlt — is frequently of the same character. The 
 mechanism is often precisely similar, being exaggerations of certain 
 movements ; in the former injuries, however, muscular action is of a 
 rather secondary importance. Gurlt, in his work on fractures, gives 
 abstracts of the results obtained by different experimentahsts. 
 
 Euysch was one of the earliest experimentalists (1713) to find 
 that considerable force was required to separate the epiphyses from 
 the diaphyses, as these were firmly connected externally by means 
 of the periosteum, and internally by the mamillary processes existing 
 between the two. In Gueretin's experiments on the bodies of 
 infants he found that the head of the humerus was more often 
 separable than any other epiphysis. 
 
 Another question to be answered is this. Does the character of 
 the violence bear any relation to that of the epiphysial separation ? 
 
 The purity of the separation, its complication with a fracture of 
 the diaphysis, or the occurrence of juxta-epiphysial separation will 
 rather depend upon the age of the subject than upon the character 
 of the violence. The latter, however, has very great influence in 
 this direction, as numerous experiments prove. 
 
 In the first place, we may say generally that violent movements 
 of all sorts apphed to a joint in childhood produce separation. Their 
 numerous forms and efficacy in producing separation will vary 
 according to the joint upon which they act. 
 
 The author himself made many experiments, both on animals 
 and on the dead bodies of children from two to seventeen years of 
 age, which essentially agree with the results obtained by previous 
 
 writers. 
 
 Indirect violence is a much more frequent cause than direct violence. 
 Klistner's experiments (Simpson, Edinburgh Med. Journal, June 
 1880) ' showed that in the lower extremities of infants the epiphyses 
 that yield most easily under a strain are those at the lower end of 
 the tibia and fibula. In one experiment the application of a weight 
 of ten kiloorams for two minutes produced a diastasis of these bones, 
 with laceration of the periosteum. The weight having been kept on 
 for four minutes, there was found besides to be great loosening of the 
 
EXPEEIMENTS IN PATHOLOGICAL ANATOMY 65 
 
 upper tibial epiphysis, and rather less in the upper fibular epiphysis. 
 The lower epiphysis of the femur was only slightly movable, the upper 
 quite firm. Kiistner quotes an experiment of Pajot, who found the 
 upper epiphysis of the femur intact after a strain of sixty-three kilo- 
 grams had been applied ; but in his own experiments he found that a 
 weight of thirty-two kilograms left it unaffected, and doubts whether 
 it can be injured under simple traction in a full-time foetus. He finds, 
 however, that this epiphysis very easily gives way from within out- 
 wards when the thigh is placed at right angles to the trunk and 
 then moved strongly outwards.' Simpson believed this was the 
 mechanism of separation of this epiphysis produced during version. 
 
 In experimenting upon the bodies of three infants aged re- 
 spectively seventeen days, a month, and two months, Colignon 
 in the first instance produced with the greatest ease separation of 
 almost all the epiphyses of the long bones. But in the second instance 
 the employment of the same force gave no result ; although very 
 energetic traction was made in the axis of the limb, Colignon w^as 
 only able to obtain an incomplete separation of the lower epiphysis 
 of the radius. On the third infant (who died of cholera) he was 
 quite unsuccessful in causing epiphysial separation ; pre-epiphysial 
 fractures were alone produced. 
 
 Traction in the axis of the limb. — Traction alone, although it may 
 be considerable, will rarely be sufficient to produce separation beyond 
 the age of infancy. Foucher, Wilson, and some others, as stated 
 above, obtained separation in infants from one to twelve months old 
 by considerable traction in the axis of the limb — viz. from 200 to 250 
 kilograms. Foucher in this manner detached the" epiphyses of the 
 femur and humerus, the lower epiphysis of the humerus usually 
 giving way first. Gurlt, in his experiments on the dead bodies of 
 infants, was unable to separate any of the epiphyses of the upper or 
 lower extremities bj^ direct traction, as many other experimentalists 
 have done ; at the ginglymoid joints he readily effected separation 
 by over-extension or by lateral movements while the epiphysis was 
 fixed, and at the enarthrodial joints by excessive abduction of the 
 diaphysis, because in this position the epiphyses were most easily 
 fixed in the articular cavity. He found it more difficult to effect 
 separation in older children. 
 
 In an experiment on traction alone by James Wilson {Lectures 
 on Diseases of the Bones and Joints, London, 1820, p. 45) it was 
 found that it required the weight of 550 lb. to detach an epiphysis 
 from a growing bone from which the periosteum was not removed ; 
 whereas when the periosteum was taken off from the corresponding 
 bone of the other side, 119 lb. detached the epiphysis. 
 
 Pajot proved the same by his experiments, with some appreciable 
 difference from those of Wilson (' Des lesions traumatiques, que 
 le fuetus peut eprouver pendant I'accouchement,' These de Goncours, 
 Paris, 1853, 8), on the bodies of newly born children, showing that 
 
 F 
 
66 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 the soft parts materially increased the connection between the epi- 
 physis and diaphysis. He found that at the upper end of the 
 humerus, separation could be effected by a weight of nineteen kilo- 
 grams after division of the muscles, the capsule and periosteum being 
 preserved ; whilst on the opposite limb, all the soft parts being 
 preserved, separation only occurred with a weight of thirty-five 
 kilograms. Thirty-eight kilograms were necessary to separate the 
 lower epiphysis of the humerus. 
 
 Pajot's experiments on the lower limbs of infants at full term, 
 which were of average development and weighed three to four 
 kilograms, gave the following detachments : 
 
 1. The upper epiphysis of the humerus with 19 kilograms (the 
 soft parts being removed). 
 
 2. The lower epiphysis of the humerus with 35 kilograms (the 
 soft parts being preserved) . 
 
 3. The lower epiphysis of the humerus with 38 kilograms. 
 
 4. The lower epiphysis of the femur with 63 kilograms during 
 nine minutes. 
 
 5. The lower epiphysis of the tibia with 16 kilograms. 
 
 Foucher had to employ a much greater weight than 100 kilo- 
 grams to produce separation in newly born infants ; 200 to 250 
 kilograms to detach the upper epiphysis of the humerus in children 
 one year old. 
 
 MM. Petit Eadel and Salmon could not in their experiments 
 separate the upper epiphysis of the humerus. Salmon separated the 
 upper epiphysis of the femur in ten instances out of twelve ; in 
 eleven children, of whom nine were less than a month old — four of 
 the latter cases being on the two sides. 
 
 The diversity in all these experiments made on the newly born 
 is explained by the amount of force necessary to separate the 
 epiphysis varying with the different bones, by the variation both in 
 the subjects and in the manner in which the traction was applied. 
 
 Although Pajot, "Wilson, Foucher and others have employed 
 heavy weights in order to detach the epiphyses, we must remember 
 that traction was employed only in the direction of the axis of the 
 bone ; whereas during life the violence also acts in more or less 
 perpendicular direction to the bone, and usually with a sudden jerk 
 or shock. 
 
 Direct traction, as in dragging a child by the arm, may separate 
 one of the epiphyses of the upper extremity. 
 
 Separation of the epiphyses during delivery of an infant may be 
 produced by the same cause. 
 
 The force required is at all times considerable ; if we find the 
 epiphyses detachable by a slight amount, some nutritive change 
 about the epiphysial line of cartilage at once suggests itself as the 
 reason. 
 
 Forcible hyper-flexion and hyper-extension of a joint, especially of 
 
EXPEEIMENTS IN PATHOLOGICAL ANATOMY 67 
 
 the ginglymoid articulations of the elbow and knee, whsre the 
 normal range of movement is limited, will readily effect a separation 
 of the epiphysis of the humerus, femur, or tibia, especially if con- 
 bined with a certain amount of rotation. 
 
 The articular Hgaments, by these forcible movements of extension, 
 are placed in their greatest state of tension ; at the ankle joint it is 
 common to find the foot fixed and the joint over-extended or flexed, 
 as when a boy, in climbing over a fence, gets his foot fixed in the 
 railings and falls over, hanging by a leg. 
 
 Colignon could nearly always separate, by forcible extension, in 
 very young children, the lower epiphysis of the humerus, but never 
 the olecranon epiphysis. 
 
 Gurlt's experiments of forcible extension and flexion easily 
 produced the same results on the same joints. Such movements 
 will have no effect upon the articulation of the shoulder. 
 
 Out of 129 cases of separation of the epiphyses at the elbow 
 joint produced by hyper-extension, Salmon found sixty-four were of 
 the whole lower epiphysis of the humerus. 
 
 Voillemier in a few instances produced separation of the lower 
 radial epiphysis by hyper-extension, ' par arrachement,' and by hyper- 
 flexion of the wrist ; Colignon, by hyper-extension, easily obtained the 
 detachment of this epiphysis, but only in young subjects ; also that 
 of the lower femoral epiphysis, though seldom that of the upper 
 tibial epiphysis, by hyper-extension of the knee-joint in newly born 
 children. Hamilton separated the olecranon while reducing a dis- 
 location of the elbow in a child. 
 
 Salmon, in his experiments, separated the lower epiphysis of the 
 humerus as a whole sixty-four times by employing forcible extension 
 at the elbow-joint in 129 bodies of infants. In one other case the 
 internal condyle was detached, in two the upper epiphysis of the 
 ulna, and in one the upper epiphysis of the radius. 
 
 Foucher was always able to separate the lower femoral and upper 
 tibial epiphyses in children less than a year old by over-extension or 
 over-flexion of the knee. 
 
 At the ankle-joint Cofignon only once separated the lower tibial 
 epiphysis by this means ; in another case of a child aged three 
 months he produced s^ pre-epvphysial fracture. 
 
 The epiphyses, having a broad and more or less flattened surface 
 of union with the diaphyses — e.g. the lower end of the femur and 
 radius and lower end of the tibia — are more easily separated on the 
 dead body than those which have an irregular reciprocal surface. 
 
 During life we mostly find that epiphysial separations are pro- 
 duced by the violence acting perpendicularly or obliquely to the axis 
 of the bone. The bone is usually fixed somewhere in the neighbour- 
 hood of the epiphysis, and gives way closely at the epiphysial line — • 
 its weakest point. A good example of this is afforded by Fontanello's 
 case. A boy, aged eleven years, whilst running caught his leg in a 
 
 y 2 
 
68 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 hole, into which it was plunged to above the knee. The child's body- 
 being carried on by the force acquired in running, the femur broke 
 at its weakest part and at a place nearest to its fixed point — viz. at 
 the level of the epiphysial line of cartilage. The lower epiphysis 
 was thereby separated. 
 
 It is quite unnecessary to describe the experiments already 
 alluded to of Oilier, Vogt, Michniowsky, and others upon living 
 animals, the anatomical conditions differing so vastly in them from 
 those of the human subject that they can only have a relative value. 
 
 Forcible abduction and adduction, combined with torsion or 
 rotation, act very powerfully in separating the lower epiphyses of 
 the feinur, tibia, fibula, and radius. 
 
 Abduction of the limb with a certain amount of rotation outwards 
 is the chief and the most easy way of producing separation of the 
 upper epiphyses of the feixiur and humerus. 
 
 Separation of the internal epicondyle may also be readily effected 
 by abduction of the forearm at the elbow. 
 
 Fixing the epiphysis and forcibly flexing or extending the shaft, 
 or moving it in a lateral direction, readily effects a separation. 
 Gurlt easily produced separation in this manner. Terrillon, Menard, 
 and Barbarin produced separation of the epiphyses at the knee-joint 
 by, powerful lateral flexion. 
 
 Torsion of the limb is most effectual when combined with flexion 
 or extension. It is more powerful in its action in older children, 
 where the articular ligaments are more resistent and rigid, than it is 
 in infants with laxer articulations. 
 
 Colignon easily produced separation of the upper epiphysis of 
 the humerus and femur by violent abduction and rotation outwards. 
 
 Ricard quotes the following case {Traite cle chirurgie, Duplay 
 and Eeclus, tom. ii. 1890, p. 346) as an illustration of epiphysial 
 separation by torsion. An altercation having sprung up between a 
 boy aged nineteen and his master, the latter seized him by the 
 middle of the left arm and violently twisted him in order to push 
 him outside. Although the youth had not received any direct blow, 
 he experienced very acute pain at the shoulder, and found himself 
 unable to use his arm. He was admitted to the Hopital de la Pitie, 
 and the next day there was found to be a fairly considerable swelling 
 of the shoulder and upper half of the arm. The elbow was a little 
 away from the side, but could be brought to it, though this caused 
 some pain. Active movement could not be effected, and passive move- 
 ments were painful. There was great effusion into the sub-deltoid 
 bursa and joint. The swelling extended to the infra-clavicular region 
 and rendered its exploration more difficult ; however, it was found 
 that there was no abnormal projection either here or in the axilla. 
 The clavicle and scapula were intact. Very acute pain was caused 
 by direct pressure on the humerus ; it was limited, and situated 
 two fingers' breadth below the acromion ; it was also produced 
 
EXPEEIMENTS IN PATHOLOGICAL ANATOMY 69 
 
 when pressure was made from below upwards on the elbow. On 
 seizing the lower part of the arm and rotating it slightly round the 
 axis of the humerus, smooth and muffled crepitus could be distinctly 
 felt by the other hand on the shoulder, and appeared to be situated 
 at the same painful spot above. This smooth crepitus was quite 
 characteristic. The next day the swelling of the shoulder was more 
 marked, and the inner aspect of the arm was extensively ecchymosed. 
 Careful measurement of the two arms did not show any appreciable 
 shortening. Firm union took place, but with some displacement of 
 the humerus forwards, so that the head formed an angle with the 
 axis of the shaft, being situated at its posterior and inner side, while 
 all movements were perfectly free. 
 
 Forcible extension and abduction, combined with rotation or 
 torsion, are then, as a general rule, the most potent means of sepa- 
 rating the epiphyses. 
 
 During life this form of mechanism is brought about when, say, a 
 child's leg is caught in the revolving spokes of a carriage wheel, and 
 the lower epiphysis of the femur separated ; or when the arm is 
 seized by the revolving strap of a machine, and the lower epiphysis 
 of the humerus detached. 
 
 Direct violence. — Malgaigne did not admit direct violence as a 
 cause of separation, but the numerous cases quoted later on in this 
 work are sufficient to disprove this opinion and to clearly establish 
 its frequent occurrence. The smallness of the epiphyses in general 
 often permits of their escape from injury in direct violence. How- 
 ever, a fall or blow on the great trochanter is sufficient to separate 
 this epiphysis, as in Aston Key's case. 
 
 Direct blows on the lower end of a limb more often produce a 
 fracture than a separation. 
 
 In many instances violence applied to the lower end of a limb, 
 though appearing direct, acts only indirectly upon the epiphysial 
 junction or the epiphysis. 
 
 M. Delorme has carefully studied, by means of experiments, the 
 form and situation of fractures of the epiphyses by gunshots. 
 
 The author has gone at some length into the causes and 
 mechanism, experimental and otherwise, of epiphysial separation, as 
 a knowledge of them is of great assistance in forming an accurate 
 diagnosis, especially when they are considered with the symptoms 
 present. 
 
70 TKAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 CHAPTEE VI 
 PATHOLOGICAL ANATOMY 
 
 Site : Pure Separations — Partial Separation with Fracture of Diaphysis — 
 
 JUXTA-EPIPHYSIAL SpRAIN — INCOMPLETE AND COMPLETE DISPLACEMENT OF 
 
 Epiphysis or Diaphysis — Complications : Fracture of Epiphysis — Separa- 
 tion wiTh Dislocation — Injury to Joints — Occlusion of Vessels — Injury 
 TO Nerve Trunks — Separations from Disease — Compound Separations 
 
 Site of Sepaeation 
 
 The pathology of epiphysial separation still affords some obscure 
 points of interest. 
 
 The epiphysial junction line of cartilage is the weakest part of 
 a bone in infancy and youth, and consequently the part most likely 
 to give way when violence is applied in the neighbourhood of an 
 epiphysis. 
 
 When a child meets with an accident, by twisting or dragging 
 of a limb, the violence will be transmitted to the elastic epiphysial 
 junction cartilage. The greatest strain will, however, be mani- 
 fested at the junction of the more rigid diaphysis with the junction 
 cartilage, which as a rule will yield. 
 
 In illustration of the epiphysial junction being the weakest 
 part of the bone, Mr. Hutchinson mentions that he had made an 
 autopsy where there were five detachments of the epiphyses with 
 only one fracture, that of the clavicle, and he could recollect 
 another where there were nearly as many in one limb. 
 
 The same author, in a clinical lecture at the London Hos- 
 pital, says {Medical Press and Circular, Nov. 18, 1885, 461) that 
 separations of the epiphyses occur not unfrequently in the lower 
 animals. ' In pigs it is not very uncommon, so I have been in- 
 formed, that, in copulation, when a heavy boar is put to a young 
 sow, his weight may be sufficient to detach the upper epiphysis of 
 the femur. I have, too, a preparation showing this accident both 
 in pigs and rabbits.' 
 
 Separation at or soon after birth. — Separation of the epiphyses 
 from the shaft of long bones in consequence of violence inflicted at 
 the time of birth or in very early infancy is of frequent occurrence, 
 although Gueretin in 1837 could not find any recorded case of intra- 
 uterine separation. 
 
 J. K. Hornidge (Holmes' System of Snrgery, 3rd edit. 1870, 
 
PATHOLOGICAL ANATOMY 71 
 
 vol. ii. p. 40) states that separation of an epiphysis may occur 
 during intra-uterine Hfe from blows received by the mother, and 
 that it has been not unfrequently produced during birth by violent 
 attempts at delivery. 
 
 0. Kiistner has given a full account {Die typischen VerUtzungen 
 des Extremitdthnochen des Eindes durch den Geburtshelfer, Halle, 
 1877) of the literature of this subject. 
 
 Since the anatomical conditions of a cartilaginous end of a bone 
 at the time of birth are very different from what they are later on, 
 and since the greater number, if not all, of these separations in 
 this early condition of the bones are really the effect of disease, but 
 little importance can be attached to many of them as true examples 
 of epiphysial detachment. 
 
 Dr. A. Eussell Simpson related to the Obstetrical Society of 
 Edinburgh {Edinhurgh Medical Journal, June 1880, p. 1057) a case 
 of diastasis in the bones of the lower extremity of a foetus 
 produced by the accoucheur. ' It was a case of multiparal placenta 
 praevia, and the right leg that was seized and brought down. 
 The child was dead before being fully delivered. The Hmb presented 
 nothing special in its external appearance beyond a slight abra- 
 sion over the internal malleolus. There was no swelhng or 
 distortion of the hmb ; and except that the foot seemed somewhat 
 more loosely jointed to the leg, as if some of the hgaments had 
 been torn, it might have been thought that no injury had been 
 sustained. Certainly there was no deformity that the eye could 
 detect, OT crepitations that the finger could produce. Yet at three 
 different points fractures were found on dissection. They were all 
 fractures of the kind known to surgeons as " diastases " — the shaft of 
 the bone, that is to say, had become detached from the epiphysis. 
 The seats of the diastases in the right leg were : first, the upper 
 end of the femur below the trochanters ; second, the lower end of 
 the tibia ; and third, the lower end of the fibula. There had also 
 baen some separation of the epiphysis of the lower end of the femur 
 of the same (right) leg, for the epiphysis was slightly movable on 
 the diaphysis ; but the upper ends of the tibia and fibula were quite 
 firm. In the left leg the epiphysis of the lower end of the tibia 
 was loosened, but the epiphyses at both ends of the femur were 
 firm.' 
 
 Pure separation. — According to the majority of authors, true 
 separation only exists where the lesion is characterised by a clean 
 separation between the osseous tissue and the epiphysial cartilage, 
 and in the larger proportion of cases the disjunction is effected by 
 means of a fracture, the cartilage dragging with it a more or less 
 appreciable portion of the osseous tissue of the diaphysis. 
 
 The writer in the British and Foreign Med. Chirurgical Beview 
 (1862, vol. ii. p. 149) quotes as follows from M. Coulon {Traite clinique 
 etpratiq^ue des fractures chez les en/ants, Paris 1861, p. 15) : ' We find 
 
72 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 that the united experience of MarjoHn and Conlon has not enabled 
 them to produce a single example of true separation of the epi- 
 physes, notwithstanding the frequent occurrence of fracture near 
 the large joints — a striking example of the rarity of the accident. 
 We may also add that after examining a good number of specimens 
 we have found in most of those in wdiich the accident was recent 
 that the fracture, if it traversed the epiphysial line at one part of 
 the bone, generally left it at another part.' 
 
 Bichet sums up the question of true epiphysial separation in the 
 following words : 
 
 ' Ce n'est la d'aillem^s, il faut bien en convenir, qu'une discussion 
 sans importance pratique, puisque le pronostic et le traitement de ces 
 pretendus decollements epiphysaires sont identiques avec ceux des 
 fractures des extremites articulaires completement ossifiees.' 
 
 In the discussion at the Societe de Chirurgie, Paris, in 1865, 
 some speakers, in particular M. Chassaignac, appeared to admit as 
 separations only those which were absolutely pure — namely, those 
 in which there is a complete separation of the epiphysis and 
 diaphysis just at the level of the junction of the cartilage and bone. 
 Taken in this way, it is true, separations are exceedingly rare, 
 inasmuch as it is a true fracture of the spongy tissue of the shaft 
 in proximity to the epiphysial cartilage, for the cartilage is usually 
 found covered with thin granular particles which have been detached 
 from the diaphysis. 
 
 Every solution of continuity near the epiphysial cartilage, or 
 between it and the bulbar region {region hulhaire) of the diaphysis, 
 must be considered as a separation. 
 
 E. W. Smith, of Dublin, maintained that separations follow 
 exactly the line of the cartilage. Some few authors stiU declare dog- 
 matically that such separations do not exist, but that in all cases the 
 line of separation passes through the osseous tissue. In many the 
 solution of continuity undoubtedly takes place through the spongy 
 tissue of the diaphysis near the epiphysis {fracture pre-eijiphysaire, 
 Foucher). We must also admit with Foucher that a large 
 majority partake of the characters of all forms, and yet, from 
 numerous specimens now in existence, the question of the reality of 
 pure forms of separation can no longer be doubted. 
 
 The frequent presence of an associated fracture is a matter of 
 secondary importance; the principal lesion is the epiphysial 
 separation. 
 
 Foucher {Annales du Congres medical de Bouen, 1863), who was 
 one of the first to carefully study the pathology of epiphysial separa- 
 tions, divided them into three classes : 
 
 1. Pure separation of the epiphysis from the diaphysis {diviilsion 
 epiphysaire) without any osseous tissue adhering to it. 
 
 2. Separation of the epiphysis with a thin, finely granular 
 layer of osseous material attached to it {fracture epiphysaire). 
 
PATHOLOGICAL ANATOMY 73 
 
 3. Solution of continuity of the diaphysis in the midst of the 
 osseous spongy tissue near the epiphysis {fracture pre-epiphysaire) . 
 In instances in which this occurs ossification is fairly well advanced, 
 the epiphysis being almost joined to the diaphysis. 
 
 Toucher adds : ' It sometimes happens that the solution of 
 continuity is not so uniform, its surface presenting these three 
 characteristics at the same time.' 
 
 The third kind mentioned is a true fracture of the diaphysis near 
 the epiphysial line, the ends of fragments being irregular, with large 
 pointed processes ; the medullary spaces are opened, and the oily red 
 marrow fluid oozes out. 
 
 In speaking of separations of the lower radial epiphysis, M. 
 Anger terms ' epiphysial fractures ' those taking place at the epi- 
 physial line after union of the epiphysis. 
 
 Since Foucher's researches, pure separations of the epiphysial 
 cartilage from the diaphysis have been generally admitted. 
 
 Bruns expresses his opinion that simple, uncomplicated cases of 
 epiphysial detachment are much more common than is generally 
 believed. 
 
 There are three hinds of inire epiphysial separations (macro- 
 scopically) : 
 
 1. The separation takes place through the cartilaginous layer 
 itself, so that more or less of this cartilage still adheres to the diaphysis 
 as a thin layer : a rare and quite exceptional form. The conjugal 
 cartilage is the only part involved. 
 
 2. The separation takes place exactly at the epiphysial Hne, the 
 epiphysial cartilage clinging entirely to the epiphysis : the common 
 form. The two fragments are separated exactly above the line of 
 junction of the epiphysis and diaphysis without any portion of bone 
 remaining on the epiphysis. All authors who have doubted the 
 reality of traumatic separations have laid particular stress upon the 
 rarity of this lesion in its pure form. This is the divulsion 
 epiphysaire of Foucher. 
 
 3. Juxta-epiphysial separation. The tract of separation passes 
 below the spongy layer of Broca. More or less of the osteoid layer 
 remains attached to the conjugal cartilage. This is the fracture 
 epiphysaire of Foucher, and is the most frequent variety of pure 
 separation. 
 
 Notable examples of pure separation passing, partly at least, 
 through the midst of the cartilage itself are given by A. Broca in 
 the case of the lower end of the femur and by Esmarch in a case 
 of compound separation of the upper epiphysis of the humerus, 
 quoted by Gurlt in his Handhuch der Lehre von den Knochenhriichen. 
 
 In one case reported by M. Eichet the diaphysial extremity was 
 said to be covered with cartilaginous projections, and in another 
 there was a compound separation of the lower epiphysis of the 
 tibia with the same existing condition. 
 
74 TKAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 In sixty-one out of eighty-one of Bruns' cases in which exact 
 details of the separated surfaces were given, twenty-eight were pure 
 epiphysial separations without any fracture of the bone, and in five 
 of these the separation was through the cartilage itself, both sepa- 
 rated surfaces being covered with cartilage. Thirty-three cases were 
 partly diaphysial — that is, were associated with a more or less 
 extensive fracture of the diaphysis. 
 
 A pure separation of the epiphj^sial cartilage from the diaphysis 
 is more frequent in young children. The diaphysis presents a 
 slightly convex or undulating surface, which has been already 
 alluded to in the anatomy of this region. Its surface is covered 
 with small projections and excavations, which look like small granu- 
 lations, and to the finger it has a soft oily sensation, as though it 
 were smeared with some greasy substance. 
 
 The surface of the epiphysis, on the other hand, is concave, 
 presents corresponding small depressions and hillocks, with a pinkish 
 grey colour and the appearance of soft vascular cartilage. To the 
 naked eye not a particle of osseous material (spongoid layer), 
 excepting perhaps a little here and there at the edges, clings 
 to it. If, however, a very thin section of it be held on a sheet 
 of glass up to the light, a very fine layer of this material may be 
 distinguished, which appears of a yellowish opaque colour placed 
 on the transparent and bluish chondroid layer indistinguishable by 
 any rougher method of examination (Curtillet) . 
 
 In the more common injury (Foucher's second class) the separa- 
 tion taking place through the juxta-epiphysial region, the surface of 
 epiphysial cartilage is covered with a layer, or more usually small 
 pgjtches or particles of the osteoid layer or true osseous tissue, which 
 is quite evident to the naked eye. 
 
 The diaphysial surface is rougher, more dry and spongy in 
 appearance, and presents numerous holes. 
 
 The general outline of both separated surfaces is the same as in 
 the last class. 
 
 Foucher and others have thought that each of these varieties 
 occurred more or less readily according to the different ages. In 
 infants from birth up to about one year, pure and simple separations ; 
 from one to four or five years of age, epiphysial fracture, so called ; 
 from five to ten years and above, pre-epiphysial fracture. 
 
 Bruns also thinks that pure separations are most commonly met 
 with in early childhood. This classification cannot be accepted with 
 our present knowledge of anatomical facts. 
 
 Gurlt, too, says that after the age of two years the separation is 
 seldom a pure one, and nearly always a more or less considerable 
 fragment is separated from the diaphysis, and remains adherent to 
 the epiphysis. 
 
 The author's own opinion is that the limit of period for the 
 ordmary cases of pure separations (Foucher's second class) is much 
 
PATHOLOGICAL ANATOMY 75 
 
 more extended than is usually supposed, and may be met with even 
 up to the eighteenth year. 
 
 Anatomy of the epiphysial region. — There are two distinct periods 
 in the growth of the bones before the final blending of the epiphysis 
 and diaphysis, in which the various parts have a somewhat different 
 relation to one another. 
 
 Clinically these two periods are now recognised not only in 
 connection with traumatic separation of the epiphyses and cartila- 
 ginous ends of the bones, but also with regard to acute periostitis, 
 rickets, syphilitic epiphysitis, acute pysemic arthritis of infants, 
 abscess of bone, tuberculous and cancerous disease, &c. Some of 
 these are clinically confined to one or other of these periods. 
 
 As Uffelmann has pointed out, separation of the cartilaginous 
 epiphysis {chondro-epiphysis), which presents a continuous mass of 
 cartilage, is to be distinguished clearly from separation of the osseous 
 epiphysis {psteo-epiphysis), in which the osseous centres in the 
 epiphysis have united, and the whole of the epiphysis is for the 
 most part ossified, leaving the thin but more or less broad cartila- 
 ginous layer between the diaphysis and ossifying epiphysis. 
 
 The causes of the separation and the manner in which it is 
 produced in the two classes are somewhat different ; the disjunction 
 itself (i.e. the injury) varies also. 
 
 Yogt believes, from experiments he has made, that separations 
 of the cartilaginous ends of the bones or epiphyses are mostly pure 
 in character, and that separations of the osseous epiphysis are mostly 
 associated with fracture of the diaphysis. In the former case he 
 thinks that the cartilaginous epiphysis yields somewhat to the 
 pressure of the firmer diaphysis, and that in the latter case no such 
 compressibility, or only a slight one from the pressure on the junction 
 cartilage, is allowed. 
 
 First period.— Although the diaphysis is rapidly ossifying, the 
 end of the bone is entirely cartilaginous, and the cartilage forming 
 the epiphysis cannot be distinguished from the articular cartilage. 
 
 In the bones forming the elbow- joint, this period lasts till about 
 the third year. 
 
 Second period. — This extends to the twenty-first and twenty- 
 second year, or even a little later. 
 
 The vascular supply of the epiphysis is now quite distinct from 
 the diaphysis. 
 
 The cartilaginous junction-disc is non-vascular, but firmly blended 
 with the deeper layer of the periosteum at its circumference. In 
 some situations, as at the head of the femur, it is entirely intra- 
 articular, in others entirely extra-articular. It is rapidly prolife- 
 rating on both surfaces, and a layer of soft embryonic tissue adjoins 
 it, situate between the medullary canal of the diaphysis and the 
 cartilaginous disc. This layer of embryonic or nearly ossified tissue 
 is called i\\Q jiLxta-epipliysial layer. 
 
76 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 Broca was the first to lay down the rule that in epiphysial 
 separations the cartilage remains with the epiphysis, and this is now 
 very generally accepted by authors, and is well established from the 
 number of authentic specimens now in existence. The surface of 
 the separated epiphysis is formed of cartilage over its gTeater extent ; 
 here and there, more often in the centre of this smooth and slightly 
 excavated surface, a few gi-anules of osseous material are to be 
 found. In the newly born and in infants the separation takes place 
 a little lower through the spongoid layer of Broca without involving 
 the spongy osseous tissue. 
 
 Hence M. E. Kohet thinks {Lyon Medical, March 29, 1891) that 
 the title of ' juxta-epiphysial detachment ' is the best one for the 
 injury usually known as epiphysial detachment, inasmuch as it is 
 really the diaphysis of the shaft of the long bone, and not the epi- 
 physis, that is separated from the intervening cartilage. 
 
 Gueretin says that there are no epiphysial separations in the 
 proper sense of the word, and that they are always accompanied by 
 fracture ; and from the histological aspect this is really true, the 
 separation taking place directly above, in the spongy osseous tissue, 
 some of which is nearly always dragged away. 
 
 This agrees with the opinion of many surgeons that the separa- 
 tion most frequently occurs immediately above the epiphysial line, 
 and that the injury is really a fracture of the extreme portion of the 
 diaphysis, a thin layer of the ossifying tissue {couche spongokle) of 
 the diaphysis still chnging to the cartilage. 
 
 Erom this anatomical point of view, juxta-epiphysial separation 
 closely resembles separation of the diaphysis in infective osteo- 
 myelitis, of which M. Lannelongue {De VosUomy elite aigue, p. 43, 
 Paris, 1879) has given so clear a description. 
 
 In this disease a layer of osseous tissue of variable thickness 
 remains attached to the epiphysis. 
 
 M. Oilier, in discusssing epiphysial separations {TraitS de la 
 regeneration des os, tom. i. p. 220, 1867), says that 'la disjonc- 
 tion ne se fait jamais sur la limite nieme du cartilage, c'est au 
 niveau de la couche spongoide normale. Cette particularite est 
 importante au point de vue de la cicatrisation, car ces decollements 
 se reparent comme des plaies osseuses et non comme des plaies 
 cartilagineuses.' 
 
 Fracture oblique or transverse of the diaphysis, immediately above 
 the epiphysial line, may occur at the same age and from the same 
 causes as epiphysial separation, which it very closely simulates. 
 
 Several specimens are now on record of transverse fracture of the 
 lower end of the humerus immediately above the epicondyles, and on 
 a level with them. 
 
 The question whether epiphysial separations of the more common 
 type are really true fractures is of interest also from the jurispruden- 
 tial aspect. 
 
PATHOLOGICAL ANATOIMY 77 
 
 A ciirioTis instance in which this question was raised, in the case 
 of a separation of the great trochanter from a kick, is related by John 
 Hilton {Guifs Hosj)ital Beports, 3rd series, vol. xi. 1865, p. 342). 
 According to the medical report of the post-mortem examination, the 
 boy's death was produced by ^fracturing the thigh hone.'' ' The counsel 
 for the defence took advantage of this verbal inaccuracy in the 
 indictment, and used it successfully in his client's favour, proving 
 satisfactorily that it was not a fracture, but a simple separation of 
 portions of bone from disease ; and so the prisoner got off. The 
 thigh bone, trochanter, and adjacent parts were sent up to Mr. Hilton 
 in order to verify the separation of the epiphysis ; and as no doubt 
 could be entertained about the character of the accident, the 
 indictment for murder failed from the inaccuracy of the designation 
 of the injury to the bone.' 
 
 Incomplete Sepaeatioxs. Juxta-epiphysial Speains 
 
 Incomplete separations, without displacement, are often entirely 
 overlooked. Clinically, as Gurlt pointed out in 1862, although 
 they are exceedingly difficult of diagnosis, their frequent occurrence 
 is midoubted. Experiments amply prove this. Gurlt says that in 
 these the mobility may be very slight, or not to be noticed at all on 
 account of the soft parts covering in the end of the bone. 
 
 Foucher says that he had never seen an incomplete separation — 
 that is, where the diaphysis and epiphysis have still some points of 
 continuity. 
 
 Incomplete fractures or sprains occurring in the juxta-epiphysial 
 region have been recently studied by M. Oilier, and are called by 
 him juxta-epiphysial twists or sprains {entorses juxta-epiphysaires) 
 (Oilier, Eevue de chirurgie, torn i. 1881, p. 785). 
 
 He describes the following lesions of the juxta-epiphysial osseous 
 tissue : incomplete fracture of the juxta-epiphysial region, character- 
 ised by crushing, fracture of the trabeculge of the bones, and sepa- 
 ration of the periosteum and of the epiphysial cartilage, indicated 
 externally by a juxta-epiphysial notch. ^ 
 
 The greatest crushing takes place eight or ten millimetres below 
 the conjugal cartilage. 
 
 The following are the conclusions arrived at by M. Oilier in his 
 memoir on juxta-epiphysial sprain, V entorse juxta-epiphysaire. 
 
 I. Juxta-epiphysial sprain is the lesion commonly produced in 
 the juxta-epiphysial region of the diaphysis of long bones by violent 
 manipulations at the articulations. 
 
 ' Ecrasement du t!ssu spongieux juxta-epiphysaire, masque d'abord par la fracture 
 incomplete sous-periosteale de la couche compacte p^ripherique, fractures tralieculaires 
 du tissu spongieux ; expression du sue medullaire a travers les orifices vasculaires et les 
 diichirures du perioste. Si I'effort continue, tassement plus prononce de la substance 
 areolaire juxta-(jpiphysaire, separation d'esquilles du tissu spongieux (Oilier). 
 
78 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 11. Such violence at the articulations, especially in young children 
 below the age of three, gives rise to lesions in the osseous tissue of 
 the juxta-epiphysial region, and not to any notable injuries to the 
 articulation. 
 
 in. These lesions of the osseous tissue consist of incomplete 
 diaphysial separations and of incomplete fractures of the juxta- 
 epiphysial region, and are very 
 readily brought about when the 
 bone has been considerably altered 
 in its structure by rickets or by 
 some other acute or chronic affec- 
 tion disturbing the proper nutrition 
 of the bone. 
 
 IV. These lesions, occurring in 
 the deeper parts of the bone be- 
 neath the periosteum, often pass 
 unobserved, not only by clinical 
 but also by experimental observers, 
 although they are of necessity 
 present in all their experiments 
 on the so-called epiphysial separa- 
 
 FlG. 5. — LESIONS PRODUCED BY FORCIBLE 
 
 ABDUCTION OF THE FEMUR IN A CHILD tlOU. 
 
 AGED TWENTY-TWO MONTHS. Obliqiio SCO- Y_ rpj^g leslous comprlsc crush- 
 
 tion of specimen, a. Commencement of . 
 
 diaphysial disjunction on tlie inner side, mg. Compression or Iracture of the 
 
 h. Periostemii intact. c. Compression trabecular processes of the spongy 
 
 of the spongy tissue on the outer side . . \. . . . 
 
 below the trochanter. (Oilier.) tlSSUe ; mllexion, twistuig, and 
 
 fracture of the thin compact peri- 
 pheral layer ; and consequently exudation of the medullary fluid, 
 extravasation of blood into the spongy tissue and under the peri- 
 osteum, which is more or less separated. 
 
 YI. If the violence be continued, permanent depression of the 
 compact layer is produced on the side of flexion, forming the juxta- 
 epiphysial notch, while rupture {fracture par arracheme^it), stretching, 
 and laceration of the periosteum occur on the side of extension. 
 Now is the time that fracture or separation of the diaphysis is on 
 the point of occurring, along with its displacement outside of the 
 periosteal sheath. 
 
 YII. Juxta-epiphysial sprain is not usually serious, and is 
 limited to a painful loss of power which soon disappears of itself ; 
 but if the child is not looked after, if it is scrofulous or has any 
 hereditary tendency to tubercle, the lesion will often be the start- 
 ing point, early or late, of some form or other of osteomyelitis, 
 which is directly explained by the bending and fracture of the 
 tubercular processes of the spongy osseous tissue. 
 
 YIII. Juxta-epiphysial sprain gives rise to a more or less pain- 
 ful but very distinct swelling of the juxta-epiphysial region, while 
 the neighbouring joints remain free. This is the characteristic 
 
PATHOLOGICAL ANATOMY 79 
 
 symptom of the lesion, and is due to the swelling of the separated 
 periosteum and to the hyperplasia of its osteogenic layer. 
 
 IX. What has been called ' painful ])Tond.i\o\\' {pronation forcee 
 doulonreiise) , painful loss of power {torpeur doulo-ureuse), may in 
 great measure be explained by juxta-epiphysial sprain. The former 
 is a juxta-epiphysial sprain of the lower end of the radius or ulna. 
 
 X. In order to prevent the dangers of juxta-epiphysial sprain, 
 the limb need only be immovably fixed for a sufficient length of 
 time. It is necessary, therefore, in young children to carefully 
 examine the limbs which have been subjected to violence, or which 
 have been injured by a fall, and if juxta-epiphysial swelling is 
 noticed, whether painful or painless, to look carefully after those 
 children until the bone has regained its normal size. 
 
 These incomplete separations have been recognised by the author 
 for many years as the origin of a large proportion of cases of hip, 
 spinal, and other diseases, such as articular ostitis and diaphysial 
 ostitis, produced by violence in the neighboin^rood of the joint, or by 
 falls, which are so frequent at an early age. 
 
 Other Lesions 
 
 Fracture of the diaphysis. — The separation passes not unfrequently 
 for a greater or less extent through the level of the epiphysial car- 
 tilage, and then runs vertically or obliquely upwards through a 
 portion of the diaphysial end, detaching a large or small portion 
 of this, which remains with the epiphysis. 
 
 Epiphysial separations are frequently complicated by a true 
 fracture or fractures of the end of the diaphysis, but very rarely or 
 never of the epiphysis ; in fact, the form of separation, with 
 more or less splintering of the shaft, is the rule, and pure separation 
 the exception. 
 
 Splinters of the diaphysis, especially if denuded of periosteum, 
 will add greatly to the severity and risks of the injury. 
 
 Under this heading some authors place those instances of pure 
 separation where a portion of the ossifying layer remains in contact 
 with the epiphysis. 
 
 Malgaigne believed that beyond the age of two years separation 
 was rarely perfect ; there being nearly always a fragment, greater or 
 smaller, detached by actual fracture from the diaphysis and remain- 
 ing adherent to the epiphysis. 
 
 M. Eichet, in his Traite d'miatomie, says that separation is 
 never simple, but ' il est accompagne d'un arrachement plus ou moins 
 etendu de la substance osseuse, ce qui constitue en definitive une 
 veritable fracture.' 
 
 Foucher thought that pure separation occurred in very young 
 children up to one year of age, that there was fracture of the diaphysis, 
 and at any rate a considerable portion of the osseous tissue clinging 
 
80 TEAUMATIC SEPAKATION OF THE EPIPHYSES 
 
 to the epiphysial cartilage, when the accident occurred from one to 
 four or five years of age. 
 
 After examining the museum specimens of epiphysial separation 
 contained in the London hospitals, and the recorded cases of com- 
 pound separation in which the condition of the separated fragments 
 
 Fig. 6. — Pure and complete 
 separation 
 
 Fig. 7. — Partial separation, with 
 fracture of the diaphysis 
 
 Fig. 8. — Partial separation, with frac- 
 ture of the epiphysis 
 
 Fig. 9. — Complete separation, with 
 fracture of the epiphysis 
 
 diagrams of the commjn forms of epiphysial separation 
 
 could be clearly seen, the author came to the conclusion that as 
 a bone approaches a certain period in its development the traumatic 
 separation would be of a more simple character. 
 
 In each long bone there is a certain period -peculiabV to its epiphysial 
 ends in which traumatic separation of the epiphysis is of a pure 
 character, uncomplicated by fracture ; beloiv this period, but more 
 
PATHOLOGICAL ANATOMY 81 
 
 especially above, the liability of the separation being accompanied 
 by fracture becomes manifest. 
 
 In numerous experiments on the dead subject, the author arrived 
 at a precisely similar conclusion with regard to all the epiphyses of the 
 long bones ; a period is reached in each end of a bone when the 
 epiphysis is fairly ossified and developed, and likewise the end 
 of the diaphysis, leaving a weak point along the epiphysial line of 
 cartilage. The separation is then a pure one. "When, however, the 
 epiphysis is approaching the time of its complete union with the 
 diaphysis, the separation will most probably be accompanied by a 
 fracture of a portion of the diaphysis. Professor Vogt has expressed 
 a somewhat different opinion {Archiv fur Idinische (7/wr.,Langenbeck, 
 1878, S. 343) — that true separations along the epiphysial line pre- 
 dominate in the case of the chondro-epiphyses, and that in the 
 osteo-epiphyses fracture of the diaphysis more commonly occurs. 
 
 We find other writers stating the same opinion, that the earlier 
 the separation occurs the more likely is the injury to be limited to 
 the epiphysial line. The older the patient the greater the probability 
 of its involving the diaphysis. 
 
 Eicard (1890) also says that in the newly born pure separations 
 which involve only the epiphysial cartilage are the rule, while in 
 later years the epiphysial region acquires greater strength on 
 account of the ossification of the cartilage, and that then they are 
 rarely pure, but accompanied with fracture. 
 
 In Bruns' sixty-one cases, thirty-three were associated with 
 fracture of the diaphysis, and almost all of these were between the 
 ages of ten and twenty years. 
 
 The diaphysial end has been observed to be much splintered or 
 even comminuted in severe separations. 
 
 The existence of a few fragments of the diaphysis does not alter 
 the characteristics of epiphysial separations, which are situated in 
 the neighbourhood of a joint, at a part of the bone which has an im- 
 portant physiological function. The fractures are in some instances 
 produced by special conditions, and the peculiarity of the fragments, 
 their displacement, and treatment must, therefore, demand careful 
 attention. 
 
 Detachment of periosteum is one of the most important concomi- 
 tants. Epiphysial separations are always accompanied by stripping 
 of the periosteum from a portion of the end of the shaft, as is, 
 to a greater extent, observed in fractures in the same position. The 
 periostemn is separated with ease from the shafts of the bones in 
 children, but still remains in nearly every case attached to the 
 epiphysis, with which it is intimately connected. This happens on 
 account of the thickness, the great vascularity, and the loose connec- 
 tion of the periosteum with the shaft, and the intimate connection 
 of the periosteum with the perichondrium of the epiphysis. Much of 
 the danger of epiphysial separations is due to this circumstance. 
 
82 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 Malgaigne was the first to point out the extensive stripping of 
 the periosteum from the diaphysis. 
 
 Foucher also strongly indicated the same fact, as he had found it 
 so constantly in his experiments. 
 
 The extent of the stripping up is very variable, according to the 
 displacement of the epiphysis — often more than half the length of 
 the diaphysis, sometimes the whole length of the bone (Foucher). 
 
 It is questionable whether this stripping will interfere with the 
 proper union of the fragments by delaying the formation of the 
 uniting callus. If it be not extensive, there is no reason to suppose 
 that it will interfere appreciably with the length of time of union. 
 
 Even in cases where tliei-e is no displacement of the fragments, 
 the periosteum may be detached for a certain extent, but yet remain 
 untorn, and by reason of its toughness it tends to keep the fragments 
 in position and prevent displacement. This is likely to be the case 
 in rickets and other diseased conditions of the bones as well as in the 
 juxta-epiphysial sprain of OWiex {Ventorse juxta-epiphysaire). This 
 must be the case whenever there is the slightest gaping or separa- 
 tion of the epiphysis from the diaphysis. 
 
 The periosteum may be separated from the whole circumference 
 of the diaphysis, or only -for a short distance on one or other aspect 
 of the bone. This arises from its loose connection with the shaft 
 and its peculiar toughness. It still retains its connections with the 
 soft parts. This adhesion of the periosteum is especially noticeable 
 in children below fifteen years of age (Oilier). 
 
 It is only torn and lacerated in cases of separation accompanied 
 by displacement ; a rent is then made in the periosteal sheath on the 
 side towards which the diaphysial end is displaced. In more severe 
 injuries the laceration takes place some little distance from the 
 epiphysis, through which rent the end of the diaphysis protrudes in 
 amongst the muscles of the limb, and offers one of the chief obstacles 
 to reduction. 
 
 The end of the diaphysis is seen thus to be embraced by a sheath 
 of periosteum clinging to the epiphysis, which Hutchinson has 
 likened to a sleeve. 
 
 Incomplete displacements, or separations tvithout displacement, are 
 much more common than cases where the epiphysis is completely dis- 
 placed from the diaphysis. 
 
 In a considerable number of cases displacement is very incomplete 
 at the time of the accident — the epiphysis being merely loosened 
 from the shaft ; for the violence which is requisite in severe separa- 
 tions to separate and completely displace the fragment is only 
 sufficient to loosen the union or to produce a slight overlapping of 
 the epiphysis. 
 
 These separations without displacement will be found to be very 
 common, especially in younger children ; they are usually looked 
 upon as sprains, and treated accordingly. The history of many 
 
PATHOLOGICAL ANATOMY 83 
 
 examples of arrest of growth of bones is that the injury had been 
 considered as that of a sprain. 
 
 As far as concerns the upper humeral epiphysis, Moore {Trans. 
 Amer. Med. Association, 1874) believes that the displacement is 
 almost always incomplete. 
 
 Separation without displacement is often the starting-point, in 
 strumous subjects, of osteo-myelitis. 
 
 Complete displacement. — The displacement of the epiphysis may 
 be completely off the diaphysis, displaying an extreme amount of 
 deformity. 
 
 The liability to displacement varies not only with the direction 
 and amount of the violence, but with the epiphysis involved. Some 
 have powerful muscles or tendons attached to them, or have the 
 same structures acting upon them, whilst others have no such 
 anatomical relations. Again, the anatomical shape of ,the diaphysial 
 and epiphysial surfaces contributes very largely to the character and 
 amount of the displacement. In some cases these surfaces — as at 
 the lower end of the tibia — are more or less flattened, and permit the 
 gliding of one surface upon the other ; whilst in others the concavity 
 and convexity of the two surfaces may, as in the upper end of the 
 humerus, become so locked or impacted in one another as to prevent 
 complete displacement, unless a very severe amount of injury be 
 present. 
 
 Those epiphysial surfaces which have an oblique as well as flat 
 surface will be still more disposed to displacement. 
 
 Multiple separations. — Not unfrequently several epiphyses are 
 detached at the same time, as in Holmes' case of separation of the 
 lower epiphysis of the femur, of the tibia, and of both epiphyses 
 of the fibula. 
 
 Fischer and Hirschfeld diagnosed separation of both epiphyses 
 of the fibula and the upper epiphysis of the tibia in one leg, and 
 separation of the lower epiphysis of the opposite femur ; the former 
 was verified by dissection. The lower epiphysis of each radius is 
 frequently separated in falls from a height. 
 
 Mr. Hutchinson also mentions a case of separation of the lower 
 epiphysis of one humerus, and of both epiphyses of the other, in a 
 sailor boy, aged fourteen, who fell from a masthead. 
 
 Complications. Fracture of the epiphysis. — It occasionally 
 happens that the separation is complicated with a fracture of the 
 epiphysis passing into the joint itself. This most often takes place 
 at the lower end of the femur, next in frequency at the lower end 
 of the humerus (before puberty), and least commonly at the lower 
 end of the radius. 
 
 It very often occurs in gunshot fractures, while a comminuted 
 separation results from direct crushing violence. It is improbable 
 that the articulation should entirely recover its normal functions after 
 such an injury, 
 
 G 2 
 
84 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 Dislocation. — Displacement of an epiphysis from its articular rela- 
 tions is very rare ; there are few dislocations or fractures in the neigh- 
 bourhood of a joint in early life which may not be complicated with 
 a partial separation of the epiphysis from the shaft, but in its com- 
 plete form it is occasionally seen at the upper and lower end of the 
 humerus, while in other situations it is exceedingly rare. At the 
 elbow a dislocation is commonly complicated by a separation of the 
 internal, or more rarely of the external, epicondyle. 
 
 Contusion and laceration of muscles, fasciae, and other soft parts 
 are often greater than in fractures in the same position. 
 
 Injury to blood vessels. — These are much more frequently injured 
 through pressure or laceration by the displaced end of the diaphysis 
 than in fractures at the corresponding part. 
 
 This is especially marked in separation of the lower epiphj^sis of 
 the femur, and next in frequency in that of the lower end of the 
 humerus. 
 
 Articular lesions.- — No definite rule can be said to exist on this 
 point. 
 
 Separations of some epiphyses might be divided into intra- 
 articular and extra-articular classes ; for particular joints are very 
 liable to be involved in detachments of the neighbouring epiphysis, 
 since the capsule in these more or less entirely includes the epiphysis 
 and epiphysial line of cartilage. 
 
 Moreover, at the different periods of infancy and puberty the 
 particular joint may be more or less likely to be opened, and its 
 synovial membrane torn in epiphj^sial separation — e.g. the upper end 
 of the humerus and upper end of femur. 
 
 Sir John E. Erichsen, in the tenth edition of his Science and Art 
 of Surgery, 1895, vol. i. p. 555, says : ' In these cases of separation 
 of an epiphysis with protrusion of the end of the shaft through the 
 skin, although the fracture is in close vicinity to the joint, the 
 articulation is not affected, and careful examination will always 
 prove its sound condition. ... In two instances I have sawn off 
 the projecting end of the shafts, in lads ; in one near the shoulder, 
 in the other near the ankle. An excellent result, without impairment 
 of the joint, followed the operation.' 
 
 Teno- synovitis. - The sheaths of the tendons, muscles, and other 
 tissues of this region are often the seat of effusion of blood as well 
 as of serous fluid from synovitis. Teno-synovitis is not so persistent 
 as in adults. 
 
 EiFusion of blood occurs to a greater or less extent in every case of 
 epiphysial separation. 
 
 It may be superficial, extending along the limb and towards the 
 joint, the outline of which is rapidly obscured, but is more constant 
 and abundant in the deeper parts, from laceration of muscles, and 
 from the detached or lacerated periosteum. 
 
PATHOLOGICAL ANATOMY 85 
 
 The space between the detached periosteum and the diaphysis 
 is constantly found to be occupied by blood clot. 
 
 Injury to nerves. — Paralysis, due to pressure upon or laceration or 
 partial division of a nerve, is not very common. It has been observed at 
 the lower end of femur, and at the upper and lower end of the humerus. 
 
 For later complications see under Sequels. 
 
 Sepaeations the Cause and Consequence of Disease 
 
 Separations the cause of disease.— It is highly probable that separa- 
 tions without any displacement of the epiphysis, or partial separations, 
 are the very frequent cause of strumous disease of a joint — e.g. hip 
 disease, caries of the spine, or suppurative disease of the bone or 
 periostemn. This is very likely in weakly or strumous children ; 
 whereas in children of a strong and healthy constitution such lesions — 
 which are very frequently overlooked from their difhculty of dia- 
 gnosis, or are only treated as sprains — will get well quickly and unite 
 firmly without any untoward consequences. 
 
 M. Fournier relates {Bulletin de la Soc. Anatomique, xxx. 1855, 
 p. 50) a well marked example of ostitis and acute disease following 
 slight injury to the epiphysial line. The ostitis affected the lower 
 two-thirds of the femur, and was accompanied by sub-periosteal 
 abscess and separation of the lower epiphysis of the femur. 
 
 Other instances are too numerous to be mentioned here. 
 
 Separations the consequence of disease, although of very considerable 
 interest and perhaps too little studied, cannot be considered in this 
 place. 
 
 Separations the result of slight injury, or spontaneous separations 
 occur in diseased conditions of the region of the conjugal cartilage, 
 osteo-myelitis, periostitis, congenital syphilis, scurvy, hsemorrhagic 
 periostitis. 
 
 Some of these separations — e.g. those due to osteo-myelitis — have 
 been known to reunite without suppuration having taken place. 
 
 Separation in syphilitic infants is of common occurrence. 
 
 Bouchut records {Diseases of Children, translated by Bird, 1855, 
 p. 693) a well marked instance of separation of several epiphyses of 
 the long bones in a newly born female child which was considered 
 by M. Valleix as due to syphilis. M. Valleix {Bulletin de la Soc. 
 Anatomique, ix. 1834, p. 169) also noted in this interesting case 
 the occurrence of subperiosteal abscess and remarkable production 
 of bone, which rather pointed to pysemic infection than to syphilis. 
 
 Macnamara has reported {Diseases of the Bones and Joints, third 
 ed. 1887, p. 165) the case of an emaciated infant in whom the epi- 
 physes of the right elbow- and knee-joints were separated and 
 movable. The child died two months after birth. There was no 
 history of syphilis in this case, nor any sign of inflammation in the 
 
86 TEAUMATIC SEPAKATION OF THE EPIPHYSES 
 
 part, but simply molecular disintegration of the tissues at the line 
 of junction between the diaphysis and epiphysis of the affected 
 bones. 
 
 Another case of separation of the lower femoral epiphysis, pro- 
 duced by osteo-myelitis, is related by A. H. Meisenbach (Annals of 
 Surgery, Feb. 1895, p. 159). 
 
 A well marked instance of separation of the articular epiphyses 
 in an idiot child aged ten with symptoms of scurvy is related by 
 Dumont-Pallier {Bulletin cle la Soc. Anato7nique,xxYii. 1852, p. 421). 
 Two interesting cases of se])aration of the lower epiphysis of the 
 femur associated with tuherculous disease of the knee-joint in 
 children aged 6^ and 3||- years are recorded by Mr. Edmund Owen 
 {Lancet, Jan. 28, 1893, p. 194). 
 
 Separation from tuberculous disease in the latter situation is 
 seldom observed, yet the same process in the neighbourhood of other 
 joints is far from rare — viz. hip-joint, spine, &c. 
 
 CoMPOuxD Separations 
 
 Considering the violence of the injury which produces compound 
 separation, and the ease w^ith which the periosteum is at all times 
 detached, it is not sm^prising that the end of the diaphysis is alw^ays 
 completely stripped of this membrane. 
 
 In Bruns' 100 cases, confirmed by direct examination, 24 were 
 compound separations. 
 
 In the author's own analysis of 692 cases, 71 were compound 
 separations terminating mostly in recovery, although in not a few 
 the limbs were amputated. 
 
 Compound separations occur with gTeater frequency in the case 
 of epiphyses of certain bones. Compound separation of the lower 
 epiphysis of the humerus, for example, is a much more common 
 accident than the same lesion at the upper end of the same bone, 
 while in the lower extremity compound separation of the lower 
 epiphysis of the femur greatly preponderates. 
 
 Maunder says : ' Compound separation of an epiphysis is a more 
 grave injury than compound fracture, both as regards the present 
 and the future. By reason of the separation of the periosteum from 
 more or less of the shaft of bone, necrosis must be anticipated and 
 suppuration will be profuse and prolonged, while the secondary con- 
 sequence, supposing the limb to be saved, will very probably be 
 arrest of development of the injured bone and permanent shortening 
 of the limb.' 
 
 Sujjpurative periostitis, followed by necrosis of the diaphj^sis, is 
 of more frequent occurrence after compound separations in certain of 
 the long bones than in others. At the lower end of the femur it is 
 
PATHOLOGICAL ANATOMY 87 
 
 a common result, while at the lower end of the humerus it has 
 seldom been recorded. 
 
 Hemorrhage may occur from the diaphysial surface, if, as is 
 often the case, the shaft is extensively fractured, and may be an 
 important factor in determining the question of primary ampu- 
 tation. 
 
 It is also probable that the occurrence of hsemorrhage may 
 interfere with the process of union in these as well as in snnple 
 cases. 
 
88 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 CHAPTEE VII 
 SYMPTOMS AND DIAGNOSIS 
 
 Sepaeation with Displacement, — Professor E. W. Smitli, in his 
 address in 1867 {British Medical Journal, August 17, 1867, p, 122) to 
 the British Medical Association on ' epiphysiary disjunctions,' says ; 
 
 ' I may mention the numerous instances in which I have seen 
 errors of diagnosis committed regarding them ; the serious resuhs of 
 such mistakes ; their being either but slightly noticed or altogether 
 omitted in our systematic works on surgei:}' ; the absence of any 
 special treatise on the subject ; and the ignorance respecting them 
 displayed by continental writers. Even Kelaton, who may be truly 
 said to wield at present the sceptre of surgery in France, has said 
 that the materials of a complete exposition of these injuries are 
 wanting ; that we have nothing to deal with but assertions unsup- 
 ported by proofs — cases destitute of value, because destitute of 
 details ; and he sums up his brief remarks by the erroneous assertion 
 that the signs which attend them are the same as those which 
 indicate the existence of fractures in their immediate vicinity. 
 
 ' Moreover, in the Gazette des Hojjitaux for the year 1865 there 
 is recorded a discussion at the Surgical Society of Paris in which 
 some of the most distinguished members stated that these injuries 
 could not be diagnosed with certainty, while others (including Chas- 
 saignac) doubted that they ever occurred. In my opinion, they 
 constitute a class of injuries the diagnosis of which can be formed 
 (by the surgeon familiar with the anatomy of the epiphysis) with 
 more facility and a greater amount of certainty than that of any 
 other variety of fracture. Moreover, they possess this special 
 peculiarity (at least as regards the shoulder, elbow, wrist, and ankles) , 
 that, although they are accompanied by many signs and symptoms 
 the aggregate of which establish the natm-e of the injury which the 
 bone has sustained, there is a single sign which, by itself, is patho- 
 gnomonic of the disjunction of the epiphysis.' 
 
 Even as late as 1882 we find Gross giving little attention to the 
 subject. He says {System of Surgery, vol. i. 1882, p. 927) : 
 
 ' The symptoms of this lesion do not differ essentially from those 
 of fracture properly so called. Its existence may generally be 
 suspected when an accident affecting a bone occurs in a young 
 subject and in the neighbourhood of a joint ; when the ends of the 
 
SYMPTOMS AND DIAGNOSIS 89 
 
 fragments are transverse or nearly so ; when the articular piece 
 retains its position while the other moves about ; and, lastly, when 
 the crepitation produced by rubbing the ends of the fragments 
 against each other is of an unusuahy dull, rough, grating character. 
 Moreover, it will commonly be found that the parts when once 
 reduced are less likely to be dragged asunder by the action of the 
 muscles than in an ordinary fracture. The prognosis is generally 
 favourable, union commonly taking place very promptly, especially 
 in young subjects. The accident, if neglected or unskilfully treated, 
 is liable to be followed by severe inflammation, abscesses, erysipelas, 
 and more or less deformity. The treatment is the same as in 
 ordinary fracture.' 
 
 Nelaton observed that separations of the epiphyses are in 
 almost all cases accompanied with fracture, and therefore present 
 identical symptoms with those of fracture in the neighbourhood of 
 the epiphysial junction. 
 
 Malgaigne likewise said that the symptoms do not differ from 
 those of simple fracture in the vicinity of joints. 
 
 In 1862 Gurlt expressed his opinion that symptoms characteristic 
 of epiphysial separation alone did not exist, and that diagnosis was 
 always obscure, but more especially when no displacement was 
 present. 
 
 The difference of opinion held by surgeons up to recent times as 
 to the occurrence of these lesions has now been permanently set at 
 rest by the large number of examples proved by dissection which 
 now exist. These have served the useful purpose of assisting in 
 forming a diagnosis in other cases during life. 
 
 Clinically they are distinct from ordinary fractures for many 
 reasons. 
 
 Apart from cases of compound separation, when the wound 
 permits of a direct examination of the lesion, there have been at the 
 present day so many clinical cases published that their symptoms 
 can be fairly established, at any rate in certain of the epiphyses. 
 
 It is true that nearly all the signs of ordinary fractures may be 
 observed in separations, yet there are a few which, although not 
 often found together, will help very considerably in diagnosis, or 
 even be quite characteristic of these injuries. 
 
 Pure separations, it need scarcely be stated, are much more easy 
 of diagnosis than the partial separations complicated with a fracture 
 of part of the diaphysis, while in soine instances the signs of epi- 
 physial separation are so little marked that it is hardly possible to 
 suspect the true nature of the injury unless we are cognisant of all 
 its forms. 
 
 In their symptoms epiphysial separations have more resemblance 
 to dislocations than fractures. 
 
 The history of the injury is of great importance. The exact 
 mode of occurrence will often suggest to a surgeon's mind at once 
 
90 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 an epiphysial separation, some epiphyses being more easy of 
 detachment with certain forms of violence, e.g. lower epiphysis of 
 femnr by entanglement of the leg in the revolving wheel of a 
 vehicle. 
 
 Age of the patient has already been fully discussed in Chapter III, 
 
 Mobility. — The only symptom upon which reliance can be placed 
 is the existence of unnatural mobility in the bone at the point where 
 anatomy informs us the epiphysis is united to the shaft, in the 
 immediate neighbourhood of the conjugal cartilage, always recol- 
 lecting that this line in the same bone alters its position in the 
 different periods of infancy and puberty. This mobility of a limb 
 after obstetrical manipulations or rough handling of an infant should 
 suggest at once an epiphysial separation. When the periosteum 
 has been stripped up or lacerated, and permits displacement, the 
 mobility will be even more marked and easier of detection in certain 
 cases than in ordinary fractures, by reason of the regularity of the 
 separated surfaces and the absence of all tooth-like projections. 
 
 In other cases mobility will be less distinct from the impaction 
 or locking of the fragments, or from the mixed character of the 
 separation, being complicated with a greater or less fracture of the 
 diaphysis. 
 
 Sometimes, after a fall or blow, a child is brought by the parents 
 for examination on account of loss of power in the limb only, when 
 the surgeon will often detect unnatural mobility, pain, and other 
 signs leading to detection of the injury. 
 
 There is often great swelling of the soft parts in ordinary cases 
 of epiphysial separations, so that the outlines of the bones about 
 the joint are completely masked, and the diagnosis without other 
 aids is rendered impossible. 
 
 Distension of the articulation is very great when the epiphysis 
 is an intra-articular one, and gives rise to acute pain, which often 
 prevents complete exploration of the part without chloroform. 
 
 Pain as a symptom of separated epiphysis is of great practical 
 use, as it indicates the precise spot where the solution of continuity 
 exists — viz. at the diaphysio-epiphysial line. It is especially valuable 
 in separations caused by indirect violence or muscular action, rather 
 than by direct violence, where there is great contusion and conse- 
 quently great pain over a considerable area. In fractures near the 
 joints or in separation of the epiphyses the pain is generally greater 
 than in fractures elsewhere. 
 
 It has been stated, somewhat theoretically, that the pain in 
 separations in very young children or in the new-born is very slight, 
 and due to the absence of bruising of the soft osseous tissue of the 
 diaphysis and medullary tissue which is found in older children. 
 This does not appear to be supported in any way by clinical facts. 
 
 Ecchymosis and extravasation of blood in the neighbourhood of 
 the juxta-epiphysial ends of the bones are often very excessive and 
 
SYMPTOMS AND DIAGNOSIS 91 
 
 dependent upon the rich vascular supply to all the structures 
 involved — viz. at the epiphysial and diaphysial junction. 
 
 A circular ecchymosis round the limb has been noted by 
 Bertrandi in the case of separation of the lower epiphysis of the 
 femur, a sign more fanciful than real. 
 
 Deformity. — The deformity will vary in each case according to 
 the displacement of the diaphysis near the joint affected, the amount 
 and mode of application or direction of the violence applied to the 
 limb, and according as the separation is a pure one or complicated 
 with fracture. 
 
 Malgaigne stated that, if there is displacement, in proportion to 
 the extent of it we easily recognise the fracture or confuse it with 
 dislocation ; but he did not believe that it was possible to determine 
 whether it was a fracture or a separation of the epiphysis. 
 
 The form of the displacement is very largely dependent upon 
 the characteristic and complete separation at the conjugal line, just as 
 we find in adults that the direction of the fracture often determines 
 the form of displacement. In epiphysial separation the detached 
 surface is often more regular, without any projection, and more easy 
 of displacement that in ordinary fractures. 
 
 In many separations the tendency to displacement is very slight, 
 due to the great breadth of the bone at the epiphysial junction, 
 the integrity of the thick periosteum, the more or less transverse 
 direction of the opposed surfaces, and the smaller amount of violence 
 required than in separation accompanied by displacement. 
 
 The projection caused by the diaphysial end may be made to 
 appear or disappear during certain movements of the limb. 
 
 The osseous projection of the end of the diaphysis often appears 
 as a distinct ridge. 
 
 Its border or surface felt beneath the skin is more or less smooth, 
 regular and uniforixi, unlike the rough and irregular projection of 
 true fractures. Sometimes it is distinctly rounded, like the articular 
 end of a bone. 
 
 The characteristic appearance of each diaphysial end differs in 
 each particular bone. The anatomical characters which each 
 epiphysis possesses as to size, form, and extent at different periods 
 of age are therefore of the greatest importance in diagnosis. 
 
 In partial separation associated with fracture, although the 
 projecting fragmgnt may be more irregular, the angular form is often 
 not altogether lost. 
 
 A depression or hollow on the epiphysial side of the separation 
 has been noted in a few rare cases, but more usually it is obscured 
 by the swelling of the soft parts. 
 
 In the case of the upper epiphysis of the humerus, a cup-like 
 hollow has been felt on the under aspect of the epiphysis. 
 
 In some instances where there is but little swelling, a gap has 
 
92 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 been noted between the ex^iphysis and the diaphysis, whilst the 
 hmb has been adducted or abducted. 
 
 In separation of an epii^hysial process, the exact form of the 
 normal epiphysis may be recognised in the detached fragment, but 
 in many instances the outline of the process is entirely obscured by 
 the surrounding extravasation of blood. 
 
 Crepitus.— Great importa,nce is to be attached to this sign. 
 
 There is no true bony crepitus. The sharpness, roughness, loud- 
 ness, or distinctness which is found in true fracture of bones is absent. 
 
 It is described as dull, indistinct, cartilaginous, soft, ' grating,' 
 * mortary,' ' of a muffled character,' and is produced by the passage of 
 the diaphysis over the epiphysis. It can be felt during the reduction 
 of the diaphysis, or after the fragments have been reduced, by a 
 slight gliding movement of one surface upon the other, as at the 
 lower end of the humerus, rather than by the rubbing of the ends. 
 
 In younger infants, where the separation is unaccompanied by 
 fracture, the diaphysial end of the bone covered by the greasy layer 
 glides over the conjugal cartilage and produces a very typical 
 crepitus ; whereas in older bones, where ossification has advanced 
 farther, the crepitus of a juxta-epiphysial separation will approach 
 nearer to that of true bony crepitus. 
 
 It will therefore be more or less decided or sharp, according as 
 the separation involves the spongy tissue of the diaphysis. When 
 this rough kind of crepitus is present Gurlt believed it to be almost 
 impossible during life to distinguish between an epiphysial separation 
 and a fracture. 
 
 In many cases it is absent, as frequently happens with separation 
 of the lower extremity of the radius, from the interposition of a 
 portion of the torn periosteum, or from the peculiar position of the 
 fragments. 
 
 Nelaton says that 'apart from the inability to use the limb — the 
 unnatural mobility and the deformity being signs which closely re- 
 semble fractures in the same position — crepitus is the only distinguish- 
 ing sign ; but then even here the modified crepitus may be overlooked ; 
 besides, this sign is wanting in a great number of cases of fracture 
 in the vicinity of the joints, and separation is seldom perfect, but is 
 accompanied by a greater or less extent of fracture of the diaphysis.' 
 
 Bouchut {Maladies des nouveaii-nes) saj^s that ' a dull crepitus 
 like rasping may be felt, very different from the clear, dry crepitus 
 which indicates a solution of continuity of the bones.' 
 
 Holmes remarks that in early infancy, when the end of the 
 bone is entirely cartilaginous, fracture may no doubt traverse the 
 epiphysial cartilage ; here there would be no crepitus, and, he would 
 suppose, little possibility in most cases of diagnosing the injury. 
 
 In separations associated w^th fracture of the diaphysis, so 
 frequently present in older children, crepitus, as in an ordinary 
 fracture, will be more of an osseous character. 
 
SYMPTOMS AND DIAGNOSIS 93 
 
 ■ In experiments on the dead body it is very easy to distinguish 
 these differences in the character of the crepitus, and to determine 
 by this means the form of the lesion produced. 
 
 Holmes says {loc. cit. supra) : ' The diagnosis of separation of the 
 epiphyses rests, then, not on any supposed peculiarity of the crepitus, 
 but on the age of the patient, and the anatomical characters which 
 will be found in each particular case.' 
 
 He adds with regard to the specimens from the St. George's Hos- 
 pital Museum : ' This collection, then, favom^s the opinion expressed 
 by the French surgeons so far as that it shows that the line of fracture 
 seldom runs accurately through the epiphysial cartilage in its whole 
 course ; and therefore that the descriptions of the symptoms of this 
 accident in which we are told that crepitus is absent, or is less 
 distinctly felt in consequence of the fractured surfaces being 
 covered with cartilage, are probably imaginary.' 
 
 Malgaigne says : ' Doubtless, when the accident occurs before 
 the age of fifteen, when the solution of continuity is on a level and 
 in the same direction with the epiphysial cartilage, the presumption 
 is in favour of separation, but certainty can be arrived at only by 
 an autopsy. It has been thought that absence of crepitus was 
 characteristic of separation ; but in many fractures near joints 
 crepitus is wanting, as, for instance, it often is in those of the lower 
 extremity of the radius.' 
 
 Other evidences of a separation being very distinct, no search for 
 this modified crepitus should be undertaken. 
 
 Inability to use the limb is a marked symptom when the separation 
 is accompanied by displacement. 
 
 Other complications. — Epiphysial separation accompanied by a 
 dislocation or displacement of the epiphysis is very rare. 
 
 It may be readily mistaken for a simple dislocation unless great 
 care be exercised. 
 
 Separations of the epiphyses, such as the upper epiphyses of the 
 radius and femur, which. are intra-articular, are especially important, 
 inasmuch as they may involve serious articular lesions and their 
 consequences. 
 
 There will be many of the same symptoms as in intra-articular 
 fractures : extensive effusion of blood, with effusion into the joint, 
 great ecchymosis, and acute pain. 
 
 Sepaeation without Displacement. — The symptoms are but 
 few, uncertain, and equivocal, often overlooked or regarded as sprains, 
 there being no deformity present ; the epiphysis being held in 
 position by the muscles, periosteum, the extent of the epiphysial 
 surfaces, and their reciprocal adaptation. It is owing to the thick- 
 ness and integrity of the periosteum, especially in very young children, 
 that displacement is absent, and abnormal mobility exceedingly 
 difficult of detection. 
 
 On account of the attendant dangers from stripping up of this 
 
94 TEAUMATIC SEPAEATIOX OF THE EPIPHYSES 
 
 membrane v,'e should not he too deterniinecl in seeking for the latter 
 
 sign. 
 
 The existence of epiphysial separation should always be suspected, 
 even though there be no displacement (Malgaigne) . 
 
 These lesions are common in rachitic children and in other morbid 
 conditions of the epiphysial ends of the bones, and are brought about 
 by slight violence. 
 
 The signs are : 
 
 Pai/i about and along the epiphysial line, and upon moving the 
 limb. 
 
 Tenderness or pressure along the epiphysial line. 
 
 Contusion or ecchymosis about the joint (a most important 
 factor) . 
 
 Mobility, often shght, from the fact of the periosteum not being 
 lacerated. 
 
 Loss of poicer over the Umh. 
 
 Immobility of the limb by the patient and the difficulty of passive 
 motion on account of pain experienced (equivocal signs). 
 
 Epiphysial Speaixs in Ixfaxct. — Omng to the absence of dis- 
 placement and the actual lesions being masked by the smTounding 
 periosteum, which is intact, the injuries often pass unobserved, 
 especially in mild cases ; but they often lead to acute or chronic 
 ostitis, or even to inflammation of the neighbom^ing joint. 
 
 The following is what generally happens, according to Oilier, in 
 simple cases after a fall or violent wrench. The child cries and holds 
 its limb fixed ; but the suffering appears to be lessened after some 
 rubbing and movement, and the child can then use its joints, although 
 a little tardily. The joint on examination is found to be movable, 
 and, vrith. the exception of a little bruising or slight swelling, nothing 
 abnormal is distinguishable. There are, however, already some spots 
 painful on pressm'e at the level of the juxta-epiphysial region, yet 
 even these in milder cases have to be sought for in order to be 
 distinguished. At the commencement there is only pain at the 
 level of the juxta-epiphysial region ; but at the end of two or three 
 days there is more or less marked swelling in this region, while the 
 joint always remains intact. In most cases this characteristic 
 swelling spontaneously disappears at the end of a few days, in others 
 it persists, and the child, who has retaken to its play after the first 
 pain has passed away, again complains, and the limb is more or less 
 swollen. In very severe cases acute periostitis, with intense fever 
 and consecutive necrosis, results. At other times it is only at the end 
 of some weeks or months that swelling above or below the injured 
 joint may be perceived ; this is accompanied by more or less dull 
 pain, when the age of the patient allows it to be complained of. 
 Symptoms of chi-onic osteo-myelitis are then present. An abscess 
 forms, and a sinus results, leading to a small sequestral cavity. 
 
 Oilier says that these juxta-epiphysial sprains are doubtless the 
 
SYMPTOMS AND DIAGNOSIS 95 
 
 explanation of the numerous cases of the affection of the elbow 
 described by Goyrand, Bourguet, and Chassaignac under the name 
 of ^pronation doidoiireuse des jeiines enfants.' 
 
 Where the separation is more complete, some mohility at the 
 epiphysial line may be expected, slight though it may be. 
 
 DIAGNOSIS. — There is no doubt whatever that numerous instances 
 of epiphysial separation are overlooked^a great many cases treated 
 without any attempt at an exact diagnosis being made. Separated 
 epiphyses, especially of the ends of certain of the long bones, are 
 extremely common, as most surgeons know who take the trouble to 
 diagnose between these and ordinary fractures ; but all recognise that 
 certain of them are among the most obscure forms of injury in the 
 vicinity of joints. 
 
 It is especially with regard to injuries about the elbow in children 
 that the greatest difficulty in diagnosis exists. 
 
 Fergusson, in his Practical Surgerij, says : ' In my notices of 
 fractures no particular allusions will be made to separation of the 
 epiphyses — diastasis, as the accident is called — a kind of injury 
 which is occasionally met with in the young subject ; and the reason 
 for this is, that I know of no difference of treatment which such 
 cases may require, whilst every anatomist must be aware that a 
 solution of continuity is as likely to occur in such situations as 
 elsewhere.' He treats the subject as though it were only a question 
 of diagnosis between epiphysial separation and fracture. 
 
 Also Packard, in Ashhurst's Encijclopcedia (vol. iv. 1884), says 
 that epiphysial separations do not differ materially from fractures, 
 although the tissue which gives way is not true bone, but the 
 cartilage-like, osteogenetic matrix. 
 
 A separation presents in certain particulars the characters both 
 of a dislocation and of a fracture. 
 
 Its occurrence is liable to be overlooked on account of the 
 absence of crepitus. 
 
 Hitherto the data for distinguishing a separation from a fracture 
 at the same point have been insufficient for the purpose of obtaining 
 statistics of the relative frequency of these two injuries in the different 
 periods of infancy and youth. 
 
 Epiphysial separations must frequently be mistaken for sprains, 
 especially in young children, where there is either no displacement 
 or the displacement is incomplete. 
 
 Partial separations are at times only suggested to the surgeon by 
 slight mobility, it may be by slight deformity, and perhaps by the 
 presence of a greenstick fracture of the shaft above. 
 
 Fracture. — Epiphysial separations differ from fractures in many 
 important particulars. 
 
 The situation of the solution of conthiuitii in a pure example 
 of separated epiphysis is exactly in the line of the epiphysial 
 cartilage. 
 
96 TBAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 The shape of the displaced epiphysial fragments in a long bone 
 is often quite -unmistakable. 
 
 The deformity in many instances of epiphysial separation is very 
 characteristic, e.g. when occm:ring at the upper end of humerus. 
 
 Crepitus in a pure separation is of the soft, smooth kind described 
 above. 
 
 Where the separation is accompanied by a greater or less fracture 
 of the diaphysis, the character of the crepitus approaches more or 
 less exactly to that of true fracture, and renders the diagnosis 
 exceedingly obscure. 
 
 Under certain circumstances, however, especially at the lower 
 end of the humerus, the diagnosis is extremely difficult. 
 
 Dislocation. — Dislocations are among the rarest of accidents in 
 young subjects, particularly in infancy ; and in experiments on the 
 dead body they can with difficulty be produced. 
 
 Until recent years almost all disjunctions of the epiphyses were 
 regarded as dislocations. In young patients under twenty years of 
 aee, where a dislocation is said to exist, a careful examination in 
 most cases will reveal the presence of an epiphysial separation. 
 
 It is on account of the proximity of the seat of injury to the 
 joint that we have to distinguish epiphysial fracture with displace- 
 ment from dislocation. Moderate traction will usually be sufficient to 
 restore the displaced fragments to their natural position, which will, 
 how^ever, only be maintained as long as the extension is kept up ; in 
 fact, in many instances of epiphysial separation it is a matter of 
 extreme difficulty to maintain thorough co-aptation ; but to this there 
 are exceptions. In dislocation there is but little tendency for the 
 displacement to recur. 
 
 The deformity of separation is frequently that of dislocation ; 
 yet on careful examination of the projecting diaphysis it may be seen 
 to differ from that of the articular end. The unnatural mobility 
 is a very distinguishing feature in separation, while the epiphysis, 
 if it be that of a long bone, occupies its normal relations Math the 
 joint. 
 
 The shortening in separation is generally much less than that in 
 dislocation. 
 
 The reduction of the displaced diaphysis is not effected with the 
 very percejptible jerk met with in reducing dislocation, although in 
 some instances it is carried out suddenly and with a 'jump.' 
 
 The pain and discomfort after reduction is not so greatly relieved 
 as in dislocation. 
 
 In many of the joints the epiphj^sis will be found to be still 
 connected with the joint, and to retain its normal relations with the 
 smrounding articular structures. 
 
 Separation also differs from dislocation in the fact that the 
 articulation is nearly always intact, and movements are frequently 
 free. 
 
SYMPTOMS AND DIAGNOSIS 97 
 
 In all cases where the swelling is so great that a definite lesion 
 cannot be clearly made out, an angesthetic should be at once 
 administered and the diagnosis cleared up. 
 
 The manipulation must be a systematic and careful one ; indeed, 
 any indiscriminate or rough examination will only add to the bruis- 
 ing and laceration of the injured soft parts. 
 
 As a rule, under the influence of an anaesthetic the necessary 
 manipulation for diagnosis, as well as for co-aptation, reduction, and 
 immobilisation of the fragments, should be effected all at the same 
 time. The plan of waiting till the swelling has subsided is most 
 fallacious, for not only are the osseous projecting fragments in these 
 young subjects less distinct after even a short interval of time (the 
 gaps between the fragments being rapidly filled up by new osseous 
 material poured out by the periosteum), but the immediate replace- 
 ment of the fragments in their normal position produces a more 
 rapid union of the fragments, and also tends to diminish the amount 
 of effusion between the fragments and in the soft parts around the 
 seat of fracture. 
 
 Both these latter points were well shown in a case of separation 
 of the lower epiphyses of the radius and ulna with considerable 
 displacement which has been mentioned in its appropriate chapter. 
 
 The clinical application of the new skiagraphy by means of 
 Eontgen's rays is of great value in the diagnosis and elucidation 
 of epiphysial lesions. The achieved and practical utility of this 
 method of producing diagnostic photographs has been lately fully 
 demonstrated by Mr. Sydney Rowland (Archives of Clinical 
 SkiagrcqjJnj , 1896) ; and it is of very great importance to obtain 
 skiagraphs of certain forms of recent complicated injuries to the 
 epiphyses {Brit. Med. Jour., Mar. 7, 1896, p. 620). At the lower 
 end of the humerus, for example, there are but few anatomical 
 specimens in museums to guide the surgeon in making an exact 
 diagnosis of the numerous and complicated lesions which from daily 
 experience must exist during life. If this knowledge be obtained 
 by Rontgen's method, it will materially assist the surgeon in giving 
 a decision as to immediate operative measures in elbow- joint injuries 
 of children, and in removing some of the many instances of subse- 
 quent severe deformity and loss of function of the joint and limb 
 now so little creditable to surgery. 
 
 As Mr. Sydney Rowland observes {Brit. Med. Jour., April 11, 1896, 
 p. 933), there seems reason to anticipate that in this rather difficult and 
 hitherto unsatisfactory class of injuries and affections the new process 
 will prove of considerable use as an auxiliary to surgical practice. 
 
 Compound dislocation. — Even in compound separation the dia- 
 physial end has been frequently mistaken for a dislocated end of the 
 bone. The articular cartilage covering the end of the bone forming 
 the joint should alone, with its characteristic features, be sufiicient to 
 distinguish it from the end of the diaphysj'5. 
 
 H 
 
98 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 CHAPTEK Vni 
 
 PROGNOSIS AND RESULTS 
 
 Union — Non-union — Deformity — Impaired Movements of Joint and Ankylosis 
 — Atrophy of Limb from Disease — Exuberant Callus — Arrest of Growth : 
 Partial and Complete — Suppuration from Ostitis —Periostitis — Necrosis 
 OF Shaft and Necrosis of Epiphysis — Aneurysm — Disease due to Partial 
 Separation — Pyemia— Prognosis in other Severe Lesions — Prognosis in 
 Compound Cases — Gangrene 
 
 TJnion. — Malgaigne believed that these injuries united as well and 
 as rapidly as ordinary fractures in the neighbourhood of the joints, 
 and mentions the case of a child, aged six, v/hom he treated for a 
 separation of the lower end of both radii, which rapidly united 
 in the usual time without deformity ; also in a case of separation of 
 the head of the humerus with great displacement at an early age, 
 the union, although faulty, was very firm, though the arm was 
 atrophied and hung almost powerless by the side of the body. 
 
 In Ollier's experiments upon animals he found that reunion 
 takes place, the spongoid tissue blending with the corresponding 
 surface of the diaphysis, the layer nearest the cartilage continuing 
 to proliferate and undergo osseous transformation. 
 
 As regards Bruns' autopsy cases, union was found in five cases — 
 two of the lower end of the femur, one each of the upper end of 
 the tibia, of the humerus, and of the radius. 
 
 In six other cases consolidation took place after re-section of the 
 displaced diaphysial end. 
 
 Dr. Edward Borck, of Saint-Louis, Mo., in a paper before the 
 American Medical Association, June 1889 (ArcJiives of Pediatrics^ 
 vol. vi., Jan. to Dec. 1889, p. 574), makes the following astonishing 
 statement which is quite at variance with facts : 
 
 ' Separation of the epiphyses I see much more frequently in late 
 years than formerly, in all shapes and forms, at all stages ; some- 
 times directly after the injury has occurred, at other times weeks, 
 months, and years afterwards. My observation has taught me that 
 separation of the epiphyses of the humerus and femur are the most 
 frequent, and no matter at what time the injury is recognised, nor 
 how carefully it is treated, the results are never very satisfactory. 
 The separated epiphysis is partly or completely absorbed and there- 
 fore will have only partial or no union at all, and the limb will have 
 a dangling motion, though time may improve the usefulness of the 
 
PEOGNOSIS AND EESULTS 99 
 
 limb ; but the patient never recovers as well as after a fracture in 
 other parts of the bone.' 
 
 Dr. Borck's words are quoted in order that a most emphatic denial 
 may here be given to his assertions, more especially to that contained 
 in the first clause of the last paragraph. 
 
 In more severe cases associated with other lesions the prognosis 
 is doubtless grave, but it is very favourable in a very large majority 
 of simple cases where the fragments are not displaced. It is a well- 
 known fact that these injuries generally do well, and consolidation 
 takes place without any further trouble or permanent deformity. 
 Whatever the ultimate result may be to the bone, reunion takes place 
 in the most rapid and satisfactory manner. 
 
 Nelaton believed that separations of the epiphyses united in all 
 probability like a fracture of cartilage. 
 
 When completely reduced they unite by the same process as frac- 
 tures of the bones, taking place in the large majority of cases in the 
 soft osseous tissue of the diaphysis, flakes of which adhere to the 
 cartilage and assist the periosteum and the separated surface of the 
 diaphysis in the formation of callus, whilst the cartilage in its 
 immediate neighbourhood continues to proliferate and carry on the 
 process of normal ossification ; an outer sheath of callus is formed as 
 in fractures, the inner callus, produced especially from the diaphysis, 
 blending with the calcifying layer of the epiphysial cartilage. 
 
 These opinions are confirmed by Michniowsky's experiments on 
 living animals in order to ascertain the precise mode of union in 
 these lesions. 
 
 It is in some respects a regrettable as well as a remarkable fact that 
 no specimen is in existence showing the normal process of union in 
 epiphysial separation, after reduction of the displacement or where 
 no displacement has taken place. 
 
 The physiological difference in the times of union of the 
 epiphyses at the elbow and knee from those at the other ends of the 
 bones led M. Gueretin to inquire {La Presse Medicale, No. 37, 
 10 Mai, 1838, p. 290) whether a separated epiphysis would unite 
 more quickly at the elbow than at the shoulder or wrist, or more 
 slowly at the knee than at the hip or ankle. 
 
 Gueretin came to the extraordinary conclusion that union took 
 place very rapidly, and was more frequently met with in the upper 
 than in the lower extremity. 
 
 The error of such a statement will be at once appreciated, 
 although as a broad rule it is clear that the smaller bones require less 
 time for healing than the larger ones. 
 
 Union takes place by callus even where displacement is present 
 and has not been reduced ; this is formed through the bridge v.i 
 periosteum uniting the two fragments. 
 
 In every case of fracture in the neighbourhood of a joint ni 
 young subjects, and in all cases in which it is presumed tliat a 
 
100 TEAUMATIC SEPAEATIOX OF THE EPIPHYSES 
 
 separation of the epiphysial ends of the long bones has occurred, it 
 is most desirable that the responsibility of the case should not rest 
 with a single surgeon. However skilful he may have been in the 
 treatment of the injury, he is liable to be unjustly blamed afterwards 
 by the parents or friends for some untoward result for which he 
 w^as in no way responsible, and which probably could not have been 
 avoided. Ankylosis of the joint, deformity, a certain loss of .power, 
 or a crippled condition of the joint, rendering the proper function 
 of the limb less than was anticipated, arrest of growth of the limb, 
 suppuration, and even death from pysemia, are all possible contin- 
 gencies. They should be carefully guarded against by a timely 
 warning to the parents, a proper explanation of the serious character 
 of the lesion, and by taking the precaution of obtaining a second 
 opinion. The prosecution of medical men for malpractice after 
 these injuries, especially at the elbow-joint, appears (from the 
 accounts given by Hamilton and others) to be a not uncommon oc- 
 currence in America ; and instances of a like kind are not unknown 
 in our own country. 
 
 Non-union. — In none of the numerous museum specimens has the 
 author been able to find any absolute evidence of non-union after 
 any epiphysial separation diagnosed during life. No authentic case 
 of non-union of the separated entire end of a long bone has been 
 recorded. Malgaigne alludes to a case of non-union of the head of 
 the fom'th metacarpal bone after an injury thirteen years previously, 
 but the diagnosis of separation in this case was not clearly made out, 
 and it has even been suggested that rachitic enlargement of the 
 epiphysial cartilage led to the traumatic separation of the epiphysis. 
 
 Beichel figures another doubtful specimen (of Ludw^g's) at the 
 upper end of the humerus. Gueretin did not consider it a true 
 epiphysial separation on account of the shortening of the bone 
 portrayed by Eeichel. Bruns alludes to one of the upper epi- 
 physes of the humerus mentioned by Bertrandi {Qpere anatomiche 
 e cerusiche, torn. v. Torino, 1787, p. 168), and also quoted by Gurlt. 
 The preparation then said to exist in Paris was taken from the body 
 of a child in whom, after detachment three years previously, the head 
 of the humerus had united to the scapula, but was hollowed out and 
 had formed a false joint at the point of separation, and took the 
 place of the glenoid cavity. The movements were not impaired. 
 
 The separation in this case was probably the result of disease — 
 a not uncommon condition already alluded to. 
 
 A similar case in an infant at birth is recorded by Dm^ocher. 
 
 Gueretin thought that non-union could only be met with at the 
 upper end of the humerus and femur ; he attributed it not only to 
 the want of fixation and to the slight nutrition of these epiphyses, 
 but also to the rotation of the epiphysis, so that its articular surface 
 came more or less in contact with the diaphysis, and prevented the 
 due formation of cahus. 
 
PEOGNOSIS AND EESULTS 101 
 
 Hamilton has seen one case in a child thirteen months old of 
 epiphysial separation of the upper end of the humerus, which had not 
 united five months after the accident, and the child had not the power 
 to lift the arm. It had been treated by an empiric, who regarded it 
 as only a sprain. 
 
 Should non-union occur, the author is strongly of opinion that it 
 will be found to be due to imperfect fixation, or to the injury being 
 overlooked and treated as a sprain, and mobility of the fragments 
 being permitted. 
 
 A skiagraphic representation of an ununited condylo-capitellar 
 detachment of the humerus is given in a later chapter. 
 
 Deformity. — The modelling process, after union has occurred, is 
 effected so rapidly and completely, even in many instances in which 
 the reduction has not been quite perfect, that within a few months 
 after the injury it is almost impossible to detect the precise situation 
 of the lesion. 
 
 A more or less considerable enlargement of the diaphysial end as 
 compared with the sound side is always present, and is especially 
 noticeable when the periosteum has been detached to any extent. 
 
 This increase in volume of the injured bone remains for a year 
 or two, but disappears more rapidly the younger the age of the 
 patient. 
 
 Deformity and shortening have hitherto been unfortunately too 
 frequent. 
 
 The displacement may be so great that, the vessels of the dia- 
 physis being no longer in contact with the epiphysial cartilage, the 
 nutrition and function of the latter may be seriously interfered 
 with ; it should, however, only be a temporary derangement until 
 the subsequent absorption of callus, which rapidly unites the sepa- 
 rated ends. 
 
 As a rule, the surface of the diaphysis still in contact with the 
 epiphysis is quite sufficient to carry on the vascular su.pply in a very 
 short period of time. 
 
 Oilier, in experiments on animals producing epiphysial separations 
 — or, as he terms them, diaphysial separations — viz. detachment 
 of the diaphysis from the conjugal cartilage of the epiphysis 
 with protrusion outwards from the periosteal sheath — found that 
 this periosteal sheath, which always accompanies the conjugal 
 cartilage, ossified and formed a new diaphysis by the side of the 
 old one. This new diaphysis gradually formed the future shaft, 
 whilst the old one tended to disappear by degrees, taking little or no 
 part in this work. 
 
 The diaphysial end in these circumstances often lacerates and 
 penetrates the periosteal sheath, and, being irreducible, undergoes 
 atrophy and partial absorption, while a greater or less portion of the 
 diaphysis, according to the extent of the displacement, is reproduced 
 by a new shaft formed by the periosteum. ■> 
 
102 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 Permanent deformity, with vicious union and impaired movements of 
 the joint from displacement of the fragments, is usually the result of 
 imperfect reduction — it may be from want of care in reduction or 
 proper appreciation of the exact form of the lesion, or from the 
 injury having been mistaken for a dislocation, an attempt made at 
 reduction, and no splint applied. 
 
 Even with the most skilful treatment and careful attempts at 
 replacement of the fragments, some irregularity or ridge of bone 
 close to the epiphysial line must be expected, scarcely amounting to 
 deformity. In other cases the lesion is so near to the articulation 
 that complete reduction is very difficult, the epiphysial fragment 
 affording so little hold for the more ordinary splints. 
 
 The projecting edge is moulded down in a very few weeks' time 
 if the displacement has not been great. 
 
 At times the deformity is due to the smallness of the epiphysis, 
 and to the difficulty experienced in grasping and retaining it with a 
 proper apparatus. 
 
 Many of these old deformities, persisting after separation, have 
 been mistaken for neglected dislocations, and attempts made to 
 reduce them. In some instances the diagnosis between the two 
 after this interval of time is somewhat difficult. 
 
 Dr. G. Jetter {Beitrdge zur klinischen Ghirurgie, 1892, S. 361) 
 states that during the ten years previous to 1892 twenty-one cases 
 of traumatic separation of the humerus had been observed at the 
 Tiibingen clinic. Out of seventeen cases of which accurate records 
 had been kept, seven treated outside the hospital had united with 
 great displacement and loss of function of the arm, necessitating 
 operative measures. 
 
 Impairment of neighbouring joint. — Traumatic arthritis is acute 
 when the epiphysis is intra-articular, and, if intense, may be the fore- 
 runner of stiffness and loss of function of the limb, of irregularity, 
 misshapen or exuberant callus, or, on the other hand and very rarely, 
 of a defective fibrous callus, or even absence of consolidation. 
 
 The joint may be left stiff, or even deformed, the result of in- 
 flammatory extension from the epiphysial injury in its neighbourhood. 
 Eoucher has correctly described intra-articular epiphysial separations 
 as having the same prognosis as a true intra-articular fracture. 
 
 In epiphysial separations about the elbow-joint, incomplete re- 
 covery of the function of the limb is especially of very common 
 occurrence. But in other separations this loss of function and 
 shape of the limb is not so apt to occur. 
 
 In cases of permanent stiffness of a joint following an injury, 
 in which a ridge of bone or some irregularity is to be felt about the 
 conjugal line, it is highly probable that the original lesion has been 
 an epiphysial detachment, and not a dislocation, for which it may 
 have been mistaken. 
 
 Although union is always effected, the neighbouring joint, from 
 
PEOGNOSIS AND KESULTS 103 
 
 one of the reasons just mentioned, may be functionally impaired ; 
 indeed, in the most simple cases this may be the result. It is 
 therefore of the greatest importance that the patient's friends should 
 in all cases be early forewarned against such an occurrence, before 
 treatment is commenced. 
 
 Ankylosis due to arthritic inflammation may be occasioned not 
 only by the injury to the joint at the time of the accident — viz. an 
 intra-articular fracture, &c. — but also by the displaced fragments, if 
 they are not properly reduced, keeping up the inflammatory process. 
 
 This point is of especial importance in the case of the elbow-joint, 
 where so much controversy has arisen as to keeping the fragments 
 in position, and shows that ankylosis may occur if special precautions 
 be not taken to guard against it, whatever be the position the limb 
 is placed in. 
 
 Displaced fragments, if not reduced, not only keep up the inflam- 
 matory process and serous effusions, but also lead to the production 
 of much irregular and vicious callus. 
 
 Exuberant callus, leading to impairment of the joint, is often 
 due to the extensive stripping up of the periosteum from the shaft. 
 
 Suppurative inflammation of the neighbouring joint is rarely met 
 with. It occurred in Fischer and Hirschfeld's case of suppuration 
 and necrosis following separation of both epiphyses of the fibula and 
 the upper epiphysis of the tibia. 
 
 Muscular atrophy is often very marked and obstinate, but dis- 
 appears as the limb regains its proper functions. 
 
 Muscular atrophy may be brought about by sero-sanguineous 
 effusion into the substances of the surrounding muscles from lacera- 
 tion of the synovial membrane. 
 
 Epiphysial separations at the lower end of the humerus and femur 
 are very liable in this way to be followed by atrophy of the triceps 
 or crureus. 
 
 In other severe instances the limb may remain in an ill developed 
 condition, the muscles having undergone atrophy and fatty degenera- 
 tion from disuse. 
 
 Exuberant callus. — An excessive amount of callus is unfortunately 
 too often met with in cases of incomplete reduction of the 
 displacement. 
 
 In many situations, as at the lower end of the humerus, it limits 
 to a very great extent the movements of the joint. 
 
 Paralysis of nerve, due to inclusion by callus, has been noted in a 
 few instances at the lower end of the humerus. 
 
 Arrest of growth. — The prognosis, as regards the subsequent 
 growth of the bone after separation of its epiphysis, is of the greatest 
 importance to the practical surgeon. For reasons which will be 
 stated presently, this growth is not of necessity interfered with, 
 because the epiphysial cartilage performs its function in many cases 
 as perfectly as before the injury. 
 
104 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 A proper study of interference with the growth of the bones 
 appears to have commenced about the middle of this century, at the 
 same time that experiments were being made to discover the normal 
 growth of bones. 
 
 Eognetta, in 1834, clearly describes shortening of the arm, 
 deflection of the hand, displacements of the foot and knee, and 
 shortening of the leg, as being most often the result of an un- 
 detected epiphysial separation. 
 
 This surgeon wrongly attributed congenital dislocation of the 
 hip to epiphysial separation, whereas, as we shall see, these conse- 
 quences are rarely met with in separation. 
 
 As a rule, in a simple case of separation the callus is more quickly 
 formed and leaves less trace than in the case of a similar fracture. 
 
 The epiphysial cartilage of union, apart from any other structure, 
 is alone responsible for the development of the bone ; and any 
 interference with its function, the proliferation and ossification of its 
 layers, will necessaril}' be immediately followed by some alteration 
 in the growth of the bone. 
 
 The function of the epiphysial cartilage has been fully inves- 
 tigated by Duhamel (' Memoires divers sur I'accroissement des os,' 
 1739-1743, Mem. Acad, des Sciences, Paris), Hales, Elourens, L. Oilier, 
 Hmnphry, Broca, Hunter, Stanley, and others, and is fully described 
 in Chapter II. 
 
 Stanley is usually credited as having been, in 1849, the first to 
 draw attention to the distm^bances in the growth of bones ; it is, 
 however, certain, as has aheady been stated, that they had been 
 observed many years previously. 
 
 In Germany, Uffelmann was the first to point out, in 1865, the 
 occurrence of a case of shortening of the limb after tramnatic 
 separation of its epiphysis. 
 
 In IbVb Bidder (' Experimente liber die klinstliche Hemmung 
 des Langenwachsthmns,' &c., Archiv f. experimentelle Path. u. 
 Fharm. 1873, S. 248) made many valuable experiments on animals 
 in artificially arresting the growth in length of the long bones. 
 
 The growth in length of the tibia in rabbits he found to be 
 dependent on the integrity of the epiphysial cartilage. In the cases 
 where arrest of growth occurred, this cartilage was degenerated or 
 replaced by bands of fibrous tissue or osseous processes, which 
 directly united the epiphysis and diaphysis. He also found that 
 arrest did not take place when the needles which he inserted in the 
 epiphysial line in order to produce local irritation had not penetrated 
 the epiphysial cartilage, but passed beneath the same into the bone. 
 
 Oilier arrested the growth of the limbs of animals by removing 
 the conjugal cartilage, by lacerating it, by crushing it up, or by 
 incising it {Traite de la regent mtiwi des os, 1867, tom. i. p. 386). 
 He also came to the conclusion that immediately reduced separa- 
 tions, not followed by inllammation, recover without appreciably 
 
PEOGNOSIS AND KESULTS 105 
 
 impeding the ulterior growth of the Hmb, whereas this effect is 
 produced if severe lacerations or subsequent inflammation have 
 occurred. He observed the same results in man. 
 
 In 1874 0. Telke described many experiments he had made for 
 ascertaining the growth of bones ; and Thiel, in 1876, made many 
 on the lower epiphysis of the radius of dogs to determine this same 
 question. 
 
 In 1877 Helferich confirmed by numerous experiments and 
 preparations the results obtained by Bidder and others on the increase 
 in length of bones. 
 
 In 1878 Prof. Paul Vogt, of Griswald {ArcJiiv fiir Mm. Chirurgie, 
 1878, B. xxii. S. 343, 'Die traumatische Epiphysentrennung,' &c.), 
 discussed at some length traumatic separation of the epiphyses and 
 its influence on the growth in length of the long bones. 
 
 Stimson says : ' Another fact, which is a reason why the inter- 
 ference should not be noticed rather than why it should not occur, 
 is that the injury is by far most frequent at an age when the growth 
 of the skeleton is almost completed, and when the result of an arrest 
 of growth, in the upper extremity at least, might easily pass un- 
 noticed.' 
 
 It is certain that separations are much less frequent dming the 
 first ten years of life than during the second decade, and the separa- 
 tion more likely to be followed by arrest of growth in the former 
 than in the latter, when the bone is more developed and less under 
 the influence of the epiphysial cartilage. 
 
 Many instances of dwarfing of the limbs have been recorded as 
 the result of epiphysial injuries, but the most marked cases have 
 occurred after injury to the upper epiphysis of the humerus. In 
 this instance, as in other epiphysial separations, the wasting and 
 diminished growth of the limb are in part dependent upon the loss of 
 the natural function or diminution in the use made of it, the result 
 of ankylosis of the joint. 
 
 As might have been supposed, arrest of growth occurs most often 
 at the upper epiphysis of the humerus, and at the lower epiphyses 
 of the femur, tibia, and radius, by reason of the late period of their 
 union with the diaphysis, and their being the most frequent seats of 
 separation. 
 
 It is probably correct, as Oilier states, that the reason why 
 these injuries are so seldom followed by arrest of growth is that the 
 separation seldom occurs in the conjugal cartilage itself, but rather 
 in the ossifying or ossified spongy tissue {couche spongo'ide) which 
 immediately adjoins the cartilage, and a certain amount of which 
 always clings to the cartilage ; again, that these injuries often occur 
 still further towards the diai^hysis— viz. in the juxta-epiphysial 
 spongy tissue. 
 
 In this connection we may remember that premature ossification 
 or destruction of the function of the epiphysial cartilage may be 
 
106 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 brought about by true fracture of the diaphysis (cases recorded by 
 Bryant and others). 
 
 Bryant mentions a case of arrest of growth of the humerus, 
 amounting to 3^ inches, following fracture of the shaft at the age of 
 eight years, which he attributed to injury of the nutrient artery, and 
 the author recently (1896) had under his observation at the City 
 Orthopaedic Hospital a well-marked arrest of growth of the lower 
 end of the tibia following transverse fracture of the diaphysis. 
 
 The relative value of each epiphysis in continuing the growth in 
 length of a bone must be taken into consideration in determining 
 the question of arrest of growth after injury — e.g. being more marked 
 in detachment of the upper than of the lower end of humerus, &c. 
 
 At whatever age the arrest of growth is produced, the end at 
 which the most rapid disturbance of growth ensues is always that 
 which joins on last, and which has the greatest function in the 
 process of the development of the bone ; but it must be borne in 
 mind that the influence of the injury upon the growth of the bone 
 will be in proportion to the age of the patient. 
 
 Professor P. Vogt reported iloc. cit. infra ; Langenbeck's ArcJiiv, 
 Bd. xxii. 1878, S. 343) an instance in which the left humerus had 
 become thirteen centimetres shorter than its fellow in consequence 
 of an injury received at the age of ten years, which was probably 
 a separation of the upper epiphysis. Biruns relates another in which 
 the shortening of the humerus in an adult, following separation of 
 the upper epiphysis of the humerus at the age of two years, was 
 fourteen centimetres. 
 
 Bryant mentions a similar shortening of the same bone which 
 amounted to five inches, and another of one inch in two years in the 
 tibia of a child aged eight. 
 
 P. Bruns {Allgemeine Lehre von den Knochenhrilchen) succeeded 
 in collecting 100 cases of traumatic separation of the epiphyses, 
 amongst which thirteen only had brought about an arrest of the 
 proper growth of the bone — eight times in the lower epiphysis of 
 the radius, three times in the upper epiphysis of the humerus, once 
 in the lower epiphysis of the femur, and once in the lower epiphysis 
 of the tibia, 
 
 Curtillet, in his These de Lyon, 1891, has collected all the 
 published cases known to him, which only amounted to twenty-four. 
 
 It is probable that non-interference with the growth of the bone 
 is due, in most cases at any rate, to the fact that the point of 
 separation is most frequently through the layer of partly formed 
 bone next to the cartilage (the spongy layer of Oilier), and not 
 actually through the cartilage itself, so that the greater portion of 
 this layer usually adheres to the cartilage, and thus there is in reality a 
 fracture of the bone at its junction with the cartilage. The osteogenic 
 layer remains, therefore, in most cases uninjured, and its function is 
 not thereby interfered with. 
 
PEOGNOSIS AND KESULTS 107 
 
 Again, separations are frequently accompanied by fracture of the 
 diaphysis, so that some portion at any rate of the epiphysial carti- 
 lao-e is not damaged. The arrest may under these circumstances 
 only occur at the injured part, producing most irregular increase of 
 the end of the bone. 
 
 Arrest of growth will probably not occur if the separation takes 
 place between the epiphysis and the epiphysial cartilage, which, 
 however, is very rare. 
 
 From the cases here recorded it is manifest that arrest of growth 
 is rare in comparison with the number of cases of epiphysial separa- 
 tion. Epiphysial separations are not so frequent during the first, 
 ten years or so of life, when the functional activity of the conjugal 
 cartilage is the greatest, but are oftener met with up to the 
 eighteenth year, when injury to the conjugal cartilage is not likely 
 to be so serious, the growth of the bone having already much 
 advanced. The cases of arrest of development reported in the present 
 volmne are 56 in number, and, though relatively few in comparison 
 with the frequency of these injuries, yet suffice to put us always on 
 our guard against such an event : 17 are of the lower epiphysis of the 
 radius ; 6 of the lower epiphysis of the ulna ; 14 of the upper end 
 of the humerus ; 10 of the lower end of the tibia ; 7 of the lower end 
 of the femur ; 2 of the upper end of the tibia. The possibility of 
 the occurrence is quite sufficient for the practitioner to have it ever 
 present to his mind, as well as to lead him to attempt to protect 
 against it by appropriate treatment and to forewarn the parents or 
 friends of the serious consequences which may attend epiphysial 
 lesions. 
 
 Emile Barbarin {Les fractures chez les enfants, These de Paris, 
 1873, No. 206, p. 41) states that in about two hundred operations, 
 in which M. Delore separated the lower epiphysis of the femur for 
 genu-valgum, in no case, even after the lapse of many years, was 
 there any shortening of the limb observed. 
 
 In a discussion at the Eoyal Academy of Medicine in Ireland, 
 Section of Pathology, November 30, 1888 {British Medical Journal, 
 December 15, 1888), on a specim.en of congenital malformation and 
 stunted growth of the humerus taken from an Egyptian mummy, 
 and another from a dissecting-room subject, exhibited by Professor 
 Bennett, it was suggested by Mr. Lentaigne that the deformity 
 m.ight have been due to epiphysiary fracture and arrest of growth. 
 
 Professor Bennett said that Mr. Jonathan Hutchinson was the 
 leading authority for arrest of development after epiphysiary frac- 
 ture. He did not know of a single recorded case of arrested develop- 
 ment following epiphysiary separation ; epiphysiary separations 
 always united with great accompanying deformity ; but there was 
 not a single trace of any such deformity on either of the bones he 
 had exhibited. 
 
 There is still great difi'erence of opinion as to the clinical con- 
 
108 TBAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 ditions under which we find these disturbances of growth of the 
 bones. The influence which traumatic lesions have is mostly 
 known as the result of experiments. The period of full activity of 
 the affected cartilage, as a rule, coincides with the occurrence of 
 arrest of growth. The practical importance of this subject in 
 articular and diaphysial resections has been fully investigated by 
 M. Oilier {Traite des resections, torn. i. & iii.) 
 
 Oilier concluded in 1867 that arrests of growth are not due to 
 premature union of the epiphyses, but arise from disturbance of the 
 ossification, so that the evolution of the epiphysial cartilage, far 
 from being accelerated, is on the contrary diminished. 
 
 That elongation is not due to exaggeration of the activity of the 
 cartilages, nor arrest of growth to their premature disappearance, 
 has lately been proved by G. Nove-Josserand's microscopical inves- 
 tigations {These, Lyon, 1893) undertaken at Ollier's instigation. 
 These show that it results from disturbance of the ossifying process 
 after injury. 
 
 Causes of arrest of growth. — Vogt, Bidder, Wegener, Maas (' Ueber 
 das Wachsthum und die Regeneration der Eohrenknochen,' Lajigen- 
 becJc's Arcliiv, Bd. xx.) and others have conclusively proved that 
 growth in length in a bone is no longer possible after epiphysial 
 separation in the midst of the conjugal cartilage. 
 
 In many of the recorded cases the precise nature of the original 
 injury about the epiphysial line is far from having been clearly 
 ascertained ; moreover, premature ossification of the epiphysial 
 cartilage can be produced by a fracture of the shaft. 
 
 M. Oilier found by incising, puncturing, lacerating, or excising a 
 portion of the cartilage that the growth of the bone was apparently 
 lessened, and by removing the whole of the cartilage the arrest of 
 growth was complete ; so that, theoretically, every case in which a 
 separation passes through the midst of the cartilage should be followed 
 by arrest of growth. However, as has been mentioned above, these 
 cases are practically very rare. 
 
 He also found that by removing a portion or the whole of the 
 epiphysis, or by removing the juxta-epiphysial region of the dia- 
 physis, he produced an arrest of development, which, however, was 
 less than in the case where the cartilage itself was removed. Theo- 
 retically, therefore, it is possible to get, temporarily at any rate, an 
 arrest of growth in all forms of epiphysial separation in which any 
 of the structures in the neighbourhood of the cartilage are involved. 
 
 Holmes says : ' The importance of the question about the precise 
 line of fracture is this : if the fracture be really a laceration of the 
 epiphysial cartilage, this structure may be expected to be more or- 
 less altered by the inflammator}^ process necessary for the cure of the 
 injury. The ossifying tissue may be permanently damaged, and loss 
 of growth may result. On the other hand, if the injury be confined 
 to the diaphysis, no such consequence seems likely to follow.' 
 
PEOGNOSIS AND EESULTS 109 
 
 But it is possible that arrest of growth may be due to lesions of 
 the struct'iires in the immediate neighboitrhood of tlie cartilage. 
 
 The assertion that the most frequent form of traumatic separa- 
 tion of the epiphysis is really a fracture of the ossifying line on the 
 diaphysis, and not likely to be followed by arrest of growth, is certainly 
 a fallacy. 
 
 Vogt thinks that a temporary stoppage or delay may be 
 produced by the formation of callus, stopping the advance of the 
 endosteal vessels, but that when normal absorption has taken place 
 in the solid callus abundant connections are formed by the vessels, 
 and the growth normally established again. Hence there will only 
 be a delay, and not an abolition of growth in length. The new 
 osseous material thrown out by the two fragments as well as by the 
 periosteum, crowding the meshes of the spongy tissue and practi- 
 cally obliterating the medullary canal, forms a provisional osseous 
 bar, as it were, which later on undergoes rarefaction, and the parts 
 return rapidly to their normal state. 
 
 Oilier thought that the normal increase in length in a bone was 
 often a little impeded. 
 
 If the injury to the epiphyses of the long bones be inflicted 
 during the period of life when their integrity is essential to their 
 proper growth, much shortening and dwarfing of the limb may 
 possibly be the after-result, and of greater importance compared 
 with the other result just mentioned. 
 
 Though this arrest of growth is rare, it is impossible to make 
 even a guess at its proportionate occurrence until the frequency of 
 separation in the cases of the different epiphyses has been approxi- 
 mately determined. 
 
 Mr. Hutchinson and others believed that it is chiefly in cases 
 in which periostitis follows the injury that arrest of growth is the 
 consequence, and that the cartilage between the epiphysis and the 
 shaft is damaged by the inflammation, and its further process of 
 growth and ossification arrested. 
 
 Fractures involving the conjugal cartilage, diaphysial separa- 
 tions, and penetrating wounds implicating both the epiphysis and the 
 conjugal cartilage, may either arrest or disturb the proliferation of the 
 cartilage, provided enough irritation has been caused by the injuries. 
 Generally speaking, all injuries of the conjugal cartilage which are 
 followed by acute inflammation, and especially by suppuration, 
 arrest more or less the growth of the bones (Oilier). 
 
 Although often only of a transient nature, it may possibly result 
 from the very common form of separation, as it passes through the 
 osteoid layer. The callus which unites the divided ends in the neigh- 
 bourhood of the ccrtilage (like the gold leaf and layer of indiarubber 
 inserted between the diaphysis and epiphysis in Vogt's experiments 
 on animals) shuts off from the diaphysis the endosteal loops of vessels 
 which preside over the phenomena of ossification, and are essential 
 
110 TEAUMATIC SEPAEATIOX OF THE EPIPHYSES 
 
 to the transformation of the cartilagmous tissue into bone, bringing 
 the materials to the cartilage necessary for the building up of the 
 ■new osseous tissue, and causing absorption of the cartilaginous 
 tissue ; the cartilage, though preserving its vitality and structure, 
 thus loses its active formative power — at any rate, for a time. 
 
 With the natural and rapid process of absorption of the callus, 
 the vessels will penetrate it and regain the surface of the cartilage. 
 The interference with the function will therefore be but small or 
 inappreciable. 
 
 Others think that the checking of the growth of the limb is 
 occasioned by j)^'&^^'''Ciiu?-e ossification of the cartilage due to the 
 inflammation which ensues after the injury and to the rapid welding 
 to the shaft. But Oilier has clearly established (by his experimental 
 laceration of the cartilage, &c.) that this ossification is not thus 
 produced ; but that it is the result of a disturbance of nutrition, of a 
 diminution or arrest in the proliferation and evolution of the cartilage 
 cells, which do not undergo their proper process of ossification. He 
 found that repair takes place by fibrous tissue, and that ossification 
 is thus retarded rather than accelerated ; at any rate, it is clear that 
 the epiphysial junction cartilage is particularly disposed to become 
 inflamed. 
 
 In the foregoing circumstances the elements of growth themselves 
 are involved or destroj^ed, but destruction of the juxta-epiphysial 
 region may also affect the nutrition of the same part and lead to 
 partial arrest of growth, although it may not have actually involved 
 the conjugal cartilage (OlHer). 
 
 In infancy the injury to the juxta-epiphysial region may be of 
 the character so well described by Oilier, and may be considered 
 at this time as a simple sprain, and yet be followed by arrest of 
 growth of the bone. Mr. Mansell Moullen has observed an instance 
 of impaired growth of the lower epiphysis and lower part of the 
 shaft of the tibia in a lad who five years previously had caught his foot 
 in a wheel, where it was severely twisted. The case was treated for 
 some weeks in bed as a simple sprain. The extraordinary malleolar 
 projection had thrust the foot into a position of false talipes varus. 
 (See LowEE Epiphysis of Tibia.) 
 
 In operations, such as re-sections, we find generally the same 
 results, arrest of development frequently following at the upper end 
 of the humerus and the lower extremity of the radius, also at the 
 ends of the bones of the leg in the neighbourhood of the knee-joint. 
 
 It is a noteworthy fact that few cases of detachment of the 
 epiphysis from suppuration, or even complete necrosis of the shaft, 
 are followed by arrest of growth, showing that the epiphysial carti- 
 lao-e has great power of resisting suppurative processes. Eemoval 
 of the diaphysial end, moreover, in compound traumatic separations 
 has not invariably led to shortening or arrest of growth. 
 
 Many authors think that partitd or complete arrest of gj'owth 
 
PEOGNOSIS AND EESULTS 111 
 
 of the long bones is associated with great displacement of the 
 epiphyses, and occurs in cases of severe local injuries. This is 
 notably the case in experiments (Oilier) . 
 
 But this does not appear to be borne out by the recorded cases 
 of arrest of growth. In many of them there has been no displace- 
 ment, in several but little local injury ; in fact, in some previously 
 narrated the injury had been regarded as a sprain. 
 
 On the other hand, very many cases of severe injury, with great 
 and even permanent displacement of bones, are recorded where there 
 has been no permanent arrest of growth of the bone, the periosteal 
 vessels being sufficient to carry on the blood supply to the cartilage 
 until consolidation is established. Neither does it appear to be 
 dependent upon the stripping up of the periosteum which is so 
 constantly found in all separations. 
 
 Oilier also believes that diaphysial separations, as he terms these 
 injuries, cause arrest of growth if reduction has not been effected 
 or if the wound suppurates, and that in cases of immediate reduc- 
 tion, where inflammation has been prevented, no appreciable arrest 
 of growth takes place as a rule. 
 
 Gurlt holds that simple separations without displacement have 
 as good a prognosis as fracture, and that union is, like the physio- 
 logical union between the diaphysis and epiphysis, an osseous one. 
 
 Histologically nearly all separations, Curtillet reminds us, are 
 in fact fractures ; the union is effected by means of callus, which, 
 being in the immediate vicinity of the conjugal cartilage, must have 
 some influence on its function. 
 
 It is more probably associated with the exact seat of the 
 separation, and dependent upon certain circumstances. 
 
 Partial arrest of growth. — It is also possible to get a partial arrest 
 of growth, or slight diminution in length (if only two or three centi- 
 metres), though the inflammatory condition which has affected the 
 epiphysial cartilage is of a milder character, insufficient to destroy 
 the proper function of cartilage. In fact, in all cases the process of 
 repair must affect the growth, if only for a very short time. The 
 disturbance of the process of normal ossification is a transient 
 one ; it is probable that this occurs more frequently in juxta- 
 epiphysial detachments— the common form of injury. It will not 
 be a permanent condition provided the normal process of union by 
 callus occurs. No great loss of length from deficient growth is 
 noticeable, as the ossifying tissue is not permanently damaged. 
 
 The amount of this transient interference with growth will be in 
 direct proportion to the particular epiphysis involved — that is, as 
 regards its importance in the growth of the bone. 
 
 Such a small amount of arrest of growth occurring at the time 
 when the growth of the bone is almost completed might easily be 
 overlooked by the surgeon as well as the patient. This is very 
 likely to be the case if it be the upper end of the humerus, or other 
 
112 TEAUMATIC SEPAEATIOX OF THE EPIPHYSES 
 
 bone of the upper extremity, instead of one in the lower extremity, 
 where the shortening is more noticeable. 
 
 Vogt believes that if the epiphysial cartilage is not materially 
 injured, and no hindrance offered to the complete inosculation of 
 endosteal vessels by incomplete apposition of the separated surfaces 
 by such complications as severe contusion, displacements, or inflam- 
 mation produced by subsequent movements of the parts, no arrest 
 of growth is to be considered likely to occur. So that he believes 
 that certain primary or secondary complications must accompany 
 the typical epiphysial separation in order to produce, directly or 
 indirectly, the condition requisite to arrest the advance of growth. 
 
 Slight stoppage or interference with growth is seen in re-sections 
 of joints in children, in which the portion of the epiphysis removed 
 does not approach the epiphysial disc ; yet slight interference ensues, 
 inappreciable though it may be in amount. 
 
 In certain cases of fracture of the diaphysis in children arrest of 
 growth has occurred, and it is interesting to note that Tillmanns, 
 Schott, and others have recorded cases in which this shortening has 
 diminished or disappeared in the course of one or two years. 
 
 A fracture of the diaphysis might have a fissure from it involving 
 the epiphysial disc, and lead to arrest of growth, but the author does 
 not know of any such case. 
 
 While some think that if the epiphysial cartilage be injured, 
 and the union of the fragments be slow or have not taken place, its 
 nutrition may be interfered with, and therefore an arrest of growth 
 may result, it would appear from the history of the published cases 
 that ')nohility of the fragments, by irritating and causing inflamma- 
 tion or destruction of the growing cells of the conjugal cartilage, is 
 the most important factor in the production of arrest of growth. 
 
 Others have thought, as already stated, that arrest is chiefly met 
 with in complete displacement of the epiphysis, but this does not 
 appear to be borne out by the recorded cases. 
 
 Want of union by callus, miassociated with want of immobility, 
 has also been given as a cause of arrest of growth, but is rarely met 
 with under healthy conditions. 
 
 Anything which causes undue inflammation, destruction, or 
 degeneration of the conjugal cartilage must be followed by cessa- 
 tion of its function. 
 
 It is interesting to note that the few instances of true separa- 
 tions through th*? middle of the cartilage, while occurring but seldom, 
 did so in the recorded cases between the tenth and seventeenth 
 years. Ossification having at this period well advanced, arrest of 
 growth cannot be at all considerable. 
 
 The risk of arrest of growth will also be proportionate!}' influenced 
 as the separation is complicated by a more or less extensive fracture 
 of the diaphysis. Where the separation takes place through only a 
 small portion of the epiphj'sial line and a considerable portion of the 
 
PEOGNOSIS AND EESULTS 113 
 
 diaphysis, principally in older patients, the risk of total arrest will be 
 almost nil. 
 
 To sum up the views of the authors quoted, a shortening of the 
 affected livah is not necessarily to be expected in all cases, provided 
 immediate reduction has been made, immobility maintained, and 
 inflammation avoided. 
 
 Jahn has lately made (Schwab's MorjjhologiscJies Jahrbuch, 1892) 
 some experiments on wounds of the conjugal cartilage, in which he 
 has especially endeavoured to ascertain the role played in the 
 regeneration of the conjugal cartilage by its different layers (couche 
 seriee, couche de proliferation) . They showed that, after excision of 
 the proliferating zone, growth is arrested almost as completely as 
 after ablation of the whole, the cells of this "layer being alone 
 capable of self-multiplication, and consequently of permitting the 
 formation of new cartilaginous material in front of theossific vessels. 
 
 M. G. Nove- Josserand has also recently (Des troubles de V accroisse- 
 ment des os par lesions de cartilages de conjugaison, These de Lyon, 
 Dec. 1893) undertaken some experimental histological work with the 
 object of proving the truth of Ollier's opinion — viz. that arrest of 
 growth is the consequence of a disturbance in the evolution of the 
 conjugal cartilage, and is not due to premature union of the epiphysis 
 resulting from an acceleration of the normal process of ossification. 
 Nove-Josserand, whilst carefully preserving asepsis to exclude 
 suppuration of the wounds, effected the simplest possible and most 
 limited injuries of the epiphysial cartilage of young rabbits ; after 
 noting the arrest of growth he made a careful histological examina- 
 tion of the changes occurring as the result. He found that two 
 different processes were present. First, a disturbance in the 
 normal development of the cartilage cells, fibrillation of the ground 
 substance, and atrophy of the cartilage cells. These processes may 
 be confined ^,0 the seat of injury, but if the latter be considerable 
 the nutritive changes will invade the whole conjugal cartilage. 
 Moreover, as M. Oilier has already observed, the diaphysial ossification 
 may be diminished in the injured zone so that the arrangement of 
 the cells in parallel series is much less marked. Secondly (but this 
 occurred only when a simultaneous injury was inflicted upon the 
 adjoining epiphysial bony layer), an ossifying process developed and 
 extended forwards through the cartilage to meet the line of ossifica- 
 tion, and then beyond into the diaphysis, so that, as it were, an 
 osseous ' nail ' joined the diaphysis to the epiphysis. Some good 
 microscopical drawings of the sections are given by this author. 
 They well illustrate the histological appearances of arrest of growth 
 due to interference with the growth of the conjugal cartilage. 
 
 C. Ghillini has also made (Archiv fiir hlin. Chir., Berlin, xlvi. 
 1893, S. 844) some experiments in the mechanical irritation of the 
 epiphysial cartilage in animals. Contrary to the usual belief that 
 ivory pegs remain unabsorbed, he finds that, although this may be 
 
 I 
 
114 TKAUMATIC SEPAKATION OF THE EPIPHYSES 
 
 true if they are inserted into the osseous substance, yet when inserted 
 in the epiphysial cartilage they may, after a very short space of time 
 (two months), disappear entirely. He describes, and gives some micro- 
 scopical drawings of, the changes in the epiphysial cartilage and the 
 pegs. The whole of the epiphysial cartilage disappears more rapidly 
 than on the uninjured limb. As the result of the arrest of growth 
 of the tibia from destruction of part of the epiphysial cartilage, he 
 finds that deformity of the diaphysis of the bone operated on, and 
 deformity of the knee are developed, whilst lessened growth of the 
 condyles of the femur is brought about by increased pressure. These 
 researches agree with Volkmann's (Virclioio's Arch., Bd. xxiv. 1862, 
 S. 512). 
 
 To conclude, the causes which may produce loss of function of 
 the cartilage may be classified as : 
 
 1. Injury to cartilage itself through crushing or bruising. 
 
 2. Callus from separation through osteoid layer stopping proper 
 
 blood supply, {a) Transient (probably common) ; (h) com- 
 plete. 
 
 3. Entire destruction or serious impairment ; inflammatory 
 
 complication from infection of seat of lesion by external 
 Abound, or destruction by inflammation of the epiphysis 
 and necrosis (rare), as in Poncet's case. 
 
 4. Deficient nutrition from (a) imperfect reduction of diaphysis ; 
 
 (5) displacement of diaphysis (rare). The epiphysis being 
 completely separated from the diaphysis, the latter ceases 
 to provide it with the proper elements of growth. 
 
 5. Deficient nutrition (1) from excessive callus, or (2) from 
 
 retarded consolidation due to mobility of the fragments 
 
 (probably common). 
 Consequent deformity. — The diminution in length of a long bone 
 from diminished growth means loss of symmetry, and in many cases 
 loss of the proper function of the injured extremity. There is also 
 a certain correlation between the growth of the bones and the soft 
 structures of the limb ; when the increase of the bone is arrested 
 there is a corresponding decrease in that of the muscles and other 
 soft parts of the limb. 
 
 Great reproach may be cast upon the surgeon at the occurrence 
 of deformity, although, in most instances, it will have been due 
 to no fault on his part. In all injuries near the joints in J^oung 
 children, it is most necessary, as has already been said, that he 
 should protect himself against any ulterior imputations which may 
 be cast upon his management of the case by clearly putting before 
 the friends the statement that an imperfect result may follow the 
 treatment. 
 
 These deformities have been carefully studied by M. Poncet, 
 especially in the parallel bones of the forearm and leg (Poncet, ' De 
 I'osteite envisagee au point de vue de I'accroissement des os,' Gazette 
 
PROGNOSIS AND RESULTS 
 
 115 
 
 hebdom., 1872 ; ' Des deformations produites par I'arret d'accroisse- 
 ment d'un des os de I'avant-bras,' Lyon Medical, 1872), as well as by 
 Vogt and some other German authors. 
 
 Bouchut was the first to notice deformity following injm-y to 
 one of the parallel bones of the extremities. In a case of separation 
 of the lower epiphysis of the tibia he observed an arrest of growth 
 of this bone whilst the fibula continued to increase in length and 
 produced a varus position of the foot. 
 
 When the arrest of growth involves one of the two parallel bones 
 of the forearm or leg, deformities which are progressive up to the 
 time of union of the epiphyses of the 
 neighbouring bone are often seen and 
 are of great interest, the retardation of 
 the growth in the one bone, with the 
 pressure from the continued growth of 
 the other, leading to considerable devia- 
 tions in the contour of the articular 
 surfaces and the peripheral parts of the 
 limb. For instance, when the radius is 
 involved the ulna continues to grow 
 and, obtaining its fulcrum from the 
 humerus, gradually drives the hand out- 
 wards. So again with regard to the 
 ulna, the radius, being intact and bound 
 to the ulna at each end, will develop and 
 grow curved or bowed and somewhat 
 flattened, as in M. Poncet's and Mr. 
 Hutchinson's cases, the deformity being 
 well marked although in an opposite 
 direction. The hand inclines to which- 
 ever side the arrest of growth has 
 taken place on. In the lower extremity 
 talipes valgus or varus may follow 
 arrest of development of the tibia or 
 fibula. 
 
 In some cases only part of the epi- 
 physial cartilage may be injured and 
 
 impaired, the rest of the cartilage escaping the inflammatory 
 change. 
 
 The hindrances to which these deformities give rise may at any 
 time become very considerable and serious. 
 
 Prof. Nicoladoni has shown (Wiener medizin. JaJirhiicher, 1886, 
 S. 266) that not only may obliteration or premature ossification of 
 the epiphysial cartilage after injury take place gradually from the 
 inner to the outer side, oi vice versa, with their attendant deformities, 
 as in cubitus varus and valgus, but that this obliteration after injury 
 may also gradually occur from behind forwards, as in the case of the 
 
 Fig. 10. — VALGUS position of -hand 
 
 PRODUCED BY AKEE3T OF GROWTH 
 OF THE RADIUS 
 
 From a dissecting-room specimen. 
 The elbow was also in a valgus 
 position (Nicoladoni) 
 
116 TEAUMATIC SEPARATION OF THE EPIPHYSES 
 
 lower end of the femur, and give rise to remarkable deformity of the 
 knee-joiijt. 
 
 It is highly probable that many asymmetrical deformities of the 
 trunk, such as those in the skull, the pelvis, and the vertebral column, 
 are brought about by arrest of growth on one side, from premature 
 ossification or impaired function of the epiphysial cartilage on that 
 side, the result of injury. 
 
 Lengthening. — While any direct injury to the conjugal cartilage 
 or its immediate vicinity may arrest the growth at this end of the 
 bone, it has been demonstrated, both clinically and experimentally, 
 that indirect irritation to the bone or medullary canal and periosteum 
 at a distance from this cartilage may, if the irritation be sufficient 
 and long continued, j)Todnce overgrowth and hypertrophic lengthening 
 of the end of the bone. The irritation and increased growth of the 
 cartilage cells are here more indirect and occur through the medium 
 of the tissue of the bone marrow or periosteum, whereas the functions 
 of the cells are arrested if directly irritated. In the human subject 
 certain cases of central ostitis of the tibia (with quiet necrosis) have 
 produced a lengthening of six to seven centimetres of the bone (Oilier), 
 
 There is sometimes, though rarely, seen a lengthening of the 
 bone after fracture of the shaft in children, produced by the same 
 cause. Oilier has mentioned the case of a child eight to ten years of 
 age, in which the femur was found to be lengthened by two centi- 
 metres, forty days after a fracture of the diaphysis. 
 
 Max Schiiller has recently {Berliner Jclin. Woch. 1891) asserted 
 (in disagreement with Oilier) that irritations in the immediate neigh- 
 bourhood of the epiphysial cartilages produce sometimes a lengthen- 
 ing, sometimes a shortening, according to their quality and intensity. 
 
 But we must all believe that Oilier is right in stating that it is 
 rather a question of the seat of the irritation ; in general terms, 
 lesions of the diaphysis, if long continued, produce lengthening, those 
 of the epiphysial cartilage and juxta-epiphysial region a greater or 
 less stoppage and arrest of development. 
 
 Bruns has collected (Deutsche Chirurgie) six cases of excessive 
 growth in length after fracture of the femur. 
 
 May this not explain the fact that fractures of the femur in children 
 so frequently unite without any shortening, although a little over- 
 lapping of the fragments has been present ? May not, in these 
 rare instances, lengthening of the femur due to the irritation of the 
 fracture have compensated for the slight shortening due to the over- 
 lapping ? However, the lengthening must be very small and only 
 occur during consolidation. Oilier says that it cannot exceed j\ or 
 yL- of the total length of the bone — e.g. in the case of the femur or 
 tibia in a child of six years, one centimetre. 
 
 The after-results of all epiphysial separations should be more 
 carefully recorded than they have been hitherto. The separations 
 should be carefully examined and the limbs measured from time to 
 
PEOGNOSIS AND EESULTS 117 
 
 time. Until this is done a proper estimate cannot be made as to 
 after-effects in all the varying conditions. 
 
 Arrest of growth from ostitis, &c., due to epiphysial sprain or contusion. 
 Oilier has shown that arrest of growth is frequently due to juxta- 
 epiphysial sprain {rentorse juxta-ejnphysaire) or contusion producing 
 ostitis in the rapidly developing bones of infants. He points out 
 that the more active the proliferation of a tissue the more susceptible 
 is it to morbid changes at any particular time, and that this is 
 especially true of the growing bones. Consequently in infancy the 
 effects of injuries to the rapidly developing bones are especially to 
 be feared. 
 
 Oilier, in his memoir ('De I'entorse juxta-epiphysaire,' Bevice 
 de Ghinirgie, 1881, p. 787), relates as an example the following case 
 of arrest of growth of the humerus, following a fall upon the arm 
 without the occurrence of abscess or acute inflammation. 
 
 The case was observed by him eighteen years previouslj^ being 
 given in his memoir presented to the Societe des Sciences medicales 
 de Lyon ('De I'inegalite d'accroissement des deux extremites des os 
 longs chez I'homme,' 1863; Mem. Soc. des Sci. med. de Lyon). A girl 
 of fifteen entered the hospital in March 1863 suffering from a con- 
 tusion of the knee, and took the opportunity of inquiring if nothing 
 could be done for her right arm, which was shorter and weaker than 
 the other. She said that at the age of seven or eight she had fallen 
 from a carriage, and that the shoulder remained painful for some time. 
 She had often been told that nothing had bee^i done for it. There 
 was no trace of old suppuration, no cicatrix of the skin, or any 
 adhesion of the deeper parts. The humerus was seven centimetres 
 shorter than that of the opposite side, but freely movable without 
 pain in both active and passive movements. The arm was weaker 
 and smaller in size, except at the level of the neck, where it was 
 somewhat larger than its fellow. The two forearms were equally 
 developed. Oilier did not think that there had been an epiphysial 
 separation, inasmuch as there was no trace of any deformity from 
 protrusion of the diaphysial end, nor any change in the direction of 
 the shaft. He says that he had met with a similar, though less 
 marked (22 millimetres), arrest of growth of the radius due to the 
 same cause. 
 
 Stanley also alludes {A Treatise on Disease of the Bones, 1849, 
 p. 9) to the case of a child in whom the formation of an abscess 
 upon the upper part of the tibia, accompanied by a partial separation 
 of its epiphysis, was followed by so slow a growth of the tibia that, 
 several years afterwards, it was found to be an inch and a half shorter 
 than the tibia of the opposite limb. 
 
 Suppui-ation, periostitis, and necrosis of bone. — Injury to the epiphyses 
 is apt to be followed by inflammation, which frequently passes on 
 to suppuration, periostitis, and even osteo-myelitis. 
 
 The periostitis, starting in the inflt mmatory action at the 
 
118 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 epiphysis, may affect the whole shaft, and cause partial or complete 
 necrosis. 
 
 Suppuration and necrosis of bone are certainly more frequent 
 consequences of epiphysial separation than is the case with true 
 fractures. They are more likely to occur in feeble and weakly 
 children, the pyogenic organisms finding in them a more favourable 
 nidus in which to develop, while similar injuries in the strong and 
 healthy would heal rapidly without being followed by any such 
 untoward results. 
 
 Suppuration round the diaphysis which has been denuded of its 
 periosteum, may be cast off in a necrosed condition as a sequestrum, 
 as in a case described by Hutchinson and also in Curtillet's case. 
 
 In Esmarch's case a large abscess formed after epiphysial separa- 
 tion of the upper end of the humerus, which had been mistaken for 
 a dislocation, and two attempts made to reduce it ; this necessitated 
 the removal of the epiphysis and a portion of the diaphysis. 
 
 These inflammatory complications are the most frequent causes 
 of arrest of grow^th after epiphysial injury. 
 
 Fig, H. DEFORMITY FOLIiOWINO TRAUMATIC SEPARATION OF THE LOWER EPIPHYSIS 
 
 OF THE UIjNA, with SUPPURATION AND NECROSIS (cURTILLET) 
 
 (See Part II. Chapter XIII.) 
 
 Periostitis and abscess. — It has been thought that the frequency 
 of suppuration is due to the extensive separation of the periosteum 
 always met with ; although this is, no doubt, an important factor, yet 
 it will be found to occur more often in certain sites than it does in 
 others — vi;:i. at the great trochanter, lower end of femur, &c. 
 
PEOGNOSIS AND EESULTS 119 
 
 In the extremities of the long bones it occurs more frequently at 
 that end which is the seat of the greatest active growth. 
 
 Packard mentions a case, communicated to him by Dr. E. S. 
 Huidekoper, of separated lower epiphysis of the femur in a foal, 
 followed by the formation of a large abscess. The animal, five 
 months old, in rushing through a gateway struck the stifle of the 
 near hind leg against a heavy post. When seen by Dr. Huide- 
 koper, there was excessive lameness ; but as the animal limped 
 the leg swung with an unnatural motion, and there was found to be 
 looseness and slight crepitus in the neighbourhood of the femoro-tibial 
 articulation. The exact nature of the injury could not be determined 
 on account of the swelling of the parts, abscess ensued, the animal 
 wasted rapidly and was destroyed. The autopsy showed a separa- 
 tion of the lower epiphysis of the femur with laceration of the 
 surrounding tissues, and a large abscess. 
 
 Acute periostitis is one of the peculiar dangers attending 
 epiphysial separation. It differs from the same complication in a 
 fracture of the shaft on account of the thickness, strength, and 
 vascularity of the periosteum, and the amount of the violence which 
 it sustains in these injuries. Moreover, many muscles, ligaments, 
 and other structures are intimately attached to it in the neighbour- 
 hood of the joints. 
 
 "We find (as mentioned above) that the periosteum is seldom torn 
 across, except where complete displacement of the epiphysis has 
 taken place, owing to the stripping up of the membrane from the 
 diaphysis ; but it always remains firmly attached to the epiphysis, 
 and hence there is great risk of suppuration about the end of the 
 bone. 
 
 This stripping of the periosteum from the end of the diaphysis 
 occurs even in cases where there is incomplete displacement or mere 
 loosening of the epiphysis. 
 
 In this connection should it not also be recalled to mind that 
 the end of the bone which contributes most to its increase in length 
 is also the most frequent seat of inflammatory affections during the 
 period of growth (Oilier), and of new growths at all ages (Oilier) ? 
 
 In association with the occurrence of inflammatory mischief in 
 the conjugal cartilage after epiphysial separation, Eoux has made 
 {La Presse Medicate, July 12, 1837) some curious statements which 
 cannot be wholly accepted at the present day. Belonging to history, 
 they may be reproduced here. ' In the neighbourJiood of the lai-ger 
 joints,' he says, ' when the displaced epiphysis has not been reduced, 
 troublesome symptoms are apt to arise : inflammation, rapidly 
 passing on to suppuration, intense pain, high fever, extensive and 
 deep abscesses, sometimes gangrene — leading to amputation. In 
 the neighhourhood of the medium-sized joints the displacement of 
 the articular surfaces is only at times at all considerable ; but con- 
 solidation in this position results in deformity of the limb, hampering 
 
120 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 and weakness of its movements. In tlie smaU joints, the displace- 
 ment of the extremity of the bone is never great ; but if retentive 
 apparatus is neglected subsequent movements of the limb are almost 
 impossible and the deformity is "shocking." ' Eoux adds that the 
 consolidation of the fragment even in a bad position is very rapid, 
 
 but that subsequently it will be found 
 impossible to straighten the limb. 
 
 Chas. Bell's case (fig. 12) is a good 
 example of periostitis and incipient 
 necrosis following separation of the 
 lower epiphysis of the femur. 
 
 Acute osteo-myelitis after epiphysial 
 injury to the lower end of the radius in 
 Page's case led to amputation of the 
 limb. 
 
 Xecrosis of both epiphyses of the 
 fibula occurred in the tenth w^eek in 
 Dr. Fischer and Dr. Hirschfeld's case 
 of separation of these epiphyses. 
 
 Humphry, in his article on the 
 * Growth of Epiphyses ' in vol. xlv. of 
 the Boy. Med. Cliirurgical Transactions 
 (p. 295), has collected many instances 
 of arrest of growth of the long bones 
 after acute epiphysitis and acute ne- 
 crosis of the diaphysial and other inflammatory affections in the 
 neighbourhood of the epiphysial junction cartilage, which we need 
 not discuss in this place, although in many of these the suppura- 
 tion and necrosis were undoubtedly due to injury, or incomplete 
 separation at the epiphysial line. 
 
 Marjolin, Stanley, Oilier, Helferich, Fischer, Paget, Birkett, 
 Bryant, Bruns, Hutchinson, and others record similar cases, too 
 numerous to mention here. 
 
 In a few the ostitis or osteo-myelitis has led to lengthening 
 of the bone. 
 
 Arrest of growth is also frequently seen in operations on the ends 
 of the bones, such as excision, interfering with the epiphysial line, 
 although this inay not have been actually injured at the time of 
 operation. 
 
 Disease due to partial separation. Hip disease. — A large number 
 of cases of arthritic diseases of the hip and of other parts of the 
 body — e.g. caries of spine, &c. — are due rather to traumatic than 
 constitutional causes, at any rate in the first instance. The tendency 
 of late years has been to attribute all such joint affections to the 
 scrofulous or tubercular diathesis quite irrespective of any mechani- 
 cal injury. 
 
 Fig. 12. — suppueative peeiostitis 
 and commencing neceosis after 
 epiphysial sepaeation 
 
 (Museum of the College of Sur- 
 geons, Edinburgh) 
 
PEOGNOSIS AND KESULTS 121 
 
 In the large majority of such cases, as has been aheady men- 
 tioned in Chapter VI., there has been a partial separation of the 
 epiphysis, or, as Oilier terms it, a juxta-epiphysial sprain or 
 separation. 
 
 Pyaemia has unfortunately been the final result in too many cases 
 in the past. Convulsions or rigors may indicate the commence- 
 ment of general infection. 
 
 Other concomitant injuries. — The prognosis of many of the severer 
 forms of injury is rendered very grave from the accompanying 
 injuries to other parts of the body (brain, &c.). 
 
 The number of deaths in 100 cases verified by autopsy as 
 collected by Bruns was nineteen from complications arising from 
 injury 'to the soft parts, fractured skull, and other severe lesions ; 
 four from causes unknown, and five from accessory causes ; two 
 from re-sections of joint made for preserving limb ; and twenty-two 
 from amputations of the limb to preserve life. 
 
 Compound separations, unless treated with every antiseptic pre- 
 caution, are liable to be followed by serious consequences, such 
 as pyaemia, septicaemia, suppuration of the articulation, absence 
 of consolidation, and necrosis of the diaphysis or epiphysis. It is 
 more common in some compound separations — e.g. the lower end of 
 the femur — than in others. At the lower end of the humerus it is of 
 very infrequent occurrence. • Again, the seat of lesion being infected, 
 the conjugal cartilage may be destroyed, or seriously altered in its 
 structure ; and an arrest of growth may result, as occurred in many 
 recorded cases. 
 
 Gangrene may be confined to the neighbourhood of the separa- 
 tion, and in these instances is due to the crushing or bruising of the 
 part by direct violence ; in others it may be due to the pressure upon 
 the skin by the displaced diaphysis. 
 
 The whole limb below the seat of separation may become 
 gangrenous from the arrest of circulation, due to complete or partial 
 laceration of large vessels in the immediate neighbourhood of the 
 diaphysial end, or to the pressure of the displaced end upon these 
 vessels, commonly met with at the lower end of the humerus and 
 femur. 
 
 This compression of the vessels has unfortunately in too many 
 cases been the result of an improperly applied splint, especially at 
 the lower end of the humerus and radius. 
 
 Tetanus is a very uncommon complication. It has occurred a 
 few tiines after compound separation, very seldom after simple 
 separation from pressure upon the neighbouring nerve by the end 
 of the displaced diaphysis, or by' excessive callus, as in Brunner's 
 case of separation of the lower end of the radius. 
 
 Aneurysm. — Pressure of the displaced diaphysis of the femur has 
 three times caused an aneurysm to develop in the neighbouring 
 
122 TRAUMATIC SEPARATION OF THE EPIPHYSES 
 
 popliteal artery after separation of the lower epiphysis. The 
 brachial artery at the elbow escapes this comphcation in a remark- 
 able manner, although often severely pressed up by the lower 
 diaphysial end of the humerus in separations. 
 
 Fig. 13. — lowek epiphysis of the femur united with great displacement upwards, 
 the projecting diaphysis produced an aneurysm of the popliteal artery 
 (Royal College of Surgeons Museum, Edinburgh. After Charles Bell. ^ size.) 
 
123 
 
 CHAPTEE IX 
 TREATMENT 
 
 In the year 1822 M. Eoux laid down in his dissertation (Dis- 
 sertatio?i sur la disjonction des epiphyses, Feb. 8, 1822, p. 16, quoted 
 by him in La Presse Medicale, No. 55, July 12, 1837, vol. i. p. 436) 
 the following principles of treatment, which, had they been more 
 generally known and acted upon, might have prevented the too 
 frequent unfortunate results which occurred in so many instances 
 in these injuries at the early part of the present century. Roux 
 also remarks upon the brevity of description of treatment of these 
 injuries before his time. As these rules are of historical interest, I 
 reproduce some of them here in the form in which they are given 
 by Roux : 
 
 ' IV. The fragments of bone should be restored as soon as 
 possible to their natural position by means of well directed traction ; 
 the same apparatus as for fractures should then be employed to hold 
 the fragments in position. But a shorter time will be required for 
 their retention than in the case of fractures. 
 
 'V. It is necessary to extend the limb beyond its normal length, 
 and direct with the hands the fragments into position in cases in 
 which the epiphysis has been dragged on to the diaphysis by the 
 action of the muscles. 
 
 ' VI. The reduced fragments are maintained with little difficulty 
 in position on account of the very feeble action of the muscles in 
 young subjects. 
 
 ' VIII. If the displacement of either of the fragments produces 
 compression of the neighbouring structures, and threatens to produce 
 tetanus, paralysis, or gangrene, it will be necessary to replace the 
 separated epiphyses ; when this is found to be impossible by simple 
 traction, then deep incisions should be made, or the separated epi- 
 physes removed. 
 
 ' IX. When the end of the diaphysis protrudes through the 
 skin, incision should be made as in VIII. , or resection of the end. 
 
 ' X. Ensuing tetanus, paralysis, or gangrene should be treated 
 without delay by amputation of the limb. 
 
 Nelaton and other surgeons state that the treatment does not 
 differ from that of fractures of the ends of long bones. 
 
124 TKAUMATIC SEPAEATIOX OF THE EPIPHYSES 
 
 The general method of treatment of traumatic epiphysial separa- 
 tions does not differ from that of true fractures in the neighbourhood 
 of joints, except that they require greater attention to details and 
 more care in preventing undue inflammation and mobility, more 
 especially in the earlier periods of childhood. 
 
 There are, nevertheless, certain separations with displacement 
 which differ very T^idely from fractures in the same situation, and 
 w^hich if treated in the same way would Ijad to most disastrous results. 
 With regard, e.g., to the lower end of the femui", Mr. Mayo 
 Eobson has recently called attention to the mischievous advice given 
 in many of the modern text-books on surgery. Other instances 
 might be mentioned here, but these will be fully discussed under 
 the head of each epiphysis. 
 
 Separation without displacement. — There being often shght swelling 
 of the soft parts, little or no articular inflammation, and compara- 
 tively trifling injmy to the periosteum, it will suffice to fix the joint 
 and hmb in a suitable, immovable splint — as plaster of Paris, 
 poroplastic felt, &c. — always taking the greatest care in application 
 that it does not press injuriously in these young subjects. At the 
 end of from ten to fourteen days the apparatus should be removed, 
 for consolidation has already well advanced by this time, and passive 
 motion should be commenced. 
 
 In juxta- epiphysial sprain in infancy it is sufficient to keep the 
 child perfectly at rest and to fix the limb ; any great exercise or 
 excessive use of the hmb may easily transform an insignificant 
 lesion into a very serious disease, and one or other of the con- 
 sequences of juxta-epiphysial sprain be the result. 
 
 Separation with displacement. Deformity. — The deformity with 
 its symptoms and complications varies so much in the different 
 separations near the joints that no definite treatment can be 
 advocated for all cases. 
 
 Beduction of the displaced fragments is the first point to be aimed 
 at, which in some few cases is readily effected with perfect co-apta- 
 tion of the fragments ; but in most others there is great difficulty 
 in reduction, a point in which epiphysial lesions differ very greatly 
 from fractures. The broad epiphysial end of the shaft having pene- 
 trated the periosteal sheath is held by it in a button-hke manner. 
 
 Though the more simple cases may be treated mthout the use 
 of an anaesthetic, it should always be administered in patients who 
 are advancing towards the later j^ears of puberty, at which period 
 epiphysial separations are most frequently met with, especially in 
 certain long bones and when very large surfaces of bone are involved 
 in the injury, as in the upper end of the humerus and the lower 
 epiphysis of the femur. 
 
 If the displacement be complete, it may be quite impossible to 
 reduce the deformity ; in incomplete separation the diaphysial end 
 is often locked, as in the cup-like epiphysis at the upper end of the 
 
TEEATMENT 125 
 
 humerus, and the deformity to a large extent is maintained by power- 
 ful muscles, so that an ansesthetic niust be administered. On the 
 other hand, it should be clearly understood that, as damage is sure 
 to be the result, the administration of an ansesthetic is strongly to 
 be deprecated as a means of employing force to reduce a displaced 
 epiphysis. Apart from the difficulty of reduction, it would be 
 necessary for diagnostic purposes alone to give an ansesthetic where 
 there is great swelling of the soft parts, and distension of the 
 articulation with blood and fluid. 
 
 The greatest difficulty often attends treatment of injuries to the 
 elbows in young subjects in whom an exact diagnosis has not been 
 made, and it has frequently been followed by a more or less deformed 
 and stiffened limb. 
 
 It may be summarily stated that reduction of all cases ought to 
 be effected a^ 07ice, and should be exact. It is a great mistake to 
 put up an epiphysial separation temporarily with the idea of doing 
 so again a little better later on. 
 
 Maintenance in the normal position. — The effort to maintain cer- 
 tain parts of the injured skeleton in their normal position is often the 
 cause of great anxiety to the surgeon. 
 
 Plaster of Paris, in the form of Croft's lateral splints, is very 
 efficient, with plenty of soft padding over the skin. The immediate 
 application of the plaster is especially useful in the milder forms 
 of separation, where there is little displacement or swelling. 
 
 It is composed of ordinary coarse household flannel cut out to 
 the shape of the limb and joint, and soaked on the outer side with 
 plaster of Paris, with a gap left front and back to prevent too great 
 pressure. 
 
 Plaster of Paris bandages should never be applied in young sub- 
 jects, on account of the danger of gangrene, for their soft, tender, 
 skin should ever be present to the surgeon's mind. 
 
 Gutta-percha, poroplastic, and other forms of felt splint (Hyde's 
 &c.), carefully moulded to the part, are all useful ; all moulded and 
 accurately fitting splints have now to a large extent replaced wooden 
 ones. Wooden splints in their angular form are highly useful, how- 
 ever, in some pt the less severe separations at the elbow joint. 
 
 Epiphysial processes which are small can with difficulty be com- 
 pletely restored to their proper position or maintained there when 
 once detached. 
 
 Owing to the smallness of the epiphysial end of a long bone 
 there is often very little to assist in retaining the separated surfaces 
 in position. Ordinary wooden or other straight splints so often 
 adopted in the case of adults render the treatment of these cases 
 both difficult and unsatisfactory. 
 
 "With respect to the ease with which the separated fragments in 
 other instances are retained in position, epiphysial separations more 
 resemble dislocations than fractures. 
 
126 TEAUMATIC SEPAKATION OF THE EPIPHYSES 
 
 Although it is easier to effect complete reduction of the diaphysis, 
 it is as a rule much more difficult to be quite sure of its accom- 
 plishment than in the case of a dislocation. This is in great measure 
 due to the fact of pure separations being quite exceptional, but in 
 the larger proportion of cases complicated by a larger or smaller 
 fracture of the diaphysis, which remains attached to the epiphysis. 
 However, it is most important to obtain as accurate a co-aptation of 
 the fragments as possible ; in proportion as the reduction is per- 
 fect, the sooner will the fragments unite, and consequently passive 
 motion become the sooner possible. 
 
 After the application of the apparatus, the condition of the 
 circulation in the limb (especially the upper extremity) should be 
 carefully watched for the first twenty-four hours. 
 
 All these injuries, but more especially those in the neighbour- 
 hood of the joints, ought to be carefully examined from day to day. 
 The surgeon cannot be too careful in the treatment of all cases of 
 separation, even the most simple ones. The retention apparatus 
 may be removed after some days to see if the displacement has not 
 recurred. 
 
 Happily these injuries unite more rapidly in children than 
 similar injuries in the adult, for children are restless, and require 
 greater and more constant supervision by the surgeon. 
 
 When the separation is intra-articiilar it is prudent to fix the 
 limb for a shorter time, viz. for seven or eight days, provided the 
 adaptation of the fragments has been well maintained. Careful 
 massage and slight passive movements, such as are now often 
 carried out in the intra-articular fractures in adults, may then be 
 commenced if they do not give rise to great pain. 
 
 Massage and early passive motion are to be most carefully 
 practised ; in some cases it may be necessary, after the first applica- 
 tion of these, to re-apply the sphnt for a further period of eight days. 
 In the more simple cases passive motion may be carried out daily 
 and the splint re-applied. 
 
 Muscular wasting may thus be diminished, the absorption of 
 inflammatory effusion, both inside and outside the joint, assisted, 
 and the consequent usefulness of the limb greatly enhanced. 
 
 Prolonged fixation, though it may not cause ankylosis, produces 
 atrophy of the muscles from disuse, the small blood vessels of the 
 part are reduced in size and number, the bones themselves become 
 softer and more spongy, and the normal development of the limb 
 is much retarded. 
 
 Ankylosis of a joint after intra-articular fracture is the result of 
 the injury or of the character and duration of the inflammation, 
 but not of temporary fixation. 
 
 The greatest care should be exercised in guarding against 
 inflammatory complications. 
 
 As to whether the flexed or extended position should be adopted 
 
TKEATMENT 127 
 
 in injuries extending into the elbow-joint, the reader may be 
 referred to the chapters on the various injuries in this situation. 
 It will depend upon whether the displaced fragments may be 
 more accurately and completely replaced or retained in their 
 normal position by one method or the other. Each lesion must 
 be judged according to its suitability for treatment in either 
 position. 
 
 As a general rule the joint should not be confined longer than 
 two to three weeks. 
 
 Numerous papers have of late been published on the immediate 
 massage treatment of fractures of the epiphysial ends of the bones 
 by the French surgeons Jeannel, Terrier, Reclus, Kirmisson, and 
 others since the discussion at the Societe de Chirurgie introduced 
 by Lucas Championniere. 
 
 It has been held that these injuries are to be regarded as 
 advanced degrees of sprains, and should be treated in the same way 
 by massage without the use of any apparatus. Ankylosis, stiffness 
 of joints and tendons, loss of function, and atrophy of the segment 
 of the limb below the fracture are quoted as evidence of the evil 
 effects of putting up the limb in immovable apparatus. 
 
 It need scarcely be pointed out how harmful such treatment must 
 be in children from the possibility of further stripping up and bruising 
 the periosteum, and of producing the periostitis or suppuration to 
 which these injuries are so prone. The reader may be referred to 
 a paper by MM. Bauby and Bardier on ' Considerations sur le 
 traitement des fractures epiphysaires,' Le Midi Medical, Toulouse, 
 October 8, 1893, p. 473, where this treatment was carried out in 
 some epiphysial fractures of the lower end of the radius in children 
 without any harm having apparently resulted. 
 
 For a complete exposition of this subject reference may be 
 made to Lucas Championniere's recent work, Traitement des 
 fractures par le massage et la mobilisation, Paris 1895. 
 
 Leblois {Des fractures chez les eiifants et leur traitement, Paris 
 1894, p. 49) advocates massage and early movement for epiphysial 
 separation on account of the abundant callus produced in these 
 lesions. This method, he thinks, gives superior results as regards 
 both the duration of the treatment and the restoration of the 
 function of the limb. 
 
 Passive movement should, as a rule, be commenced on the tenth 
 day, and carried out gently each day, the range of movement being 
 gradually increased. 
 
 If swelling and heat, or distension of the joint, or other signs of 
 inflammatory action, have supervened before the patient has been 
 seen, evaporating lotions or an ice-bag may be applied over the 
 affected part, and the limb placed as far as possible in its normal 
 position until the swelling has subsided. Eeduction should then 
 be effected at the first opportunity. 
 
128 TEAUMATIC SEPAEATIOX OF THE EPIPHYSES 
 
 A careful and moderate use of massage has been recommended 
 under these cu'cumstances to hasten the process of absorption. 
 
 If suppuration takes place it must be treated in accordance with 
 the general principles of surgery. 
 
 Incisions should be made at once into boggy parts. It is not 
 necessary to wait for fluctuation. 
 
 Compound separations are frequently the most serious of epiphysial 
 injuries. In the past they have involved, if not the death of the 
 patient, often primary amputation. Primary amputation is now very 
 rarely necessary. Fortunately, in compound separation of some 
 epiphyses, e.g. the lower end of the humerus, the injury is not so 
 severe as to require it.- Antiseptic surgery permits us to save many 
 Hmbs which would formerly have been sacrificed. In the milder 
 cases, where the injury is caused by indirect violence without pro- 
 trusion of the diaphysis, the w^ound may be disinfected, closed, and 
 treated like a simple separation, especial care being directed to the 
 subsequent course of the case and the temperature of the patient. 
 
 When the diaphysis is protruded and cannot be effectually re- 
 duced, or when its end has become soiled wdth dirt or exposed to 
 the air for a long time, although it appears to be perfectly clean, it 
 is necessary to carefully disinfect the wound, and remove all traces 
 of the soiled or apparently soiled soft tissues with scissors. It is 
 imperative to remove the protruding end of the diaphysis with a saw — 
 a most simple procedure — and to replace the bone in position; other 
 damaged or soiled portions of the surface of the bone in its longi- 
 tudinal length may be easily cut away by means of a stout knife. 
 Its reduction must be effected after disinfection of the wound, even 
 though it has been extensively stripped of its periosteum ; but it is 
 often more prudent to remove a portion of the diaphysial end, for 
 by this means subsequent necrosis and suppuration may be avoided. 
 
 A drainage is usually required, but the drain or tube should be 
 away from the periosteal sheath, and more especially away from 
 the opening through which the shaft has protruded (Olher). 
 
 The fraoments are easily maintained in position after reduction. 
 
 Union in the more simple cases rapidly takes place between the 
 epiphysis and the sawn end of the diaphysis, and a good result 
 ensues. 
 
 Besection of the diaphysial end has been performed by Esmarch 
 in the case of separation of the upper epiphysis of the humerus 
 {Arcli.f. Uin. Chirurgie, 1863. iv. S. 585) ; by Kichet and by Pean 
 at the lower end of the radius ; by Gay and many other surgeons 
 at the lower end of the femur ; and by Erichsen, Spillman, and others 
 at the lower end of the humerus. 
 
 Comminution of the diaphysis is far less common than in com- 
 pound fractures in adults ; the fragments should not be removed 
 unless they are interfering with the reduction of the displaced 
 epiphysis. 
 
TEEATMENT 129 
 
 The fragments, after being accurately brought into apposition, 
 may be held immovably together by wire or by metal or ivory nails. 
 
 The chief success in these cases lies in rendering the v^ound 
 aseptic — often a very difficult matter, requiring the greatest care 
 and patience on the part of the surgeon in the removal of all septic 
 and contaminating material. Every such undertaking should be 
 looked upon in the light of an important, skilful, and deliberate 
 surgical operation in all its details. 
 
 Pressure upon the nerves or main vessels, fracture of the 
 epiphysis into the joint, and even comminution of the fragments in 
 compound cases, are insufficient grounds for amputation in these 
 days of careful antiseptic measures. 
 
 So much may be effected even in apparently hopeless cases where 
 the tissues are soiled with dirt, that primary amputation for 
 compound separation is only necessary in complete rupture of main 
 vessels or nerves of the limb or other extensive laceration and 
 destruction of the soft parts. 
 
 Oilier lost a case of juxta-epiphysial fracture of the lower end of 
 the humerus in a child from severe haemorrhage twenty-eight days 
 after resection of the end of the bone. Whether the brachial artery 
 had been wounded subsequent to the operation by a projecting 
 splinter of bone during the movements of the patient, or by some- 
 thing that had occurred previously, was not ascertained, as no 
 autopsy could be made. 
 
 The protruding portion of the diaphysis, denuded of its cartilage, 
 may be easily removed with a strong knife when the separation has 
 only involved the ossifying layer of the epiphysial cartilage. 
 
 It is a fortunate circumstance, from the resection point of view, 
 that the cartilage almost always remains with the epiphysis, so that 
 the grow^th of bone will not be arrested in this operation. 
 
 Moreover, the articulation so often escapes by reason of the 
 blending of the conjugal cartilage and epiphysis with the periosteum 
 that but little danger is to be feared from articular complication. 
 
 More often the injury is a complicated one, the separation of the 
 epiphysis being only partial, and accompanied by a fracture of the 
 diaphysis of a greater or less extent. This diaphysial fragment 
 attached to the epiphysis will require to be re-united to the rest of 
 the shaft by pegs or other means. 
 
 Ligature of veins for infective thrombosis. — The timely ligature 
 of one of the main venous trunks for thrombosis, due to injury or 
 pressure upon them by displaced epiphysis or diaphysis, may arrest 
 an incipient pyaemia and save a patient's life. This is particularly 
 true in the case of compound separations. 
 
 Primary operations for irreducibility. — In many cases of epiphysial 
 fractures, where the fragments are so locked together that they can- 
 not be restored to their proper position, or where a fracture or com- 
 minution of the epipliysis extending into the neighbouring joint is 
 
 K 
 
130 TEAUMATIC SBPAEATION OF THE EPIPHYSES 
 
 likely to interfere permanently with its normal function, or where the 
 separation is accompanied by a dislocation impossible of reduction 
 and by pressure upon important surrounding structures, it is certain 
 that immediate incision under strict antiseptic precautions and re- 
 placement of the fragments is called for. This would be imperatively 
 demanded if Oilier and other authors were correct in their belief that 
 arrest of growth in the limb is usually the result of want of proper 
 co-aptation of the separated surfaces. 
 
 Mr. Watson Cheyne has recorded {British Medical Journal, 
 March 7, 1891, p. 516) several cases in adults and children where 
 he had successfully and with great benefit to the patients operated 
 for recent fracture extending into the joints. 
 
 Irreducibility may also, as has been seen in several instances, be 
 due to the presence of a portion of muscle, or fibrous or ligamentous 
 tissue, between the fragments. Again, it may be brought about 
 through the penetration, in a button-hole manner, of a muscle by 
 the diaphysial end. 
 
 Before the present days of aseptic and antiseptic surgery the 
 surgeon was content with putting up these fractures in children 
 in as good a position as possible. We have now to consider the 
 advisability of immediate operation in irreducible separations, 
 especially those involving an articulation. It must, however, only be 
 undertaken after due consultation with the child's friends. The 
 operation should be performed by a skilled surgeon, by one who 
 has a thorough and practical knowledge of aseptic and antiseptic 
 methods as well as of operative measures in general. The ' technique ' 
 should be carefully carried out in the smallest details. Otherwise 
 the patient and surgeon may find themselves stranded in grave 
 disaster. 
 
 Replacement of diaphysis by operation. — In 1884 the author re- 
 commended operation in recent cases of epiphysial separation when, 
 owing to the locking of the fragments or from other causes, the 
 deformity could not be reduced, or when it has been found impossible 
 to keep the fragments in position by the use of splints or other 
 dressings — any of which are potent causes of permanent loss of 
 function of the joint. An incision should be made down to the 
 separated epiphysis under strict antiseptic precautions, the diaphysis 
 loosened, replaced, and its end wired to the epiphysis if necessary. 
 
 Soon afterwards the author found that Bruns recommended pre- 
 cisely the same operation under similar conditions. 
 
 In some it will be found necessary to resect a portion of the 
 diaphysial end. 
 
 Wiring the fragments together has been successfully performed 
 at the upper epiphysis of the humerus and at the lower epiphysis 
 of the femur, great difiiculty being experienced in maintaining the 
 fragments in their proper position. 
 
 Secondaryamputation has been considered necessary for threatening 
 
TEEATMENT 131 
 
 gangrene from pressure of one or other fragment upon the vessels, 
 for suppurative periostitis, and for necrosis. 
 
 Refracturing in recent cases for deformity. — A grave question is 
 that of refracturing and resetting the bone when union is found 
 to have taken place v^ith some amount of deformity, and when all 
 swelling has subsided, displaying the actual condition of the 
 fragments. The operation should only be undertaken where the 
 deformity is very great. The lower end of the radius, more especially, 
 may require this treatment. 
 
 From such procedure, periostitis, acute suppuration, or severe 
 local inflammation, may result, and at a later period arrest of growth 
 of the bone from disturbance of the epiphysial cartilage. 
 
 These badly united separations must therefore be treated in this 
 manner only in the early condition, viz., two or three weeks after 
 the injury — an ansesthetic always being administered. 
 
 Loss of function and utility of the limb. — Loss of function of the 
 limb irovd stiffness of the joint or muscular atrophy, the result of pro- 
 longed fixation, usually disappears if careful and systematic move- 
 ment is daily carried out. 
 
 Massage and electricity will also render considerable service in 
 causing the absorption of inflammatory exudation and adhesions, 
 besides improving the quality of the muscles and hastening con- 
 valescence. Massage of the limb should be made, day by day, very 
 gently at first, and afterwards more vigorously, but pain must never 
 be caused. 
 
 Active movements of the limb should also be encouraged, and 
 the child taught to make as much use of it as possible, or special 
 exercises, such as carrying a weight for the purpose of extension in 
 injuries of the elbow, will prove of great assistance. 
 
 Massage has of late years been advocated by many surgeons, both 
 here and in Germany, to hasten the process of repair after fracture, 
 and to diminish the risk of permanent stiffness in separation of the 
 epiphyses in the vicinity of the joints. 
 
 Landerer's method of treatment of cases in which there is no 
 comminution, or in which there is no great tendency to displace- 
 ment of the fragments, is to replace the fragments in position, and 
 ' to fix them in a firm dressing, such as plaster of Paris, until the 
 disappearance of the swelling due to the injury. When the soft 
 provisional callus is fully formed (which takes place in from eight 
 to fourteen days in the case of the adult, and earlier in children), 
 it and the surrounding muscles are to be massaged twice a 
 day — at first gently, but later more energetically, and the mobility 
 of the neighbouring joints is to be kept up by active and passive 
 movements.' 
 
 Massage in the after-treatment assists very much in the absorption 
 of the effused blood and infiltrated material around the injured bone, 
 nerves, and other structures : for much of the muscular atrophy met 
 
 K 2 
 
132 TEAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 With is due to the reflex irritation of this effused tissue upon the 
 peripheral nerves, and may therefore be kept up by the too long 
 fixation of the injured part. 
 
 The loss of function of the limb may be the result of irregular 
 union, of displacements which have not been properly adjusted, or 
 of the excessive formation of callus at the epiphysial line close to 
 the articulation. Each and all of these may considerably hamper 
 the movements of the joint and obstruct the muscles in their action, 
 even after the completion of the modelling process. 
 
 The crippled condition of the limb and joint may under these 
 circumstances demand resection of the joint. 
 
 The dangers of operative measures on the bones in these days of 
 antiseptic surgery are slight compared with the great advantages 
 which accrue from them. 
 
 Resection and replacement of diaphysial end, and removal of any 
 irregular osseous projections, in old separations accompanied with 
 great deformity, in which the natural function of the limb is greatly 
 impaired, have been advocated and carried out by Bruns and others. 
 This operation should be attempted in all cases in which the anatomy 
 of the part permits such interference, but the precise details must 
 vary with each case. 
 
 Sometimes the displaced diaphysis appears to be ready to pene- 
 trate the skin, as at the upper end of the humerus, yet the natural 
 moulding process is often sufficient to ultimately remove even 
 considerable deformity. 
 
 In two cases of old separation of the upper end of the humerus, 
 Bruns successfully cut down on the epiphysis and detached the two 
 fragments by means of a small saw, resected a portion of the dia- 
 physial end, and replaced the fragments in their natural position. 
 
 Mr. Johnson- Smith, in the same injury, pegged and wired the 
 fragments together after re-section of the diaphysial ends. 
 
 M. Poncet in two cases of the same lesion removed a portion of 
 the projecting diaphysial end which had separated the fibres of the 
 deltoid, and obtained good results. 
 
 Projecting portions of bone which are left after the moulding 
 down of the parts, and tend to cripple the limb, should be chiselled 
 away. The author has done this on many occasions, with the result 
 of considerable-restoration of function and symmetry of the limb. 
 
 Vicious union in the later stages, if very extreme, may require 
 osteotomy. 
 
 Neglected cases, or cases that have fallen into the hands of bone- 
 setters, when seen after the lapse of some little time, are very difficult 
 of treatment if the fragments are still unreduced. Excessive callus, 
 articular ankylosis, &c., are often advanced when seen by the surgeon, 
 and require resection of the joint. 
 
 Operations for deformity due to arrest of growth. — The deformities 
 of the leg or forearm arising from arrest of growth of one of the 
 
TEEATMENT 133 
 
 bones and progressive increase in the other, from injury and other 
 causes, have been specially dealt with by Oilier {Traite des resections, 
 torn. ii. 1888, p. 440). 
 
 When the deformity due to the lesion of one of the parallel 
 bones is commencing (radius and ulna in forearm, tibia and fibula in 
 the leg) it must be treated immediately by some form of a2:)paratus 
 M^hich will correct the deviation or by incising the conjugal cartilage 
 of the sound bone (chondrotomie). 
 
 If the deformity is of longer standing, the growth of the bone 
 which is relatively too long may be checked by the operation intro- 
 duced by Oilier of removal of one or both of the conjugal cartilages 
 (chondrectomie) (Oilier, Traite des resections, tom. i. 1885, p. 110) ; 
 the other bone then continuing to grow, however slightly, will correct 
 the deformity, although the limb may be shortened. Up to the 
 present, surgeons have been content to resect a portion of the 
 bone. 
 
 After Ollier's operation the sound bone will cease to grow, 
 although the limb will be permanently shortened — but straightened 
 — that is, if the shortened bone regain the length it has lost. Much 
 will depend upon this growth of the shortened bone, if its end 
 still retains enough elements for growth — i.e. if the cartilage is not 
 entirely destroyed, which, unfortunately, is usually the case. 
 
 In the choice of either of these operations, a careful consideration 
 of the patient's age, the amount of the deformity, and the relative 
 importance as regards the growth of the particular cartilage have 
 to be taken into consideration. 
 
 On the other hand, indirect irritation of the cartilage by intro- 
 duction of a foreign body into the medullary cavity and by lacerating 
 the periosteum, at a distance, under antiseptic precautions may 
 increase the growth and length of a long bone during its period of 
 growth. The irritation set up need not be intense, but it must be 
 long continued. 
 
 In the fully developed, adolescent youth or adult, sub-periostcal 
 resection of the end of the sound bone may suflice to correct the 
 deformity. 
 
 M. Oilier (Traite des resections, tom. ii. 1888, p. 445, fig. ; Oilier, 
 Bevue Mensuelle cle Medecine etde Chirurgie, Mars 1877 ; 'De I'excision 
 des cartilages de conjugaison pour arreter I'accroissement des os et 
 remedier a certaines difformites du squelette'), by removing a slice of 
 the conjugal cartilage of the ulna in a youth whose hand was dis- 
 torted after suppurative ostitis of the lower end of the radius, 
 succeeded in checking the deformity, so that arrest of growth of the 
 ulna took place, and the radius was able in five years to increase up 
 to its proper relationship with the ulna. The growth of the two 
 parallel bones developed afterwards at a regular and equal rate. 
 
 The lower epiphysis of the ulna is subcutaneous and easily 
 reached ; as regards the radius Oilier says that it should be reached 
 
134 TKAUMATIC SEPAEATION OF THE EPIPHYSES 
 
 from the dorsal aspect, between the extensor tendons, and that the 
 operation is a very simple one. 
 
 A small knife is introduced parallel to the cartilage which is incised, 
 and a second cut made somewhat obliquely to the first, and another 
 portion of cartilage removed. This is repeated several times until 
 enough — either a third or a fourth of the whole — has been removed 
 to ensure the amount of arrest of growth required to be produced. 
 Oilier recommended, however, several partial operations repeated at 
 intervals of some months, since such great difficulty is experienced 
 in ascertaining exactly the amount of cartilaginous-growing elements 
 left in the sound limb, and therefore the requisite amount to be 
 removed from it. The effects of the first operation should, therefore, 
 be carefully watched. 
 
 a. 
 
 ~A 
 
 Fig. 14. — deviation or the hand, the ee- 
 
 SULT OF AKEEST OE GEOWTH FOLLOWING 
 JUXTA-EPIPHYSIAL - OSTITIS OF THE LOWEH 
 END OF THE EADIUS. THE ULNA CONTINIjED 
 TO GEOAV AND BECAME DISPLACED DOWNWAEDS 
 AND BACKWAEDS, WHILE THE HAND WAS BENT 
 TOWAEDS THE EADIAL BOEDER OF THE FOEE- 
 ABM 
 
 A, olecranon ; a', styloid process of the ulna pr 
 which necrosed bone was removed ; c, radio 
 transverse afterwards. 
 
 ,^ 
 
 Fig. 15. — appeaeance of the hand after 
 excision of the conjugal cartilage of 
 the ulna. the growth of this bone 
 has ceased, while that of the eadius 
 continued to a slight extent, placing 
 
 BOTH BONES ON A LEVEL. (aFTEK 
 
 olliee) 
 
 ejecting backwards ; o, o', sinuses through 
 -carpal fold, very oblique before operation, 
 
 Oilier has also proposed the irritation of the injured bone by 
 means of nails, cauterisation, &c., applied to the diaphysis, to cause 
 increase in the growth of the epiphysial disc. 
 
 Helferich and Max Schiiller have also carried out similar attempts 
 with success. 
 
 Some surgeons think it more advisable in such cases to await 
 the full development of the bones before performing resection of the 
 sound diaphysis. 
 
135 
 
 PAET II 
 
 SEPABATION OF THE EPIPHYSES OF THE 
 UPPEB E XT BE MIT Y 
 
 CHAPTEE I 
 SEPARATION OP THE EPIPHYSIS OF THE CLAVICLE 
 
 ANATOMY.— Although the clavicle begins to ossify at the fifth 
 week of intra-uterine life before any other of the long bones in the 
 body (immediately after ossification has commenced in the lower 
 jaw), yet the small epiphysis which is developed in the cartilage of 
 its sternal end does not begin to ossify until the eighteenth year. 
 But this may be a little sooner or later in different subjects. It is 
 remarkable that the clavicle — the first of the long bones to ossify in 
 its shaft — has its epiphysis commencing to do so the last of all. At 
 thirteen years of age the cartilaginous end is 15 mm. wide vertically 
 by 12 mm. antero-posteriorly ; at twenty years, 22 mm. vertically, 
 and 18 mm. antero-posteriorly. Up to this time the cartilaginous 
 end is extremely thin. A number of granules appear first in the 
 cartilaginous disc, which is only about 3 mm. thick at the eighteenth 
 year, 2 centimetres antero-posteriorly, and 2^ centimetres vertically, 
 and these soon coalesce to form a thin epiphysial plate. This lamellar 
 epiphysis does not occupy quite the whole of the sternal end of the 
 bone, but is mostly confined to the surface articulating with the 
 sternum. About its centre it is slightly convex or raised to a point 
 externally, and is about 3 mm. in thickness. 
 
 Fig. 16. — clavicle at the nineteenth yeae. thin epiphysial 
 
 PLATE AT sternal END 
 
 The epiphysial plate joins the diaphysis from the twenty-second 
 to the twenty-fifth year, the centre of the epiphysis being the first 
 part to weld on to the shaft. Even in the fully developed state at the 
 twenty-fifth year it does not seem much more than 4 mm. in thickness, 
 
136 EPIPHYSES OF UPPEE EXTEEMITY 
 
 It is not an uncommon thing to find this epiphysis the only one 
 still unmiited to the shaft while all the rest of the epiphyses in the 
 body have joined on. 
 
 The capsular ligament of the sterno-clavicular joint is attached 
 to this end of the clavicle ; and from the upper and back part of the 
 same, just beyond the epiphysial level, spring the inter-clavicular 
 ligament and the intra-articular fibro-cartilage. The whole of the 
 epiphysis is covered by the synovial membrane of the menisco- 
 clavicular portion of the sterno-clavicular joint. 
 
 The epiphysial cartilage is overlapped by the synovial membrane, 
 especially at the lower part. 
 
 The acromial end has no epiphysis. 
 
 ETIOLOGY. — There must be some particular mode of application 
 of the violence to account for fracture of the inner end of the clavicle 
 or separation of the epiphysis, which are both of such rare 
 occurrence. 
 
 The author has collected five cases and one doubtful one 
 (Lonsdale). 
 
 M. Polaillon, in his article {Diet. Encydop. des Sciences Medicales, 
 1875, Tome dix-septieme), has collected twenty-eight cases of fracture 
 of the inner end of the clavicle. To these M. Delens has added three 
 more (Arch. Gen. de Medecine, Mai 1873). Twelve of the total were 
 from muscular, and sixteen from traumatic causes, while in three 
 the cause was unknown. Delens has pointed out how completely 
 they differ from fractures of the shaft proper. 
 
 Indirect violence, such as a fall or blow upon the apex of the 
 shoulder, driving the bone inwards and forwards, will be found to be 
 the most common cause. Even a fall on the elbow, while it is 
 away from the side, might produce this injury in the same manner. 
 
 In Verchere's and Lonsdale's cases the violence was applied 
 indirectly. 
 
 Direct violence. — Although it is stated in Maunder's case of 
 compound separation that it was not evident in which direction the 
 force had been applied, and although it might easily be imagined 
 that the injury was caused by direct violence, through the cart wheel 
 passing over the inner end of the bone, yet it is more probable that the 
 force was applied more indirectly, and that the wound in front and 
 below the separated epiphysis (the usual situation of the end of the 
 shaft in fractures from indirect violence) was produced by the end 
 of the diaphysis, which afterwards slipped back into its normal 
 position. 
 
 Muscular action. — The end of the clavicle has twice (in Le Gros 
 Clark's and Heath's cases) been detached by muscular violence. 
 Mr. Heath believes that the entirely cartilaginous end, in his case, 
 at the age of fourteen, must have been torn from the thoroughly 
 ossified shaft by violent muscular action. He says : ' This does not 
 imply, as has been erroneously supposed, a rupture of the strong, 
 
SEPAEATION OF EPIPHYSIS OF CLAVICLE 137 
 
 costo-clavicular or rhomboid ligament, which acted as the fulcnim 
 upon which the bone rotated, the weight of the arm and shoulder 
 drawing the outer end of the clavicle backwards and throwing the 
 inner end forward beneath the skin.' 
 
 In Le Gros Clark's lad, who, performing on a trapeze, was 
 hanging by two feet and trying to raise himself so as to seize the 
 bar with his hands, the clavicle gave way during the effort. 
 
 The powerful clavicular fibres of the pectoralis major and 
 deltoid are most effective factors in producing separation and caus- 
 ing displacement of the inner end of the bone forwards and down- 
 wards, by drawing on this portion of the clavicle whilst the 
 humerus is fixed. This direction of displacement forwards is that 
 usually found in fracture of the inner end of clavicle, as in 
 separation. 
 
 AG-E. — There is only a short period of time during which a true 
 epiphysial separation of the clavicle can occur ; from the time, that 
 is, of commencement of ossification to the time of union with the 
 shaft — viz. from about the eighteenth to the twenty-second year 
 or a little later. Some give the twenty-fifth year as the limit of 
 the time of union, while Sappey says the epiphysis does not appear 
 till towards the twentieth year. 
 
 Of the three examples of separation of the ossifying or completely 
 osseous epiphysis, Verchere's specimen was obtained from a young 
 man aged twenty. 
 
 The clinical cases comprise Le Gros Clark's, aged eighteen 
 years ; and Mr. Eivington's, aged seventeen. 
 
 The examples of separation of the cartilaginous end are no more 
 numerous : Mr. Christopher Heath's, aged fourteen ; Mr, Maunder's, 
 aged eleven ; and Mr. Lonsdale's, aged three years. 
 
 The latter case of Lonsdale's was probably a fracture of the 
 inner end of the bone. 
 
 Separation or Fracture of the Cartilaginous Sternal End. 
 Before the existence of the epiphysis at the eighteenth year a true 
 fracture or detachment of the cartilaginous sternal end of the clavicle 
 may occur at any age. 
 
 Maunder's case of compound separation of the cartilaginous 
 inner end occurred in a lad aged eleven years. 
 
 PATHOLOGICAL ANATOMY.— Separation of the epiphysis of the 
 clavicle is one of the most rare of epiphysial detachments. 
 
 M. Delens, in the Archives cle Medecine in 1873, has collected 
 thirty-one cases of fracture of the inner end of the clavicle, without 
 recording one of epiphysial separation. 
 
 The following case described by M. Verchere {Le Progrcs 
 Medical, 2^^"^" Serie, vol. iv. No. 50, December 11, 1886, and 
 Bulletins de la Societe Anatomique, 1886, p. 484) is the only one in 
 which an autopsy has been made. The separation of this epiphysis 
 was accompanied by a wound of the pleural sac on the same side, 
 
138 EPIPHYSES OF UPPEE EXTEEMITY 
 
 and extensive empliysema — rare complications even in fractures of 
 the clavicle. 
 
 A young man (D., a mason), aged twenty, was brought on 
 June 22 to the Hopital de la Pitie, under the care of M. Yerneuil. 
 Whilst working in a refinery he was caught by his clothes in the 
 transnaission strap of some machinery and carried round three times, 
 being finally hurled against the neighbouring wall and on to the 
 ground. He was admitted in a collapsed and insensible condition, 
 with rapid breathing and violent dyspnoea, skin pale and cold, tem- 
 perature 35°'2 C. Subcutaneous emphysema was found occupying 
 the whole of the upper part of the thorax, the neck, and the lower 
 half of the face, completely effacing the natural depressions at the 
 lower part of the neck. Some crepitation was perceived as far as 
 the lower part of the thorax. There was no hemoptysis. It was 
 found to be impossible to determine the exact cause of the injury 
 on account of the extensive swelling from the emphysema. The 
 patient could not move the upper extremities, which did not present 
 any signs of fracture. 
 
 There was very extensive contusion and extravasation of blood 
 in both legs and feet, pulping of both calves, and the skin was 
 completely stripped from the right heel. Injections of ether and 
 morphine were administered. By the following day the breathing 
 had become more quiet, and the emphysema had not increased to 
 any notable extent ; but there was gxeat pain in both legs, and 
 threatening gangrene of skin of the right calf as far as the knee and 
 of the skin of left leg. The threatened gangrenous condition of both 
 legs having spread, sloughs of the skin coming away in large pieces, 
 and the whole of the right foot looking gangrenous, incisions and 
 punctures were made on June 28 with the thermo-cautery in both 
 feet and legs. On June 29 amputation was performed through the 
 right thigh, and was followed by death the same evening. 
 
 At the autopsy the day after death emphysema of the face, 
 neck, and chest was still present. No fracture of the ribs was to 
 be seen on either side, but there was an epiphj^sial detachment of 
 the inner end of the right clavicle. The periosteum was detached 
 from the whole inner third of the bone, whose smooth, rounded, and 
 regular end projected forwards ; in the centre of this extremity 
 two or three small cartilaginous particles still adhered to the bone. 
 The sterno-clavicular articulation was uninjured, a disc remaining 
 about five millimetres thick formed by the cartilage and the epiphysis 
 of the clavicle. This fragment was firmly held by the ligaments of 
 the articulation, and was crossed in front by the sternal head of the 
 sterno-mastoid muscle. In the damaged cellular tissue at this level 
 a cavity had been produced by the displaced end of the clavicle, and 
 in the post-clavicular region at the same level an extensive per- 
 foration of the pleural sac was found, about the size of a two-franc 
 piece. The pneumothorax which was present on this side com- 
 
SEPAKATION OF EPIPHYSIS OF CLAVICLE 139 
 
 municated freely with the subcutaneous emphysema. The right 
 lung was uninjured, but yet emphysematous ; the left, adherent 
 to a slight extent in front, was in a state of hepatisation. 
 Death ensued from septicsemia, following gangrene of the lower 
 extremities. The specimen of the separated epiphysis was placed 
 in the Dupuytren Museum. 
 
 Mr. C. F. Maunder describes {London Hospital Beports, vol. iv. 
 1867-8, p. 227) a case of compound separation of the epiphysis of 
 the clavicle in a lad aged eleven years who was knocked down by a 
 cart, but it was not evident in what direction the force was applied 
 which effected the injury. There was a loss of continuity near the 
 sternal end and a small wound in the integument just below, over 
 the first rib, but there was no displacement of the fragments. 
 
 The clavicle could be moved to and fro independently of its 
 epiphysis, and instead of the hard crepitus of fracture a soft grating 
 was felt. Unlike dislocation of the sternal end of the bone, 
 there was no tendency to displacement. Rest in bed with a figure- 
 of-eight bandage was the treatment adopted. The bone remained in 
 good position, but the wound healed slowly. Twelve months after- 
 wards the injured clavicle was found to be three-eighths of an inch 
 shorter than its fellow. 
 
 Notwithstanding the intimate relations of the inner end of the 
 clavicle with the subclavian artery and vein, there is no recorded 
 case of injury to either, or to the brachial plexus, as complications of 
 the separation of the epiphysis of this bone. 
 
 SYMPTOMS. — Displacement forwards of cliaphysis has occurred 
 in all the cases at present published. 
 
 Deformity. — Upon the anterior part of the sternum there is an 
 abrupt and striking projection on a level with the sterno-clavicular 
 joint, and it is found to be continuous with the diaphysis. This 
 closely simulates a dislocation forwards. 
 
 If the case has been seen before any great amount of swelling 
 has taken place, the flattened diaphysial end may be felt, quite 
 unlike the pointed end of a fracture, but more like the articular end 
 of the bone dislocated forwards. Separation of the epiphj^sis differs 
 from the latter in that the supra-sternal notch remains intact. 
 
 The clavicular head of the sterno-mastoid is carried forwards 
 and stands out prominently, so that the head of the patient may 
 be drawn to the affected side. 
 
 If the shoulder be drawn forwards, the end of the diaphysis falls 
 into its place, and the tumour then entirely disappears, or nearly so. 
 
 The thin osseous plate, of which this epiphysis consists, may be 
 discovered, if there is not much effusion of blood, towards one side 
 of the supra-sternal notch, or between it and the end of the displaced 
 diaphysis. The supra-sternal notch is intact. In Heath's case it 
 was ' quite distinct and equally defined on both sides.' 
 ^ In Verchere's patient the extensive swelling from emphysema 
 
140 EPIPHYSES OE UPPEE EXTEEMITY 
 
 due to injury of the pleura prohibited any diagnosis being made 
 before death. 
 
 Mr. Le Gros Clark mentions {St. Thomas's Hospital Beports, vol. 
 xvii. 1887, p. 1) the case already referred to of a gymnast, aged 
 eighteen years, who was performing on the trapeze, and whilst hang- 
 ing by his feet and trying to draw up his body between his legs, felt 
 something give way on the left side of his neck. This injury was at 
 first diagnosed as a dislocation of the sternal end of the clavicle, and 
 unavailing attempts were made to reduce the displacement. When 
 Mr. Le Gros Clark saw the patient the swelling had abated, and he 
 was satisfied that the sternal epiphysis was separated from the shaft 
 of the bone. The inner end of the shaft rested upon the sternal 
 epiphysis of the bone, the latter occupying its normal position in 
 relation to the sternum. The case was treated as one of ordinary 
 fracture of the clavicle. An interesting feature in this case is the 
 mode in which the accident occurred. There was no evidence of 
 violence having been directly applied to the injured part ; the accident 
 was produced by muscular action during the violent effort made by 
 the patient in performing his gymnastic feat. 
 
 Mr. Christopher Heath has put on record {Clinical Society's 
 Transactions, vol. xvi. 1883, p. 37, and Lancet, vol. ii. 1882, p. 851) 
 the following case of separation of the epiphysis of the clavicle by 
 muscular action. On May 9, 1882, he was asked to see a boy, aged 
 fourteen, who that morning, whilst forcibly raising his arm to bowl 
 ' over-hand ' at cricket, felt something give way at his collar-bone, 
 causing great pain. The inner end of the right clavicle was found to 
 be unduly prominent, and presented a sharp edge beneath the skin, 
 quite unlike the smooth end of a bone covered with articular 
 cartilage. The supra-sternal notch was quite distinct and equally 
 defined on both sides, and a thin lamella could be felt on the right 
 side intervening between it and the gap caused by the starting for- 
 wards of the inner end of the clavicle. On the patient being laid flat 
 on a mattress the bone at once slipped into place, and the deformity 
 and pain disappeared. The arm was subsequently secured to the 
 side with a plaster of Paris bandage and kept fixed for a month, after 
 which gentle movement was allowed. In October the boy was 
 reported to be quite well, there being only a little thickening left 
 over the seat of injury. 
 
 A case of Mr. Eivington's at the London Hospital is mentioned 
 by Mr. Hutchinson, jun., as having occurred at the age of seven- 
 teen. 
 
 Shortsmiig. — On very careful measurement some slight shorten- 
 ing of the diaphysis will be found from the diaphysial end to the 
 acromion process, as compared with the whole length of the clavicle 
 on the other side. There will be, as in dislocation, shortening on 
 the affected side, measuring from the acromion to the median line. 
 
 Crepitus of the usual muffled character may be felt during the 
 
SEPAEATION OF EPIPHYSIS OF CLAVICLE 141 
 
 reduction of the displaced diaphysis by raising the arm and drawing 
 it backwards with the diaphysis of the clavicle. ' Soft ' grating is 
 especially noted in Maunder's case. 
 
 Crepitus was felt in Lonsdale's case, and pointed rather to fracture 
 than epiphysial separation ; however, attempts should never be under- 
 taken to discover this sign on account of the serious damage that 
 may be done to the periosteum and soft structures. 
 
 Mobility has only been noted in one case — that of Mr. Maunder ; 
 some amount of movement between the epiphysis and diaphysis, 
 if the former can be distinguished, must, however, be present. 
 
 Lonsdale mentions (Lonsdale, Practical Treatise on Fractures, 
 1838, p. 206) a case, in a child (J. C.) three years old, which came 
 under his observation at the Middlesex Hospital in 1835, and which 
 he believed to be a separation of the epiphysis, the point of frac- 
 ture being half an inch from the sternum. Crepitus could be felt, 
 and the end of the bone moved from its natural position. The 
 injury was caused by the child falling while at play and striking his 
 shoulder against the edge of some steps. The other clavicle had 
 been broken about a fortnight previously. 
 
 It is difficult to believe that this was really any other injury than 
 a fracture of the inner end of the clavicle, for it is improbable that 
 the cartilaginous end of the bone could be as thick as half an inch 
 even at this early age. 
 
 Le Gros Clark has also recorded a similar case in a young child. 
 
 Swelling, from extravasated blood over the separated diaphysis, 
 may obscure the outline of the fragments. 
 
 Mr. Edmund Owen {The Surgical Diseases of Children, third 
 edition, 1897, p. 382) has met with separation of the sternal epiphysis 
 of the clavicle on one occasion, but has given no details of the case. 
 
 Epiphysial sepaeation without displacement occurred in 
 Maunder's patient. The injury was a compound one, 
 
 DIAGNOSIS. Dislocation fonoar els of inner end of clavicle. — Dis- 
 location of the clavicle is rarely caused by muscular action, but more 
 usuall}^ is produced by great violence applied to the shoulder. More- 
 over, great difficulty is experienced in keeping the bone in position 
 after it has been reduced. On the hold being relaxed, the bone nearly 
 always slips out again from its proper position, and in some cases 
 reduction has been found to be extremely difficult, and in many 
 a certain degree of deformity is sure to exist afterwards. The bones 
 of the sides are almost of equal length, although in dislocation the 
 thin intra-articular fibro-cartilage remains with the sternum. In 
 epiphysial separation, on the other hand, at least in the recorded 
 cases, the bone has been replaced in position with great ease, and 
 no difficulty was in most cases experienced in maintaining the bones 
 in their natural position. 
 
 The age of the patient is a most important point in the diagnosis 
 of these two lesions, at any rate as regards the true osseous epiphysis 
 
142 EPIPHYSES OF UPPEE EXTEEMITY 
 
 — viz. from the seventeenth to the twentj'-fifth years, vv'hich are the 
 extreme hmits of commencement of ossification and final union given- 
 by anatomists. 
 
 Fracture on the inner side of the costo-claviciilar or rhomboid 
 ligament. 
 
 The age of the patient helps but little in distinguishing between 
 fracture and ex^iphysial separation, inasmuch as fracture of the inner 
 end of the clavicle generally occurs in early life. 
 
 Position of the fracture is a somewhat better guide ; for fracture 
 takes place, as a rule, from three-quarters to one inch from the sternal 
 articulation. 
 
 RESULTS, PROGNOSIS, &c.— Xon-union in fractured clavicle is a 
 very rare event, and is still more unlikely to occur as the result 
 of epiphysial separation, which unites with great rapidity. 
 
 Shortening and deformity from malposition and displacement of 
 the fragments will be very rare, if we regard the ease with which the 
 diaphysis is replaced and maintained in position. 
 
 Shortening from arrest of growth is a possible though unlikely 
 occurrence after separation of the osseous epiphysis. But it may 
 occasionally occur as the result of fracture of the inner end of the 
 bone or of the cartilaginous extremity. 
 
 Mr. Maunder draws a very gloomy picture of the possible con- 
 sequence of arrest of growth of the clavicle after epiphysial injury. 
 He says : ' The clavicle is the only osseous means by which the 
 trunk and upper extremities are connected ; it suspends the arm, as 
 it were, holds it off (after the fashion of the milkman's joke) that it 
 may have full play and not press down upon the ribs and interfere 
 with respiration, but if it cease to grow while the rest of the body 
 is still undeveloped, its good offices towards the corresponding 
 extremity and half of the chest fail, and with this failure I should 
 fear an enfeebled extremity, a curved spine, diminished chest 
 capacity, partially developed lung, ill aerated blood, feeble circula- 
 tion, and an ill nomished body generally — a state of things likely 
 to engender serious disease hereafter.' 
 
 The recorded instances of non-union after fracture of the clavicle 
 do not bear out Maunder's opinion ; in some, indeed, little or no 
 disturbance of function or inconvenience has been experienced. 
 
 TREATMENT. — In mild cases wifJiout displacement, should such 
 an injury be supposed to have occurred, it will be sufficient to sup- 
 port the elbow in a sling and fix the arm to the side by means of 
 strapping to prevent any subsequent displacement of the diaphysis. 
 
 Rsdnction of the diaphysis when displaced is easily effected by 
 the surgeon standing behind the patient and drawing both shoulders 
 backwards ; in some cases it may be necessary to place the knee 
 between the scapulae before the reduction can be effected. 
 
 Pressure by means of the fingers or' thumb upon the diaphysial 
 end will assist in replacing the bone in position. 
 
SEPAEATION OF EPIPHYSIS OF CLAVICLE 143 
 
 In Mr. Heath's case, as already stated, reduction took place on 
 simply placing the patient on his back, the .bone immediately 
 slipping into position. 
 
 From the records of published cases it is evident that placing the 
 patients upon their backs with the arm in a sling or fixed to the 
 side by a plaster of Paris bandage over a jersey is quite enough to 
 retain the bone in position. 
 
 If the patient is obliged to move about, the arm should be placed 
 in a sling with a bandage round the elbow and body to keep the arm 
 at rest, or the triangular bandage, applied in Mayor's fashion, may be 
 employed. No pad in the axilla is requisite. 
 
 Union ensues very rapidly, but the upper extremity should be 
 kept at rest for at least two weeks. At the end of this time passive 
 motion may be commenced. 
 
 Should it be found impossible to keep the diaphysis in position, 
 or should there be evidence of pressure upon the subclavian artery 
 or vein, or upon the brachial plexus of nerves, the surgeon may feel 
 justified in cutting down on the fragments and fixing them in 
 position. 
 
 Compound Sepaeation. — In compound cases like Maunder's, 
 unaccompanied by any displacement of the fragments, it will be 
 necessary to thoroughly cleanse the wound, and if the periosteum 
 be torn (which is unlikely without displacement of the diaphysis), it 
 should be united with carbolised silk, and the wound dressed with 
 the strictest antiseptic precautions on account of the important 
 blood vessels and other structures in close proximity to it. 
 
 Reduction of the displaced diaphysis and suturing of the ends 
 with wire or stout Chinese silk, and uniting the lacerated periosteum, 
 should be undertaken under the most careful antiseptic measures in 
 all instances of compound separation with displacement. 
 
144 
 
 EPIPHYSES OF UPPEE EXTREMITY 
 
 CHAPTER II 
 
 SEPARATION OP THE EPIPHYSES OF THE SCAPULA 
 
 Sepaeatiox of the Qlenoib axd Coracoid Cartilage — Separation of the 
 Epiphysis of the Base of the Scapula, Supra-scapula — Separation of 
 THE Epiphysis of the Coracoid Process — Separation of the Epiphysis 
 OF the Acromion Process 
 
 CAHriLAGINOUS PARTS OF SCAPITLA AT BIRTH 
 
 ANATOMY. — At birth the scapula is formed of a principal 
 osseous piece — comprising a body and spine — and a cartilaginous 
 mass — consisting of the coracoid and glenoid processes and two 
 secondary cartilaginous processes (which do not ossify until late in 
 puberty), the acromion and the supra-scapula (including the base and 
 inferior angle) . The edges of the spine are also cartilaginous. 
 
 Although the coracoid process com- 
 mences to ossify during the first year 
 (sometimes at the ninth month of intra- 
 uterine life), for the first few years of 
 life it remains connected with the 
 glenoid cartilaginous process, until the 
 extension of the coracoid ossification 
 has advanced, which it does fairly 
 rapidly ; and almost up to the time of 
 the ossification of the intermediary (sub- 
 coracoid) cartilage placed between the 
 base of the coracoid and the upper part 
 of the glenoid, it is possible for the 
 coraco-glenoid mass to be detached by 
 severe violence. In fig. 17 is represented 
 an instance which (through the kind- 
 ness of Dr. Fullerton) came under the 
 author's observation in 1892 at the 
 Miller Hospital. 
 
 The symptoms in the following 
 case, also at the Miller Hospital (Ai^ril 
 1896), suggested to the author the possibility of partial separation of 
 the cartilaginous glenoid from the body of the scapula without dis- 
 placement. F. P., aged 1^ years, had been violently Hfted by the 
 
 Fig. 17. — separation of the carti- 
 
 LAaiNOUS OUTER PAET OF THE 
 SCAPULA, COirPKISrS'G THE GLENOID 
 CAVITY AND CORACOID PROCESS, 
 FROM A CHILD TWO TEARS jiND NINE 
 MONTHS WHO HAD BEEN RUN OVER 
 BY A WAGGON. 
 
 There was also a greenstick frac- 
 ture of the clavicle, and many 
 other fractures of the body. 
 
SEPARATION OF EPIPHYSES OF SCAPULA 145 
 
 armpits by his sister, and had since been unable to use the left 
 arm, keeping it close to his side. There was no swelling or 
 external contusion, and the head of the humerus rotated freely, 
 smoothly, and without pain. By steadying the clavicle, coracoid, 
 and shoulder in front with the left hand, and pressing with the 
 right over the spine and body of the scapula downwards and 
 forwards, slight movement could be felt accompanied by soft 
 crepitus ; with the left hand in the axilla and by forcibly rotating 
 the humerus forwards, the same crepitus could be felt behind over 
 the scapula. 
 
 EPIPHYSIS OF THE BASE OF THE SCAPULA— 
 SUPRA-SCAPULAR EPIPHYSIS 
 
 ANATOMY. — The cartilaginous base of the scapula or epiphysis 
 corresponding to the supra-scapular bone in many animals ossifies 
 at the inferior angle at the sixteenth year, and also higher upwards 
 as a line of osseous material along the posterior border of the bone 
 at the seventeenth to eighteenth year. 
 
 An osseous frame or border along the inferior angle and 
 posterior or spinal border is thus formed. 
 
 This epiphysis unites about the twenty-fifth year, and is the last 
 one to join on to the body of the bone. 
 
 Although it is much exposed to such injuries as might detach it 
 from the body of the scapula, and also to the action of powerful 
 muscles, the author is not aware of anycase of traumatic separation 
 to which he can refer. 
 
 SEPARATION OF THE EPIPHYSIS OP THE ACROMION 
 
 PROCESS 
 
 ANATOMY. — Two nuclei, one at the base, the other at the apex, and 
 sometimes three, appear betAveen the fourteenth and sixteenth years, 
 often a little later. Frequently one appears at the fifteenth and 
 the other at the sixteenth year. Humphry and others give only one 
 nucleus for the apex of the acromion, but state that it varies in the 
 size to which it attains, in some cases constituting the chief part of 
 this process. These nuclei soon coalesce, and form one epiphysis 
 about the nineteenth year. 
 
 The epiphysis is united to the outgrowing spine from the 
 twenty-second to twenty-fifth year. 
 
 The extension from the spine varies very much in different 
 subjects. 
 
 This epiphysis generally includes the oval articular facet for the 
 clavicle, and has attached to its apical piece the acromio-clavicular 
 and coraco-acromial ligaments. The junction of the epiphysis with 
 the rest of the acromion is therefore immediately behind the 
 
 L 
 
146 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 acromio-clavicular joint. In many instances it includes mncli more 
 of this process, extending sometimes as far as the outer hmit of 
 
 the spine of the scapula, i.e. the whole of 
 the acromion, surgically speaking. 
 
 One or other of these centres is said 
 to remain ununited with the spine of the 
 scapula throughout life, the junction with 
 the spine being represented by fibrous 
 tissue only. 
 
 This has led to the belief, which is 
 not without much in its favour, that this 
 process has been fractured and not reunited. 
 The tardy union of the acromial epi- 
 physis has undoubtedly led to its being 
 mistaken after death for fracture, but 
 during life such a condition of separation 
 of the bones has not been absolutely made 
 out. 
 
 The following description by Professor 
 Alex. Macalister of the development of 
 this process will be found to differ in many 
 respects from the accounts given by other 
 authors {Journal of Anatomy and Physio- 
 logy, N.s. 7, 1892-3, p. 248). 
 
 ' The first trace of ossification I have 
 found consists of a number of bony 
 points on the surface of the cartilage from the metacromion 
 (hindermost tubercle) forward to the middle of the deltoid edge. 
 These rapidly coalesce into a bony strip, narrow behind, wider in 
 front, corresponding to Uffelmann's osteo-epiphysis posterior. 
 Almost simultaneously there appears a middle portion, consisting at 
 first of a number of nuclei. Those ossifying points which lie along 
 the outer margin of this area coalesce and form the most of the 
 remainder of the outer edge. The ossification of this part extends 
 gradually inwards, the clavicular facet portion of it being the last to 
 develop. Anteriorly a single large nucleus forms, from which the 
 anterior tubercle is ossified. All these nuclei are more extensive on 
 the upper than on the lower surface of the acromion, the portion of 
 the process formed by them on the lower surface being that bounded 
 by a line drawn from the middle of the clavicular facet to the meta- 
 cromion. I have counted in all five large and eight small nuclei in 
 the scapula of a boy of seventeen. These have coalesced in a boy of 
 eighteen into three large and four small centres. 
 
 ' It is extremely probable that the number of these ectosteally 
 ossifying nuclei is irregular ; but in all cases which I have examined 
 of acromia under eighteen there are three sets of these wdiich fuse 
 into three independent parts — the jnetacromial epiphysis, very 
 
 Fig. 18. — scapula about the 
 sevknteenth year, showing 
 two centbes of ossification, 
 one at apex and one at 
 
 BASE. (after EAilBAUD AND 
 RENAULT) 
 
 A few osseous granules, 
 cj, g, are seen in the cartila- 
 ginous posterior border of 
 the spine. 
 
SEPAEATION OF EPIPHYSES OF SCAPULA 147 
 
 slender ; the mesacromial, which is always the most complex in 
 formation ; and the preacromial. 
 
 ' The order of ossification is also variable. In six cases the 
 metacromiai strip had united to the base, while yet the others were 
 detached. In all the apical preacromial portion had united with 
 the mesacromial before the final consolidation of the latter with the 
 spine. I have only twice seen the metacromiai joined to the mesa- 
 cromial before consohdation had begun. I have never found a 
 
 Scapula, at 18| years 
 
 Fig. 19.— epiphysis of the aceovion extending to the spine of the scapula 
 The scale-like epiphysis at the trapezoid ridge of the coracoid process is also seen. 
 
 central ossification in the cartilage like that figured by Quani or 
 Gray. I can, however, believe that such may occur, but it must be 
 the exception, not the rule, as in the twenty scapulae which I have 
 seen in this stage of growth I have detected no trace of this 
 condition.' 
 
 The condition of the persistently separate os acromiale which 
 Professor Macalister has found in fifteen out of a hundred scapula? 
 taken at random is due to the consolidation of the preacromial and 
 
 L 2 
 
148 EPIPHYSES OE UPPEE EXTEEMITY 
 
 mesacromial centres, and the persistence of their separation from 
 the base of the spine and from the metacromial centre which 
 always consoHdates with the base. 
 
 This is probably too high a degree of frequency of occurrence, as 
 many of the specimens were museum ones, among which cases 
 of such an anomaly were naturally numerous. 
 
 Out of forty-five instances of this condition which he had 
 examined he hid never found the metacromial element attached to 
 the ossicle. ' It is very rare,' he says, ' to find the partition of the 
 preacromial and mesacromial centres except in young bones.' Pie 
 had seen it once, but this was, he believed, only a transitory 
 condition. 
 
 In the cases where the real os acromiale persists as a permanent 
 condition, its union has ceased to be a true synchondrosis, and the 
 unitincy material is generally fibro-cartilage. Professor Macalister 
 has once seen a true synovial joint with a surrounding capsule, but 
 he had at least five times found a cavity in the uniting medium 
 comparable, as far as the histological structure of its wall is 
 concerned, with that of the sacro-iliac joint. 
 
 Macalister believes the order of ossification to be normally : 
 ' 1. Many bony nuclei, forming about the fifteenth year. 
 ' 2. Consolidation of these into three marginal centres, about 
 seventeen. 
 
 ' 3. Extension of the mesacromial centre inwards towards the 
 clavicle, between seventeen and eighteen. 
 
 ' 4. Consolidation of the metacromial centre with the basis, and 
 of the preacromial and mesacromial with each other, about eighteen. 
 ' 5. Consolidation of this element with the spine.' 
 In all cases it has been only the aspect of the metacromial angle 
 toward the outer side that has originated from the metacromial epi- 
 physis, here diminishing to a superficial crust, and it never extends 
 on the hinder aspect of the process, which invariably is ossified along 
 with the base of the scapula. (See figures 5, 7, and 8 of Professor 
 A. Macahster's paper, Journal of Anatomy and Plnjsiologij, N.s. 7, 
 1892-93, pi. XV.) • 
 
 Professor Macalister refers to a good account of observations on 
 this process given by Uffelmann {Anatomisch-chirurgische Studien, 
 Hameln, 1865). 
 
 In some instances the epiphysis of the acromion is more obliquely 
 placed, and it usually then runs forwards into the articular surf ace of 
 the acromio-clavicular joint — about its inner third. This articula- 
 tion will necessarily be opened in this case, should separation occur. 
 ETIOLOGY. — The epiphysis may be detached by a direct blow 
 or fall upon the shoulder, or, more indirectly, by violence applied 
 through the humerus, as in a fall upon the elbow. 
 
 PATHOLOGICAL ANATOMY. — There is no real specimen of 
 traumatic separation of this epiphysis known. 
 
SEPAEATION OF EPIPHYSES OF SCAPULA 149 
 
 The number of museum specimens in existence of separate 
 acromial process are considered by most authors as examples of 
 traumatic separation of the epiphysis, or of incomplete ossification 
 from the time of birth, and in this way the rarity of true fracture 
 of the acromion has been accounted for. 
 
 The line of separation is just behind the joint, but in some 
 instances it passes into the acromio-clavicular joint. 
 
 Mr. Lizars was one of the first to point out that ' in some indi- 
 viduals the acromial process continues an epiphysis during life ' 
 {System of Practical Sicrgerij, John Lizars, Edinburgh, 1847). 
 
 Hamilton quotes Fergusson, who remarks ' that he had dissected 
 a number of examples of apparent fracture of the end of this process, 
 but in such instances it is doubtful if the movable portion had ever 
 been fixed to the rest of the bone.' 
 
 Before the Anatomical Society of Great Britain and Ireland, in 
 November 1887, Professor Curnow showed specimens of un-united 
 acromial epiphyses. In January 1888 Dr. Struthers also exhibited 
 before the same society a series of specimens of permanently 
 separate acromion process, simulating fracture. On November 27, 
 1889, Professor Windle showed before the same society {Lancet, 
 December 7, 1889) another series of specimens, which, he main- 
 tained, proved that the separated portions of the acromion were 
 ununited epiphyses, and not fractures. The main evidence for this 
 belief was that the separate parts were always symmetrical, and 
 that there was no callus, but an intervening layer of cartilage. 
 
 At the annual meeting of the British Medical Association in 
 Birmingham, July 1890, Dr. A. E. Mahood likewise exhibited a 
 very interesting collection of scapulae, showing non-union of the 
 acromial epiphysis in advanced age on one or both sides. 
 
 Professor J. Struthers read a paper on ' Separate Acromion 
 Process simulating Fracture ' before the Medico-Chirurgical Society 
 of Edinburgh, June 6, 1894 {Lancet, June 16, 1894, p. 1506 ; Edin- 
 burgh Medical Journal, September 1894, p. 253 ; also ibid. October 
 1895, p. 289; ibid. April 1896, p. 900; ibid. June 1896, p. 1088; 
 ibid. August 1896, p. 97), in which he gives a complete account 
 of this condition and the whole Uterature of the subject. He main- 
 tains that the condition is a much more common one than was 
 generally believed, and that its existence frequently leads to errors 
 of diagnosis in injuries about the shoulder- joint. 
 
 ' The condition,' he says, ' comes (possibly) within the category 
 of fracture in the sense that it may, in some cases, have begun as a 
 fracture of the layer of cartilage between the basi-acromion and the 
 ossified epiphysis, and, in that event, the movements of the acromiou 
 against the clavicle might be sufficient to prevent union and to 
 establish a joint between the two parts of the acromion. That, 
 however, is not likely to have been the history in cases in which the 
 separation exists on both sides.' 
 
150 EPIPHYSES OF UPPEE EXTEEMITY - 
 
 Dr. Struthers adds that, while fractures of the acromion may 
 occur at any part, the usual place of separation is at, or close to, the 
 post-clavicular line, the point of union of the epiphysis (just behind 
 the acromio-clavicular articulation). This is the locality for all 
 of the thirteen cases described, and he has not seen a specimen 
 of its occurrence at any other part of the acromion. While not 
 doubting that true fractures of the acromion occur at and in front 
 of the clavicular connection, and that they may remain in the 
 ununited condition, he thinks that the fact, that the usual locality 
 of separate acromion is at the post-clavicular region, remains for 
 some anatomical explanation. 
 
 He arrived at the following considerations for and against the 
 non-union or separation of the epiphysis theory : 
 
 ' The place of junction of the epiphysis corresponds to the post -clavicular line. 
 But although the epiphysial line thus corresponds to the weak point of the 
 acromion, it is not the cause of the weakness, as after the union is completed 
 (between the twenty-second and twenty-fifth year) there is no difference in the 
 internal structure and no special thinness exactly at the line of iinion. The corre- 
 spondence of the two lines is incidental except in so far that the extent of the 
 epiphysis appears to be in adaptation to the clavicular connection. But the fact of 
 the correspondence of the two lines introduces the element of doubt in the interpre- 
 tation as between fracture and epiphysial separation when the separation occurs, as 
 it usually does, at the post-clavicular line. 
 
 ' In support of the epiphysis theory may be given : (a) That the usual place 
 of separation corresponds to the place of epiphysial meeting, expressed generally. 
 (b) It is conceivable that union may be delayed beyond the twenty-fifth year, and 
 that if union does not occur at the usual period non-union may be permanent, as 
 seen occasionally in tlie case of the inter-frontal suture, (c) If the specimen has 
 been from a subject under the twenty-fifth year, the intervening lajev of cartilage 
 may have been broken by an accident to the shoulder, and the synarthrodial con- 
 nection thus converted into a diarthrodial joint by the movement of the parts, as 
 after fracture of the ossified acromion followed by non-union. That, of course, 
 brings the case into the category of fracture (diastasis), but the line is determined 
 by the epiphysis. 
 
 ^Against the theories of non union or detachment of the epiphysis, as occurring 
 in the living body, may be put : (a) There is a source of fallacy in regard to the 
 interpretation of some specimens met with, in that they are but normal scapulae 
 just under the age at which the acromial epiphysis (the last of the epiphyses of the 
 scapula to unite) is consolidated, the separation having taken place during macera- 
 tion. Such scapulae, wanting the epi-acromion but otherwise full-grown, are to be 
 seen in museums. But, in regard to specimens undoubtedly beyond that age, 
 (6) the Ime of post-clavicular separation is not exactly what would be expected had 
 the cause been non-union or detachment of the epiphysis. Among the thirteen 
 specimens described the separation begins, on the inner side, in some exactly at or 
 very close to the posterior end of the facet, in some a little in front of that point, 
 in some a little behind. 
 
 'These moderate variations in the starting-point of the separation on the inner 
 side do not, perhaps, go against the epiphysis theory, as we do not know that 
 normally the posterior limits of the epiphysis and of the facet correspond precisely 
 to each other ; but the outward course of the line of separation is not much, in some 
 the opposite, of what we should expect when we bear in mind that epiphyses have 
 a very definite shape. As seen in four specinaens, the epiphysis meets the basi- 
 acromion in a line curving outwards and very mitch backwards from the posterior 
 
SEPAEATION OF EPIPHYSES OF SCAPULA 151 
 
 end of the clavicular facet. Even should the posterior nucleus not unite with the 
 main body of the epiphysis, the line of union is still curved, with the concavity 
 backwards. But in some of my specimens, as described, there is very little back- 
 ward direction of the outer part of the line ; in some the outward direction is even 
 a little forwards. Two figures show the direction to be different on the two sides 
 in the same person, though symmetrical in regard to beginning on the inside just 
 behind the facet. On the whole, the general direction of the line of separation, 
 while somewhat undulating, may be regarded as transverse or nearly so. 
 
 ' Allowance must, no doubt, be made for any changes of form during perhaps 
 many years of active working at a false joint after a supposed epiphysial detach- 
 ment ; hut, on the whole, when the line of separation usually seen is considered, 
 the epiphysial theory, whether by delayed union or by detachment, fails to satisfy, 
 while the line of separation, as usually seen, with its minor variations at the post- 
 clavicular region and its general transverse direction, tends to support the fracture 
 theory. 
 
 ' The occasional occurrence of symmetrical separate acromion appears at first to 
 be a difficulty in accepting the view that in all cases the condition is one of 
 fracture, while it is intelligible on the theory of delayed union of the epiphysis, 
 or as a result of advanced rheumatoid disease of both shoulder-joints. Of the three 
 cases above referred to, in two (those by R. W. Smith and J. G. Smith) there was 
 rheumatoid disease, while in my case, a female a^t. eighty-two, there was no 
 disease. These two theories, however, when critically examined as above, must 
 be regarded as improbable, as inapplicable to at least the great majority of the 
 specimens. It remains only to inquire whether the seemingly not very likely 
 occurrence of fracture of both acromions can be believed as, after all, not so very 
 unlikely to occur. This difficultj^ will disappear when Ave think of the occasional 
 occurrence of dislocation of both shoulder-joints, a result implying a much more 
 forcible cause than would suffice to fracture the acromion. 
 
 ' With such examples of symmetrical injury, in two of them both sides dislocated 
 simultaneously, we need have little difficulty in believing in the occurrence of sym- 
 metrical fracture of the acromion process. 
 
 ' The epiphysis theory is attractive to the anatomical mind, but, when the evidence 
 is critically examined, has to be abandoned for the fracture theory. The explanation 
 above given of the frequency of the locality in which the fracture is found to have 
 occurred, the post-clavicular line, giving the family likeness to the great majority 
 of the specimens, is, however, no less an anatomical one, and appears to me to be 
 the true interpretation.' 
 
 In the discussion which followed, Mr. Joseph Bell said that he 
 thought Professor Struthers had achieved a very distinct point by 
 bringing out the fact how common it was that the terminal portion 
 of the acromion only had separated. He thought that fracture 
 of the acromion was not common. Eeflecting on the cases he had 
 seen, he could recall one in which he thought that he had not 
 succeeded in curing a fracture of the acromion, but the patient 
 was' no worse. No doubt it was a case of separation of the terminal 
 end of the acromion. Dr. Eonaldson stated that he had seen two 
 cases in father and child of separate acromion process on both sides. 
 He believed that when it was congenital it would always be found on 
 both sides. Mr. David Wallace said that the subject was one that 
 had interested him and others in the surgical department at the 
 university for some time. Professor Chiene happened to possess at 
 least three, if not four, specimens of the condition. It had been 
 pointed out for a long while that fracture of the acromion process 
 
152 EPIPHYSES OF UPPEE EXTEEMITY 
 
 was rare, and it had always been referred to in the books as one of 
 the instances where a persistent epiphysis might simulate fracture. 
 Mr. W. A. Lane said that, ' examining in the dissecting rooms for 
 fracture, he had found that fractures of the acromion process were 
 the most common in the body. They were in all probability really 
 examples of the condition to which Professor Struthers had alluded — 
 persistent epiphysis. With regard to the diagnosis between fracture 
 of the acromion and persistent epiphysis, in the former they would 
 get crepitus. Further, as Hamilton pointed out, in fracture of the 
 acromion they would have displacement downwards of the fractured 
 portion by the fibres of the deltoid attached to it. In the specimens 
 in the Surgical Museum there was evidence of chronic rheumatoid 
 arthritis, but this was due, in all probability, simply to the too free 
 movement of the head of the humerus upon the under surface of the 
 acromion process, because the osteophytic projection and the so- 
 called porcellanous deposit, which was really simply a burnishing 
 of the bone, were chiefly situated on the under surface. The 
 complete destruction of the long tendon of the biceps to which 
 Professor Struthers had referred was further marked evidence in 
 support of this view. Mr. Wallace had seen two such cases. 
 
 Nearly all the London hospitals contain specimens in their 
 museums of non-union of the acromial epiphyses, the epiphyses 
 having been loose from the time of their formation. They have 
 probably not been separated in later life, for there exists little 
 evidence of an epiphysis failing to unite. 
 
 Some surgeons think that the non-union of this epiphysis is an 
 example of ununited fracture of the acromion, and that it is readily 
 developed on account of the position and muscular attachments of 
 this process, as well as of the difficulty in maintaining the detached 
 fragment in a fixed position when the injury has been recognised, 
 which they say is seldom done. 
 
 Hamilton, in discussing {Fractures and Dislocations, 1884, p. 244) 
 the question of the rare occurrence of fracture of the acromion pro- 
 cess in the adult, quotes a number of museum specimens in his 
 own and other collections in which it was considered doubtful 
 whether the detached portion had ever been fixed to the rest of the 
 bone, and this fact, he believed, illustrated the lateness of the period 
 to which bony union is sometimes delayed. In one specimen the 
 acromial process of each scapula was fully formed, but had no 
 osseous union whatever with the bone itself, the union being liga- 
 mentous but strong and close. 
 
 He says : ' There is some reason to believe that a true fracture of 
 the acromion process is much more rare than surgeons have supposed, 
 and that in a considerable number of the cases reported there was 
 merely a separation of the epiphysis, the bony union having never 
 been completed. If such fractures or separations occurred only in 
 children, very little doubt might remain as to the general character 
 
SEPAEATION OF EPIPHYSES OF SCAPULA 153 
 
 of the accident ; but the specimens which I have found in the museums, 
 and the cases reported in the books, have been mostly from adults. 
 It is more difficult, therefore, to suppose these to be examples of 
 separation of epiphyses, but I am inclined to think that in a majority 
 of instances such has been the fact. 
 
 ' It is very probable, also, that in the case of many of the 
 specimens found in the museums, called fractures, the histories of 
 v\^hich are unknown, they were united originally by cartilage, and 
 that in the process of boiling, or of maceration, the disjunction has 
 been completed. The narrow crest of elevated bone which frequently 
 
 FlG.S. 20 AND 21. — SYMMETRICAL SEPABATE ACROMION PEOCESS 
 
 The clavicular facet is limited posteriorly by the line of junction 
 
 surrounds the process at the point of separation, and which Malgaigne 
 may have mistaken for callus, is found upon very many examples of 
 undoubted epiphysial separations which I have examined ; and this 
 circumstance, no doubt, has tended to strengthen the suspicion that 
 these were cases of fracture. 
 
 ' I wish to mention, also, that in the case of my own specimens of 
 epiphysial separation, as well as most of the specimens which I 
 have examined, the ends of the fragments were closed with a com- 
 pact bony tissue.' 
 
 Besides his own specimens, Hamilton mentions a number of 
 similar specimens in the Massachusetts Medical College Museum 
 
154 EPIPHYSES OE UPPEE EXTEEMITY 
 
 (reported to him by Dr. J. B. S. Jackson, of Boston, U.S.A.), the 
 Mutter, the Jefferson Medical, and other museuixis in America. 
 
 Eergusson, Jackson, and others have also considered that 
 specimens put up in museums as fractures are really delayed union 
 of this epiphysis, separated by maceration. 
 
 The specimen here represented was obtained from the dissecting- 
 room of Guy's Hospital "when the author was Senior Demonstrator 
 of Anatom5^ It shows very clearly the separate condition of the 
 epiphysis on the two sides in an old subject. There is no appear- 
 ance of callus, and the process on both sides is united to the rest 
 of the bone by a layer of cartilaginous-looking tissue. There was 
 no history obtainable. 
 
 There appears to exist some connection between the absence of 
 osseous union in these cases and osteo-arthritis of the shoulder-joint, 
 with which it is often associated. With regard to the co-existence of 
 these two conditions, the reader may be referred to Professor J. 
 Struthers' exhaustive paper already quoted. He says : ' The sup- 
 position that the rheumatic tendency has had the effect of delaying 
 the union of the acromial epiphysis would imply that the rheumatic 
 tendency had shown itself in early life, by the age of about the 
 twenty-fifth year, and it is not evident why that tendency should 
 single out the acromial epiphysis among all the epiphyses of the 
 skeleton.' 
 
 SYMPTOMS. — No case has been recorded in which the diagnosis 
 has been absolutely established during life. 
 
 Displacement will be usually absent, as in fractures of this 
 process, rendering the diagnosis extremely difficult ; its detection 
 will be quite impossible if any swelling has taken place. 
 
 In Sepaeation without Displacement from the periosteum re- 
 maining untorn, there will be merely some dropping of the shoulder, 
 pain, and some loss of power to raise the arm. 
 
 In SEPARATIO^T WITH DISPLACEMENT the edge of the separation 
 may be felt with the finger, or slight irregularity or depression at the 
 line of separation ; and muffled or soft crepitus may be detected in 
 replacing the fragments by elevation of the arm, the humerus being 
 pressed upwards against the acromiial arch by one hand, while the 
 other hand is placed over the shoulder, or the arm being rotated, 
 one hand is kept in the same position over the shoulder. 
 
 Mobility at the epiphysial junction may be felt whilst the 
 epiphysial fragment is replaced in position by abducting and ele- 
 vating the arm, or by pushing up the humerus, if displacement be 
 present. 
 
 Pain and tenderness will exist at the epiphysial line of a fixed 
 character, which may be increased on moving the arm. 
 
 Slight flattening of the shoulder will occur from dragging down- 
 wards of the epiphysial fragment by the weight of the upper extremity 
 through the attachment of the deltoid muscles. While the spine of 
 
SEPAEATION OF EPIPHYSES OF SCAPULA 155 
 
 the scapula may be drawn up by the action of the trapezius and levator 
 anguli scapulas muscles, the head of the humerus retains its normal 
 position. 
 
 Inability to use the arm will always be noticeable, especially in 
 abduction ; while in others the head may be observed to be drawn 
 towards the affected side. 
 
 The age of the patient is an important factor. From the four- 
 teenth or fifteenth to the twenty-second year is the period when 
 separation of the ossifying epiphysis is most likeh/ to occur. 
 
 DIAGNOSIS. Simple contusion. — The contusion and swelling 
 around a separated epiphysis may entirely obscure the signs due 
 to the injury, even when some displacement is present. The pain 
 on pressure over the epiphysial line, and mobility and crepitus, are, 
 however, distinguishing signs. 
 
 PEOGNOSIS. — It is unlikely, from the absence of displacement 
 and the small amount of muscular fibres attached to this process, 
 that the muscular power in the upper extremity will be interfered 
 with to any appreciable extent. 
 
 When there is but little displacement, separations of the acromial 
 epiphysis will probably unite by bone. The union may, in other 
 instances, be ligamentous, especially when the injury has not been 
 recognised and the scapula allowed to move constantly on its 
 epiphysis. 
 
 TREATMENT. — In all cases, even where there is little displace- 
 ment, a good-sized cushion should be placed between the elbow and the 
 side of the body, and the arm bandaged to the chest in this position, 
 which relaxes the fibres of the deltoid and prevents displacement. 
 
 If displacement be present it may be reduced by pressure of the 
 humerus against the acromial arch, and, to maintain the natural 
 position, the elbow should be elevated and supported in this position 
 by means of a sling. 
 
 It is not advisable to place a pad in the axilla, as in fractured 
 clavicle, since it tends to displace the upper end of the humerus 
 too much outwards, and may therefore drag the separated process 
 out of position. 
 
 The simple roller bandage and sling may be conveniently replaced 
 by a plaster of Paris dressing round the chest and over the opposite 
 shoulder. 
 
 Passive movement should be commenced in about a fortnight. 
 
156 
 
 EPIPHYSES OF UPPEK EXTEEMITY 
 
 SEPARATION OF THE EPIPHYSES OP THE 
 CORACOID PROCESS 
 
 ANATOMY. — During the first year of life ossification of the 
 coracoid process commences in the middle of the cartilaginous 
 process, which is rapidly invaded by it. 
 
 The coracoid process rests by its base upon the upper part of 
 the glenoid cavity, but between its base and the circumference of 
 the cavity at the part corresponding to the posterior half of the 
 coracoid an intermediate cartilage is placed. The centre of ossification 
 of the latter appears between the seventh and tenth years. This 
 small epiphysis, sometimes called the suhcoracoid bone, is pyramidal 
 
 Fig. 22. — ossification of coracoid 
 pbocess, sub-coeacoid bone, and 
 glenoid cavity 
 
 (eAMBAUD AND EENAULT) 
 
 Fig. 23.— scapula seen feom above, 
 showing the two cokacoid epiphyses 
 and the moee extended foem of 
 aceomial epiphysis between the 
 eighteenth and nineteenth yeaes 
 
 in shape when fully ossified, and placed between the coracoid process 
 and the glenoid cavity, the apex of which it assists in forming 
 by its articular aspect. 
 
 The coracoid, as seen about the tenth year, is therefore separated 
 from the body of the scapula by an epiphysial fine of cartilage, which 
 thence extends outwards and divides into two hues hmiting the 
 pyramidal subcoracoid. 
 
 In a short time after its appearance the subcoracoid bone joins 
 at first behind with the body of the scapula, and afterwards a little 
 later with the coracoid epiphysis, and finally with the bottom of the 
 
SEPAEATION OF EPIPHYSES OF SCAPULA 157 
 
 glenoid cavity. Sometimes the miion is delayed till the seventeenth 
 year. 
 
 The glenoid cavity is formed of four pieces : (1) that from the 
 body of the scapula ; (2) a portion of the coracoid process internally ; 
 (3) the subcoracoid bone ; (4) a thin glenoid or epiphysial plate at 
 the margin of the glenoid, thicker at the edge and very thin towards 
 the centre, resembling the epiphysial plate of the body of a vertebra. 
 The glenoid cavity in its primitive state is somewhat convex ; it 
 afterwards becomes flat, then angular, and at last concave, by the 
 appearance of the new 
 portions. The epiphysial 
 margin of the glenoid joins 
 the body of the bone from 
 the twentieth to the 
 twenty-fifth year. 
 
 According to Beclard, 
 the coracoid process joins 
 the body of the scapula 
 from about the thirteenth 
 to the sixteenth year, but 
 it may take place, though 
 rarely, as early as the 
 fourteenth year, or be 
 delayed till the seven- 
 teenth — usually about the 
 time that the other epi- 
 physes of the scapula 
 (the acromial and supra- 
 scapular epiphyses) are 
 making their appearance. 
 
 A scale-like epiphysis 
 appears on the upper and 
 posterior aspect of the 
 coracoid process at the 
 convex trapezoid ridge 
 about the fourteenth year, 
 and joins on at the eigh- 
 teenth year, or even a little later — that is, after the rest of the 
 coracoid process has been joined on to the body of the scapula. 
 
 In some instances the apex of the coracoid process has an 
 additional point of ossification, which at the seventeenth year is 
 seen to cover the apex like a cap. This centre never unites with 
 the scale-like epiphysis just mentioned, but joins the body of the 
 process from the twentieth to the twenty-fifth year. 
 
 The synovial membrane of the shoulder-joint covers the outer 
 aspect of the subcoracoid bone, and is in close relation to a small 
 portion of the base of the coracoid process on the inner side. 
 
 Fig. 24.- -scapula of a subject aged seventeen 
 (after kambaud and bbnault) 
 
 /, Line still separating coracoid process from body 
 of bone. L, L', Apical and basal epiphyses of 
 t'le coracoid process, separated by a cartilaginous 
 space, n; the latter epiphysis overlaps the junc- 
 tion with the body. F, Body of coracoid process. 
 g, Osseous granules in posterior border. 0, Os- 
 sific plate of glenoid cavity. C, Inferior angle. 
 P, Osseous centre in inferior angle. 
 
158 EPIPHYSES OF UPPEE EXTEEMITY - 
 
 It is quite possible between the first and the fourteenth years to 
 get detachment of this process without the shoulder-joint being 
 opened, the process being separated from the body of the scapula 
 and the subcoracoid epiphysial mass. 
 
 From the tenth to the seventeenth year, especially towards the 
 latter end of this period, separation of the coracoid process, together 
 with the subcoracoid bone, from the body of the bone is likely to 
 occur in one piece. The upper part of the glenoid cavity will 
 necessarily be torn open. This may also happen while the sub- 
 coracoid mass is still cartilaginous. 
 
 ETIOLOGY. — This separation may be produced by severe direct 
 violence, such as the passage of a wheel over the shoulder, as in 
 Bennett's case {loc cit. infra), or it may be caused by a fall upon 
 the shoulder, as in the author's case narrated below. It is probable 
 in the latter case that the direct pressure of the head of the humerus 
 upon the coracoid and upper part of the glenoid was sufficient to 
 cause an incomplete separation of this process. Mr. Lane believes 
 that fracture of the coracoid process is caused by indirect violence, 
 as in a fall with the arm fully flexed at the shoulder- joint, so 
 that the coracoid process is pressed against the under surface of 
 the clavicle ; it may also be produced and the coracoid forced 
 against the clavicle by a person falling from a height and suddenly 
 seizing some object and arresting his fall. 
 
 Mr. E. Clement Lucas, in an article (Guy's Hospital Beporfs, 
 vol. xlvii. 1890, p. 45) upon fracture of the coracoid process, draws 
 attention to the various ways in which this process may be fractured 
 in adults, and alludes to two cases mentioned by Bryant which he 
 thought ought to be regarded as epiphysial separations. Both 
 were caused by direct violence, and occurred in girls of fifteen 
 (or sixteen) and fourteen years of age. He says : ' It is evident 
 that as mobility and crepitus were the two symptoms by which these 
 cases were diagnosed, there could not have been any great displace- 
 ment. Judging by the time the coracoid epiphysis unites, these 
 cases ought, however, to be classed as separations of the epiphysis.' 
 
 Muscular action. — It is possible for the apical epiphysis of the 
 coracoid process to be torn off by the violent contraction of the 
 muscles attached to it. No instance has as yet been recorded. 
 
 AGE.— Separation can only occur up to the seventeenth year 
 of life. 
 
 PATHOLOGICAL ANATOMY. — Separation of the coracoid epi- 
 physis is an extremely rare form of injury. It is possible that 
 separation of the coracoid epiphysis alone may occur before its 
 junction with the subcoracoid bone or portion of the coracoid car- 
 tilage — that is, before the tenth year — and the joint escape injury. 
 It is, however, most probable, that, as in Bennett's case, the whole of 
 the coracoid epiphysis, including the subcoracoid bone, will be 
 detached, and the upper part of the glenoid cavity thus torn away 
 
SEPAKATION OF EPIPHYSES OF SCAPULA 159 
 
 with the capsular Hgament and tendon of the biceps. The hne 
 of separation is on the scapular side of the epiphysial cartilage 
 which remains with the coracoid process, and quite internal to the 
 attachments of the powerful conoid and trapezoid ligaments to 
 the under surface of the clavicle. The transverse ligament also 
 attached to its base behind, and the coraco-humeral ligament to 
 the process in front, will likewise go with the epiphysis. The 
 ligaments, together with the coraco-acromial ligament along the 
 outer border, will tend to prevent any large amount of displacement, 
 and hence but little deformity will probably be met with. 
 
 E. H. Bennett {Transactions Boy. Acad. Med., Ireland, vol. vi. 
 1888, p. 408, and Dublin Journal of Med. Science, August 1, 1888, 
 vol. Ixxxvi. p. 97) read a paper at the Royal Academy of Medicine 
 in Ireland on June 1, 1888, on the following case of separation of 
 the coracoid process produced by severe direct violence, accompanied 
 by other serious injuries. 
 
 A boy (J. C), aged six, was knocked down by a tramcar, and 
 picked up from beneath its guard-board. A large flap of skin was 
 found torn up from the front of the right side of the chest, and a 
 second rent of the skin passed backwards beneath the axilla from 
 the point of the anterior wound. The axillary vessels and most of 
 the nerves were also torn through, and the upper limb all but torn 
 off. The right forearm and many of the ribs on the right side 
 were broken. No operation was performed for forty-eight hours on 
 account of the collapsed condition of the patient ; gangrene of the 
 whole limb had then commenced, and amputation at the shoulder- 
 joint was performed. Death ensued on the eighth day from tetanus. 
 At the autopsy the second to the ninth ribs were found to be frac- 
 tured (the eighth and ninth incompletely) and the coracoid process 
 of the scapula separated. There was no injury of the lung or 
 pleura. Professor Bennett continues : ' From the character of the 
 wound, particularly that of the skin, it is clear that the force which 
 inflicted the injury of the axilla was directed from below and in 
 front, upwards and backwards, and its action ceased a little below 
 the clavicle, which was intact. The lesion of the coracoid confirms 
 this view. It is detached at its base, the line of separation passing- 
 through the proximal side of the cartilage, and at the upper and 
 back part taking off a scale of bone from the supra- spinous fossa of 
 the scapula. By misadventure the ligament of the scapular notch 
 was cut away in making the early investigation of the injury, but 
 the posterior margin of the notch bears incontestable proof of the 
 quality of force that produced the lesion. A partial fracture of the 
 scapular border behind the notch extends into the supra-spinous 
 fossa for half an inch, and its anterior border has been sprung back- 
 wards, so that the thin layer of bone has overlapped the opposite 
 side of the fracture and remains fixed in its displacement. This 
 shows that the ligament of the notch attached in front to the base 
 
160 EPIPHYSES OF UPPEE EXTEEMITY 
 
 of the coracoid had ah but torn off backwards with it a strip of bone 
 from the superior border of the supra-spinous fossa. As the base of 
 the coracoid in its epiphysiary condition forms a part of the glenoid 
 cavity just at its summit and along the concave part of its upper 
 and inner border, we find these parts detached and displaced with 
 the coracoid ; the upper and inner end of the cotyloid ligament is 
 torn through, and with the base of the coracoid the attachment of 
 the outer limb of the cotyloid ligament is displaced unbroken, and 
 the tendon of the biceps along with it. There is no lesion of the 
 clavicle or any other part of the scapula, but it is of interest to note 
 that the acromial epiphysis is joined to the spine by a diarthrodial 
 joint.' 
 
 Before the Anatomical Society in November 1887 Prof. Curnow 
 exhibited specimens of ununited coracoid epiphyses. 
 
 The author has no doubt that many specimens of fractures in 
 adults —which are situated at the base, in the vicinity of the glenoid 
 cavity — are in reality instances of traumatic separation ununited, 
 or possibly of non- ossification from the time of birth. 
 
 In May 1887 the author showed before the Pathological Society 
 (PatJiological Society's Transactions, vol. xxxviii. 1887, p. 261) a 
 spe3imen of separation of the coracoid epiphysis following a fall 
 upon the shoulder. 
 
 George L., aged twelve years, was admitted into Guy's Hospital 
 on October 11, 1886, under the care of Mr. Durham. Nine days 
 previously he was said to have baen thrown down by a dog, and to 
 have fallen on his right shoulder, his right thumb also being bitten. 
 Three days after, vomiting set in with feverishness and great pain 
 in the shoulder. On admission the temperature was 103°-6 ; P. 124. 
 There was a fluctuating area over the scapula, and some redness 
 and puffiness over the back of the right hand. Incisions were made 
 into the swelling on the dorsum of the scapula, and the infra-spinous 
 fossa was found to be bare. Death took place early the next morning 
 from pyaemia. At the autopsy it was found that the right scapula 
 was almost entirely denuded of its periosteum, the subscapular, 
 supra- and infra-spinous fossae being bare, with the exception of the 
 upper and lower angles, and full of bloody pus. The abscess cavity 
 on the dorsal surface communicated freely with that in front by 
 means of the shoulder-joint, and also over the neck of the bone. 
 The joint was acutely inflamed and full of pus, the ca]3sule partly 
 destroyed, and the articular cartilages were beginning" to be eroded. 
 The scapula itself was of a greenish yellow colour, and, on section, 
 infiltrated with pus. The coracoid epiphysis was completely de- 
 tached, and only a small flake of the cartilaginous epiphysial line 
 remained. The muscles were still attached to its apex, and around 
 this process were the remains of what had apparently been a cavity 
 full of blood, suggesting that this was the original seat of the 
 disease — viz. that this process had been detached by the injury at 
 
SEPAKATION OF EPIPHYSES OF SCAPULA 161 
 
 its epiphysial line of cartilage, and that the injured tissue at the 
 epiphysial line furnished a congenial soil for micro-organisms to 
 flourish, acute osteomyelitis of the scapula taking place in a similar 
 manner to that of the shaft of a long bone, and with it other signs 
 of general infection. There were pygemic abscesses in the lungs, 
 heart, brain, abdominal viscera, and fourth metacarpal bone. 
 
 This specimen is in the Eoyal College of Surgeons' Museum, 
 No. 1218 E. The catalogue gives the following brief description ; * A 
 portion of a right scapula, the coracoid epiphysis of which is com- 
 pletely detached. The root of the epiphysis is denuded of its 
 periosteum, and the intervening cartilage is in great part destroyed. 
 In the recent condition the periosteum was stripped from the dorsal 
 and ventral surfaces of the scapula by the formation of pus beneath 
 it, and these abscess-cavities communicated freely above the neck 
 of the bone. On section the medullary tissue of the bone was 
 infiltrated with pus. From a boy, aged twelve, who died of pyaemia 
 ten days after a fall upon his right shoulder.' 
 SYMPTOMS. — Pai?i over coracoid. 
 
 Inability to raise or adduct the arm, on account of the attach- 
 ment of its biceps and coraco-brachialis muscles. 
 
 Mobility. — Preternatural mobility of the process may be felt on 
 grasping this small fragment between the fingers and thumb, or on 
 rotating or abducting the arm, or pressing on the tip of the process, 
 whilst the scapula is fixed. It may be grasped readily enough 
 between the clavicular fibres of the pectoralis major and deltoid 
 muscle if no displacement and swelling have occurred ; but should 
 these be present its depth from the surface will completely prevent 
 its being grasped by the fingers. 
 
 Crepitus of the usual soft character, if there is but little dis- 
 placement of the process. If this cannot be detected on moving 
 the process, it may be elicited by moving the humerus at the 
 shoulder-joint whilst the finger is placed in the depression between 
 the deltoid and pectoral muscles in front. 
 Great swelling from direct violence. 
 
 If the coracoid process is displaced at all, it will be in the 
 downward and inward direction, by the combined action of the 
 pectoralis minor, biceps, and coraco-brachialis muscles. 
 
 A case has been reported by Dr. E. C. Huse, of U.S.A. {Chicago 
 Medical Journal and Examiner, vol. xxix. August 1879, p. 175), but 
 has not been confirmed by an autopsy. 
 
 M. Chauvel alludes {Diction, encycl. des Sciences Medicales, 1881, 
 tom. quinzieme, p. 294) to this form of injury when he says, in 
 speaking of fractures of the base of the coracoid process, that 
 fracture is sometimes met with in children at the line of junction of 
 this epiphysis with the body of the scapula. 
 
 Separation of the Apical Epiphysis of the coracoid might be 
 brought about by the combined muscular action of the coraco- 
 
 M 
 
162 EPIPHYSES OF UPPEK EXTEEMITY 
 
 brachialis, biceps, and pectoralis minor, and might give rise to great 
 displacement of the tip of this process in a downward direction. 
 The process of union in this case will probably only be by liga- 
 mentous tissue. 
 
 Complications. — Like the corresponding fractures in the 
 adult, separation of the coracoid may be accompanied by either : 
 
 {a) Dislocation or fracture of the humerus, or (&) dislocation of 
 the outer end of the clavicle. 
 
 TREATMENT. — If the separation has taken place at the base of 
 the coracoid process, there will be but little difficulty in maintaining 
 the fragments in good position, on account of the small amount 
 of tendency to displacement through the attachment of the strong 
 coraco-clavicular (conoid and rhomboid) and coraco-acromial liga- 
 ments. 
 
 Should, however, the separation occur at the apical epiphysis 
 beyond these ligaments, nothing can be done to keep the separated 
 fragment in its proper position through the combined action of the 
 pectoralis minor, coraco-brachialis, and biceps muscles, but a small 
 pad maj^ be placed below the process, which will tend to support it 
 in position. 
 
 The arm and forearm should always be flexed acutely, so as 
 to relax the biceps and other muscles, and the elbow should be 
 sux^ported and the wdiole Hmb bound to the body. This may be 
 effected by the hand of the injured side being fixed upon the opposite 
 shoulder with the arm and elbow in the sling across the chest, while 
 the scapula is supported behind by means of a soft broad pad. 
 
163 
 
 CHAPTEE III 
 
 SEPARATION OP THE UPPER EPIPHYSIS 
 OP THE HUMERUS 
 
 ANATOMY. — In the first year of life the diaphysis of the 
 humerus already attains the osseous shape which it keeps during 
 the rest of life. Its upper end, which is in the first instance con- 
 cave, and then a plane surface, is even now slightly convex, and fits into 
 the cartilaginous epiphysis. The upward and inward extension of 
 the diaphysis, the part which supports the head, is morphologically 
 the same as the neck of the femur at this period. 
 
 During the first year, usually towards the middle of the year, 
 osseous granules appear scattered in this cartilaginous end. Dr. 
 Herbert B. Spencer (Journal of Anatomy and Physiology, vol. xxv. 
 July 1891, p. 554) has found that a centre of ossification is not rarely 
 met with in the head of the humerus at the time of birth. About the 
 end of the first year these granules begin to group themselves into 
 three centres, that for the head appearing first at the beginning 
 of the second year, and that for the greater tuberosity during 
 the third. The centre for the lesser tuberosity is not well marked 
 until the end of the fourth year, at times as late as the end of 
 the fifth. At this period these three centres are pretty accurately 
 divided from each other by the anatomical neck and the bicipital 
 groove ; they begin to blend with each other about the sixth year (some 
 anatomists state from the third to the fifth year), the lesser tuberosity 
 joining first by its upper part with the head and greater tuberosity, 
 and the latter being still separated from the head by a layer of 
 cartilage. It is therefore possible to have a separation of the 
 epiphysis of the head alone. 
 
 Somewhat later the greater tuberosity blends with the upper 
 part of the head, and the large upper epiphysis is fully formed. It 
 is entirely osseous at the age of puberty. This cup-hke epiphysis 
 includes the two tuberosities, the upper fourth of the bicipital 
 groove, and the whole of the head and anatomical neck, as well as 
 a very small portion of the bone external to the lesser tuberosity, 
 between it and the anatomical neck, which constitutes part of the 
 shaft in the adult. The limit of the epiphysial line on the inner 
 
 M 2 
 
164 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 side is situated directly below the cartilaginous articular surface of 
 the head at its axillary margin and runs horizontally outwards, 
 rising considerably in a point at the centre and terminating on the 
 outer side directly below the tuberosities. 
 
 The cup-like epiphysis rests with its concavity upon the pointed 
 concave end of the diaphysis. The cone-shaped end of the diaphysis 
 only develops as age increases ; in infancy it is almost flat, and after- 
 wards becomes slightly convex. 
 
 Each osseous nucleus of the head and tuberosities thus appears 
 about the fourth or fifth year to be surrounded by cartilage — viz. 
 
 that covering the articular surface 
 and tuberosities, and that between 
 the parts of the epiphysis. 
 
 Fig. 25. — humerus at the thiedyear. 
 
 (after RAMBAUD and RENAULT.) 
 ABOUT HALF NATURAL SIZE 
 
 Fig. 26. — vertical section of upper 
 and lower ends of humerus at 
 
 THE THIRD YEAR. (aETER RAMBAUD 
 AND RENAULT.) ABOUT H.VLF 
 
 NATURAL SIZE 
 
 The three pieces of which the epiphysis is originally composed 
 form by their union a kind of recess about the centre, which 
 accurately fits the pointed pyramidal projection on the upper end 
 of the diaphysis — a cone-like shape which has gradually developed 
 as age advanced. Numerous small elevations and depressions are 
 well marked over the surface. 
 
 Buttress-like ledges on the outer aspect of the upper end of the 
 diaphysis support the greater and lesser tuberosities. As the bone 
 grows the conjugal cartilage diminishes in thickness until it becomes 
 a thin layer, and constitutes a weak point up to the time of final 
 union of the epiphysis. 
 
 The younger the child the farther this line will be found from 
 the head of the bone. 
 
 The epiphysis, when complete, is eleven millimetres thick in the 
 centre opposite the depression for the central point of the dia- 
 
SEPAEATION OF UPPER EPIPHYSIS OF HUMERUS 165 
 
 physis, twenty-two millimetres on the outer side at the tuberosities, 
 and on the inner side, about the middle of the head, fifteen 
 millimetres. 
 
 De Paoli gives the following table of measurements of the height 
 and breadth of the upper epiphysis of the humerus in different 
 individuals according to age. 
 
 The height is taken proportionally from the front half of a 
 vertical coronal section dividing the head of the humerus into 
 two halves, one anterior and the other posterior ; the breadth is 
 taken from the same section at the base of the epiphysis. He 
 also measured the apparent height — that is, the distance from 
 the middle of the upper surface and the base of the epiphysis. 
 
 Age 
 
 Heieht 
 
 Apparent 
 Leiglit 
 
 Breadth 
 
 
 mm. 
 
 mm. 
 
 mm. 
 
 Before birth 
 
 11 
 
 12 
 
 12 1 
 
 15 
 
 18 
 
 26 
 
 28 
 
 First year 
 
 
 19 
 
 20 
 
 Second 
 
 Fourth 
 
 12 
 
 
 19 
 
 29 
 
 Fifth 
 
 12 
 
 
 21 
 
 37 
 
 Sixth 
 
 13 
 
 
 2J 
 
 85 
 
 Seventh 
 
 15 
 
 
 23 
 
 38 
 
 Eighth 
 
 IG 
 
 
 24 
 
 ... .34 
 
 
 jl6 
 
 
 24 
 
 41 
 
 Nmth 
 
 ••• il6 
 
 
 
 39 
 
 Twelfth 
 
 14 
 
 
 — 
 
 48 
 
 
 fl8 
 
 
 29 
 
 41 
 
 Sixteenth 
 
 ... il6 
 
 il6 
 
 
 24 
 
 41 
 
 
 
 26 ■ 
 
 40 
 
 Seventeenth 
 
 ,16 
 
 ••• 118 
 
 
 24...... 
 
 55 
 
 40 
 
 Eighteenth 
 
 13 
 
 
 26 
 
 45 
 
 This epiphysis does not begin to unite with the shaft until the 
 twentieth year, or even a little later, and its central portion is the 
 first to ossify on to the prominent point of the diaphysis, union being 
 effected in the male somewhat later than in the case of the female. 
 Some authors have stated that the union may not take place till the 
 twenty-fourth year, or even later. 
 
 The epiphysial line marks the upper limit of the surgical neck of 
 the bone in the adult. 
 
 In proportion as the spongy bone of the diaphysis at the level 
 of the epiphysial line becomes rarefied and the medullary canal 
 formed, the external compact layer of bone becomes thicker and 
 more dense. 
 
 A trace of the line of union sometimes persists for a considerable 
 time. 
 
 Posteriorly the line passes below the greater tuberosity, through 
 the muscular fibres of the lowest thin part of the attachment of 
 the teres minor into the shaft of the humerus. It is half to three- 
 
166 
 
 EPIPHYSES OF UPPEE EXTREMITY 
 
 quarters of an inch below the level of the tip of the coracoid 
 when the arm is hanging by the side of the body, but if the arm 
 be abducted from the side, the outer margin of the line is almost 
 XDrecisely. on a level with this process. At fom^teen years of age 
 the outer margin is twenty millimetres below the acromial 
 
 Fig. 27 — veetical sectiox of the uppee 
 end of hcileeus at the age of seven- 
 teen teaes. anteeioe half of sec- 
 tiox, sho'mxg the cexteal conical 
 peojection of the dliphtsial end 
 and cancellous steuctuee. actual 
 
 SIZE 
 
 Fig. 28. — uppee end of humeeus at 
 
 THE eighteenth TEAE 
 
 The epiphysis has been detached to 
 show the pyramidal end of the 
 diaphysis with its apex projecting 
 upwards. 
 
 arch ; at eighteen years of age 
 twenty-five to thirty millimetres 
 below. 
 
 In the fully formed epiphy- 
 sis the synovial membrane on 
 the inner or under aspect, both 
 towards the front and back, 
 overlaps the epiphysial line for 
 
 several millimetres, and the attachment of the capsular ligament 
 corresponds here exactly to the epiphysial line. But separation of 
 the epiphysis will not necessarily, except in cases of great violence, 
 lead to opening of the articular cavity, inasmuch as the capsule is 
 firmly attached to the epiphysis, and the synovial membrane pass- 
 ing off from the articular cartilage is but loosely attached to the 
 diaphysis. 
 
 On the outer or upper surface the synovial membrane is far 
 from the limit of the epiphysial line, the whole thickness of the 
 tuberosities, with the capsular ligament, and many tendinous and 
 
SEPAEATION OF UPPEK EPIPHYSIS OF HUMEPUS 167 
 
 muscular attachments to these processes intervening. The mem- 
 brane approaches closer the line the nearer the inner aspect of the 
 humerus is reached. In infancy, the synovial membrane is seen 
 
 Fig. 29. — boxes FORiiixc; the shodlder-joixt at the t^msntieth teak. 
 
 RELATIONSHIP OF EPIPHYSIAL JUNCTION OE UPPER END OF HUMERUS 
 
 to pass over the upper surface of the cartilaginous epiphysis as 
 far as the point where later on the osseous centres of the head 
 and great tuberosities join together. 
 
 Fig. 30. frontal section of the right shoulder-joint of a female inf.ant 
 xt. if years. posterior half of section, the abm hanging vertically 
 downwards 
 
 cl, acromial end of clavicle cut obliquely ; D, deltoid muscle ; Sb, synovial bursa 
 beneath its origin ; Ssj), supraspinatus ; T, triceps ; pa, profunda artery ; 
 pea, posterior circumflex artery ; Ss, scapula. (A. v. Brunn.) 
 
 The synovial membrane appears to overlap the inner aspect of 
 the diaphysis as age advances ; at three years of age it overlaps 
 it for tvi^o miUimetres, at thirteen years for five or six millimetres 
 (Sesary). 
 
168 
 
 EPIPHYSES OF UPPER EXTREMITY 
 
 We see, therefore, that in infancy up to about the fifth year 
 all the bony nucleus of the head is entirely within the capsule of 
 
 the shoulder-joint, while after this 
 period, the ossific centres becoming 
 blended with that of the head, part 
 of this epiphysis is internal and part 
 external to the synovial membrane. 
 
 The growth in length of the dia- 
 physis principally proceeds from the 
 upper epiphysis. 
 
 The muscles attached to this epi- 
 physis are the subscapularis — to its 
 lesser tuberosity — the supraspinatus, 
 infraspinatus, and teres minor — to its 
 three facets on the great tuberosity ; 
 the long tendon of the biceps occu- 
 pying the groove between these two 
 processes surrounded by the process 
 of the synovial membrane of the 
 shoulder-joint. 
 
 The capsular ligament is attached 
 on the inner side at the level of the 
 epiphysial line for rather more than 
 the inner ' third of its extent, and 
 then follows the rest of the line of 
 the anatomical neck, between the 
 head and the tuberosities. 
 
 E. M. Moore says : ' Taking the 
 head of a bone from a subject ten years of age, parted by macera- 
 tion, we find that the angle made by the junction of the plane, 
 
 Fig. 31. — upper epiphysis of the 
 humerus at the nineteenth 
 year. half natural size 
 
 Fig. 32. — eight shoulder- joint in a subject ^t. sixteen, the arm being 
 parallel to the middle line of the body, the section passes through the 
 
 COKACOID process of the SCAPULA AND THROUGH THE HEAD OF HUMERUS, ABOUT A 
 QUARTER -WAY DISTANT FROM ITS ANTERIOR ASPECT. THE SYNOVIAL CAPSULE AND 
 PERIOSTEUM APPEAR THICK ON ACCOUNT OF THEIR OBLIQUE DIVISION . 
 
 ss, spine of scapula ; pc, coracoid process separated from the body of scapula by 
 an epiphysial plate of cartilage, which increases considerably in thickness 
 towards the articular surface ; on, osseous nucleus appearing in the thickest por- 
 tion of the cartilage (Uffelmann's osteo-epiphysis bicipitalis) ; c, capsular ligament. 
 (Brunn.) 
 
SEPxiKATION OF UPPEK EPIPHYSIS OF HUMEEUS 169 
 
 projected through the anatomical neck (which forms two-fifths of 
 the whole surface), with the plane passing below the tuberosities, 
 measures about 100 degrees.' 
 
 The periosteum passing from the epiphysis to the diaphysis is 
 thick and strong. 
 
 AGE. — Instances have been recorded from the time of birth up 
 to twenty-five years of age. 
 
 Dr. H. E. Wharton says (' Separation or Disjunction of the 
 Upper Epiphysis of the Humerus,' University Medical Magazine, 
 Philadelx^hia, January 1889, vol. i. No. 4, p. 212) that this accident 
 is not a very unusual one in children from five to fifteen years 
 of age as the result of falls upon the arm. 
 
 D'Arcy Power says {Surgical Diseases of Children, 1895, p. 171) : 
 ' It is generally met with about puberty, and the separation 
 results from direct violence to the shoulder. Separation of the 
 whole epiphysis takes place after the sixth year, for it is only then 
 that the nuclei of the head unite with that of the greater tuberosity 
 to form a single mass.' As will be seen presently, separation does 
 very frequently take place in infancy. The whole upper end of tha 
 bone is formed of one cartilaginous mass, in which the osseous 
 centres for head and tuberosities appear. Therefore separation of 
 any one of these component parts can only be effected by accom- 
 panying fracture of the cartilage uniting the centres, which must 
 be an accident of extremely rare occurrence. 
 
 The author's own statistics are as follows : 
 
 Out of a total of twenty-one pathological specimens we must 
 omit seven doubtful at the time of birth; and seven in which the 
 age is not stated (one of the latter being in a young person and 
 one in a young adult) ; and in the remaining seven museum 
 specimens, in which the age is given, two are at thirteen, one at 
 seventeen, one at fifteen, one at eleven, one between four and five 
 years of age, and. one between three and four years. 
 
 In seven compound cases, in all of which the age is stated, two 
 were at nineteen, two at fifteen, two at sixteen, and one at fourteen 
 years. 
 
 Taking the whole fourteen cases verified by dissectioji, nine were 
 from thirteen to nineteen years of age, six of these being from 
 thirteen to sixteen — an average of thirteen years for those cases 
 in which the age is stated. 
 
 Analysing the twelve cases of arrest of groivth, the ages at which 
 the separation is said to have taken place are : one at fourteen, one 
 at eleven, one at ten, one at nine, one at eight, one at four, one 
 at three, two at two, one at one and a half years, one at six months, 
 and one in early infancy. 
 
 Among the eighteen cases operated upon for recent separation, 
 or later for deformity, we find that : in one the age is not stated, 
 two were at twenty-three, one at nineteen, one at eighteen, three 
 
170 EPIPHYSES OF UPPEK EXTEEMITY 
 
 at seventeen, three at sixteen, one at fifteen, one at fourteen, three 
 at ten, one at nine, and one at seven years. 
 
 Taking the sixty-one cases of simple separation, the age is not 
 stated in five (one of these, however, in a child) ; in thirty the age 
 is stated to have been from thirteen to nineteen years of age — viz. 
 four at nineteen, one at eighteen, one at seventeen, seven at six- 
 teen, six at fifteen, six at fourteen, five at thirteen (amongst these 
 thirty are recorded eleven cases from Guy's Hospital not hitherto 
 published, and eight of these were from thirteen to seventeen years 
 of age) ; twenty-four between four and twelve years of age — viz. six 
 at twelve, three at eleven, two at ten, four at nine, three at eight, 
 three at seven, and one each at six, five, and four years ; of the 
 remainder, two in infancy, one at six months and the other at 
 about thirteen months. 
 
 Analysing the total 119 cases recorded, in ninety-eight the age 
 is accurately given, and amongst these the greatest number, sixty- 
 six, occurred between the ages of nine and seventeen. 
 
 Hutchinson thinks that this injury occurs most often in boys 
 from ten to fifteen years of age. 
 
 Dr. Jetter's seventeen cases from the Tubingen Clinic also give 
 the maximum frequency of this separation from the tenth to the 
 fifteenth year : 
 
 5 to 10 years 10 to 15 years 15 to 20 years 20 to 25 years 
 
 Five cases Seven cases Three cases Two cases 
 
 He thinks, like many other surgeons, that the pure form of separa- 
 tion is most frequent during the earlier years of life. 
 
 SEX. — Out of forty-six cases, the sex is stated in thirty-seven, 
 thirty-one being in males and six in females ; and out of a total of 
 119 cases, the sex being stated in 104, eighty-five were males and 
 nineteen females. 
 
 ETIOLOGY. — Separation most frequently results from forcible 
 traction of the arm outwards and upwards. According to Gurlt, it 
 is produced by violence much greater than that which is the usual 
 cause of fracture at the corresponding periods of life. He produced 
 it by violent abduction while the epiphysis was fixed, and Colignon 
 did so by violent abduction and rotation outwards of the limb. 
 
 Eognetta, by means of experiments, especially studied detach- 
 ments of this epiphysis in the newly born. Salmon, however, in his 
 experiments could not effect separation on the bodies of infants of 
 less than a month old. According to Kiistner's experiments on 
 newly born children, separation is most easily effected by rotation of 
 the upper extremity. Pajot separated this epiphysis by traction 
 of a weight of nineteen kilogrammes after the soft parts had been 
 removed from the articulation, but he found that, if these were 
 preserved intact, it required a weight of thirty-five kilogrammes 
 to effect its separation. 
 
SEPAEATION OF UPPEE EPIPHYSIS OF HUMEEUS 171 
 
 The injury may be occasioned by direct as well as indirect 
 molence. 
 
 Separations the result of severe direct violence applied to the 
 shoulder — such as the kick of a horse, a fall of a heavy box (1 cwt.) 
 on the shoulder, a fall upon the shoulder (a projecting body striking 
 it below the acromion), or some severe crushing accident (as being 
 run over by a tramcar, waggon, or cart — are sometimes simple 
 injuries, although out of seven cases known to have been produced 
 in this way four were rendered compound. 
 
 Indirect violence. — We find in analysing forty cases that in the 
 large majority (twenty-seven) the separation was produced by a 
 blow or a fall on to the front or outer side of the shoulder, such as a 
 fall from a waggon or from a tree sixteen feet high or less, or simply 
 by a fall on the pavement from slipping on orange peel or whilst 
 running. In one case the patient fell a distance of sixty feet from 
 a warehouse. 
 
 Eollet says {loc. cit. infra) : ' As an element in the diagnosis let 
 us also add the nature of the injury ; in the two cases which we 
 mention, and in the four others observed by M. Poncet, the direct 
 cause was a fall upon the prominence of the shoulder.' 
 
 In sixteen cases described by Dr. Jetter, twelve were caused by 
 a fall upon the shoulder from a greater or less height — viz. varying 
 from a man's height to seven metres high — on to the level ground or 
 on to an object lying upon the ground ; once by a fall upon the 
 shoulder, from slipping upon ice ; and twice by a fall on the out- 
 stretched arm, causing forcible abduction. In three of the cases 
 the mode of production was uncertain. 
 
 Bruns observed a case of separation of the upper epiphysis of 
 the humerus in a boy aged fourteen who had fallen from a tree, a 
 height of five feet. 
 
 Sir Charles Bell {Institutes of Surgery, vol. i. p. 3) says that 
 he has known epiphysial separation of the upper end of the 
 humerus occur from a boy firing a musket. 
 
 In two instances the violence was apparently even more indirect. 
 It is stated in one instance that the separation was caused by a fall 
 the height of a few feet on to the elbow ; while in another it was 
 produced by the patient suddenly throwing, with great violence, 
 his arms upwards and somewhat laterally ; in a third by the child 
 being suddenly seized and raised by its arms ; and in a fourth case 
 by the arms being caught between the spokes of a wheel. 
 
 Professor Kocher believes that violence applied from below, as in 
 a fall on the outer side of the elbow, is often clinically the mode of 
 production. He thinks that the abrasions and contusions frequently 
 seen on the outer side of the elbow prove this. 
 
 On the dead subject the author has found that forcible abduction 
 of the arm with rotation, especially outwards, is the most easy way 
 to produce a separation of this epiphysis. 
 
172 EPIPHYSES OF UPPEE EXTKEMITY 
 
 From this forcible abduction or elevation of the arm arise some 
 of the frequent causes of dislocation in the adult. 
 
 Edmund Owen {Surgical Diseases of Children, 1885, p. 382) 
 alludes to the case of a girl, aged eight, who had recently been 
 under his care ; the fracture occurred from the nurse twisting the 
 child's arm behind her back, but with no great violence. Thus 
 the humerus was converted into a lever of the first order, the 
 fulcrum being found at the spot where the bone was brought into 
 firm contact with the chest wall. On examining the joint under 
 chloroform, crepitus of a peculiar * mortary ' feel was easily obtained. 
 The end of the diaphysis projected somewhat outwards, and could 
 be easily felt through the thin deltoid. 
 
 An interesting case is described by M. Eicard (S. Duplay and 
 V.'Rec\yis,,Traite de Chirurgie, tom. ii. 1890), in which this epiphysis 
 was clearly separated by a violent twist of the arm without any 
 direct blow. 
 
 A youth, aged nineteen years, was seized by the middle of the 
 arm during a quarrel, and violently twisted and pushed. Although 
 no direct injury was received, the patient immediately experienced 
 acute pain at the shoulder, with inability to move the arm. The 
 next day there was found a fairly considerable swelling occupying 
 the whole region of the shoulder and upper half of the arm, and 
 extending upwards to the infra-clavicular region (rendering explora- 
 tion of the latter very difticult), and also to the outer wall of the 
 axilla. No abnormal projection, however, was detected. Active 
 movements were impossible, and passive movements were only 
 effected with much pain. The elbow was a little away from the 
 trunk, but could be brought nearer with some pain. The sub- 
 deltoid bursa and shoulder- joint appeared to contain abundant 
 serous effusion. Direct pressure on the humerus and pressure on 
 the elbow from below upwards gave rise to acute pain, which was 
 limited to a spot two fingers' breadth below the acromion. Slight 
 mobility was felt on seizing the arm by its lower extremity and 
 rotating the humerus round its axis, while on placing the other 
 hand on the shoulder very characteristic, but indistinct and muffled, 
 crepitus could be plainly felt at the same spot as the pain. There 
 was no appreciable shortening. Consohdation was effected with a 
 certain amount of displacement of the humerus forwards, so that 
 the head formed a marked angle with the axis of the humerus, 
 being situated at its posterior and inner aspect. Movements, how- 
 ever, could be freely carried out. 
 
 In the following interesting case of incomplete displacement 
 inwards of the end of the diaphysis recorded by A. Demoulin 
 {Archives generales de Medecine, November 1893, p. 611) the separa- 
 tion was caused by a fall upon the elbow, the shoulder not touching 
 the ground. 
 
 A pale thin girl (C. A.), aged fourteen years, came under the 
 
SEPAEATION OF UPPEE EPIPHYSIS OF HUMEEUS 173 
 
 care of M. Duplay at the Hopital de la Charite on February 4, 
 1893. About an hour previously she had fallen on to the right elbow 
 whilst sliding on the pavement ; this was followed by acute pain in 
 the corresponding shoulder. On examination there was great pain 
 on the slightest movement. The elbow was carried backwards and 
 the arm somewhat abducted, the forearm being flexed at a rio-ht 
 angle. Over the olecranon there was slight redness only ; but no 
 flattening of shoulder or projection of the acromion. In front of the 
 deltoid region, two good fingers' breadth below the acromio-coracoid 
 interspace, there was a slight projection forwards, with pain on 
 pressure, but an absence of blood extravasation. The osseous 
 border of this projection was about two centimetres broad, could 
 be felt below the greater and lesser tuberosities, and had a pro- 
 minent edge. Between this directly forward (and slightly inward) 
 displacement of the upper end of the diaphysis and the head (which 
 preserved its normal relations) a depression could be felt by the 
 finger, but on the posterior aspect of the shoulder no depression 
 could be made out under the epiphysis, although the thin condition 
 of the patient rendered palpation very easy. No mobility, shorten- 
 ing of the arm, or crepitus was felt. The diaphysis was clearly not 
 completely displaced off the epiphysis ; however, the effect of 
 rotation of the shaft upon the epiphysis could not be determined on 
 account of the reflex contraction of the muscles about the shoulder. 
 The least active movement of the arm was accompanied by great 
 pain. The arm was put up in a sHng. On the fourth day an 
 unsuccessful attempt was made to reduce the displacement by 
 traction on the lower end of the humerus, and again on the sixth 
 day a third attempt under chloroform also failed ; the limb was 
 then put up in a plaster splint. From this time the patient ex- 
 perienced no further pain. The sphnt was removed on March 3, 
 the twenty-seventh day. Although there was some wasting of the 
 deltoid, consolidation was perfect, and rotation and all other move- 
 ments of the shoulder-joint were completely restored. When the 
 patient was seen a month later, after the use of massage, &c., the 
 deltoid was normal, and the persisting deformity did not give rise 
 to any inconvenience whatever. 
 
 Allusion is made below to separation during extraction of the 
 child in delivery by dragging on the presenting arm, or by brinoino- 
 this down when the legs and body were already delivered, or by the 
 finger hooked into the axilla. 
 
 The following case has recently been recorded by Dr. J. Gurney 
 Taylor (University Medical Magazine, Philadelphia, vol. ix. No. 2, 
 November 1896, p. 118) as one of separation of the upper epiphysis 
 of the humerus in a male infant, aged five months, due to simply 
 lifting the child up by the arms. But it is a matter of some doubt if 
 so shght an injury to a healthy bone could have produced such acute 
 suppuration with pyemia; it appears more probable that the affection 
 
174 EPIPHYSES OF UPPEE EXTEEMITY 
 
 was rather of the nature of infective arthritis of infants. Four days 
 previous to admission into St. Christopher's Hospital for Children, the 
 child at its christening had been picked up by the arms several times. 
 From that time he had cried continually, and the following day the 
 left shoulder was noticed to be swollen. On admission the swelling 
 had greatly increased, reaching from the insertion of the deltoid to the 
 middle of the clavicle ; the axilla also was very much swollen. The 
 skin was tense and red, and there was ' pitting ' on pressure. Over the 
 tendon of the biceps there was fluctuation. The head of the humerus 
 was felt in its normal position, yet there was decided crepitus and 
 great pain upon motion. A diagnosis was made of fracture of the 
 humerus. The temperature was 104-5° F. and the pulse 180. Dr. 
 H. C. Deaver opened the abscess, which contained about 2 oz. of pus. 
 The humerus was intact, but the upper epiphysis was found to have 
 separated. Pysemia developed, and the infant died about two weeks 
 from the date of the accident. 
 
 Muscular action. — The only recorded case of displacement by mus- 
 cular action is that referred to by Colignon and quoted in Ashhurst's 
 EncyclopcBdia of Surgery, vol. iv. p. 121. This remarkable case is also 
 mentioned by Bouchut, as seen by Foucher (Memoire sur les dis- 
 jonctions epiphysaires) in the practice of M. Velpeau in 1855. A 
 girl, previously in good health, aged thirteen years, is said to have 
 produced this injury by muscular action in taking an embroidery 
 frame down from a wall above her head. A sudden crackling, 
 followed by acute pain, was experienced in the left shoulder. Con- 
 siderable swelling and redness of the shoulder, with fever, appeared. 
 An abscess formed, which was incised on the fom"th day, letting 
 out a great quantity of pus. It was noted at the time that the 
 upper end of the humerus was broken. Suppuration continued, with 
 diarrhoea and hectic, and death took place at the end of six weeks. 
 The diagnosis w^as verified by the autopsy. The extremity of the dia- 
 physis was in a state of necrosis at its upper third, and commencing 
 already to be exfoUated. The epiphysial cartilage remained with 
 the epiphysis, which was still in contact with the glenoid cavity, 
 heincf held there by the muscles inserted into it and by the capsule 
 of the joint. It had been separated from the diaphysis exactly 
 at the conjugal cartilage. The periosteum, though still remaining 
 attached to the epiphysis, was extensively separated. A vast purulent 
 ca^aty occupied the axilla, being Hmited by the deltoid and great 
 pectoral muscles. 
 
 It is questionable whether this was a true case of traumatic 
 separation, or one rather of acute purulent epiphysial osteo- 
 myelitis followed by detachment of the epiphysis at the juxta- 
 epiphysial region. 
 
 Other predisposing causes. — Mr. Cooper Forster had the case of 
 Thos. H., aged four, under his care in Guy's Hospital in October 
 1878. Five weeks previously he had fallen on to his right shoulder, 
 
SEPAEATION OF UPPEK EPIPHYSIS OF HUMEKUS 175 
 
 causing a separation of the epiphysis. Eight months before he had 
 been trephined for a compound comminuted depressed fracture of the 
 left parietal bone, and partial hemiplegia of the right side had since 
 been present. A pad was placed in the axilla, and the arm secured 
 to the body, and on his discharge twenty-six days afterwards there 
 was good mobility of the arm. 
 
 PATHOLOGICAL ANATOMY. Separation of the cartilaginous upper 
 end in the newly born infant or during delivery. — Such cases have 
 been frequently recorded as having occurred from violent traction 
 upon the arm or in the axilla during delivery, but in many of them 
 there is every reason to believe that some disease or altered condition 
 of nutrition was present in the bones. 
 
 Thus Bitot describes {Journal de Bordeaux, 1859, and Gazette 
 Medicate de Paris, 1860) a very interesting case of separation of the 
 upper epiphysis of the humerus which had been brought about by 
 violent traction at the arm, combined with a see-saw movement. 
 The shoulder was not deformed, but there was pain when the arm 
 was moved. Death ensued at the end of twelve days, and at the 
 autopsy the epiphysial separation was discovered and the humerus 
 found to be notably diminished in size, being one centimetre shorter 
 than that of the sound side. 
 
 From the shortening of the humerus (which was supposed to 
 have taken place in the brief space of twelve days), from the altered 
 condition of the bicipital groove and upper end of the bone found 
 on comparison with the sound side, it is evident that the separation 
 in this case cannot be considered as one due entirely to injury to a 
 healthy bone. 
 
 The cases recorded by Bertrandi of Turin {Opere ajiatomiche 
 e cerusiche, tom. v. Torino, 1787-8, p. 163), De la Motte, and 
 Dubroca {Bull. Medical de Bordeaux, 1835) come under the same 
 category. They are so open to doubt that the propriety of accepting 
 them as true separations unaccompanied by disease or maceration 
 must be carefully considered. 
 
 In some cases, however, union took place in eight to twelve 
 days. In Dubroca's case the callus was very excessive, so that 
 the shoulder was three times its proper circumference. 
 
 Examples in still-born and other new-born infants are doubtless 
 of the same description, often caused by traction on the arm in 
 shoulder presentation. No account has been taken in the present 
 work of several other separations of the upper cartilaginous end of 
 the humerus occurring in new-born infants, and produced by violent 
 traction during birth, such as those related by Bruns, Durocher, 
 Volkmann, Hamilton, Eeichel, and others. 
 
 These epiphysial fractures of the humerus in the new-born are 
 treated by Professor O. Kiistner {Annals of Surgenj, vol. i. No. 5, 
 May 1885, p. 492 ; ' Ueber epiphysaire Diaphysen-Fractur am 
 Humerus der Neugeborenen, Archiv f. Idin. CJiir. Berl. 1884, 
 
176 EPIPHYSES OF UPPEE EXTEEMITY 
 
 xxxi. 310 ; ' Verletzungen des Kindes bei der Geburt,' Handhuch 
 der Gehurtshillfe, Bd. iii. Stuttgart, 1889). In their situation, 
 from the fact that the junction of the cartilaginous ujper end lies 
 nearer the diaphysis, they approach more nearly fractures of the 
 
 surgical neck in adults. 
 Pajot {These d' Agreg. 
 Supraspmcmai_M^~.. A 1853, Paris) found that a 
 
 ff^^^m^f!!Z-iE=Sc^ ) ^veight of thirty-five kilo- 
 
 grams (77 lb.) was sufficient 
 ^LaUss.dorst. *o ^^tach this epiphysis in 
 _Teres major. ^^'^^ new-born, and only 
 nineteen kilograms (41 lb.) 
 Fig. 33. — frontal section of the upper end of were needed when the soft 
 THE HUMERUS AT BIRTH ^^^^g j^^^ ^^^^ removed. 
 
 y , head of the bone ; a, greater tuberosity. It T "H V. ' ^nv, 
 is seen that the junction of the cartilaginous ^^^ JJUrOCner S CaSB (Una- 
 upper end encroaches more on the diapliysis at pelain Durocher, TheSB 
 this period tlaan later. The attachments of the • 1 Q "P ' Q 
 rotator muscles are indicated. (After Kiistner.) mauguraie, OVO. JrariS, O 
 
 frimaire an xii.) the child 
 died fourteen months after an injury of this kind. 
 
 In Volkmann's {Beitrdge zur Chirurgie, 1875, S. 72) case of 
 separation of the upper cartilaginous end of the right humerus in a 
 newly born infant from traction during delivery, death" took place 
 on the fifth day. The separation was found to have taken place 
 cleanly between the cartilage and the bone, except on the inner 
 side, where the fracture ran somewhat through the bone. There 
 was also an oblique fracture of the left clavicle and subluxation of 
 the sterno-clavicular joint. 
 
 Separation of the upper epiphysis of the humerus after infancy. — 
 Palletta, in his Exercitationes PatJiologiccB, 1820, alludes (cap. vi. 
 p. 59) to the possibility of separation of the upper epiphysis of 
 the humerus ; and Malgaigne, in his work Anatomie chirurgicale, 
 considered this injury to be excessively rare. He says : ' It is 
 only from the eighteenth to the twentieth year that the union of 
 the epiphysis with the diaphysis is concluded, and up to that time 
 separation of the epiphysis may take place. These separations 
 are, however, very rare, and are more difficult of production as 
 the child increases in age. I know of only four examples alto- 
 gether ; two brought about during labour, a third in a child whose 
 age was not given, and the fourth observed by Champion in a child 
 of eleven.' 
 
 Boyer, writing in the Dictionnaire des Sciences medicales, toin. 
 xxii. p. 1, referred to separation of this epiphysis as .a very rare 
 accident, possible only in the very earliest years of life. 
 
 It is somewhat remarkable that so few specimens of this lesion 
 are preserved in museums, since we recognise the injury during life 
 as being of common occurrence. The author has been able to 
 collect only eight. 
 
SEPAEATION OF UPPEE EPIPHYSIS OF HUMEKUS 177 
 
 Many compound separations, and cases operated upon for 
 deformity, or for irreducibility soon after the accident, prove, how- 
 ever, that it is not so rare as is generally supposed. 
 
 Gurlt collected three cases in which the injury was caused 
 during delivery (mentioned above), one each in children aged four, 
 eleven, and fifteen years, and a specimen obtained three years after 
 the injury. 
 
 Bruns collected only eleven cases confirmed by anatomical 
 inspection ; all these are fully related below. 
 
 But, as Bruns says, this epiphysial separation occurs much 
 more frequently than is generally supposed, and is one of the most 
 common forms of the injury. 
 
 In all these specimens, and in compound separations, the whole 
 of the upper extremity of the bone is detached — the head, with the 
 tuberosities attached, being still in contact with the glenoid cavity 
 of the scapula ; and the synovial membrane is often uninjured. 
 
 Separation of either of the tuberosities is possible before their 
 union with the head — that is, up to the end of the fifth year. Such 
 a lesion would probably be extracapsular, unless the violence were 
 so severe as to lacerate the bicipital extension from the synovial 
 membrane. The author cannot find any specimen of such a lesion 
 or of simple separation of the osseous head. The latter is very 
 improbable as the result of injury, and would be entirely within 
 the capsule of the joint. 
 
 PuEE Sepaeations. — Pure separation through the cartilage is 
 extremely rare. 
 
 The separation took place, in Esmarch's case, through the 
 substance of the conjugal cartilage, one layer of which remained 
 attached to the epiphysis and another to the diaphysis. 
 
 In Foucher's case the whole of the epiphysial cartilage, as 
 usually happens, remained with the epiphysis. 
 
 In one of two cases operated upon by Professor De Paoli of 
 Perugia, the diaphysial end was said to be covered here and there 
 with small areas of the conjugal cartilage. 
 
 According to Michniowsky, separation never occurs through the 
 cartilage. Although this statement cannot be accepted, in a very 
 large proportion of cases the conjugal cartilage becomes detached 
 from the diaphysis through its ossifying line and remains attached 
 to the epiphysis ; and often small granules of bone of the diaphysis 
 still adhere to the conjugal cartilage, though they are not large 
 enough to constitute a fracture of the diaphysis. 
 
 Out of Dr. Jetter's seven cases in which the diagnosis was 
 confirmed by operation three were pure separations and three con- 
 nected with an oblique fracture through the diaphysis ; in one the 
 condition could not be made out with accuracy on account of the 
 formation of two sequestra of bone. From these cases, Dr. Jetter 
 believes that pure separations are more frequent in the earlier 
 
178 EPIPHYSES OF UPPEE EXTEEMITY 
 
 years of life ; but he records one in a woman aged twenty-three 
 years. 
 
 PuEE Sepaeatioxs WITH DisPLACEiMEXT. Complete displacement 
 forwards and inwards of the diaphysis. — Esmarch {Archiv fiir Min. 
 Chiriirg. 1863, Bd. iv. S. 585 ; also Caspar Xissen, De resectionihus, 
 Diss. Inang. Kilise, 1859, iv. S. 8) describes the case of a boy aged 
 fifteen, whose left arm was seriously injured by a threshing machine. 
 There was a lacerated wound at the inner margin of the deltoid 
 muscle, through which the upper end of the diaphysis protruded five 
 centimetres in length, with a thin layer of bluish cartilage covering 
 it. The separation had taken place through the epiphysial cartilage, 
 and the muscles were found to be ]nuch lacerated. The diaphysis 
 could only be reduced after resection of two centimetres of its end 
 and division of some muscular fibres. The wound rapidly healed, 
 with free movement of the joint and two centimetres shortening. 
 The separation had probably taken place in the midst of the conjugal 
 cartilage. 
 
 In three of Dr. Jetter's cases which were operated upon for 
 deformity the displacement was complete ; the epiphysis had entirely 
 left the diaphysial end, and had united to the side of the diaphysis, 
 with which it was in contact. In two of the cases the displace- 
 ment was extreiue. In Dr. C. McBurney's case, treated by open 
 operation for irreducibility of complete displacement of the dia- 
 physis from the epiphysis, the separation was found to be exactly 
 at the junction of the epiphysis and the shaft. 
 
 B. W. Smith thought that complete displacement of the diaphysis 
 off the epiphysis was of very rare occurrence, and could not occur 
 without being compound. 
 
 Incomplete displacement forwards of diaphysis. — The diaphysis is 
 more frequently displaced only half the Vvddth of its diameter off 
 the epiphysis, but the distance may be more or less than this. 
 
 There are two museum specimens and several others verified 
 during life in which this form of displacement occurred. 
 
 Packard alludes to a notable example of epiphysial disjunction in 
 the Mutter Museum (Ashhurst's EncijdopcEclia of Surgery, vol. iv. 
 p. 122), in which the lower fragment overlapped the upper inwardly 
 and in close contact with it, while the latter was tilted by the action 
 of the scapular luuscles, so that a space was left — filled up, however, 
 by callus — between the two fragments at the outer part of the 
 fracture. 
 
 Another specimen in the Musee Dupuytren, ISTo. 91, is figured 
 by Malgaigne in his treatise on fractures {Traite des Fractures et 
 des Luxations, 1855, vol. i. p. 72 ; Atlas, plate i. fig. 4 ; Champion, 
 Journ. Complement du Diction, des Sc. Med. Paris, 1818, vol. i. 
 p. 318 ; Bulletin de la Faculte de Medecine de Paris, 1812, No. vi. 
 p. 117). There was a complete separation of the epiphysial line, but 
 at the outer side of the diaphj'sis there was a small splinter torn off 
 
SEPAEATION OF UPPER EPIPHYSIS OF HUMERUS 179 
 
 Fig. 34. champion's specijien 
 of sepap>atiox of the upper 
 epiphysis of the hrmeeus 
 
 (mALGATGXe). ON THE OUTER 
 SIDE A TAG OF PERIOSTEUM 
 COVERS A SMALL SCALE, WHICH 
 HAS BEEN DETACHED FROM 
 THE DIAPHYSIS 
 
 which remained attached to the epiphysis. The diaphysis was dis- 
 placed inwards, passing beyond the epiphysis for several millimetres, 
 and the epiphysis was connected with the diaphysis only on the outer 
 side. The periostemn in many places was torn from the diaphysis, 
 especially on the inner side, and was hang- 
 ing to the epiphysis. The synovial capsule 
 was lacerated towards the front and inner 
 side. It was taken from a boy aged eleven, 
 who was injured by his arm being caught 
 in the spokes of a wheel and his body 
 thrown violently backwards. The end of 
 the humerus could be felt through a deep 
 and contused wound at the outer part of 
 the axilla, and there was extensive lacera- 
 tion of the skin of arm and forearm. Death 
 occurred on the seventh day from exhaus- 
 tion. A portion of the skin of the arm 
 had become gangrenous. The separation 
 had not been detected before death. The 
 artery, nerves, and muscles were intact. 
 
 In many cases which have now been 
 operated upon for deformity, the epiphysis 
 
 has been found placed upon and united to the outer aspect of the upper 
 end of the diaphysis, which has not completely left the epiphysis. 
 
 The same displacement, although complete, occurred in H. E. 
 Clark's case (vide infra). 
 
 Incomplete displacement backwards of the diaphysis is rarely met 
 with. St. Bartholomew's Hospital Museum contains a specimen, 
 No. 909 {Catalogue of the Anato- 
 7nical and PatJiological Musetmn 
 of St. BariJwlomew's Hospital, 
 vol. i. p. 132), in which the dia- 
 physis is displaced backwards 
 halfway off the epiphysis, the 
 epiphysis retaining its normal 
 position. The periosteum and 
 part of the capsular ligament 
 remain attached to the epiphysis 
 on the inner and outer aspects. 
 There is a rent in the periosteum 
 on the posterior aspect through 
 which the diaphysial end pro- 
 jects. The diaphysis is not frac- 
 tured, but a fracture extends 
 through the body of the scapula 
 and through the base of the coracoid process, indicating severe 
 violence ; but unfortunately there is no history of this interesting 
 
 N 2 
 
 Fig. 35. incomplete displacement back- 
 wards OF HUMERAL DI.APHYSIS (ST. BAR- 
 THOLOMEW'S HOSPITAIi MCSEUJr) 
 
180 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 specimen, excepting the statement tliat it was taken from a young 
 person. 
 
 Thndicliiun, in his account of fractures occurring in the upper 
 end of the humerus (Ueher die am oheren Ende des Humerus 
 vollkommenden Knochenhrilche, Giessen, 1851) provides a description 
 analogous to Malgaigne's preparation in a child four years old. 
 
 But in this case, from the figure given by Thudichum, it appears 
 that the displacement is backwards. The preparation is in the 
 Pathological Museum at Giessen, No. 35, 125 a. The capsule was 
 torn in two places — at the inner side from the lesser tuberosity, and 
 on the posterior aspect from the edge of the glenoid cavity of the 
 scapula up to the greater tuberosity. The diaphysis projected back- 
 wards, and the periosteum was separated from it for a short distance. 
 The capsular ligament was stretched and lengthened on the inner side. 
 
 Fig. 36. — traumatic separation of the tppek epiphysis of the humerus, ixcom- 
 
 PLETE DISPLACEMEXT BACKWAKDS. (aFTEE THUWCHUM, COPIED BY BEUXS, DeUtSCllC 
 
 CMriirgic, 1886, Cap. xi. S. 122) 
 
 The child from whom the specimen was taken had its left arm 
 thrown violently and Cjuickly upwards and in a lateral direction. 
 It died from inflammation of the brain a few days later. 
 
 Dr. J. Ludw. Thudichum gives the following description (' Die 
 Absprengung de Epiphysen,' lUiistr. med. Zeitsclir. 1855, Bd. iii. 
 S. 188) and figures the same case. The child was three or four 
 j^ears of age. The separation was said to be complete through the 
 epiphysial line, and was caused by the patient suddenly throwing its 
 arm upwards and somewhat laterally. There was no displacement, 
 on account of the ligamentous tissues about the tuberosities being 
 intact ; the periosteum, however, was partly separated from the 
 diaphysis, and the capsular ligament torn in two places. Death 
 resulted in a few days from other causes. 
 
 Complete displacement backwards. — A specimen of compound 
 separation in which this form of displacement occurred has recently 
 
SEPAEATION OF UPPEK EPIPHYSIS OF HUMEEUS 181 
 
 {St. Thomas's Hospital Beports, N.S., vol. xxiv., 1895, p. 375) been 
 placed in the museum of St. Thomas's Hospital. A boy aged 13 
 was run over by a van across the chest and sustained an anterior 
 dislocation of the sternal end of the clavicle and a compound separa- 
 tion of the upper epiphysis of the left humerus, the bone protruding 
 on the posterior aspect of the arm. The wound was cleaned, and 
 through it the shaft and epiphysis were manipulated into position. 
 The periosteum was 
 then stitched over the 
 shaft to retain it in its 
 normal axis. The joint 
 apparently was not 
 opened. Pneumothorax 
 was present on the 
 right side, and surgical 
 emphysema appeared 
 at the root of the neck 
 in front and spread into 
 the arms, neck, and 
 abdomen. The wound 
 in the arm suppurated, 
 and although pus was 
 evacuated from the 
 chest, death took place 
 on the sixteenth day. 
 At the autopsy the pyo- 
 pneumothorax on the 
 right side was found to 
 be due to a longitudi- 
 nal rupture of the right 
 bronchus. There were 
 no fractured ribs. 
 
 Complete displacement outwards of diaphysis. — Charles AVilliams 
 describes {Lancet, July 15, 1865, vol. ii. p. 66) a case of compound 
 separation in which the diaphysis was driven through the deltoid 
 muscle. A farm boy, aged nineteen, was thrown from a cart-horse 
 and fell with great force on to the right elbow, producing on the 
 outer aspect of the right shoulder a transverse wound, through 
 which the diaphysis protruded for one inch, penetrating the deltoid 
 muscle. It was directed upwards, through the muscle above the 
 level of the head of the bone ; its upper surface was rough, and 
 corresponded with the under surface of the epiphysial cartilage. 
 Eeduction was effected with ease after the removal of the prominent 
 portion of the diaphysis. The diaphysis was drawn into the wound 
 and placed under the epiphysis, which was still in contact with the 
 glenoid cavity. The wound reinained unhealed for a long time. 
 Two years afterwards some necrosed bone was removed. Half a 
 
 Fig. 37. — pure separation of the upper epiphysis op 
 the humerus with complete displacement backwards 
 of the diaphysis (st. thomas's hospital museum) 
 
182 EPIPHYSES OF UPPEE EXTEEMITY 
 
 year later all the necrosed bone had come away. The shape and the 
 rotundity of the shoulder were perfect and the union firm, so that 
 the youth could move his arm in any direction, and had followed his 
 occupation for some months. The case was under care for three 
 years and seven months. 
 
 Malgaigne alludes to another compound case. 
 
 ' Bichat says he has seen the lower fragment carried upwards 
 with so much violence as to pierce the integuments and pass up 
 much above the level of the head of the bone ; and M. Gueretin has 
 reported an instance in which the wound was caused by the lower 
 fragment piercing through the deltoid and integuments. The patient 
 was injured by the caving in of a gravel bank. The purulent dis- 
 charge from this wound was enormous. Amputation was performed 
 on the forty-ninth day, and death ensued on the sixty-third. It is 
 remarkable that the amputation was intended to be and was sup- 
 posed to have been done through the joint, but at the autopsy the 
 head of the bone was found in place ; its end was hollowed out to 
 the depth of about one-third of an inch, and this concave surface 
 had been mistaken for the glenoid cavity.' 
 
 In the case of compound epiphysial diastasis related by K. W. 
 Knox {Medical Netus, Philadelphia, 1885, xlvii. p. 622) a lad, D. C, 
 aged sixteen, received an injury whilst racing, his horse falling upon 
 him. The shaft of the humerus protruded through the skin for one 
 inch over the outer, or rather inferior, aspect of the deltoid muscle ; 
 and the end of the bone presented a transverse surface without 
 spicules, comparatively smooth and devoid of cartilage. The head 
 of the humerus could not be reached with the finger in the wound, 
 but externally was felt to be in situ. Reduction was easily effected 
 under chloroform, and an inside angular splint of zinc and shoulder- 
 cap of felt moulded from the hand to the shoulder was applied. 
 Bapid and complete recovery took place, and six months afterwards 
 there was perfect movement and no appreciable difference in the 
 size of the two arms. 
 
 A specimen of compound separation of the superior epiphysis of 
 the humerus, with comminution of the diaphysis close to the line of 
 the epiphysiary cartilage, was shown to the Pathological Society of 
 Dublin by Dr. E. H. Bennett {Proceedings of the Pathological Society 
 of Dubli7i, N.s. vol. vii. 1877, p. 220 ; Diihlin Journal of Med. Science, 
 1877, vol. Ixiii. p. 491). A powerfully built boy, aged about fifteen 
 or sixteen years, was struck by the pole of a tramcar and knocked 
 down, receiving, besides the injury to the humerus, an extensive 
 fracture of the base of the skull and an impacted fracture of the 
 shaft of the femur, from which he died in four or five hours' time. 
 When the boy was admitted into Sir P. Dun's Hospital, the diaphysis 
 was seen protruding for two inches through the skin on the outer 
 side of the limb above the groove of insertion of the deltoid muscle, 
 and the bone was entirely stripped of periosteum. On dividing the 
 
SEPAEATION OF UPPEE EPIPHYSIS OF HUMEEUS 183 
 
 skin and deltoid muscle vertically the lower fragment could with 
 some difficulty be replaced. On dissection a small part of the 
 mammillated surface was present on the diaphysis, and the project- 
 ing points of the diaphysis in the centre and on the inside had been 
 broken off, and were seen lying detached alike from the cartilage 
 and diaphysis, except that a few shreds of periosteum still connected 
 them to the cartilage. The periosteum, torn completely through on 
 the outside, was stripped off the diaphysis down to the insertion of 
 the deltoid, and even beyond this. It lay in shreds on the inner 
 limit of the wound, and still retained its connections with the epiphysis 
 undisturbed, the epiph3^siary cartilage, as it were, preventing any 
 detachment of it from the upper fragment. 
 
 The London Hospital Museum contains two specimens of this 
 separation, No. 376 from a young adult, and No. 377 probably from 
 a child four or five years old. 
 
 Juxta-epiphysial separation. — The separation, though a pare and 
 complete one, may traverse the osseous material of the diaphysis, 
 which directly adjoins the conjugal cartilage. A thin layer of the 
 diaphysis in this manner remains adherent to the epiphysis. This 
 is termed juxta-epiphysial separation by Oilier, and is probably a 
 very frequent form of lesion, but it requires further confirmation by 
 more specimens than those now recorded. 
 
 Complications. — Separation loith fractiLre of the ejnphysis can 
 only result from severe direct violence. 
 
 In the London Hospital Museum, No. 372 (Descriptive Cata- 
 logue of the Pathological Museum of the London Hospital, 1890, 
 p. 89), there is a specimen showing the epiphysis of the head torn 
 off, and a vertical line of fracture separating the great tuberosity, 
 the bicipital groove, and a portion of the lesser tuberosity from the 
 head of the bone. The shaft of the bone has clearly been crushed, 
 its upper end is wanting, and there are the marks of spikes on its 
 surface. It is about two inches long, and the lower extremity is 
 irregular, as if fractured. 
 
 Separation with fracture of the greater tuberosity. — Gurlt (LeJire 
 von den Knochenhriichen, II. Theil, S. 698, fig. 92) figures a specimen 
 of fracture in the epiphysial line with fracture of the great tuberosity, 
 which was separated from the head and shaft. The upper fragment 
 was placed beneath the coracoid process, and was slightly hollowed 
 out on the under side for the humeral shaft. It was taken from the 
 body of a sailor aged seventeen, who had been thrown against the 
 side of a ship and taken into Langenbeck's Klinik eight weeks after 
 the injury. There was some projection of the acromion, and below 
 the acromion there existed an arched projection, which could also 
 be felt from the axilla, and was connected with the articulation. 
 This projection became more prominent during abduction and 
 movement of the arm backwards. The arm was slightly drawn 
 backwards and abducted. The movements were very restricted. 
 
184 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 Fig. 38. — sepaeatiox of the upper 
 epiphysis with fpvacture of the 
 
 GREAT TUBEROSITY (a^-TER GUELT) 
 
 especially forwards. Ten days later an attempt at reduction was 
 made by Sclineider-Mennel's apparatus, and was followed by 
 death from septicemia {Senftlehen, 1855). 
 
 Fracture of diajjhysis is a very fre- 
 quent form of injury. The line of 
 separation commonly deviates to some 
 extent from the epiphysiary junction, 
 and traverses somewhat obliquely the 
 soft and friable osseous tissue of the 
 diaphysis, so that the injury is partly a 
 separation and partly a true fracture. 
 
 Erom the age of two or three years 
 upwards a few osseous granules gene- 
 rally adhere to the epiphysial cartilage 
 which has been detached, but these are 
 not sufficiently large to constitute a 
 fracture of the diaphysis. 
 
 The fragments detached from the 
 diaphysis clinging to the epiphysis are 
 often found to be small, but, on the other 
 hand, large w^edge-shaped splinters may 
 be split off, as in P. Bruns's, Bennett's, 
 KJnox's, Champion's, and Eondon Hospital cases. 
 
 Jetter thinks this combination of fracture and epiphysial frac- 
 ture to be most frequent about the twentieth year. 
 
 The diaphj^sial fragments may be from the outer side as in 
 Champion's case, or from the inner side. In one of Mr. Johnson 
 Smith's cases {loc. cit. infra) the shaft of the humerus on the inner 
 side was involved by a fracture of 2| inches in length; in one of 
 Bruns's cases by a fractm'e of the shaft on the outer side. 
 
 There was comminution of a portion of the diaphysis close to 
 the epiphysial line on the inner side in Bennett's case. 
 
 Lange'& case was accompanied by an oblique fracture of the 
 diaphysis on the inner and posterior aspect, reaching for two inches 
 below the epiphysial line. 
 
 Detachment of periosteum is one of the most important lesions. 
 The periosteum, being loosely attached to the diaphysis and more 
 strongly to the epiphysis, is always stripped off the diaphysial end 
 to a greater or less extent, and has the appearance of a deep cup 
 attached to the lower edge of the epiphysis, so that probably other 
 muscles than those directly attached to the epiphysis — e.g. the lower 
 fibres of the teres minor— will be detached with the periosteum 
 and act upon this fragment. The periosteum is never stripped off 
 from the epiphysis. In Foucher's specimen and many others it is 
 clearly noted that the periosteum remained attached to the epiphysis, 
 while it was extensively separated from the diaphysis. The extent 
 of the detachment of the periosteum will vary, as a rule, with the 
 
SEPAEATION OF UPPEE EPIPHYSIS OF HUMEEUS 185 
 
 intensity of the violence, and consequently with the amount of dis- 
 placement of the diaphysis ; as age advances and the periosteum 
 becomes more adherent, the detachment will be less extensive. 
 
 The periosteal sleeve detached from the diaphysis may be five to 
 ten centimetres in length. 
 
 Laceration and jjeneti'ation of the deltoid at its anterior margin by 
 the upper end of the diaphysis is of frequent occurrence where the 
 displacement is considerable, but it will be found to a less extent in 
 cases of incomplete displacement. 
 
 M. Eollet noted this lesion in three cases which had been operated 
 upon. The author saw it also in one of Mr. Johnson Smith's cases. 
 
 The deltoid was lacerated in Pery's case. 
 
 This lesion will contribute very materially to the difficulty in 
 reduction as well as, later on, to impaired functional activity of the 
 limb ; and, taken along with locking of the lower into the upper 
 fragment, it forms one of the most urgent reasons for immediate 
 operation. 
 
 Wounds. — Compound separation of the upper epiphysis of the 
 humerus is a rare injury. P. Bruns, of Tubingen, collected four 
 cases of compound separation. 
 
 In two out of seven cases of compound diaphysial separation of 
 the upper end of the humerus, the wound was on the inner or front 
 aspect of the shoulder to the inner side of the deltoid nauscle ; the 
 other five were on the outer side penetrating this muscle. Two of 
 the latter ended fatally. In the St. Thomas's Hospital specimen the 
 end of the diaphysis projected on the posterior aspect of the arm. 
 
 Wound of axillm-y artery. — It is remarkable that the brachial 
 plexus and other important nerves and vessels in the neighbourhood 
 of the upper end of the humerus are not often injured. 
 
 One unique case is related by H. E. Clark {Glasgow Medical 
 Journal, n.s. vol. xxvi. 1886, p. 206, plate, p. 210) of compound 
 separation complicated with wound of the axillary artery. The 
 wound of the soft parts was not very large, and there was very little 
 laceration. 
 
 A boy, aged thirteen, had his arm caught in machinery, and was 
 suddenly raised by the hand and arm with a jerk, the arm being drawn 
 upwards and outwards. The injury was supposed to be a compound 
 fracture of the humerus close to the head, the fragment protruding 
 through the skin at the lower part of the axillary space. Although 
 there was free hemorrhage from the wound and the arm and hand 
 were a little cold, with absence of pulsation in the radial artery, yet 
 the colour of the skin was good and the fragment easily reduced 
 under ether. Gangrene of the hand and wrist, however, set in on 
 the fourth day, necessitating amputation at the shoulder-joint by 
 Dupuytren's method and removal of the upper epiphysis, the operation 
 being followed by good recovery. On dissection, the capsule of the 
 shoulder-joint was found not torn at any part, and the tendon of the 
 
186 EPIPHYSES OF UPPEE EXTEEMITY 
 
 biceps still traversed the articular cavity ; but that part of the 
 capsule which extends below the anatomical neck was separated 
 from the diaphysis along with the periosteum. The axillary artery 
 was plugged above the line of amputation. The specimen is in 
 the museum of the Glasgow Eoyal Infirmary. 
 
 Injury to shoulder -joint. — It is but seldom that this separation is 
 complicated with any direct lesion of the shoulder-joint. 
 
 From the records of six cases Gurlt believed that laceration of 
 the articular capsule was frequent. 
 
 The part of the capsular ligaments which extends below the line 
 of the anatomical neck on the inner side is usually separated from 
 the diaphysis with the periosteum, and so in the majority of cases 
 escapes laceration. 
 
 Its proximity to the epiphysial junction should, however, make 
 us guard against subsequent articular inflammation, and attempts 
 at reduction of a supposed dislocation may soon be followed by 
 symptoms indicative of articular lesion. 
 
 In Champion's case the synovial capsule was lacerated at the 
 front and inner aspect. 
 
 Separatio7i tvith displacement or dislocation of the epiphysial head. 
 Although no specimen has been recorded of such a rare injury, the 
 analogous accident in the adult has been frequently verified and 
 its pathology studied. In most of those cases the lower fragment 
 has been found lying on the outer side of the upper fragment, 
 and more or less drawn upwards and outwards towards the glenoid 
 cavity. For an excellent treatment of this subject Dr. Charles 
 McBurney, and Dr. C. N. Dowd's article ' On Dislocation of the 
 Humerus complicated by Fracture at or near the Surgical Neck, 
 with a New Method of Eeduction' {Annals of Surgery, 1894, April, 
 p. 399), should be consulted. Eeferences will be found here to 
 Oger's Paris Thesis, 1884, together with a list of published cases ; 
 and a very complete paper on this subject is given by Poirier and 
 Mauclaire {Bevue de Chirurgie, October 10, 1892). A satisfactory 
 discussion of the subject is to be found in L. A. Stimson's Treatise 
 on Dislocation. 
 
 At times the concomitant lesions are so extensive that death 
 results in a few hours, as in Champion's case, where the child 
 succumbed twenty-two hours after the accident. 
 
 Periostitis and necrosis of the suppurative kind are uncommon 
 except in compound cases. They occurred in Foucher's case ; an 
 enormous abscess formed in the axilla, with commencing necrosis of 
 the diaphysis, and terminated in death at the end of the sixth week 
 from pyaemia. 
 
 In a case reported in 1878 by Esmarch (Archiv filr hlin. 
 Chirurg. vol. xxi. 1878) a large abscess formed, and led to the 
 removal of the epiphysis and a portion of the upper end of the shaft 
 of the humerus ; the injury had been mistaken for a dislocation of 
 
SEPAEATION OF UPPEE EPIPHYSIS OF HUMEKUS 187 
 
 the shoulder, and two attempts had been made to reduce it. A 
 useful limb was the result, for there was but little shortening and a 
 free shoulder-joint. 
 
 Dr. Jetter relates a similar instance of secondary suppuration and 
 necrosis of part of the epiphysis, as well as of the diaphysis, after 
 separation. A boy (F. P.) aged seven years had fallen seven weeks 
 previously from a tree about two metres high. There was great 
 pain and swelling, but no wound. A sprain was diagnosed by a 
 doctor, and leeches and ointment ordered. After eight days the 
 father observed something projecting beneath the skin and took the 
 child again to the doctor, who ' set ' the arm and applied a stiff 
 bandage. But three weeks later the father, perceiving pus soaking 
 through the bandage, took it off and brought the child to the 
 hospital on October 15, 1886. The boy was pale and thin, with 
 diffuse swelling about the left shoulder, and a small granulating surface 
 discharging thick pus situate between the acromion and cora.coid 
 process. The arm was shortened two centimetres ; the movements 
 of the joint were free but painful. On October 19 a large sequestrum 
 (one centimetre), showing the characteristic forination of the upper 
 epiphysis of the humerus, was removed by means of forceps. The 
 following day, under an anaesthetic, the movements of the joint were 
 free, showing that consolidation had taken place. Suppuration was 
 found to have extended down the inner side of the humerus. The 
 abscess cavity was therefore scraped out, and a sequestrum of the 
 upper part of the humerus removed about the size of a bean. 
 By November 11 the functions of the arm were good, and the patient 
 was discharged, the wound being nearly healed. 
 
 Compound separations not infrequently have been followed by 
 septic wound infection, giving rise to profuse suppuration of the 
 arm, secondary ostitis and periostitis from the stripping up of the 
 periosteum and injury to the osseous tissue, and leading to more or 
 less necrosis of the end of the diaphysis. 
 
 P. Bruns mentions (Langenbeck's Arcliiv fur hlin. Chirurg. 
 Bd. xxvii. S. 240) the case of a boy aged nineteen who was thrown 
 against a waggon-wheel by a falling weight. There was found a 
 complete separation of the epiphysis, with only a few fragments of 
 the diaphysis adhering to it, and the diaphysial end penetrated the 
 skin and soft parts. Firm union took place, but with necrosis of 
 the end of the diaphysis, which required, after the lapse of ten 
 months, the removal of a sequestrum two centimetres in length 
 involving the whole circumference of the bone. 
 
 Charing Cross Hospital Museum affords a similar example 
 (specimen No. 37), and displays the epiphysis and upper part of the 
 shaft of the humerus removed by Mr. Hancock from a lad who 
 suffered separation of the upper epiphysis from accident, necrosis 
 subsequently attacking the bone. The separation appears to have 
 taken place completely through the epiphysial junction, although 
 
188 EPIPHYSES OF UPPEK EXTEEMITY 
 
 several necrosed plates of the inner and posterior aspects of the 
 diaphysial end have been removed. 
 
 Necrosis also occurred in Charles Williams's case [vide siqjva). 
 
 Dr. G. Pery, of the Bordeaux Faculty of Medicine, has kindly 
 furnished the author with an account of an interesting case published 
 by him in 1861 (' Desepiphysation de I'extremite superieure de 
 I'humerus/ Union Med. de la Gironde, Bordeaux, 1861, torn. vi. 
 pp. 49-51). 
 
 The separation was a compound one with displacement forwards 
 of the diaphysial end of the humerus. Suppuration and sloughing 
 of the wound ensued, and death took place on the sixth day. 
 Paraplegia also complicated the case, being due to haemorrhage into 
 the spinal meninges. 
 
 Jean M., aged sixteen years, was admitted into the hospital 
 November 3, 1860, under the care of M. Dupuy, having fallen from 
 nearly the height of a second story, A doctor who saw him at the 
 time replaced the end of the humerus, which protruded through 
 the skin, but reduction w^as not completely effected. A temporary 
 dressing was applied. The following day M. Dupuy noticed that 
 the patient lay upon his back in a semi-unconscious condition. 
 Paraplegia was present, with loss of power over the bladder and 
 rectum. On the outer side of the shoulder, almost at the middle of 
 the deltoid, there was an oblique wound four centimetres across, 
 through which the index finger could feel the upper extremity of 
 the lower fragment quite disconnected from the upper fragment. 
 This extremity was unlike an ordinary fracture with its sharp 
 projection, but, on the contrary, was rough in a uniform kind of 
 way and somewhat rounded off. Separation of the upper epiphysis 
 w^as diagnosed by M. Dupuy, and attempts were made to complete the 
 reduction of the fragments, but without success. 
 
 Water dressings and a retentive apparatus were applied. 
 Delirium followed, and on November 6 sloughing of the edges of 
 the wound commenced with suppm'ation. On November 7 a 
 counter opening was made at a dependent spot, letting out some 
 foetid pus, and a drain was inserted from one opening to the other. 
 On November 9 the patient died in a comatose condition. 
 
 At the necropsy the thoracic organs and abdomen were found 
 to be healthy, and there was no external lesion of the vertebral 
 column. On opening the spinal canal small extravasations of blood 
 were found on the inner aspect of the lamina, and on the posterior 
 aspect of the bodies of the vertebrae at the end of the dorsal and in 
 the lumbar regions ; but there was no appreciable alteration in the 
 spinal cord. Beneath the skin of the right shoulder there was a 
 collection of thick pus, and the deltoid was fomid to have been 
 lacerated by the humeral diaphysis. The end of the diaphysis or 
 lower fragment was rounded and but little roughened on the outer 
 side, while on the inner side it was a little more so. The upper 
 
SEPAEATION OF UPPEE EPIPHYSIS OF HUMEEUS 189 
 
 fragment, composed of the head and two tuberosities, was hollowed 
 out corresponding to the end of the lower fragment. On the outer 
 third of its surface the remains of the epiphysial cartilage were 
 clearly to be seen. On the inner side, on the other hand, the thin 
 compact layer which completes the diaphysial end above remained 
 adherent to the epiphysial fragment. At the periphery there was 
 some tearing away of the compact tissue, which dragged with it 
 some small splinters of the diaphysis. 
 
 Gangrene of arm, from pressure on the axillary artery, occurred 
 on the fourth day in Clark's case of compound separation, and in 
 Hamilton's case. 
 
 Fig. 39. — diagram of separation of the upper epiphysis of the hujieeus, with 
 very little space between the fragments and no displacejient 
 
 Ankijlosis (osseous) is likely to occur in compound cases 
 attended with suppuration, but no specimen has been recorded. 
 
 Separation without displacement may certainly occur, if we are 
 to regard the numerous clinical examples recorded, but as yet it has 
 not been anatomically verified. 
 
 SYMPTOMS.— Separation of the upper epiphysis of the humerus 
 is not unfrequently met with, the mild form often occurring in 
 private practice, whilst the more severe forms of displacement 
 frequently come under the hospital surgeon's treatment. 
 
 Separation without displacement. — It is probable that the majority 
 
190 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 of the separations of the upper cartilaginous end of the humerus 
 in early infancy are of this nature, while in older children detach- 
 ment is undoubtedly common without any displacement of the 
 diaphysis. 
 
 Pain and sioelling are less marked than in separations accom- 
 panied by displacement. The pain is not severe on passive movement, 
 yet the great loss of function of the shoulder is always a suspicious 
 feature. The swelling about the shoulder conies on rapidly after the 
 injury. 
 
 Fig. 40. — diagram op sepaeation of the upper epiphysis of the humerus at 
 
 THE eighteenth TEAR. THERE IS A CONSIDERABLE GAP BETWEEN THE EPIPHYSIS 
 AND THE DIAPHYSIS, W^THOUT ANY DISPLACEMENT FORWARDS OF THE LATTER. 
 THE EPIPHYSIS HAS UNDERGONE SOME ROTATION IN THE GLENOID CAVITY 
 
 Deformity is absent ; it will, in fact, often be thought that only 
 a severe bruising or sprain at the shoulder- joint has occurred. 
 
 If traction, however, be made in the axis of the limb, and the 
 swelling be not very great, a slight depressioji may be felt at the 
 level of the junction cartilage, between the separated fragments. 
 
 Crepitus is of the usual peculiar soft or mufHed character, for in 
 these very simple cases in infancy displacement and fracture of the 
 diaphysis are both absent. When present it is almost patho- 
 
SEPAEATION OF UPPEE EPIPHYSIS OF HUMEEUS 191 
 
 gnomonic, and is produced by the rubbing of the two fragments one 
 over the other. 
 
 Unnatural mohility will be very limited where no displacement 
 exists. It may be produced in trying to obtain crepitus, and will 
 be detected at the normal diaphysio-epiphysial line. 
 
 In effecting these movements, especially abduction, a slight angle 
 is formed at the seat of separation. 
 
 In the following case there appeared to be little or no appre- 
 ciable deformity at the time of injury. William McC, aged 
 fourteen, came under the care of Mr. Durham at Guy's Hospital 
 on March 28, 1885 (Mr. Durham's Surgical Beports, 1885, No. 312), 
 having fallen 8^ feet off a gangway on to his left shoulder. There 
 was much swelling and pain in the shoulder, but no deformity, 
 the head occupying the glenoid cavity. Some antero- posterior 
 movement of the humerus was permitted, with soft crepitus. 
 Separation of the epiphysis with partial dislocation of the head 
 was diagnosed later under chloroform. The treatment adopted was 
 extension by weight on the arm and counter-extension by a jack- 
 towel beneath the arms. After eighteen days there was good 
 movement of the arm, and the boy was able to abduct it to 
 a right angle from the trunk ; there was, however, about one inch 
 shortening. 
 
 Displacement of subsequent occurrence. — Should the nature of in- 
 jury under these circumstances be overlooked at the time and the 
 humerus be insufficiently supported, it is possible for the diaphysis 
 to be subsequently displaced, the characteristic signs subsequently 
 developing — viz. formation of slight hollow beneath acromion, 
 projection forwards of diaphysial end, &c. 
 
 In the following case under the care of M. Davaine, recorded by 
 Berges {loc. cit. supra), displacement occurred on the sixth day. In 
 July 1889 a child, aged eight years, fell from a horse and complained 
 of difficulty in moving its right shoulder. When examined almost 
 immediately afterwards by a doctor, no sign of fracture or disloca- 
 tion of the shoulder could be detected, and a diagnosis of simple 
 contusion was made. The following day, as the patient still com- 
 plained of pain on moving the arm, M. Davaine, after a careful 
 examination, being unable to detect any sign of fracture or disloca- 
 tion, and considering it to be a sprain, ordered the arm to be fixed 
 in a sling. The patient was seen again by him on the following 
 day without any new sign being noticed. The child, however, in 
 spite of the sling, made frequent use of its arm, and on the sixth 
 day M. Davaine found a projection (size of walnut) situated at the 
 inner lip of the bicipital groove, about 2^ centimetres below the 
 .acromion ; this, with its rounded upper border, might have been 
 mistaken for the head of the humerus had not the latter been felt 
 in the glenoid cavity. No ecchymosis, abnormal mobility, crepitus, 
 or shortenino- on measurement was detected. M. Lannelongue then 
 
192 EPIPHYSES OE UPPEE EXTEEMITY 
 
 saw the case, and, making the diagnosis of traumatic separation of 
 the upper epiphysis of the humerus, placed the arm in a plaster 
 splint with continuous extension. On removing the splint on the 
 twentieth day, the projection had totally disappeared, and the move- 
 ments of the arm were normal. Only a slight wasting of the 
 muscles due to the prolonged fixation was noticed, but this was 
 soon remedied by the use of massage and electricity, and a month 
 later the patient had completely recovered. 
 
 This displacement of the diaphysis occurring later when the 
 patient is under treatment has also been noted by Jetter in three 
 cases which had been under careful observation. 
 
 In none of them was there any displacement detected at the time 
 of the accident. These three are recorded in another part of this 
 chapter. The following is a fourth case. 
 
 M. N., eleven years old, fell from a first story four metres high 
 on to the ground. Two days after (July 7, 1890) he came to the 
 hospital. There was diffuse swelling and extensive contusion of the 
 left shoulder. The humeral head was still in the glenoid cavity, 
 and in the neighbourhood of the epiphysial line of the humerus 
 abnormal mobility and marked crepitus were detected. Velpeau's 
 bandage was applied. Ten days afterwards, on July 17, on changing 
 the bandage, the diaphysis was found to project forwards and inwards. 
 An anaesthetic was therefore given, and the fragments were replaced 
 in their normal position by extending the arm and by pressure 
 backwards on the lower fragment, but the deformity was reproduced 
 as soon as the limb was let go. After reduction a second time, a 
 plaster-of-Paris splint was applied to the trunk and arm, but even 
 this allowed displacement two days later. The patient was finally 
 treated for ten days by extension, lying upon his back with his arm 
 elevated perpendicularly. After this, Velpeau's bandage was again 
 applied, and on removing this eight days later the fragments were 
 well united without much deformity, but the movements of the 
 shoulder were restricted. After two years (March 20, 1892) there 
 was to be seen on examination slight increase in the antero-posterior 
 width of the shoulder, with slight displacement forward of the lower 
 fragment. No measurable shortening or wasting of the arm super- 
 vened. All movements, especially elevation and rotation, were 
 perfectly normal and painless. 
 
 Separation of the cartilaginous upper end of the humerus. — In infants 
 separation will usually occur without any noticeable displacement of 
 the fragments, and can only be recognised by abnormal mobiHty, soft 
 crepitus, and swelHng about the shoulder ; while loss of function 
 and pain at the shoulder-joint are suggestive signs. The solution of 
 continuity is somewhat further away from the head than when it 
 occurs after the first few years of life, yet the dimensions of the epi- 
 physis are now so small that the diagnosis is extremely difficult, 
 especially when the displacement is not a marked feature. 
 
SEPAEATION OF UPPEE EPIPHYSIS OF HUMEEUS 193 
 
 The cases hitherto reported are too untrustworthy to throw any 
 light upon the subject ; yet fracture and dislocation are both so rare 
 at this age that an epiphysial separation should always suggest 
 itself. 
 
 Simple separation with displacement. — This is undoubtedly one of 
 the commonest accidents of early life, and one frequently met with in 
 the accident department of any large hospital ; comparatively few cases, 
 however, have been put on record. Sir Astley Cooper and other 
 older writers speak of it as of common occurrence. It was also recog- 
 nised by Sir Charles Bell, who says {Institutes of Surgery, 1838, 
 vol. i. p. 110) : ' I have known it occur from a boy firing a musket.' 
 
 Professor E. W. Smith, of Dublin, was the first to accurately 
 describe it in 1847. 
 
 P. Bruns considers the injury as far from rare : out of fifteen 
 cases of traumatic epiphysial separation which he had observed in 
 the living subject, up to 1884, eight cases belonged to the upper 
 epiphysis of the humerus. 
 
 Out of 105 cases verified by anatomical examination by Professor 
 De Paoli, fourteen were of the upper end of the humerus. 
 
 The signs of simple divulsion of this epiphysis, owing to its 
 anatomical relations, are comparable to those of fractures of the 
 surgical neck of the humerus in so far as the displacements of 
 the diaphysis are concerned, although they partake somewhat of the 
 nature of a dislocation. 
 
 Sir Astley Cooper says : ' The signs of this accident are as 
 follows : — the head of the bone remains in the glenoid cavity of the 
 scapula, so that the shoulder is not sunken, as in dislocation ; a pro- 
 jection of bone is perceived upon the point of the coracoid process, 
 and when the elbow is raised and brought forwards this projection 
 is rendered particularly conspicuous. By drawing down the arm 
 the projection is removed, but it immediately re-appears upon giving 
 up the extension, and the natural contour of the shoulder is lost. 
 The diagnosis of this injury is not difficult, yet I have known the 
 accident mistaken for dislocation. The point of the broken bone is 
 felt at the coracoid process, and this is supposed to be the head of 
 the OS humeri ; but with care the head of the bone can be felt still 
 filling the glenoid cavity. When the elbow is rolled, the head of the 
 bone does not obey its motion. Upon dissection of these cases in 
 the young, the head of the humerus is found broken off at the' 
 tubercles, but it remains in the glenoid cavity.' 
 
 Incomplete displacement forwards of diaphysis. Deformity. — Con- 
 sidering that the solution of continuity always takes place in the 
 same situation, it is not difficult to understand that the appearance 
 of the shoulder should be so characteristic. 
 
 "With so large a surface involved in epiphysial separation, and 
 seeing that the upper end of the diaphysis is not a perfectly plane 
 or transverse surface, but more or less pointed and fitting tl^e 
 
 o 
 
194 
 
 EPIPHYSES OE UPPEE EXTEEMITY 
 
 concavity of the epiphysis as a kind of socket, it cannot be 
 wondered that displacement is usually incomplete. In fact between 
 separation without any appreciable displacement of the diaphysis, 
 and separation where the latter almost penetrates the skin, many 
 degrees of displacement are met with in practice. Moreover, the 
 long heads of the biceps and triceps muscles will tend to keep the 
 fragments in position. 
 
 The displacement forwards, or inwards and upwards, is no doubt 
 kept up, if not caused in some degree, by the action of the coraco- 
 
 FlG. 41 DIAGRAM OF SEPAEATION, WITH LOCKING OF LOWER INTO UPPEE FEAGJIENT. THE 
 
 HEAD OF THE BONE HAS UNDERGONE SOME ROTATION IN THE GLENOID CAVITY 
 
 brachialis, pectoralis major, teres major, and latissimus dorsi 
 muscles which are attached to it. 
 
 The epiphysis will be directed a little outwards by the action of 
 the subscapularis, supraspinatus, infraspinatus, and teres minor, 
 which make the head of the bone perform a rotatory motion in the 
 glenoid cavity, and tilt the lower end of the upper fragment 
 upwards, so that its separated surface looks more or less outwards. 
 
 In fractures Boyer thought that these articular muscles, the 
 supraspinatus, infraspinatus, and teres minor, elevated the fractured 
 portion, because, the bone being thick, separation of the end must 
 take place before displacement can occur. 
 
 If there is great swelling of the shoulder, axilla, or infraclavicular 
 
SEPAKATION OF UPPEK EPIPHYSIS OF HUMEEUS 195 
 
 region, and mucli extravasation of blood into the subcutaneous 
 tissue, it may be extremely difficult to determine with an}^ exact- 
 ness the nature of the injury. 
 
 Serous effusion into the articulation and into the subdeltoid 
 bursa will also render the swelling more marked. 
 
 Mr. Hancock, describing separation of the upper epiphysis of the 
 humerus in the Provincial Medical Journal (Medical Times, Decem- 
 ber 21, 1844, p. 249, and Braithwaite's Betrospect of Med. and 
 Surgery, vol. xi. 1845, p. 247), and attempting to account for the 
 signs of reproduction of the deformity, believed that in these acci- 
 dents the long tendon of the biceps is either ruptured, or that by 
 the fracture of the head of the humerus it is deprived of the 
 fulcrum which it acquires in passing over that process, and is thus 
 unable to antagonise the capsular muscles. The upper end of the 
 bone is consequently drawn upwards and forwards by the supra- 
 spinatus and subscapularis muscles. 
 
 It is now certain that the diaphysis is mostly acted upon by the 
 pectoral and other muscles described above, and that the scapular 
 muscles, although powerfully acting upon the epiphysis, can have 
 but little effect upon the lower portion of the bone. The tendon, 
 moreover, of the biceps has never been found ruptured in this 
 injury. 
 
 Professor E. M. Moore, of Eochester, U.S.A., in a paper read 
 before the American Medical Association in 1874, and published in 
 the Transactions for that year, has called attention to what he 
 considers the true condition of the separated fragments in most 
 of these cases, and to the proper remedy. He observes that the 
 displacement is not usually complete, but that -the upper end of the 
 lower fragment is carried inwards to the distance of about one- 
 fourth of its diameter, when it is arrested by a convexity of the 
 lower fragment becoming lodged in a natural concavity in the upper 
 fragment. The smaller posterior facet of the superior diaphysial 
 surface is locked with the larger corresponding anterior surface of 
 the head. The upper fragment now becomes tilted by the action 
 of the muscles attached to the tubercles, its internal margin 
 ascending into the glenoid cavity, and its outer margin descending 
 until it is arrested by the capsule. 
 
 If under these circumstances, as in reducing the fragments, the 
 arm is carried forwards and upwards to the perpendicular line 
 without extension, the upper fragment or epiphysis will remain 
 fixed, being held fast by the capsule inserted into the posterior and 
 under margin of the head, while the lower fragment or diaphysis, 
 aided by the natural action of the muscles, will move outwards and 
 resume its original position. The epiphysis will not participate in 
 this movement, being fixed by the posterior part of the capsule, 
 which is attached to it. The diaphysis slides back, producing a 
 coaptation of the corresponding facet. See the figure in Agnew's 
 
 o 2 
 
196 EPIPHYSES OF UPPEE EXTEEMITY 
 
 Surgerij (1878, vol. i. p. 882, fig. 684), taken from Dr. Moore's 
 paper. 
 
 Packard (' Axtic. Fractures and Dislocations,' CijclopcBclia of 
 Diseases of Children, Keating, 1890, vol. iii. p. 1064) says : ' An 
 important fact, pointed out by Mr. Jonathan Hutchinson and 
 myself {New Yo?-k Medical Journal,- Octoher 1866), is the rotation 
 inward of the upper fragment by the action of the supraspinatus, 
 infraspinatus, and subscapularis muscles, and this idea was again 
 brought forward by Dr. Moore.' 
 
 The author is of opinion that the muscles lying parallel with 
 the axis of the arm play an important role in carrpng the lower 
 fragment upwards until it is arrested by becoming fixed in the 
 upper epiphysis, although the violence at the time of the accident 
 is certainly the principal factor. 
 
 P. Bruns noted displacement upwards and inwards of the 
 diaphysis in five out of eight cases which he observed in the living 
 subject. 
 
 Jetter states that this displacement occurred in all of his seven- 
 teen cases, including recent and old cases. In four of the cases 
 it was not present at the time of the accident, but it appeared 
 later on. 
 
 The prominence which usually appears below the acromial end 
 of the clavicle, to the outer side of and below the coracoid process, 
 consisting of the upper end of the diaphysis, is not sharp, pointed, 
 and irregular as in fracture through the surgical neck, but is 
 smooth, more or less horizontal, transverse, or flat. Moving ^^th 
 every motion of the arm, v/hen covered only by the skin and 
 muscle, and feeling smooth or even slightly convex, it might be 
 mistaken for the rounded head of the humerus ; but it is less 
 rounded than this, and in thin subjects the iiTegularities on the 
 flattened surface may even be felt. It is quite unhke the end of 
 a fractured bone. Frequently it is only the antero-internal edge of 
 the diaphysial end that can be felt, but at other times a greater or 
 smaller portion of the convexity of its upper surface may, as just 
 stated, be perceived. 
 
 The situation of this projection has been noted by various 
 writers as being beneath the deltoid, in front and below the 
 acromion process, in front of the head of the bone beneath the joint, 
 below the coracoid process, or forwards and upwards under the 
 coracoid process. 
 
 It will vary according to the degree of displacement of the 
 diaphysis, and in a small degree according to the age of the patient, 
 or according to the presence or absence of the locked condition of the 
 fragments which Professor Moore has so ably described from the 
 cases seen by him. In some instances, therefore, it may be made to 
 disappear by manipulating the arm in the manner he has indicated. 
 
 Moore says that the prominence is usually found about an inch 
 
SEPAEATION OF UPPEE EPIPHYSIS OF HUMEEUS 197 
 
 and a half below the acromion and near the coracoid process. 
 ' The curved line,' he says, ' from the acromion down to this 
 projection has a long sweep, instead of the small sphere of the 
 natural head. The appearance is pathognomonic, and may be 
 safely trusted in diagnosis without insisting upon crepitus.' 
 
 Other observers give two" fingers' breadth below the clavicle in 
 the neighbourhood of the coracoid process as the site of the projec- 
 tion, and others, again, one inch below the acromion in front of the 
 shoulder. 
 
 Demoulin describes it in his case as a good two fingers' breadth 
 below the acromio-coracoid interspace. 
 
 In Professor E. W. Smith's case it w^as found to be three-quarters 
 of an inch below the coracoid process, and Hamilton states that in 
 three of the cases reported by him the symptoms were present 
 which are described by Professor Moore as characteristic of this 
 form of injury. The projection was less marked and on a level with 
 the coracoid process, or a little below it. 
 
 Packard says that in the few cases which he had seen the ridge 
 has been less prominent than it is represented by Professor E. W. 
 Smith in his work. 
 
 The truth of these observations is borne out if we look at the 
 relationship of the epiphysial line to the coracoid process. It is 
 almost on a level with it, and but little disp^a^.ement of the shaft, 
 with little rotation or descent of the epiphysis in the glenoid cavity, 
 will be required to render it entirely so (see fig. 29). 
 
 Where the displacement inwards is greater, the diaphysial end 
 will be felt below the coracoid process. 
 
 This projection of the diaphysial end follows all the movements 
 imparted to the arm, which are effected with ease. 
 
 Professor E. W. Smith, in his work on Fractures and Dislocations 
 (p. 199), clearly describes, and gives a figure of, this form of separa- 
 tion of the upper epiphysis of the humerus. He says, in his 
 concise language : 'It is attended by a considerable degree of 
 deformity, but of so striking a nature that there is no great difficulty 
 in recognising the true nature of the injury. The axis of the arm 
 is directed from above, within, and before, downwards, outwards, 
 and backwards. The elbow, however, projects but little from 
 the side, and can be brought into contact with it with facility. 
 The head of the bone can be distinctly felt in the glenoid cavity ; 
 a slight depression is seen beneath it, and it remains motionless 
 when the shaft of the humerus is rotated. The most remarkable 
 feature, however, of this injury is a striking and abrupt projection, 
 situated beneath the coracoid process, and caused by the upper 
 extremity of the lower fragment or shaft of the bone, drawn 
 inwards by the muscles which constitute the folds of the axilla. 
 There is but little displacement as regards the length of the bone, 
 for the extremity of the inferior fragment is seldom drawn so far 
 
198 EPIPHYSES OF UPPEE EXTEEMITY 
 
 inwards as to enable it to clear completely the surface of the 
 superior. 
 
 'Were this to occur, the humerus would, of course, be drawn 
 upwards by the muscles passing from the shoulder to the arm, in a 
 direction parallel, or nearly so, to the axis of the humerus, and a 
 corresponding diminution in the length of the limb would result. 
 This remarkable and abrupt projection does not present the sharp, 
 irregular margin of an ordinary fracture ; on the contrary, it feels 
 rounded, and its superior surface is smooth and slightly convex. 
 The latter can be felt as plainly as the cup-like cavity of the head of 
 the radius in cases of luxation of that bone backwards at the elbow- 
 joint. By pressing the upper end of the lower fragment outwards, 
 and directing the elbow inwards, during extension and counter- 
 extension, crepitus can be perceived and the deformity removed 
 without much difficulty ; but the moment the parts are abandoned 
 to the uncontrolled action of the muscles the deformity recurs.' 
 
 The same author records {Fractures and Dislocations, p. 201) 
 a characteristic and often-quoted case, of which he gives many 
 details. 
 
 A boy, aged eight, was admitted into the Richmond Hospital 
 under the care of Dr. MacDonnell. About a wxek previously he 
 had fallen upon the shoulder, and at once lost the power of using 
 the arm. There was no diminution of the natural rotundity of the 
 shoulder, nor any unusual prominence of the acromion process. 
 The head of the bone could be distinctly felt in the glenoid cavity, 
 and it remained motionless when the arm was rotated ; there was 
 very little separation of the elbow from the side, but it was directed 
 slightly backwards. About three-c[uarters of an inch below" the 
 coracoid process there existed a remarkable and abrupt projection, 
 manifestly formed by the upper extremity of the shaft, the upper 
 surface of which was smooth and slightly convex, its margin having 
 nothing of the sharpness which tlie edge of a recently broken 
 bone presents in ordinary fractures. A crepitus was produced on 
 replacing the fragments and rotating the shaft, the head of the 
 humerus being fixed as far as it was possible to do so. The crepitus 
 did not resemble the ordinary crepitus of fracture. All attempts to 
 maintain the fragments in their proper relative position were in- 
 . effectual, although various mechanical contrivances were employed. 
 
 Mr. T. Holmes {Surgical Treatment of Children' s Diseases, 1886, 
 p. 249, fig. 39) figures a case in which all the features corresponded 
 most accurately with those of Dr. Smith's, but he did not see it 
 till eight weeks after the accident. The boy, aged fifteen, was then 
 rapidly recovering useful motion in the joint. 
 
 In the museum of the Middlesex Hospital, No. 93, series xliii. 
 {Descriptive Catalogue of the Pathological Museum of the Middlesex 
 Hospital, 1884, p. 293), there is a cast of a shoulder showing this 
 separation in a child ; and Mr. Bryant also gives a representation of 
 
SEPAEATION OF UPPEE EPIPHYSIS OF HUMEEUS 199 
 
 this injury {Practice of Snrgerjj, vol. ii. 1884, 4th edition, p. 4*20, 
 fig. 483) in a boy aged sixteen, who was under his care in Guy's 
 Hospital in 1872. The end of the diaphysis of the right humerus 
 was displaced forwards and inwards, and projected beneath the skin 
 in front of the acromion as a rounded, slightly convex, prominence. 
 The lad was carrying a box of fish (1 cwt.) on his head when he 
 slipped and fell with the load on his shoulder. The head of the 
 bone was in position, and on reducing the diaphysis backwards soft 
 crepitus was both heard and felt. 
 
 On July 17, 1884, the author saw in consultation a boy (C), aged 
 fourteen years, with almost precisely the same symptoms. About 
 1| hours previously he had fallen from a tree a distance of fourteen 
 feet to the ground ; a branch, however, was said to have ' broken 
 his fall.' The doctor said when he first saw the boy that the end of 
 the bone was almost through the skin in front, but he w^as able to 
 readily reduce it by pushing the shaft backwards. It went back with 
 a ' jump,' so as to suggest to his mind a dislocation, yet the deformity 
 had at once recurred to a slight extent. When the patient arrived 
 the arm projected a little backwards and outwards, the elbow being 
 only a short distance from the side. Three-quarters of an inch 
 below the coracoid process there was considerable bruising and the 
 characteristic angular projection of the diaphysis. This was accom- 
 j)anied by slight depression on the outer aspect of the shoulder 
 about the middle of the deltoid. There was no shortening of the 
 limb, which hung powerless. The head of the bone w^as felt in the 
 glenoid cavity, and did not follow the movements of the shaft when 
 this was rotated. The deformity was again readily reduced, being 
 accompanied by a ' dummy ' crepitus and a peculiar sensation as of 
 the gliding of two more or less flattened surfaces one upon the other. 
 The depression on the outer side immediately disappeared. The 
 arm was kept to the side and wooden splints applied. In spite of 
 the greatest care in endeaA^ouring to keep the bone in its place, slight 
 deformity remained in front at the end of a month. All the move- 
 ments of the arm w^ere very good, and there was firm union without 
 shortening. 
 
 The depression here mentioned on the outer or postero-lateral 
 aspect of the shoulder is situate below the head and tuberosities at 
 the level of the epiphysial line. This, between the ages of sixteen 
 and eighteen, is from one inch to an inch and a quarter below 
 the acromion process, not quite down to the middle of the deltoid 
 muscle. The distance will of course vary with the size of the patient. 
 The depression is often to be noticed still higher up, about half 
 an inch below the acromion in cases of greater displacement ; its 
 presence may be accounted for by the rotation of the epiphysis 
 in the joints so that it takes an oblique or even perpendicular position, 
 its separated surface looking more or less outwards, and its outer end 
 being raised. 
 
200 EPIPHYSES OF UPPER EXTREMITY 
 
 In other instances, the diaphysis being displaced forwards and 
 inwards for less than half the extent of its upper end, the epiphysis 
 with its cup-shaped hollow fits upon the outer part of the diaphysial 
 end. The epiphysis is often rotated so that its inner edge passes 
 upwards and its other end downwards. 
 
 Berges quotes a case from M. Nimier's Thesis (Berges, De la 
 disjonction traumatique de Vextremite superieure de V humerus, These 
 de Paris, 1890, p. 33 ; Nimier, These, 1879), in which there was 
 only a slight projection (of half a centimetre) of the anterior border 
 of the lower fragment, and accompanied behind with a shght de- 
 pression, indicating very little displacement of the diaphysis. The 
 case was that of a child, aged nine years, which had fallen on to its 
 left shoulder, fracturing the humerus above the insertion of the 
 pectoralis major muscle. Reduction of the diaphysis was readily 
 effected by manipulation and maintained by a simple bandage fixed 
 against the trunk. Gentle movements by elevating the arm could 
 be carried out on the fifteenth day. 
 
 H. E. Clark {Glasgow Medical Journal, N.s. vol. xxvi. 1886, p. 247) 
 relates a case of separation with very little displacement inwards of 
 the diaphysis. A boy aged fifteen slipped on a piece of orange-peel 
 and fell on the pavement. On examination there was found 
 extensive bruising of the shoulder, and when the head of the bone 
 was fixed and the shaft moved in an angular direction the epiphysis 
 was stationary, but if the shaft was rotated on its own axis the epi- 
 physis moved ivith the diaphysis. A poroplastic splint was applied, 
 and the patient did well. 
 
 Moscati diagnosed (Memoir'es de V Academie Boy ale de Chirurgie, 
 tom. iv. 1768, p. 618 ; obs. 1, 1739) a case of separation of the 
 upper epiphysis of the humerus in a girl aged nine years, who had 
 fallen a short distance on to the upper part of her right arm, and 
 had immediately lost all power of using it. The pain was very 
 slight, but above the middle of the deltoid muscle there was an 
 appreciable depression, and the head of the humerus had not left 
 the glenoid cavity. Although there was but little abnormal mobility 
 in all directions and no crepitus, a gliding movement was detected 
 on moving the shaft. Perfect recovery ensued in a month and a 
 half. The patient had been rachitic up to seven years of age. 
 
 A case of disjunction of this epiphysis is related by Dr. H. R. 
 Wharton {Med. and Surg. Beporter, Phila. 1886, Hv. p. 385), with 
 slight projection in front and below the acromion process. The boy, 
 who was aged twelve, fell off a waggon on to his left shoulder. 
 There was slight flattening of the shoulder, and the arm rested 
 against the side of the body. The head of the bone appeared to be 
 slightly behind and below its normal position with reference to the 
 shaft. Fergusson's dressing — roller bandage from tip of fingers to 
 shoulder, and moulded pasteboard splint padded with cotton— was 
 applied. 
 
SEPAEATION OF UPPEE EPIPHYSIS OF HUMEEUS 201 
 
 Bardenheuer has observed {Deutsche Chirurgie, ' Die Krank- 
 heiten der oberen Extremitaten,' 1886, 1 Theil, S. 175) five cases of 
 undoubted epiphysial separation of 
 the upper end of the humerus, in 
 all of which there existed a certain 
 amount of angular displacement, and 
 which could only be recognised by 
 strongly abducting the elbow. In 
 each there was the characteristic 
 angular projection of the fragment 
 forwards and inwards. Bardenheuer 
 gives a figure of one such case. 
 
 The general aspect of the shoulder, 
 apart from the deformity of the dis- 
 placed diaphysis, is not materially 
 altered. Thsre is, in most cases, no 
 loss of its natural roundness and 
 smooth contour, but in others a slight 
 flattening, or rather depression, may 
 bs seen on the affected side, never 
 so distinct as in a dislocation. But 
 its antero-posterior diameter is in- 
 creased. 
 
 Prof. Helferich depicts (Atlas der fig 
 traumatischen Fracturen unci Luxa- 
 tionen, 1895, tab. 28, fig. 2) the 
 posterolateral aspect of the shoulder 
 of a boy aged fourteen years, in 
 which the displaced diaphysis is well 
 portrayed in this position. The dis- 
 placement and characteristic angular 
 projection of the diaphysis could, 
 however, be best seen when the 
 shoulder was viewed from above. 
 
 As we have seen in the preceding 
 examples, the arm hangs against 
 the side of the body in a helpless 
 manner — all voluntary movements 
 being nearly impossible, although 
 there may be little or no displacement 
 of the fragments. But it is more or 
 less away from the side, the elbow 
 being drawn slightly away therefrom 
 in the abducted position, or at times 
 projecting backwards and outwards 
 when, as in many of the above cases, 
 displacement is present in any degree. 
 
 42. incomplete displacement 
 
 forwards of diaphysis of humerus 
 (after bardenheuer) 
 
 Acromion 
 
 Humerus 
 
 % 
 
 Fig. 43 . — displacement of the dia- 
 physial end of humerus seen 
 
 FROM THE POSTERO-LATERAL ASPECT 
 
 (after helferich) 
 (The prominence of the humerus behind 
 has been exaggerated by the artist) 
 
202 EPIPHYSES OF UPPEK EXTEEMITY 
 
 The arm can be brought close to the side with ease, and other 
 passive niovements are tolerably free, although painful. 
 
 Moore says : ' The ability to convey the arm upwards and forwards, 
 as well as upwards and outwards, is impossible much beyond a right 
 angle with the body.' 
 
 Pain and siuelling are often great. The swelling often extends 
 over the whole of the shoulder and upper third of the arm, and 
 takes place with great rapidity after the injury ; it is always greater 
 than in separation without displacement, and is due to the effusion 
 into and swelling of the periosteum, as well as to the direct injury 
 to the soft structures. 
 
 The presence of painful areas below the tuberosities is oftentimes 
 very noticeable on pressure, and forms an essentially distinguishing 
 sign from dislocation. Pain at the conjugal line is also experienced 
 when pressure or a gentle blow is made from beneath the elbow 
 upwards towards the acromial arch. 
 
 Increase of breadth of shoulder. Antero-posterior increase is 
 seen when the shoulder is viewed latsrally. 
 
 Mobility at about the epiphysial level may usually be recognised 
 by grasping the epiphysial head and rotating the diaphysis ; 
 it is not great in amount and is absent when the fragments 
 are locked together. Mr. H. E. Clark says in his case {Joe. cit. 
 supra) : ' The head of the bone being grasped with the fingers of 
 one hand, and the elbow with those of the other, and the shaft 
 being made to move, it w^as found that if the movements were 
 angular in their character, the epiphysis was quite stationary, 
 showing how complete was the solution of continuity. If, however, 
 the movement consisted in rotation of the humerus on its own axis, 
 the epiphysis moved ivith the diaphysis.' 
 
 The head of the hone is always to be felt occupjung its proper 
 socket, even although, with the tuberosities, it may have undergone 
 some rotation. We have also seen that it may or may not {e.g. 
 without or with impaction of the shaft) rotate with the movements 
 imparted to it. If the arm is gently moved without the head being 
 grasped, it will rotate where there is the slightest degree of locking 
 of the fragments. When, however, the displacement is more com- 
 plete, the head of the bone will not obey the movements of the 
 diaphysis when the arm is rotated. 
 
 The former fact, taken with the circumstance that dislocations 
 are among the rarest of accidents in young subjects, renders it certain 
 that the case recorded by Sir Astley Cooper {Treatise on Fractures 
 and Dislocations, London, edited by Bransby Cooper, 1842, p. 431, 
 and Guy's Hospital Beports No. ix.) belongs to this class of 
 injury. A child, aged ten, was admitted into Guy's Hospital, having 
 fallen upon the shoulder a distance of eight feet into a sawpit. 
 There was inability to move the arm from the side and to support 
 it without great pain. When the head of the bone, which still 
 
SEPAEATION OF UPPEK EPIPHYSIS OF HUMEEUS 203 
 
 occupied the glenoid cavity, was fixed, the fractured end of the bone 
 could be tilted and felt, and even seen, under the deltoid, by raising 
 the arm at the elbow^, but on rotation of the arm the head did not 
 move. Crepitus v/as felt in raising the humerus and pushing it 
 laterally outwards. 
 
 Crepitus. — The modified crepitus — which is usually described as 
 * muffled,' ' mortary,' ' feeble,' ' soft ' — at any rate is much softer and 
 less distinct than that which is met with in ordinary fractures, 
 and must not be sought for too strictly without the use of an. 
 anaesthetic . 
 
 In many cases of incomplete displacement definite crepitus has 
 been found difficult to obtain, for in certain cases on rotating the 
 humerus the epiphysis will rotate with the shaft, the rounded 
 diaphysis being locked in its concavity in the manner described 
 above. The arm may even be bent somewhat towards the back of 
 the trunk without crepitus being felt in these cases of impaction. 
 In non-impacted instances, the head of the bone remaining without 
 any movement during the manipulation of the shaft (especially if 
 this is more of an angular than a rotatory character) , crepitus will be 
 elicited. 
 
 Crepitus may be absent also in the less frequent instances of 
 complete displacement of the diaphysis from the epiphysis. 
 
 In Dr. C. McBurney's case, crepitus, it is especially noticed, did 
 not exist on account of the displacement upwards and forwards of 
 the diaphysis in front of the epiphysis — its rough end being felt 
 just beneath the skin. 
 
 It can usually be felt in the different manipulations, such as 
 pressing the upper end of the shaft backwards, drawing the arm 
 inwards across the chest and at the same time extending it, which 
 are necessary to effect reduction, thereby causing the two separated 
 surfaces to pass in contact one over the other, or by fixing the 
 head, rotating the humerus, and carrying the elbow inwards. 
 
 Crepitus was present in eight out of the eleven cases recorded by 
 Bruns. 
 
 Dull crepitus was a notable sign in "Wharton's, Moscati's, E. AV. 
 Smith's, Paletta's, Middeldorpf's (two cases), Hamilton's, and many 
 other examples. 
 
 Mr. Le Gros Clark gives {St. Thomas s Hospital Beports, new 
 series, vol. xvii. 1887, p. 2) the following note of a case in which 
 crepitus was well marked : 
 
 ' A lad, aged sixteen, was admitted into the hospital in conse- 
 quence of a fall down a flight of steps, whereby his head, shoulder, 
 and side were contused. The shoulder was swollen, and the 
 deformity was thereby masked. Crepitus of a muffled character 
 was elicited most readily by moving the arm backwards and for- 
 wards, especially when the hand was pressed up into the axilla ; the 
 pain was referred to the front of the joint. When the swelling had 
 
204 EPIPHYSES OF UPPEE EXTEEMITY 
 
 subsided a large pad was placed in the axilla, and the shoulder was 
 covered with a pasteboard cap. The boy soon recovered the use of 
 the arm, and was dismissed at the end of the month.' 
 
 Jetter attributes the imperfectly marked crepitus as well as the 
 small extent of the abnormal mobility to a partial preservation of 
 the periosteum, and quotes the two following cases as instances. 
 
 Case I. B. S., aged six years, on February 5, 1891, fell down 
 ten steps of a stair. The following day she was brought to the hospital. 
 The shoulder and upper half of right arm were greatly swollen, with 
 tenderness on pressure. The arm appeared to be shortened. Under, 
 an ansesthetic there was abnormal mobility and soft-friction- crepitus 
 at the epiphysial line during flexion, wdrile the tuberosities of the 
 humerus were fixed. During rotation the head in some degree 
 accompanied the movements of the humerus, which was probably 
 accounted for by a partial preservation of the periosteum. Vel- 
 peau's bandage was applied. By February 24 there was no swelling 
 of the arm, but a slight angular projection of fragments could be 
 felt at the epiphysial line ; the arm was shortened by about one 
 centimetre, and the head of the humerus rotated with the shaft. On 
 March 4 electricity showed a partial degeneration of the deltoid 
 muscle, the result presumably of contusion of the circuniflex nerve 
 at the time of the accident. The patient gradually regained the 
 power in the deltoid, and could make active use of the arm for 
 playing, eating, &c. 
 
 Case II. H. K., sixteen years old, on August 16, 1891, w^as 
 struck on the left shoulder by a falling empty cask, and came 
 immediately to the hospital. Passive but not active movements 
 were possible at the shoulder joint. At the epiphysial line there 
 was some abnormal mobility without distinct crepitus ; from this it 
 was concluded that the periosteum, at all events on the outer side, 
 was still intact. Velpeau's bandage was applied. On August 26 
 there was no effusion into the joint, and movement was good. Frag- 
 ments united in very good position. On March 31, 1892, there was 
 no wasting of the arm or appreciable shortening, and no deformity 
 could be seen or felt. All movements, especially elevation and 
 rotation of the arm, were normal, so that the patient was again 
 perfectly fit for work. 
 
 Shortening . — Shortening, or loss of length of the arm, is generally 
 absent in any marked degree in incomplete displacements, being 
 not more than one to two centimetres. This means that there is 
 but little tilting or overlapping of the fragments, that the periosteum 
 is untorn, and the biceps tendon intact. 
 
 E. Dale {Epitome of Surgery, 1889, p. 65) and others say that 
 there is neither shortening nor lengthening of the limb, but at the 
 same time state that displacement readily recurs ; but this cannot be 
 very great in the cases to which they allude, in which there is 
 this absence of shorteninfi'. 
 
SEPARATION OF UPPEE EPIPHYSIS OF HUMERUS 205 
 
 The following case of separation is reported by Hamilton 
 {Treatise on Fractures and Dislocations, 7th edition, 1884, p. 260), 
 which he had seen two weeks after the accident. There was then 
 ^ inch shortening, the lower fragment projecting in front still un- 
 united. The patient (Samuel E.), aged thirteen, fell through a hatch- 
 way, striking his shoulder. At the time the injury was diagnosed 
 as a dislocation, and an attempt had been made to reduce it under 
 chloroform. The result of this case was not known to Hamilton. 
 
 C. Puzey reported {Liverpool Medico-Chirurgical Journal, vol. v. 
 1885, p. 45) a case of separation with impaction, or rather locking, 
 of the shaft into the concave under-surface of the epiphysis. 
 Anthony B., aged twelve, was admitted into the Northern Hospital 
 October 30, 1882, having some hours before fallen on his left elbow. 
 The shoulder was swollen, especially anteriorly, with well-marked 
 bony prominence 1^ inches below the acromio-clavicular joint, and at 
 one point the skin was caught by a small spiculum of bone. Great 
 pain resulted on movement. Under an ansesthetic the arm could be 
 brought to the side and over the chest. The head of the humerus was 
 in the glenoid cavity, and followed the movements of rotation made at 
 the elbow, but these were accompanied by a rough sensation or click. 
 The bony prominence,* which appeared quite smooth, followed 
 the movements of rotation, and the finger could be placed on its 
 upper surface as on a ledge. There was | inch shortening of the 
 arm. The deformity failed to be reduced, so the arm was fixed to 
 the side, and at the end of four weeks movements were commenced. 
 At the end of two months there was perfect movement of the 
 arm, the osseous projection rounding off, but with the same amount 
 of shortening, viz. | inch. 
 
 Moore describes the shortening of the humerus in these cases 
 as 'from half to three-fourths of an inch.' 
 
 Professor Kocher {Beitrdge zur Kenntniss einiger practisch- 
 wichtiger Fracturformen, Basel und Leipzig, 1896) describes in detail 
 and gives representations of seven cases of fracture about or through 
 the epiphysial line (pertubercular fracture). In some the diaphysis 
 had completely cleared the upper fragment, but in most it was in- 
 completely displaced forwards and inwards, in one only forwards. 
 The ages were in the case of the boys 18, 17 (two), 16, 10 years, in 
 two girls 14^ and 12 years. Operation was subsequently performed in 
 two of the cases for loss of function of the arms — a partial resection 
 in one and a complete resection of the diaphysis in the other. 
 
 Effusion into shoulder-joint. — Effusion into the articular cavity 
 has been noted in a few instances, coming on a few hours after the 
 injury, but it is a noteworthy fact that in a large number of cases 
 no evidence of synovial lesion has been present. 
 
 Although the synovial membrane extends below the upper end 
 of the diaphysis on the inner aspect, immunity from injury of the 
 articulation may be explained by the displacement forwards of the 
 
206 EPIPHYSES OF UPPEE EXTEEMITY 
 
 diaphysis (the most common form of inim-y), leaving the synovial 
 membrane intact on the inner side, v^hile lacerating the periostemn 
 in front. 
 
 The following case of marked effusion into the joint is noted by 
 Dr. Jetter. 
 
 F. B., aged fifteen, on May 24, 1882, fell upon the left shoulder in 
 a gymnasium, and suffered immediate loss of power and movement of 
 the arm. When seen the next day there was diffuse swelling of the 
 whole shoulder and marked effusion into the joint. The head of the 
 humerus remained in the articular cavity. Active movements were 
 impossible, and passive movements painful, and these, when forcible, 
 produced smooth crepitus. The end of the diaphysis was dis- 
 placed forwards and inwards. After reduction, Leiter's coils were 
 a]3phed to the shoulder, then Velpeau's bandage. By June 3 the 
 swelling had considerably diminished, and by June 7 the effusion 
 into the shoulder-joint was very much less. The shght displacement 
 forwards of the upper end of the bone was now very distinctly seen, 
 and the epiphysis moved with it. On July 10 the patient left the 
 hospital, and there was no subsequent shortening or loss of power in 
 the arm, the patient being declared fit for mihtary service. 
 
 Incomplete displacement, outwards. — Edmund Owen's case, already 
 mentioned, was caused by indirect violence. 
 
 Incomplete displacement, backwards. — Although such displacement 
 is probably not uncommon, the author is only able to record two 
 instances. The specimen in the St. Bartholomew's Hospital 
 Museum, and that figured by Thudichum, have both been referred 
 to above; according to Kiistner, the diaphysis in newly born 
 children may be displaced backwards, as in a post-glenoid dis- 
 location. 
 
 Complete displacement of diaphysis, forwards and inwards. — Several 
 cases of complete displacement forwards of the diaphysis have been 
 placed on record, but these are less frequent than the incomplete 
 cases we have just discussed. Complete displacement was present 
 in seven of the eight cases of compound separation described above, 
 but it must be noted that in several instances the displacement was 
 more forwards and outwards ; in one only was it forwards and 
 inwards. In these rare instances the epiphysis, being perfectly free 
 from the diaphysis, will be very powerfully acted upon by the muscles 
 attached to it, so that its separated surface wiU look more or less 
 directly outwards. The diaphysis acted upon by the pectorahs major, 
 latissimus dorsi, and teres major muscles is drawn upwards and in- 
 wards towards the coracoid process. Sometimes the smooth end 
 of the diaphysis may be felt in the axilla. 
 
 Hamilton inclined to the belief that complete displacement was 
 the more common form of separation, while E. W. Smith says : ' So 
 great a degree of displacement as to enable the lower fragment to 
 clear the under surface of the superior fragment must indeed 
 
SEPAEATION OF UPPEK EPIPHYSIS OF HUMEEUS 207 
 
 necessarily be of very rare occurrence, and could scarcely happen 
 without rendering the fracture compound.' 
 
 On abducting the arm, the convex end of the diaphysis can be 
 felt in the axilla. The anterior diameter of the shoulder is increased, 
 and the elbow can be brought to the side. 
 
 Numbness of the fingers may occasionally occur, as in the two 
 instances recorded by Middeldorpf. 
 
 The characteristic displacement forwards and inwards of the 
 diaphysis is also well shown in a case figured by Bruns {Deutsche 
 Chirurgie, 1886, S. 126) in a girl aged 
 fifteen years. / \ 
 
 Complete displacement forwards above v ,^.:^''^ - - \ 
 
 coracoid process. — The lower fragment, ,.-s| 
 
 of an irregular transverse shape, will /^ ' ■ ■ 
 
 be situated immediately beneath the / '•:;:. % 
 
 skin, and might be mistaken for the I J | 1 
 
 head of the bone. |! m -fc 
 
 Hamilton gives (Treatise on Frac- l ^5; . '%. w '%, i 
 tiires and Dislocations, 7th edition, |f pr #! 
 
 1884, p. 261) the three following cases, | p. ^^^s- I 
 
 which were probably examples of com- |- ffj "' ^fcll | 
 
 plete displacement, in which the upper , ■'■ ^l-- ^ 
 
 end of the lower fragment was above '"" '' .•• 
 
 the level of the coracoid process, and 
 seemed to be directly beneath the skin, p,,^ 44.-separation of upper epi- 
 
 Case I. C. H., aged nineteen, in physis of the humerus, complete 
 
 J.1 -IT- -11 £ £ ■\^ £ DISPLACEMENT INWARDS OF DIAPHY- 
 
 the dehrmm caused by fever, fell from gjg, (after bruns) 
 a third-story window. Two physicians 
 
 who were called in thought there was a fracture of the acromion pro- 
 cess, accompanied by a dislocation of the head of the humerus, and 
 they attempted to reduce it, but without success. Three weeks 
 afterwards, Hamilton found a separation of the upper epiphysis of 
 the humerus, and the upper end of the shaft projecting in front 
 of the acromion process, a little above the level of the process and 
 covered only by the skin. No union had occurred between the two 
 fragments. 
 
 Case II. John D., aged eighteen, fell about eight feet. The injury 
 at first was believed to be a dislocation or fracture, and, the patient 
 being placed under the influence of ether, attempts were made to 
 reduce the deformity. The end of the bone seemed just under the 
 skin, and almost ready to be thrust through, but the extension made 
 it retire somewhat. Hamilton diagnosed a separation, although the 
 shoulder was a good deal swollen. The upper end of the lower 
 fragment could be felt distinctly — rough and serrated in front of the 
 acromion process. On extension he was able to detect a slight 
 crepitus or click, and on employing Dugas's test the elbow rested 
 upon the front of the chest. One long splint was applied with a 
 
208 
 
 EPIPHYSES OF UPPER EXTREMITY 
 
 sling under the wrist, but not under the elbow. The fragments 
 united with very little deformity. The diagnosis was confirmed by 
 Dr. Moore. 
 
 Case III. William H., aged nineteen, fell on a side-walk and 
 fractured the humerus at its upper epiphysis. On the third day the 
 fragments were thought to have been reduced, and the limb was 
 secured in splints. Subsequent attempts at reduction by Moore's 
 method under ether were unsuccessful. The displacement was 
 complete, and the entire upper end of the lower fragment could be 
 distinctly felt. 
 
 Agnew {Surgery, Philadelphia, vol. i. p. 882) speaks of the 
 presence of a prominence immediately ahove the coracoid process 
 
 Fig. 45. — diagram of complete displacejient inwaeds of diaphtsis beneath 
 
 cokacoid pkocess 
 
 of the scapula, with loss of power in the limb (the arm hanging 
 helpless by the side) as the signs which indicate the existence of this 
 fracture. In Dr. C. McBurney's case the displacement was probably 
 of this description, the shaft being displaced upwards and forwards 
 in front of the epiphysis. 
 
 Complete displacement forwards below coracoid process is a more 
 common form of injury. 
 
 The upper end of the diaphysis is drawn upwards and inwards 
 just beneath the coracoid process. In fact, this infra-coracoid pro- 
 jection is almost pathognomonic of the injury. In this case, the 
 
SEPAEATION OF UPPER EPIPHYSIS OF HUMEEUS 209 
 
 diaphysis having completely cleared the epiphysis, and lying on its 
 inner side, the latter will be powerfully acted upon and rotated by 
 the three muscles attached to it, so that its separated surface will 
 look directly outwards instead of downwards. The rounded or 
 slightly convex end of the bone can be readily felt with the fingers — 
 in fact, in lean subjects nearly the whole of the epiphysial aspect of 
 the diaphysis may be recognised by the characteristic cone-shaped 
 projection at its middle — the sharp rim of bone, with the central 
 elevated portion sloping off to the sides. The axis of the upper 
 extremity is directed downwards, outwards, and backwards. Ab- 
 duction of the arm will increase the deformity, while adduction with 
 extension will render it less marked- 
 It is quite possible in thin subjects in which complete displace- 
 ment has taken place, that on the lower aspect of the epiphysis a 
 cavity may be felt in which the finger may be placed for nearly 
 1^ inches through the deltoid. 
 
 Mr. Bryant figures a case of complete displacement forwards 
 of the diaphysis, projecting below the coracoid process, in a male 
 patient aged sixteen years. 
 
 The slight hollow below the acromial arch is at times less marked 
 than in incomplete displacement, on account of the rotation of the 
 epiphysis in an opposite direction to that just alluded to. Its separated 
 surface under these circumstances looks obliquely or perpendicularly 
 inwards, and is in contact with the outer aspect of the diaphysis, as 
 in Bruns's case. 
 
 The epiphysis, being fixed by the rotators of the arm, will not 
 readily follow the movements of the diaphysis, unless it be held to 
 it by the tough periosteum ; but even then it will only be movable 
 to a small extent. 
 
 The diaphysis is held in its displaced position by the periosteum, 
 as well as by the powerful muscles attached to its upper end. 
 
 Sir Astley Cooper, in alluding to the symptoms of this injury, 
 says that the head of the bone remains in its place, but that the body 
 of the humerus sinks into the axilla (where its extremity can be felt) , 
 and draws down the deltoid muscle, so as to lessen the roundness of 
 the shoulder. 
 
 C. Puzey's case {Liverpool Medico-Chirurgical Journal, vol. v. 
 1885, p. 46) was probably an example of this form of displacement. 
 
 Thos. S., aged five, a delicate, unhealthy-looking child with 
 eczema of the scalp and inflamed eyelids, had been run over by a 
 light spring cart. Under chloroform the right shoulder was found 
 to be much swollen, and the elbow away from the side, the smooth 
 and rounded upper end of the humerus lying in the axilla. There 
 was one inch shortening of the arm. Beneath the acromion the head 
 and tuberosities of the humerus could be felt and moved. On fixing 
 this fragment and rotating and drawing forwards the shaft, soft 
 crepitus was noticed. When the arm was let go, the upper end of 
 
 p 
 
210 EPIPHYSES OF UPPEE EXTREMITY 
 
 the shaft rolled back into the axilla, and projected under the coracoid 
 process. Suitable bandages were applied with a pad in the axilla. 
 At the end of four weeks there was considerable osseous thickening 
 but a good position of the fragments ; and by the end of four months 
 there was perfect use of the shoulder- joint and a good arm, with but 
 little bowing forwards and inwards of the bone at the epiphysial 
 junction, and no shortening. 
 
 One of the most marked cases of complete displacement of the 
 diaphysis forwards seen by the present writer was the case of E. B., 
 whom he had the opportunity of carefully examining when he was 
 Surgical Registrar at Guy's Hospital. The girl, aged sixteen, was 
 admitted under the care of Mr. Davies-Colley (Mr. Davies-CoUey's 
 Surgical Beports, 1884, No. 319), having been thrown out of a 
 waggonette, one of the other people in the carriage falling on the top 
 of her shoulder and the feet of a third person coming into direct 
 contact with her shoulder. It was thought to be a dislocation of the 
 shoulder ; the following measurements, however, were obtained, not- 
 withstanding the considerable swelling of the right shoulder, which 
 measured 2^ inches more in circumference than the left. The angular 
 projection of the end of the diaphysis could be seen in front, and it 
 was possible to place the tips of the fingers upon this transverse 
 mass of bone, which was situated 1| inch below the coracoid process, 
 and more than two inches below the acromial end of the clavicle. 
 There was one inch and a quarter shortening from the external epi- 
 condyle of the humerus to the acromion process. The head was felt 
 to be occupying the glenoid cavity, and the elbow was away from the 
 trunk and pointed backwards and outwards. The diagnosis was fully 
 confirmed under ether, and the diaphysis was easily replaced in its 
 normal position by means of extension and manipulation. A gutta- 
 percha splint was afterwards moulded to the shoulder, but six days 
 later the diaphysis was found to be again displaced. This was again 
 reduced, and extension applied to the arm by weights with counter- 
 extension. After twenty-one days the patient was discharged from 
 the hospital with the limb in good position and the upper epiphysis 
 firmly attached to the shaft. 
 
 Berges quotes a like case from Nimier's Thesis (Berges, ' De la 
 disjonction traumatique de V extremite superieure de V humerus,'' These 
 de Paris, 1890, p. 33 ; Nimier, These, 1879), in which a child fell from 
 a cart over four feet high. The upper end of the lower fragment, with 
 its rounded outline, and its forward, inward, and slightly upward 
 displacement, very like the displaced head of the humerus, pushed 
 up the anterior wall of the axilla, below the coracoid process. How- 
 ever, the humeral head remained in position, for it could be felt below 
 the coraco-acromial arch. The examining fingers could in the axilla 
 easily feel the projection of the displaced end of the lower fragment 
 and another behind belonging to the head in its proper position. 
 Extension was employed, but the displacement was reproduced 
 
SEPAEATION OF UPPEE EPIPHYSIS OF HUMEEUS 211 
 
 through, the restlessness of the patient. Ultimately, firm miion took 
 place, with free and painless performance of motion. 
 
 Kirmisson relates (Legons cliniques sur les maladies de Va^ypareil 
 locomoteur, Paris, 1890) a good case of separation of the upper epi- 
 physis of the humerus, with complete displacement of the diaphysial 
 end to the inner side of the coracoid. Eeduction was very easily 
 effected, and perfect recovery took place, both in the natural contour 
 and function of the arm and shoulder. Mayor's sling was the only 
 apparatus employed. 
 
 Complete displacement, outwards and upwards. — The incomplete 
 form of displacement furnishes the most frequent examples, but it 
 has been met with in more complete form, especially in compound 
 separations. 
 
 Shortening in both these forms is considerably greater than m 
 the incomplete displacements ; Moore says from half to three- 
 quarters of an inch. 
 
 Complications. —Z?2/i^r?/ to axillary artery is of infrequent 
 occurrence. 
 
 In H. E. Clark's case of compound separation, as well as in 
 Hamilton's, the injury to the axillary vessels resulted in gangrene of 
 the hand, &c. 
 
 Mr. Le Gros Clark records {Lancet, 1885, May 20, vol. i. p. 535) 
 a case of separation of the head from the shaft of the humerus, the 
 result of a fall from a height, complicated with singular chest 
 symptoms. 
 
 J. H., aged twelve, hodman's boy, was admitted, December 2, 
 into St. Thomas's Hospital, having fallen, half an hour previously, 
 from a height of forty or fifty feet. Although there was considerable 
 swelling of the shoulder, obscuring the nature of the injury at first, it 
 afterwards became apparent that the epiphysis was separated from 
 the shaft of the humerus, the length on the injured side being nearly 
 an inch shorter than on the sound side, measuring from the acromion 
 to the external condyle. There was no very marked falling in of the 
 deltoid, but the upper extremity of the shaft of the bone penetrated 
 between its fibres, and threatened to pierce the superjacent bruised 
 skin. It was found impracticable to restore it to its direct and accurate 
 relations with the head of the bone, and this state of affairs must 
 have been due to the interposition of some tendinous fibres or to the 
 impaction of the shaft in the head. The thin covering of skin over 
 the upper extremity of the diaphysis ulcerated, but subsequently 
 healed well. Good union and free mobility were ultimately regained. 
 The interest of this case is, however, especially associated with the 
 following condition, which supervened on the afternoon of the day 
 after the patient was admitted. On visiting him Mr. Le Gros Clark 
 found his face flushed, his respiration hurried and oppressed ; but, 
 though the dyspnoea was urgent, there was no lividity or coldness of 
 the lips or extremities. The heart's action was forcible and frequent, 
 
212 EPIPHYSES OF UPPER EXTREMITY 
 
 but the sounds were normal. Over the left side of the chest there 
 was complete dulness on percussion, and also absence of respiratory 
 murmur, and, indeed, of any sound but the heart's action, except, 
 perhaps, a scarcely perceptible murmur under the clavicle. Vocal 
 thrill was equally audible on both sides. On the right side there 
 was normal resonance on percussion, and the respiratory murmur 
 was very distinctly audible — indeed, puerile. There was no cough 
 nor expectoration. Four leeches were applied to the upper part of 
 the chest, and relief almost inmiediately followed. On the following 
 day the boy was breathing quietly, and in less than forty-eight hours 
 all the above symptoms had disappeared, and the respiratory sounds 
 on percussion and auscultation, as well as the heart's action, were 
 perfectly normal. Mr. Le Gros Clark asks what was the cause of 
 suspended respiration in the entire left lung. The extremely 
 excited action of the heart seemed to indicate serious obstruction 
 in the pulmonary circulation, and the result of treatment seemed to 
 point in the same direction. If not engorgement of the lung from 
 the violence done to the chest by the fall, what could it be, cpn- 
 sistently with the rapid disappearance of the symptoms ? 
 
 Pressure tipon hracliial plexus. — The diaphysial end, if it be dis- 
 placed far into the axillary space, may cause pressure upon the brachial 
 plexus. This was probably the cause of the numbness of the fingers 
 in two cases observed by Middeldorpf. 
 
 In one case (Middeldorpf, Knoclienh7'uche, S. 86, 1851) a boy, 
 aged fifteen, after a fall from a stair, experienced very acute pain 
 with complete loss of power of the arm, and any attempt at 
 movement caused great distress. There was some falling in of the 
 deltoid muscle, and the arm was abducted from the thorax at an angle 
 of about thirty degrees, and shortened one centimetre. Numbness 
 of the fingers was also present. High up in the axilla, beneath the 
 vessels and nerves, the sharp edge of the bone could be clearly felt. 
 Reduction was effected by powerful extension and pressure upon the 
 edge in the axilla, and was accompanied by mild crepitus. There 
 was no reproduction of the displacement on slight elevation of the 
 arm. Union took place after fourteen days, without any deformity 
 or loss of utility of the arm. 
 
 In the second case (Middeldorpf, Knochenbrilche, 1852) a boj'', 
 aged thirteen years, had fallen downstairs the previous day on to 
 his left shoulder. Acute pain, numbness of the fingers, and loss of 
 power of movement were experienced, with great swelling, especially 
 of the deltoid, and abduction of the elbow. The lower fragment 
 projected inwards and forwards into the axillary space. Crepitus 
 and shortening were absent. Reduction was effected as in the pre- 
 ceding case, but recurred the next day, when a starch bandage was 
 applied. Consolidation took place in seventeen days, without any 
 trace of callus to be felt externally ; thirteen days later complete 
 use of the arm was regained. 
 
SEPAKATION OF UPPEK EPIPHYSIS OF HUMERUS 213 
 
 Separation with dislocation of the head of the bone. — It is possible 
 in separations caused by very severe violence that the capsule of the 
 joint may be more or less lacerated and the head of the bone 
 displaced from its socket. 
 
 In March 1873 Mr. Durham had the following case under his 
 care at Guy's Hospital. Robert. E., aged seventeen, fell from a 
 warehouse a distance of sixty feet on to the pavement. On exami- 
 nation there was found considerable contusion and swelling in 
 front of the left shoulder, a subspinous dislocation of the left 
 humerus, with separation of its upper epiphysis, Colles's fracture 
 (? separation of lower epiphysis) of left forearm, fracture of the upper 
 third of shaft of right femur, and fracture of the clavicle. There 
 was some numbness of the shoulder, but this was the only evidence 
 of any nerve lesion. The head of the humerus could not be replaced ; 
 the other fractures were treated with the usual splints. Two 
 months later the patient was discharged with very fair movement 
 of his shoulder. 
 
 The diagnosis of this complication must always be a matter of 
 considerable difficulty, greatly increased by the swelling of soft parts 
 about the shoulder. The presence of the epiphysial head of the bone 
 in an unnatural position, the glenoid cavity not being occupied by it, 
 and its failure to move when rotation of the arm is made, are the most 
 characteristic signs. McBurney and Dowd {loc. cit. supra) point 
 out that (in the adult) shortening of the limb and crepitus may or 
 may not be capable of definition. A careful examination under an 
 anaesthetic is imperative. 
 
 McBurney says : ' Usually the mobility of the shaft of the 
 humerus, and the readiness with which it falls close to the side of 
 the thorax, would prove the presence of fracture, the existence of 
 dislocation of the head having been determined, but, as has been 
 pointed out by Stimson {Treatise on Dislocations, p. 255), the 
 same mobility may exist in a case of dislocation without fracture, 
 provided the capsule of the joint has been sufficiently lacerated.' 
 
 DIFFERENTIAL DIAGNOSIS. Sub-coracoid, sub-clavicular, and 
 intra-coracoid dislocations of the humerus forwards are the most com- 
 mon forms of injury likely to be mistaken for epiphysial separations, 
 
 Giraldes and E. W. Smith and others have drawn especial 
 attention to the frequency of confusing these fractures with disloca- 
 tions in children. The former surgeon says that in his wards he 
 had a certain number of cases of separation of the diaphysis or 
 epiphysis, all of which had been mistaken by practitioners for dislo- 
 cations of the shoulder. 
 
 It should always be borne in mind that epiphysial separations 
 can only occur at a period of life when dislocations are exceedingly 
 rare ; and dislocation of the shoulder-joint in children is extremely 
 so. 
 
 Mr. Henry Morris records (Holmes, System of Surgery, 1883, vol. i. 
 
214 EPIPHYSES OF UPPEE EXTEEMITY 
 
 p. 972) a case of dislocation forwards in an infant fourteen days old, 
 and Mr. Mayo Kobson, of Leeds, describes {Lancet, July 26, 1890, 
 p. 172) a case of supra-coracoid dislocation of the right humerus in 
 a youth aged sixteen. At the time of operation by exploratory 
 incision, there was, in addition, a split fracture separating the great 
 tuberosity from the bone and extending down the shaft, and the 
 glenoid cavity was filled with callus. Eraser {American Journal of 
 the Medical Sciences, 1869) replaced the dislocated head of the bone in 
 a boy aged fifteen years, and obtained a good result. These rare cases 
 may almost be disregarded in practice : separations of the upper 
 end of the humerus replace dislocations before the twentieth year. 
 
 The end of the diaphysis situated in front of the shoulder, being 
 slightly convex and rather smooth, may be easily mistaken for the 
 head of the bone, displaced below or above the coracoid process— 
 especially as the central conical projection is the first part to ossify 
 on to the epiphysis, so that it may readily be broken off and cause 
 this surface to appear flatter than it otherwise would do. But it is 
 never so smooth, rounded, or situated so high in the axilla as in 
 dislocation. On the other hand, it has an abrupt anterior ledge 
 situated lower down and smaller than the normal head of the bone. 
 The skin often presents over the displaced lower fragment a peculiar 
 depressed appearance ; it is held firmly over the projection and 
 cannot be moved over it, while occasionally a distinct pit is seen in 
 the integument on attempting to replace the diaphysis in its natural 
 position. This condition of the skin is the result of the penetration 
 of the muscular fibres of the deltoid, deltoid aponeurosis, and even 
 the superficial fascia by the diaphysial end. It is not met with in 
 dislocation. 
 
 In a large proportion of the cases described above a diagnosis 
 of dislocation was at first made. 
 
 Jetter says that out of seven cases operated upon for deformity 
 and loss of function of the arm after union had taken place the 
 displacement had, on five occasions, been diagnosed as a dislocation, 
 and attempts at reduction had been made by the medical attendant. 
 
 As late as June 1893 we find (according to Lejars) a case being 
 mistaken at one of the Erench hospitals and vain attempts made 
 at reduction by Kocher's method. 
 
 Dr. J. E. Erdmann, of New York, mentions {Neio Yorli Medical 
 Becord, October 26, 1895, p. 586) the case of a boy (M. McG.), aged 
 sixteen, who had fallen upon his shoulder six weeks before. He 
 had been an inmate of one of the large New York hospitals, and 
 was being treated for a sub-coracoid dislocation of the humerus. 
 There was no swelling, but marked flattening of the shoulder, 
 broadening from before backwards, and 1^ inch shortening. A 
 slightly convex deformity, continuous with the shaft, with the 
 bicipital groove well marked upon it, was found beneath the acromion, 
 and downwards and in front, practically sub-coracoid, a round, fairly 
 
SEPAEATION OF UPPER EPIPHYSIS OF HUMERUS 215 
 
 movable mass was felt. A diagnosis of epiphysial separation was 
 then made and operative treatment recommended, but refused. 
 
 The author has seen the same mistake made at the hospitals in 
 London. 
 
 There are many other signs, as well as the prominence referred 
 to above, in which epiphysial separation and dislocation somewhat 
 resemble one another. Great bruising and swelling render the 
 diagnosis still more difficult. 
 
 Unnatural mobility of the upper end of the bone is mostly, but 
 not invariably, present in separation, and consequently cannot be 
 considered as diagnostic from dislocation ; it is nearer to the joint as 
 infancy is approached. For the head of the bone remaining in the 
 glenoid cavity is usually motionless when the shaft is moved, except 
 in the cases of incomplete displacement with impaction described 
 above. 
 
 In this connection H. E. Clark observes {vide supra) : ' One 
 noteworthy sign which may be found useful in the diagnosis of such 
 cases is this : the head of the bone being fixed with the fingers of 
 one hand, while the elbow was held with those of the other, the shaft 
 was made to move with the result that if the movements were angular 
 in their character the epiphysis was quite stationary, a fact which 
 showed how complete was the separation of the bone. If, however, 
 the movement consisted in the rotation of the humerus on its own axis, 
 the epiphysis moved with the diaphysis. This may be explained by 
 the convexity of the upper end of the lower fragment fitting into 
 the cup-like surface on the under surface of the upper fragment ; 
 this arrangement of the parts, while allowing angular movement to 
 take place at the line of separation, will not permit rotatory move- 
 ment of the one upon the other.' 
 
 The shoulder still retains its general rotundity. Although there 
 may be some depression (one inch or more) below the acromion, it 
 is not immediately below the acromion process, nor does it extend 
 at all backwards behind this process, as in dislocations. There is, 
 therefore, no projection of the acromion, nor any deep excavation 
 immediately below it, inasmuch as the epiphysis still retains its 
 normal position, and, in thin subjects, may be felt below the acromion 
 process when there is an absence of great extravasation of blood. 
 
 The head of the bone, often distinctly felt in its socket, is one of 
 the best distinguishing signs. It is often placed obliquely in the 
 glenoid cavity — being retained there by the muscles attached to the 
 epiphysis and by the capsule of the joint — and may rotate with the 
 diaphysis if the locking of the fragments is very firm ; in complete 
 displacements it does not move with the diaphysis. 
 
 The fragments are not easily maintained in position after reduction, 
 the deformity immediately recurring on letting the parts go free, 
 except where the two fragments can be made to fit accurately one in 
 the other. On the contrary, in dislocation after reduction the parts 
 
216 EPIPHYSES OF UPPEE EXTEEMITY 
 
 usually maintain tlieir normal position, and tlie movements are again 
 very free. 
 
 Professor R. W. Smith says, in reference to diagnosis : ' The 
 chief diagnostic signs are an abrupt projection beneath the coracoid 
 process, caused by the upper end of the lower fragment, and the 
 immediate recurrence of the deformity when the means employed 
 for its reduction cease to be in operation.' In another paragTaph he 
 says : ' There is no fracture incidental to the upper end of the 
 humerus in which it is more difficult to maintain the fragments in 
 their proper relative position.' 
 
 Modified crepitus may be felt during reduction, and, if present, is 
 characteristic. 
 
 Shortening is not usually marked, except in complete displacement. 
 
 There is no fixation of the limb in its abnormal position, as in 
 dislocation. 
 
 The elbow does not project to such a very marked degree from the 
 side of the body as it does in dislocation, nor is there any difficulty 
 in bringing it into contact with the side of the trunk. 
 
 Dugas's test (L.-A. Dugas, Trans. Amer. Med. Association, vol. x. 
 p. 175) is most useful. The hand of the affected side can easily be 
 placed by the surgeon upon the opposite shoulder, while at the same 
 time the elbow may be brought against the front of the chest. If 
 this can be done readily there is no dislocation. 
 
 Acute p)ain is also felt at the epip)hysial line on pressure and 
 during manipulation. 
 
 Chloroform should be given in all cases where there is the 
 slightest doubt about the diagnosis or where difficulty is subse- 
 quently experienced in reduction. 
 
 In one of the cases of complete displacement seen hj Hamilton 
 a fracture of the acromion process with a dislocation of the head 
 of the humerus was believed to have taken place. Such an error 
 could not have occurred if the above means of diagnosis had 
 been carefully applied. 
 
 When, however, a true dislocation is associated loith a fracture 
 of some part of the neighbouring bone, as of either of the tuberosities 
 (not unconnnon with forward dislocation), the anatomical neck, kc, 
 the signs are usually so obscure as to render the diagnosis well nigh 
 impossible. They have been mostly recognised after death. 
 
 An exploratory incision under strict antiseptic precautions, as 
 advocated by Mayo Eobson, should be undertaken in all such cases, 
 at any rate when ordinary means of reduction have failed. The 
 same operation must be carried out in all epiphysial sejKcrations 
 accompanied by dislocation, whether partial or complete ; or even 
 excision of the head may be required. 
 
 Fracture of the surgical neck. — So many signs of tliis transverse 
 fracture in the adult are obviously the same as in separation in 
 children — namely, the general character of the deformity, direction 
 
SEPAEATION OF UPPEK EPIPHYSIS OF HUMERUS 217 
 
 of the displacement, unnatural mobility, shortening of arm, causation 
 &c. — that we have to rely upon the age of the j^aMent and upon 
 the fact that the fracture takes place in the immediate vicinity of 
 the conjugal cartilage. In youths, during the period of growth, a 
 direct injury to the shoulder is more likely to be followed by 
 epiphysial separation than fracture of the surgical neck, therefore in 
 them every solution of continuity in this situation should suggest the 
 former lesion, especially if accompanied by deformity. M. Coulon 
 describes {Fractures chez les enfants, Paris, 1861, p. 127) two or 
 three cases of supposed fracture of the surgical neck in children. 
 M. de Saint-Germain {Chirurgie 
 des enfants, Paris, 1884, p. 178) 
 says that he has seen several cases 
 of fracture of the upper extremity 
 of the humerus in children, but 
 believes they are rare. 
 
 The angular, convex, or smooth 
 end of the diaphysis, upon which, 
 in complete displacements, the ex- 
 amining finger may be placed as 
 upon a ledge, is unlike the sharp 
 pointed projection of a fracture, 
 which is situated somewhat lower 
 than in separation. Even in in- 
 complete displacements the exact 
 seat and character of the diaphysial 
 end or edge are most important 
 for diagnosis. 
 
 D. W. Cheever, of Harvard Uni- 
 versity, puts the matter as follows 
 {Boston M. and S. Journal, 1893, 
 cxxviii. p. 585) : ' Separation of the fkj. 46.— diagkam of situation of separa- 
 epiphysis is practically about the ™^ -^^^ feacture of the upper end 
 
 -'--'-'' -^ '' OF THE HUMERUS IN CHILDREN 
 
 same thing as fracture of the surgi- 
 
 (Actual size) 
 
 cal neck ; it takes place within a 
 fraction of an inch of the same locahty, and whether the epiphysis 
 or the surgical neck will give way depends on the age of the patient. 
 Then these two are combined usually under the ordinary name of 
 fracture of the surgical neck.' 
 
 It is very improbable, however, that the line of fracture in the 
 adult, which is generally very irregular, will be transverse — in fact, 
 it is never so tranverse as in separation of the epiphysis. Trans- 
 verse fractures, again, are often impacted, and so do not permit 
 any movements between the fragments ; in epiphysial separa- 
 tion some lateral movement may commonly be obtained of the 
 diaphysis on the epiphysis on moving the arm, whereas in the 
 impacted fracture no such movement can be effected, the upper 
 
218 EPIPHYSES OE UPPEE EXTEEMITY 
 
 fragment rotating at the shoulder-joint. According to Poncet, the 
 chief points in the diagnosis of this injury are the age of the 
 patient, the high position of the lesion in the immediate neighbour- 
 hood of the shoulder-joint, and the displacement forwards and 
 inwards of the lower frae^ment. 
 
 The muffled crepitus, when present, is characteristic. Seeing that 
 the separation may be only partial, being accompanied by a fracture of 
 the shaft as in Mr. Johnson Smith's case, the crepitus more distinc- 
 tive of an ordinary fracture will be met with. The soft crepitus 
 will then be obscured by the fine dry crepitus of the fracture. 
 
 The signs of separation of either tuberosity in the child will for 
 the most part be negative and obscure, and indistinguishable from 
 fracture of the tuberosities in the adult. 
 
 Both will be extrascapular, and caused by direct violence to the 
 shoulder. Some increase in breadth of shoulder, localised^ pain at 
 the epiphysial line, and the possibility of seizing the se^^arated 
 process between the fingers and replacing it in its natural position 
 when the arm is abducted, will be present both in separation and 
 fracture. 
 
 Both those limited injuries are distinguishable from separation 
 of the whole epiphysis by displacement forwards in the case of the 
 lesser tuberosity and by displacement backwards in that of the 
 greater tuberosity, giving rise to a projection which is movable, and a 
 gap or depression between it and the rest of the upper part of the 
 bone. Crepitus will be absent, or with difficulty obtained in these 
 fractures by grasping the process and rotating the arm. 
 
 The head of the bone will not as a rule rotate in the glenoid 
 cavity if the remaining portion of the upper end of the humerus 
 be broken through at the epiphysial junction. 
 
 Sprains and contusions of the shoulder in childhood offer some of 
 the most difficult cases for diagnosis from epiphysial separation with 
 little or no displacement. In this connection the author would refer 
 the reader to Ollier's description of juxta-epiphysial sprains. 
 
 TEEATMENT. — The treatment of this separation will vary with 
 the particular character of the lesion presented — w^ith or without 
 displacement, or accompanied by some complication. 
 
 Wliere displacement is absent, or has been reduced, the treat- 
 ment will not differ from that of fracture of the upper end of the 
 humerus, care being taken to prevent any subsequent displace- 
 ment or movement of the fractured surfaces, and thereby to guard 
 against the possibility of arrest of growth of the bone, whilst the 
 arm is fixed to the side by a simple bandage, with or without a 
 cap of felt or other material over the shoulder. 
 
 Mr. Thomas Call&way (Dislocations and Fractures of the Clavicle 
 and Shoulder -joint, 1849), in describing the ease with wdiich several 
 cases of fracture of the surgical neck of the humerus, occurring at 
 Guy's Hospital in children at puberty, were reduced and maintained 
 
SEPAEATION OF UPPER EPIPHYSIS OF HUMEEUS 219 
 
 in position, does not even allude to the frequent occurrence of epi- 
 physial separation at almost the same point. 
 
 They- certainly present much greater difficulties in treatment 
 than fractures of the surgical neck, on account of the lesion of the 
 bone being placed higher in position, especially on the inner side, 
 thus rendering the upper fragment very short and difficult to be 
 fixed by a retentive a^^paratus. 
 
 Incomplete Displacement. — In certain cases of incomplete 
 displacements of the epiphysis, the deformity is so shght that but 
 
 o /nches 
 
 Fig. 47.— pattern in house-flannel oe plastek-of-paris shoulder cap for a 
 
 child of eight years 
 
 Reduced to one-quarter size on scale of inches. 
 
 little manipulation of the upper end of the epiphysis is required to 
 replace the fragment, and therefore but simple measures are required 
 to retain the same in proper position. In these the reduction of the 
 fragments is usually maintained. Simple fixation of the arm to the 
 side and flexion of the elbow are often sufficient for this purpose, 
 the chest affording a very good support for the diaphysis ; or a plaster- 
 of-Paris splint, taking in the shoulder and arm, in the form of a 
 cap with the arm bandaged to the side and a wedge-shaped axillary 
 pad, may be necessary. 
 
220 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 Eeduction in the more 
 simple cases is effected under 
 an angesthetic by . pressing 
 with the greatest gentleness 
 the upper end of the lower 
 fragment backw^ards and out- 
 wards with one hand, and 
 by making extension or trac- 
 tion at the elbow with the 
 other hand and at the same 
 time drawing the elbow for- 
 wards and upwards. In these 
 incomplete cases reduction 
 by this or Moore's method 
 can only be successful if the 
 deltoid has not been trans- 
 fixed by the diaphysial end, 
 a complication which so often 
 happens in the more complete 
 displacements. 
 
 The following cases have 
 been treated at Guy's Hospi- 
 tal upon this simple plan with 
 favourable results. 
 
 No. 1. W. H., aged thir- 
 teen, was admitted under the 
 care of Mr. Durham, Novem- 
 ber 20, 1874, having fallen 
 off a van on to his right 
 shoulder. There was dia- 
 gnosed a separation of the 
 upper epiphysis of the hu- 
 merus with considerable con- 
 tusion around the joint ; arm 
 was bandaged to side, and 
 some days later a felt cap 
 was applied. Discharged 
 December 15, 1874. 
 
 No. 2. H. L., aged six- 
 teen, admitted under the care 
 of Mr. Bryant, October 16, 
 1876. He fell off a swing 
 Tig. 49.— plaster-of-paeis splint removed on to his right shoulder, 
 
 causing separation of the 
 upper epiphysis with much bruising ; arm was fixed to chest by 
 bandage. Discharged November 7, 1876. 
 
 No. 3. Eliza B., aged seven, under the care of Mr. Howse, was 
 
 Fig. 48. — method of applying plaster-of-paeis 
 splint to trunk and upper extremity 
 
SEPAEATION OF UPPER EPIPHYSIS OF HUMEEUS 221 
 
 admitted on July 5, 1877. She had been run over by a cart, the 
 wheel passing over her right shoulder. There was found to be a 
 fractured clavicle, and separation of the upper epiphysis of the 
 humerus. ' The arm was fixed to the side, and ten days later a 
 gutta-percha splint moulded to shoulder. Discharged August 8, 
 1877. 
 
 An accurate diagnosis should in all cases be made under an 
 anapsthetic before swelling, which rapidly ensues, takes place. The 
 fragments should then be gently replaced in position. The author 
 would add that the medical attendant should not undertake the 
 entire responsibility. However skilfully the injury may have been 
 treated, he is sure to be blamed for any deformity, or any arrest 
 of growth of the limb, that may result. 
 
 Complete Displacement. — Separation with more or less complete 
 displacement forwards may be one of the most difficult injuries to 
 treat at the upper end of the humerus. It should be reduced by 
 means of extension and abduction of the arm, assisted by direct 
 pressure upon the displaced diaphysis. 
 
 Prompt reduction is absolutely essential if the functions of the 
 shoulder are to be rapidly restored. 
 
 Moore does not believe that extension alone will produce com- 
 plete reduction. He says : ' Traction does not produce reduction, 
 for the reason that it does not remain in place after it appears to be 
 reduced ; the symptoms recur as soon as the extension ceases.' 
 
 E. F. Lonsdale relates {A Practical Treatise on Fractures, 
 1838, p. 179) a case of locking together of the fragments in a 
 boy about twelve years old, which shows the difficulty of complete 
 reduction. The fracture was situated apparently through the lower 
 limit of the epiphysis of the bone, about an inch below the 
 tubercles ; the fractured end of the shaft of the bone was projecting 
 anteriorly under the acromion, being almost through the integument. 
 The portion of bone was so jammed in this position that long con- 
 tinued extension, very violently applied, could not reduce it ; the 
 joint was not injured, and the bone united, with no other deformity 
 than this small proixiinence that was felt beneath the skin. Mr. 
 Lonsdale continues : ' It was difficult in this case to say upon what 
 the opposition to the reduction depended, for the muscular power 
 of the boy was small, and acted but very slightly.' 
 
 The elbow and forearm should not be raised, otherwise the upper 
 end of the diaphysis will tend to be displaced forwards again. 
 
 Even when the fragments have been reduced, it has been found 
 extremely difficult to retain the bones in their proper position. 
 
 After the lapse of three or four weeks, on taking off the splints, 
 there will at times be found, in spite of every attention, some 
 displacement forwards, or irregularity or unevenness at the line of 
 union. The union is quickly effected, probably from the great vascu- 
 larity of the epiphysis, and the number of muscles attached to it. 
 
222 
 
 EPIPHYSES OP UPPEE EXTEEMITY 
 
 The functions of the joint are very seldom x^ermanently impaired, 
 and the projecting mass of bone -v^-ill mould down and become 
 rounded off in the course of time with the subsequent growth of the 
 bone, so that after two years the angular deformity becomes 
 scarcely perceptible. 
 
 Jetter alludes in three instances to this continual displacement 
 of the lower fragment forwards and inwards, in spite of careful 
 treatment by Yelpeau's bandage. Two of these have been related 
 above, the third is as follows : 
 
 M. T., nine years old, fell on March 25, 1891, from a loaded 
 wao-o-on upon her left arm. On admission to hospital the next day 
 there was great swelling of the left shoulder and upper third of arm, 
 
 deviation of the axis of the humerus, 
 .^mmi>^ j-^Q head of which still occupied the 
 
 articular cavity, with typical displace- 
 ment upwards and inwards of the 
 lower fragment. Abnormal mobihty 
 and soft crepitus were also present. 
 The fragments were easily reduced by 
 extension, and Yelpeau's bandage was 
 applied ; but, in spite of this, displace- 
 ment occurred again the next day. 
 The arm was therefore elevated and 
 extension employed. This kept the 
 fragments in good position, but the 
 extension had to be removed after five 
 days on account of some excoriation 
 at the bend of the elbow. Yelpeau's 
 bandage was again applied for nine 
 days, when the displacement had re- 
 appeared, which necessitated a resort 
 to the former method of treatment till 
 April 16, when it was removed, and 
 there was no further displacement. 
 On April 19 the patient was discharged with ah the movements 
 tolerably free. 
 
 In all cases it is advisable to insert a flat soft pad into the axilla, 
 and the arm must be bandaged to the chest as in a fracture of the 
 clavicle, assistance being suppHed by a moulded poroplastic splint or 
 other material for the sake of compression and rest to the deltoid 
 and other muscles. 
 
 At Guy's Hospital, in 1874, Mr. Birkett treated, with an exceUent 
 result, a case of separation of the upper epiphysis of the right 
 humerus by means of a gutta-percha cap to shoulder. Michel K., 
 aged seven, had been run over by a van, the wheel passing over 
 his shoulder. Twenty-eight days later there was good union and no 
 appreciable deformity. 
 
 Fig. 50. — method of applying b-\n- 
 dage after the di-vphtsis has been 
 restored to its norm.vl position 
 
 The moulded shoulder cap is not 
 shown 
 
SEPAEATION OF UPPER EPIPHYSIS OF HUMEEUS 223 
 
 Or the arm may be placed on a pja-amidal pillow, inserted after 
 Dupuytren's method into the axilla, and the arm bandaged to the 
 body. The hand of the injured arm may be placed upon the 
 opposite shoulder, as in fractured clavicle ; occasionally this is the 
 only position in which reduction of the fragments can be main- 
 tained. 
 
 Mr. Durham treated a case at Guy's Hospital in this manner. 
 Sam S., aged fifteen, fell off a cart, pitching on to his left shoulder, 
 and causing separa- 
 tion of the upper 
 epiphysis of the hu- 
 merus. A pad was 
 placed in the axilla, 
 and the elbow bound 
 to the side. He 
 was discharged from 
 the hospital after a 
 month. There was 
 then firm union, and 
 all movements of the 
 arm were good, but 
 the shaft still pro- 
 jected somewhat for- 
 wards. In this case 
 an inside splint was 
 applied in addition, 
 but this could not 
 be of great service, 
 inasmuch as the sepa- 
 ration is close to the 
 head of the bone. 
 
 Some surgeons 
 prefer to abduct the 
 limb from the trunk 
 to a right angle or 
 less, with or without 
 a posterior splint 
 passing over the sca- 
 pula. This method 
 entails great incon- 
 venience, as the patient will be confined to his bed. In other 
 respects it will be found to be very efficient in remedying the dis- 
 placement, and bringing the upper end of the lower fragment into 
 com]3lete apposition with the epiphysis, which has undergone 
 rotation. 
 
 A laminated plaster-of-Paris sphnt may be applied with the arm 
 in the abducted position, the patient lying upon his back. 
 
 Fig. 51. — middeldoepf's triangle, consisting of a double 
 inclined plane framed out of three boards 
 
 The longest side is fixed to the trunk by straps, whilst the 
 arm, bent to an obtuse angle, is placed upon the two 
 shorter sides, and fixed there by bandages or Gooch's 
 splinting. (After Esmarch) 
 
224 EPIPHYSES OF UPPEPv EXTEEMITY . 
 
 Unfortunately, the reduction is often by no means easy, great 
 difficulty being experienced from the locking of the fragments and 
 the small size of the upper fragment. The head of the humerus, 
 by a firm grasp of the thumb and fingers on either side, may be 
 restrained enough to produce crepitus, but not enough to answer 
 the necessities of reduction. 
 
 Mr. E. M. Moore's method (' Epiphysial Fracture of the Superior 
 Extremity of the Humerus,' Trans. American Med. Association, 1874, 
 p. 296) of reduction of incomplete displacement forwards of the 
 diaphysis by completely drawing the arm at right angles to the 
 trunk without extension has already been mentioned. The reduc- 
 tion is effected by carrying the humerus forwards and upwards to 
 the perpendicular line. When once reduced the displacement has 
 shown no tendency to recur, any simple apparatus being sufficient 
 to complete the cure. The arm is then carefully lowered and fixed 
 in this position. Mr. Moore has verified the correctness of his opinion 
 by having in this manner effected the reduction with great ease in 
 three cases which came under his observation. The patients were 
 respectively six, fourteen, and sixteen years of age. 
 
 In the first case reduction was effected on the fourteenth day, 
 in the second case on the second day, and in the third on the 
 seventeenth day. In both of the latter ineffectual attempts had 
 been already made to reduce what was supposed to be a dislocation. 
 In order to maintain the reduction all that was found necessary was to 
 bring the arm down beside the body while in a state of moderate 
 extension, and to secure it with a Swinburne extension sphnt. In 
 all three cases there was a perfect result. The restoration to full 
 use was accomplished in less than thirty days. 
 
 Others have employed Mobre's method with equally good 
 results. 
 
 Packard, in this connection, says {Gyclopcedia of Diseases of 
 Children, Keating, 1890, vol. iii. p. 1064) : ' I would venture to 
 express my behef that a better plan is to follow the upper fragment 
 with the lower, first by extension, overcoming any impaction that 
 may exist, and then carrying the elbow upwards and outwards, so that 
 the arm shall be at an angle of perhaps forty-five degrees with the 
 body, in which position it can be readily supported by means of a 
 sphnt, one branch of which should be applied to the side of the 
 chest, the other to the inner side of the arm. After a week or two 
 the splint may be changed so as to lessen the angle, and again 
 two or three days later, and so on until the arm is brought down 
 close to the body.' 
 
 Dr. Chas. H. Eichmond {Neio York Medical Journal, November 
 1877, No. 26, p. 504) diagnosed this separation in a boy aged nine- 
 teen, who had fallen backwards a distance of six feet to the ground, 
 and successfully reduced the displacement by Moore's method, the 
 arm being carried upwards and forwards while extended. There 
 
SEPARATION OF UPPER EPIPHYSIS OF HUMERUS 225 
 
 was slight depression existing beneath the acromion, with the 
 characteristic forward and outward projection a little below, 
 together with ' muffled ' crepitus. A splint was applied, and at the 
 end of four to five weeks the result was perfect. 
 
 When this form of displacement has been followed by suc- 
 cessful reduction by this method, it appears to be less liable to 
 become again displaced, owing to the irregularities and the cup-like 
 manner in which the separated surfaces fit together when once 
 reduced. 
 
 Continuous extension may be employed after complete reduction, 
 and for cases of constantly recurring displacement. It has prin- 
 cipally been found useful in older children, and is effected by means 
 of a weight attached to the extremity, a wedge-shaped cushion in the 
 axilla being of assistance in preventing the displacement of the lower 
 fragment. 
 
 A simple method of continuous extension is that employed by 
 Lannelongue. The shoulder, trunk, and arm, as far as its lower 
 part, are surrounded by a plaster trough made with a bandage, in 
 which a wooden splint is firmly fixed, descending a short distance 
 below the elbow. To the lower end of this some india-rubber tubing 
 is attached and fastened above to the lower end of the arm. The 
 forearm is fixed to the trunk by a sling. 
 
 In spite of all perseverance, skill, attention, and the use of exten- 
 sion, counter-extension, and other mechanical means, it has in 
 exceptional instances been found impossible to effect reduction. 
 
 Hamilton describes the following case (Treatise on Fractures 
 and Dislocations, 7th edit. 1884, p. 261) of Joseph S., aged sixteen, 
 who fell backwards down a flight of steps, striking his back and arm 
 near the shoulder, and causing a separation of the upper epiphysis 
 of the left humerus. It was supposed that there was a dislocation 
 of the humerus, and an attempt had been made to effect reduction 
 with the heel in the axilla and without an angesthetic. He was 
 seen by Hamilton the following day, when, all efforts at replace- 
 ment proving ineffectual, splints were applied. The patient left the 
 hospital nine weeks afterwards with the fragments united, but over- 
 lapping at the point of fracture, the upper end of the lower fragment 
 being in front of the upper fragment. The Hmb was shortened one 
 inch, but its motions were free and its utility unimpaired. 
 
 Demoulin, Hutchinson, and others have described many similar 
 cases (see under Peognosis, Sequels, &c.). Some go so far as to 
 believe that irreducibility is the rule after separation of the upper 
 epiphysis of the humerus. But we need only point to Kirmisson's 
 and other cases in which perfect reposition of complete dis- 
 placement was most easy, and followed by absolute recovery of 
 the shape and use of the arm. 
 
 R. W. Smith says {he. cit. supra, p. 202) : ' I am sure that, 
 however experienced the practitioner may be, he will find the treat- 
 
 Q 
 
226 EPIPHYSES OF UPPEE EXTEEMITY 
 
 ment of the case embarrassing, and that it ^Yill require the exercise 
 of all his ingenuity and skill to prevent a certain amount of dis- 
 placement from being permanent, and to counteract the influence 
 of the muscles, which unceasingly act upon the lower fragment. 
 The consolation, however, remains that, notwithstanding the de- 
 formity, the patient will ultimately regain the almost unimpaired 
 use of the limb.' 
 
 One of the chief difflculties of reduction occurs, however, from the 
 insertion hetiveeii the epiphysial fragments of bands of periosteum, 
 fascia, or muscle, or from the penetration of the periosteal sheath 
 by the diaphysial end. 
 
 Union of fragments by operation, resection of diaphysial end, &c. — In 
 recent cases, in which it is found to be impossible to reduce the 
 deformity on account of the displacement of the diaphysis, and in 
 which it is probable that the utility, of the arm will suffer in conse- 
 quence, the propriety of cutting dow^n upon the fragments, resecting 
 the end of the diaphysis, directly placing the fragments in position, 
 and wiring the fragments together will at once suggest itself to the 
 surgeon. 
 
 This especially applies to cases of complete displacement, and 
 others where the difficulty of retaining the fragments in position is 
 great. The presence of the diaphysial end beneath the skin in front 
 of the shoulder indicates that it has passed through the deltoid, 
 transfixing and lacerating the front portion of the muscle. 
 
 At a meeting of the Society of German Surgeons in 1888 (Sajous, 
 Annual of the Medical Sciences, vol. iii. G. 3; Annals of Surgery, 
 February 1889, vol. ix. Xo. 2, p. 153) Professor Helferich (Greifswald) 
 narrated the history of a case in which he had cut down upon the 
 separated epiphysis of a humerus. At the same meeting Bruns 
 reported two cases, and Woelfler one, of separation of the epiphysis, 
 with dislocation of the head, successfully treated by excision of the 
 upper fragment. 
 
 In Professor Helferich's case {Milnchen med. IVoch. Is o. 40, 1887) 
 a lad of sixteen, while wrestling, fell violently to the ground, 
 striking the left shoulder. The head of the humerus was found in 
 its normal position under the acromion, while the rounded upper 
 end of the shaft was displaced forwards and inwards, under the 
 coracoid process, from w^hich position it could be slipped up and 
 down, and, when strong downward traction was made, soft crepitus 
 was developed. An apparent shortening of the arm of li centi- 
 metres was observed. All attempts at reposition proved unsuccessful 
 owing to the interposition of soft parts between the fragments, and 
 an incision was made in front of the shoulder. The upper end of 
 the humerus had penetrated into the axilla through a buttonhole 
 slit in the periosteum and capsule, which latter it was found needful 
 to incise before reduction could be accomplished. The fragments 
 were then fastened together with a long awl-shaped steel pin, which 
 
SEPAEATION OF UPPEK EPIPHYSIS OF HUMEEUS 227 
 
 projected beyond the surface at the Hne of sutures. This was 
 removed at the first change of dressings at the end of eight days. 
 The shoulder-joint regained its function in a short time. 
 
 In the case of a boy aged ten years, recorded by Dr. Jetter, 
 resection of the diaphysial end for complete displacement only left 
 11 centimetres shortening after the lapse of nine years. 
 
 Dr. Fred. Lange, of New York, has published (New York 
 Surgical Society, November 22, 1886, Annals of Surgery, vol. v. 
 1887, p. 448) another case in which operative measures were resorted 
 to as an immediate method of treatment. He describes this as a 
 fracture of the humerus with interposition of soft parts treated by 
 operative replacement. 
 
 A boy, aged ten, fell about eight feet, striking his right shoulder, 
 and sustaining a fracture of the humerus immediately below the 
 head ; the lower fragment had apparently perforated the deltoid 
 muscle, and, with a sharp edge, was fixed in the deep layers 
 of the skin without penetrating it. A distinct protrusion was 
 formed on the anterior aspect of the shoulder, the elbow being 
 thrown backwards so that the axis of the bone was directed 
 abnormally to the front. The lower fragment could not be released 
 from its abnormal attachment, even after the swelling and 
 tension had markedly subsided. On the seventh day, the patient 
 being placed under ether, an incision was made over the displaced 
 fragment, and the slit in the deltoid enlarged. A separation was then 
 found in the epiphysial line as far as the naiddle of the bone, whence 
 a line of fracture went in an oblique direction downwards and back- 
 wards, its lowest point being about two inches below the epiphysial 
 line. In order to bring the fragments into proper apposition, it was 
 necessary to elevate the arm above the horizontal line and to give it 
 a decided outward rotation, at the same time bringing it slightly 
 forwards. The periosteum and fibrous attachments on the edge of 
 the upper fragment were not torn exactly in the line of the fracture, 
 but at a short distance below, so that they overlapped the edge of 
 the upper fragment and had to be turned up, a condition similar to 
 that found in fractures of the patella. The periosteum had to be 
 slightly indented, and then coaptation could be effected. The long 
 head of the biceps was not torn, but lifted out of its groove and 
 dislocated to the inner side ; with the lower fragment, it returned to 
 its normal relations. Union without necrosis and complete cicatri- 
 sation ensued. The upper fragment, by the action of the muscles 
 inserted into the greater tuberosity, was abducted and rotated 
 outwards ; consequently, during the after-treatment the corre- 
 sponding position of the arm was maintained with slight extension 
 by means of a sphnt passing from the posterior aspect of the arm 
 over the back to the opposite scapula. 
 
 Dr. F. W. Murray described {Annual of the Universal Med. 
 Sciences, 1891, vol. iii. I. 8) a case of separation in a patient seven- 
 
 Q 2 
 
'228 EPIPHYSES OF UPPEE EXTREMITY 
 
 teen years old with displacement of the end of the shaft inwards, 
 in which he found it necessary to excise | inch of the shaft. 
 Kirmisson {Lemons sur les maladies de Fappareil locomoteur, Paris, 
 1890) has also adopted the same procedure. M. Eollet states that 
 a patient of M. Poncet was readily admitted into the military service 
 five years after a similar operation. 
 
 M. PoUet {vide supra) expresses himself thus : ' In cases in which 
 this displacement cannot be reduced, and where the upper end of 
 the lower fragment has either perforated the skin, or, after having 
 torn through the fibres of the deltoid, forms a very prominent 
 subcutaneous projection, it is necessary to resect the extremity of 
 the displaced lower fragment of bone. By such operation alone — 
 which, being an extra-articular one, presents very little if any 
 danger — can deformity be removed, and the functions of the injured 
 limb completely restored.' 
 
 Professor Erasmo de Paoli, of Perugia, recommends {Gominunica- 
 zioni della Clinica ChirurgicaPropedeutica delV XJnivei'sitd di Perugia, 
 Perugia, 1891) the method of fixing the fragments by means of one 
 or two sutures of sterilised silk. These buried silk sutures appeared 
 to him to be preferable to the steel pin used by Helferich, because 
 they permitted an immediate and perfect closure of the wound. The 
 permanent presence of this extraneous material in connection with the 
 epiphysial cartilage appeared to him to have also the advantage of 
 exciting formative activity in it, and correcting the slight shortening 
 produced by the resection. 
 
 The two following cases operated upon by De Paoli were not 
 quite recent, being ten days and seventeen days respectively after 
 the accident. The displacement of the lower fragment was abso- 
 lutely irreducible by external means. The difficulty of reduction 
 was caused by the powerful resistance of the periosteal sleeve 
 attached to the epiphysis, as well as by the rapid formation of 
 .adhesions with the surrounding structures, and by the displacement 
 of the epiphysis upwards and backwards. Consolidation in the 
 abnormal position had already commenced in so short a time. 
 With regard to this it is interesting to note in the second case that 
 after seventeen days there was no longer any trace of mobility 
 of the fragments. In both cases it was necessary to remove a small 
 portion of the diaphysial end. 
 
 Case 1. B. R., aged fourteen, fell, on May 4, 1891, from a 
 height of three metres, striking his shoulder. He was at once seen 
 by a doctor, who suspected fracture of the upper end of the 
 humerus with great displacement, and attempted the reduction of it 
 under an ansesthetic ; a bandage was applied to retain the parts in 
 position. On May 14 he was admitted to the hospital. Beneath 
 the coracoid process there was to be seen and felt a dome-shaped 
 prominence one inch in width, the head of the humerus occupying 
 its normal position ; this, as well as the diaphysial end, followed the 
 
SEPAKATION OF UPPER EPIPHYSIS OF HUMERUS 229 
 
 movements of the arm, but when the former was firmly fixed 
 with tire fingers, only the projecting diaphysis moved. The boy 
 could move his arm backwards and a little forwards and inwards, 
 but incompletely elevate it. The right humerus was shortened 
 2| centimetres as compared with the left. 
 
 The diagnosis was made of traumatic separation of the upper 
 epiphysis of the humerus with marked displacement and com- 
 mencing consolidation. On June 20, 1891, a vertical incision was 
 made from the apex of the acromion downwards over the projecting 
 end of the diaphysis, which was readily recognised, and covered 
 here and there with small areas of epiphysial cartilage. The union 
 already established between the two fragments was broken across by 
 means of a raspatory and by forcible adduction. To effect reduction 
 it was necessary to pare away a small amount of the end of the 
 diaphysis, and after the lower aspect of the epiphysis had been 
 freshened by scraping, the two fragments were united together with 
 a stout sterilised silk suture. Catgut suture was used for the 
 periosteum and deltoid, and silk for the skin. A small drain was 
 inserted in the lowest part of the wound, and the wound dressed 
 antiseptically, the shoulder being fixed immovably in the abducted 
 position. 
 
 On Jmie 23rd the patient was sent home, there having been no 
 rise of temperature. On July 21 the boy had never had any pain of 
 any kind, the dressings were removed, and perfect union was found, 
 with all deformity corrected. Active and passive movements of the 
 shoulder were perfectly free. 
 
 Case 2. T. B., aged seventeen, fell from a tree, seventeen 
 days before his admission into the hospital, on to some stony 
 ground, striking his left shoulder. Pain and swelling of the 
 shoulder were felt at the time, but of this he took no notice and 
 attempted to continue his work. Becoming worse, he was sent to 
 the hospital by the local doctor. On examination an abnormal 
 projection was noticed two inches from the apex of the acromion 
 process continuous with the humeral diaphysis ; it had a sharp 
 anterior edge, and a somewhat convex upper surface. The shoulder 
 retained its normal convex shape. 
 
 The upper epiphysis of the humerus appeared somewhat bulk}^ 
 but was in its normal position. Active movements were very 
 restricted in every direction. Passive motion, with the exception of 
 abduction, was altogether free, and the epiphysis moved freely 
 with the projecting diaphysis. The left humerus was shortened 
 three centimetres. Separation with great displacement of the 
 humeral diaphysis was diagnosed. 
 
 On June 4, 1891, an incision was made over the projecting lower 
 fragment through the antero-internal aspect- of the deltoid, which 
 was adherent to it. The adhesion between the fragments was 
 broken ■' down by forcible movemen4;s. ' A- portion of the bone, .1^ 
 
230 EPIPHYSES OF UPPEK EXTEEMITY 
 
 centimetres in length, had to be removed by a saw. It was then 
 seen that the separation did not whohy follow the epiphysial line, 
 but that a splinter of the diaphysis had been broken off from its 
 postero-internal aspect. The two fragments, after being replaced 
 in perfect apposition, were united by two sutures of sterilised silk 
 passed through the bone. The periosteum was next sutured, then the 
 muscle, and finally the skin. Antiseptic dressings were employed, 
 and an immovable bandage applied. On July 9 the patient was 
 discharged. There had been no pain and no rise of temperature. 
 On July 13 the patient was seen again ; there was then perfect union 
 of the fragments, and normal freedom of movement of the shoulder- 
 joint. 
 
 M. C. Walther (Bevue cVOrthopedie, Jan. 1897, No. 1, p. 40) ope- 
 rated successfully for irreducible displacement on a lad aged seventeen, 
 three days after the accident. AYhilst at play the lad had fallen 
 heavily from his comrade's back to the ground on to his left shoulder. 
 There were the characteristic signs of displacement forwards and in- 
 wards of the diaphj'sis, the end of which presented the usual ' plateau '- 
 like surface. Under an ansesthetic reduction of the displacement 
 was found impossible, although several attempts by extension of the 
 upper limb were made ; a vertical incision was therefore made over 
 the front of the shoulder, and the irreducibility was found to be due 
 to the projection through the deltoid of the lower fragment, which 
 was made fast in a narrow buttonhole of muscle substance. Even 
 after a wide incision of the muscle, and having the fragments under 
 direct observation, it was still impossible to make the proper coapta- 
 tion of the fragments. A second cause of irreducibility appeared to 
 be the preservation of a wide band of intact periosteum, which held 
 the fragments so firmly that their replacement was impossible. After 
 having resected from the diaphysial fragment the length necessary 
 to obtain reduction, M. Walther simply reunited the soft parts 
 without employing any suture to the bone, since there now remained 
 between the fragments no obstacle to their proper coaptation, 
 reduction being complete. The separation was not perfectly pure, 
 inasmuch as a vertical splinter of the diaphysis was detached from 
 its posterior and inner aspect and remained attached to the ej)iphysis. 
 Consolidation took place readily and uniformly, the arm being secured 
 in Hennequin's apparatus. The result at the end of the second 
 month was perfect ; there was no deformity and no restriction of 
 movements, which could be carried out fully and with their natural 
 force. 
 
 Helferich {Fracturen unci Luxationen, 3 Auflage, Miinchen, 
 1897, S. 133) gives two figures of another case before operation seen 
 from the outer aspect and from above. The girl (L. V.), aged 
 fifteen, had fallen from a high heap of straw upon her left shoulder. 
 Fom'teen days later (October 1894) she came under treatment, 
 and the displaced diaphysis was replaced by means of an anterior 
 
SEPAEATIOX OF UPPER EPIPHYSIS OF HUMERUS 231 
 
 incision and fixed in position by a steel pin. Consolidation took 
 place, with good mobility of the joint. 
 
 Finally, the author would insist that in separations with consider- 
 able deformity which are irreducible, and in others where the impac- 
 tion of the fragments is an important and possibly the only factor 
 in the causation of the subsequent loss of functional activity of the 
 limb, operative measures should not be delayed. They should also 
 be undertaken in the rare examples of complete displacement of 
 the diaphysis from the epiphysis, where the epiphysis has undergone 
 considerable rotation. Operation should also be practised in cases 
 where there is evidence of pressure upon the axillary vessels or 
 brachial plexus of nerves. In these instances the diaphysial frag- 
 ment must be replaced, for by no other surgical method can this 
 satisfactorily or effectuall}^ be accomplished. 
 
 In the larger proportion of cases the operation is extra-articular, 
 and at the present day it cannot be considered so grave as before 
 the introduction of aseptic and antiseptic methods, wound infection 
 being absent. 
 
 The new skiagraphy will, in the near future, undoubtedly 
 furnish some exact data upon which the surgeon may rely in 
 deciding upon the advisability of an operation. 
 
 Eeplacement and union of fragments by operation without resec- 
 tion of the diaphysis will sometimes be found sufficient in recent 
 cases. 
 
 It should be recommended in the cases of great and irreducible 
 displacements of the diaphysis, especially if associated with any of 
 the complications already enumerated, and in the younger periods of 
 childhood, when many years of growth still remain to the humerus. 
 Laceration of the periosteum and muscles, folding of their torn 
 fibres over the diaphysial end, or their intervention between the 
 fragments, being the most frequent causes of irreducibility, simple 
 aseptic incision over the protruding diaphysis, division of the soft 
 structures, and enlargement of the rent in the periosteal sheath will 
 be enough to enable the bone to be gently replaced in position. 
 
 After pegging the fragments together by means of pins to 
 prevent displacement, the divided edges of the periosteum and 
 capsule should be carefully sutured with carbolised catgut or silk, 
 then the edges of the muscles, and finally the skin. 
 
 Antiseptic dressings should then be carefully applied, and a drain 
 inserted if considered necessary. 
 
 Passive motion should be commenced in from two to three 
 weeks, and the other subsequent treatment carried out as in a recent 
 fracture. 
 
 At the New York Surgical Society, November 13, 1895, Dr. 
 Chas. McBurney (Annals of Surgery, February 1896, p. 177) 
 presented a boy in whom separation of the upper epiphysis of the 
 humerus had been treated by open operation. The patient was 
 
232 EPIPHYSES OF UPPEE EXTEEMITY 
 
 fifteen years of age, and was first seen in the previous June, 
 five days after he had fallen in a gymnasium upon his left 
 shoulder. The shoulder was then uniformly swollen and the skin 
 red, the temperature was 101° F., and the pulse rapid. The head 
 of the bone was in the glenoid cavity and separated from the shaft 
 at the epiphysial junction. Crepitus did not exist, for the shaft was 
 displaced upwards and forwards in front of the epiphysis, and its 
 rough end could be felt but a short distance beneath the skin. 
 Ether was administered, but reduction could not be accomplished 
 by traction and manipulation. McBurney therefore made a vertical 
 incision about three inches long over the prominent upper extremity 
 of the shaft. The fracture was found to be exactly at the junction 
 of the epiphysis and shaft, and the latter projected through nearly 
 the entire thickness of the deltoid muscle. The periosteum had. 
 been split vertically, and it and the muscular fibres were so folded 
 under the upper end of the shaft that reduction could not be made 
 without incision. These soft parts being held aside with retractors, 
 reduction was easily effected, and accurate apposition of the bone ends 
 obtained. The slit in the periosteum was then closed with catgut, 
 and the more superficial wound closed in the same way with 
 drainage. The wound healed cleanly and rapidly. The movement 
 at the joint was now entirely restored, and one arm could be 
 used quite as well as the other. No difference in the length of the 
 two humeri exists, although the boy has grown much since the 
 injury. 
 
 In another instance reported by Dr. Jetter {Beitrdge zur 
 klinisclien Ghirurgie, 1892, S. 373) resection of the diaphysis was 
 found to be unnecessary. 
 
 Maria E., aged twenty-three, on May 19, 1890, was pushed 
 into a ditch and fell upon the right shoulder. She was unable to 
 move the arm, and cold fomentations were applied on account of the 
 great swelling. The arm was then ' set ' by a doctor, and a plaster- 
 of-Paris bandage applied for four weeks. Five weeks after the 
 accident the patient was admitted into the hospital. There was 
 about one centimetre shortening, and the usual displacement for- 
 wards of the diaphysis, its end being directly below the coracoid 
 process. Abduction, flexion, extension, and rotation were very 
 limited. 
 
 After division of the soft structures, and breaking down of the 
 uniting callus by rotating the arm, the fragments could be separated 
 from one another. The fracture followed the epiphysial line, and 
 the lower fragment, after it had been freed of adhesions and part of 
 its periosteum, could be readily replaced in position without resec- 
 tion of its end. As the lower fragment had some tendency to be- 
 come displaced subsequently, the arm and hand were placed in the 
 elevated position. When seen nearly two years later (1892) the 
 movements of the humerus were normal, with the exception of slight 
 
SEPAEATION OF UPPEE EPIPHYSIS OF HUMEEUS 233 
 
 limitation of outward rotation. There was no deformity, and the 
 woman could again do any sort of work. 
 
 Resection and replacement of the diaphysial end in old cases of 
 separation were first recommended and carried out by Bruns in 1884 
 for correction of the deformity and restoration of the function of the 
 limb, elevation and rotation of the limb being especially impaired. 
 Arrest of growth, which may result from great displacement, must 
 also be taken into consideration. In two instances which had not 
 been recognised at the time of accident as epiphysial separations, 
 and had united with so much displacement that the utility of the 
 arm was greatly impaired, Bruns {Centralhl. f. Chirurgie, 1884, 
 S. 277 ; Mittheil'ungen aus der chirurgischen Klinik zu Tubingen, 
 i. 1884, S. 248 ; Beitrdge z. kiln. Chirurg. Bd. i. 1885, S. 241) cut 
 down by a longitudinal incision along the outer edge of the diaphysis 
 under strict antiseptic precautions, separated the united fragments 
 with a chisel and raspatory, removed a portion (one centimetre in 
 one case and two centimetres in the other) of the end of the diaphysis, 
 and successfully replaced them in their natural position. In one case 
 the fragments fitted so firmly against one another after this pro- 
 cedure that the epiphysis moved freely when the diaphysis was 
 manipulated, and there was no tendency to displacement. In the 
 other case, the fragments were retained in position by placing the 
 elbow in front of the chest and the hand on the opposite clavicle. 
 No osseous suture was used. 
 
 The first case was that of a young man (B. S.), aged twenty-four 
 (a very exceptional age for this injury), who four weeks previously 
 had fallen (1882) from the eighth step of a staircase to the ground, 
 striking his shoulder. 
 
 The second was that of a boy (A. H.), aged ten years, who had 
 fallen, five weeks previously, on to his shoulder from about the sixth 
 step of a ladder. 
 
 Both were diagnosed as dislocations, and attempts made to 
 reduce them, in the first without any success, and in the second 
 the deformity, though reduced for a time, was soon reproduced. 
 
 The characteristic deformity was well marked in both, the dia- 
 physis, with its rounded end, being displaced upwards and inwards 
 against the coracoid process, and the epiphysis firmly united to it, 
 although the fragments were probably only in contact at their edges. 
 All movements of the arm in both cases were greatly interfered 
 with, but more especially rotation and abduction. In the first case 
 the shortening measured two centimetres, in the second one and a 
 half centimetres. 
 
 At the operation the separation of the epiphysis in the boy's 
 case was found to be a pure one, whilst in the other it only 
 took place through the inner half of the epiphysial line, and then 
 ran obliquely outwards through the diaphysial end. In both the 
 epiphysis had rotated on its antero posterior axis very considerably, 
 
234 EPIPHYSES OF UPPEE EXTEEMITY 
 
 so that its separated surface looked inwards, and was in contact 
 with the outer side of the displaced diaphysis. 
 
 In both consolidation took place in three or four weeks, the 
 free mobility of the arm being completely restored, and the 
 deformity obliterated. In the boy's case nine years after the opera- 
 tion (1892) all movements of the shoulder were complete, and he 
 could work perfectly with this arm. Only a slight wasting of the 
 deltoid and three centimetres shortening of the humerus could be 
 detected. 
 
 Dr. Jetter (a former assistant of Bruns) adds two other examples 
 from the Tubingen Clinic. After resection of the diaphysial end 
 and reduction, the fragments were kept in position by means of 
 steel pins, which were removed between the second and third weeks. 
 
 Case I. A lad (J. B.), aged nineteen years, on July 28, 1890, fell 
 from a height of seven metres in a barn, and the handle of a pitchfork 
 which he was carrying was thrust into the right axilla. Great pain 
 and inability to move the arm were immediately experienced. No 
 diagnosis was made by the doctor, who applied an ice-bag, and later on, 
 electricity. On September 1, 1890, the patient was admitted to the 
 hospital on account of the impaired use of the arm. The diaphysis 
 of the humerus was detached at the epiphysial line and displaced 
 forwards and inwards. The fragments had united, as the head 
 moved with the shaft. Elevation of the arm could not be effected, 
 and rotation was limited. 
 
 After division of the soft structures, the uniting callus was divided 
 by a chisel. On the inner side the separation was accompanied by 
 a fracture of the diaphysis. Beduction could only be effected after 
 resection of one centimetre of the end of the diaphysis. The 
 fragments were held in position by means of two steel pins. 
 By September 8 the wounds had healed without drainage. On 
 September 26 the patient was discharged ; shoulder- joint normal. 
 Three weeks later, pins were removed. Movements of joint quite 
 free. 
 
 Case II. A boy (A. M.), aged nine, fourteen days before admission, 
 1891, fell from a tree on to his face with his left arm outstretched. 
 The end of the diaphysis was displaced forwards and inwards, near 
 the coracoid process, two fingers' breadth below the acromio-clavicular 
 joint. The head of the bone occupied the glenoid cavity, and moved 
 with the diaphysis. The humerus was shortened about one centi- 
 metre, and the movements of the joint were greatly hampered, rota- 
 tion being almost impossible. 
 
 On October 17, the usual incision over the end of the bone 
 was made, the fragments divided through their uniting material, and 
 one centimetre of the diaphysial end resected. The diaphysis was 
 then replaced and fixed with two pins. On November 4 the patient 
 was discharged with a starch bandage, and on November 13 the 
 pins were removed, the fragrnents having consolidated in good 
 
SEPAEATION OF UPPEE EPIPHYSIS OF HUMEEUS 235 
 
 position. When seen on April 1, 1892, the shoulder-joint was free 
 in every way, and the power in both arms appeared to be almost 
 equal. 
 
 Where there appears to be no tendency to displacement or 
 separation of the fragments after they have been placed in contact, 
 simple suture of the periosteal covering of the fragments, com- 
 bined with deep sutures to the fascial structures round the joint, 
 will suffice, instead of making use of the osseous suture. 
 
 Lejars successfully adopted this plan {Bevue de Chirurgie, August 
 1894, p. 636) in the following operation for the relief of deformity of 
 the shoulder and impaired function of the upper limb. 
 
 A boy aged sixteen years came under his care at the Necker 
 Hospital in June 1893. On May 12 he had fallen and struck his right 
 shoulder against the ground. On getting up he experienced great 
 pain and was unable to use his right arm, so that he had to hold it up 
 with the other hand. He went to a hospital, where subcoracoid dislo- 
 cation was diagnosed and an attempt made (of course unsuccess- 
 fully) to reduce it by Kocher's method. The swehing, which was 
 considerable, and the pain prevented a complete examination, but by 
 the first few days in June, when he was admitted, the effusion of 
 blood had diminished, so that there could be made out below the 
 coracoid process a rounded osseous projection which elevated the 
 skin and looked somewhat like the dislocated head of the humerus, 
 although smaller and having a less regular outhne. It rolled 
 to and fro during rotation of the arm, showing that it was 
 clearly in direct continuity with the shaft of the bone. Beneath 
 the acromion the humeral head could be felt in position. It moved 
 slightly with the arm. The diaphysis of the humerus was displaced 
 upwards, forwards, and inwards, and a distinct gap left on the outer 
 side of the epiphysial line. Consolidation was almost complete. 
 The diagnosis of old separation of the upper epiphysis of the 
 humerus was very clear. There existed also extreme loss of functional 
 power — so much so that, as regards flexion and abduction, these 
 were scarcely represented. The deltoid was already markedly 
 atrophied. Operative interference appearing to be the only thing 
 capable of rectifying matters, on June 15, the patient being placed 
 under chloroform, a long incision was made in front of the 
 shoulder along the pectoro-deltoid furrow and the inter-muscular 
 space widely opened out, after Hgature and division of the cephalic 
 vein. This gave sufficient access to the seat of the old injury. 
 The pointed and cone-shaped end of the diaphysis was found 
 to be almost in contact with the coracoid process, the line of 
 consohdation ran very obliquely outwards, and the uniting callus was 
 already solid. After the use of the rugine for clearly displaying the 
 ends of the bones, M. Lejars with chisel and mallet removed the 
 callus, resected about two centimetres of the sharp end of the dia- 
 physial fragment, and made the two surfaces which he wished to 
 
236 
 
 EPIPHYSES OF UPPEK EXTEEMITY 
 
 bring in contact quite regular. The lower fragment could now be 
 made to glide fairly easily under the epiphysial fragment, so 
 that the continuity was re-established and the direction of the 
 bone made perfectly straight. As the surfaces of the two fragments 
 then corresponded tolerably well, it was considered sufficient to use 
 four simple periosteal ligatures of silk applied to the antero-internal 
 aspect of the humerus, to insure the fragments keeping their proper 
 position. Some catgut was used to unite the peri-articular planes 
 of fibrous tissue and the separated borders of the pectoralis major 
 and deltoid. The skin was united without any drainage, iodoform 
 dressings were applied, and careful fixation made by means of plaster. 
 
 
 Fig. 52. — outlixe of shouldeb pekfect, 
 without any of the defoemity which 
 
 WAS PRESENT BEFOEE OPERATION. (lEJAEs) 
 
 Fig. 53. — the arms completely 
 
 ELEVATED. (lEJARS) 
 
 There were no important after results. At the end of three weeks 
 the apparatus and dressings were removed, and union was complete ; 
 the humerus was not only firmly united, but in a perfectly straight 
 line, and without the existence of any trace of the deformity in 
 front. Massage and electricity were now commenced, and continued 
 regularly every day. 
 
 When the patient left the hospital, on July 28, the movements 
 of the upper extremity were already very free ; he could place his hand 
 to his head and abduct his arm almost to a right angle (the scapula 
 being fixed). Extension was the only very limited and difficult 
 movement. Electricity and massage were continued every second 
 day. Improvement rajDidly took place after the end of July, so that 
 the patient went to work again. When seen quite recently (1894) 
 the functions of the shoulder were almost complete ; there was the 
 normal range of movement, without any trace of deformity, of 
 atrophy, or rigidity of the joint (see figures). 
 
SEPAEATION OF UPPEE EPIPHYSIS OF HUMEEUS 237 
 
 M. A. Ley {La Presse Medicale Beige, No. 33, 16 Aout 1896, 
 p. 257) records a similar example of resection and replacement of the 
 diaphysial end of the hmiierus in simple separation of the upper epi- 
 physis in a boy aged i6|- years. The operation was midertaken three 
 weeks after the injury (April 3, 1896) by M. Lambotte, for repeated 
 recurrence of displacement after reduction and after the application 
 of a plaster bandage. An exact diagnosis was not made previous to 
 the operation, beyond that a fracture of the upper end of the humerus 
 was discovered. The usual symptoms of displacement forwards of 
 the humerus with soft crepitus were present. The deltoid muscle 
 was found to be almost transfixed by the end of the diaphysis, which 
 still had a little of the conjugal cartilage adherent to it. Eeduction 
 of the diaphysis was effected, but on the slightest movement the dis- 
 placement w^as reproduced ; three to four centimetres of the end of the 
 bone were therefore removed. The periosteum was found to be torn 
 and separated from ihe shaft for a considerable extent. Iodoform 
 gauze dressings and Desault's apparatus were then applied, and the 
 after results were excellent. Seventeen days after the operation the 
 wound was almost completely healed and union perfect. About a 
 fortnight later the patient could freely elevate his arms, and there 
 was scarcely any deformity ; two months afterwards, through the 
 employment of active and mechanical movement, the functions 
 of the shoulder- joint were quite restored, with only half a centi- 
 metre shortening. M. Ley believed that a tuberculous family history 
 in this case predisposed to the epiphysial separation. It was the 
 result of direct violence ; the patient, whilst at play, having been 
 thrown to the ground, with a comrade falling upon him and striking 
 him on the right shoulder. 
 
 The results of the operation being so successful, we ought to 
 carefully consider the question of resection and suturing when the 
 active movements of the arm are merely limited, and not confine 
 our operative interference to cases in which all or nearly all move- 
 ment is lost. 
 
 Mr. W. Johnson Smith, of the Seamen's Hospital, Greenwich, 
 showed before the West Kent Medico-Chirurgical Society {British 
 Medical Journal, February 28, 1892 ; and Lancet, March 5, 1892, 
 p. 526) a patient in whom compound separation of the incom- 
 plete variety, with displacement forwards and inwards, and an exten- 
 sive fracture of the diaphysis, had occurred two and a half months 
 previously. The lesion resulted in distortion and uselessness of the 
 arm. The subject of this injury, W. L., aged eighteen, a Danish sea- 
 man, was admitted into the Seamen's Hospital on January 28, 
 1891. On November 16, 1890, he had faUen from the topsail yard 
 on to the deck, injuring his head and left shoulder. He stated 
 that there was a large wound in front of the joint, through which 
 immediately after the accident a long piece of bone protruded. This, 
 in the course of the voyage, which lasted till January 26, gradually fell 
 
238 , EPIPHYSES OE UPPEE EXTKEMITY 
 
 back into the wound, and was covered over by scar tissue. There was 
 no medical man on board the ship, and the patient was treated simply 
 by rest and the application of ointments to the wound. At the time 
 of the patient's admission, the left upper limb as compared with the 
 right was w^asted and cold. He could move the limb freely at the 
 elbow and wrist, but the movements of the shoulder were much 
 retarded. He could move the elbow away from the side of the 
 chest to the extent of about 1^ inches only. The length of tbe left 
 arm, measured from the acromion to the external condyle, was Hi 
 inches ; that of the right arm 12| inches. In front of the shoulder, 
 beginning about 2 inches below it, was a broad irregularly -shaped 
 cicatrix measuring 3 inches in the vertical direction. Immediately 
 beneath this, projecting under the skin, near the coracoid process, 
 was a prominent hard projection, formed by the upper end of the 
 shaft of the humerus displaced inwards and forwards. The upper 
 end of this portion of the bone, which had evidently been detached 
 from the head, was smooth, even, and slightly rounded. The head 
 of the humerus seemed to be in its normal position, and could be 
 rotated. After attempts had been made without success to restore 
 the free action of the shoulder-joint by passive movements, ether was 
 administered on Eebruary 17, and the prominent portion of bone 
 exposed by a vertical incision about 4 inches in length. The anterior 
 two-thirds of the upper end of the shaft presented a free surface, which 
 was quite flat and smooth. The posterior third, on the other hand, 
 was united to the anterior and inner portions of the upper segment of 
 the humerus, and the posterior and outer surfaces of the shaft 
 near its upper end had contracted firm osseous union with a long 
 piece of bone 2i inches in length continuous with the head, or rather 
 with the anatomical neck. The union between the two segments of 
 the humerus having been severed by bone forceps, and a portion of 
 the posterior spine of bone removed, the upper end of the shaft was 
 applied to the under surface of the head and fixed in its normal 
 position by a loop of thick wire, and also by an ivory peg driven 
 through the anterior surface of the shaft into the cancellous 
 tissue of the upper segment. The wound, having been drained 
 and closed by superficial sutures, was covered by cyanide gauze 
 and a large pad of wood-wool. The patient did well after the 
 operation, and was discharged on May 17, quite free from any 
 deformity in front of the shoulder, which joint the patient could 
 move very freely, and, according to his own report, as well as 
 that on the right side. In a letter written in August he stated that 
 he had been at work for some time as a seaman. 
 
 One of the cases recorded by Jetter and one by Bruns revealed 
 a less extensive fracture of the diaphysis. 
 
 Resection of the projecting diaphysis in old separations. — After the 
 lapse of some weeks, or even months, for severe deformity and 
 
SEPAEATION OF UPPEE EPIPHYSIS OF HUMERUS 289 
 
 impairment of utility of the arm, removal of the displaced diaphysial 
 end may be had recourse to. 
 
 In these instances it is only necessary to remove the rarefied 
 anterior projecting portion of the diaphysis, after separating it from 
 the lacerated fibres of the deltoid. The posterior part, about two- 
 thirds of the thickness of the bone, will be found firmly consolidated 
 wath the epiphysis. The epiphysis should not under these circum- 
 stances be separated from the shaft. 
 
 M. E. Rollet {Lyon Medical, March 29, 1891) reports two cases 
 of detachment of the head of the humerus that came at the same 
 time under the care of Professor Poncet, of Lyons. One patient 
 was aged fifteen and the other seventeen years. In each the de- 
 formity at the seat of injury and the impairment of the function 
 of the limb were relieved by resection of the upper extremity 
 of the lower fragment at five and a half and seven weeks respectively 
 after the injury. In the first case the girl, while running, had fallen 
 upon the antero-external aspect of the left shoulder and experienced 
 acute pain in the shoulder ; ecchymosis and some swelling appeared, 
 with inability to use the arm. Eight days after the accident she 
 noticed a projection at the upper part of the arm. On her admission 
 on the twenty-fifth day there was a marked projection in front of the 
 shoulder, five centimetres below the middle of the space between 
 the coracoid and acromial processes. It was visible beneath the 
 skin, which appeared to be almost penetrated. 
 
 Where the epiphysial separation is associated w^th a fracture 
 of the diaphysis and the loss of function is not very marked, this 
 simple process of removal of the small portion of the diaphysis 
 which projects too much will not interfere with the connection of 
 the head wdth the rest of the diaphysis. 
 
 Dr. Jetter records a case of this kind of a boy (K. E.), aged 
 sixteen years, who had fallen upon his left arm while sfiding on the 
 ice on Xew Year's Day 1891. The arm was ' set ' under chloroform 
 by a doctor, and a dressing applied for fourteen days, when passive 
 motion was commenced. An osseous projection being noticed at 
 the end of four weeks, another attempt was made to ' reset ' the 
 arm, and a plaster-of-Paris bandage applied for another four 
 weeks. The patient was then admitted into hospital for the very 
 marked loss of use of the arm. The arm was shortened one and a 
 half centimetres. An incision was made (March 19) over the bony 
 protuberance, which was two fingers' breadth below the coracoid 
 process, the soft parts divided, and the periosteum detached from 
 the bone. The inner half only of the diaphysis was found to be 
 separated at the epiphysial line, and to project away from the 
 epiphysis, while the outer half was broken off by a longitudinal 
 fracture of the diaphysis. This outer portion, to which the head 
 was still attached, was displaced backwards and downwards, and 
 
240 EPIPHYSES OF UPPEK EXTEEMITY 
 
 had united in this position. The projecting end of the diaphysis pre- 
 senting the epiphysial surface was merely chiselled off, and the soft 
 parts reunited, with drainage. The patient was discharged on 
 March 28 perfectly cured. 
 
 Dr. Chas. L. Leonard {The American Journal of the Medical 
 Sciences, August 1896, p. 143) records an example of diastasis of 
 the proximal epiphysis of the humerus, with overlapping of the 
 fragments and union in a faulty position. The state of the parts 
 was revealed by means of the Eontgen rays. S. B., aged sixteen 
 years, fell heavily on the left shoulder while playing football in 
 December 1895. He passed through the hands of two doctors, 
 and was subsequently sent to the University Hospital of Pennsyl- 
 vania for operation. A longitudinal incision through the deltoid 
 towards its anterior border showed the proximal end of the 
 lower fragment overlapping the upper fragment by about two inches, 
 with firm bony union between the two fragments. The upper end 
 of the lower fragment lay beneath the coracoid process and interfered 
 materially with the function of the joint. The upper portion of the 
 lower fragment was resected, giving the joint free motion. The 
 patient made a good recovery. The skiagraph showed the position 
 of the fragments after the operation and their lateral union in a 
 faulty position. 
 
 M. C. Walther {Bevue d'Orthopedie, Jan. 1897, No. 1, p. 43) 
 operated upon a similar case for irreducible displacement of the 
 diaphysis forwards, inwards, and upwards in front of the epiphysis. 
 The ' plateau '-like surface of the end of the diaphysis was well 
 marked. Fixed in this position it led to decided functional impair- 
 ment of the injured limb, the range of elevation and forward 
 projection of the arm being restricted by contact of the displaced 
 diaphysial fragment with the coracoid process. (A front and a 
 profile drawing of the deformity are given by this author.) The 
 patient was a lad aged eighteen years, who had fallen from a 
 scaffold about four metres high. At the beginning of the sixth week 
 after the accident a vertical incision was made over the projecting 
 bone on the outer side of the pectoro-deltoid groove. As a mass of 
 callus had already formed between the posterior aspect of the dis- 
 placed epiphysis and the front of the epiphysis, M. Walther had to 
 determine between two procedures ; either to completely resect the 
 callus in order to place the fragments absolutely in apposition, or to 
 freely remove the projecting end of the diaphysial fragment without 
 interfering with the callus, now so very solid. He decided to resect 
 only the end of the fragment, to carve away the callus, and to model 
 it in order to efface the projecting angle. This he performed for 
 two reasons : the desire to profit by the consolidation already 
 established, and also the difficulty which apparently would be present 
 in resecting the callus from a very robust and muscular subject, in 
 a very deep operation wound. The result was very good. Although 
 
SEPARATION OF UPPER EPIPHYSIS OF HUMERUS 241 
 
 elevation of the arm forwards was not perfectly complete, on account 
 of the slight projection forwards which the callus still made, this 
 slight limitation of movement did not entail any loss of function of 
 the limb. 
 
 Professor Kocher {Beitrdge ziir Kenntniss einiger praJctisch- 
 loichtiger Fracturformen, 1896, Basel und Leipzig) has performed 
 resection of a portion or the whole of the diaphysial end eight times. 
 
 Excision of head of the bone, leaving the epiphysial cartilage in 
 situ, has been suggested for angular deformity and impairment of 
 movements of the shoulder-joint. The severity of the operation 
 precludes its performance under these conditions, while there is 
 nothing to recommend it. 
 
 Compound Separations. — The majority of compound separa- 
 tions will require resection of the end of the py-otruding diaphysis 
 before reduction can be accomplished, notwithstanding the lacera- 
 tion of the soft parts. 
 
 After the fragments have been placed in position and the wound 
 irrigated, they must be retained in proper apposition by means of 
 ivory or steel pins, or by means of wire sutures. 
 
 This has been done by Esmarch and others, and a plaster 
 splint applied. Antiseptic methods and dressings should be care- 
 fully applied to the wound. Many of the untoward complications 
 so frequently recorded have probably been due to failure in, or want 
 of, antisepsis. 
 
 The first authentic case on record of resection of the diaphysial 
 end in compound separation of the upper epiphysis of the humerus 
 by gunshot wound was M. Roux's in 1837 {La Presse Medicale, 1837, 
 July 12). A youth (R.), aged fifteen, received (March 20, 1837) a gun- 
 shot wound, with the muzzle held close to him, the bullet penetrating 
 the right shoulder-joint and fracturing the head of the humerus. • A 
 month after the accident, M. Roux performed resection of the upper 
 end of the bone below the surgical neck. The operation was most 
 successful, the arm recovering all its movements. The examina- 
 tion of the part removed showed a complete separation of the 
 epiphysis by the bullet, which had shattered the epiphysis and 
 penetrated the diaphysis. 
 
 In the case of a boy aged fifteen years, operated upon by Esmarch 
 (Casper Nissen, De resectionihus ; Dissert, inaugur. Kiliae, 1859 ; 
 Archil) filr klin. Chirurg. Bd. xxi. S. 835), reduction of the dia- 
 physis could not be efi^ected, even after division of the lacerated 
 muscles in the wound, and resection of two centimetres of the 
 diaphysial end. At the end of three months all movements of the 
 shoulder-joint were completely restored, and the arm — shortened only 
 2 centimetres — was still useful for all kinds of work. 
 
 The following instance of compound separation, recorded by 
 Mr. Johnson Smith, of the Seamen's Hospital, Greenwich {Lancet, 
 March 5, 1892, p. 526), shows the good results which may be 
 
 B 
 
242 EPIPHYSES OF UPPEK EXTEEMITY 
 
 obtained by this procedure. It is especially worthy of note, for 
 it appears that although nearly 2^ inches of the shaft were excised, 
 sufficient new bone was formed from the periosteum which remained, 
 and from the separated ends, to compensate for about 1^ inch of this, 
 and to form a bone apparently perfect. 
 
 John F., an Irish boy, aged fourteen, was admitted on August 18, 
 1891, with an injury to the right shoulder, complicated by protrusion 
 of bone through a wound in the axilla. All that could be learnt as 
 to the cause of this injury, which had occurred about half an hour 
 before admission, was that the right sleeve of the patient's coat 
 had been caught in some machinery, and that the arm had been 
 violently wrenched. The boy, when first seen in the ward, was pale 
 and collapsed. The injured arm was abducted and rotated outwards, 
 and there was much swelling over the outer side of the shoulder. In 
 the outer boundary of the lower third of the aixilla there was a trans- 
 verse wound about 2^ inches in length, through which protruded 
 the upper end of the shaft of the humerus detached from the head. 
 This protruded portion of bone, which was 2 inches in length, was 
 completely denuded of periosteum. The upper surface, which was 
 also quite bare, was even over its anterior third, then rose into a 
 small rounded elevation, and shelved off obliquely to the posterior 
 surface of the bone. The anterior half of the surface was smooth, 
 and presented a continuous layer of compact bone tissue, whilst in the 
 posterior half the spongy tissue was exposed, as if a small portion 
 of the upper end of the shaft had been broken away. There was 
 no bleeding from the wound at the time of admission, and the 
 patient's clothes were but shghtly stained by blood. On examina- 
 tion of the seat of injury, whilst the patient was under the influence 
 of ether, it was found that the protruded end of the humerus had 
 passed between the median and ulnar nerves, and that one surface 
 of the bone rested upon and firmly compressed the main artery. 
 The denuded portion of the shaft of the humerus was thrust through 
 the w^ound in the axilla and sawn off. The detached portion from 
 which the periosteum had been stripped away measured 2^ inches 
 in length. The shortened end of the shaft then fell back into 
 the axillary space, and rested very near to the head of the bone. 
 The capsule seemed to be intact, and no orifice could be found 
 leading into the joint. As there was much swehing in front 
 of the shoulder, it was found impossible to ascertain whether or 
 not the long tendon of the biceps had been ruptured. A drainage 
 tube had been thrust to the bottom of the wound ; this was closed 
 by sutures, and the seat of injury covered by a large w^ood-wool 
 pad. A firm pad was placed in the axilla, and the upper limb 
 bandaged to the side of the chest. 
 
 The patient progressed favourably after the operation. During 
 the first three weeks the recorded temperature was usually normal, 
 and never higher than 99-5°. The wound healed slowly, but with- 
 
SEPAEATION OF UPPER EPIPHYSIS OE HUMERUS 243 
 
 out any discharge of pus. The movements of the arm were much 
 restricted for some weeks, but when the boy was discharged, on 
 October 13, they were quite free. He could then hft the hmb a httle 
 above the level of the shoulder, and ixiove it to the full extent in 
 the forward and backward directions. The movements of rotation 
 were much restricted. 
 
 On January 12, 1892, the movements of the right arm were 
 quite free in every direction, and this limb, the boy asserted, was 
 as strong and useful as the left one. There were no signs of 
 muscular atrophy, and no appreciable difference could be observed 
 in the thickness of the two limbs. Repeated measurements were 
 made of both arms from the tip of the aci-omion to the external 
 condyle, but shortening of not more than 1 inch could be discovered 
 on the right side. The right shoulder was rounded, and did not 
 differ in external appearance from that on the opposite side. There 
 was clearly firm union between the head and the shaft of the bone. 
 The boy had since the middle of November been employed in 
 manual labour, consisting mainly in moving heavily laden wheel- 
 barrows. 
 
 If the large axillary vessels or nerves are irremediably damaged, 
 primary amputation is usually indicated. 
 
 Much, however, may be done to save the limb in young subjects, 
 even under these unfavourable circumstances. 
 
 Separation with dislocation of the epiphysial head. — Treating the 
 separation until firm union has occurred, and then using the 
 repaired shaft for extension, rotation, or leverage in attempts at 
 reduction, cannot be too strongly condemned at this early age. 
 The dislocation should always be reduced first by operative measures, 
 the difficulty of reduction by other means being due to the small 
 size of the epiphysial fragment destroying the power which the shaft 
 has to control its movements. 
 
 Seeing that it is almost impossible to reduce the head of the 
 bone in these extremely rare cases, an incision should be made with 
 antiseptic precautions through the skin and deltoid muscle from 
 the acromial end of the clavicle down to the seat of separation, and 
 the epiphysis replaced in position. It will be found necessary to open 
 the capsule of the shoulder-joint before the epiphysis can be reduced. 
 This should be accomplished by direct manipulation of the head 
 into its place by pressure of the thumb and fingers, or by means of 
 traction made upon it by a traction hook inserted into a hole 
 drilled in it after the method advocated by McBurney {Annals of 
 Surgei-y, April 1894, p. 408). The fragments should then be fastened 
 together in their normal position by means of pegs or other sutures. 
 
 Riberi's method (made use of in adults) of treatment by passive 
 motion employed from the commencement, so as to establish a false 
 joint at the point of fracture, the dislocated head of the bone being 
 left unreduced, is quite out of the question in the case of children. 
 
 E 2 
 
244 EPIPHYSES OF UPPER EXTREMITY 
 
 Massage, electricity, &c. — Much may be effected, often very 
 rapidly, by active and passive movements carried out day by day, 
 supplemented by massage and by electricity where there is great 
 loss of power and usefulness of the limb or rigidity, the result of too 
 long fixation, with atrophy of the muscles. 
 
 The following case described by Curtillet {Du decollement trau- 
 matiqiie des epiphyses, Lyon, 1891, p. 100) under the care of M. 
 Levrat, was one in which great loss of functional power of the limb 
 and want of any improvement of the fixed position of the arm against 
 the trunk was rapidly and very successfully treated after the lapse 
 of six months by massage and by repeated daily movements of the 
 limb. 
 
 A boy (E. L.), aged nine years, entered the hospital onKovember 
 28, 1890. Six weeks previously the child's shoulder had been 
 jammed between a wall and the edge of a cart, causing very acute 
 pain, with great swelUng and complete loss of power over the arm. 
 
 A doctor applied two leeches but no apparatus, and, at the end of 
 four or five weeks, first a doctor, and then a bone-setter, attempted 
 to reduce the supposed dislocation. When examined, the arm was 
 found to be carefully fixed by the patient to the side of the body 
 with the forearm forcibly flexed against the front of the chest. The 
 scapula moved when attempts were made to move the shoulder-joint. 
 
 There was no flattening of the shoulder, but below the coraco- 
 acromial arch the rounded head of the humerus could be felt in its 
 normal position, and moved w4th the shaft of the bone. The 
 edge of the diaphysial end displaced forwards from the epiphysis 
 could be seen and felt 5 centimetres below and a little external to 
 the apex of the acromion, and above it a very clear depression. 
 The circumference of the arm was here 2 centimetres greater 
 compared with the opposite side, and its length from the acromion 
 to the epitrochlea 2 centimetres less. Each day massage was 
 employed with systematic movements while the scapula was fixed ; 
 and an excellent result was obtained, so that at the end of a month 
 the child left the hospital with almost complete recoA'ery of all move- 
 m.ents and usefulness of the limb. 
 
 PROGNOSIS, SEQTJELiE, &c. — The progress of these separations 
 will naturally depend upon the character of the injury. 
 
 In simple separation, without displacement of the diaphysis, 
 laceration, or any extensive stripping of the periosteum, union of the 
 fragments by callus is rapid and the prognosis as a rule very good ; 
 though occasionally, as will be pointed out presently, arrest of growth 
 takes place. 
 
 It is an important fact that firm union by osseous material is 
 the usual termination. Notwithstanding that so large an osseous 
 surface is involved, consolidation will be complete in two or three 
 weeks. Even if displacement or deformity remains, the movements 
 of the shoulder are ultimately entirely restored. Indeed, the author 
 
SEPAEATION OF UPPEK EPIPHYSIS OF HUMEEUS 245 
 
 has not been able to find any authentic example of non-union of this 
 epiphysis which was permanent. 
 
 Professor R. W. Smith, writing in 1867 (Address in Surgery, 
 British Med. Association, Brit. Med. Journal, Aug. 17, 1867, p. 122 ; 
 see also Fractures and Dislocations, 1847, p. 202), says: 'I have 
 already mentioned the anatomical error into which some have fallen, 
 of supposing that the tubercles of the humerus formed a portion of the 
 shaft of the bone, and it has been to them a matter of surprise that 
 in cases of separation of the epiphysis, osseous union should occur, 
 the head of the bone being, according to their statement, detached 
 from all connection with living structures. 
 
 ' Vidal (de Cassis) has observed (Traite de j^ccthologie externe, 
 toin. ii. p. 114) that the occurrence of osseous union would be easy 
 to conceive if the head of the bone formed one body with the tuber- 
 osities. Had M. Vidal examined in the young subject the situation 
 of the line of the epiphysis, he would have learned the simple 
 anatomical fact that, in the injury under consideration, the tubercles 
 formed a portion of the superior fragment ; and that the epiphysis 
 comprised not only the head of the bone, but likewise the entire of 
 both tubercles, with that portion of the bicipital groove which is 
 situated between these processes ; and he would not have stated, as 
 he has done, that in cases of separation of the epiphysis the lower 
 fragment was acted upon by the supraspinatus and infraspinatus, for 
 he would have seen that these muscles were attached to the superior 
 fragment.' 
 
 There can therefore be no difficulty in the matter of the blood 
 supply to the head, which is so intimately connected with the tuber- 
 osities, nor any difficulty in understanding the occurrence of the 
 osseous union of the fragments. 
 
 Hamilton reports a case of delayed union in a child thirteen 
 months old, which is often quoted as a case of non-union. However, 
 it is not conclusive, as the ultimate result is not stated nor the 
 possibly diseased condition of the bone from some constitutional 
 affection excluded. 
 
 In 18-55 M. B., aged thirteen months, fell sideways from his 
 cradle, causing some injury to the arm near the shoulder. He was 
 taken to an empiric, who called it a sprain and applied liniments. 
 Three weeks after the accident he was brought to Hamilton, who 
 found the arm hanging beside the body, with little or no power on 
 the part of the child to move it. There was a slight depression 
 below the acromion process, and considerable tenderness about the 
 joint ; but the shoulder was not swollen, nor had it been at anytime. 
 The line of the axis of the bone, as it hung by the side, was directed 
 a little in front of the socket. On moving the elbow backwards and 
 forwards, the upper end of the shaft moved in the opposite direction 
 with great freedom, and could be distinctly felt under the skin 
 and muscles. This motion was accompanied by a slight sound or 
 
246 EPIPHYSES OF UPPER EXTREMITY 
 
 sensation, not unlike the grating of broken bone, but mucli less 
 rough. There was no shortening of the limb. When the elbow 
 was carried a little forwards upon the chest, the fragments seemed 
 to be restored to complete coaptation ; and of this Hamilton judged 
 by the restoration of the line of the axis of the shaft to the centre of 
 the socket, and by the complete disappearance of the depression 
 under the point of the acromion process. Suitable dressings were 
 applied to retain the arm in this position ; but five months after the 
 injury was received the fragments had not united, and the child was 
 still unable to lift the arm, although the forearm and hand retained 
 their usual strength and freedom of motion. The same crepitus 
 could occasionally be felt in the shoulder, and the same preter- 
 natural mobility. The shoulder was at this time neither swollen nor 
 tender. 
 
 Altered sliaipe of the shoulder and limb. — In incomplete displace- 
 ments terminating favourably we find the deformity that remains is 
 slight, without any shortening or disturbance in the function of the 
 limb. But hitherto, from the difficulty of complete reduction of the 
 diaphysis, there has not uncommonly been found some projection 
 of this portion of bone, so that after repair has taken place many 
 of the initial signs of this lesion are still present. This prominence of 
 the bone, however, will rapidly become rounded off in its subsequent 
 growth, and the deltoid and other muscles as they increase in bulk 
 will hide even considerable deformity. The utility of the arm as re- 
 gards movements, especially at the shoulder- joint, is surprisingly little 
 impaired. Although the injury may have been overlooked, and the 
 deformity be extreme, the amount of movement is often considerable. 
 
 Deformity is often great after complete displacements, and con- 
 siderably interferes with the function of the limb ; while in many 
 others the deformity, though present in some slight degree, does not 
 give rise to any great interference with its utility. Indeed, when 
 these patients are seen some years after the injury, no disturbance in 
 the function of the limb is present, and the deformity is then hardly 
 appreciable. 
 
 Dr. Jetter relates four cases to show the completeness of the 
 return of function of the extremity associated with slight deformity, 
 and sometimes shortening. 
 
 Case I. B. W., aged eleven years, was hurled from a machine, 
 striking his left arm against a cart-wheel. He was immediately 
 admitted into hospital (October 23, 1885). The whole of the shoulder 
 was very much swollen. At the level of the epiphysial line, on the 
 outer side, a slight depression was felt, and the axis of the arm 
 deviated a little. The epiphysis was in its normal position, and did 
 not rotate with the humerus during passive motion, which was 
 painful. No crepitus. Leiter's coils were applied. On October 30 
 Velpeau's bandage was employed, with plaster of Paris, as in frac- 
 ture of the clavicle. On November 5 the patient was discharged, 
 
SEPAKATION'OF UPPEE EPIPHYSIS OF HUMEEUS 247 
 
 and by December 14 the fracture was perfectly united and the move- 
 ments free, but the lower fragment projected somewhat forwards 
 and inwards. When seen seven years afterwards (March 18, 1892), 
 the patient was a big strong fellow, with the muscles of both arms 
 equally well developed, and the function of the left arm quite as 
 good as that of the right, so that without experiencing any pain 
 he could work well as a bricklayer. On the inner side of the 
 humeral neck, however, there was a slight convexity forwards of 
 the bene, and a shortening of about 1 centimetre. 
 
 Case II. A. W., aged thirteen, on October 3, 1887, fell from a 
 tree to the ground, about a man's height, alighting upon her back 
 and right shoulder. The humerus was found to be broken, and was 
 attended to by a doctor, who kept the patient in bed for eight days, 
 putting the bone into position and applying a bandage. The patient 
 then came to the hospital (October 9), complaining of great pain 
 in the shoulder, which was somewhat depressed, though its rotundity 
 remained unaltered. The arm was slightly abducted, with a bending 
 forwards of its axis at the upper third. This became more marked 
 on elevating the limb. Slight crepitus at the epiphysial line was 
 felt during passive movement, and, on fixing the head of the 
 humerus, there was only slight abnormal inobility but no shorten- 
 ing. The shoulder was put up in plaster of Paris, and a Velpeau's 
 bandage applied. On its removal (October 24) there was no 
 deformity or swelling, and the head of the bone moved with the 
 shaft. Patient was discharged on October 28. When seen five 
 years later (March 20, 1892) the muscles of both arms were equally 
 well developed, no displacement was to be seen or felt, and there 
 was no shortening. All the movements of the joint were free, 
 and the patient was perfectly fit for work. 
 
 Case III. F. E., aged fourteen years, two days previously fell 
 from a height of about two metres upon her left shoulder. On her 
 admission to the hospital (June 28, 1889), the upper half of the 
 arm and the shoulder were greatly swollen and painful. The head 
 of the bone was still in position, and the tuberosities moved with the 
 humerus as long as they were not held firmly, but directly the head 
 was held fast it did not rotate with the bone. There was no crepitus. 
 Velpeau's bandage and Leiter's coils were applied. The bandage 
 was removed on July 6, and on July 20 the swelling had much 
 diminished. A projection forwards of the upper end of the diaphysis 
 could now be felt at the epiphysial limit ; rotation and all movements 
 were good, with the exception of abduction, which was imperfect. 
 Three years later (March 20, 1892) the shoulder, on examination, 
 had somewhat increased in its antero-posterior diameter. Consoli- 
 dation had taken place, with slight displacement forwards of the 
 lower fragment. Measurement showed no shortening. The muscles 
 were equally developed in both arms ; elevation of the arm was 
 possible, and the patient was again perfectly able to do her work. 
 
248 EPIPHYSES OF UPPEK EXTEEMITY 
 
 Case IV. F. S., twelve years old, on June 30, 1889, fell down 
 stairs upon her left shoulder. On examination there were the usual 
 appearances of epiphysial separation with contusion. A Velpeau's 
 bandage was applied, and removed six days later. On July 20 
 the deltoid was found to be somewhat wasted, the end of the 
 humeral diaphysis projecting forwards. On July 31 the patient was 
 able to elevate the arm horizontally, and the shoulder was no longer 
 painful. Three years later (March 22, 1892) the muscles of the arms 
 were found to be equally well developed. No measurable shortening 
 was observed, but there was still slight displacement forwards of the 
 lower fragment. Abduction, rotation, and all other movements were 
 normal, and the girl was fully able to perform her duties. 
 
 Malgaigne states that he had seen a separation of the head of 
 the humerus, sustained at an early age, and united with great dis- 
 placement ; the arm had lost its power, hanging atrophied and 
 nearly useless beside the trunk, but the union, though unsatisfactory, 
 was very solid. 
 
 Mr. William Lynn, Senior Surgeon to the Westminster Hospital, 
 as long ago as 1833, commented {Lancet, December 28, 1833, p. 517) 
 on the case of a girl (L. C ), aged eleven years, under the care of 
 Mr. Guthrie at the same hospital, which formed the subject of a 
 lecture by Mr. Guthrie on 'A PecuHar Kind of Injury of the 
 Shoulder- joint.' On October 8 the child had fallen out of a second- 
 story window upon her shoulder. There was a considerable pro- 
 minence visible in front beneath the coracoid process, which might 
 have been mistaken for a dislocation of the head had it not been for 
 the irregular projection of the bone, and the fact that the head could 
 be felt and moved in the glenoid cavity. The projection of the end 
 of the humerus followed the movements imparted to the elbow. 
 The arm could be elevated and the hand placed on the top of the 
 head, the elbow also could be brought close to the side with ease, 
 although it tended a Httle backwards. The forefinger could be 
 made to sink into a hollow between the projecting end of the bone 
 and the head of the humerus. The arm was shortened half an inch, 
 and there was great swelling of the shoulder. Mr. Lynn found 
 the joint broader and flatter than normal, and the hmb shortened 
 about 1 inch. Under the anterior part of the deltoid there was a 
 broad and flat projection — manifestly the upper end of the humeral 
 diaphysis. The head of the bone was felt to move (with the shaft) 
 in the glenoid cavity. All the movements of the joint were per- 
 formed somewhat imperfectly, from the angular union that had 
 taken place, although the integrity of the joint had probably not 
 been invaded. Mr. Lynn also felt another projection beneath the 
 deltoid, which he took to be the epiphysis of the acromion, and this, 
 being supported by the head of bone, had speedily united. 
 
 Mr. Guthrie alluded to a similar case in a boy, who also had good 
 use of the arm. 
 
SEPARATION OF UPPER EPIPHYSIS OF HUMERUS 249 
 
 R. W. Smith gives (Fractures and Dislocations, 1847, p. 204) 
 a representation of an example of fracture through the hne of the 
 epiphysis, united by bone, and states that it exhibits very well 
 the displacement which the upper end of the lower fragment usually 
 suffers under the influence of the action of the muscles constituting 
 the folds of the axilla. It has been drawn inwards, but not so far 
 as to enable it to clear the under surface of the superior fragment. 
 
 So great a degree of displace- 
 ment as this would imply is of 
 very rare occurrence, and could 
 scarcely happen without rendering 
 the fracture compound. 
 
 Dr. Wharton (' Separation or 
 Disjunction of the Upper Epiphy- 
 sis of the Humerus,' University 
 Medical Magazine, Philadelphia, 
 January 1889, vol. i. No. 4, p. 212) 
 relates the case of a girl, aged 
 seven years, who, in going down Fig. 54.— old fracture of the humerus 
 
 , • , • J n £ ^^ 1 THROUGH THE LINE OF THE EPIPHYSIS 
 
 stairs, tripped and fell upon her united by bone, displacement of the 
 right arm. Upon examination a lower fragment inwards. 
 few hours after, the right arm ^^' ^^' ^^"^' 
 
 was found to be helpless, and any attempt to move the arm was 
 followed by pain ; there was no rigidity in the neighbourhood of the 
 shoulder-joint, and the arm could without difficulty be brought in 
 contact with the side of the body. There was no flattening of the 
 shoulder, but a marked prominence in front and to the inner side 
 of the acromion process of the scapula. On grasping the arm at the 
 elbow and gently rotating it, and placing one hand over the pro- 
 minence in front of the acromion, the smooth upper-end of the 
 humerus could be felt moving under the hand, the head of the bone 
 still remaining in the glenoid cavity. Reduction was effected by 
 extension upon the arm from the elbow and by pressure backwards 
 upon the projecting end of the humerus. Dull crepitus was elicited 
 by rotating the arm during the same movements. A moulded splint 
 was applied to the shoulder and arm, and the arm fixed against the 
 side of the body, the hand and forearm being supported in a sling. 
 This apparatus was renewed every second or third day, and finally 
 removed at the end of the fourth week, the union at this time being 
 quite firm. The patient had a good range of motion at the 
 shoulder-joint, and subsequently regained the full use of her arm, 
 although a very perceptible projection of the upper end of the hume- 
 rus could be plainly felt in front of the shoulder-joint immediately 
 above the coracoid process. 
 
 In Durocher's case the separation of the epiphysis occurred 
 during birth, and was found on the death of the child at fourteen 
 months to have been followed by shortening of the diaphysis of the 
 
250 EPIPHYSES OF UPPEE EXTREMITY 
 
 humerus for a quarter of its length. The muscles of the shoulder 
 were also considerably atrophied. 
 
 Hutchinson once examined {Med. Times and Gazette, March 10, 
 1866 ; London Hospital Beports, vol. i. 1864, p. 89) a lad, aged thirteen 
 years, in whom it seemed probable that both upper and lower epiphyses 
 of the right humerus had been detached. There had been separation 
 of the lower epiphysis in the left arm and a fracture of one clavicle. 
 These complicated injuries had been sustained in a fall from a 
 ship's mast eight months previously. The right humerus was much 
 shortened, partly by arrest of growth and partly by union with dis- 
 placement. 
 
 Dr. Charles T. Parkes, Professor of Surgery in the Rush 
 Medical College, Chicago {International Clinics, vol. i. 1891, p. 1'28), 
 describes the following case in a clinical lecture. A boy, ten years 
 of age, fell from a fence five weeks previously, producing an epi- 
 physial fracture, as was shown by the unusually well marked 
 projection about two inches below the acromion process on the 
 anterior surface of the arm. This prominence was just beneath the 
 shoulder-joint, and directly continuous with the shaft below. The 
 lower end of the humerus projected too far backwards as compared 
 with the uninjured bone. The upper end of the lower fragment 
 had been displaced so far forward that it stood entirely away from 
 the direction of the short fragment still attached to the head of the 
 bone ; the broken surfaces were absolutely separated from each other. 
 On moving the shoulder- joint there was some limitation to the full 
 degree of motion on the injured side ; still, it moved freely and 
 easily in all directions within this limited range of motion. 
 
 Dr. Parkes continues : ' This case also gives an excellent illustra- 
 tion of angular deformity, forward in this instance and extreme in 
 degree. It also demonstrates that firm and solid union will take 
 place between broken bones, even if the broken ends are not any- 
 where in contact with each other, provided one of the broken ends 
 is held in contact with some portion of the shaft of the other 
 fragment. Notice again that, notwithstanding the presence of this 
 deformity, the boy has a very useful and movable joint. The extent 
 of range of motion is limited somewhat, but with use will increase 
 from day to day until it is restored quite to the normal condition. 
 Is any operation advisable in this case to overcome the deformity ? 
 I think not, unless it be the rather simple one of exposing the upper 
 end of the lower fragment and chiselling away this projection, 
 mainly to prevent ulceration of the skin covering it, which seems 
 imminent.' 
 
 . In the following case, described by Dr. J. H. Pooley {New York 
 Medical Journal, 1875, xxi. p. 139) the projection of the shaft in 
 front of the shoulder was after treatment nearly as marked as at the 
 time of the accident. 
 
 A girl (Alice F.), aged twelve years, fell from a tree on to her 
 
SEPAEATION OF UPPEE EPIPHYSIS OF HUMEEUS 251 
 
 left shoulder, separating the upper epiphysis of the humerus. The 
 arm was quite useless, and painful on movement. There was some 
 slight depression of the shoulder, but no globular swehing, hke the 
 head of the humerus in the axilla ; but in front, one inch or more 
 below the joint, a peculiar pointed but not sharp projection. Under 
 chloroform there was found unnatural mobihty near the shoulder, 
 with obscure crepitus. A pasteboard splint was moulded to the 
 shoulder and outer side of the arm, and the arm was brought close to 
 the side and the elbow raised. Three weeks later the spUnt was 
 removed and passive motion commenced. Union had taken place, 
 but there was still some projection in front. At the end of several 
 months the arm was practically as good and useful as the other, 
 the movements being all but perfect, although the prominence in 
 front was still quite noticeable, though less marked, with half an 
 inch shortening. 
 
 In Charles H. Eichmond'scase (iVew York MedicalJournal, 1S77, 
 No. xxvi., p. 504) the deformity was the same as at the time of 
 fracture. 
 
 A girl, aged ten, fell backwards from a height of three or four feet, 
 causing a separation of the superior epiphysis of the humerus. 
 The forward and outward projection of the lower fragment, with its 
 rounded margin, produced marked deformity. There w^as but little 
 shortening, and only 'muffled' crepitus was present. Eeduction was 
 effected and a leather sphnt apphed to the outside of the shoulder, 
 with extension. On removing this subsequently the deformity was 
 found to be the same as at the time of the fracture. Five or six years 
 later the deformity still existed, although much smoothed down. 
 
 Eicard, in Duplay and Eeclus' Traite de chiriirgie, tom. ii. 1890, 
 p. 456, figures a specimen of separation of the upper humeral epi- 
 physis united apparently by osseous material, but with considerable 
 angular deformity (see figs. 55 and 56). 
 
 Hutchinson alludes {Med. Times and Gazette, March 10, 1866, 
 p. 248) to a lad, aged fourteen, who was brought to him on account 
 of deformity, some time after the accident, when the swehing had 
 disappeared. The lower fragment was displaced forwards, and the 
 finger could be laid on a fiat ledge of bone a third of an inch wide, 
 looking directly upwards and presenting the irregularities charac- 
 teristic of an epiphysial surface. 
 
 In all the examples just quoted there must have been great 
 detachment of the periosteum accompanying the displacement, while 
 the difficulty experienced in reducing these epiphysial separations, 
 leading either to total failure or incomplete coaptation of the frac- 
 tures, no doubt accounts for the prevalence of deformity after this 
 form of injury. Bruns has noted deformity in five out of eight 
 cases under his observation. 
 
 To sum up the signs remaining a few months after the accident, 
 we may find the following very characteristic appearances, seen also in 
 
252 
 
 EPIPHYSES OE UPPEE EXTEEMITY 
 
 certain fractures of the surgical neck of the humerus, and described 
 since 1645 by Boyer, Debrou, Hennequin, Decamps, and many 
 others. Shght flattening of the shoulder, with some atrophy of the 
 deltoid, biceps, and muscles of the arm. Half to one inch shorten- 
 ing. Long axis of the arm directed backwards and outwards, and 
 the forearm semiflexed. Marked impediment to the movements of 
 the arm, although the hand can be placed on the opposite shoulder. 
 Slight depression below the acromial arch from stretching of the 
 deltoid. The head of the humerus is in position, and follows the 
 movements of the arm, showing that the fragments are well united. 
 In front of the shoulder, 1^ to 2 inches or more below the acromion 
 process, there exists a very considerable and characteristic projection, 
 
 Fig. 55. — disjunction o? the upper epiphysis 07 
 the humebus, united with locking of the upper 
 
 END OF THE DIAPHYSIS IN THE EPIPHYSIS. RICARD'S 
 SPECIMEN. (after DUPLAY AND BECLUs) 
 
 
 Fig. 56. — section of bicard's 
 
 SPECIMEN. (after DUPLAT 
 AND RECLUS) 
 
 somewhat rounded in front but flattened above. (This projection of 
 the diaphysial end forwards and inwards towards the coracoid 
 process may be so great as to be in contact with this process, or 
 there may be only some irregularity and thickening about the epi- 
 physial line.) Considerable loss of function. Loss of active power 
 in the hand and whole extremity, while passive movements, although 
 free, are limited. 
 
 Defo7'mity is so very much like dislocation that attempts have 
 frequently been made to reduce the supposed displaced head of the 
 bone. 
 
 Mr. Hutchinson says {Medical Times and Gazette, March 10, 
 1866, p. 247) that a few months after a separation of the epiphysis 
 
SEPARATION OF UPPEE EPIPHYSIS OF HUMERUS 253 
 
 it is very likely tha.t all the appearances of a dislocation will be 
 assumed. Owing to the altered form of the neck of the bone, the 
 head is gradually displaced downwards, until a hollow is caused 
 under the acromion, the aspect being exactly like that of a disloca- 
 tion. The head of the bone may even be felt in the axilla, though 
 not so low down, nor so distinctly as in a true dislocation. It may 
 be thought that a dislocation has been overlooked. The appearance 
 is usually produced when the patient begins to use his arm, and if 
 present at first it always increases. The neck of the humerus 
 would come to resemble in form the neck of the femur of a young 
 subject, and subsequently the elevation of the arm by the deltoid 
 would push the head of the bone lower and lower in the glenoid 
 cavity. 
 
 Hutchinson has seen reduction attempted not unfrequently. He 
 relates the following case. A boy, aged fourteen, was brought to him 
 in the belief that a dislocation had been overlooked. The deformity 
 was very considerable — a hollow under the acromion, the head of 
 the bone felt in the axilla, and the fibres of the deltoid stretched. The 
 symptoms then present (two months after the injury) were said not 
 to have been there at first. Irregularity and thickening were felt 
 about the line of the epiphysis, and by pressing the arm straight 
 upwards the subacromial hollow was almost filled up. 
 
 Non-union of the epiphysis is often alluded to by writers, but, 
 as has been already stated, the instances of false joint recorded up 
 to the present time cannot be relied on. 
 
 Eeichel, in his work, figures and minutely describes a specimen in 
 the possession of Ludwig (Leipzig) which is open to much doubt. 
 The head of the left humerus he describes as separated as a cap 
 from the diaphysis, more than an inch below the great tuberosity, so 
 that this limb was shorter than the other. It was said that the 
 separation had taken place in infancy, and that there was an entire 
 absence of osseous union, and a false joint produced. It was said also 
 that this was probably the result of too early movement of the limb. 
 Those cases related by Durocher, Bertrandi, and Hamilton as 
 occurring in newly born infants are in like manner open to consider- 
 able doubt. They were all ]3robably due to disease. 
 
 Loss of power and utility of the arm, apart from the causes just 
 mentioned, may be the result of too long fixation of the limb, and 
 consequent muscular atrophy, even though the displacement may 
 not have been very great. 
 
 From the close relationship of the synovial cavity to the inner part 
 of the epiphysial line it might be supposed that subsequent articular 
 rigidity is a frequent consequence of separation, but this is not 
 usually the case. 
 
 Reichel's case, and another, described byPalletta {Exercitationes 
 pathoIogiccE, Mediolani, 1820, iv. p. 59) in a youth, aged fifteen, are 
 quoted by Rognetta as examples of deformity and shortening in 
 
254 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 cases where the injury was not diagnosed or was badly treated. 
 Palletta saw his case one month after the injury, which was from a fall 
 from a high roof on to the shoulder. The end of the diaphysis Vv'as 
 two fingers' breadth below the acromion, and the arm was shortened 
 a thumb's breadth. The motions, at first very limited, were 
 ultimately completely restored. 
 
 Ankylosis, the result of neglect of proper treatment, is well shown 
 in Hoffa's case. 
 
 Bony ankylosis of the shoulder-joint, from some cause difficult 
 to explain, followed in four of J. Hutchinson junior's cases. How- 
 ever, in one suppuration had occurred. 
 
 Shortening of the arm as the result of imperfect reduction or of the 
 impossibility of keeping the fragments in position is very frequent. 
 It is well exemplified by Hamilton's and Puzey's cases. 
 
 In Jetter's cases which were treated at the time of the accident 
 no appreciable shortening could be found on examination. 
 
 Table of Shoetekixg in Incomplete Displacements after Teeatiient 
 
 Surgeon 
 
 Sex of 
 patient 
 
 kge 
 
 Amount of 
 sliorteuing 
 
 Bate of 
 measurement 
 
 1 
 Shortening at time of accident 
 
 Hamilton 
 
 Male 
 
 13 years 
 
 ^ inch 
 
 14 days 
 
 Not stated 
 
 Hamilton 
 
 Male 
 
 16 years 
 
 1 inch 
 
 9 weeks 
 
 Not stated 
 
 Pooley 
 
 Female 
 
 12 years 
 
 1 inch 
 
 several 
 months 
 
 Displacement 1 inch or 
 more below joint 
 
 Durham 
 
 Male 
 
 14 years 
 
 1 inch 
 
 18 days 
 
 Not stated. Partial dislo- 
 cation of head 
 
 Eiclimond 
 
 Female 
 
 10 years 
 
 A little, same 
 as at time 
 of accident 
 
 5 or 6 years 
 
 A little shortening 
 
 Puzey 
 
 Male 
 
 12 years 
 
 f inch 
 
 4 weeks 
 
 f inch shortening 
 
 Johnson 
 
 
 
 
 
 
 Smith 
 
 Male 
 
 18 years 
 
 1| inches 
 
 2i months 
 
 Not stated. Complicated 
 with fracture of dia- 
 physis 
 
 Arrest of growth of the humerus. — The upper epiphysis of the 
 humerus is mainly concerned in the growth in length of the 
 bone, the average increase in ieng-th of the humerus through 
 the upper end dnring life being about 18 centimetres — more than 
 double, according to Vogt's calculations, that of the lower end. 
 
 The upper epiphysis from the tenth 3'ear will add 7 to 10 centi- 
 metres to the length of the humerus, whilst the lower epiphysis adds 
 only 1"5 to 2 centimetres. 
 
 The accounts of conical stump published by Mr. Owen {Lancet, 
 October 3, 1892), by Dr. Lediard (Lancet, January 9, 1892, p. 88), 
 by Dr. Felix Lejars {Lec^ons de chirurgie, 1893-94), and others, show 
 how active the upper epiphysis of the humerus is, and bear out the 
 fact that conical stump is very apt to result in the arm after 
 amputation. 
 
 Injuries to the cartilaginous junction of the epiphysis with the 
 
SEPAEATION OF UPPER EPIPHYSIS OF HUMERUS 255 
 
 diaphysis, which are of almost daily occurrence, have been com- 
 paratively seldom followed by arrest of growth of the shaft. Yet 
 its occasional occurrence should place the surgeon on his guard, so 
 that the nature of the injury may be thoroughly explained at the time 
 to the patient or friends so far as the future condition of the hmb is 
 concerned. 
 
 This serious interference with the proper development of the 
 bone has taken place after the most simple injuries to the upper 
 end of the humerus. In several cases the injury has been entirely 
 overlooked; in others the injury was obscure and left unrelieved, 
 while in others it was recognised as an epiphysial separation. The 
 author is unable, therefore, to agree with those who beheve that arrest 
 of growth of the bone never need be feared in simple separation. 
 
 At the age when this separation is most common — viz. ten to 
 seventeen years— arrest of growth will not occur to any impor- 
 tant extent. 
 
 It has been thought by some writers that epiphysial separations 
 which are not simple, but accompanied by fracture of the diaphysis 
 of the humerus, may lead to premature ossification of the cartilage 
 produced during the formation of the callus, and bring about an 
 arrest of growth. 
 
 . Others, again, believe that arrest of growth is dependent upon 
 the displacement of the diaphysis. However, in Knox's, Hamilton's, 
 the author's, and many other cases, there was no shortening, 
 although displacement was a notable feature. 
 
 In several separations of the upper epiphysis of the humerus 
 which Dr. Wharton had under his observation {loc. cit. supra) he 
 could detect no difference in the growth, development, or useful- 
 ness of the arm, although the injury had occurred several years 
 previously. 
 
 No arrest of growth followed any of the compound injuries. 
 
 There is usually no loss in the proper thickness of the shaft, the 
 bone continuing to grow by means of the periosteum. This is 
 especially noticed in Bruns's, Vogt's, Dittmayer's, and Hoffa's cases. 
 
 Albert Hoffa describes {Berliner klinische Wochenschrift, No. 4, 
 S. 49, January 28, 1884, and Bevue des Sciences Medicales, No. 48, 
 October 15, 1884, vol. xxiv. fasc. 2, p. 637) a case of arrest of 
 growth in the length of the arm, with ankylosis of the shoulder-joint, 
 following traumatic separation. 
 
 A man, aged twenty-nine, received a blow at the age of nine 
 years from the butt end of a gun on the right shoulder. Although 
 there was great pain, the injury was not treated at the time, as the 
 boy concealed it from his father. A subsequent attempt to restore 
 the mobiUty of the arm was unsuccessful. There was no further 
 injury, inflammatory process, or disease to account for the defor- 
 mity, viz. considerable flattening of the shoulder, projection of the 
 acromial arch, and atrophy of the trapezius and deltoid, which 
 
256 EPIPHYSES OF UPPEE EXTEEMITY 
 
 reacted, however, to electricity. All the other muscles, as well as 
 those of the forearm and hand, the clavicle and scapula, presented 
 no difference from those of the left side. The right arm was as thick 
 as its fellow, but shortened 6^ centimetres (2'559 inches). The 
 humeral head was displaced forwards, upwards, and inwards, and at 
 the level of the epiphysiary line an angular bend in the bone could 
 be felt. The shoulder-joint was completely ankylosed, rendering 
 abduction impossible, all the other movements of the arm being 
 carried out through the scapula. 
 
 At the Congress of the German Surgical Association of Berlin 
 in 1877, Vogt (Langenbeck, Archiv fur klinische Chirurgie, 1878, 
 Bd. xxii .S. 341) exhibited a patient, aged twenty, who since his tenth 
 year had suffered from complete cessation of growth in the length of 
 the left humerus, following an injury which at the time was thought 
 to be a sprain, but which was doubtless, he said, a traumatic epiphysial 
 separation of the humerus with displacement. From that time the 
 arm entirely ceased to grow in length, while the functions of the limb 
 were unimpaired, excepting that a slight difficulty was experienced in 
 abduction. All the muscles of the arm and forearm were well 
 developed, with the exception of the deltoid and trapezius, which 
 were much atrophied. The shortening of the humerus amounted to 
 13 centimetres (5"121 inches), while the growth in thickness was the 
 same as on the opposite side. 
 
 Dr. J. F. Erdmann, of New York, mentions (New York Medical 
 Record, October 26, 1895, p. 587) the case of a boy (J. D.), 
 thirteen years of age, who was knocked down by a mail waggon and 
 thrown forward on to his right shoulder. When seen within half 
 an hour after the injury swelling was very slight and pain considerable, 
 but no deformity ; unnatural mobility was felt high up, and by grasping 
 the shoulder with the left hand, and moving the arm with the right, 
 grating of a peculiar soft character was obtained. He was discharged 
 at the end of the third week, and the family reported ' that you would 
 not know the arm had been broken.' Measurements, four years 
 after the injury, revealed a shortening of three-quarters of an inch. 
 
 Bruns relates (Langenbeck, Archiv filr klinische Chirurgie, 
 1882, Bd. xxvii.) two cases which came under his own observation. 
 In one, almost identical with that of Vogt, a healthy, power- 
 fully built man, aged forty-nine, had fallen when two years old 
 from the arms of the nurse on to his right shoulder. The injury 
 w^as treated, and no signs of inflammation followed, but the 
 longitudinal growth of the arm did not progress from this time, 
 whilst the growth in thickness of the bone was not arrested. The 
 shortening of the right humerus was enormous, amounting to 14 
 centimetres (nearly 6 inches) ; the neighbouring bones, clavicle, 
 scapula, radius, and ulna and muscles were normal. All movements 
 of the shoulder-joint were free except abduction, so that the patient 
 could not elevate the arm above the horizontal position. There was 
 
SEPAKATION OF UPPEE EPIPHYSIS OF HUMEEUS 257 
 
 some deformity or irregular projection, probably caused by displace- 
 ment of the diaphysial end. 
 
 In the other case, a boy, aged twelve, had in his fourth year sus- 
 tained an injury to his left arm by being lifted violently up by his arms. 
 A sudden ' crack ' was felt, and he found he could not use the arm. 
 Epiphysial separation was dia- 
 gnosed, and a plaster of Paris 
 splint was applied for some 
 weeks. Bruns found a shorten- 
 ing of about four centimetres of 
 the humerus, whilst the growth 
 of the forearm was perfect. The 
 shoulder-joint was completely 
 ankylosed, so that all move- 
 ments of the arms were carried 
 out through the mobility of the 
 scapula. Slight atrophy of the 
 muscles of the arm and an in- 
 distinct projection of the dia- 
 physis close to the epiphysis 
 were found. 
 
 Helferich figures (Atlas der 
 traumatiscJien FractiLren tmd 
 Luxationen, Mlinchen, 1897, 
 Tab. 34, Fig. 2) the case of a 
 man (Bertram, 1878) who had 
 considerable shortening of the 
 right humerus from arrest of 
 growth, the result of an injury 
 in very early youth to the epi- 
 physial cartilage of the upper 
 end of the humerus. 
 
 In common with many other 
 observers, this surgeon believes 
 that the amount of shortening is greatest when union has taken 
 place with considerable displacement. It will, of course, vary 
 according to the time which has elapsed since the accident. 
 
 The two following cases, mentioned by M. Curtillet as described 
 by Dittmayer (Dittmayer, Th. de Wurzhourg , 1887 ; Curtillet, Du 
 Decollement traumatique des JE])iphyses, Lyon, 1891), illustrate this 
 very well. 
 
 In the first case a boy, aged thirteen years, had fallen on to his 
 right shoulder at the age of eleven. Very acute pain in the 
 shoulder and inability to move the arm were experienced at the 
 time. Soft crepitus and abnormal mobility were detected on 
 examination by a doctor, who fixed the arm in the adducted 
 position with a pad in the axilla. At the end of three weeks the 
 
 s 
 
 Fig. 57.^-AnREST of growth of humerus 
 after injury to its upper epiphysis, 
 (after Helferich) 
 
258 EPIPHYSES OF UPPEE EXTEEMITY 
 
 arm was placed in a simple sling, and eight days later this was 
 removed, and no further treatment adopted, as the patient appeared 
 to be completely cured. No inflammatory condition was subse- 
 quently observed. On admission into hospital the right shoulder 
 was found to be flattened, a depression was to be seen below 
 the acromion, and at the same spot the humeral head could be felt 
 still occupying its normal position. The deltoid muscle was wasted, 
 but yet reacted to electricity. The osseous projection of the end 
 of the diaphysis could be seen and felt displaced forwards and 
 inwards in Morenheim's fossa. The shoulder- joint was completely 
 ankylosed, and only slight abduction could be effected through 
 movement of the scapula. 
 
 The clavicle, scapula, other bones, muscles, and joints of the 
 forearm were normal, and the thickness of the arms on the two 
 sides was the same. The shortening of the right arm, amounting 
 to 2^ centimetres, was considered by Dittmayer to be due to arrest 
 of growth following the disjunction, for the overlapping of the frag- 
 ments could not have produced the same amount of shortening. 
 
 The second case was that of a boy, aged fourteen years, who had 
 fallen, at the beginning of April (1887), from a ladder on to his 
 right arm. Acute pain was felt, with loss of power over the limb. 
 A disjunction of the upper humeral epiphysis was diagnosed, with 
 displacement inwards and upwards of the diaphysis. Middeldorpf's 
 triangular apparatus was applied, and the bone rapidly united by 
 osseous material. Active and passive movements of the limb were 
 obtained ; massage and electricity were employed successfully in 
 restoring the function of the limb. However, on the patient's 
 admission to the hospital, he could not carry out the movements 
 of the arm completely nor elevate it above the horizontal position. 
 There was some deformity due to the incomplete reduction of 
 the displacement, and as a consequence of the ossification of the 
 epiphysial line there was an arrest of development which gave 
 rise to a shortening of 3 centimetres, but there was no diminu- 
 tion in the thickness of the limb, nor any other abnormality of 
 the bones or soft parts. 
 
 Bryant mentions {Guy's Hospital Beioorts, third series, vol. viii. 
 1862, plate) having seen a woman, aged thirty, whose humerus 
 was shortened five inches from a fall on the right shoulder in early 
 infancy. There was atrophy of the deltoid and complete ankylosis of 
 the shoulder-joint, but with the forearm well developed. Although 
 the accident had not been followed by any suppuration, the case was 
 a somewhat uncertain one, as due to traumatic causes alone. 
 
 A similar instance of three inches shortening of the humerus 
 with impaired movements is recorded by Humphry in the Boyal 
 Medico-Chirurgical Transactions, vol. xlv. 1862, p. 285. The woman, 
 aged seventy, had been told that the arm was natural at birth, but 
 had been injured at the shoulder when she was six months old. 
 
SEPAEATION OF UPPEE EPIPHYSIS OF HUMEEUS 259 
 
 Mr. A. H. Tubby mentions {Lancet, June 6, 1891) a similar case 
 of 3^ inches shortening of the humerus in a young lady, aged 
 twenty-five years, who was injured at the age of three years by 
 being lifted up by the right hand. The injury was diagnosed at the 
 time as diastasis of the upper end of the humerus. 
 
 Table of Cases in which Abrest of Growth followed Separation of the Upper 
 Epiphysis of the Humerus 
 
 Surgeon 
 
 Sex of 
 patient 
 
 Age 
 
 Amount of 
 shortening 
 
 A ge when 
 injured 
 
 Nature of injury, &c. 
 
 Hoffa 
 
 Male 
 
 29 years 
 
 6| centimetres 
 
 9 years 
 
 Blow on shoulder from 
 gun. No treatment 
 
 Vogt 
 
 Male 
 
 20 years 
 
 13 centimetres 
 
 10 years 
 
 Thought to be a sprain 
 
 Brums 
 
 Male 
 
 49 years 
 
 14 centimetres 
 
 2 years 
 
 Fall from nurse on to 
 shoulder 
 
 Bruns 
 
 Male 
 
 12 years 
 
 4 centimetres 
 
 4 years 
 
 Violently lifted by arms 
 
 Bryant 
 
 Female 
 
 30 years 
 
 5 inches 
 
 a few months 
 
 Injury to shoulder from 
 a fall 
 
 Shearer 
 
 Male 
 
 53 years 
 
 4 inches 
 
 Not stated 
 
 Not stated 
 
 Tubby 
 
 Female 
 
 25 years 
 
 3| inches 
 
 3 years 
 
 Diagnosed as epiphysial 
 separation 
 
 Helferich 
 
 Male 
 
 ? 
 
 ? 
 
 very early 
 youth 
 
 " " 
 
 Arrest of growth from inflammation due to traumatic causes. — In 
 
 the Guy's Hospital Eeports, 1862, 3rd series, vol. viii., Mr. Birkett 
 reports an example of shortening by six inches, which was clearly 
 due to extensive inflammation and suppuration about the upper 
 epiphysis. A cicatrix was present. 
 
 Bidder and Langenbeck mention like cases. In Bidder's case 
 the humerus was shortened six to seven centimetres, which was 
 attributed by the patient to vaccination improperly performed. 
 
 Mr. Jonathan Hutchinson reported {British Medical Journal, 
 July 25, 1885, p. 152) a remarkable case of arrest of growth of the 
 left humerus in a young lad aged sixteen. The shortening amounted 
 to four inches, and resulted from an injury followed by inflammation 
 and ankylosis at the age of a year and a half. The injury was 
 believed to have been slight, but it was followed by inflammation, 
 and the arm was said to have been kept at rest for six months. 
 There was bony ankylosis at the shoulder-joint, but there was no 
 proof that the epiphysis had been detached. The clavicle and 
 scapula were thin and atrophied, which might have been attributed 
 to the absence of motion at the joint. 
 
 Dr. F. Shearer {Brit. Med. Journal, October 10, 1885, p. 700) 
 also records an instance of four inches shortening of the arm in a 
 man aged fifty-three, following a fracture of the humerus near the 
 right shoulder- joint sustained at two years of age, which was 
 doubtless a case of separation of the epiphysis, and, as in the cases 
 just alluded to, was followed by inflammation and the formation 
 of an abscess. There was no ankylosis of the shoulder, and there- 
 fore no atrophy of the shoulder girdle as in Hutchmson's case. 
 
 s 2 
 
260 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 The same observer mentions a more authentic case which he 
 had seen of a man aged fifty-three, whose arm was shortened 
 by four inches, measuring from the tip of the acromion to the 
 olecranon process. In other respects the right arm was well 
 developed, and hkewise the forearm. The shoulder-joint was not 
 
 ankylosed, and there was no wast- 
 ing of the muscles of the shoulder. 
 Arrest of growth may follow 
 fractm^es other than epiphysiary 
 separation. 
 
 Fig. 59. 
 (Guy's Hospital Museum, 
 
 size) 
 
 Fig. 58.— uninjueed humeeus 
 (Guy's Hospital Museum, J size) 
 
 In the museum of Guy's Hos- 
 pital there is a specimen of arrest 
 of growth of the left humerus for 
 three and a half inches after what 
 was probably a fracture of the 
 shaft at eight years old. The 
 
 author removed it, as well as the opposite humerus, while acting 
 
 as dresser to Mr. Bryant. Figured in Bryant's Practice of Surgery, 
 
 4th ed. vol. ii. 1884, p. 425. 
 
 Necrosis of the diaphysis and suppuration have been a common 
 
 result of compound separations. 
 
SEPAEATION OF UPPEE EPIPHYSIS OF HUMEEUS 261 
 
 Necrosis occurred in Williams's and Bruns's cases and is seen in 
 the specimen in the Charing Cross Hospital Museum. Extensive 
 osteomyelitis and suppuration of the joint occurred in Esmarch's 
 case in a child of five years. The head of the bone and the upper 
 end of the diaphysis were excised with a good result — viz. a use- 
 ful arm, with but little shortening, and a free shoulder -joint. 
 Suppuration occurred in one of Hutchinson's cases, in a boy aged 
 fourteen. 
 
 Gangrene, &c. — Although gangrene occurred in two instances, 
 permanent paralysis from pressure and injury to the brachial plexus 
 had not followed in any. 
 
262 
 
 EPIPHYSES OF UPPEE EXTKEMITY 
 
 CHAPTEE IV 
 
 SEPARATION OP THE LOWER END OF THE 
 HUMERUS BEFORE PUBERTY 
 
 ANATOMY. — The lower end of the humerus, comprising the 
 external and internal epicondyles, and the lower quarter of the coronoid 
 and olecranon fossae (Krause), remains cartilaginous from birth up to 
 
 the third year, with the exception of 
 some scattered osseous granules in 
 the capitellar portion. 
 
 Henle says this centre in the 
 capitellum is distinguishable towards 
 the second year. The author has 
 often observed a distinct nucleus 
 about the middle of the second 
 year. Humphry notes its appear- 
 ance at a few months after the 
 centre of the head of the bone — 
 viz. during the first year. 
 
 At the end of the third year the 
 nucleus of the capitellum, which 
 is therefore the first of the four 
 centres to appear, attains a con- 
 siderable size, and is situated at the 
 beginning towards the inner side 
 of this process, but rapidly spreads, 
 so that at the termination of the 
 sixth year the whole of this is in- 
 vaded. It also extends inwards so as to form the outer half of the 
 trochlear surface, ending by becoming much thinner at the bottom 
 of the trochlear groove, and it remains disconnected with the rest 
 of the articular end of the humerus for more than ten years — i.e. till 
 the fifteenth or sixteenth year. By the sixteenth year the whole of 
 this portion of the articular surface is entirely osseous, and forms 
 a hemispherical mass, with its convex surface below and in front 
 towards the cup of the radius, whilst its upper slightly excavated 
 surface is presented towards the end of the diaphysis. 
 
 The next centre to appear is that for the inner epicondyle 
 (epitrochlea), which does so about the fifth year (Henle), or the 
 
 Fig. 60. -vertical section of the upper 
 and lower ends of the humerus in 
 a child aged two tears and nine 
 
 MONTHS 
 
SEPAEATION OF LOWEE END OF HUMEEUS 263 
 
 fourth or fifth according to Sappey, 
 appearance until the tenth or eleventh 
 year. 
 
 In the cartilage of the trochlea an 
 osseous centre next becomes visible 
 towards the projecting part or inner 
 lip of this surface. Sometimes there 
 are tv\^o, the second smaller one being 
 more external and soon blending v^ith 
 the larger. This appears between 
 the eleventh and twelfth years, at 
 times a little later. 
 
 The last to appear is the nucleus 
 for the outer epicondyle, which does 
 so at the thirteenth or fourteenth 
 year (Henle), sometimes a little later, 
 in the middle of the cartilage form- 
 ing this process ; the latter is soon 
 ossified throughout its small extent, 
 and unites a year or two later — 
 about the sixteenth year — with the 
 two portions forming the articular 
 surface. 
 
 The lower end of the humerus 
 varies much in the times of com- 
 plete ossification of its different 
 component parts. They may all be 
 entirely ossified as early as the 
 fourteenth year, often as late as at 
 the sixteenth year. 
 
 A most careful study of the exact 
 shape and extent of this epiphysis, 
 and of the articular connections and 
 muscular attachments, is very essen- 
 tial to the proper understanding of 
 the numerous and complicated lesions 
 of the elbow-joint which occur in 
 young subjects. 
 
 It is certain that separations of a 
 portion (not the whole) of this wide 
 epiphysis are much more frequent 
 than they have hitherto been gene- 
 rally supposed to be. 
 
 Formation of the lower epiphy- 
 sis.— Great confusion has existed 
 amongst British and other writers 
 with regard to the nomenclature of 
 
 though it may be delayed in its 
 
 c 
 
 
 Fig. 61. — frontal section of lower 
 end of humerus at the age of six 
 and a half years. anterior half 
 of section. centres of capitellum 
 and internal epicondyle well de- 
 veloped, actual size 
 
 Fig. 62.— LOWER end of the hume- 
 rus, ABOUT the eleventh YEAR, 
 SHOWING the CARTILAGINOUS EPI- 
 PHYSIS DETACHED (aFTER RAMliAUD 
 AND RENAULT) 
 
 At this age the centres of capitellura 
 and internal epicondyle are fairly 
 large, while some osseous granules 
 indicate the centre for the trochlea. 
 The epiphysis rises some millimetres 
 above the lateral portions of tlie 
 diaphysis. The fully formed coro- 
 noid and olecranon foss;e are limited 
 below by the epiphysis. 
 
264 EPIPHYSES OF UPPEK EXTKEMITY 
 
 the different i^arts of this epiphysis. The French terms introduced 
 by Chaussier of condyle and epicondyle for the usual ones of 
 capitellmn and external epicondyle, and trochlea and epitrochlea for 
 the trochlea and internal epicondyle, might well be adopted. In the 
 older text-books of anatomy the terms inner and outer condyles, which 
 are still adopted by most sm^geons, have been appHed to the internal 
 epicondyle and external epicondyle. Not infrequently the condyles 
 have vaguely been alluded to as including parts of the trochlea or 
 capitellum respectively ; these names are still employed in this way 
 by many American surgeons. 
 
 We still find in most anatomical works that the fully formed 
 epiphysis is composed of four centres — internal condyle, external 
 condyle, trochlea, and capitellum — and that these form the lower 
 end of the humerus. They do so in the infant, and for the first 
 few years of life; after this time the end of the bone is very 
 differently constituted. 
 
 Alex. Manquat {Essaisur les decoHements Spvphysaires traumcctiques, 
 1877), in common with a few anatomists, makes a grave error when 
 he says : ' The epicondyle (external epicondyle) unites with the 
 condyle (ca^pitellum) towards the fifteenth or sixteenth year, and the 
 epitrochlea {internal epicondyle) to the trochlea a little later, at the 
 sixteenth or seventeenth year.' 
 
 About the fifteenth or sixteenth year, the two portions of the 
 articular surface formed by the capitellum and trochlea blend 
 together (commencing at the groove of the trochlear sm'face) and 
 produce one articular surface ; the external epicondyle is then joined 
 on. These three portions form by their junction the lowxr epiphysis 
 of the humerus, which -does not include the internal epicondyle. 
 This is relatively to the developing shaft much thinner than the 
 cartilaginous lower end of the humerus of infancy, consequently the 
 epiphysial line of junction is much nearer to the articular cavity 
 than in the earlier period of life. 
 
 The internal epicondyle forms a distinct epiphysis by the down- 
 ward growth of the diaphysis separating it from the rest of the end 
 of the bone, which usually unites with the diaphysis without blend- 
 ing with the trochlea. This junction is effected from the eighteenth 
 to the twentieth year, but as late as the twenty-fifth year traces 
 of the line of junction may still be seen. 
 
 The lower end of the bone decreases relatively in size as child- 
 hood advances. The transverse measurement from the apex of the 
 internal epicondyle to that of the external epicondyle is exactly six 
 centimetres at the age of seventeen years, and its vertical depth is 
 only eleven millimetres at the middle of the trochlear surface, while 
 the width from epicondyle to epicondyle during the third year is 
 about three centimetres, and the vertical depth seven millimetres. 
 At fourteen and a half years the width is rather more than four and 
 a half centimetres, and the depth eight millimetres. 
 
SEPAEATION OF LOWEK END OF HUMEKUS 2G5 
 
 It will thus be seen that as age advances the increase in size 
 of the lower end of the bone is rather in width than in vertical 
 depth. The point of junction of the trochlear and capitellar portions 
 of the lower epiphysis at the middle of the trochlear groove at the 
 sixteenth year is the narrowest portion of the bone, and much more 
 likely to be broken across, detaching one or other portion of bone 
 rather than the whole epiphysis separating at this age. 
 
 De Paoli gives the following table of measurements of the height 
 and breadth of the lower epiphysis of the humerus in individuals 
 of various ages taken in frontal section (dividing the epiphysis in 
 two parts, one anterior and the other posterior). 
 
 Before birth. 
 One year 
 Two years 
 Four years 
 Five years 
 Six years 
 Eight years 
 Nine years 
 Ten years 
 Eleven years . 
 Thirteen years 
 Fifteen years . 
 
 Height at the middle 
 of the trochlea 
 
 ..6 mm. 
 
 ..6 
 
 ..6 
 
 ..7 
 
 ..6 
 
 ..6 
 
 ..6 
 
 ..6 
 
 ..7 
 
 ..4 
 
 ..5 
 
 Height at the middle 
 of the condyle 
 
 . 8 mm. 
 .10 
 
 . 8 
 .11 
 .11 
 .12 
 .12 
 .11 
 .10 
 .10 
 .10 
 
 Breadth at the 
 upper part 
 
 .22 mm. 
 .29 
 .35 
 .36 
 .86 
 .37 
 .41 
 .40 
 .41 
 .42 
 42 
 .52 
 
 It is common to find an error in surgical works as to the fully 
 formed epiphysis. Thus Erichsen, alluding to separation of the 
 lower epiphysis of the humerus as a frequent accident in children, 
 makes the statement that in this accident the trochlea, the capi- 
 tellum, and the condyles are broken off from the shaft, which 
 remains in situ. 
 
 The anatomical difference of the lower epiphysis of the humerus 
 at puberty and the lower end of the same bone in infancy led 
 E. W. Smith to suppose that this epiphysis was only composed 
 of the trochlea and capitellum, so that the epiphysial line ran below 
 the epicondyles at all ages. 
 
 The upper surface of the lower end of the bone in childhood, 
 when removed from the shaft, presents a nmnber of projections 
 which fit on to corresponding depressions on the end of the dia- 
 physis. It is somewhat cup-shaped, or lipped, at the sides, rising 
 about a quarter of an inch above the diaphysis. In infancy it is 
 almost flat. 
 
 The olecranon and coronoid fossse, as seen at the twelfth year, 
 are formed almost entirely in the diaphysis, and are limited below 
 by the osseous margin which corresponds to the epiphysis. While 
 in infancy the cartilaginous epiphysial end completes the lower part of 
 the olecranon fossa, in the fully formed bone the fossa is formed in 
 no way by the epiphysis. 
 
266 EPIPHYSES OF UPPEK EXTEEMITY 
 
 It is an error to suppose that the epiphysial Hue is transverse in 
 the youth. It is ahnost so at birth, when the whole of the lower 
 extremity of the humerus is cartilaginous, and remains like this 
 for a few years, completely above the epicondyles. The diaphysis 
 in its growth enlarges, thickens at each side to form the lateral pro- 
 jections, and extends downwards, forming the whole of the olecranon 
 fossa ; but it is especially on the inner side, towards the internal 
 epicondyle, that the increase takes place, apparentlj^ at the expense 
 of the epiphysis. The humeral diaphysis penetrates, as it were, 
 the trochlea, and gives great support to this part of the epij^hysis, 
 the separation of which will become more difficult after the age 
 of four years. However, on the outer side the epiphysis remains 
 much thicker — nearly double the size of the trochlea — is not 
 invaded by the diaphysis, and consists of more than half an inch 
 of bone as seen from behind, above the articular surface of the 
 capitellum. 
 
 So that at about thirteen years of age the epiphysial line mil be 
 seen to be placed very obliquely downwards and inwards, the epi- 
 physis on the inner side being thin, and limited precisely by the 
 cartilage-clad area in front and behind. On the inner side it rises 
 slightly towards the internal epicondyle, which at this age is almost 
 separated from the rest of the lower extremity of the grovvdng 
 diaphysis. The external epicondyle is very rarely isolated in the 
 same manner from the epiphysis. 
 
 The epiphysial line at this age is relatively much nearer to the 
 articular surface than in infancy, from the increasing growth of 
 the diaphysis. It is still, as in infancy, above the external, 
 but below the internal epicondyle, which is now excluded from its 
 formation. The epiphysial line of epiphysis proper, comprising the 
 external epicondyle, capitellum, and trochlea, is therefore very 
 obliquely placed if we draw a transverse line uniting the apex of the 
 two epicondyles. The plane of the articular surface likewise makes 
 an acute angle inwards with the same transverse line. On the outer 
 side the epiphysial line terminates above the external epicondyle, 
 and on the inner side below the internal epicondyle. The distance 
 from the latter increases slightly as the diaphysis grows downwards, 
 and the internal epicondyle is further removed from the epiphysis 
 until the time of complete union. 
 
 This epiphysis after its complete formation rapidly unites to the 
 diaphysis, being firmly welded on by the seventeenth year. After 
 this year the growth in length of the humerus is therefore arrested 
 as far as the lower extremity is concerned, but it is carried on by 
 the epiphysis of the upper extremity till adolescence. 
 
 Some anatomists have stated that the external, but more 
 frequently the internal epicondyle, after being quite developed and 
 osseous, often remains isolated for a considerable number of years, 
 sometimes for life. 
 
SEPAEATION OF LOWEE END OF HUMEEUS 267 
 
 Relations of the synovial membrane to the epiphysial lines. — The 
 
 lower extremity of the humeral diaphysis has very extensive 
 relations with the synovial membrane. 
 
 The synovial membrane, as seen at fifteen years of age, passes 
 for some distance upwards over the epiphysial line of cartilage, both 
 in front and behind the lower end of the humerus. In front it is 
 thick, and but loosely connected with the diaphysis, and springs 
 from the articular surface. It is readily detached from the coronoid 
 and radial fossae in front, whereas behind it is much thinner and 
 extends upwards from the articular surface, being firmly attached to 
 the lower part of the olecranon fossa beneath the lobe of fat fitting 
 the upper part of this cavity. 
 
 Hence it is obvious that the synovial membrane may be easily 
 torn through, and the articulation liable to be opened at the olecranon 
 fossa in separations of the lower epiphyses. On a vertical median 
 section we see that at the olecra- 
 non fossa the synovial membrane 
 overlaps the diaphysis for 0-008 
 millimetres at three years of age, 
 and for fifteen millimetres at thir- 
 teen years of age (Sesary). Behind 
 the capitellar portion of the epi- 
 physis, the synovial membrane 
 does not quite reach up to the 
 epiphysial line. 
 
 The synovial membrane on the 
 outer side passes up on the outer 
 aspect of the capitellum above 
 the articular surface as far as the 
 external epicondyle, rendering it 
 possible for the synovial membrane 
 to be opened here in separation of 
 this process. 
 
 On the vmier side the synovial 
 membrane does not extend upwards 
 
 over the inner aspect of the trochlea, much above the epiphysial 
 line ; about three-sixteenths of an inch below the internal epicondyle. 
 Therefore, detachment of this process is not necessarily accom- 
 panied by opening of the articular cavity. 
 
 The epiphysial line lies more deeply in the joint during child- 
 hood than it does in infancy. 
 
 Detachment of the capitellar or trochlear portions of the epi- 
 physis must necessarily be associated with opening of the articular 
 cavity, through the fracture of the articular cartilage uniting these 
 two portions about the middle of the trochlear surface. This open- 
 ing of the cavity will happen whether these portions of the epiphysis 
 are connected with the corresponding external and internal epicon- 
 
 FlG. 63. SAGITTAL SECTION OF THE ELBOW- 
 JOINT ; HUMEKO-ULNAB ARTICULATION IN A 
 YOUTH AGED FIFTEEN AND A HALF YEARS, 
 SHOWING THE RELATION OF THE SYNOVIAL 
 MEMBRANE TO THE EPIPHYSIAL LINES 
 
268 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 dyles or the contrary. The external epicondyle will most likely 
 accompany such a separation of the capitellum from the fifteenth 
 to the seventeenth year of age. 
 
 The capsule of the joint is attached to the humerus immediately 
 above the coronoid and radial fossae in front, and is continuous at the 
 
 sides with the lateral ligaments, which 
 are merely thickened portions of the 
 capsule. It is attached here to the 
 lower aspects of the external and inter- 
 nal epicondyles. Behind, it is attached 
 to the humerus in a line passing 
 through the upper part of the olecranon 
 fossa ; below, to the edges of the ole- 
 cranon and coronoid processes of the 
 ulna, to the edge of the greater sigmoid 
 cavity, and to the orbicular ligament 
 surrounding the head of the radius. 
 
 The precise relationship of the ar- 
 ticular structures is important not only 
 from the occurrence of the separation 
 being attended by a fracture into the 
 joint, but from the facility with which 
 the extensive synovial membrane in- 
 flames in the case of separations in 
 its neighbourhood. The effusion into 
 its cavity renders both the diagnosis 
 and treatment more difficult. 
 
 The close proximity of the median and musculo-spiral nerves, 
 and brachial vessels in front, and the ulnar nerve behind, to the 
 end of the diaphysis must always be remembered. 
 
 AGE. — Composing the thirteen pathological specimens here col- 
 lected there were four at the age of two years, one at four, one at 
 ten, one at thirteen, two 'in children,' and two in which the age was 
 not given. In two old separations the age was between four and six. 
 Out of the seventeen compound cases the age is given in 
 thirteen — two at thirteen, one at eleven, two at ten, one at eight 
 and a half, one at eight, one at seven, three at six, and one at three 
 years of age. In three the age is not stated. In one the separation 
 occurred in a girl, and in another the age is given as fifteen 
 (Bryant's) ; the latter is a dubious one, inasmuch as the condition of 
 the parts at the time of operation is insufficiently stated. It may 
 have been a very unusual case of delayed ossification of the epiphysis. 
 In the author's own records of forty-two simple cases, one in a 
 recently born child is very questionable. Apart from this — there 
 are six in which the age is not stated ; three occurred in young 
 children, and one in a boy. The youngest patient was one year and 
 eight months, and the two oldest thirteen years old ; two cases occurred 
 
 Fig. 64. — frontal section or boxes 
 
 rOiniING THE LEFT ELBOW-JOINT 
 OF A CHILD FOURTEEN YEARS NINE 
 MONTHS OLD. FRONT HALF OF 
 SECTION. RELATION OF SYNOVIAL 
 MEMBRANE TO THE EPIPHYSES 
 
SEPAEATION OF LOWEE END OF HUMEEUS 269 
 
 at twelve, one at eleven, two at ten, two at nine and a half, two at 
 nine, nine at eight, three at seven, three at five, three at four, 
 and one at two years of age. 
 
 Out of the total of sevenkj-two cases, the age was given in fifty- 
 five, while seven were in children or young boys, and forty-four 
 occurred from about the second up to the tenth year. 
 
 Although some surgeons consider this injury to be very rare 
 after the age of four years, certainly it is only possible as a complete 
 separation of the whole lower end before thirteen years of age. 
 
 D'Arcy Power says {Surgical Diseases of Children, 1895, p. 174) : 
 ' The lower epiphysis may be separated at any time up to the 
 thirteenth or fourteenth year, though the separation is somewhat 
 more frequent under four years of age.' 
 
 Out of fifty-two cases collected by Mr. Hutchinson junior {Brit. 
 Med. Journal, December 31, 1893) twenty-four were simple separa- 
 tions (fifteen under his own care), twenty-three complicated, mostly 
 compound ; and five cases of old separation of the epiphysis. 
 He thought that clean separation was present probably only in the 
 minority. The youngest patient was eighteen months old, the oldest 
 fourteen years. 
 
 Out of fifty cases of fracture of the lower end of the humerus 
 which came under the care of Dr. C. A. Powers of New York, nine 
 were over twenty years of age and forty-one were under. Of the 
 forty-one, thirteen were under five, twelve between five and ten, 
 thirteen between ten and fifteen, and three between fifteen and 
 twenty years of age. 
 
 SEX. — In only two of the author's cases is it stated that the 
 accident occurred in girls, but it should be noted that in a very great 
 number of instances mention is merely made that the accident 
 occurred to children. 
 
 ETIOLOGY. — Separation of the entire epiphysis is usually pro- 
 duced by direct violence applied to the elbow, such as a fall upon the 
 elbow while bent, or the passage of a cartwheel over it, or a kick from 
 a horse. 
 
 In other cases the violence is more indirect, the force being trans- 
 mitted through the bones of the forearm, as by a fall upon the out- 
 stretched hand, the forearm being semiflexed. 
 
 In one case the patient had fallen upon the hand, and in another 
 a boy fell across the back of the extended limb. 
 
 Separation has been known to occur from a fall upon the palm of 
 the hand, the forearm and elbow being at the time in the extended 
 position ; also from falling on the forearm. 
 
 On the dead body, it is remarkably easy to separate the lower 
 epiphysis of the humerus in infancy by forcible hyper-extension 
 or flexion of the forearm ; more especially the author has found it 
 detachable from the third to the eighth year. Schiiller and 
 others have made the same observation. 
 
270 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 Fig. 65. — diagkam of sepaeation 
 of the lower end of the hu- 
 merus before puberty 
 
 Separation produced in the body 
 of a girl aged six and a half. 
 The whole cartilaginous mass 
 of the lower end of the hume- 
 rus, consisting of both epicon- 
 dylcs, the trochlea, and capitel- 
 lum, is cleanly detached. 
 
 In 1876 Berthomier found in his experiments that less violence 
 was required to effect epiphysial separation than to fracture the 
 lower end of the humerus. He observed that direct traction on the 
 forearm led usually to an epiphysial fracture of the humerus ; that 
 
 it was perfect and pure up to ten years 
 of age, and accompanied by small 
 scales of bone beyond that age ; and 
 he believed that falls upon the hand 
 which produced an injury of the elbow 
 always produced a more or less perfect 
 separation of the lower epiphysis of 
 the humerus. 
 
 Bardenheuer thought that separa- 
 tion was most frequently brought about 
 by adduction or abduction of the fore- 
 arm while in the extended or flexed 
 position. 
 
 The narrow lower end of the hu- 
 merus escapes detachment in many 
 falls upon the elbow on account of the 
 protection afforded by the bones of the 
 forearm, as well as by its own elas- 
 ticity. It is at this early period — i.e. 
 up to the eleventh or twelfth year — - 
 almost entirely composed of cartilage ; a much greater amount of 
 force will consequently be required to separate it than if it were 
 osseous, so that Gurlt and others are right in believing that on the 
 living subject this lesion always requires a great degree of violence 
 for its production. 
 
 PATHOLOGICAL ANATOMY.— Of all injuries to the elbow-joint, 
 those to the epiphyses of the humerus are the most important and 
 complicated. 
 
 Writing in 1886 {Bulletins et Memoires de la Societe de Chirurgie, 
 Paris, 1886, n. s. xii.) M. Farabeuf says, very erroneously, that separa- 
 tion of the whole lower end of the humerus cannot occur after about 
 the fourth year ; but his experiments and remarks upon the osseous 
 epiphysis of early puberty, formed by the capitellum, trochlea, and 
 external epicondyle, which he calls the lower epiphysis, are interest- 
 ing, and will be alluded to in Chapter V. 
 
 Other surgeons have, on the contrary, declared separation of the 
 lower epiphysis of the humerus to be the most frequent of all epi- 
 physial separations. From the published records it appears to be 
 not uncommon, but not so much so as some other epiphysial 
 separations ; yet cases examined anatomically have been seldom 
 met with. Up to the time of Bruns's paper four cases only had 
 been recorded as verified in this way. 
 Gurlt considered it a very rare injury. 
 
SEPAKATION OF LOWEK END OF HUMERUS 271 
 
 Bardenheuer agrees (Deutsche Chirurgie) with Schiiller's opinion 
 that it is far more frequent than is generally supposed, and says 
 that three times he has resected cases of old injury in which the 
 whole epiphysis in children of four to six years of age had been 
 broken off the diaphysis and displaced backwards. The function of 
 the limb was considerably impaired, flexion being quite impossible 
 In two cases the capitellum, together with the external epicondyle, 
 was separated and accompanied on the inner side with a fracture 
 above the trochlea. 
 
 Malgaigne very rightly classes disjunction of this epiphysis with 
 supracondyloid fractures of the humerus. 
 
 The lower epiphysis of the humerus is often found to be 
 detached in severe direct injury or crushing of the elbow and arm. 
 Polaillon mentions {Affections chirurgicales des memhres, 1885, p. 687) 
 the case of a little boy, aged seven and a half years, whose right arm 
 was crushed under the wheel of a carriage. Through an extensive 
 wound the elbow-joint was seen to be opened, and the lower 
 epiphysis of the humerus separated. The humeral diaphysis was 
 broken into several fragments and the muscles pulped. Death took 
 place from shock six hours after disarticulation of the shoulder. 
 
 The separation takes place in the usual position in the ossifying 
 layer immediately adjoining the epiphysial cartilage. 
 
 It is possible for it to occur in the cartilaginous layer itself, but 
 no specimens exist. Yet a portion of the cartilage has remained 
 attached to the diaphysis in several of the compound separations 
 of part of the epiphysis recorded in advancing childhood. 
 
 St. Thomas's Hospital Museum, No. 115 (Descriptive Catalogue 
 of the Pathological Museum, St. Thomas's Hosjntal, Part I. 1890, 
 p. 22, 2nd edition), contains the best specimen of a complete and 
 pure separation of this epiphysis, presented by Sir AVilham 
 MacCormac. It consists of the lower part of a child's humerus, 
 showing a complete separation of the lower epiphysis along the 
 normal line of junction (see fig. 66). 
 
 The epicondyles remain with the trochlea and capitellum as a 
 w^hole. The internal epicondyle has an osseous centre of f of an 
 inch in diameter, and the external has dragged away a few granules 
 of the diaphysis along its base. The diaphysis is otherwise un- 
 injured. 
 
 Stimson says (Treatise on Fractures, 1883, p. 411) : ' There is 
 also a specimen in the museum of Bellevue Hospital, U.S.A., of the 
 bones of the forearm of a child with a shrunken cartilage attached, 
 which seems to be the lower epiphj^sis of the humerus.' 
 
 In St. Mary's Hospital (St. Marifs Hosjntal Museum Patho- 
 logical Catalogue, 1891, p. 10) is a specimen, No. 94, of a pure 
 separation of the lower epiphysis of the humerus, the separation 
 passing exactly through the epiphysial junction without any fracture 
 of the diaphysis, but the olecranon is fractured into three pieces. No 
 
272 
 
 EPIPHYSES OE UPPEE EXTEEMITY 
 
 cartilage remained on the humeral diaphysis, the separation being 
 in the juxta-epiphysial layer of new bone. It was taken from a 
 child aged about four years, whose arm was ' jammed ' in a gate. 
 
 nucleus of internal epicondyle 
 
 external epicondyle 
 
 capitellnm 
 
 Fig. 66. — pure separation oe lower end of humerus before puberty. 
 (sT. Thomas's hospital museum) 
 
 In this specimen most of the articular end is cartilage ; that in connection with 
 the external epicondyle forms a cap to the bone of the shaft. For this drawing 
 the author is indebted to Mr. S. G. Shattock, who kindly sketched it for him. 
 
 The brachial artery was bruised and subsequently thrombosed, but 
 the separation v/as a simple one. The limb was amputated by Mr. 
 Page at the shoulder-joint, traumatic gangrene threatening to 
 spread upwards (see fig. 67). 
 
 St. George's Hospital Museum contains a specimen of united 
 fracture a quarter of an inch above the epiphysial line which was 
 
 only distinguishable from epiphysial 
 separation during life by the rough loud 
 crepitus. The diaphysis was displaced 
 forwards, and the gap behind filled up 
 with new bone. The specimen is de- 
 scribed by Mr. Holmes in the Path. Soc. 
 Trans, vol. xiii. p. 186. 
 
 In the London Hospital Museum 
 is a specimen. No. 389 {London Hos- 
 pital Museum Catalogue, 1890, p. 92), 
 of compound fracture near to the line 
 of the lower epiphysis. The lower end 
 of the upper fragment projected into 
 the wound, and was accordingly sawn 
 off. The line of junction of the epi- 
 physis was pretty nearly followed. The 
 patient recovered with a stiff elbow. 
 
 Separation with vertical fracture of 
 epiphysis into elbow-joint. It is quite 
 possible for simple separation to be complicated with a vertical 
 fracture into the elbow-joint, either between the trochlea and capi- 
 tellnm, or through the trochlea at the junction of the two epiphysial 
 portions. 
 
 Fig. 67. — complete separation of 
 the lower end of the humerus 
 
 AT about four tears OF AGE. 
 
 (sT. mart's hospital museum) 
 
SEPAEATION OF LOWEE END OF HUMEEUS 273 
 
 There is, however, no specnnen in existence showing this form 
 of lesion. 
 
 Separation, with siight fracture of the diaphysis. — As the period of 
 childhood advances, in all probability the greater will be the likelihood 
 of separation being accompanied by a detachment of some small 
 portion of the diaphysis. This is, indeed, a not uncommon form of 
 injury Even in infants, a portion of the bone may be torn away. 
 
 In 1818 Champion {Journal Complement, du Diction, des Sci. 
 Med., Paris, 1818, tom. 1, p. 323) described the case of a boy, aged 
 thirteen, whose arm had been caught (1816) by the sleeve and rolled 
 round seven times by some machinery. 
 
 The separation was without difficulty made out on account of the 
 absence of swelling of the arm — the easily recognised lower end of 
 the humerus being twisted from before backwards, and from within 
 outwards. The displacement was readily reduced by twisting the 
 forearm in an opposite direction. 
 
 On dissection there was revealed a complete separation of the 
 lower epiphysis of the humerus, together with a thin flake from the 
 posterior and outer part of the diaphysis the size of a finger-nail, 
 half an inch in width and a quarter of an inch in thickness. The 
 periosteum was stripped from the outer side of the diaphysis up to 
 the insertion of the deltoid, and the anterior and posterior capsular 
 ligaments of the joint were lacerated in front and behind, as well as the 
 portion of the synovial membrane which corresponded to the separa- 
 tion of the epiphysis. Compound fracture of the bones of the 
 forearm rendered primary amputation of the arm necessary, and the 
 patient recovered. The ej^iphysis preserved its relations with the 
 bones of the forearm by means of the lateral and capsular ligaments. 
 
 In the London Hospital Museum, No. 550a {loc. cit. supra,]). 121), 
 is a specimen of separation of the lower epiphysis of the humerus, 
 accompanied by fracture of the femur a short distance above the 
 inferior epiphysial line, and other injuries. They were caused by 
 the parents, who, whilst drunk, dragged the child about by its 
 limbs. The child's age is not stated, but it was probably about 
 two years. 
 
 Partial separation, with fracture of diaphysis. — A very common 
 condition, as seen by the number recorded below under compound 
 separations. 
 
 The outer portion of the epiphysis, consisting of the capitellum 
 and external epicondyle, appears to be most often detached, the 
 fracture then passing through a portion of the diaphysis above 
 the epiphysial line of the internal epicondyle and trochlea. 
 
 Mr. Jonathan Hutchinson junior's specimen at the Eoyal 
 College of Surgeons Museum, 1888, No. 940a, is a good example. 
 
 It consists of the right elbow-joint, from a child aged two, 
 showing incomplete detachment of the lower epiphysis of the 
 humerus, the periosteum being torn from the back of the diaphysis. 
 
 T 
 
274 
 
 EPIPHYSES OE UPPEK EXTEEMITY 
 
 The line of separation has followed almost exactly the epiphysial 
 disk, except at the inner side, where a small piece has been wrenched 
 off the diaphysis for | inch in height and ^ inch in width. The injury 
 was due to the child being violently dragged about by the arm. 
 
 Schiiller found the same condition in 
 his experiments, and Bardenheuer alludes 
 to the frequency of this form of injury. 
 
 Mr. Jonathan Hutchinson junior's 
 specimen. Royal College of Surgeons Mu- 
 seum, No. 940b, 1889, comprises the lower 
 end of the left humerus from a child aged 
 two years, who fell out of bed sixteen days 
 before death (which was due to croup). 
 The lower epiphysis has been separated, 
 taking with it a small part of the adjacent 
 diaphysial end on the inner side, while on 
 the outer half it is through the epiphysial 
 line. The displacement was backwards 
 and inwards. Under treatment with an 
 angular splint, bony union had aheady 
 occurred to a great extent, chiefly through 
 cartilaginous formation. But some lateral 
 displacement, with forwara projection of 
 the diaphysis, may still be seen in the 
 preparation. 
 
 Hamilton showed, before the New York 
 Pathological Society {Neio York Medical 
 Journal, September 1865, p. 461), a partial 
 separation of the lower epiphysis of the 
 humerus. A girl, aged ten, had fallen on 
 her elbow. Three weeks afterwards the upper fragment was thrust 
 through the skin. Resection was refused by the parents, so ampu- 
 tation was performed. The line of separation passed partly through 
 the epiphysial line and partly through the diaphysis. 
 
 Dr. Little, at the same society. May 1865 {New Yorh Medical 
 Journal, vol. ii. 1866, p. 133), presented the lower end of a 
 humerus, with a portion of the epiphysis, which he had removed. 
 The injury which occasioned its removal was a fracture which 
 extended half across the epiphysial Hne and then across the lower 
 extremity of the bone higher up. The patient recovered with a 
 
 stiff arm. 
 
 Bardenheuer alludes (loc. cit. supra) to two cases of old separa- 
 tion of the capitellum and external ei^icondyle, together with frac- 
 ture above the trochlea on the inner side, in which he performed 
 resection for loss of function, flexion being entirely lost. The ages 
 were from four to six years of age. 
 
 A partial separation of the inner and middle portion of the lower 
 
 Fig. G8. — paetial separation, 
 with fkactuke of the dl\- 
 
 PHYSIS. (EOTAL college OF 
 SURGEONS MUSEUll) 
 
SEPAEATION OF LOWEE END OF HUMEEUS 275 
 
 humeral epiphysis is portrayed by Helferich (Atlas der trauma- 
 tischen Fracturen und Liixationen, 1895, Tab. 30, Fig. la and Ih). 
 There existed also a transverse fracture and fissure of the humeral 
 shaft, and a longitudinal fracture of the ulna associated with a 
 separation of the olecranon epiphysis. The radius was uninjured. 
 The injury to the child's arm was caused by a severe machinery 
 accident which necessitated amputation. 
 
 Fig. 69. — partial separation of epi- 
 physis, WITH FISSURE AND TRANSVERSE 
 FRACTURE OF THE SHAFT (aFTER 
 
 Helferich) 
 
 Fig. 70. — separation of the ole- 
 cranon EPIPHYSIS, with longitudinal 
 
 fracture OF shaft (after Helferich, 
 
 SAME case) 
 
 Compound Sepaeations. Pure separations. — Many compound 
 separations have revealed the precise condition of the separated frag- 
 ments. Mr. Hutchinson says a compound fracture at the line of 
 the epiphysis is necessarily a compound fracture into the joint, since 
 it was barely possible the joint should not be opened. The author 
 cannot agree with this unless it be a complicated case, and associated 
 with a vertical fracture into the articular surface, or with a fracture 
 between the internal epicondyloid portion and trochlea surface, 
 opening the synovial membrane at that spot. 
 
 In the following instance part, at any rate, of the epiphysial 
 cartilage adhered to the diaphysis. 
 
 Mr. Jonathan Hutchinson related, from the London Hospital, 
 the case [Medical Times and Gazette, Apiil 7, 1866, p. 360) of a lad, 
 aged thirteen, in whom the lower end of the diaphysis projected 
 through a large laceration in front of the left elbow. From the 
 character of the exposed surface it was clear that the line of 
 epiphysial junction had been almost accurately observed. 
 
 Although there was no difficulty in reduction, the end w^as 
 resected, as it was thought that sufficient extension could not be 
 effected through the injury to the soft parts ; the lower end of the 
 upper fragment w^ould certainly have rested in front of the lower 
 fragment and elbow-joint, and deformity would have resulted. 
 The lower margin of the fragment removed was capped with the 
 epiphysial cartilage. The lad subsequently had his elbow^ bent at 
 
 T 2 
 
276 EPIPHYSES OF UPPEK EXTEEMITY 
 
 a right angle and quite stiff, but he could use his arm well. Mr. 
 Hutchinson says the ankylosis at the elbow was unavoidable, and 
 must have occurred whatever the treatment had been. It is probable 
 that this was an unusually complicated case of separation, suggesting 
 also a fracture between the internal epicondyle and trochlea, opening 
 the synovial membrane on this side, and a fissure extending between 
 the trochlear and capitellar portions. 
 
 Spillman (Bull, de la Soc. de Chirurg., Paris, 1875, November 10, 
 p. 771) records the following case of compound separation in the 
 epiphysial line directly above the epicondyle and epitrochlea. 
 
 The boy, aged eleven years, fell off a mule at full gallop, causing 
 a transverse wound four centimetres long on the outer side of the 
 biceps tendon, one centimetre above the bend of the left elbow, 
 through which the end of the diaphysis protruded. The diaphysis 
 was separated directly above the epicondyle (external epicondyle) 
 and the epitrochlea (internal epicondyle), and comprised a small 
 portion of the olecranon fossa. It was only after resection of 
 forty-three millimetres of its end under chloroform that reduction 
 was effected, the periosteum being carefully preserved. There was 
 no fracture of the epiphysis penetrating the joint. The elbow 
 was placed in splints in a semiflexed position, and the patient 
 recovered the complete use of his arm, although he fell about the 
 ninth week and refractured the humerus a little above the site of 
 resection, which caused a small sequestrum to separate in the 
 eighteenth week. 
 
 Spillman also mentions a second case {Bull, de la Soc. de 
 Chiriirgie, Paris, 1875, p. 772) which presented a precisely similar 
 lesion to the last, with detachment of the periosteum and a small 
 flake of the diaphysis. The child (0. A.), aged six years, had fallen 
 from a wall one metre high. The same difficulty was experienced in 
 reduction of the displaced diaphysis, and it was necessary to remove 
 twenty-eight millimetres of the diaphysial end before it could be 
 effected. With the exception of the formation of a small abscess 
 on the inner side of the arm, which was opened, the wound healed, 
 and consolidation took place in about five weeks' time, the humerus 
 of each side being equal in length ; and the child had completely 
 recovered when it left the hospital a month later. 
 
 Dr. Lange, of New York, had a similar case (Hamilton, Fractures 
 and Dislocations, 1884, p. 291, fig. 80) of compound separation of 
 this epiphysis, the separation following the conjugal cartilage. The 
 epiphysis was removed through the wound, with a portion of the 
 diaphysis, and the patient recovered with a useful arm. 
 
 Maisonneuve {CUnique Ghirurgicale, 1863, tome i. p. 533) met 
 with a compound separation of the lower epiphysis, the shaft pro- 
 jecting a considerable distance through a large lacerated wound at 
 the lower and antero-external part of the arm, whilst the lower 
 epiphysis remained in its normal position. The periosteum was 
 
SEPAEATION OF LOWEK END OF HUMEEUS 277 
 
 completely stripped off the protruding bone for about four centimetres, 
 but remained adherent to the epiphysial cartilage below, and was 
 torn longitudinally for the passage of the shaft. The diaphysial end 
 was regular and perfectly free from any fracture, and was an exact 
 counterpart of the supra-epiphysial portion of the bone. The patient, 
 a boy (A.) aged seven, had fallen about three metres with his left 
 hand stretched forwards. Eeduction was effected with some diffi- 
 culty, and Maisonneuve replaced the bone within its periosteal 
 sheath. The limb was kept semiflexed with a plaster splint. In 
 two months the wound healed, and a complete recovery ensued after 
 the lapse of eighteen months, all the movements of the limb having 
 recovered to their fullest extent by the regular active use of the arm 
 combined with massage and sulphur baths. 
 
 In his address in Surgery {British Medical Journal, 1867, vol. ii. 
 Aug. 17, p. 123) at Dublin, 1867, E. W. Smith alluded to a case 
 under the care of Dr. Hutton in the Eichmond Hospital, Dublin. 
 The injury was compound, the extremities of the radius and ulna, 
 surmounted by the epiphysis of the humerus, projecting through a 
 large transverse wound, which was placed at the back of the elbow ; 
 and an opportunity was thus afforded of observing the anatomical 
 characters of this injury and the relative position of the bones 
 which is not presented when the wound is situated in front of the 
 articulation. Two projections were visible posteriorly, both placed 
 above and behind the plane of the condyles, the inner formed by the 
 olecranon, the outer by the capitellum of the humerus surmounting 
 the head of the radius. 
 
 The Indian Medical Record (Calcutta), April 1, 1892, vol. iii. 
 p. 119, contains the following case of separation of the lower epi- 
 physis of the humerus and protrusion of the upper fragment through 
 the skin, reported by Surgeon Captain Geo. S. Thomson, M.B., Indian 
 Medical Service (Deesa) . It occurred in a little boy three years of age. 
 Whilst playing he fell from a bridge on February 27, 1892, alighting 
 on his right elbow, which was then in a bent position ; he was a very 
 heavy child for his age, and a compound fracture of the humerus 
 just above the condyles was produced. The upper fragment — con- 
 sisting of the shaft of the bone down to the coronoid and olecranon 
 fossae and including a small portion of the thin lamella of bone between 
 those hollows — projected externally for fully one inch through a large 
 wound at the outer side of the arm above the elbow-joint. The 
 lower fragment and elbow-joint were carried upwards and backwards 
 behind the shaft of the bone to its inner side. The forearm was 
 slightly flexed upon the arm, at an angle of about thirty degrees at the 
 elbow ; and the hand and forearm were held pronated. The child 
 complained of very little pain, and there was but trifling haemorrhage. 
 
 An attempt was made to reduce the displaced fragments by 
 gentle manipulation, but this resulted in failure, owing to the con- 
 traction and rigidity of the muscles surrounding the elbow. Under 
 
278 EPIPHYSES OF UPPEE EXTEEMITY 
 
 angesthesia the fracture was readily adjusted. The wound was 
 cleansed with perchloride of mercury lotion ; and iodoform, sal 
 alembroth wool, and angular splints were applied. Next day the 
 dressings were re-apphed and the limb was put up in a plaster- of- 
 Paris bandage in a semiflexed position ; a window was then cut 
 in the bandage when it had set, and through this dry antiseptic 
 dressings were appHed to the wound. Eiglit days after the 
 accident the plaster -of -Paris bandage was slit up, and the 
 amount of union present warranted passive motion being employed 
 in a very steady and gentle manner in order, as far as possible, to 
 prevent ankylosis. The moulded plaster-of-Paris splint was re- 
 applied, but was dispensed with the third day following, and passive 
 motion was persevered w^ith daily. The wound healed without sup- 
 puration, and was completely healed on March 12, or fifteen days 
 after the accident. The child regained the perfect use of his arm, 
 and could place it on his head, on the opposite shoulder, and up to 
 his mouth ; in fact, all the motions of the elbow-joint were unimpaired 
 at the date of the report — twenty-one days after the accident. 
 
 Dr. John Ashhurst published in the University Medical Magazine, 
 Philadelx^hia, April 1892, p. 518, another example of compound 
 separation of the lower epiphysis of the humerus, in which resection 
 was performed. 
 
 Wm. F., aged eight years, was admitted to the University 
 hospital, when the upper fragTuent, consisting of the diaphysis of the 
 humerus, projected nearly three inches from a large triangular- 
 shaped wound on the anterior surface of the arm a short distance 
 above the elbow. The brachial artery could be seen stretched 
 across the wound, pulseless, but apparently uninjured, while the arm 
 below the seat of injury was cold. The question of amputation 
 arose, but the youth of the patient, combined with the fact that the 
 wound was produced by the protrusion of the bone itself from within 
 outwards, and that the main vessels were probably uninjured, impelled 
 Dr. Ashhurst to make an attempt at saving the arm. In order to 
 effect reduction an inch of bone was removed, after which the 
 protruding part was easily replaced. A counter-opening was made, 
 a drainage-tube passed through, and the wound closed, after having 
 been thoroughly washed out with a warm solution of bichloride of 
 mercury, 1 in 2,000. It was then dressed antiseptically, and the 
 arm placed on an internal angular splint. The circulation returned 
 to the hand in a few hours. At the first dressing, on the fifth day, 
 the drainage tube was shortened, and at the second dressing, six 
 days later, it was removed. Passive motion was practised as soon as 
 the external wound was healed. The splint was removed in eight 
 weeks, and the arm supported by soap plaster and a bandage. The 
 union eight weeks after the injury was firm. There was then some 
 movement at the elbow-joint, with very good motion in the direction 
 of pronation and supination. 
 
SEPAKATION OF LOWEK END OF HUMEEUS 279 
 
 Dr. Harry Finley kindly sent the author the notes of the follow- 
 ing case which came under his notice. Alex. A., set. seven years, was 
 admitted to Carhsle Infirmary, July 11, 1894, under Dr. H. A. 
 Lediard. He had fallen whilst climbing some iron railings. On 
 examination, the lower end of the diaphysis of the humerus was 
 protruding through a vertical wound just large enough to admit its 
 passage, about one and a quarter inches from the centre of the 
 bend of the elbow-joint. The bone was quite bare of periosteum 
 and cartilage. The deformity was very well marked, the forearm 
 being halfway between supination and pronation, movable with- 
 out pain and displaced backwards ; but for the appearance of 
 the humerus it would have looked much like a dislocation of the 
 forearm backwards. However, the lower epiphysis could be readily 
 felt, there being no effusion. Keduction not being accompUshed, 
 even after some enlargement of the wound, a piece of the shaft 
 about three quarters of an inch long was sawn off, within an hour, 
 under chloroform, and the shaft was then easily replaced and 
 found to have its proper relation to the periosteum. The epiphysis 
 appeared to be entire, without fracture into the joint. After the usual 
 douching, &c., a small drainage tube was inserted and the wound 
 closed. The tube was removed on the fourth day. The arm was 
 put up in an anterior splint, and an internal right-angled splint on 
 alternate days till August 6, when the patient was discharged. In 
 December all the movements of the joint were excellent, and there 
 was no backward or other displacement, and very little if any thicken- 
 ing around the end of the diaphyses. The ' carrying angle ' was 
 increased about 20°. There was no more than | inch difference in 
 the length of the two arms. 
 
 Compound separation, with fracture of the diaphysis. — Fracture of 
 the diaphysis to a greater or less extent is usually observed in com- 
 pound separations. 
 
 In 1864 Dr. J. C. Eeeve, of Ohio {Hamilton' s Fractures and Dis- 
 locations, 7th edition, 1884, p. 291, fig. 79 ; Cincinnati Lancet and 
 Clinic, November 23, 1878, p. 386), saw a girl, aged ten, who had 
 fallen a few feet, striking, probably, her elbow. The separation 
 being compound, the end of the humerus protruded in front. 
 Union not having occurred at the end of three weeks, as the arm 
 had been kept for about two weeks on a wooden splint without a 
 particle of padding, and the olecranon was projecting from a large 
 ulcerated wound behind, the condition of the arm rendered amputa- 
 tion necessary. A small fragment of the shaft came away with the 
 epiphysis. 
 
 Dr. J. A. Macdougall {Edinburgh Medical Journal, March 1891, 
 p. 827) mentions the following case of compound separation with a 
 shaving of the shaft attached. B. G., a little lad of ten, fell from the 
 railing of an outside staircase, and in landing pitched upon his right 
 elbow. On examination it was found that the shaft of the humerus 
 
280 EPIPHYSES OF UPPEE EXTEEMITY 
 
 protruded from a ragged and contused wound on the outer side of the 
 arm immediately above the elbow, the fracture having taken place a 
 little way below the expansion of the condyles. The separation had 
 occurred immediately above, and passed through the line of the 
 ex3iphysis from before backwards, and it was noted that the peri- 
 osteum was entirely stripped from the posterior surface of the exposed 
 humerus for nearly an inch. Primary excision was performed, and 
 gave a very excellent result. 
 
 Bardenheuer also removed the diaphysial end of the humerus, 
 which projected directly forwards in a second case — figured by him. 
 {Deutsche Chirurgie) — complicated with fracture of the posterior 
 part of this end, which remained attached to the epiphysis. 
 
 In a case alluded to by Mr. Hutchinson junior (British Med. 
 Journal, 1893, December 30, p. 1417), the detachment followed the 
 epiphysial line exactly, except at the extreme external part. The 
 patient was aged thirteen. Primary amputation was performed. 
 
 El the majority of the pathological specimens, and in the com- 
 pound separations just mentioned, the epiphysis was displaced more 
 or less hacl'icards from the diaphysis. 
 
 Displacement forwards of the epiphysis. — A unique case of trans- 
 verse fracture of the lower end of the humerus immediately above 
 the epiphysial line, with displacement forwards, indistinguishable 
 from pure separation of the epiphysis, and associated with separation 
 of the olecranon epiphj'sis, came under the author's observation in 
 1893. 
 
 On May 17, 1893, a girl, H. B., aged six j^ears, fell from a third- 
 story window, her head striking the pavement below. She was 
 admitted to the Miller Hospital a quarter of an hour after the acci- 
 dent, with fracture of the parietal bone and severe concussion of 
 the brain. There was severe contusion and swelling of the elbow, 
 with what was believed to be separation of the lower epiphysis of 
 the humerus, fractured olecranon process, and fracture of the shaft 
 of the ulna about the junction of the upper and middle third. She 
 recovered from the fractured skull, and the injured humerus and 
 ulna appeared to unite very well, although there was some deformity. 
 However, she was admitted again on July 25, with the history of 
 having fallen tw^ce downstairs upon her elbow. The movement of 
 the elbow, which was pretty free when she left the hospital, was 
 now very restricted. Flexion was only possible to an angle of 125°, 
 and extension to an angle of 135°. The olecranon process was now 
 found to be separated about half an inch from the rest of the 
 bone, and firmly fixed at the back of the elbow. On August 10 
 (three months after the accident) she was placed under the author's 
 care for operation by Mr. Thomas Moore, who had been in charge of 
 the case. The movements of the elbow-joint were then very slight, 
 flexion being prevented by the impact of the head of the radius 
 against the front of the lower end of the hmnerus, and there was 
 
SEPAEATION OF LOWEE END OF HUMEEUS 281 
 
 much deformity. The condition of the elbow only permitted ex- 
 cision of the joint, which was performed. 
 
 Examination of the parts removed by this excision showed that the 
 whole epiphysis and epicondyles of the humerus had been removed, 
 together with a small portion of the lower end of the humeral diaphysis, 
 the greater portion of the cup-Hke end of the radius, the olecranon 
 process, and a portion of the upper end of the ulna. The humerus had 
 been transversely fractured immediately above the epiphysis, so that 
 the track on each side almost touched the cartilaginous epicondyles, 
 whilst in the centre it was rather more than a quarter of an inch above 
 the epiphysial hne. The epiphysis, showing a considerable osseous 
 
 , F 
 
 C 
 
 Fig. 71. — feactuke of diaphysis directly above epiphysis, displacement op 
 
 EPIPHYSIS FOEWAKDS. SEPAEATION OF OLECEANON EPIPHYSIS. PARTS REMOVED 
 
 BY EXCISION. (natural SIZE) 
 
 A, Lower end of humerus. B, External epicondyle. C, Upper end of 
 ulna. D, Space at olecranon fossa between the olecranon fragments filled 
 with fibrous tissue. £, Olecranon epiphysis displaced and united to lower 
 end of humerus. F, Portion of head of radius. 
 
 nucleus in the capitellar and commencing ossification in the internal 
 epicondylar portion, was displaced forwards with the head of the 
 radius and the ulna, and firmly united to the lower end of the 
 humerus in this position. The capitellum of the humerus thus 
 looked directly forwards, and the anterior margin of the radial cup 
 in this displaced position had come in contact with the front of the 
 humerus. The cartilaginous epiphysis of the olecranon was dis- 
 placed rather more than half an inch backwards off the upper end 
 of the ulna, and firmly fixed to the lower end of the diaphysis of the 
 humerus posteriorly. The space between the olecranon, upper end 
 of the ulna, and posterior aspect of the epiphysis of the humerus was 
 occupied by dense fibrous tissue (see figures). 
 
282 
 
 EPIPHYSES OF UPPEE EXTREMITY 
 
 The child made an excellent recovery, and obtained a most useful 
 and freely movable joint. 
 
 Fig. 72. — antebo-posteeiok vertical section of same specimen 
 (natueal size ) 
 
 A, Diaphysis of humerus. B, Epiphysis with a small portion of the 
 diaphysis. C, Ulna. D, Space between olecranon fragments. E, 
 Olecranon. 
 
 Fig. 73. — feontal veetical section of the humeeal part removed 
 
 A, Lower end of diaphysis of humerus. B, Lower epiphysis. C, Commencing 
 ossification of internal epicondylar portion. D, Osseous nucleus of capi- 
 tellum. 
 
 Displacement outwards. — Mr. Bryant had a case of compound 
 separation of the lower epiphysis of the humerus under his care 
 at Guy's Hospital in October 1876, in v^hich the epiphysis is said to 
 have been displaced outwards. The patient (Eliza W.), aged fifteen, 
 was injured by the passage of the wheel of a cart over her left arm. 
 The wound was dressed with compound tincture of benzoin, and the 
 arm placed on an outside angular splint. Seven weeks later the 
 elbow could be flexed to some extent. 
 
 Displacement inwards and backwards. — Bardenheuer gives two 
 figures of a case of incomplete displacement inwards of the epi- 
 
SEPAEATION OF LOWEE END OF HUMEEUS 283 
 
 physis and forearm in a girl (C. S.) ux^on whom he operated. The 
 diaphysial end of the hmnerus, displaced outwards and forwards, 
 was removed, and is represented in one of the drawings (see Deutsche 
 Chirurgie). The radial fossa was completely hoUowed out, and 
 before the operation its inner edge was mistaken for the anterior 
 edge of the trochlea. The epiphysis was displaced backwards, 
 carrying with it a portion (i to ^ centimetre) of the posterior part 
 of the diaphysis, which formed a firm band of continuity between 
 the displaced epiphysis and the diaphysis. At the operation the 
 joint was opened, but this was followed by complete restoration 
 of the function of the joint. 
 
 Displacement inwards. — In the case already mentioned under the 
 care of Mr. Hutchinson junior, the Hne of separation followed only 
 halfway the epiphysial disk, diverging for the other half into the 
 diaphysis. Bony union occurred, with some lateral displacement 
 inwards. (Eoyal College of Surgeons Museum.) 
 
 Detachment of periosteum. — In displacement of the epiphysis 
 backwards, the periosteum is mostly detached from the posterior 
 aspect of the lower end of the diaphysis. 
 
 In two of Bardenheuer's cases of old separation the periosteum 
 had evidently been separated at this part, for a complete new 
 shell of thin bone had formed which so exactly took the normal 
 position of the bone that at first sight it looked Hke the bone 
 itself, but was thinner and narrower. The humerus itself, with the 
 olecranon fossa above the epiphysial line, projected in front in line 
 with the axis of the shaft, whilst the thin, narrow new layer of 
 bone behind made an angle with it. 
 
 Other Complications. — Injury to the brachial artery. Pressure 
 upon the brachial artery leading to its occlusion has been met with 
 in a few compound separations. 
 
 Professor E. W. Smith exhibited to the Pathological Society of 
 Dublin (Proceedings of the Pathological Society of Dublin, n.s. 
 vol. iv. 1870, p. 109) a cast of a recent example of separation of the 
 lower and epitrochlear epiphyses of the humerus, the diaphysis 
 having protruded through a large transverse rent in the integuments, 
 just above the flexure of the elbow. A few moments before his 
 admission, the boy, aged eight and a half, was thrown to the ground 
 from a donkey, and on examination half an hour afterwards the 
 following conditions were noted. Two inches of the diaphysis 
 protruded through the wound ; the periosteum was detached along 
 with the articular epiphysis and that of the epitrochlea ; the 
 coronoid depression was distinctly seen ; the temperature of the 
 limb, below the seat of the injury, was normal, but the pulsation 
 of the radial and ulnar arteries could not be felt. The absence 
 of pulsation was noted very shortly after the receipt of the 
 injury. The pulsation ceased to be distinguishable at the point of 
 bifurcation of the brachial artery, but the temperature of the 
 
284 EPIPHYSES OF UPPEE EXTEEMITY 
 
 limb continued normal. The patient being under the influence of 
 chloroform, the forearm was semiflexed, and the epiphysis of the 
 humerus (still resting upon the radius and ulna) was found to have 
 passed backwards and upwards with these bones. Dr. Smith com- 
 pletely reduced the fragments, restored the parts to their normal 
 relative position, and the limb was then secured in an angular 
 splint in the semiflexed position. The patient left the hospital at 
 the end of five weeks. The ultimate condition of the limb was as 
 follows : the range of motion of the elbow-joint was extensive, 
 though neither complete extension nor perfect flexion was possible. 
 The lower end of the humerus formed a slight projection in front, 
 while posteriorly two prominences were plainly visible, which were 
 as nearly as possible on the same level ; the inner was formed by 
 the olecranon, and the outer by the capitellum, surmounting the 
 head of the radius. When the boy was last seen the pulsation had 
 not re-appeared in either the radial or ulnar artery. 
 
 Laceration, of elbow-joint. — In Champion's case of simple separa- 
 tion accompanied by other severe injuries, the anterior and posterior 
 ligaments, as well as the part of the synovial membrane which 
 corresponded to them, were lacerated. 
 
 Laceration of tlie bracMalis anticus. — This muscle may be torn at 
 its lower part, either in front or at the sides, by the displaced end 
 of the diaphysis. 
 
 The biceps tendon may be displaced somewhat to either side. 
 
 Dislocation of elbow. — Mr. C. J. Bond, of Leicester, has recorded 
 (Provincial Medical Journal, March 1, 1895, p. 138) a unique case 
 of se])aration of the loiver epiphysis of the humerus, together ivith 
 a dislocation of the elboiv-joint. A boy of twelve fell off a bicycle, 
 and was thought ' to have a fractured elbow.' The arm was put 
 up in the extended position in splints for some weeks. When 
 Mr. Bond saw the boy, six weeks later, the appearance was that 
 of a backward dislocation of the elbow, except that the shortening 
 was in excess, and the prominence on the anterior aspect of the 
 joint was larger than usual. As no reduction or alteration of the 
 relation of the bones could be effected under chloroform, three 
 months after the accident the joint was opened by a vertical posterior 
 incision, and by sawing across the olecranon. The following con- 
 dition was then found : the lower epiphysis of the humerus carrying 
 the articular surfaces had been separated from the shaft, and had 
 re-united at a right angle with it ; and, the radius and ulna 
 having also been displaced somewhat backwards, the articular end 
 of the epiphysis of the humerus lay on the ulna in front of the 
 coronoid process. Mr. Bond first tried by chiselling through the 
 line of union of the epiphysis to bend that straight, and bring it into 
 a line with the shaft, and then to carry the ulna and radius forwards, 
 and so reduce the dislocation. This was so far successful ; but the 
 same difficulty occmTed here which so frequently occm's in dealing 
 
SEPAKATION OF LOWEE END OF HUMEEUS 285 
 
 with soft parts which have contracted up in any new position after 
 injury — namely, the difficulty that, when the bones were in position 
 and the dislocation reduced, the olecranon could not be brought 
 down anywhere near the end of the ulna, so that the joint could not 
 be closed posteriorly, nor the bones be kept in position. The loosened 
 epiphysis was therefore removed, the forearm bones replaced, and 
 the olecranon wired ; the wide flattened end of the. shaft of the 
 humerus now lay in the articular concavity of the ulna, and formed 
 the new elbow-joint. 
 
 Primary union of the wound occurred, and the recovery was 
 soon complete. Mr. Bond saw the patient eighteen months after 
 operation, and the limb was a very useful one ; the patient could 
 flex and extend through an angle of 45 degrees, and get his hand up 
 to his mouth. The forearm was in the position midway between 
 pronation and supination, but there was no further movement of 
 that kind. 
 
 Later Complications. — Suppuration has frequently occurred 
 after compound separations. It may also take place after sloughing 
 of the skin from pressure of the displaced diaphysis. 
 
 Gangrene has ensued, especially in compound cases that have 
 been neglected. 
 
 SYMPTOMS. Separation without Displacement. — Separation 
 is not necessarily accompanied with displacement, the parts being held 
 by the periosteum and other soft tissues ; but from the comparative 
 thinness of this epiphysis in the antero-posterior diameter it is not 
 likely to be free from some degree of displacement, even though the 
 violence may have been slight. The signs about to be mentioned 
 will then be absent. 
 
 Besides the age and the history of the accident, we have 
 only unnatural mohility at the level of the diaphysio-epiphysiary 
 junction to guide us. This, on account of the lipping of the 
 epiphysis on each side, will be more marked in the antero-posterior 
 direciion than in the lateral ; but even lateral movement is 
 often obtainable. The elbow should be grasped with one hand 
 upon the epicondylar portion of the humerus, and the lower end 
 of the shaft of the humerus with the other, and gentle pressure 
 made. 
 
 ' Muffled ' crepitus will usually be absent or difficult of detec- 
 tion. 
 
 Stripping up of the periosteuni may be expected to have occurred, 
 and to give rise to considerable subsequent thickening about the lower 
 end of the bone in a short interval of time. 
 
 G. A. Wright (Ashby and Wright, Diseases of Children, 1889, 
 p. 642) thinks it is possible that in some instances the violence may 
 strip up muscles and the thick loose periosteum without any 
 fracture or diastasis, and this injury of the periosteum may be the 
 cause of that subsequent thickening. 
 
286 EPIPHYSES OF UPPEE EXTEEMITY 
 
 Sepaeation with Displacement.— Such great confusion has 
 arisen with regard to these epiphysial separations of the lower end 
 of the humerus amongst even modern writers that it is necessary 
 to state clearly the nature of separation in each. In these, as in all 
 other separations, the author has taken the anatomy of the epiphyses 
 as the only true guide for a correct description of these lesions. It 
 would only be confusing to discuss the correctness or incorrectness 
 of the terms apphed to the different portions of the bone in each 
 case that has been recorded. All that can be done is to give as clear 
 a description as possible, based on anatomical and experimental 
 grounds, of the nature of the lesion hkely to be met with in each case. 
 
 The injury under consideration— which should be more correctly 
 described as separation of the lower end of the humerus— is more 
 rare in its pure form than the similar separation at the upper end 
 of the humerus. The lower osseous epiphysis proper is formed by 
 the external epicondyle, the capitellum, -and trochlea, the internal 
 epicondyle constituting a distinct epiphysis attached to the humerus. 
 But this arrangement only takes place after puberty, about the 
 thirteenth year, by the growth of the diaphysis. Before this period 
 the internal condyle is still part of the lower end of the humerus. 
 Consequently it is impossible for complete traumatic separation 
 of the entire epiphysial end of the humerus, including in this term 
 both epicondyles and the whole of the articular surface, to occur 
 after this period. The internal and. external epicondyles are 
 separated, together with the rest of the articular portion, as a 
 complete mass, so that the line of separation slopes downwards 
 from above each epicondyle, and then runs almost transversely above 
 the articular surfaces. 
 
 Separation of the lower end is infrequent compared with separa- 
 tion of the part of the epiphysis or articular surface occurring after 
 this period. 
 
 Writing in 1884 Hamilton said that he had never met with a 
 case ; and Agnew {Agnetv's Surgery, vol. i. 1878, p. 889) says 
 the injury is very rare. 
 
 Hutchinson says {Medical Times and Gazette, Jan. 5, 1884, 
 p. 1) it is quite possible for the whole epiphysis to be clearly 
 separated from the shaft by a transverse line of detachment, which 
 permits the condyles and epicondyles to pass backwards together 
 with the bones of the forearm. ' I have seen many examples of 
 complete transverse detachment of the whole lower epiphysis. 
 Most of them have come to me late on account of awkward union, 
 but in a certain number I have had an opportunity of examining 
 the state of things immediately after the accident.' 
 
 They are rightly placed by Malgaigne {Traite des fractures et 
 des luxations, 1847, p. 542) among supra-condijloid fractures of the 
 humerus ('fracture sus-condylienne '), thus: 'Fractures sus-con- 
 dijliennes de V Humerus. Je designe sous ce nom ce que Dupuytren 
 
SEPAKATION OF LOWEE END OF HUMERUS 287 
 
 appelait /rac^wre cle Vextremite inferieure de V humerus, afin d'etablir 
 plus de precision et d'exactitude dans le langage. C'est done une 
 solution de continuite qui separe toute I'extremite articulaire du 
 corps de I'os, sans penetrer dans la jointure ; et chez les enfants, 
 qui y sont plus sujets que les adultes, il y a probaMement, dans 
 beaucoup de cas, une disjonction de I'epiphyse.' 
 
 Dupuytren, Vidal (De Cassis), and Adams {CyclopcBdia of 
 Anatomy and Physiology, vol. ii. p. 68) also correctly state that the 
 deformity is not accompanied by any changes of the normal relations 
 existing between the olecranon and the condyles (epicondyles) . The 
 symptoms of supra-condyloid fractures and separations of the whole 
 lower epiphysis are so similar that it is often very difficult to 
 distinguish the one from the other. 
 
 Dupuytren, moreover, remarks that whatever may be the pro- 
 minence of the olecranon posteriorly, it is never further distant from 
 the condyles of the humerus than in the normal condition of the 
 parts in the case of fracture, but that in dislocation the separation is 
 very considerable. 
 
 Dr. E. M. Moore is of opinion that supra-articular fracture of 
 the humerus in a child is almost always epiphysial. 
 
 Displacement backwaeds of the epiphysis. Deformity. — In 
 the majority of cases the lower fragment comprising the epicondyles 
 and the whole of the articular portion is displaced backwards to 
 a greater or less extent by the force of the injury, carrying with 
 it the radius and ulna, while the lower end of the diaphysis projects 
 in front of the elbow, producing an appearance very similar to that 
 of dislocation of both bones backwards. 
 
 The forearm is semiflexed at an angle of about 25 degrees by 
 the action of the brachialis anticus and biceps muscles, the hand 
 in a position midway between supination and pronation, and the 
 arm powerless. 
 
 The olecranon projects posteriorly, being drawn upwards and 
 backwards by the triceps, and is in normal relation with both the 
 external and internal epicondyles. The external epicondyle is also 
 in natural relation with the radial head below. The tip of the 
 olecranon and the epicondyles are in the same line when the elbow 
 is extended, and below the line between the two epicondyles when 
 the elbow is flexed to a right angle. The antero-posterior diameter 
 of the elbow is greatly increased just above the elbow. 
 
 The depression behind the elbow above the displaced epiphysis is 
 somewhat wedge-shaped, due to the curving inwards of the triceps, 
 which is prominent. 
 
 The deformity is very readily effaced by slight force. 
 
 Among the earliest cases recorded was one under the care of 
 M. Dupuytren, 1832 {Leqons orales de clinique chirurgicale, 1832, 
 tom. iii. p. 396), in which the displacement was backwards, the lower 
 end of the humerus projecting in front. The injury had occurred a 
 
288 EPIPHYSES OF UPPEE EXTREMITY 
 
 month previously, and was mistaken for a dislocation, attempts being 
 made to reduce it. The fragments were united in a bad position, 
 which caused considerable loss of extension of the elbow-joint. 
 Unfortunately the age of the patient is not given ; it is only stated 
 that the case was that of a young child. 
 
 In separations of the whole lower epiphysis which Packard 
 has seen, the lower fragment has always been carried backwards, 
 the radius and ulna following it, and the lower end of the upper 
 fragment projecting somewhat strongly in front of the elbow. 
 
 Sir Astley Cooper mentions a case which was most probably an 
 epiphysial separation. 
 
 A boy, aged nine years, was admitted into Guy's Hospital with 
 a fracture of the condyles of the humerus above the elbow-joint, 
 which had been caused by his being thrown from a cart and having 
 fallen upon his elbow. The following symptoms were present : 
 forearm slightly bent, with considerable projection backwards of the 
 radius and ulna ; while just above the projection there was a hollow 
 in the back of the arm, so that the appearances much resembled 
 those of dislocation. On extending the forearm reduction was 
 effected, but the deformity was immediately reproduced directly this 
 was discontinued. SpHnts were employed for ten days, when 
 they were occasionally removed, and passive motion commenced. 
 
 The disx^laced diaphysis differs very much in characteristics both 
 from a dislocation and a fracture. Its anterior edge under the 
 brachiaUs anticus is somewhat rounded and quite regular, unHke 
 the sharpness and irregularity of a fracture ; at the same time its 
 lower surface is convex, even, and smooth, unhke the trochlear and 
 capitellar surfaces of the joint. The breadth of this lower end of 
 the upper fragment is greater than in the case of a fracture above 
 the condyles of the humerus, but considerably less than in the case 
 of dislocation, when it is equal to that of the opposite humerus. 
 
 The hne of separation takes place nearer the end of the bone 
 than in a true supra-condyloid fracture, as in the adult, and con- 
 sequently the lower edge of the diaphysis is usually situated 
 somewhat lower, almost on a level with the flexure of the elbow. 
 In fracture the prominence is above the fold of the elbow and in 
 dislocation much helow, so that it is often very difficult to feel the 
 articular surfaces. 
 
 Although the end of the diaphysis in the first few years of life 
 will be found to be transverse, yet as puberty is reached the epi- 
 physial line becomes oblique from without inwards, and from behind 
 forwards, and will often allow some rotation or twisting of the 
 epiphysis, so that the inner epicondyle is placed behind the corre- 
 sponding outer condyle of the humerus, and the external epicondyle 
 somewhat in front of the corresponding part of the humerus. Either 
 epicondyle, in consequence, appears very prominent on the inner 
 or outer side. 
 
SEPAEATION OF LOWER END OF HUMERUS 289 
 
 Mr. Hutchinson showed before the Pathological Society {Patho- 
 logical Society's Transactions, vol. xv. 1864, p. 199) a photograph of 
 this injury taken half an hour after the accident. A boy, aged ten, 
 fell off a horse in front of the London Hospital, and was at once 
 carried in, enabling the state of the parts to be examined before 
 any swelling had obscured them. The olecranon projected pro- 
 minently, and the tendon of the triceps stood out as in dislocation 
 backwards of the radius and ulna. The sharp ends of the bone just 
 above the condyles could be easily felt ; the inner one, indeed, 
 was almost through the skin, and the outlines of these parts made 
 it clear that the shaft was completely detached from the epiphysis. 
 The lowest parts of the condyles themselves could be felt to be still 
 in situ — i.e. having passed backwards with the ulna and radius. It 
 appeared to be a complete transverse detachment, of the whole of 
 the three parts of which the lower epiphysis of this bone is com- 
 posed. Even in the photograph the prominence forwards of the 
 lower angles (condyles) of the shaft was easily recognised. In 
 front of the joint, just over the tendon of the biceps, there was a 
 very deep dimple, caused, no doubt, by the skin being tied down by 
 attachment to the fascia. Swelling took place with great rapidity. 
 No difhculty was experienced in effecting reduction, but the de- 
 forinity was reproduced as soon as the restraining force was 
 removed. A splint was applied to the back of the arm and elbow, 
 and a pad placed over the lower end of the shaft kept it in place. 
 A second rectangular splint was applied to the inner aspect of the 
 arm. 
 
 The same surgeon saw another child who had fallen off a tree a 
 short time previously, and under chloroform diagnosed a complete 
 detachment of the lower epiphysis of the humerus. 
 
 It was easily reduced, but at once returned. A rectangular 
 concave back splint was applied, and very little displacement 
 resulted. 
 
 Mobility of the forearm and lower end of the humerus with the 
 epicondyles, especially in the antero-posterior direction, is nearly 
 always a prominent feature. 
 
 Another very important sign is the great tendency to reproduction 
 of the deformity. Reduction is easily effected by the application of 
 gentle extension, pressure of the diaphysis backwards and of the 
 elbow forwards, and the limb regains its normal appearance, but when 
 the extension is discontinued immediately shortens again, whilst 
 the deformity recurs — the powerful action of the muscles passing 
 from the arm to the forearm being the chief factor in producing 
 this result. In dislocation the bones are not disposed to become 
 again displaced after reduction. 
 
 This was well marked in Hutchinson's case just related, and also 
 in another case alluded to by the same author {Medical Times and 
 Gazette, January 5, 1884, p. 2) of a girl aged twelve, who fell from 
 
 u 
 
290 EPIPHYSES OF UPPEE EXTEEMITY 
 
 an apple-tree. Ether being administered, he was enabled to make 
 an examination of a most marked example of transverse separation. 
 It was not difficult to get the bone into place, but almost impossible 
 to keep it there. It was put up in a moulded back splint. 
 
 Muffled crepitus. —During extension and replacing of the fragments 
 by grasping the arm in one hand and the forearm in the other, the 
 fragments are made to move backwards upon each other. The 
 characteristic ' muffled ' crepitus will usually be detected. 
 
 It will be found to be more characteristic and more easily 
 obtainable in this than in any other form of epiphysial separation. 
 However, on the contrary, crepitus may be absent, although a 
 disjunction is present. 
 
 Writing in 1837 (Presse Mklicale, No. 55, July 12, 1837, torn, i.) 
 M. Eoux drew special attention to this sign in lower humeral 
 separation. 
 
 A child of ten or eleven years had a severe fall, in which the 
 ground was struck by the palmar aspect of the right hand. When 
 seen by M. Roux some hours afterwards the following signs were 
 present, which led him to diagnose disjunction of the lower end 
 of the humerus : pain in the humero-ulnar articulation, no notice- 
 able swelling ; depression on either side of the olecranon, and the 
 tendon of the biceps rendered prominent by a firm, hard, osseous 
 mass. Eeplacement of the limb to its normal position was effected 
 by moderate extension, and ' soft ' crepitus was produced by the 
 rubbing together of the granular surfaces of the fragments, which 
 were invested with a layer of ossifying cartilage. The crepitus was 
 characteristic and somewhat feeble, but differed from that which is 
 felt in the case of fracture. The arm was maintained in the flexed 
 position, and the reduced epiphysis fixed by an apparatus. The 
 parents made light of the injury, and took the apparatus off on the 
 thirteenth or fourteenth day. The child used its arm, now free, in 
 a very irregular manner — perhaps had a fresh fall ; at any rate, the 
 same evening he was unable to move his arm. A doctor who was 
 consulted thought .there was some simple rigidity about the articular 
 ligaments. However, when the child was seen by M. Eoux three 
 months afterwards, the arm was still about a quarter flexed. Exten- 
 sion was impossible and flexion very limited. The deformity of the 
 joint was irreparable, and in the position described by Hippocrates 
 as ' coude de belette.' 
 
 H. E. Clark, of Glasgow, relates {Glasgow Medical Journal, vol. 
 xxvi. p. 248) a somewhat doubtful case in a recently born child, 
 which he diagnosed as separation on account of the peculiar crepitus 
 and mobility of the condyles with the forearm. The arm appeared 
 to be paralysed from birth. The result of treatment was good, the 
 elbow being flexed at a right angle. 
 
 If a fracture of the diaphysis accompanies the separation, the dry 
 crepitus then obtained will obscure the more characteristic crepitus. 
 
SEPAEATION OF LOWEE END OF HUMEKUS 291 
 
 Shortening of arm. — On carefully measuring the arm from the 
 prominence of the external and internal epicondyle to the acromion 
 process, shortening of the humerus from ^ inch to an inch will be 
 found. \ 
 
 The active movements of the elbow in flexion and extension of the 
 forearm are limited, mostly on account of the pain, never absolutely 
 wanting, as in dislocation. Flexion is usually more painful than 
 extension. Passive movements of pronation and supination are 
 permitted to a great extent, and are more extensive than in intra- 
 articular lesions, e.g. in the corresponding separation in youth, viz. 
 separation of the trochlea, capitellum, and external epicondyle. 
 
 It must always be remembered that attempts at extensive 
 movement cause great pain, and the above signs can only satis- 
 factorily be detected while the young patient is under the ansesthetic. 
 Without its use some damage is sure to be done to the soft struc- 
 tures — e.g. the periosteum may be still further stripped up, or the 
 synovial membrane lacerated. 
 
 Shortening of forearm. — The forearm as seen from the front is 
 shortened, as in. dislocation. 
 
 The distance from the front of the displaced diaphysis to the 
 styloid process of the radius will be found shortened as compared 
 with the opposite side. 
 
 Swelling occurs with great rapidity after the accident, obscuring 
 the various prominences of the displaced bones, and rendering the 
 diagnosis very embarrassing. 
 
 In Hutchinson's case, just quoted, the quickness of the swelling 
 was very noticeable, although no time was lost ; yet before the 
 photograph could be completed the contour of the parts had been 
 to a large extent concealed. 
 
 The lapse of a few hours is quite sufficient to obscure the parts 
 completely by such a swelling, which extends upwards and downwards 
 beyond the seat of separation. It will then be absolutely necessary 
 to place the patient under an ansesthetic and make a careful exami- 
 nation of the injured elbow. An ansesthetic would have to be given 
 even for the proper reduction of the fragments and the application 
 of splints ; all violent attempts at reduction will only increase the 
 gravity of the injury. 
 
 Where a surgeon sees the case before swelling has taken place 
 an exact diagnosis can easily be made. 
 
 Dr. John Watson, of the New York Hospital, records {Neio York 
 Journal of Medicine, N.s. vol. xi. November 1853, p. 430) the case 
 of a girl, aged twenty months, who had her elbow injured by the 
 mother suddenly wrenching the limb in attempting to lift her. The 
 whole arm, when seen by Dr. Watson on the fourth day, was too 
 much swollen to make out very clearly the exact natm-e of the 
 accident. But eleven days later this had subsided, and it was 
 apparent that the shaft of the humerus had been separated from 
 
292 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 its cartilaginous expansion at the condyles. By the use of angular 
 pasteboard splints the reduction was maintained, and the disjoined 
 condyles united again to the shaft after about four or six weeks. 
 Hamilton also quotes Dr. Watson's case. It is exceedingly doubtful 
 whether this was a true case of traumatic separation in a healthy 
 subject, but it is quoted here on Hamilton's authority. 
 
 In four days' time the periosteum, which has been stripped 
 off from the displaced shaft, especially behind where an interval is 
 left between it and the diaphysis, although still adherent to the 
 epiphysis, pours out abundant inflammatory material. A day or 
 two later the outlines of the bones will have been quite obscured 
 by the new osseous material, and the diagnosis then becomes 
 absolutely impossible. 
 
 Fig. 74. — chesterman's steel calliper gauge for measurixg height and 
 width of the epiphyses at the various ages 
 
 Divided : inches into thirty-seconds, centimetres into millimetres and laalves 
 
 This interval between the diaphysis and the epiphysis the author 
 has noticed in all the experiments made by him on the dead body. 
 
 Ecchymosis about the elbow is often very marked from extrava- 
 sated blood. 
 
 The breadth between epicondyles is not altered, thereby dis- 
 tinguishing it from separation of the lower epiphysis during the 
 period of youth. 
 
 Complications. — Injury to the brachial artery. 
 
 The close relation of the brachial artery to the front of the 
 lower end of the diaphysis is a fertile source of danger. Yet it is 
 remarkable how often the vessels at the head of the elbow escape 
 injury. Probably their curved position and great mobility tend to 
 bring this about. 
 
 In Professor R. W. Smith's case of compound separation absence 
 of pulsation was present from the bifurcation of the brachial artery 
 downwards, due to pressure upon this vessel. 
 
SEPAEATION OF LOWER END OF HUMEEUS 293 
 
 T. Bryant {Practice of Surgerij, 4th edition, 1884, vol. ii. p. 369) 
 alludes to the case of a boy aged nine years. The lower epiphysis 
 of the humerus, with the bones of the forearm, was displaced back- 
 wards : the anterior border of the diaphysis injured the brachial 
 artery and occluded it. Reduction was effected and splints applied. 
 At the end of six weeks there was good movement of the joint, and 
 pulsation had returned in the radial, but not in the brachial, artery. 
 This appears to be the same case as that of a boy who had fallen 
 downstairs and separated his epiphysis, with occlusion of the brachial 
 artery, recorded by Chas. Wood in the Guy's Hospital Gazette, July 
 1878, p. 82. The age of the patient is, however, given here as 
 five years. 
 
 Bryant also gives {Brit. Med. Journal, May 30, 1896, p. 1487) 
 the following case of separation of the lower epiphysis of the 
 humerus from the diaphysis, and displacement of the epiphysis with 
 the bones of the forearm backwards, with occlusion of the brachial 
 artery. A boy, aged five years, was admitted into Guy's Hospital 
 on May 27, 1878, under his care, having injured his elbow one week 
 previously in falling dow^nstairs. The limb was cold, swollen, and 
 pulseless below the elbow. The forearm, with the lower epiphysis 
 of the humerus, was displaced backwards, and the anterior edge of 
 the extremity of the diaphysis was pressing seriously upon the 
 brachial artery, which was in front. When the deformity was 
 reduced pulsation did not return in the vessel. The limb was put 
 into a good position and fastened in a splint after having been 
 raised and well wrapped up in cotton- wool ; everything went on 
 well. Subsequently, on the seventeenth day after his admission, or 
 the twenty-fourth day after the accident, pulsation returned in the 
 radial artery, but when the child left the hospital in the sixth week 
 no pulsation had returned in the brachial artery below the seat of 
 injury. At that spot the vessel was clearly occluded. 
 
 G. A. Wright gives the following case {Guy's Hosjntal Bejjorts, 
 third series, vol. xxiv. 1879, p. 52) of occlusion of the artery for 
 twenty-two days, caused by an ill-applied anterior angular splint ; 
 fortunately no ill results followed. S. M., aged five. On May 11, 
 1878, the boy fell from some banisters upon his right elbow ; 
 separation of the lower epiphysis of the humerus resulted from the 
 injury, the lower fragment, as usual, being displaced backwards, 
 while the end of the diaphysis projected forwards prominently upon 
 the anterior surface of the arm. The arm was placed upon an 
 anterior right-angled splint with the object of correcting the deformity 
 produced by the contraction of the triceps. Eleven days later 
 (May 22), great swelling of the limb having ensued, a fresh exami- 
 nation showed absence of pulsation in the radial artery at the wrist, 
 the arm being cold. The patient was then admitted into the hospital. 
 The splint having been removed, the swelling subsided, pulsation 
 returned in the radial and ulnar arteries on June 2, and the boy was 
 
294 EPIPHYSES .OF UPPEE EXTKEMITY 
 
 discharged with complete power of pronation and supination, but 
 very hmited flexion and extension, and much callus about the seat 
 of injury. In this case the occlusion of the artery probably 
 depended upon direct compression between the lower end of the 
 diaphysis and the splint, a result pointing to the advisability of 
 avoiding the use of anterior splints in these cases, as also in the 
 similar condition of dislocation backwards of the radius and ulna 
 with fracture of the coronoid process, and consequent tendency to 
 recurrence of dislocation, although anterior splints are the best 
 adapted to remedy the deformity. 
 
 Dr. Bristow relates {BrooMyn Medical Journal, vol. ix. April 
 1895, No. 4, p. 250) a case of compression of the brachial artery by 
 diastasis of humerus in backward dislocation of ulna that had 
 occurred at Long Island College Hospital. A diagnosis of disloca- 
 tion of the ulna backwards had been made, but on a more careful 
 examination there was found a diastasis of the humerus with pro- 
 jection of the upper fragment forwards into the bend of the arm. 
 There was no pulsation of the radial and ulnar arteries, the forearm 
 being quite cold. The pressure of the upper fragment against the 
 artery could not have lasted more than three-quarters of an hour, 
 for the child had only been injured one half-hour before being 
 examined, and in fifteen minutes the fragment had been reduced 
 and the arm put into an angular splint. A clot must have formed 
 from the compression in a very short time indeed. The collateral 
 circulation was produced in the forearm, however, through the 
 precaution which was adopted to practically omit all bandages on 
 the forearm. Pulsation returned in the vessels at the end of five 
 days. 
 
 Dr. Bristow pointed out that a bandage properly applied may 
 yet result in gangrene if the artery has been occluded by the 
 pressure of the anterior fragment. In this case it would not have 
 been difficult for this occlusion to have escaped notice at the time, 
 and a very slight pressure on the forearm might be just sufficient to 
 overcome the force of the collateral circulation, and gangrene might 
 result, although there was no undue pressure. 
 
 A case in which the pressure was such that no pulsation could 
 be detected in the vessels at the wrist is alluded to by Mr. Jonathan 
 Hutchinson {Med. Press aiid Circular, 1885, p. 461, November 18). 
 It had been mentioned to him by his son, who has referred to 
 another case (Brit. Med. Journal, November 3, 1894, p. 967), 
 quoted below, in which the end of the diaphysis passed through 
 the soft tissues in front of the elbow between the brachial artery 
 and the biceps tendon. 
 
 In Page's case gangrene occurred as the result of the bruising 
 and thrombosis of the brachial artery. 
 
 Injury to nerves, — It is remarkable that the large nerve trunks 
 — such as the musculo-spiral, the median, or ulnar nerve — are not 
 
SEPAEATION OF LOWEE END OF HUMEEUS 295 
 
 frequently affected. The ulnar nerve, being in close contact with 
 the internal condyloid portion of the diaphysis of the humerus, 
 would appear to be especially liable to injury ; but fortunately, in 
 the usual form of injury, the upper diaphysial fragment passes 
 forwards and the nerve escapes injury. The ending of the musculo- 
 spiral in front of the outer end of the humerus, and the median nerve, 
 also in front, are, together with their branches, equally liable to be 
 involved and produce loss of sensation, pain, or paralysis in the parts 
 supplied by them, although examples have been rarely published. 
 
 All these complications are frequently met with in fractures 
 of the lower end of the humerus. 
 
 G. A. Wright, however, says {loc. cit. supra, p. 645) that implica- 
 tion of the musculo-spiral nerve in the callus of a separated lower 
 epiphysis of the humerus is not uncommon, and there may be 
 paralysis of the nerve for a time ; usually this disappears, and he 
 thinks that no hasty operation for the release of the nerve is 
 called for. 
 
 In one of Mr. Jonathan Hutchinson junior's cases {Brit. Med. 
 Journal, Dec. 30, 1893), 'pulsation at the wrist was stopped by the 
 forward projecting diaphysis, and there were marked signs of pressure 
 on the median nerve. These symptoms disappeared on reduction, 
 and recovery was perfect, excepting that flexion was limited to a 
 right angle.' 
 
 Wounds. — In many instances this injury has been complicated 
 by a wound rendering the lesion compound, vide cases of E. W. 
 Smith, Champion, Spillman(2), Eeeve, Lange, Bryant, Hutchinson, 
 Thomson, Ashhurst, Lediard, MacDougall, and Maisonneuve. The 
 wound is usually placed in front of the flexure of the elbow. 
 In the second case of Spillman's it was a transverse one just above 
 the elbow, in Lediard' s it was vertical. In one case recorded by 
 Professor Smith the wound was situated at the back of the elbow, 
 through which the lower epiphysis protruded. Sturrock's case {vide 
 infra) was followed by suppuration, and the range of movement 
 limited to less than a right angle. 
 
 Fracture of the bones of the forearm. — Champion's case was compli- 
 cated by compound fracture of the bones of the forearm, and .Wight 
 {Annals of the Anatomical and Surgical Society, Brooklyn, N.Y., 
 October 1880, p. 433) met with a somewhat similar case in a boy 
 aged eight, who fell from a cart and sustained a greenstick fracture 
 of both bones of the forearm, less than an inch from the wrist-joint. 
 There was displacement to an angle of about 45 degrees. Eeduction 
 was effected by forcible manipulation. No crepitus was eHcited. 
 Separation of the lower epiphysis of the humerus also existed, with 
 extensive extravasation around the elbow-joint. The case was 
 treated with a double-angled spHnt. Passive motion of both joints 
 was begun on the third day, and good union was obtained, although 
 at the time of the report the movements of the elbow were still 
 
296 EPIPHYSES OF UPPEK EXTEEMITY 
 
 somewhat hindered by excessive deposit of callus. The wrist 
 motions were almost perfect. 
 
 Stripping up of the periosteum occurs in all cases, probably to some 
 extent even in separation without displacement. 
 
 In the form of displacement which we are now considering— viz. 
 backwards of the epiphysis — allusion need only again be made to the 
 space left behind between the detached periosteum and the posterior 
 aspect of the diaphysis. 
 
 In compound separations the detachment of the periosteum has 
 been effected for nearly halfway up the shaft on one side. It is 
 also noted in Spillman's case. 
 
 Synovitis of the elbow is a very common complication, especially 
 in its milder forms. Suppuration of the joint is rarely met with 
 except as the result of extension from a suppurating focus in its 
 neighbourhood. 
 
 At the period in which this form of diastasis occurs, laceration 
 of the synovial membrane will necessarily be less frequent than in 
 later years, when the separations are frequently partial and com- 
 plicated. Moreover, the earlier the age the less firm is the synovial 
 membrane attached to the olecranon fossa and posterior aspect of 
 the diaphysis. During the first few years of life this depression is 
 so little developed, and the synovial membrane is so loosely attached 
 to the bone in this situation, that it is likely to escape any serious 
 injury. 
 
 In a case under the care of Mr. Durham at Guy's Hospital in 
 July 1876, a boy (John G.) aged eight, had fallen off a donkey into the 
 road and separated the lower epiphysis of his humerus. There was 
 found a great amount of effusion into the elbow-joint. The patient 
 did well, the arm being put up in lateral splints. 
 
 Suppuration of joint or limb has been noted in several of the 
 compound cases. 
 
 In a few neglected examples the skin over the displaced dia- 
 physis has sloughed from pressure, and given rise to suppuration. 
 
 Displacement outwards of epiphysis. — The few cases the author has 
 been able to find recorded include one under the care of Mr. Howse, at 
 Guy's Hospital, in June 1888. Joseph S., aged seven years, tumbled 
 and fell, striking his right elbow on the ground. There was 
 found a separation of the lower ^iphysis of the humerus, with 
 displacement outwards and somewhat backwards. The lower end 
 of the diaphysis projected forwards above the bend of the elbow- 
 joint, and the relation of the internal condyle to the olecranon 
 process was not altered. Soft crepitus was felt, and the deformity 
 could easily be reduced, but it re-appeared when the parts were 
 relaxed. An anterior rectangular splint was applied, and the patient 
 did well, so that he was able to leave the hospital on the sixteenth 
 day, though the elbow was still considerably swollen. 
 
 The following case was seen by the author with Dr. Hearnden, of 
 
SEPAEATION OF LOWEK END OF HUMEKUS 297 
 
 Sutton, Surrey : L. E., aged eight years, on September 17, 1894, fell 
 off a summer-house about ten feet high, detaching the lower epiphysis 
 of her left humerus, which was displaced outwards and very shghtly 
 backwards, the inner side of the diaphysis being found, on examina- 
 tion, in its displaced position to the inner side above the internal 
 epicondyle. There was considerable contusion over the inner side of 
 the elbow, and the radial artery could not be felt to pulsate at the wrist. 
 ' Dummy ' crepitus was well marked, with mobility in the lateral 
 direction. The fracture did not implicate the joint. There was also 
 a fracture of the lower end of the radius, about three-quarters of an 
 inch above the epiphysial line, the wrist with the hand being dis- 
 placed backwards and the shaft of the bone forwards. There was 
 
 Fig. 75. — displacement of lower epiphysis of hcmekus outwaeds, with injury to 
 median nerve. amount of extension ax the elbow-joint three months ai^ter 
 the accident. 
 
 loss of sensation of the whole index-jfinger and the outer side of 
 the middle finger. Both fractures were easily reduced ; an anterior 
 rectangular splint, to include the separated epiphysis as well as the 
 fractured radius, was applied, and an external rectangular splint with 
 a short lateral splint on the inner side, to prevent the displacement 
 of the shaft inwards. Four days later there was great swelling of the 
 elbow, the forearm, and the whole of the hand, and numerous blebs had 
 formed over the elbow. There was also effusion into the joint. The 
 loss of sensation, coldness, and inability to flex the index-finger still 
 persisted ; the inner splint was therefore removed, although the injury 
 to the median nerve was probably caused at the time of the accident 
 and not by any undue pressure of the splint. Seven days after 
 the accident the spHnts were removed, and displacement inwards 
 
298 EPIPHYSES OF UPPEE EXTEEMITY 
 
 of the diaphysis was found to still exist. The radial artery could 
 now be felt pulsating, and there was some return of sensation in 
 the middle finger. The anterior rectangular and outer splints were 
 re-applied. On the thirteenth day a posterior rectangular splint was 
 applied, with interruption at elbow, but at the end of a week this 
 made no alteration in the condition of the median nerve, for the 
 index-finger still could not be flexed, and there was the same area 
 of loss of sensation. The humerus continued a little displaced 
 inwards, but the elbow-joint could be freely moved and the fracture 
 of the radius had firmly united in good position. In the second week 
 in December, 1894, although pronation, supination, and flexion of the 
 elbow were almost perfect, extension could not be effected beyond 
 135 degrees, on account of the pain, presumably from pressure upon 
 the injured median nerve. The inner projecting angle of the dia- 
 physis, after the swelling had cleared up, was now very prominent 
 on the inner side ; it was therefore decided to remove the projecting 
 portion of the bone, which was done with antiseptic and aseptic 
 precautions, no drainage being used. The median nerve was found 
 in front of the outer edge of the projection, and had to be drawn 
 aside during the operation. A week or two afterwards the sensation 
 and use of the index finger suddenly returned, and have remained 
 ever since. Their restoration was preceded by a tingling sensation. 
 The extension of the forearm was subsequently perfect, no deformity 
 being noticeable. 
 
 Mobility of the epiphysis and elbow- joint is most marked in the 
 lateral direction, distinguishing the injury from dislocation outwards 
 of the elbow. 
 
 Displacement outwards, with fracture of the diaphysis, is not an un- 
 common form of injury. The following is an example which the author 
 had the opportunity of seeing some days after the injury. A girl, aged 
 seven, came under the care of Dr. F. D. Atkins, of Sutton, on August 23, 
 1893. She had fallen from a tree five or six feet high on to the 
 ground, striking her left elbow. When seen by Dr. Atkins within an 
 hour after the accident there was already very great swelling, and the 
 lower epiphysis of the humerus was displaced outwards. Chloroform 
 was immediately administered, the displacement reduced, and the 
 elbow put up on an anterior rectangular splint. When the author saw 
 her there was still great swelling with ecchymosis about the jomt, but 
 mobility in the antero-posterior and lateral directions, crepitus, dis- 
 placement of the epiphysial fragment outwards and slightly back- 
 wards, and the normal relations of the epicondyles rendered the 
 diagnosis clear. Chloroform was again given, and the fragments 
 replaced in position ; but, notwithstanding all efforts, there was a 
 great tendency for the displacement outwards to recur. A sharp- 
 pointed process on the outer side, a small portion of the diaphysis, 
 half an inch long, remained connected with the outer part of the 
 epiphysis above the external epicondyle. The anterior rectangular 
 
DISPLACEMENT FORWARDS OF LOWER EPIPHYSIS OF HUMERUS. 
 Dr. Campbjell Pope's case. Taken by Dr. F. H. Low. 
 
SEPAEATION OF LOWEE END OF HUMEKUS 299 
 
 splint was again applied. The diaphysis became again displaced, 
 in spite of the careful application of the splints. Slight sloughing 
 of the skin occurred over the end of the diaphysis, a small portion of 
 which was subsequently removed. 
 
 Displacement inwards of epiphysis. — This, like the preceding lateral 
 displacement, is very rare and likely to be overlooked. 
 
 The case from the Children's Hospital, Pendlebury, quoted below 
 is, however, a good example of this injury. 
 
 Displacement forwards of epiphysis. — Mr. Jonathan Hutchinson's 
 case, alluded to below, was probably of this variety. His son also 
 alludes to another case of forward dis- 
 placement under his care {British Medical 
 Journal, December 20, 1893, p. 1418). The 
 author's case of fracture directly above the 
 epiphysial line with displacement of the 
 epiphysis forwards has already been de- 
 scribed. The thin edge of the diaphysis 
 may be felt behind in these instances. 
 
 Separation of part of the epiphysis, with 
 fracture of the diaphysis. — This is a very 
 frequent injury near the elbow- joint in p. 
 
 children, and might with good reason be 
 placed in a separate group. The author 
 has seen many instances ; the following is 
 one of them. A girl, Edith L., aged eight 
 years, was under the care of Mr. Wm. F. 
 Hearnden, of Sutton. She had fallen a 
 distance of five feet on to her elbow. The 
 fracture had traversed more than the 
 inner half of the epiphysial line, and 
 thence passed upwards obliquely through 
 the diaphysis to above the external supra- 
 condyloid ridge. When the author saw 
 the case in 1890, four months after the 
 accident, there was still visible some 
 projection forwards of the diaphysis in 
 front, and great thickening about the 1^^^- 76.-partial sepakation, 
 
 -. p . -. A 1 WITH EXTENSIVK OBLIQUE 
 
 lower end of the bone. All movements of feacture of the diaphysis 
 the elbow were excellent, with the excep- ""^ ^"^ humerus, (mr. w. f. 
 
 . . ••- hearnden s case) 
 
 tion of complete extension, which was 
 
 prevented apparently by the callus in the olecranon fossa behind. 
 
 Union was complete. 
 
 J. Hutchinson junior states that a clean separation at the epi- 
 physial disc is probably uncommon after the age of five or six, but 
 that it may occur some years later, and that in over fifty cases it 
 was present probably only in the minority. The youngest patient 
 was one and- a half years old, and the eldest fourteen years. 
 
300 EPIPHYSES OF UPPEE EXTKEMITY 
 
 The signs present are as follows : Projection of portion of the end 
 of the diaphysis forwards. Crepitus characteristic of fracture. The 
 epicondyles in normal relation with olecranon, while the pointed end 
 of the lower fragment of the diaphysis may be felt about the external 
 or internal supra-condyloid ridge, and perfect movements of joint. 
 
 Separation of the epiphysis, with vertical fracture into joint. — In 
 addition to ihe signs already given of separation of the lower epiphysis 
 of the humerus, there is that of unnatural mobility of the portions of 
 the epiphysis. On grasping the inner and outer portions of the 
 epiphysis, with the accompanying epicondyles, with each hand, 
 these two portions will be found to move backwards and forwards, 
 one upon the other. Such movement will probably be accompanied 
 by crepitus. 
 
 If the upper fragment be driven downwards or the olecranon 
 upwards between the portions of the epiphysis, the increase in the 
 breadth of the elbow from one epicondyle to another will be a 
 notable feature. 
 
 DIFFERENTIAL DIAGNOSIS. — Epiphysial separations are much 
 more frequent at the elbow-joint than dislocations ; in fact, the latter 
 are comparatively rare. 
 
 Many of the signs of traumatic separation are common to it and 
 to fracture above the condyles and to dislocation of both bones of the 
 forearm backwards, which is most frequent about the age of puberty ; 
 but the diagnosis is generally easy, provided an angesthetic be given. 
 It should be arrived at as soon as possible before any swelling has 
 occurred. Even should this have taken place, it is very undesirable 
 that the injured arm be left for the inflammatory swelling to subside. 
 
 In all cases in which the signs are at all indefinite, an anaesthetic 
 should be at once administered and a thorough examination made. 
 
 Dislocation of the elbow-joint (both bones of forearm backwards). — 
 In dislocation as well as separation the arm is semiflexed, or 
 nearly so. 
 
 The following points met with in dislocation are sufficient to. 
 prevent its being mistaken for diastasis : 
 
 1. Immobility of forearm. 
 
 2. Absence of crepitus. 
 
 3. No tendency for deformity to be reproduced after reduction, 
 which is often difficult to be carried out. 
 
 4. End of humerus deeply placed in flexure of elbow, and often 
 .not to be felt. In separation the diaphysial end is felt on a level 
 with it. 
 
 5. The relations of the olecranon process to the epicondyles 
 very markedly changed, the distance between them being greatly 
 increased. 
 
 6. No shortening of arm. 
 
 7. Seldom produced by a fall on the elbow, as in diastasis or 
 fracture. 
 
DISPLACEMENT BACKWARDS OF LOWER EPIPHYSIS OP HUMERUS, 
 
 WITH FRACTURE OF DIAPHYSIS. 
 
 Four months after injury. Child aged eight years. Dr. Campbell Pope's case. Taken by Dr. P. H. Low. 
 
SEPAEATION OF LOWEE END OF HUMEKUS 301 
 
 8. The top of the olecranon is raised much above the normal 
 horizontal line passing through the epicondyles of the humerus. 
 
 9. Elastic stiifness is a distinguishing sign mentioned by Dr. 
 L. C. Lane, of San Francisco. It is a slight rebound of the forearm 
 with an elastic jerk when it is flexed or extended. This rebound is 
 much less or wholly absent in supra-condyloid fracture. 
 
 As E. W. Smith remarks, the observations of Dupuytren respect- 
 ing the danger of confounding fracture immediately above the elbow 
 with dislocation backwards apply with peculiar force to the injury 
 we are considering. 
 
 ' If,' says this distinguished surgeon, ' the opinion that the case 
 is one of luxation be acted upon, extension and counter-extension 
 are employed, the reduction is accomplished without much difficulty, 
 and the surgeon congratulates himself upon the ease with which he 
 has restored the bones to their places. But soon the displacement 
 is reproduced, and at the end of a few days, in the midst of the 
 swelling, something unnatural is felt. This accident is generally 
 ascribed to the patient, who is charged with being intractable. The 
 reduction is again effected, but the deformity soon recurs, and con- 
 siderable swelling then supervenes. As long as this condition lasts 
 the surgeon continues severe, but when the swelling has disappeared, 
 after the lapse of a few weeks, he discovers the error which he has 
 committed ; but the mischief cannot now be repaired, the motions 
 of the joint are never perfectly regained, and the deformity is 
 incurable.' 
 
 Dupuytren relates {On the Injuries and Diseases of Bones, 
 Sydenham Society, 1846, p. 103) the case already alluded to above, 
 in which such an error had been made, and deformity consequently 
 resulted. 
 
 In the latter end of 1832 a young child was brought to him, 
 who, a month previously, had fallen whilst in the act of getting on 
 a donkey. Two doctors were successively called in, who pro- 
 nounced the case to be one of dislocation, and treated it accordingly. 
 When Dupuytren saw the child's arm there was an irregular tumour 
 in front, which was evidently the lower extremity of the humerus ; 
 the olecranon forming a prominence behind. From the tender 
 age of the patient, he believed that there was a separation of the 
 epiphysis ; the two fragments were united, but with deformity. 
 
 A rare case of compound dislocation of .the elbow-joint without 
 fracture is described by Chauncy Puzey {Lancet, 1893, July 8, p. 87). 
 * The boy, aged nine years, had sustained a compound dislocation of the 
 right elbow-joint. The sharp trochlear portion of the lower end of 
 the humerus had penetrated the soft parts in front of the joint, and, 
 with the inner condyle, appeared on the front of the upper part of 
 the forearm, tightly embraced by the skin, through which it had 
 burst. The forearm was considerably shortened by the backward 
 displacement of its bones, and the elbow was kept fixed at a point 
 
302 EPIPHYSES OF UPPEE EXTEEMITY 
 
 aboat halfway between extension and a right angle. The hand 
 and lower part of the forearm was dusky in hue, and the radial pulsa- 
 tion at the wrist was barely perceptible. The dislocation, after some 
 difficulty, was reduced, the joint drained, and an aseptic dressing 
 applied. The boy made a good recovery, and an examination of 
 the joint one year later showed recovery, with unimpaired move- 
 ments of the joint.' 
 
 Simple contusion of elbow. — In instances where the displacement 
 of the epiphysis is not very great, great swelling and ecchymosis 
 may completely mask the slight deformity present, and cause its 
 being mistaken for a simple contusion. 
 
 Fracture above the condyles. — This form of fracture is common 
 enough in children. Hamilton says that of eighteen fractures at 
 this point, twelve occurred in children under ten years of age, the 
 youngest being two years old. 
 
 There is a good specimen of this in St, George's Hospital 
 Museum described by Mr. Holmes. 
 
 The error of confounding a diastasis with a fracture is not so 
 disastrous as confounding it with a dislocation, since in the former 
 case the mistake is of comparatively slight importance, inasmuch as 
 the same treatment is applicable to both. The latter must always 
 be considered as a serious error. 
 
 Out of sixty cases of injury to the elbow-joint in children, recorded 
 by Guedeney from M. Vincent's clinic during seven years, twenty- 
 seven were of the lower end of the humerus (excluding injuries to 
 the epicondyles and articular processes). Of these, thirteen were 
 diagnosed as separations of the lower epiphysis of the humerus, 
 ten as fractures of the lower end of the humerus (two being 
 compound), three T-shaped fractures, and one Y-shaped fracture. 
 
 The following points in epiphysial separations will assist in 
 distinguishing them from fractures : 
 
 1. Muffled crepitus. 
 
 2. The lower end of the upper fragment has greater breadth than 
 
 in fracture. 
 
 3. The line of separation is nearer the end of the bone and the 
 
 anterior projection of the diaphysis on a level with the fold 
 of the elbow ; in fracture it is usually above it. 
 
 4. The anterior projection in diastasis has a rounded extremity 
 
 unlike the projections of the sharp ends of a fracture. 
 Mr. Holmes showed, at the Pathological Society in 1862 (Path. 
 Soc. Transactions, vol. xiii. p. 187), a specimen of fracture, about 
 i inch above the epiphysial Hne, in which the injury was only 
 distinguishable during life from separation of the epiphysis by the 
 distinctness of the crepitus. The child was aged nine years, and had 
 fallen three months before upon her elbow. She died of chorea. 
 There was a large smooth mass of bone on the posterior aspect, 
 filling up the gap that would otherwise have been left by the pro- 
 
SEPAEATION OF LOWEK END OF HUMEEUS 303 
 
 jection of the upper fragment forwards, so that no irregularity was 
 seen here. But in front the upper fragment projected beyond the 
 lower by a large irregular prominence, half as thick as the humerus 
 itself. 
 
 The London Hospital Museum contains two specimens of fracture 
 of the lower end of the humerus a little above but close to the 
 epiphysial line. They were both removed from boys the subjects 
 of compound fracture. The author's specimen figured above (p. 281) 
 also shows this form of fracture. 
 
 Berthomier pointed out that the usual seat of this form of 
 fracture is lower than is generally supposed. 
 
 M. Halle presented to La Societe Anatomique de Paris, in 
 November 1886 {Bull, de la Soc. Anat. 1886, p. 647), a specimen of an 
 elbow of a child whose age was not given. During life, after the swelling 
 had disappeared, the displacement of the head of the radius and of the 
 olecranon suggested incomplete dislocation of the elbow inwards. 
 On the death of the child shortly afterwards from broncho-pneumonia 
 complicating measles, there was found a supra-condyloid fracture 
 detaching the trochlea, the condyle (capitellum) , and the epitrochlea 
 (internal epicondyle). The course of the fracture was lower than the 
 usual situation of fracture of the lower end of the humerus, but was, 
 on the other hand, higher than the epiphysial line. 
 
 Comminuted fractures of the lower end of the humerus are of fre- 
 quent occurrence, and have the characteristic feel of a ' bao- of 
 beans.' 
 
 It is very probable that several of the fragments traverse the 
 epiphysial line, but will in no way allow of the injury being considered 
 in any other light than that of a fracture. The separation of the 
 epiphysial portion may pass through the capitellar, trochlear, or 
 epiphysial line, or through the line of the epicondylar epiphyses, 
 the fissures between the fractures and epiphysial fragments com- 
 municating in numerous directions. 
 
 Although great swelling and extravasation of blood are present 
 in a very marked degree, it is surprising to see how completely the 
 function of the limb will be regained in these young subjects. 
 Crepitus is very easily detected. 
 
 Guedeney gives details of seven cases diagnosed as fractures of the 
 lower end of the humerus in children : female aged six years, 
 male aged eleven years, male aged seven (complicated by fracture of 
 the lower extremity of the bones of the forearm), male aged seven and 
 a half years, male thirteen years, female two years, and male nine 
 years (? pressure on brachial artery) . Three were cases of fracture of 
 the lower end of the humerus complicated with looimds in children : 
 female aged three and a half, female aged six, and female aged eight 
 and a half years. (In the last case numerous fragments of bone 
 were removed from the lower end of the humerus by means of incision 
 on the outer side and on the inner side through the seat of the 
 
304 EPIPHYSES OF UPPEE EXTKEMITY 
 
 wound.) Tlwee were cases diagnosed as T-shaped fractures of the 
 lower end of the humerus in children aged — male (?) six years, male 
 six years, and male six and a half years. One case was diagnosed 
 as ^-shaped fracture of the lower end of the humerus in a male 
 (?) child aged twelve years. All were treated by fixation in the 
 extended and supine position, and later on in the flexed position. 
 
 The most valuable aid in the treatment as well as in the diagnosis 
 of epiphysial separations at the elbow-joint has been recently de- 
 veloped under the Rontgen rays and in the additional use of the 
 fluoroscope. As Professor W. B. van Lennep, of Philadelphia, says : 
 ' Not only is the diagnosis greatly facilitated, but, what is of more 
 value, the position of the fragments can be inspected from day to day 
 with the fluoroscope after the application of non-metallic splints. 
 Subsequent taking down of the dressings, with its accompanying pain 
 and disturbance, can thus be often avoided. So, too, the approxi- 
 mation of the fragments may be accurately accomplished under the 
 guidance of the eye.' He gives {The Hahnemannian Institute, 
 January 1897, vol. iv. No. 3, p. 15 ; Hahnemannian Monthly, 
 February 1897) an illustrative skiagraph of separation of the lower 
 epiphysis of the humerus in a child aged four years. There was 
 the usual displacement of the epiphysis backwards, which had been 
 presumably reduced. It is interesting to notice the splint faintly 
 outlined in the skiagraph, while the nails holding its two pieces 
 together are distinctly seen. The other dim shadows are the padding 
 and bandages. The olecranon epiphysis gives the impression of a 
 separation there. 
 
 Dr. Chas. L. Leonard {American Journal of the Medical 
 Sciences, August 1896) also gives a skiagraph of diastasis of the 
 distal epiphysis of the humerus. W. McL., aged eleven years, 
 came to the University Hospital of Pennsylvania on March 31, 
 1896, with fracture of the humerus. The history was of a fall from 
 a wall five feet high to the pavement, striking the left hand. The 
 patient weighed about seventy-five pounds ; he sustained no other 
 injury. The case was diagnosed and dressed before the skiagraph 
 was developed, the latter demonstrating the correctness of the 
 diagnosis and showing the position of the fragments resulting from 
 this form of epiphysial separation.^ 
 
 PROGNOSIS AND RESULTS. Union.— Good firm union always 
 results, and takes place very rapidly, for in common with all epi- 
 
 ' Dr. 0. Biittner and Dr. K. Miiller give the following practical remarks on the use of 
 the screen and photographic plate in the Rontgen process {Encyklopadie dcr Photo- 
 qranhie, Heft 28, 1897, S. 105 ; Tecnik unci Verwerthung dcr Rontgen'' sdien Strahlen) : 
 
 ' In the case of fractures and luxations the use of the screen is to some extent pre- 
 cluded, as the pain caused by moving the patient would be too great. Pyknography (i.e. 
 the representation of the shadows on a photographic plate) is therefore of special value 
 in such cases. The plate may be wrapped in paper and placed under the limb, and the 
 exposure may be made by a trustworthy attendant. With a spark of twenty centimetres 
 the exposure should be from ten to thirty minutes, according to the thickness of the part. 
 
SEPARATION OP LOWER EPIPHYSIS OF HUMERUS. 
 Shadows o£ the splint and padding are seen. Prof. W. B. Van Lennep's case. 
 
SEPARATION AND DISPLACEMENT BACKWARDS OF THE LOWER EPIPHYSIS OF THE HUIIERUS. 
 
 Dr. Chas. L. Leoxakd'8 case. 
 
SEPAEATION OF LOWEE END OF HUMEKUS 305 
 
 physial separations these injuries unite with greater rapidity than 
 fractures. 
 
 Although in even the simplest cases union takes place, some 
 impairment of the functions of the joint may ensue from one or 
 other cause (to be presently described), so that a perfect recovery 
 cannot be said to be the invariable rule. It is therefore prudent 
 in all cases to impress early upon the minds of the parents or 
 friends the idea or suggestion of an unfavourable prognosis. It is 
 always necessary to be most cautious in this matter. 
 
 In the following case recorded by C. A. Sturrock {Eclinhurgh 
 Hospital Beports, vol. ii. 1894, p. 600), eight months after the 
 injury (displacement backwards of the epiphysis), there was only 
 
 Fractures and displacements of the superficial bones are scarcely to be seen with the 
 screen, but by proper direction of the latter the authors have been able to see good shadow 
 outlines of the shoulder-joint. The details are completely rendered on the plate. 
 
 ' In a plate given of the pyknogram of a fracture of the humerus through the " anatomi- 
 cal neck,' taken four weeks after the accident, the contours of the bones, the acromion, the 
 glenoid cavity, the scapula, the ribs, and the upper arm are quite distinct. It is clearly 
 seen how the articular surface of the head is displaced laterally. A bridge of periosteum, 
 which has separated from the diaphysis of the upper arm, has already produced bone and 
 therefore appears as a shadow. In the humerus the medulla and compact tissue are dis- 
 tinctly differentiated. An important advantage of the pyknographic image is that the 
 healing process may be watched from day to day. We can see the healing process in the 
 living body, instead of having the difficulty of studying it in specimens obtained only 
 casually. 
 
 ' As plaster of Paris and splints do hot obstruct the rays much, we can see if the 
 re-adjustment of the broken bones or luxations is accurate, and if the callus is converted 
 normally into bone. False union may be avoided more and more. Those who are accus- 
 tomed to inspect all fractures in several directions with the screen, and also to photograph 
 thena, will be astonished to see how defectively fractures are healed even when they have 
 been considered perfect examples. There can be no question that pyknoscopy will do 
 good service in the effective treatment of injuries to the extremities, and that new and 
 unsuspected improvements will be made in the direction of remedial treatment of trau- 
 matic lesions. According to our observations, defective " setting " is not infrequently 
 brought about by the interposition of small splinters of bone between the fragments. 
 
 ' With recent injuries, especially to the joints, the accumulation of blood renders the 
 use of the screen more difficult, but it does not interfere with a photograph. Injuries to 
 the vertebral column can always be recognised in children, but with greater difficulty in 
 adults. 
 
 ' Especially favourable objects for observation are articular fractures, and those 
 rare fractures which have hitherto presented insurmountable difficulties to the methods 
 of diagnosis, for which recourse could only be had to mere supposition— e.g. fractures of 
 the hand and tarsal bones of the foot, (fee, and more particularly those of the glenoid 
 cavity of the shoulder and hip. We can see small splinters of bone in a joint and proceed 
 to their removal, if necessary. 
 
 ' We need not point out how much this knowledge means to surgical procedure, nor of 
 what importance it is that we have other means than the sense of touch to guide us 
 when operating upon badly united fractures. A large number of cases of injuries to 
 joints will doubtless present themselves that have healed under conditions of movement, 
 in which we are enabled by pyknoscopy to observe directly the impediments to motion, 
 and thus to adopt proper operative treatment. Fractures and other injuries that were 
 difficult to recognise formerly may now be distinctly seen and placed graphically before 
 laymen. The pj'knogram will therefore be of use to convince the patient himself, and 
 those interested in him, of the necessity of a useful operation.' 
 
 For further practical details of this process the reader must be referred to Dr. D. 
 Walsh's recent book, TJic Bontgcn Bays in Medical WorJc, London 1897. 
 
 X 
 
306 EPIPHYSES OE UPPEE EXTKEMITY 
 
 a slight degree of thickening traceable above the joint, no shortening, 
 and perfect movement. 
 
 AV. H., aged 12, admitted to Eoyal Infirmary, Edinburgh, on 
 Eebruary 6, 1893, with a history of having fahen on his bent wrist 
 when rmming, and of having felt something ' give M^ay ' in the region 
 of the elbow. Under anaesthesia, it was found that the articular 
 surface of the lower end of the humerus, along with the radius and 
 ulna, was displaced backwards ; the shaft of the humerus, to which 
 were attached both the condyles {sic), formed a projection in front of 
 the elbow. On manipulation, cartilaginous crepitus was readily 
 obtained : when the arm was flexed to a right angle the deformity 
 disappeared, and the relation of the bony prominences was apparently 
 normal. The parts were accordingly x^laced in sphnts in this position 
 for two weeks, when passive movements — at first very gentle, after- 
 wards more forcible — were commenced, and continued for ten weeks. 
 After the splints were removed the arm was retained on alternate 
 nights, first in the flexed, then in the extended position. The earliest 
 movements were exceedingly painful, and necessarily very limited 
 in range. On one occasion, five weeks after the accident, the boy 
 absented himself for some days, and when he returned for treatment 
 the arm had become much stiffer. Eight months after the accident, 
 except for a shght degree of thickening above the joint, no trace of 
 the injury could be discovered ; there w^as no shortening, and the 
 range of movement was perfect. The case is of further interest in 
 that some years previously the boy had sustained a compound 
 diastasis of the lower end of the other humerus. Suppuration had 
 occurred, and the range of movement was less than a right angle. 
 
 Deformity is found to be very great where the injury has been 
 mistaken for a fracture. 
 
 One of the chief objects in the treatment is to prevent the 
 projection forwards of the diaphysis, and this can be successfully 
 accomphshed by careful treatment. Unless this deformity be 
 remedied early, there is sure to be some restriction of movement of 
 the elbow-joint. 
 
 Mr. Hutchinson says that after union has occurred with a certain 
 amount of deformity, the surgeon, unless well acquainted with the 
 subject, is a^ot to supx^ose that he has overlooked a dislocation. 
 Several such cases had come under his notice, and in some it had 
 been proposed to attempt reduction. He mentions {Medical Times 
 and Gazette, January 1884, p. 2) the case of a boy who was brought 
 to him for stiffness of the elbow a month after the accident. Two 
 years previously he had excised one of his knee-joints. He had now 
 fallen downstairs, and, instead of breaking his ankylosed lower limb, 
 had displaced the epiphysis of one elbow. Union had occurred, with 
 much displacement backwards still remaining. The swelling had 
 pretty well disappeared, and the outline of the lower end of the 
 bone was easily distinguished. The elbow was at an obtuse angle, 
 
SEPAEATION OF LOWER END OF HUMEEUS 307 
 
 and its area of flexion was very limited. Free movements were 
 instituted and w^ere followed by much improvement at the end of a 
 year, but the power of flexion was far from complete. 
 
 Mr. C. G. Wheelhouse, in a clinical lecture on the Surgery of 
 the Epiphyses in 1885 {British Medical Journal, March 7, 1885, 
 p. 475), mentions the case of a child who had been treated for a 
 supposed simple dislocation backwards of the bones of the forearm 
 under the care of the late Mr. Teale. There resulted a considerable 
 amount of deformity, with tolerably free movements of the joint, 
 accompanied, however, by some permanent stiffness and locking. 
 After careful examination Mr. Wlieelhouse came to the conclusion 
 that the injury had been a dislocation accompanied by a fracture 
 through the epiphysis, and that, though the joint had not been 
 restored to its original condition of perfection, the result was, for 
 such an injury, very excellent, and one with which the parents of 
 the child should have had every reason to be content. But they 
 were not, and taking legal advice upon the subject, they threatened 
 an action at law against Mr. Teale. They were only dissuaded from 
 it with difficulty. 
 
 Fig. 77. — HYPER-EXTENSION OF ELBOW AFTER DISPLACEMENT E0RW/ED3 
 OF DIAPHTSIS OF HUMERUS 
 
 Great deformity, accompanied by hyper-extension at the elbow- 
 joint, existed in the following example of old separation with dis- 
 placement backwards which came under the author's care in May 
 1895. Eight and a half months previously the girl (Dorothy C), aged 
 six years, had fallen in the playground at school and injured her left 
 elbow. The injury was said to have been treated as a sprain and 
 lotions had been applied. Probably at this time there was little 
 deformity, but on admission to the Miller Hospital there was a 
 large projecting mass of bone discovered in front of the elbow, most 
 marked towards the inner side. This was clearly the lower diaphysial 
 end of the humerus, and over its edge the brachial artery could be seen 
 and felt pulsating. The epicondyles and olecranon held their normal 
 relations. While movements of pronation and supination were 
 absolutely perfect, flexion at the elbow could be effected onty to a 
 right angle. Extension, both active and passive, was greatly 
 beyond the normal limit, the forearm posteriorly being at an angle 
 of 125 degrees with the arm (see fig. 77). 
 
308 EPIPHYSES OF UPPEE EXTREMITY 
 
 After incision of the skin the author removed the projecting inner 
 angle of the diaphysis by means of a chisel. The brachial artery and 
 median nerve lying over the bone had to be drawn aside at the time 
 of operation. Primary union of the wound took place, and at the 
 end of six months flexion was greatly increased, reaching even 
 50 degrees. The patient could touch the front of her shoulder, 
 which she could not do before the operation. The whole hmb had 
 gained in muscular power, but hyper-extension at the elbow 
 remained the same. 
 
 In a few rare instances, in spite of ah care, some deformity will 
 remain with considerable thickening ; in the course of some months, 
 however, the parts become so much remodelled that the final 
 result is usually good. 
 
 Lannelongue lays it down that fractures of the elbow in children 
 are serious lesions and difficult of cure, and that it is saying too 
 much to assert that after one of these fractures all the proper move- 
 ments will be preserved. 
 
 Besides the specimen of displacement forwards of the epiphysis 
 described above from the patient whose elbow the author resected, 
 there is another case, to which Mr. Hutchinson alludes, where a man 
 had a very curiously shaped elbow, which looked altogether narrower 
 tha.n usual ; the olecranon projected a little, but not so much as would 
 have been expected ; and he came to the conclusion that the reverse 
 of the usual state of things had taken place, and that instead of the 
 epiphysis with the ulna and radius being carried behind the humerus, 
 the opposite condition of displacement forwards had occurred. 
 
 Limited movement. — Where the joint has been patiently and care- 
 fully treated, good movements of flexion and extension are to be 
 ultimately expected in most cases ; although the friends of the 
 patient should always be made to clearly understand that the joint 
 must be stiff for some time — probably for many months— subse- 
 quent to the injury. 
 
 The movements of pronation and supination are rarely affected. 
 
 Limitation of movement may be due to (1) Stiffness and thicken- 
 ing of the joint from {a) ■ imiDlication or laceration of the synovial 
 membrane ; ih) from extension to the joint of the inflammation at 
 the seat of the separation ; (c) from the limb being kept at rest too 
 lono-. (2) Excessive deposit of callus, either in front or behind the 
 articulation, which may hinder the movements of the elbow, as in 
 Wight's case. (3) Imperfect reduction of fragments. 
 
 Exuberant callus, by its presence, may cause the greatest im- 
 pediment to the functions of the limb, especially if the displacement 
 has not been entirely corrected. It is produced by the periosteum, 
 which may have been stripped up or otherwise injured, and the 
 close proximity to the conjugal cartilage and growing end of the 
 bone also conduces to its formation. In like manner at an earher 
 period after the injury, the newly formed callus may produce pressure 
 
SEPAEATION OF LOWEE END OF HUMEBUS 809 
 
 upon the brachial artery or median, uhiar, or musculo-spiral nerves 
 in the vicinity of the elbow-joint. The provisional callus filling up 
 the olecranon and coronoid fossge often hampers for some time the 
 free movement of the elbow-joint. 
 
 Ankylosis of elbow. — At first sight it would appear that ankylosis 
 after injury to the elbow-joint in children was more common than 
 after injury in the neighbourhood of other joints. The multiple 
 character of its functions in part accounts for this. 
 
 In rare instances the joint remains permanently affected and 
 stife. 
 
 Considering that the attachment of the capsule of the joint is 
 above the epiphysis, especially in front, it is not surprising if articular 
 inflammation and subsequent rigidity should ensue, unless the frag- 
 ments be accurately placed in normal position. Yet M. Guersant, 
 in reporting {Bulletin cle la Societe cle Ghirurgie, 1861, 2'^'™"^ Serie, 
 toni. i. p. 679) a case of separation of the lower epiphysis of the 
 humerus with displacement backwards, seemed astonished that at 
 the end of a month there was still some impediment to free move- 
 ment of the elbow. The patient was a boy aged eight who had 
 fallen on to his elbow, and the usual signs were present. 
 
 M. See and some other surgeons believed that the subacute in- 
 flammation and plastic infiltrations of the articular and peri- 
 articular structures are brought about by effusion of blood and serum. 
 
 Jonathan Hutchinson's case of resection for compound diastasis 
 resulted in an elbow bent at right angles, and quite stiff. 
 
 The advocates of the treatment by the extended position of the 
 joint maintain that the liability to ankylosis after this method is 
 much less than after treatment in the flexed position. However, 
 most British surgeons maintain that the latter position is the one in 
 which the ultimate results are better, at any rate in the form of 
 the injury under consideration. 
 
 Implication, of nerves. — The musculo-spiral, the median, and 
 ulnar nerves are each of them liable to be implicated in the 
 abundant callus which is often present, extending even up the 
 humerus for some distance, and their injury may give rise to paralysis, 
 loss of sensation, hyperossthesia, vesication, &c. 
 
 Eesection of the callus pressing upon the nerve may be required, 
 that the nerve may be set free. 
 
 Hamilton relates {Fractures and Dislocations, 8th edition, 1891, 
 p. 240) a case in which a fracture just above the condyles occurred 
 at the age of four years. Appreciable deformity remained at the age 
 of twenty-seven years. The patient could not then completely 
 supinate the forearm. The whole arm was weak, and the ulnar nerve 
 remarkably sensitive. The ulnar side of the forearm, and also the 
 ring and little fingers, were numb, and had been in this condition 
 ever since the accident. In another case of fracture, which occurred 
 nine months previously in a lad aged nine years, he had operated 
 
310 EPIPHYSES OF UPPEB EXTEEMITY 
 
 by sawing off the projecting end of the upper fragment. This 
 fragment was lying in front of the lower one, and the skin covering 
 its sharp point was very thin and tender. There was no ankylosis 
 at the elbow-joint, but the hand was flexed forcibly upon the wrist, 
 the first phalanges of all the fingers being extended and the second 
 and third phalanges flexed. Supination and pronation were lost. 
 The forearm and hand were almost completely paralysed, and at 
 times very painful. The ulnar nerve could be felt lying across the 
 end of the bone. The projecting fragment was exposed and 
 removed, and the nerve Hfted and laid aside, but a year later the 
 arm was found to be in the same condition. 
 
 Dr. Deanesley {Lancet, April 22, 1893) thinks, how^ever, that in 
 many cases of this kind the paralysis is present soon after the 
 accident, but is often overlooked, and is due to the imperfectly 
 reduced separation of the epiphysis ; also that, although the para- 
 lysis might be attributed to pressure of callus involving the nerve 
 (for in his cases much callus was thrown out), yet it did not appear 
 to him to be very well established that this is ever a real cause of 
 nerve paralysis. He expresses his behef that, nerve lesions not being 
 thought of, paralysis and contracture of muscles are confused with 
 the general weakness and stiffness so often left for a considerable 
 time after the fracture has united. 
 
 Paralysis, however, of the musculo-spiral nerve produces the 
 characteristic and familiar wrist-drop, which is little likely to be 
 overlooked. If any doubt as to the existence of nerve lesion remains 
 after the examination of the voluntary power, sensation, and atti- 
 tude of the limb, it can generally be set at rest by testing the 
 electric excitability of the muscles and nerves to the faradaic and 
 galvanic currents. Faradaic excitability is usually lost, while 
 galvanic irritabihty, on the other hand, is retained, and in some 
 cases is increased. 
 
 Dr. Deanesley recommends that as a rule no attempt should be 
 made to deal with the nerve injury until the fracture is soundly 
 united. The whole limb should be treated with systematic rubbing, 
 and with faradaic or galvanic electric currents. No operation 
 should be advised unless there is reason to beheve that there still 
 exists some pressure or traction on the nerve which can be relieved, 
 ' or any marked displacement of the bony fragments.' He relates 
 {Lancet, April 22, 1893, p. 928) the two fohowing cases from the 
 General Hospital, Wolverhampton : 
 
 (1) Separation of lower epiphysis of left humerus ; paralysis of 
 musculo-spiral 7ierve. — A boy, aged eight years. The accident, 
 caused by a fall on February 18, 1892, was recognised by the 
 usual signs. After reduction the elbow was immobihsed at a right 
 angle by plaster of Paris. When this was removed at the end of 
 four weeks there was much bony thickening about the lower end 
 of the humerus, and the elbow was very stiff. There was also 
 
SEPAEATION OF LOWEK END OF HUMEEUS 311 
 
 complete paralysis of all the muscles supplied by the musculo-spiral 
 nerve below the elbow. These muscles gave no response to farad aism, 
 but responded to a smaller minimal galvanic stimulation than the 
 corresponding muscles of the opposite side. No loss of sensation 
 could be detected. Friction, passive movement, and the galvanic 
 current were employed daily. Eecovery of voluntary power began 
 in the supinators on March 9, and was complete in all the affected 
 muscles on May 2, although then, and for long after, there was no 
 recovery of faradaic excitability. Eedundant callus having been 
 absorbed, it was found that the displaced fragments had not been 
 perfectly reduced, the lower end of the shaft being in front of and 
 overlapping the lower fragment, forming a prominence at the front 
 of the elbow which stopped flexion at a right angle. Extension was 
 also slightly limited. In other respects the limb was perfectly 
 normal. 
 
 (2) Separation of lower epiphysis of right humerus ; paralysis of 
 musculo-spiral nerve. — A boy, aged eight years. The accident was 
 caused by a fall off a gate on September 6, 1892. The displacement 
 was reduced and the limb put up on an internal angular splint. On 
 September 10 he was found to have complete paralysis of the 
 extensors of the wrist and fingers and of the supinator longus. No 
 anaesthesia was detected. This resembled the previous case in almost 
 every respect, both in the imperfect reduction of the fragments and 
 in the result. The muscles, which had lost faradaic, but preserved 
 galvanic, excitability, were treated daily with one or other form of 
 electricity. Eecovery began in the supinator on October 27, and 
 was complete in all muscles on November 27, the patient having 
 been under treatment nearly three months. 
 
 Numerous similar cases are recorded by Callender, Hamilton, 
 and others. 
 
 Lange records {New York Medical Journal, April 28, 1883. 
 p. 469) the case of a girl, aged eight, who, after a fracture close to 
 the lower end (supra-condyloid fracture) of the humerus, experienced 
 pain at the seat of injury, the wrist and fingers being flexed, with a 
 very limited degree of motion. A sharp edge of bone could be felt. 
 An incision was made, and the median nerve found flattened against 
 the edge of bone ; above this point the nerve was thickened. The 
 nerve was loosened and the edge of bone excised, with decided 
 relief. The colour and temperature of the limb were also markedly 
 improved. A curious point is that in this case the growth of the 
 nails, as indicated by ridges on them, was interfered with previous 
 to the operation. 
 
 In a case of Volkmann's, after resection and reduction of the 
 protruding diaphysis for compound fracture, persistent paralysis 
 of the musculo-spiral nerve resulted, although the elbow-joint was 
 movable. 
 
 Gangrene. — The possibility of the occurrence of gangrene from 
 
312 EPIPHYSES OF UPPEE EXTEEMITY 
 
 interference with the circulation in the brachial artery should ever 
 be present to the surgeon's mind. The vessel may be unavoidably 
 pressed upon by the lower end of the upper fra,g]xient, or may have 
 been injured at the time of the accident, but this serious mishap 
 may be the result of a badly fitting splint or- bandages applied too 
 tightly ; especially is this true of the plaster-of -Paris dressing. 
 
 Shortening of arm. — Unless very great difficulty has been 
 experienced in keeping the fragments in position, and some over- 
 lapx^ing remain, there will be found to be little or no shortening of 
 the arm in separation ; yet it is usual to find half an inch or more 
 shortening after fracture above the epicondyles. 
 
 Arrest of growth in length of the arm. — Although the increase in 
 the length of the humerus takes place in a very small degree at the 
 lower end of the bone, it is possible that the injury may be followed 
 by a partial arrest of development or irregular growth in the lower 
 end of the humerus. 
 
 Vogt reckons that the increase of the humerus through the 
 lower epiphysis is only about 7 cm. for the whole period of life. 
 After the tenth year the epiphysis only adds about 1 cm. to the 
 increase in length of the bone, so that after the twelfth year of life 
 the influence of this end of the humerus in causing any appreciable 
 shortening of the arm can have but little value. 
 
 M. Goyrand {Bulletin de la Soc. de Chirurgie, 1861, p. 534) 
 watched for eight years the development of the humerus in a case of 
 epiphysial separation of its lower end, in w^hich the injured limb 
 was developed absolutely like the other. The patient was a girl, 
 who had met with the injury to her arm from a fall at the age of 
 three years. 
 
 Suppuration may result from periosteal inflammation ; it is 
 certainly less common after this form of separation than after 
 many others. It is, however, more often met with after compound 
 separation. 
 
 Mr. Hutchinson refers {London Hospital Beports, 1864, vol. i. 
 p. 89) to a case of suppuration after epiphysial injury in a sailor lad, 
 who fell from a ship's mast and received severe and complicated 
 injuries. The patient had fracture of one clavicle and separation 
 of three epiphyses. Of his right humerus both the upper and 
 lower epiphyses were detached, and about the lower injury suppura- 
 tion occurred. In his other arm there was separation of the lower 
 epiphysis of the humerus, and here again suppuration occurred. 
 Eight months after the accident union had taken place at all 
 the injured parts, but with the characteristic deformit}" at each. 
 The right humerus was already considerably shortened, partly by 
 arrest of growth, but chiefly by union with displacement. The lad 
 (who was aged fourteen, and was growing very rapidly) had not 
 been treated at the hospital. 
 
 In over fifty cases J. Hutchinson junior found that suppuration 
 
SEPAEATION OF LOWER END OF HUMERUS 313 
 
 never occurred unless the injury had been compound from the first, 
 and had become so owing to sloughing of the over-stretched skin. 
 The youngest patient vs^as eighteen months, the oldest fourteen 
 years old. 
 
 Suppuration of the elbow-joint may occur (1) by extension 
 from periosteal inflammation ; (2) by wound of the synovial 
 membrane. It is frequent in compound separations. 
 
 Suppuration occurred in Sturrock's case, leaving the range of 
 movement less than a right angle. 
 
 Necrosis of diaphysis is a not uncommon result in compound 
 separations. 
 
 Marjolin, in a short article upon 'Fracture of the Humerus above 
 the Condyles in Children ' {Journal cle Med. et Chir. Prat., Paris, 1868, 
 xxiv. 397-399), remarks that M. Velpeau w^as wont to observe in his 
 lectures that one of the worst things that could happen to a young 
 surgeon beginning practice is to meet with a case cf traumatic injury 
 of the elbow in a child. Marjolin believed this to be very true 
 regarding complicated and obscure injuries, which so often occasion 
 errors of diagnosis and of prognosis fatal to the practitioner's 
 reputation. Such cases require the utmost care in examination, 
 for the whole subsequent progress and treatment depend upon 
 an accurate diagnosis. 
 
 TREATMENT. Simple cases. — The treatment is, for the most part, 
 the same as in supra-condyloid fracture. Reduction of the deformity 
 is effected without any difficulty in most cases by extension and 
 gentle manipulation of the diaphysial end. For this purpose the 
 humerus should be grasped with one hand and the forearm with the 
 other or by an assistant. 
 
 To maintain the fragments in good position is often a question 
 of extreme difficulty, so great is the tendency of the deformity to 
 be reproduced. This is to a large extent dependent upon the character 
 of the disunited surfaces, the powerful action of the triceps and other 
 muscles upon the ulna and lower epiphysis of the humerus, the small 
 size of the lower fragment, and its proximity to the elbow-joint. 
 
 The elbow should be fixed at a right angle and & plastic splint 
 (previously cut out and prepared by means of a paper pattern shaped 
 to the sound limb) moulded to the elbow accurately, evenly, and 
 firmly. The elbow and fragments should be kept in the corrected 
 position until the mould is quite hard. The splint should extend 
 well up the arm and down the forearm to the wrists, so that the 
 whole length of the limb may be supported. 
 
 It matters but little of what material the splint is composed, 
 provided that it will harden at once. Flannel soaked in plaster of 
 Paris, gutta-percha, Cocking's poro-plastic splinting, &c., axe all 
 good. 
 
 Croft's plaster-of-Paris lateral splints, with an interval on the 
 anterior and posterior aspects of the elbow, the author has found to 
 
314 
 
 EPIPHYSES OF UPPEK EXTEEMITY 
 
 be one of the best forms of splint in injuries about the elbow-joint 
 in children. These splints can be readjusted day by day as the 
 
 o /ncnes 
 
 Fig. 78. — pattern for inner pieces of lateral splints with eleow at 
 right angles. for a boy of fifteen years 
 
 Eecluced to one quarter size on scale of inches. Splints for all ag may 
 be cut from this pattern 
 
 O /nches 5 'O /P 
 
 Fig. 79. — pattern for outer pieces of lateral splints with elbow at 
 
 right angles. foe a boy of fifteen years 
 
 Reduced to one quarter size on scale of inches 
 
 swelling subsides, and be evenly and carefully bandaged again to the 
 limb. 
 
 Croft's splints consist of four pieces of common house flannel 
 accurately cut to the shape of the joint and adjoining portions of the 
 
SEPAEATION OF LOWEE END OF HUMERUS 315 
 
 limb to which they are about to be apphed. Two of the pieces are used 
 on each side of the hmb, leaving a gap or interval a half to three-quarters 
 of an inch wide on either lateral aspect (or on the front and back 
 when antero-posterior splints are required). The two external pieces 
 
 Fig. 80. — semidiagrammatic view of croft's lateral splints of plaster of paris 
 applied to arm and forearm 
 
 Fig. 81. — the same with outer splint laid aside by the muslin bandage along 
 the whole of gap in front and of gap behind in the forearm portion 
 
 are soaked in plaster of Paris of the consistency of cream, and 
 placed on the outer surface of the two internal pieces. The whole 
 is retained in position by means of bandages made of porous muslin, 
 and rolled on evenly without tension, while the limb is held in the 
 required position until the plaster sets (see fig. 80). The splint 
 
316 EPIPHYSES OF UPPEE EXTEEMITY 
 
 may be readily removed by cutting the muslin bandage through 
 at the gaps left on either side between the edges of the flannel. 
 One side only of the splint may be removed or laid aside in a hinge- 
 like manner for the necessary examination of the joint by merely 
 cutting through the bandage on one aspect of the limb (see fig. 81) . 
 
 On account of their danger, plaster of-Paris-bandages should be 
 scrupulously avoided. 
 
 Some surgeons use pasteboard, leather, &c. ; but these have the 
 disadvantage of requiring some time to harden. Others recommend 
 the hand and forearm to be evenly bandaged before the splint is 
 applied. 
 
 A simple rectangular posterior splint of wood, or other material, 
 shaped in a concave manner, w^U often be found sufficient. 
 
 An interruption at the elbow is an advantage to the back splint. 
 Sir Astley Cooper added a short splint in front of the arm to correct 
 the tendency to displacement forwards. 
 
 Fig. 82 
 
 Hamilton preferred a thick sheet of gutta-percha, moulded and 
 applied accurately to the limb. It should be extended over the 
 shoulder, the back of the arm and forearm to the wrist. The splint 
 should first be lined with woollen cloth or some such material. A 
 pretty large pledget of fine cotton- wool is laid in front of the elbow- 
 joint to prevent the bandage from excoriating the delicate and 
 inflamed skin, and great care taken to protect the bony eminences 
 about the joint, or, rather, to relieve them from pressure, by 
 increasing the thickness of the pads in a horseshoe shape above 
 and below these eminences. 
 
 Packard, writing in Keating's Cyclopcedia of Diseases of Children, 
 describes the following splint, which meets the indications, and 
 which, he says, has given him the best results. Measuring by the 
 sound limb, a piece of binder's board is cut out — or, for a very young 
 child, a piece of pasteboard — in the shape shown in the diagram 
 (fig. 82). This is then again cut in the dotted lines, and it will 
 be seen that a can be turned over so as to fit along the front of the 
 arm, while h will be on its inner side, and c on that of the forearm. 
 
SEPARATION OF LOWER END OF HUMERUS 317 
 
 The portions, c, c, c, c, turned up, will steady the forearm and hand, 
 while d is turned up so as to push the olecranon forward and, along 
 with it, the lower end of the lower humeral fragment. Properly- 
 padded, this splint is secured by means of a bandage accurately 
 applied from the fingers to the shoulder, and the hand and forearm 
 are supported by a sling. 
 
 Anterior rectangular splints to the elbow, made of wood or other 
 material, are to be avoided for many reasons. First, as Packard 
 remarks, the obliquity of the line of the articulation is not sufficiently 
 recognised, and the application of splints which lie straight across 
 the front of the joint pushes the trochlea upwards, and so presses 
 the upper and inner angle of the lower fragment behind the opposing 
 point of the upper fragment. Secondly, the epiphysial line of car- 
 tilage itself is not quite transverse, but extends obliquely downwards 
 and inwards, so that however easy it may be to secure the diaphysis 
 backwards, it will be found almost impossible by these measures to 
 remedy the twisting which, as it were, the epiphysis undergoes. 
 
 Fig. 83. — Winchester's tin splint, can be placed at any angle by means of joint 
 at elbow or bent to the required width at the sides by means of wrenches 
 
 Thirdly, the pressure of the splint at the bend of the elbow will 
 tend to injure the brachial artery by compressing it against the 
 projecting upper fragment. 
 
 Many observers have written upon the treatment of fracture 
 of the elbow- joint in children, and these injuries have been the 
 subject of many discussions before different societies. Some blame 
 the flexed position with fixation as the cause of ankylosis ; others 
 blame the condition of the joint. 
 
 Hamilton says that Dr. Physick's simple angular side-splints, 
 made of wood, without joints, are still used by some American 
 surgeons in fractures about the elbow-joint. 
 
 Various forms of angular splints with a hinge at the elbow, some 
 fitting the forearm and arm accurately, are all more or less cumber- 
 some. 
 
 A combination is often useful, such as a gutta-percha, leather, or 
 Gooch splint on one side, and on the other an angular splint reaching 
 from the shoulder to the end of the fingers ; or a leather or gutta-percha 
 
318 EPIPHYSES OF UPPEE EXTEEMITY 
 
 splint moulded behind the elbow, and a small wooden splint to 
 the front of the arm, with a pad over its lower end, between it and 
 the projecting part of the diaphysis. 
 
 The author is convinced that, as a rule, all injuries to the lower 
 end of the humerus should be treated with moulded rather than 
 manufactured splints. 
 
 The splint should be applied as soon as the diagnosis has been 
 made, and, if possible, under the influence of an ansesthetic. By 
 this means the formation of a projection in front may be avoided. 
 No time should be lost in waiting for the swelling or inflammation 
 to subside, for even after the lapse of a few days it will be found 
 almost impossible to accurately re-adjust the fragments. 
 
 Fractures about the elbow-joint are treated by fixation in many 
 positions, viz. complete flexion, semiflexion, complete extension, and 
 incomplete extension, any of these being combined with pronation 
 or supination of the forearm. 
 
 Hitherto, with the exception of fracture of the olecranon and 
 some few others, each surgeon has had his own particular method 
 for all fractures, irrespective of their nature. 
 
 In this country Mr. Jonathan Hutchinson is one of the chief 
 advocates for treatment in the flexed position, but, at the same time, 
 he states {Medical Times and Gazette, 1866, vol. i. p. 515) ' that it 
 is difficult, if not impossible, to effect accurate coaptation of the 
 fragments. There is almost certain to be some overlapping ; but 
 still, the bent position is the best one,' His son gives {British 
 Medical Journal, December 30, 1893, August 11, 1894, and 
 November 3, 1894) the results of fourteen cases treated with splints 
 in the flexed position. ' In six the result, as regards absence of 
 deformity and the elbow movement, was practically perfect. In 
 the remaining eight a certain amount of limitation of extension and 
 flexion — usually about 20 degrees in either direction— with thicken- 
 ing of the lower third of the humerus, remained when the patient 
 was last seen. In only one was the power of rotation in the least 
 affected, and it need hardly be said that a range of flexion amounting 
 to 80 or 90 degrees is, whilst not ideal, of extreme value to the 
 patient.' 
 
 Powers mentions two cases of separation of the lower epiphysis 
 of the hmnerus in children aged two and six years respectively, and 
 in each a perfect result was attained by simple confinement at a 
 right angle, the lower fragment being drawn well forward. 
 
 Mr. Christopher Heath and many other British surgeons still 
 employ this method. 
 
 Malgaigne, Marjolin, Coulon, Boyer, and Nelaton always em- 
 ployed the semiflexed position in fractures about the elbow. 
 
 Konig, Goyeneche {Fract. du coude cliez les en/ants, These de 
 Paris, 1872), Hamilton, and other more recent writers maintain the 
 advantages of the same position, the forearm being flexed at 90 to 
 
SEPARATION OF LOWEE END OF HUMERUS 319 
 
 100 degrees. In this position the flexor and other muscles attached 
 to the epicondyles are relaxed, and the tilting forwards of the 
 lower fragment is prevented. 
 
 Others prefer to fix the elbow in the rectangular position for a 
 week or ten days, and then change the angle day by day, without 
 passive motion. 
 
 Dr. E. M. Moore employs a lateral angular splint, and every 
 alternate day flexes the elbow more and more until the hand can 
 touch the neck ; the forearm is then carried downwards by degrees, 
 and the process is reversed, but the arm is never brought out 
 perfectly straight. 
 
 Others, again, prefer to treat these fractures with the forearm 
 flexed to less than a right angle with the arm. 
 
 Bardenheuer recommends permanent extension, in the first 
 instance, for this form of injury, and many French surgeons hope 
 that the flexed position may be entirely given up ; while Pitha and 
 Billroth and other German surgeons go so far as to say that juxta- 
 epiphysial separations can only be reduced by means of extension, 
 
 Eicard, however (in Duplay and Eeclus's Traite cle chirurgie, 
 1890), still advises treatment by fixation in the rectangular 
 position, but advocates early movement (fifteen to eighteen days in 
 children), rubbing, massage, &c., to guard against ankylosis. 
 
 In spite of all the advantages claimed for it even from the days 
 of Hippocrates, this plan is one that cannot be recommended, 
 
 Liston, and a few other British surgeons, also treated supra- 
 condyloid fracture in the straight position. 
 
 M, C, Guedeney, in his thesis upon the treatment of fractures of 
 the elbow in children (These de Lyon, Mars 1893), gives an account 
 of sixty cases of fractures about the elbow, at ages varying from six to 
 seven years, treated (with the exception of three) by a modification 
 of the principle laid down by Laroyenne and advocated by his pupil, 
 Berthomier, in 1875— viz. by fixation in complete and permanent 
 extension. This modification, introduced by M. Vincent, of Lyons, 
 consists of fixation in the extended position for a time, alternating 
 with flexion in the supine position. The results, at the time of 
 leaving the hospital or later on, in many cases were said to have been 
 excellent, but some eight of them were very incomplete ; in five the 
 results were unknown. Immediately, or a few days after such an 
 accident, under an anaesthetic, the fragments are reduced and the 
 limb immovably fixed in complete extension and supination by 
 applying a posterior trough splint of plaster, or silicate, extending 
 from the shoulder to the fingers. A small tongue-piece over the palm 
 of the hand passing between the thumb and fingers ensures perfect 
 fixation in the supine position. This allows free access to the limb 
 in front, and does not, as some have said, exercise too great constric- 
 tion; neither is the position unbearable for children. The pain at first 
 experienced passes off in two days. The dressing is usually changed 
 
320 EPIPHYSES OF UPPEE EXTEEMITY 
 
 on the day after its first application, and re-applied. On acute pain, 
 or other sign of compression, the splint must be removed at once. 
 On the eighth to the tenth day, according to the swelling, the splint 
 is removed and the forearm slightly flexed, the joint being now care- 
 fully examined. Consolidation will have occurred to a great extent, 
 and does not prevent the limb being put up in the flexed position 
 for eight or ten days in a plaster trough. At the end of this time 
 (the twentieth day) the fracture is perfectly united, and passive 
 motion is commenced ; or, if ununited, the splint is left on some days 
 longer, or a third one is applied as the first in the completely extended 
 and supine position. 
 
 M. Vincent himself adds : ' The position is alternately total 
 extension and flexion, more or less at a right angle. At each 
 renewal of the immovable apparatus shght movements are carried 
 out at the articulation.' 
 
 Of the following thirteen cases of separation of the lower end 
 of the humerus pubhshed by M. Guedeney, in four the displacement 
 of the epiphysis was more or less backwards, in four there was little 
 or no displacement, and in five the displacement is not stated. 
 
 Displacement backwards. I. Juxta-epijjhysial disjunction of the 
 left humerus. — Boy (J. L.), aged eleven years, was admitted May 31, 
 1890, having fallen on his left side with the forearm bent. Juxta- 
 epiphysial fracture of the lower end of the humerus was diagnosed. 
 The arm was directed obliquely from below upwards, and from 
 without inwards. There was little bruising or swelling, but crepitus 
 was distinct. Under an angesthetic the fragments were placed in 
 position, and a plaster apparatus applied in complete extension. 
 On June 22 consolidation was complete, but there was abundant 
 callus ; arm and forearm in same axis, with a tendency to adduc- 
 tion. There was no ankylosis, all movements being free. The 
 forearm was bent to a right angle and the elbow put up again. 
 The following day the child left. Eesults unknown. 
 
 II. Juxta- epiphysial disjunction. — Boy (P. C), aged four, ad- 
 mitted May 6, 1891, having fallen from a height of one and a half 
 metres on to the right arm. The humerus was found displaced in 
 front of the lower fragment. Eeducfcion was effected by extension 
 and counter-extension, and a posterior plaster splint was applied in the 
 extended and supine position. When seen after some time there was 
 no ankylosis. The limb was sound, and displayed a perfect result. 
 
 III. Epiphysial disjunction, tvith displacement backtvards. — A 
 girl (M. B.), age not stated, admitted June 20, 1884 ; she had fallen 
 upon a staircase on to her elbow, and was treated at first by a bone- 
 setter in the country. When seen there was swelling, traces of 
 extravasated blood, projection of the humeral end forwards, of the 
 olecranon backwards, with a depression above and two or three cen- 
 timetres shortening. Complete extension could be carried out, but 
 flexion only halfway. Under an ansesthetic a sharp ridge could be 
 
SEPAKATION OF LOWEK END OF HUMEEUS 821 
 
 felt in the bend of the elbow. Reduction was effected, and the limb 
 fixed in the extended position. On July 11, flexion was limited to a 
 right angle, and there still existed marked swelling. On July 18, 
 the extent of movements had increased. Passive movements were 
 now commenced, and the elbow fixed in the flexed position. Left 
 the hospital January 25, 1893. Parents stated that the child was 
 quite cured, and that she does not recollect which was the injured arm. 
 
 IV. Disjunction of the lower epiphysis of the humerus. — A girl 
 (A. J.), aged eight years, was admitted Augusts, 1885, having fallen 
 from a wall a height of about two metres on to her right elbow. 
 Slight swelling without bruising was noticed ; the movements of 
 the joint were free, and there was abnormal mobility, but no 
 crepitus. The lower part of the humerus projected forwards and 
 inwards, the epiphysis being displaced backwards and outwards. The 
 fragments were immediately reduced by extension, and counter- 
 extension, and a plaster splint was applied in the extended position. 
 On August 30 the splint was removed ; good consolidation took place, 
 after which passive movements were carried out. On September 18 
 the child left the hospital ; on February 5, 1893, she was seen again. 
 The result was perfect ; all movements of the elbow were normal, 
 extension being even a little exaggerated. The child said that this 
 arm was now stronger than the other, and could do needlework. 
 No trace whatever of callus. 
 
 Little or no displacement. V. Epiphysial disjunction of the 
 humerus. — Boy (P. M.), aged nine and a half years, admitted 
 November 5, 1885, after a fall on the elbow. There was con- 
 siderable swelling about the elbow, bruising of the lower part of the 
 arm, and limitation of movements. At the lower end of the humerus 
 there was a little abnormal mobility and distinct crepitus, but no 
 displacement. Silicate splint applied in the extended position. 
 November 9. — Slight swelling of fingers. November 18. — Swelling- 
 still remained ; the arm put up in silicate splint flexed at a right 
 angle. On December 17, all swelling gone, and complete union of 
 the fragments. The result was perfect, the arm having recovered 
 the use of all movements. 
 
 VI. Disjunction of the loioer epiphysis of the humerus. — Boy 
 (P. M.), aged nine and a half, fell on the elbow. There was some 
 ecchymosis, but no displacement. Silicate splint applied in the 
 completely extended position. Dressing removed at the end of 
 fifteen days, and forearm placed in the flexed position. On removal 
 of the last splint there was no more swelling, and all the movements 
 of the elbow were good. 
 
 VII. Disjunction of the lower epiphysis of the humerus.-^— Jjoj 
 (J. B.), age not stated, admitted July 21, 1885, after a fall from an 
 apricot tree. There were swelling and abnormal mobility above the 
 humeral epiphysis, and very little displacement. Beduction was 
 effected, and a plaster splint applied in the extended position. 
 
 Y 
 
322 EPIPHYSES OF UPPEE EXTEEMITY 
 
 July 30, 1885. — Left tlie hospital with a new spHiit. Patient could 
 not be traced again. 
 
 VIII. Juxta -epiphysial disjunction of the humerus. — A boy (P. D.), 
 aged seven years, admitted January 8, 1892, after a fall frora making a 
 false step. Immediately there was loss of power, and the arm (espe- 
 cially a little above the elbow) and the forearm were swollen and 
 painful. Movements of the joints were free, but extreme flexion 
 dragged backwards the lower fragment of the humerus. Crepitus was 
 present. Keduction and fixation with silicate splint in extension. 
 January 18. — The result was good ; a plaster splint appHed in the 
 semiflexed position (135 degrees). February 16. — Flexion beyond 
 a right angle difficult and painful. February 28. — The abundant 
 callus hindered flexion, while the other movements were preserved. 
 
 Displacement not stated. IX. Epiphysial disjunction of the lower 
 end of the humerus, with fracture of the radius and ulna.— A girl 
 (Julia M.), age not stated, admitted April 1887, having fallen the 
 previous day from a chair on to the ground. There was effusion 
 of blood about the left elbow, olecranon uninjured. The radius and 
 ulna were fractured at the lower end, with a small wound in front 
 of forearm. April 22. — Under an anaesthetic, reduction and plaster 
 splint appHed in extended position. Seen in January 1893, six 
 years after, the elbow had rapidly recovered, and preserved all its 
 movements, including pronation and supination. 
 
 X. J'uxta-epiphysial disjunction of the lower end of the humerus. 
 A boy (Chas. M.), aged eight years. No details are given, but under 
 chloroform a plaster sphnt was applied in extreme extension and 
 supination. The child did not attend the hospital again, and the 
 results were unknown. 
 
 XL Juxta-epiphysial disjunction of the right humerus. — Boy 
 (A. B.), aged five years, admitted December 23, 1890, after a fall 
 upon a stone. The usual treatment was carried out. When seen 
 on March 18, 1893, there was a perfect recovery ; the child could 
 use his arm in every direction, the injured limb being as strong and 
 sound as the uninjured one. An appreciable amount of callus still 
 persisted. Although complete flexion could not be carried out, all 
 the other movements of the limb were free. 
 
 XII. Juxta-epiphysial disjunction of the humertis. — Boy (L. S.), 
 age not stated, admitted November 28, 1890, fell upon his elbow 
 while carrying a load. No details are given except that he was 
 treated by the usual method. Eigidity of the joint persisted for 
 some time. On March 7, 1893, he could flex and extend his arm ' as 
 he wished.' No pain or swelling ; complete recovery. 
 
 XIII. Juxta-epiphysial fracture of the humerus. — A boy (F. E.), 
 aged thirteen, admitted October 14, 1891, after a fall upon the front of 
 the left forearm. The arm seemed to have been subjected to a twist- 
 ing movement, which detached the lower epiphysis. The line appeared 
 to be obhque, and to involve the joint. Crepitus was distinct, not- 
 
SEPAEATION OF LOWEE END OF HUMEEUS 323 
 
 withstanding the swehing ; radius and ulna intact. Eeduction was 
 effected by means of strong extension, and the hmb was fixed in a 
 plaster apparatus in the extended position. October 25. — Fresh 
 apparatus applied in the extended position. November 17. — Passive 
 niovements were carried out, and the arm put up in the flexed and 
 supine position in a metal trough splint. When seen on January 25, 
 1893, the child had recovered all the movements of his limb. 
 
 By this method the advantages of the flexed position are said to 
 be added to the complete reduction of the fragments gained by the 
 extended position. Compound fractures are treated in the same 
 way after the wound has been cleansed. 
 
 Older cases of ankylosis, &c., however, are treated by M.Vincent 
 by forcible replacement of the fragments, and put up in the flexed 
 position. 
 
 T. W. Nunn {Clinical Society Transactions, vol. xxv. p. 245), 
 Allis, Illingworth {Brit. Med. Journal, February 1889), Berthomier, 
 Bardenheuer, Warren {Trans. American Med. Association, vol. i. 
 p. 174), Frere, Lauenstein of Hamburg (Langenbeck's Archives, 
 vol.xxxvii.), Stimson, L. C. Lane, and others, including Billroth and 
 Koenig, have of late years advocated putting up the limb in all 
 injuries of the elbow in the straight position, with the forearm 
 prone. 
 
 They claim that the deformity of cubitus valgus or cubitus 
 varus, so frequently seen after treatment in the rectangular position, 
 is to a great extent obviated, and a much earlier return of mobility 
 of joint and usefulness is obtained. 
 
 Bardenheuer combines traction with extension in all these 
 fractures. He has for five years (1888) treated all elbow fractures 
 with permanent extension, both longitudinal and transverse, and 
 with satisfactory results. Of course in this method of treatment 
 the patient is confined to his bed for some weeks. 
 
 Dr. Lauenstein says, in support of this plan, that in the 
 extended position the bones of the forearm afford a lever in 
 adjusting the fracture of the lower end of the humerus ; the ante- 
 rior part of the capsular ligament is kept on the stretch, thereby 
 lessening ' the danger of the bones of the forearm becoming 
 entangled in the callus, and of the mobility of the joint being interfered 
 with ; ' also that the surgeon can, in this position, ' readily detect 
 any deviation from the normal direction of the axes of the humerus 
 and bones of the forearm.' He advises {Beitrag zum Centralblatt 
 filr Chirurg. No. 24, 1888), for all fractures of the lower end of 
 the humerus, treatment in the extended position, having for six 
 years had good success in all his cases. He thinks that the surgeon 
 should not be content with the preservation of the mobility of the 
 joint, but that the deformity of cubitus valgus or varus, which is so 
 prejudicial to the ulterior welfare of the patient, should also be 
 seriously considered in treating such cases. An autopsy upon a 
 
 T 2 
 
324 EPIPHYSES OF UPPER EXTREMITY 
 
 T-sliaped fracture showed iiim that the flexed position produced 
 bending, not at the joint, but at the seat of fracture. Previous to 
 this he had employed this position for all fractures of the elbow. 
 
 Koenig in the same year, 1888, recommended the extended 
 position for hospital practice, and the angular splint for private 
 patients. 
 
 Nunn believed that in the extended position there was less 
 danger of the anterior part of the capsular ligaments of the joint 
 being involved in the callus, as it was held on the stretch, and that 
 the risk of ankylosis was diminished, especially as the position 
 permitted of effectual apphcation of the ice-bags for the control 
 of inflammatory action. 
 
 Wagner and Sonnenburg, while admitting the value of this 
 method, claimed (1888) that some cases do better when treated in 
 the right-angled position. 
 
 In 1875 Berthomier {Mecanisme des fractures du coude cJiez les 
 enfants ; leur traitement par V extension, Paris, 1875) following the 
 views of Coulon, Marjolin, Pezerat, Laroyenne, and others already 
 mentioned, recommended the extended position in transverse frac- 
 tures of the lower end of the humerus. They beheved that 
 reduction was much more perfect in the extended than in the 
 flexed position, and that it was not accompanied by the subse- 
 quent deformity met with under the latter mode of treatment. In 
 a large number (eighty) of fractures and epiphysial separations 
 of the lower end of the humerus, as a result of experiments on the 
 bodies of children of all ages, but more especially from two to ten 
 years, M. Berthomier came to the conclusion that the extended 
 position was the best for maintaining the fragments in position. 
 He quotes twelve cases of fracture of the elbow in the living subject, 
 observed in the Lyons Hospital, in which good results had foUow^ed 
 treatment by the extended position, and is of opinion that all 
 fractures of the elbow — with the exception of that of the external 
 epicondyle, in which he considers the flexed position the best — 
 ought to be fixed in the extended position. 
 
 In a communication to the Erench Congress of Surgery in 1888 
 Berthomier adds ' that the flexed position is an obstacle to the 
 reduction and coaptation of the fragments, and may give rise to 
 ankylosis, whereas in extension and supination the coaptation is 
 perfect,' the lower fragment being firmly held posteriorly by the 
 olecranon, and in front by the detached periosteum and the anterior 
 ligament, which form a very resisting splint. He thinks that 
 ankylosis and stiffness following fractures of the elbow in children 
 are always due to incomplete reduction of the fragments, and 
 not to inflammation of the joint brought about by intra-articular 
 fracture. 
 
 Dr. A. Hanbury Erere, speaking of the treatment of separation 
 of this epiphysis, says : ' In these cases the fragment can be brought 
 
SEPAKATION OF LOWEK END OF HUMEKUS 325 
 
 into good position, when the arm is straight, by traction on the 
 forearm ; and, therefore, the arm should be dressed in the straight 
 position with plaster or starch bandage, keeping up gentle extension 
 on the forearm till the dressing has set.' 
 
 To an admirable article on ' Fractures of the Bones of the Elbow- 
 joint,' by Dr. L. C. Lane, of San Francisco {Transactions of the 
 American Surgical Association, vol. ix. 1891, p. 393), the reader may 
 be referred for the treatment of all such fractures by extension. 
 
 Many American surgeons believe that the ' carrying function ' of 
 the limb — viz. the normal angle outwards which the forearm makes 
 with the arm in full extension — can only be preserved by adopting 
 the extended position. Although in certain fractures (alluded to later 
 on) involving the elbow-joint, the displaced fragments may be more 
 completely reduced by the extended position, the author believes that 
 
 Fig. 84. — author's anterior rectangular splint for the left elbow 
 
 The dotted lines are inserted to show the amount of outward deviation of the 
 forearm piece. The angle at A is not transverse, but slopes obliquely to the 
 inner side, according to the natural obliquity of the elbow-joint 
 
 separations of the lower end of the humerus are best treated in the 
 flexed position, provided always that the natural obliquity of the 
 elbow is fully maintained. 
 
 Mr. Jonathan Hutchinson says that the muscles retain the 
 lower fragment in such a position that the joint itself is always 
 flexed ; and, therefore, if we straighten the arm there will be back- 
 ward displacement. 
 
 The author's own experience agrees with this ; the usual displace- 
 ment backwards of the epiphysis is not nearly so well remedied 
 in the fully extended position as when the forearm is flexed. 
 
 He is therefore of opinion that epiphysial separation of the lower 
 end of the humerus is best treated by the flexed position, however 
 strongly the position of full extension may be urged in the treatment 
 of some of the other forms of injury to the elbow-joint in children. 
 
 For an excellent resume of the various opinions as to the straight 
 
326 EPIPHYSES OF UPPEE EXTEEMITY 
 
 and rectangular positions in fractures of the elbow-joint, the reader 
 should consult Dr. A. Hanbury Frere's valuable papers in the 
 Provincial Medical Journal for January, March, and April, 1892, and 
 Dr. J. B. Eoberts's excellent contribution to the Traiisactions of the 
 Ajiierican Surgical Association, vol. x. 1892, p. 15. 
 
 No absolute rule can be laid down applicable to all separations or 
 fractures. The mechanism and form of displacement are so totally 
 different in each separation, whether of the lower end of the 
 humerus or of one of the other epiphyses, that it is manifestly 
 unscientific to treat them all by the same method. 
 
 Professor J. S. Wight, of Brooklyn, enumerates {Annals of Sur- 
 gery, vol. xvii. August 1893) some cases of fracture of the lower end 
 of the humerus, treated in the nearly extended (straight) position, 
 in which ankylosis of the elbow-joint resulted. He argues from 
 these in support of the bent position — that is, by treating all cases 
 of fractures of the elbow-joint in the rectangular position. 
 
 In five cases recorded by him which had been treated in the 
 extended position, midway between complete extension and right- 
 angled flexion, the ankylosis and disability of the arm were very 
 great, so that operative measures were resorted to, and with good 
 result. In four other cases Dr. Wight used ' forcible joint infraction ' 
 to remedy the ankylosis. Two of these had been treated by the 
 above method, one by a right-angled splint, and one (the only case) 
 by a fully extended straight splint. 
 
 In one other case, treated by a nearly straight splint, the limb 
 was very much disabled. Operation was in this case emphatically 
 declined. 
 
 Dr. H. L. Smith, of Boston, U.S.A., has lately {Boston Medical 
 and Surgical Journal, October 1894, p. 386) made a series of 
 experiments with a view of determining the best position of the arm 
 in the treatment of fracture involving the joint. He found, in frac- 
 tures of the inner or outer side — internal or external condyle {sic) — 
 T-shaped fractures, and transverse epiphysial separations, that 
 the deformity was always reduced and the fragment firmly locked in 
 position by flexing the forearm into the acute position (45°), with 
 the forearm semi-pronated. 
 
 It is possible, in certain forms of this injury, that semi-pronation 
 and extreme flexion may bring about a greater amount of movement 
 of the elbow, but further experience is desirable upon this point. 
 
 Dr. W. Bruce, of Dingwall, suggests {British Medical Journal, 
 October 24, 1896, p. 1201) simply reducing the fracture, bending the 
 elbow to an acute angle, and laying the arm across the chest over a 
 thick sheet of cotton-wool. A bandage enveloping the trunk and 
 injured limb is then applied. The arm is undone daily and in- 
 spected. 
 
 Without any fixation. — The fear of ankylosis has led many 
 surgeons, from the time of Hippocrates and Celsus, to treat fractures 
 
SIMPLE SEPARATION OP LOWER EPIPHYSIS OP HUMERUS WITH COMPLETE 
 
 DISPLACEMENT BACKWARDS. 
 
 From a girl aged five years. Irreduoibilicy of epiphysis. Wirin? to diaphysis after open iucision and re.iuction. 
 
 Elbow joint uninjured. 
 Mr. Thomas Moore's case. Taken by Mr. Thomas Moore. 
 
SEPAEATION OF LOWEE END OF HUMEEUS 327 
 
 about the elbow without any fixation of the fragments by spHnts or 
 apparatus. This method has of late years been revived, especially 
 by French surgeons. The elbow is simply placed in a sling, and 
 passive moveixient commenced from the time of the injury and 
 increased at intervals. At the Societe de Chirurgie, Paris, this 
 subject was discussed in 1880, and again in 1888. Tripier, of 
 Lyons, in 1888, thought that immediate passive movement and 
 massage should be carried out in injuries to the elbow-joint in 
 children, both intra- and extra-articular, provided there was no dis- 
 placement. 
 
 The plan cannot be too strongly condemned. 
 
 Passive motion should be commenced very early. At the end of 
 seven or eight days the splint should be removed, and, while the 
 limb is firmly grasped at the seat of fracture, gentle flexion and 
 extension of the joint through a small arc should be made, without 
 inflicting pain, and the splint re-adjusted. 
 
 This should be repeated every second or third day, a larger arc 
 being made each time. At the end of three weeks the splint should 
 be left off, and the arm placed in a sling. By this time the limb 
 will have almost regained its usefulness. 
 
 Gentle passive motion should still be kept up and all violent 
 attempts at movement avoided, the amount of movement being 
 progressive at each time of application. 
 
 If great pain, with effusion into the joint, is produced, the elbow 
 must be allowed rest for a few days. In fact, many of the older 
 children will not submit to movement if it is in any way painful, and 
 will not come back again for treatment ; at least, this has been the 
 author's experience in hospital practice. 
 
 Dr. L. C. Lane, in his extension treatment, commences passive 
 motion on the second or third day, and repeats it daily for twenty- 
 five days. The forearm should be flexed twice to a right angle 
 slowly and deliberately, whilst the seat of fracture is grasped 
 securely. The patient should offer no resistance. At the end of 
 this time the arm is unbandaged, flexed to an angle of 60 degrees, 
 and carried in a sling. The patient may then commence voluntary 
 movements. 
 
 Later on flexion and extension should be repeated several times 
 daily, in order to counteract the shortening of the peri-articular 
 structures through cicatricial contraction. 
 
 Mr. Joseph Bell, of Edinburgh, teaches that fractures near the 
 elbow in young peojple should be kept quiet for a period correspond- 
 ing to the age of the child, a day for each year ; e.g. a child of five 
 years for five days, of ten years for ten days. 
 
 Other surgeons prefer to wait for three weeks before commencing 
 passive motion, but there does not appear to be any advantage in 
 allowing this lapse of time, at any rate in the case of children. 
 
 The thickening and stiffness of the joint wiU subside in time. 
 
328 EPIPHYSES OF UPPEE EXTEEMITY 
 
 To attempt to hasten this by forcible flexion or manipulation would 
 be disastrous, and followed by disjunction of some neighbouring 
 epiphysis. Several months are often required in children to com- 
 jjletely re-establish the mobility by gentle movement and massage. 
 
 Active motion. — The child should be taught to exercise its elbow 
 in diiiferent ways. These movements may alternate with the 
 more careful and methodical movements carried out by the surgeon 
 in the later stages of treatment. Active movements are more pro- 
 ductive of serious results than passive motion. In the latter, if 
 properly carried out, there should not be any mobility whatever 
 at the seat of separation. 
 
 Electricity, massage, friction, are of great utility in the later 
 stages, when there is much atrophy of the muscles of the arm 
 and forearm, although the usual result is that when union is com- 
 plete the mobility of the joint is generally perfect. But even w^hen 
 deformity is present and the motions much restricted, great benefit 
 will be obtained in time. In the course of years the end of the 
 bone will become remodelled, until scarcely any trace of the lesion 
 remains. 
 
 Partial separation -with oblique fracture of the shaft.^ — The treat- 
 ment is the same as for complete separation, but greater difficulty 
 will be experienced in keeping the fragments in position on account 
 of the oblique direction of the fracture. 
 
 Separation of the epiphysis with vertical fracture into joint. — The 
 treatment will be the same as for simple separation, with the 
 exception that it will be found more difficult in this case to keep 
 the fragments in proper position. Some deformity is, therefore, 
 sure to result, and probably some permanent stiffness of the joint, 
 through the lesion being an intra-articular one. 
 
 Compound separations. — Eeduction of the protruding diaphysis is 
 usually impossible without resection of a portion of its end. If 
 sufficient be removed, it will be found easier to keep the fragments 
 in position, and there will be less likelihood for displacement to 
 recur. Spillman removed rather more than an inch in one of his 
 cases, and one inch and three quarters in another, before reduction 
 could be effected. Both terminated in recovery. 
 
 The womid must be carefully cleansed, and all portions of the 
 bone removed that are seen to be soiled with mud or other foreign 
 matter. If the joint has been opened, it should be syringed out 
 with carbolic or perchloride lotion (1 in 2000), and any pieces of 
 bone which are wholly detached from the periosteum and other 
 tissue must be removed. Care should be taken to fix the elbow at 
 aright angle with the forearm in the prone or half-prone position, the 
 most useful position in the event of ankylosis supervening, which 
 is very likely to occur if the strictest cleanliness of modern surgery 
 be not adhered to. 
 
 Maisonneuve was able to successfullj' replace the bone, which 
 
SEPAEATION OF LOWER END OF HUMEEUS 329 
 
 protruded for four centimetres, and cause it to re-enter its periosteal 
 sheath without resection of the diaphysial end. 
 
 Dr. E. W. Smith did the same in a case where there were signs 
 of pressure upon the brachial artery. 
 
 In Hutchinson's case, after excision of the upper fragment 
 which protruded, the patient recovered with a stiff elbow. 
 
 Erichsen removed the projecting end of the shaft of the 
 humerus in a case of compound separation. An excellent result, 
 without impairment of free- 
 dom of action of the joint, 
 followed the operation. 
 
 The author has collected 
 seventeen compound cases, 
 many of which recovered the 
 function, and obtained a use- 
 ful arm. 
 
 These cases, being so often 
 septic before coming under 
 treatment, take many weeks, 
 or even months, to heal, and 
 the suppuration present is 
 often accompanied by necrosis 
 of fragments of bone. But J. 
 Hutchinson junior has men- 
 tioned {Brit. Med. Journal, 
 
 November 3, 1894, p. 967) a case under his care in which there 
 was very little suppuration and no necrosis, although the periosteum 
 had been completely stripped up to the deltoid insertion. The 
 diaphysis had worked through the soft tissues in front of the elbow 
 between the brachial artery and the biceps tendon. It was im- 
 possible to effect perfect reduction without cutting off one inch 
 of the shaft. In this case a careful trial was given to extension, 
 but it had to be abandoned after a day or two. 
 
 Lange {loc. cit. supra, fig. 80, p. 290) found it necessary in his 
 case to remove the epiphysis as well as a portion of the shaft, the 
 patient recovering with a useful arm. But this must be a very 
 exceptional case in the present days of antiseptic surgery, even 
 though the compound separation involve the elbow-joint. 
 
 The old plan of excision of the whole joint in all cases of 
 compound injuries into the joint is no longer justifiable. 
 
 Beach reports {Boston Medical and Surgical Journal, January 4, 
 1877) a case of compound fracture and separation of the lower 
 epiphysis of the humerus, with crushing of the ends of the radius 
 and ulna, in a boy, aged eight, who had been run over by a horse- 
 car. Excision of the joint was adopted, and the patient made a 
 perfect recovery, the arm being as useful as the other, although 
 three inches . shorter. 
 
 Fig. 85. — jones's posterior trough splint 
 of tin, with interruption for compound 
 injuries at the elbow-joint. the forearm 
 piece can be bent into the semi-prone 
 position or be deflected outwards 
 
330 EPIPHYSES OF UPPEE EXTEEMITY 
 
 Mr. Jonathan Hutchinson junior summarises (British Medical 
 Journal, December 30, 1893) the records of fifteen compound cases 
 where the diaphysis protruded through the skin. 
 
 ' In six of these the diaphysis was reduced more or less per- 
 fectly ; one recovered with an almost perfect arm, one with throm- 
 bosis of the brachial, and a third with paralysis of the musculo- 
 spiral. The other three ended in amputation — one primary, two 
 secondary, owing to gangrene from the artery being torn or 
 obliterated by splint pressure. In three cases a more or less 
 complete excision of the joint was performed ; one recovered with 
 very good movements, one with a stiff elbow, the third with a fairly 
 movable one. In six cases the projecting diaphysial end was cut 
 off in order to procure reduction ; four of these ended with most 
 satisfactory results, one recovered with an ankylosed elbow, and the 
 sixth underwent amputation at the end of three weeks because no 
 union had occurred. In two of the fifteen cases an action for 
 malpractice was brought.' 
 
 Primary amputation. — Extensive lesions of the soft parts, or injury 
 to important vessels or nerves, may render amputation necessary. 
 But even in apparently hopeless cases much may be done to save 
 the upper extremity in young subjects. 
 
 Extensive stripping-up of the periosteum, laceration of the 
 ligaments of the elbow-joint, and compound fracture of the bones of 
 the forearm, necessitated primary amputation in Champion's case. 
 Eecovery followed. 
 
 Secondary amputation. — In compound separations, should gan- 
 grene, or extensive suppuration, with its consequent dangers, 
 threaten the life of the patient, secondary amputation must be 
 performed. 
 
 In Eeeves's case {loc. cit. supra) amputation was performed at the 
 end of three weeks, on account of the condition of the arm, no 
 union having occurred. 
 
 Deformity, if quite recent, may be treated by breaking up the soft 
 uniting material under an anaesthetic, and replacing the bones in 
 their natural position. 
 
 Dr. Eobert Abbe brought before the New York Clinical Society, 
 1886 {New York Medical Journal, October 23, 1886, p. 469), three 
 cases in which the epiphysial separation had been overlooked at the 
 time, two of which he had successfully treated by breaking up the 
 uniting callus by means of lateral flexions and over-extension, and 
 reducing the displacement of the fragments. 
 
 Case I. — Five weeks before coming under observation, a boy, 
 five years old, had fallen headlong from a wagon, striking with his 
 left elbow under him. An examination under anesthesia showed 
 marked deformity, with forward prominence of the shaft. The 
 biceps tendon had slipped to the inner side of the shaft. The callus 
 having been broken up by manual force, reduction was effected, and 
 
SEPAEATION OF LOWEE END OF HUMEEUS 331 
 
 a plaster-of-Paris splint applied. At the end of three weeks and 
 a half the splint was removed, and the boy allowed free use of the 
 limb. At the end of six weeks the joint could be moved with 
 the greatest freedom, and there was no appreciable deformity. 
 Case II. — An injury of the same kind was sustained by a boy, two 
 years old, by falling down three steps and striking on his elbow. Two 
 weeks had passed before he was placed under treatment. The same 
 methods were employed, and at the end of three weeks the position 
 was excellent and moderate freedom was allowed. Case III. — A boy, 
 four years old, fell from a table. He complained, at the time, only of 
 his thumb, but subsequently the elbow swelled, and when the swelling 
 had subsided, a week after the fall, deformity was noticed, and the 
 boy was brought for treatment. The deformity was the same as in 
 the two other cases. Under ansesthesia crepitus was detected, and 
 the fracture was regarded as deviating somewhat from the epiphysial 
 line near the outer condyle. Flexion was abruptly arrested at a 
 right angle, but the power of extension was nearly complete. 
 
 Dr. Abbe added the following remarks : 
 
 ' 1. Epiphysial and other fractures at the elbow are often treated 
 as sprains, and leave impaired joint motion. 2. The deformity is 
 not extreme, being chiefly an antero-posterior thickening above the 
 joint, with rather a full ridge, parallel to and just above the flexure- 
 crease caused by the lower edge of the shaft. There is usually no 
 heel-like backward prominence of the elbow, as in dislocations. 
 3. There is impairment of flexion, but not so much of extension. 
 The elbow can scarcely be bent to a right angle before flexion is 
 stopped abruptly by the overhanging shaft, the lower end of which 
 comes in contact with the radius. 4. Eeduction can be accom- 
 plished several weeks after the injury, if the deformity is bad enough 
 to call for it. 5. Sufficient manipulation to break up the callus at a 
 late date is said to be dangerous to the integrity of the joint ; but, 
 while great force is required to loosen the fragments if applied 
 so as to flex the elbow forcibly, less is needed to over-extend it, and 
 much less when it is exerted laterally. Therefore backward and for- 
 ward lateral bending, with some over-extension and only occasional 
 violent flexion, succeed best in freeing the fragments with least 
 risk to the joint. 6. The repair of the damage done to a child's 
 joint by fracture in its vicinity, which leaves it in a state of 
 so-called fibrous ankylosis, is best left to nature ; as the free use 
 of the arm is allowed, the mobility will usually be restored at least 
 as quickly as by frequent passive motion.' 
 
 Bardenheuer resected a portion of the humerus with great 
 improvement to the deformity in two cases of old standing 
 separation, with displacement backwards and inwards of the 
 epiphysis. 
 
 The author has performed the same operation three times in old 
 separations of the lower epiphysis of the humerus, with good results. 
 
332 EPIPHYSES OF UPPEE EXTREMITY 
 
 In one case the edge of the humeral diaphysis pressed up the median 
 nerve, with loss of sensation in the fingers, the brachial artery- 
 being pushed by the diaphysis prominently forwards beneath, 
 threatening to produce a rupture or aneurism on the slightest blow 
 over the edge of the bone. In a second case the inner angle of the 
 diaphysis beneath the median nerve and brachial artery was removed 
 with a chisel. Hyperextension of the elbow existed in this 
 instance. 
 
 Osteotomy of the shaft above the elbow-joint may be suitable in 
 certain and well-selected deformities after separation. 
 
 A case of old separation of the lower epiphysis of the humerus, 
 in which the bone was divided above the line of separation, is re- 
 ported from the Hospital for Sick Children, Pendlebury {Abstracts 
 of Medical and Surgical Cases at the General Hospital for Sick 
 Children, Pendlebury, 1885, p. 173). E. H., aged four years, was 
 admitted October 14, 1885. Eighteen months previously he broke 
 his arm. It was put in splints for three weeks ; when taken out 
 it was crooked; he could do anything but carry weights with it. On 
 admission, he could flex, extend, pronate, and, with little difficulty, 
 supinate ; in flexion the forearm was in same plane with the arm, 
 but in extension there was much abduction ; there had been separation 
 (supra-condylar) of the lower epiphysis of humerus, with displacement 
 of the lower fragment and forearm inwards, and considerable wasting 
 of muscles. October 23. — Section with chisel just above line of 
 separation ; antiseptic ; put up on inside angular splint. October 
 30.— Tube removed. November 5. — Stitches taken out, wound nearly 
 healed ; arm almost straight in extension ; passive motion on splint. 
 16. — Slightly adducted in extension, owing to original deformity 
 being over-corrected ; put up on straight back and inside splints ; 
 flexion not quite perfect owing to callus. 18. — The splints left off. 
 December 4. — Straight back splint at night only ; no rise of tempera- 
 ture since operation. December 16. — Sent home. 
 
333 
 
 CHAPTEE V 
 
 SEPARATION OP THE LOWER EPIPHYSIS OF THE 
 HUMERUS IN YOUTHS 
 
 Sepaeation of the lower epiphysis of the humerus after puberty — 
 i.e. the articular and external epicondylar epiphyses — or separation 
 of the articular epiphyses just before puberty, accoinpanied hy frac- 
 ture of the cartilage uniting the internal epicondyle to the trochlear 
 portion of the epiphysis, is a much more rare form of injury than 
 the one we have just considered in the last chapter. For details 
 of the development we must refer the reader to it. 
 
 ANATOMY. — The lack of discrimination between the anatomical 
 features of the lower end of the humerus at the different ages of 
 infancy and youth has led to much confusion amongst authors. 
 
 The difference of opinion between Malgaigne and E. W. Smith 
 in connection with lesions of this end of the hmnerus can be readily 
 explained in this way. 
 
 Fig. 86. — epiphyses about the left 
 elbow-joint at fiftehn years of 
 age. view feom the inner side 
 
 Fig. 87.— same as fig. 86. 
 view from the outer side 
 
 To reconcile Dr. E. W. Smith's views of separation of the lower 
 epiphysis of the humerus, which he published in 1850 (' Observa- 
 tions on Disjunction of the Lower Epiphysis of the Humerus,' 
 Dublin Quarterly Journal of Med. Science, No. 9, n.s. 1850, p. 6S), 
 with precise anatomical facts would be impossible. He says ' that 
 the lower epiphysis of the humerus does not include the condyles, 
 which belong entirely to the shaft of the bone,' and, after alluding to 
 
334 
 
 EPIPHYSES OF UPPEK EXTKEMITY 
 
 the writings of Malgaigne, Dupuytren, Adams, and Vidal, he goes 
 on : ^ ' The preceding extracts from the works of some of the most 
 celebrated authors upon the subject of fractures are, I should think, 
 sufficient to show that disjunction of the lower epiphysis of the 
 humerus (of which I find no particular mention made either by 
 
 Borger or Sir Astley Cooper) is an acci- 
 dent which has hitherto been confounded 
 with fracture immediately above the con- 
 dyles, an error from which it may be 
 inferred, I think, that the exact line of 
 junction of the epiphysis with the shaft 
 of the bone is not generally known to 
 surgeons. At all events it is manifest 
 that, by the authors from whose writings 
 I have quoted, this line has been supposed 
 to traverse the bone above the condyles, 
 whereas the anatomical fact is, that these 
 jjrocesses belong exclusively to the shaft of 
 the bone, and form no loortion wliatever of 
 the epiphysis, which comprises nothing hut 
 the capitellum and the trochlea. The 
 line which marks its junction with the 
 shaft is directed downwards and inwards, 
 terminating below and external to the 
 epicondyle, which, in the young subject, 
 is distinct both from the epiphysis and 
 from the shaft.' 
 
 After referring to the differences in the 
 condition of the trochlea and capitellum in 
 the young and adult, Dr. Smith says : 
 ' The knowledge of this fact is not destitute 
 of practical importance in the diagnosis 
 of that embarrassing accident, fracture 
 through the line of the epiphj^sis with the 
 shaft, or, in other words, fracture of the humerus immediately below 
 the condyles.' 
 
 Again, after alluding to the signs he believes to be common to 
 these lesions — dislocation backwards and fracture above the condyles 
 — Dr. Smith writes thus : ' As the loss of the normal relation between 
 the olecranon and the condyles renders the separation of the epiphysis 
 peculiarly hable to be confounded with dislocation of the forearm 
 iiackwards, and as it is obviously a matter of the utmost importance 
 to distinguish carefully between these accidents, let us now consider 
 the signs, by availing ourselves of which we materially diminish the 
 chance of mistaking it either for luxation or for fracture above the 
 condyles. In the case of fracture traversing the Hne of the epiphysis, 
 ' The italics in the following passages are tlie author's. 
 
 Fig. 88. — lo'CT'zk epiphysis 
 
 (PEOPEKLT SO called) OF 
 THE HUJIEKUS AT SIXTEEN 
 AKD A HALF TEAP>S OF AGE, 
 SEPAEATED BY ilACEBATION 
 
 The external epicondyle, the 
 trochlea, and capitellum 
 form one osseous mass. The 
 internal epicondyle is still 
 an isolated epiphysis, not 
 yet united to the diaphysis. 
 i size. 
 
SEPAKATION OF LOAVEE EPIPHYSIS OF HUMEEUS 333 
 
 the transverse diameter of the tumour which projects in front is 
 equal to that of the opposite humerus, measured anteriorly from 
 condyle to condyle ; in this respect the accident resembles the 
 dislocation of both bones backwards, but differs from fracture above 
 the condyles. The outline of this osseous tumour is rounded, 
 presents to the feel none of the irregularities or sharpness of an 
 ordinary fracture ; and upon its inferior surface, which is convex, 
 and limited at either extremity by the condyles, neither trochlea 
 nor capitellum can be distinguished. When the joint is viewed 
 posteriorly, two osseoas prominences are seen, and can be distinctly 
 felt ; they are both placed above and behind the plane of the 
 condyles, but are themselves situated (if the patient be not more 
 than six or eight years of age) nearly upon the same level, the 
 internal, however, being always a little higher up than the external. 
 At a more advanced age the distance between these two prominences 
 is observed to be greater, in consequence of the increased develop- 
 ment of the internal, which is formed by the olecranon, the summit 
 of which process grows by an epiphysis. At no period of life, how- 
 ever, at which it is possible for the accident in question to happen, 
 is the distance between the two projections nearly as great as it is 
 always found to be between those which, in cases of luxation of 
 both bones of the forearm backwards, constitute so marked a feature 
 of the injury. In the latter accident the distance averages about 
 one inch and a half, while in the former it is seldom more than 
 three-quarters of an inch ; the external tumour, in this case, being 
 formed by the capitelhim of the humerus, still surmounting the head 
 of the radius, for which, in consequence of the concave form of its 
 superior surface, it is extremely liable to be mistaken, if attention 
 be not paid to the diagnostic sign which has just been mentioned.' 
 
 In the rough figure given by E. W. Smith the external condyle 
 (external epicondyle) of the humerus is very distinct from the capi- 
 tellum and the rest of the articular process, and produces a very 
 erroneous impression of this portion of the lower epiphysis. 
 
 Farabeuf, in a paper in 1886 ' On the Lower Epiphysis of the 
 Humerus and its Traumatic Separation ' {Bulletins et Memoires cle la 
 Societe de Chirurg. Paris, N.s. xii. p. 692 ; Bevue des Sciences 
 Medicales, No. 57, 15 January, 1887 ; Le Brogres Medical, second 
 series, vol. iv. No. 32, 1886), agrees with Dr. Smith's observations, 
 and states that in this separation the humerus, displaced forwards, 
 carries with it its lateral eminences, the epitrochlea and epicondyle, 
 whose lower part only remains with the condyle (capitellum), and 
 preserves its toidth as in dislocation of the elbow, and that the signs 
 differ considerably from those of supra-condyloid fractures. He, 
 moreover, says that Dr. Smith's views were adopted by Giraldes 
 in his clinics. 
 
 E. Bottini (' Note sur la disjonction de I'epiphyse inferieure de 
 I'humerus et son tmitciiient,' Bullet, general de Tkerapcutlqne, Paris, 
 
336 EPIPHYSES OF UPPEE EXTEEMITY 
 
 1850, xxxix. pp. 167-170) has reproduced and endorsed E. W. Smith's 
 views as to the characters of this form of separation. 
 
 A recent writer in the AmericanText-hook of Surgery, 1892, Part I., 
 in speaking of separation of the lower epiphysis of the hmnerus, falls 
 into a similar error. ' The lower fragment usually comprises,' he 
 says, ' the entire epiphysis, which is composed of several distinct 
 pieces, but it is possible that either or both epicondyles may remain 
 attached to the upper fragment.' 
 
 It is difficult to aOTee with E. W. Smith in believing: that 
 separation of the two articular processes alone is frequent while 
 hotli epicondyles remain in contact vvdth the diaphysis. 
 
 His observations are true with regard to the internal epicondyle 
 after or just before the thirteenth year of life. About this period 
 this process, by the natural gTowth of the diaphysis, is isolated from 
 the rest of the lower epiphysial end, and may, and probably will, go 
 with the diaphysis. But for the external epicondyle to remain 
 attached to the shaft is inexplicable at any age. It appears as a 
 small nodule towards the outer and upper aspect of the capitellum 
 in the cartilage of the lower epiphysis about the thirteenth or four- 
 teenth year, and very rapidly, generally about the fifteenth to six- 
 teenth year, ossifies to the rest of the epiphysis. As seen at the 
 fourteenth to fifteenth year, not more than a third of its upper end 
 comes in contact with the diaphysis. 
 
 Now, as we shall see later on, the internal epicondyle usually 
 does, after puberty, remain attached to the diaphysis in this 
 accident, but from its anatomical condition it is difficult to under- 
 stand how the external epicondyle can ever remain attached to the 
 shaft. 
 
 While Bardenheuer calls all four pieces of the lower end of 
 the humerus the whole epiphysis, he recognises a separation of the 
 trochlea and capitellum together, without any reference to the 
 external epicondyle. He says {Deutsche Chirurgie, ' Die Krankheiten 
 der oberen Extremitaten, I. Theil, 1886, S. 729) that these may be 
 displaced either backwards or forwards. He calls the injury ' separa- 
 tion of the trochlea and capitellum,' stating that Gurlt has collected 
 five, and Bruns four, authentic cases ; but, as the author has elsewhere 
 mentioned, these are not clear cases of separation of these two 
 processes alone. 
 
 If we take Dr. Siuith's description, wdth the exception that the 
 external epicondyle remains with the capitellum, we should have a 
 good description of complete separation of the loioer epiphysis of the 
 humerus at or beyond the age of puherty {thirteen or fourteen) , ih.e 
 epiphysis comprising the articular processes and the external epi- 
 condyle. The epiphysial line of cartilage then passes from the outer 
 edge of the diaphysis from ahove the external epicondyle, not trans- 
 versely, but obliquely downw^ards and inwards towards the lower 
 edo-e of the trochlea on the inner side. 
 
SEPAEATiON OF LOWER EPIPHYSIS OF HUMEEUS 337 
 
 Sucli a lesion is by no means infrequent, but rare in comparison 
 witli the complicated epiphysial injuries of the elbow ; for experience 
 has shown that separations of this epiphysis after this age are 
 usually partial and often complicated by other lesions. 
 
 The greater portion of the external condyle (of anatomists) in the 
 adult is formed by the outer end of the diaphysis of the humerus 
 and the very small external epicondylar epiphysis. After the forma- 
 tion of the latter in the cartilage adjoining the capitellar portion 
 of the lower epiphysis, it very rapidly blends with it, so that its 
 detachment from this part must be an occurrence of extreme rarity 
 in the injury under consideration. 
 
 It is more than probable that separation of the true lower epi- 
 physis just below the age of puberty, before the internal epicondyle 
 is completely separated from the lower 
 end of the bone, will in consequence be 
 accompanied by a fracture through the 
 small cartilaginous strip between the 
 internal epicondylar and trochlear epi- 
 physes. AVe then have a separation of 
 the external epicondylar, capitellar, and 
 trochlear epiphysial mass, associated 
 with a fracture between the trochlea 
 and internal epicondyle. 
 
 In the adult, from an examination 
 of museum specimens and from experi- 
 mental research, these epiphysial pro- 
 cesses are found to be frequently 
 detached from the rest of the bone. 
 
 AGE. — Six published cases may be 
 considered under this heading. In Mr. 
 Heath's case of operation for deformity 
 the age was eighteen years; in Smith's 
 compound separation, about twelve 
 years ; in one simple case it was 
 twelve years ; and in three other simple 
 cases, presumably accompanied by frac- 
 ture of the lateral epicondylar strip on the inner side separating it 
 from the rest of the cartilaginous epiphysis, the age was five years. 
 
 PATHOLOGICAL ANATOMY.— Displacement of the epiphysis may be 
 backwards, forwards, or lateral. 
 
 The only specimen recorded is that of cUsplaGemeiit backwards 
 and outwards. 
 
 Professor Smith {Proceedings of the Pathological Society of Dublin, 
 N.s. vol. iv. 1870, p. Ill) has described it as follows in a case of 
 compound separation, sent to him by Dr. F. E. Clarke, county of 
 Donegal. It is also recorded {Med. Press and Circular, August 31, 
 1870, p. 157) by Dr. Clarke himself. The case was treated by a 
 
 z 
 
 Fig. 89. — coronal section of the 
 lower end of the humerus 
 at fourteen and a half years 
 
 OF AGE. i size. 
 
338 EPIPHYSES OF UPPEK EXTKEMITY 
 
 bone-setter, and resulted in gangrene of the hand and forearm from 
 the appHcation of a tight bandage and spHnts, and in death on the 
 eleventh day after the accident. 
 
 In 1868 a boy, in county Donegal, aged about twelve years, v^as 
 throw^n v^hen wrestling with a companion, and sustained a compound 
 fracture of the humerus through the line of junction of the epiphysis 
 of the lower extremity with the shaft of the bone. It appeared that 
 the lad, in falling, put out his right arm with a view of ' breaking his 
 fall,' and that his antagonist fell across the extended arm. On his 
 being brought home, the bone was seen to protrude through the skin. 
 Ten hours after the accident he was seen by a bone-setter, who 
 ' set ' the broken limb with splints and bandages, after reduction of 
 the displacement. Although the sufferings of the patient were 
 great and the pain intense from the tightness of the apparatus, 
 he was not seen by the bone-setter again for six days. Death 
 ensued five days after his second visit, and eleven days after the 
 receipt of the injury, gangrene having supervened. On the fifth 
 day after death, and second after interment, the body was exhumed 
 by order of the coroner for the purpose of having an inquest held 
 and an autopsy made, a feeling of indignation having arisen against 
 the bone-setter, to whose mismanagement the death of the boy was 
 attributed. On superficial examination a large external wound was 
 to be seen traversing the antecubital fossa, through which the 
 lower end of the upper fragment could be felt projecting forwards, 
 but it did not protrude beyond the edges of the wound. The edges 
 of the wound had not been approximated nor the bone reduced. 
 From upwards of an inch above, the entire forearm and hand were 
 extensively gangrenous ; so much so that it was impossible to make 
 an accurate dissection of the soft parts or to determine the state 
 of the vessels or nerves in the neighbourhood of the fracture. The 
 body had, in addition, undergone great decomposition. When the 
 wound was extended both above and below by incision, the con- 
 tinuity of the entire shaft of the humerus was found to he complete, 
 and contained the two condyles in an uninjured condition ; it was 
 devoid, however, of the two eminences which form respectively the 
 trochlea and capitellum and articulate with the two bones of the 
 forearm. The upper fragment, then, was the entire humerus merely 
 denuded of its inferior epiphyses ; the lower, those epiphyses them- 
 selves. The lower end of the upper fragment was nearly at the 
 external orifice of the wound, and directed forwards; and including, 
 as it did, the two condyles, was broad, with an extremely roughened, 
 jagged, and uneven extremity. The epiphyses alone constituted the 
 lower fragment, and still continued united together in one piece 
 and attached by the ligaments of the joint to the bones of the 
 forearm ; so that the articulation proper remained normal. The 
 upper extremity of this fragment was directed backwards and out- 
 wards. On measuring the arm before dissection, there was found 
 
SEPARATION OF LOWEE EPIPHYSIS OF HUMERUS 339 
 
 slight shortening as compared with the other, but the normal 
 relation of the olecranon process to the condyles (epicondyles) was 
 lost. The limb was gangrenous from an inch above the wound to 
 the extremity of the hand. 
 
 Dr. Clarke says that the lesion was in all particulars similar to 
 that described by Professor R. W. Smith. 
 
 In October 1897, Dr. F. B. Judge Baldwin, of Rotherham, an 
 old friend of the author, mentioned to him a case of compound 
 separation of the lower humeral epiphysis. It occurred in a boy aged 
 seventeen years. The diaphysis, stripped anteriorly and posteriorly 
 of periosteum, protruded for two inches through the wound on the 
 anterior surface of the arm, just above the bend of the elbow. The 
 joint was intact, and the brachial artery uninjured. A partial excision 
 of the joint was performed — that is, only the olecranon process of the 
 ulna was removed besides the humeral epiphysis. The internal epicon- 
 dyle was found to be absent from the epiphysis, while the external was 
 contused. Unfortunately this important specimen was not preserved. 
 
 Separation with fracture of the epiphysis. — Mr. Christopher Heath 
 excised (Clinical Soc. of London, British Medical Journal, October 
 20, 1888, p. 879) the elbow-joint of a young man aged eighteen, 
 which was ankylosed and distorted after injury. There was found 
 to be much thickening of the lower end of the humerus around the 
 fractured and separated epiphysis. 
 
 ETIOLOGY. — The direction of the force, whether it be direct or 
 indirect, determines the form of the displacement. 
 
 Gurlt, in describing the mechanism of this form of fracture 
 with displacement forwards, says that a priori it ought only to be 
 possible in complete extension of the elbow. The violence, then, 
 acting directly on the posterior aspect of the olecranon, causes this 
 process to start forwards ; and in support of this he observes that, 
 in a specimen in the Vienna Museum, there is a small fracture of the 
 olecranon. 
 
 Bardenheuer also believes that this form of injury is produced in 
 children by falls upon the olecranon, and that the violence is more 
 direct. 
 
 In several of the recorded cases of displacement hachioards the 
 injury was said to have been produced by a fall on the elbow. 
 
 It is more frequently caused by the violence being more indirect, 
 as by a fall on the palmar surface of the outstretched hand during 
 extension of the forearm, the violence being transmitted to the 
 capitellum and trochlea. 
 
 According to Farabeuf, it is the result of a retro-humeral blow 
 whilst the hand is in contact with the ground. 
 
 ' La meilleure condition pour que le decollement de I'epiphyse 
 inferieure de I'humerus se produise, c'est un choc retro-humeral 
 pendant que I'avant-bras est fiechi et la main appuyee sur une table 
 ou sur le sol.' 
 
 z 2 
 
340 EPIPHYSES OF UPPEPv EXTEEMITY 
 
 ' Le radius, fixe par la main, ne pent suivre le mouvement en 
 avant imp rime par le choc a rhumerus ; la tete du radius fait sauter 
 I'epiphj'se condylienne, qui se detache suivant la ligne oblique inter- 
 diaphyso-epiplij'saire. L'action du cubitus est dans cette circon- 
 stance toute differente de celle du radius ; le crochet coronoidien 
 accroche la partie diax^hysaire de Tos et ne pent contribuer au 
 decollement de Tepiphyse.' 
 
 Schiiller's experiments prove that forcible abduction, adduction, 
 flexion, extension, or pronation, or a combination of these, is x^ro- 
 bably sufficient, by still more indirect violence, to cause a detachment 
 of these processes. 
 
 SYMPTOMS. — E. W. Smith was the first to describe this form 
 of injury. 
 
 Deformity. — This differs, as in other epiphysial separations, 
 according to the direction of the displaced epiphysis. 
 
 DiSPLACEMEXT BACKWAEDS. — The forearm is flexed, and in a 
 position midway between pronation and supination. 
 
 The outhne of the joint has much the appearance of dislocation 
 of the radius and ulna backwards. 
 
 The signs of this injury as given by E. W. Smith (quoted in 
 E. E. Clarke's case, Med. Press and Circular, 1870, p. 157) are : ' The 
 great transverse breadth of the anterior tumour caused by the 
 retention of the two condyles in the lower extremity of the upper 
 fragment, and the two osseous tumours posteriorly, both of which 
 signs serve to distinguish it from a supra-condyloid fracture of the 
 humerus, which it much resembles, not only from the facts of 
 shortening and anterior osseous tmnours being present in both 
 lesions, but also because the antero-posterior diameter of the arm is 
 increased likewise by each form of injmy. It is also to be borne, in 
 mind that the normal relation of the three bony projections at the 
 back of the elbow was disturbed, the olecranon being above the 
 condyles, a fact which also serves to distinguish this epiphysiary 
 fracture from a supra-condyloid fracture, but which causes it to 
 resemble much a luxation of both bones of the forearm backwards, 
 a surgical lesion which Professor Smith likewise pointed out as 
 liable to be confounded in diagnosis with this fracture of the 
 humerus through the line of juncture with its lower epiphyses if 
 the important differential signs of the latter be not accm^ately 
 attended to. The two tumours posteriorly in an epiphysiary frac- 
 ture, being the head of the olecranon and the end of the epiphyses, 
 are nearly on a level, but those caused by a dislocation are fully an 
 inch one above the other, as they are formed by the olecranon and 
 of the radius respectively.' 
 
 Smith sums up by saying : ' It is manifest that (contrarj^ to 
 what the statement of authors would lead us to infer) implicit 
 reliance is not to be placed upon the loss of the normal relation 
 between the olecranon and the condvles of the humerus, as a 
 
SEPAEATION OF LOWEE EPIPHYSIS OF HUMEKUS 341 
 
 means of distinguishing between luxation of the forearm back- 
 wards, and fracture of the lower extremity of the humerus. It is 
 evident that there is an accident of the elbow in which the bones 
 of the forearm lose their natural relations to the condyles, and yet 
 that accident is not necessarily a dislocation, but may be a fracture 
 through the line of the lower epiphysis 
 of the humerus, which line is situated 
 below the condyles. 
 
 Bardenheuer also states that the 
 distance of the olecranon from the epi- 
 condijles is increased in this injury.' 
 The epicondyles are in normal relation 
 with one another and with the humerus, 
 and immovable, but the olecranon is 
 drawn considerably upwards and back- 
 wards by the triceps, which is curved. 
 The antero-posterior diameter of the 
 joint is increased, and the lower end of 
 the humerus projects forw^ards, capped 
 on the inner and outer sides by the 
 epicondyles. This resemblance to dis- 
 location has caused Pitha to term it 
 disjunctive dislocation. Bardenheuer 
 clearly describes epiphysial separation 
 of the trochlea and capitellum. 
 
 Farabeuf also mentions this preser- 
 vation of the natural breadth of the 
 upper fragment in contradistinction to 
 tranverse supra-condyloid fracture, where 
 it is much smaller and the lateral pro- 
 cesses are carried much furthex forwards 
 than in fracture. But instead of feeling, 
 as in dislocation, the radial cup on the 
 outer side, and very much beneath the 
 olecranon summit, the finger detects, 
 in separation, the condyloid (capitellar) 
 fragment in place, on the outer side of 
 the olecranon but a slight distance only 
 from the summit of this process. 
 
 To this description the author would add that the measurement 
 from the internal epicondyle to the styloid process of the ulna will 
 be greatly diminished, as in dislocation. 
 
 If the author's views are correct with regard to the external 
 epicondyle remaining with the articular epiphysis, the distance 
 between this epicondyle and the styloid process of the radius wall 
 not be diminished. 
 
 Dr. Smith concludes by quoting a case bearing out his views. 
 
 Fig. 90. — diageaii of separation 
 of the lower epiphysis of the 
 humerus at the age of fifteen 
 
 AND A HALF YEARS. USUAL FORil 
 OF INJURY. FRONT VIEW 
 
 The internal epicondyle is quite 
 distinct from the epiphysis, and 
 is not detached. Its normal 
 relation with the olecranon is 
 lost ; that of the external epicon- 
 dyle to the radius is preserved. 
 
342 EPIPHYSES OF UPPEK EXTEEMITY 
 
 Michael F., aged twelve, was admitted on August 24, 1847, into 
 Jervis Street Hospital under Dr. J. S. Hughes. He stated that he 
 was thrown down by another boy with great violence, and in falling 
 stretched out his arm to save himself, while the other boy fell with all 
 his weight across the back of the extended limb. On being examined 
 twenty minutes after the accident, before swelling occurred, the arm 
 was found to be powerless, the forearm semiflexed, and the hand in 
 position of half supination. The olecranon formed a remarkable pro- 
 jection above and behind the condyles of the humerus. A second 
 osseous tumour — the upper surface of which was concave, and which 
 was supposed at first to be the head of the radius — could be distin- 
 guished behind the outer condyle as the capitellum. The lower 
 extremity of the humerus formed a considerable prominence in front. 
 A moderate amount of flexion was permitted at the joint, and distinct 
 crepitus was felt on grasping the arm and forearm in each hand and 
 moving the fragments. The diagnosis was made of fracture through 
 the line of junction of the epiphysis with the shaft, with displace- 
 ment upwards and backwards of the epiphysis. The deformity was 
 easily removed by extension and counter-extension, and the limb was 
 secured by angular splints. There was some difficulty in keeping 
 the fragments in position, so that there was ultimately some projec- 
 tion forwards of the diaphysis, indicated by increase in the antero- 
 posterior diameter of the elbow, but the boy recovered very con- 
 siderable use of the limb ; he was able to extend the forearm 
 perfectly, and could flex it beyond a right angle. 
 
 Mobility is a marked feature. Adduction, abduction, and exten- 
 sion and flexion of the forearm may produce mobility close to the 
 joint. 
 
 Crepitus of the usual muffled character may often be detected, 
 especially during the reduction of the displaced epiphysis, which is 
 easily effected. 
 
 The following case of G. C, aged five years (for which he is 
 indebted to Dr. Andrew Fullerton), came under the author's observa- 
 tion at the Miller Hospital, Greenwich, in August 1891. The left in- 
 ternal epicondyle was still attached to the humerus, but the remaining 
 portion of the lower epiphysis of the humerus was detached and 
 drawn backwards and somewhat outwards, forming a projection 
 at the back of the lower part of arm. The distance between the 
 internal condyle and the olecranon was greater than on the sound 
 side. Muffled crepitus was readily felt. Active movements of all 
 kinds were completely lost. Pain, mobility, &c. were also present. 
 
 In this instance, the child being below the age of puberty, the 
 separation was accompanied by a fracture of the cartilage uniting 
 the internal epicondylar portion to the rest of the lower end of the 
 humerus. 
 
 Other symptoms of intra-articular fracture are often present, 
 but effusion into the joint will always be more marked than in 
 
SEPAKATION OF LOWEK EPIPHYSIS OF HUMEKUS 343 
 
 separation above the epicondyles in infancy, in which the articular 
 lesions may be wholly absent. 
 
 Enlargement of antero-posterior diameter of elbow is present in 
 both forms of backward displacement of the epiphysis, as well as 
 in the forward variety. 
 
 Fig. 91. — diagrammatic view (feom the outer side) of separation of the 
 
 LOWER epiphysis OF THE HUMERUS AT THE AGE OF FIFTEEN AND A HALF 
 YEARS. DISPLACEMENT OF DIAPHYSIS FORWARDS 
 
 The external epicondyle remains united to the capitellar portion of the epiphysis. 
 
 Passive movements of flexion and extension ; pronation and 
 supination may be effected in some degree, but never to the same 
 extent as in separation of the whole lower end of the humerus 
 during infancy. 
 
 Shortening of arm is very slight. 
 
 Displacement forwaeds. — The symptoms are almost the same 
 as in separation of the whole cartilaginous epiphysis, and both epi- 
 condyles with displacement forwards. 
 
 Loss of flexure of elbow-joint in front, which is occupied by an 
 osseous mass. 
 
 Increase of antero-posterior diameter of joint. 
 
 Measurement between epicondyles altered very slightly. The 
 internal one is immovable, in normal relation with the diaphysis 
 and on a level with the olecranon. 
 
 The olecranon does not project, and the triceps tendon is not curved. 
 
 There is mobility of the forearm with the epiphysis, especially 
 in the antero-posterior direction. 
 
 DIFFERENTIAL DIAGNOSIS. Dislocation backwards of elbow. — 
 This accident may be distinguished from a dislocation by the 
 readiness with which the epiphysis is replaced and again recurs, 
 also by the absence of the hollow of the sigmoid notch. 
 
344 EPIPHYSES OF UPPEE EXTREMITY 
 
 There is likewise a certain amount of lateral motion which is not 
 met with in dislocation at the elbow-joint, and muffled crepitus is 
 frequently present. 
 
 In this form of epiphysial separation, as in dislocation, the 
 relative position of the internal epicondyle to the olecranon is 
 altered. 
 
 Bardenheuer says that the absence of the trochlear process of the 
 humerus in front of the joint is a symptom in favour of epiphysial 
 separation. 
 
 Pitha (according to Bardenheuer) relates a case in which the 
 epiphysis (sic) was broken off and displaced backwards, simulating a 
 dislocation in this direction. A boy, aged five years, fell from a 
 window on to the open hand. The elbow was greatly swollen and 
 distorted, the triceps tendon concave, and the olecranon pro- 
 jected markedly an inch distant from the humerus. The flexure 
 of the elbow was sharply defined, and immediately above it 
 there was felt the sharp projecting edge of the humerus, which 
 threatened to penetrate the skin. The separate portions forming 
 the joint could not be made out on account of the swelling. The 
 forearm, which was kept slightly pronated and flexed, could be 
 more fully flexed, pronated, and supinated without difficulty and 
 without crepitation. There was an inch shortening of the arm, and 
 the diameter in depth increased by fourteen lines. Although the dia- 
 gnosis was said to be clear, and the injury classed by Bardenheuer as 
 one of epiphysial separation of trochlea and capitellum, it is by no 
 means evident that it was not an example of separation of the whole 
 lower end in infancy. 
 
 Smith epitomises the points of resemblance and dissimilarity 
 between this form of separation of the lower end of the humerus 
 and the two injuries with which it is most liable to be confounded — 
 viz. fracture immediately above the condyles and luxation of both 
 bones of the forearm backwards — but he says it is to the latter 
 it bears the greatest resemblance. 
 
 ' The symptoms which belong to it in common with fracture 
 above the condyles are the following: shortening, crepitus, the 
 removal of the deformity by extension, and its tendency to recur 
 when the extending force is relaxed, the presence of an osseous 
 tumour in front of the joint, and the increase in the antero-posterior 
 diameter of the elbow. 
 
 ' It differs from the supra-condyloid fracture in the greater 
 transverse breadth and regular convex outline of the anterior 
 tumour, in the existence of two tumours posteriorly, and in the 
 loss of the normal relation of the olecranon to the condyles. 
 
 ' It resembles dislocation of both bones of the forearm backwards 
 in the following" particulars : the transverse diameter of the anterior 
 tumour is the same in each case ; so also is the antero-posterior 
 breadth of the elbow, and in both the olecranon ascends above the 
 
SEPAKATION OF LOWEB EPIPHYSIS OF HUMEKUS 345 
 
 condyles, the limb is shortened, and two osseous prominences can 
 be distinguished posteriorly. It differs, however, from luxation in 
 the existence of crepitus, the tendency of the deformity to recur, in the 
 anterior tumour being destitute of trochlea and capitellum, and in 
 the circumstance of the two posterior tumours being nearly upon 
 the same level.' 
 
 These remarks of Professor E. W. Smith are quoted again by him 
 in his address to the British Medical Association in 1867 {British 
 Medical Journal, August 17, 1867, p. 122) on ' Epiphysiary Dis- 
 junctions.' 
 
 Displacement of the epiphysis forwards simulates in like manner 
 dislocation of the radius and ulna forwards at the elbow-joint. 
 
 Pitha (according to Bardenheuer) relates an instance where 
 the separated trochlea and capitellum were displaced forwards, 
 resembling dislocation of the forearm. 
 
 A child, aged five, sustained a fall upon its elbow. The flexure of 
 the elbow was found to be obliterated, the biceps and brachialis anticus 
 raised up by a rounded mass, and the diameter of the joint in its 
 depth increased by eight lines, but the olecranon was not prominent, 
 nor the triceps curved. The epicondyles were well marked and 
 immovable, and on a level and in normal relation with the olecranon. 
 Mobility of the trochlea and capitellum from before backwards was 
 detected, with crepitus, when they were held by the hands and the 
 olecranon fixed. Reduction was effected by means of pressure upon 
 the trochlea and capitellum, and by increase of the flexion. Complete 
 recovery took place. 
 
 From the age of this child it is difficult to understand how the 
 epiphysis of the external epicondyle could have gone with the 
 diaphysis, although on the inner side the cartilaginous process of the 
 internal epicondyle might have been broken off from the rest of the 
 lower, almost cartilaginous, end of the humerus. 
 
 Bardenheuer adds that the differential diagnosis of the injury 
 from displacement through dislocation is the normal relation between 
 the olecranon and the epicondyles {sic). 
 
 The PROGNOSIS and TREATMENT are precisely the same as 
 for epiphysial separation below the age of puberty. 
 
346 EPIPHYSES OF UPPEK EXTKEMITY 
 
 CHAPTEE VI 
 
 SEPARATION OP INTERNAL EPICONDYLB 
 OP THE HUMERUS 
 
 ANATOMY. — It is preferable to restrict the terms 'internal' and 
 ' external epicondyles ' to the lateral epicondylar epiphyses, as being 
 anatomically correct. They are placed upon — or, rather, comprise — a 
 large portion of the abrupt lateral projections on the inner and outer 
 sides of the lower end of the humerus ; and for the projections them- 
 selves it is better to keep the names mostly known to English 
 anatomists — viz. the ' internal ' and ' external condyles.' 
 
 These condyles are thus formed in part by a prolongation of the 
 inner and outer elevated margins of the diaphysis of the humerus, 
 and in part from separate centres of ossification, which in early life 
 are formed from the lateral elevated portions of the cartilaginous 
 lower epiphysis. 
 
 The external condyle, in addition, is formed by a portion of the 
 non-articular posterior part of the capitellar epiphysis. 
 
 They do not include any part of the articular surface, but 
 American and some British surgeons speak of the internal and 
 external condyles as including as much of the articular surface as 
 belongs to the trochlea and capitellum. 
 
 As the lower end of the diaphysis develops and grows downwards, 
 especially on the inner side, these lateral epiphyses or epicondyles 
 overlie the diaphysis more than before. This is especially the case 
 on the inner side, where the internal epicondyle becomes entirely 
 separated from the rest of the lower epiphysis. It becomes a distinct 
 epiphysis, the osseous nucleus of which unites with the inner aspect 
 of the diaphysial projection ; whereas the external epicondyle is 
 seldom separated from the rest of the lower epiphysis, and overlaps 
 the diaphysis to a very small extent. 
 
 The osseous epiphysis of the internal condyle, which develops in 
 the upper portion of the primary cartilage of the end of the humerus 
 at the inner side, has nothing to do with the fully formed lower epi- 
 physis, properly so called — at any rate after the thirteenth year. 
 From this time it is separated from the trochlea by a quarter of an 
 inch and more of the lower end of the diaphysis of the humerus 
 
INTEKNAL EPICONDYLE OF HUMEEUS 
 
 347 
 
 which forms the inner aspect of this process, and its lower end is 
 f\j inch above the synovial cavity on the inner side. 
 
 But from the time of the first appearance of this centre for 
 twelve years and more it may be detached. In the first years its 
 separation must be accompanied by a 
 fracture of the thin cartilaginous strip 
 extending between it and the trochlear 
 portion of the lower epiphysis. On 
 making a frontal section of the fully 
 developed lower end of the humerus, 
 this process is found to be nearly a 
 quarter of an inch above the epiphysial 
 line of junction (see fig. 89) . 
 
 The centre for the internal epicon- 
 dyle (epitrochlea) appears at about the 
 fifth year, and is the origin of its pro- 
 jection. This process is almost sepa- 
 rated from the rest of the lower epi- 
 physis by the growing diaphysis about 
 the thirteenth year or a little later. It 
 becomes a separate epiphysis and unites 
 with the lever-like process of the 
 humeral diaphysis at the eighteenth or 
 twentieth year. 
 
 The internal epicondyle is directed 
 a little backwards, and from its anterior 
 aspect arise five of the flexor muscles — 
 viz. the flexor carpi radialis, flexor carpi 
 
 ulnaris, flexor sublimis digitorum, palmaris longus, and a small 
 portion of the pronator radii teres at the upper part. The internal 
 lateral ligament is attached to its lower aspect, which spreads out in 
 a radiating manner, and connects it to the coronoid and inner border 
 of the olecranon process. 
 
 The ulnar nerve runs in a groove at the back of this process. 
 This relation is of great importance from the fact that injury to this 
 nerve is of frequent occurrence in epiphysial separations. It should 
 be remembered that the fibro-osseous canal for this nerve is com- 
 pleted by the fibrous band which stretches from the epicondyle to the 
 inner border of the olecranon, and has fibres of the flexor carpi ulnaris 
 attached to it. 
 
 Although the base of this process is slightly curved, with the 
 convexity outwards, at "the age of fourteen to fifteen years, it is 
 almost on a level with the inner border of the trochlea continued 
 upwards. After this period, from the continued inward and down- 
 ward growth of the diaphysis, its convex base is placed further 
 to the inner side of this, so that at the eighteenth year it is nearly 
 three-eighths of an inch from the same line. ' 
 
 Fig. 92. — epiphysis of the in- 
 ternal EPICONDYLE AT SEVEN- 
 TEEN AND A HALF YEARS OF AGE 
 
 All the other epiphyses of the 
 lower end of the humerus united. 
 i size. 
 
348 EPIPHYSES OF UPPEE EXTKEMITY 
 
 At this age the epicondyle projects two centimetres beyond the 
 inner side of the trochlea ; this measurement, therefore, corresponds 
 now exactly to the length of the lower border of the x:)rocess. 
 
 In its fully formed condition the epicondyle is five-eighths of an 
 inch vertically, three-eighths of an inch thick, and nearly half an 
 inch wide in the antero- posterior direction ; convex on its anterior 
 aspect, concave and smooth on its posterior aspect. Its lower 
 border is almost transverse and of some length, while its upper is 
 not of any extent, it being the commencement of the inner or upper 
 border of the internal condyle formed by the diaphysis of the humerus. 
 
 At fourteen years of age the apex of the internal epicondyle is 
 15 mm. from the inner margin of the olecranon when the elbow 
 is bent at a right angle ; at nineteen years of age it is 20 mm. 
 distant. 
 
 True separations of the internal epicondyle are therefore limited 
 to this epicondylar epiphysis, and can only occur in a pure form 
 after the formation of the epiphysis, from about the thirteenth to the 
 twentieth year — that is, before union has taken place to the humeral 
 portion of the internal condyle — and will be extra-articular. Before 
 this period the internal epicondyle is still part of the lower car- 
 tilaginous epiphysis, and its separation will be attended by a 
 cartilaginous fracture detaching it from the rest of the lower end ; 
 while at this age it is probable that the synovial membrane will be 
 opened on the inner side of the trochlea, but this need not of 
 necessity occur. 
 
 The epicondylar epiphysis sometimes persists to the age of 
 twenty-five years, according to Bambaud and Renault (Developpe- 
 ment des os, Paris, 1864, p. 203), or even further into adult life, 
 rendering an epiphysial separation possible in the adult. 
 
 The author will endeavour to omit as far as possible all discussion 
 of fractures of the whole of the internal condyle (including in this 
 term the diaphysial as well as the epiphysial portion), which are even 
 more commonly met with in children than they are in adults, and 
 draw a line of distinction between them and separation of the smaU 
 epiphysial portion of this process. 
 
 Many surgeons reject this distinction, because ' practically there 
 is no difference in the treatment or in the results ; and, furthermore, 
 they state that the differential diagnosis between the tw^o cannot be 
 made upon the living with anything like certainty.' 
 
 This opinion cannot any longer be held, since so many cases 
 of fracture limited to the epiphysial line have now been verified in 
 the recent state by direct examination. 
 
 ETIOLOG-Y. Muscular action. — Granger, who was the first to 
 describe this injury in 1818 (' On a Particular Fracture of the 
 Inner Condyle of the Humerus,' by Benjamin Granger, Burton- 
 on-Trent ; Edinhurgli Med. and Surgical Journal, vol. xiv. p. 196, 
 April 1818), attributed it solely to muscular action. 
 
INTERNAL EPICONDYLE OF HUMERUS 349 
 
 He says : ' A distinguishing circumstance attending this frac- 
 ture ' — which he calls a particular fracture of the internal condyle — 
 ' is that of its being occasioned by sudden and violent muscular 
 exertion ; and it will be recollected that from the inner condyle 
 those powerful muscles which constitute the bulk of the fleshy 
 substance of the ulnar aspect of the forearm have their principal 
 origin. The way in which the muscles of the inner condyle are 
 involuntarily thrown into sudden and excessive action I take to be 
 this : the endeavour to prevent a fall by stretching out the arm, and 
 thus receiving the percussion from the weight of the body on the 
 hand.' 
 
 In only two of Granger's cases does he clearly establish that the 
 fracture was caused by muscular action ; but, on the contrary, as 
 Hamilton says, from the violent inflammation which generally 
 ensued in his cases, the frequency of ecchymosis, and the injury 
 done to the ulnar nerve in at least three instances, one must rather 
 believe that most of them were produced by direct blows from below 
 in the fall upon the ground. 
 
 Denuce and Cesar thought, like Granger, that this lesion could 
 only be produced by muscular action or direct violence. 
 
 Certainly, in children muscular action alone is quite sufficient to 
 effect a separation. 
 
 Hamilton relates {loc. cit. supra, p. 304) the case of a man, aged 
 thirty-four, who, probably from muscular action, separated a portion 
 of the internal condyle, presumably the epicondyle. It was displaced 
 downwards, and was accompanied by a dislocation backwards of the 
 forearm. He thought that delay in the epiphysial union might have 
 been present m this case. 
 
 Poinsot refers to one case, mentioned by M. E. Hirtz, in which 
 the accident was declared to be plainly the result of muscular action, 
 it being occasioned in a little boy aged nine years by the act of 
 raising himself by his arms while suspended from a trapeze. 
 
 Clement Dukes {British Medical Journal, 1874, vol. ii. p. 403) 
 reports the case of T., aged sixteen. For three months he had 
 had a little pain at the inner side of the arm at the elbow when 
 exercising in the gymnasium. On July 4, 1874, he injured his elbow 
 through a fall from the horizontal bar while performing the exercise 
 called 'back away.' He says that he kept hold of the bar with his 
 hands too long, so that, instead of alighting on his feet as usual, he 
 fell on ' all fours,' with his arms extended ; but the force was suffi- 
 cient to make the left arm suddenly flex outwards. He felt some- 
 thing crack and cause him pain at the elbow and a feeling of 
 faintness. On examination the arm was held stiff, neither flexed nor 
 extended. There was a swehing over the internal condyle of the 
 humerus like a swollen bursa, making the condyle appear very 
 prominent. Immediately below this, instead of the usual convex 
 contour on the inner side of the forearm, there was a considerable 
 
350 EPIPHYSES OF UPPEE EXTEEMITY 
 
 hollow or concave outline, with slight extra thickness of the 
 muscles of the forearm antero-posteriorly. Owing to this the outer 
 contour of the forearm seemed increased in convexity, but was in 
 reality normal when the two arms were compared, thus dispelling 
 the idea of a dislocation of the radius and ulna outwards, which it 
 resembled at first from the prominent inner condyle with the 
 depression below. ' On manipulation, flexion and extension were 
 perfect and almost painless, also rotation internally and externally ; 
 but when the palm of the left hand was placed over the inner 
 condyle and the arm moved, great pain was elicited. Over the 
 inner condyle a free, movable morsel of bone could be felt, causing 
 no crepitus, but moving easily and smoothly, and distinctly external 
 to the joint, being a separation of the internal epicondyle of the 
 humerus, caused by muscular action through the forcible flexion 
 of the forearm on the arm. There was no injury of the ulnar 
 nerve. A rectangular splint was applied, with a figure-of-eight 
 bandage and a pad on the elbow. Position and union were effected 
 well. 
 
 Direct violence. — This injury is frequently occasioned by a direct 
 fall upon the inner side of the elbow% although in adults direct 
 violence is much more commonly a cause of fracture of the internal 
 condyle than in children, where the internal epicondyle is less 
 prominent and therefore less hable to be injured by direct violence. 
 The marked projection of this process in adults might almost make 
 it regarded as a predisposing cause of the injury. 
 
 Separation of the internal epicondyle before twelve or thirteen 
 years of age will be more adequately produced by direct violence, 
 which will also detach it from the trochlear portion of the lower 
 epiphysis, and the synovial membrane of the joint will become more 
 liable to injury, as has already been said. 
 
 Out of fourteen cases collected by M. Cesar (A. Cesar, These, 
 Essai sur lafract. de VejpitrochUe, Paris 1876), four being in adults, 
 at least eight were said to have been produced by a direct cause. ^ 
 
 A lad, aged eleven, was brought to Hamilton, in October 1848. 
 He had just fallen upon his elbow, the blow having been received — 
 as he affirmed and as the ecchymosis showed pretty conclusively — 
 directly upon the inner condyle. The fragment was. quite loose, 
 and crepitus was distinct. He could fiex and extend the arm and 
 rotate the forearm without pain or inconvenience. Hamilton was 
 quite sure the fracture did not extend into the joint. The result 
 seemed also to confirm this opinion, for in three months from the 
 time of the accident the motions of the elbow-joint were almost 
 completely restored. 
 
 Indirect violence. — In several instances it has been produced by a 
 fall upon the wrist or palm of the hand, the arm being extended. 
 
 1 It must be stated that two of these are Granger's cases, in which the cause of the 
 injury is but vaguely given. 
 
INTERNAL EPICONDYLE OF HUMERUS 351 
 
 In these the result may sometimes be due to the action of the 
 internal lateral ligament, the epiphysis being torn away by the stress 
 thrown upon this ligament during the over-extension rather than by 
 muscular action (Packard, Pingaud, Bouilly, and others). 
 
 Two of Granger's cases were due to falls on the hand, and this 
 author thought that such falls were a common mode of injury, the 
 epiphysis being torn off by violent contraction of the muscles in the 
 act of the patient putting out his hand in falling ; but this theory is 
 hardly borne out by the recorded cases. In five out of ten instances, 
 complicated with dislocation (two in adults), collected by G. Eallier, 
 the fracture was produced by a fall upon the palm of the hand, in 
 two by a fall on the elbow, and in one by a fall on the dorsal aspect 
 of the wrist. The remaining few were caused by direct violence, 
 showing that in these complicated cases the violence is usually 
 indirect. 
 
 In separations accompanied by dislocation the injury is less 
 indirect. Forcible adduction, abduction, and powerful rotation of 
 the forearm are common modes of violence. 
 
 In two of Fallier's cases caused by a fall on the elbow, the one 
 (Richet's) case was complicated by a dislocation of the elbow back- 
 wards and inwards ; the other, also inwards, was in an adult. 
 
 It will be seen hereafter that separations produced by indirect 
 violence, from the tearing away of this process by the resisting 
 internal lateral ligament and other ligamentous structures attached 
 to it, are usually accompanied by dislocation backwards or outwards 
 of the elbow — a mechanism sufficiently obvious when we see how 
 firmly the epicondyle is bound to the ulna. 
 
 The force of the fall upon the palm of the hand produces over- 
 extension of the forearm, with forcible lateral flexion towards the 
 outer side, causing the natural inclination of the forearm outwards 
 to become greatly exaggerated and the internal lateral ligament 
 violently put on the stretch. 
 
 Hence it cannot be wondered that some surgeons, especially in 
 Germany, regard the separation of this process as the usual compli- 
 cation of outward dislocation of the elbow. 
 
 In Berthomier's experiments lateral flexion, with or withoui" 
 torsion, produced epiphysial separation of the internal epicondyle 
 (epi trochlea) or of the external epicondyle (epicondyle), according to 
 the direction of the flexion. He thought that the latter injury was 
 sometimes mistaken in very young children for the injury called 
 ' subluxation of the head of the radius.' 
 
 AGE. — Detachment of the internal condyle is much more frequent 
 in children than in adults, whether it be a pure separation of this 
 epiphysis or a true fracture of its diaphysial portion. 
 
 Malgaigne treated a fracture of the epitrochlea in a boy of ten. 
 M. Pezerat had also seen (1832) one in a boy aged ten (' Sur la 
 fract. de I'epitrochlee, Journal Complementaire, t. xlii. p. 418). 
 
352 EPIPHYSES OF UPPEK EXTEEMITY 
 
 Denuce considered all fractures of the epitrochlea in subjects 
 below eighteen years of age as epiphysial separations. 
 
 In an instance just quoted Hamilton has gone so far as to 
 assume that a fracture of the internal epicondyle in a man aged 
 thirty-four, the result of muscular action, must have been due to 
 delay in the union of this epiphysis. 
 
 Coulson, in a discussion at the Eoyal Medical and Chirurgical 
 Society, January 11, 1859, gave three instances— two in boys aged 
 ten and a half and eleven, respectively ; and one in a girl aged three 
 and a half. 
 
 Stimson mentions two cases, one in a girl aged thirteen, and the 
 other in a boy aged eleven. 
 
 M. Cesar desciibes ten cases in children out of a total of four- 
 teen. Two were from eight to ten years old, five from eleven to 
 twelve, and three from fifteen to sixteen (Cesar, Essai sur la fract. 
 de repitrochUe, These de Paris, 1876). 
 
 Out of five cases mentioned by Hamilton four occurred in children 
 between two and fifteen years of age. 
 
 In Ealher's eight cases, compHcated with dislocation, one was at 
 nineteen years of age, one at eighteen, three at fifteen, and one each 
 at fourteen, twelve, and eleven ; that is, six cases between eleven 
 and fifteen years. 
 
 In thirty-eight cases of detachment of the internal epicondyle 
 collected by Mr. Jonathan Hutchinson junior {British Medical 
 Journal, December 30, 1893, p. 1419) ' the age ranged between eight 
 and eighteen years.' 
 
 In the author's collection of cases, amounting to sixty-one, the 
 ages in the five operation cases were : one at eighteen years, one at 
 thirteen, one at eleven, and one at ten and a half ; while in one 
 the age was not stated. 
 
 In the five pathological specimens the age was undeterminable. 
 
 Among the simple cases the age is not given in six ; in three others 
 it occurred in young boys ; of the remaining forty-two no less than 
 thirty-one ranged from ten years to sixteen ; only one above this age, 
 at seventeen years ; and ten cases from three to nine years of age. 
 
 SEX, In Cesar's fourteen subjects only one was of the female 
 
 sex, and that was an adult. 
 
 The ten cases recorded by M. Ealher — which were all complicated 
 with dislocation, and two of them in adults— were all of the male 
 sex. He thinks that, besides the occupation of the male sex render- 
 in^y these subjects especially Hable to this as to other forms of fracture, 
 the presence of the adipose tissue which surrounds and protects this 
 process in the female from direct violence, the lesser power of the 
 epitrochlear muscles, and the smaher projection of the process in 
 women than in men, may account for the greater preponderance 
 in men of this form of injury, which is even greater than in 
 ordinary fractures. 
 
INTEENAL EPICONDYLE OF HUMEEUS 353 
 
 Fallier collected forty-eight cases of fracture of the internal epi- 
 condyle, simple or with dislocation, including adults. Of these, 
 nineteen were complicated with dislocation of the elbow. 
 
 Although the author has been able to collect only sixty-one authen- 
 tic examples of separation of this process in children, it cannot be 
 doubted that this injury must be vastly more frequent than these 
 figures would lead us to suppose. 
 
 PATHOLOGICAL ANATOMY.— Specimens showing the existence 
 of a diastasis of the epiphysial internal epicondyle are few in 
 number, although it must be admitted that it is a very frequent 
 injury in the living subject. 
 
 With the exception of the dissecting-room specimens, most have 
 been accompanied by other serious complications. 
 
 It is probable that separation of this small epiphysis is even 
 more frequent than separation of the whole lower epiphysis of the 
 humerus. Bardenheuer puts it next to the lower epiphysis of the 
 humerus in order of frequency. 
 
 Malgaigne, in speaking of fracture of the epitrochlea, or the 
 whole of the internal epicondyle, says ' there is good ground for 
 supposing that, in some cases at least, it is a disjunction of the 
 epiphysis.' Yet no drawing of one is to be found in Malgaigne 's 
 * Atlas.' 
 
 Gurlt also states {Handhuch cler Lehre von den Knochenhrilchen, 
 Hamm. 1862, pp. 796, 797) that clinical experience shows that both 
 the inner and outer epiphyses are sometimes broken, however diffi- 
 cult it may be to demonstrate the fact anatomically. 
 
 Displacement downwards. — Hamilton gives (Iog. cit. supra, 305) 
 a full description and a figure of a specimen sent to him by 
 Dr. Zuckerkandl — demonstrator of anatomy in the University of 
 Vienna — but without a clinical history. The following is Zucker- 
 kandl's account of the specimen : 
 
 ' The separation of the internal epicondyle I found on the left 
 arm of a strong-boned man. After the removal of the flexors, the 
 epicondyle appeared projecting forwards tumour-like, but im- 
 movable, so that at first sight I thought of a fracture healed by 
 callus. As I removed the dense connective tissue which sur- 
 rounded the epicondyle, there appeared a furrow, which encircled 
 the irregular bony prominence, and formed a sharp line of demarca- 
 tion between it and the humeral epicondyle. The tumour-like bony 
 prominence, therefore, represented the epiphysial epicondyle. On 
 further examination it was seen that the epiphysial was connected 
 with the humeral epicondyle only by dense tissue, was irregularly 
 formed on its uneven upper surface, slightly concave on its superior 
 attached side, and of about the size of an os lunatum, In the 
 figure is plainly seen the intact humeral epicondyle, the epiphysial 
 epicondyle, and between them the above-described furrow, which 
 was filled with fibrous tissue. The separated epicondyle does not 
 
 A A 
 
354 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 correspond in form to that of a youthful person, nor to the inferior 
 part of the flexor condyle in the adult. Its long axis in the latter is 
 parallel with that of the humerus ; in our preparation, however, it 
 is sagittal, twisted, as it were, on its axis. The inferior portion of 
 the epicondyle is, in the adult, about one-half centimetre distant from 
 the edge of the trochlea, but it is more than one centimetre removed 
 in this preparation, so that the lateral surface of the trochlea is very 
 deep.' 
 
 However, Hamilton adds that ' the bone is from an adult, as 
 stated by Dr. Zuckerkandl, but he has omitted to mention that the 
 coronoid fossa is small and the olecranon fossa nearly obliterated, 
 indicating that for a long time before death the motions of the joint 
 were limited. The presumption is, therefore, that this was an old 
 
 fracture, a fact which increases greatly 
 the difficulty of determining precisely 
 the original character of the accident. 
 There is a broad, vertical, and remark- 
 able facet mentioned by Dr. Zucker- 
 kandl on the inner side of the trochlea ; 
 the outer condyle is probably not nor- 
 mal in its shape, and altogether there 
 are indications that the bone has at 
 some time suffered a very severe and 
 perhaps complicated injury. Perhaps 
 there was more than one line of frac- 
 ture, possibly a transverse fracture 
 through the shaft at the base of the 
 condyles, or through the line of the 
 epiphysial junction. If such were the 
 fact, the specimen does not illustrate a 
 simple fracture of the epicondyle ; but 
 these are points which the ancient 
 character of the fracture does not permit us to determine positively. 
 We think, however, this may properly be called a separation of the 
 epiphysial portion of the internal epicondyle, but whether it was a 
 simple fracture or separation, uncomplicated with any other lesion 
 of the bone, cannot now be determined.' 
 
 This is presumably the specimen from a fully developed man 
 figured and alluded to by Dr. Zuckerkandl {AUgemeine Wiener 
 medizinische Zeitung, February 1878) as a true epiphysiary disjunc- 
 tion united by fibrous material to the shaft. 
 
 A specimen is here figured of separation of the internal epicondyle 
 removed by the author from the body of an adult in the dissecting 
 room of Guy's Hospital in 1888. 
 
 The displacement is directly downwards and a little forwards ; 
 it is completely off the internal condyle, to which it is still 
 connected at its lower and posterior part by a thick band of fibrous 
 
 Fig. 93. — detachment and dis 
 placement downwabds of in 
 ternal epicondyle 
 
INTEENAL EPICONDYLE OF HUMEEUS 355 
 
 tissue. The process of bone is almost exactly the shape of the 
 normal epiphysis, and is in contact with the inner side of the 
 trochlea of the hmxierus, between which there was some fibrous 
 tissue. There are no other signs of fracture in the bone (see fig. 93), 
 
 M. Paulet found by dissection on a dead subject the epicondyle 
 * carried downwards and lodged on the inner border of the great 
 sigmoid cavity of the ulna, over which it played and looked like a 
 kind of independent sesamoid bone adhering by its inner aspect 
 alone to the lateral ligament.' 
 
 Dr. Kammerer showed, before the New York Surgical Society on 
 October 24, 1888 {New York Medical Journal, January 26, 1889, 
 p. 109), a specimen of separation of the internal epicondyle that he 
 had removed in resecting the elbow of a man aged sixty-one. He 
 found the epicondyle separated from the humerus, and attached to 
 it by fibrous tissue. There were no other injuries of the bone. On 
 section of both portions across the line of separation the inner 
 fragment was found to be lined with hyaline articular cartilage. It 
 was doubtful whether the epicondyle had been united to the 
 humerus at all, or had been separated by a fracture, a new joint 
 forming subsequently. 
 
 Gurlt figures {Lehre von den Knochenbrilchen, II. Theil, 
 II. Lieferung, S. 797, fig. 109) a specimen of fracture of the internal 
 condyle in the museum of Wlirzburg. The fragment is displaced 
 directly downwards a little beyond the lower border of the trochlea, 
 to the inner side of which it has become united. This was the only 
 specimen of united fracture known to Gurlt. From the figure it 
 appears probable that the epitrochlear fragment included also a 
 small portion of the shaft above it. Such a specimen cannot be 
 regarded as a non-union of the normal epiphysis : on account, first, 
 of the dissimilarity with the normal epiphysis, and, secondly, its 
 displaced position downwards. 
 
 In Mr. Hutchinson junior's excised specimen it was proved on 
 section to include the whole of the small epiphysis for the internal 
 epicondyle. 
 
 Displacement backwards. — A notable example of this form of dis- 
 placement came under the author's care at the Miller Hospital on 
 December 18, 1893, in which there was pressure upon the ulnar 
 nerve by backward displacement of the fragment. 
 
 E. J., aged eleven years, was running along the street when he 
 fell and struck his left elbow against the pavement. On admission 
 the arm was semiflexed and midway between pronation and supina- 
 tion. Any attempt at movement caused the greatest pain. There 
 was great swelling and extravasation of blood over the posterior and 
 outer aspects of the arm and elbow ; less on the inner side, so that 
 the outline of the olecranon was not much obscured. The deformity 
 on the inner side was very marked. The internal epicondyle was 
 very prominent and movable on the inner and posterior aspects of 
 
356 
 
 EPIPHYSES OE UPPEE EXTEEMITY 
 
 the joint in the position in which the patient held it ; but when the 
 elbow was more extended the inner side of the olecranon tip came 
 in contact with this process, so that in extension merely a wrinkled 
 fold of skin was left between these two points. The internal 
 epicondyle was also above the normal inter-epicondylar line crossing 
 the tip of the olecranon posteriorly. All measurements showed the 
 close approximation of the internal epicondyle to the inner side 
 of the olecranon process, while the external epicondyle, olecranon, 
 &c., held their normal relation one with another. There was 
 some loss of sensation on the inner side of the hand. The elbow 
 was put up on an anterior rectangular splint, and the epicondyle 
 
 placed in position. However, the loss 
 of sensation, with some weakness of the 
 muscles of the little finger, continued, 
 while at the end of a fortnight the 
 internal epicondyle did not appear to be 
 so much displaced backwards as it had 
 been previously. As the condition had 
 its possible origin in direct injury to the 
 ulnar nerve at the time of the injury, 
 operative measures were delayed till 
 January 5, 1894. The loss of sensation 
 then extended over the whole of the little 
 finger, and the inner half of the ring 
 finger, and inner side of the hand. 
 " Elexion, extension, and pronation and 
 supination were limited. Under chloro- 
 form, January 5 (eighteenth day after 
 the accident) , a small incision was made 
 through the skin over the internal e]3i- 
 condyle, which was found to be almost 
 quite loose, i.e. with the exception of a 
 sHght process of fibro-cartilaginous tissue at the lower part. The peri- 
 osteum and the muscular and tendinous attachments were completely 
 stripped from off its apex, leaving the bone quite bare. The epi- 
 condyle was rotated backwards on its vertical axis, so that the sharp 
 anterior edge where it joined the internal condylar portion of the 
 humeral diaphysis was directed backwards and inwards, and the 
 fractured surface, which still presented a very small amount of un- 
 ossified cartilage, looked inwards and forwards. Its size was, after 
 removal, 13 centimetres vertically and 10 centimetres antero- 
 posteriorly (see fig. 95). 
 
 After removal of the epicondyle, three silk sutures closed the 
 wound, without drainage ; a rectangular splint was again applied for 
 ten days. On the following day, January 6, the loss of sensation 
 in the parts suppHed by the ulnar nerve had almost entirely dis- 
 appeared. On January 10 the wound had healed by primary union. 
 
 Fig. 94. — separation of internal 
 epicondyle, with displacement 
 backwards and pressure upon 
 ulnar nerve. diagraim op area 
 of loss of sensation before 
 operation 
 
INTEKNAL EPICONDYLE OF HUMEEUS 357 
 
 Sensation had entirely recovered two days previously ; the sutures 
 were removed. On January 20 passive movement was begun. AYhen 
 the author saw the patient again on May 4, 1894, the functions of the 
 elbow were almost perfect ; extension was the only movement that 
 could not be carried out to its fullest extent ; this was so slight as 
 to be quite inappreciable to the patient. An interesting feature was 
 now present in marked prominence at the site of the original epi- 
 condyle ; in fact, a new epicondyle had been formed, the base of it 
 no doubt by the continued growth of the diaphysis of the humerus, 
 but the bulk of it by the periosteal covering of the epicondyle. 
 This, as well as the complete return of function of the muscles 
 attached to the epicondyle, is probably accounted for by the fact 
 that the periosteum was completely stripped' with the muscles 
 from off the epiphysis. 
 
 Two months later the elbow was completely restored to its 
 normal range of movement. 
 
 Fig. 95. — internal epicondyle .of humerus removed by operation 
 
 a, Under or separated surface of conjugal cartilage, with a few granules of the 
 diaphysis adherent to it. b, Upper or superficial aspect; osseous nucleus 
 exposed, c, Section showing cartilage and osseous nucleus. 
 
 Complications are numerous and frequent ; so much so that 
 separations of the internal epicondyle appear to be insignificant 
 compared with other concomitant lesions. 
 
 Articular lesion. — The articulation is not so likely to be primarily 
 involved after thirteen years of age. 
 
 Although in these instances the separation may be at first extra- 
 articular, the epiphysis, being displaced downwards on the inner 
 side of the trochlea and placed against the synovial membrane, the 
 latter will ultimately become adherent to the epicondyle, and, if an 
 attempt be made to remove this process by operation, it will lead t@ 
 opening of the articular cavity. 
 
 In younger children — from the fifth to the twelfth year — the 
 internal epicondyle being still part of the cartilaginous epiphysis, 
 its separation is much more likely to be intra-articular, but opening 
 of the articulation need not, of necessity, occur ; the earlier the age 
 the greater the probability of its occurrence. 
 
358 EPIPHYSES OF UPPEE EXTEEMITY 
 
 The author cannot agree with J. Hutchinson junior, that 'when the 
 epicondyle is separated, the elbow-joint is probably always opened.' 
 
 Comminution of the epicondyle is the result of direct violence. 
 
 An example which came under the author's observation at the 
 Miller Hospital in May 1893 was compound, and caused by direct 
 crushing violence. Some small comminuted fragments were removed, 
 and a most successful recovery obtained. 
 
 Dislocation of elbow is one of the most frequent complications, 
 especially in the outward direction. 
 
 Professor Humphry's specimen of detachment of this process with 
 fracture of the olecranon preserved in the Cambridge Museum, and 
 figured by Mr. Jonathan Hutchinson junior {British Medical Journal, 
 January 16, 1892), was also complicated wdth forward dislocation of 
 the elbow-joint. 
 
 An interesting case of detachment of a portion of the internal 
 epicondyle, associated with dislocation of the elbow backwards and 
 outwards, is quoted by M. Fallier from M. Debruyn's memoir on 
 luxations of the elbow (' Memoire sur les luxations du coude,' 
 Annales de la Chirurgie, ix. 1843) : 
 
 In 1841 a lad (F. V.), aged eighteen, while descending a ladder 
 quickly, slipped and fell to the ground, a distance of twelve feet. 
 The whole weight of the body was received upon the palm of the 
 left hand, the arm being stretched out in front of the body. The 
 forearm was found to be slightly flexed, pronated, and somewhat 
 shortened. The deformity of the elbow was very considerable, and 
 the articular lower end of the humerus was readily recognised at the 
 bend of the elbow ; the olecranon, displaced upwards and back- 
 w^ards, was situated near the outer border of the humerus. Directly 
 below and behind the external epicondyle the head of the radius 
 could be felt and rotated, while below the epitrochlea (mternal 
 epicondyle), which was very prominent on the inner side, a very 
 distinct depression was noticeable. Repeated attempts at reduction 
 were unsuccessful, and gangrene of the forearm supervened, which 
 necessitated amputation at the lower part of the arm on the eighth day. 
 
 On dissection of the limb, the tendons of the brachialis anticus 
 and biceps were seen to be displaced behind the external epicondyle, 
 and the ulna and radius were situated on the outer and posterior 
 aspect of the humerus. The brachial artery was ruptured, and on 
 the inner side of the elbow there was a portion of bone which had 
 been detached from the internal epicondyle, and to which the 
 muscles were still attached. 
 
 Langenbeck quotes (Lucke, Langenbeck's Arcliiv filr klin. Cliir. 
 Bd. 3, 1862, S. 311, No. 139, 1858) a case recorded and figured by 
 H. Senftleben, in which ankylosis followed, the bones of the fore- 
 arm being disjjlaced backwards and outwards. Resection of the 
 whole elbow-joint was performed seven months after the injury, 
 when the internal epicondyle was found lying in the olecranon fossa 
 
INTEENAL EPICONDYLE OE HUMERUS 359 
 
 attached by fibroas tissue. The bones were completely dislocated 
 backwards and outwards. The trochlea and capitellum were intact. 
 Death occurred on the thirteenth day from pygemia. 
 
 Paralysis of ulnar nerve.— The paralysis may be immediate, from 
 direct contusion or injury to the nerve or from pressure of the 
 displaced epiphysis. 
 
 In the author's case, just related, the paralysis was noticed imme- 
 diately after the injury. As it was considered that it might be due 
 to direct injury to the nerve, the epicondyle was not removed until the 
 eighteenth day. The nerve was then found to be directly pressed 
 upon by the displaced epiphysis. 
 
 Paralysis may be observed later from pressure of displaced 
 fragment or excessive callus. 
 
 Denuce excised the internal epicondyle of a man for intense 
 neuralgia of the ulnar nerve caused by the displaced fragment 
 having united in a false position. The man had fallen upon his 
 elbow three months previously. 
 
 In 1887 Professor Kocher {Beitrdge practisch loichtiger Fractur- 
 formen, 1896, S. 158) successfully excised the internal epicondyle four 
 months after the accident in a boy aged seventeen and a half years. 
 The elbow had been dislocated backwards, but was immediately 
 reduced. For three weeks sensibility over the distribution of the ulnar 
 nerve to the ring and little fingers was diminished. The left forearm 
 being thinner, and the interossei muscles of the hand, especially 
 between the thumb and index finger, weaker than the right, and as 
 extension was limited and the detached epicondyle felt in contact 
 with the side of the olecranon, the operation was undertaken. The 
 epicondyle was found displaced downwards and forwards, and firmly 
 fixed by fibrous tissue between the coronoid process and olecranon. 
 The joint was not opened. 
 
 In many of the simple cases the separation was only detected 
 after the dislocation had been reduced. 
 
 SYMPTOMS. — In spite of the well-recognised fact that separation 
 of the internal epicondyle is so common an accident in children, 
 few authentic cases have been published. 
 
 Little attention seems to have been given to it before Granger's 
 time, but it has been followed up to some extent by Cesar, Denuce, 
 Hamilton, Pingaud, Pezerat, Malgaigne, Fallier, and a few others. 
 
 Packard says : ' With regard to separations of the outer and inner 
 angles of the lower extremity of the humerus, of the epicondyle or 
 epitrochlea, or of the epiphysis, it is impossible to lay down any 
 distinct and definite statements, partly because of the small number 
 of recorded cases, and partly because of the obscurity of the condi- 
 tions attending these lesions.' Like many other writers, he makes 
 no attempt to differentiate these injuries, and places fractures of the 
 internal epicondyle with those accompanied by fracture of the 
 trochlea as well. 
 
360 EPIPHYSES OF UPPEE EXTEEMITY 
 
 Cheever dismisses the subject of separation of the epicondyles 
 {Boston Medical and Surgical Journal, cxxvii. p. 588) as follows : 
 
 ' The most common accident that happens to little children is 
 separation of the epicondyles, and inasmuch as the internal epicon- 
 dyle is by far the more prominent of the two, this is the one that 
 ordinarily breaks. "Why it does not occur universally is probably 
 because, being carried next the body, it is not quite so apt to receive 
 blows as the outer one, on which the child falls more frequently. 
 The latter is a small affair, and, if broken off, it is drawn down by 
 the muscles, and mobihty can be felt. The internal epicondyle is 
 quite large, and gives perceptible widening if broken, and mobility 
 is obtained.' 
 
 Sepaeation without displacement. — If the violence be sHght, 
 it is improbable that there will be any displacement of the epiphysis, 
 but it is seldom that, when quite detached, it is not displaced by the 
 action of the internal lateral hgament attached to its lower surface 
 and of the powerful muscles attached to its apex. 
 
 In Hamilton's case, already quoted, that of the lad aged eleven 
 years, with epiphysial separation from a direct blow, the motions of 
 pronation, with flexion, were not at all impaired, either imme- 
 diately or at any subsequent period, whilst the fragment was never 
 sensibly, or only very shghtly, displaced. 
 
 The same surgeon has seen other cases in which the fragment 
 did not seem to be displaced. 
 
 Dr. Powers, of New York, showed the following as an example 
 of eight cases which he had observed in children : 
 
 P. B., a boy, aged eight, fell three feet, striking the inner aspect 
 of the left elbow. Examination revealed tenderness over the inner 
 condyle, together with moderate swelhng. Active movements at 
 the elbow were feeble and painful. The internal epicondyle was 
 freely movable, and on moving it crepitus was elicited. In full 
 extension of the forearm it slipped a little downwards, but on flexing 
 the elbow to a right angle it was easily replaced. The forearm was 
 placed, midway between pronation and supination, at an angle of 
 90 degrees, in a plaster-of-Paris sphnt. The sphnt was removed 
 at the end of ten days, then re-apphed, and finally removed on the 
 twenty-eighth day. The joint was free from pain and swelling ; 
 the epicondyle was in place, but moderately thickened. The patient 
 could flex the forearm to 75 degrees, and could extend it to 135 
 degrees. Pronation and supination were nearly perfect. The 
 functions quickly improved, and on the sixtieth day they were com- 
 pletely restored, but moderate thickening persisted at the seat 
 of the fracture. 
 
 On the other hand. Granger believed that displacement was 
 always present. 
 
 Displacement of epiphysis. — Displacement of the epiphysis 
 is one of the principal signs of this diastasis. 
 
INTEENAL EPICONDYLE OF HUMEEUS 361 
 
 Downwards. — The detached portion is usually, or nearly always, 
 drawn somewhat downwards towards the hand, or downwards and a 
 little forwards, by the action and in the direction of the fibres of some 
 of the superficial flexors and pronators, especially the pronator radii 
 teres, attached to this process. 
 
 The extent of the displacement downwards is variable, in some 
 cases from two to four centimetres. 
 
 In some instances it may be displaced as far downwards as the 
 inner side of the trochlea, but in others the displacement is more 
 gradual before the time of formation of callus. 
 
 When the separation is the result of muscular action, this 
 direction of the displaced epiphysis is the only one possible. 
 
 Hamilton says that he had seen what he supposed to be this 
 epiphysis displaced in the direction of the hand, or downwards, 
 very manifestly, twice, and in two other examples a careful 
 measurement showed a slight displacement in the same direction. 
 
 Granger also found in his cases the epicondyle carried towards 
 the hand, with more or less variation in its lateral position, so that 
 while in some instances it touched the olecranon, in others it was 
 removed an inch or more in the opposite direction. 
 
 Fallier, in ten cases of fracture of the internal epicondyle accom- 
 panied with dislocation (adults and children), noted that in nine 
 there was this form of displacement. 
 
 Careful measurement should be made from the internal epicon- 
 dyle to the apex of the styloid process of the ulna on the two sides. 
 The internal epicondyle will also be absent from the normal trans- 
 verse line which passes through the apex of the epicondyles and 
 olecranon during the extended position of the elbov/. 
 
 The following case of disjunction of the epiphysis of the internal 
 epicondyle was treated in July 1891 at the MiUer Hospital. The 
 patient, a lad (Wm. C), aged ten years, had fallen on his left elbow. 
 On examination the inner side of his left elbow was found to be 
 swollen and painful ; however, a small nodule of bone, the epiphysis 
 of the internal epicondyle, could be moved up and down in a 
 vertical direction on the inner side of the humerus. This process 
 of bone was displaced downwards by the muscles attached to it. 
 There was pain on pronation and on flexion and extension of the 
 forearm. The epicondyle was replaced, and the elbow fixed in a 
 rectangular splint. Union, apparently bony, occurred in the normal 
 position, with no restriction of any of the movements of the joint. 
 
 The internal supra-condyloid ridge is often felt to be abruptly 
 terminated below, and in the position of the normal internal epi- 
 condyle the finger may feel a somewhat rugged surface or elevation, 
 never so prominent, however, as the epicondyle itself. Below this, if 
 the displacement has been great and the contusion slight, the finger' 
 may feel the flat inner side of the trochlea, and then, a little in 
 front of this, the displaced fragment. 
 
362 EPIPHYSES OF UPPEE EXTEEMITY 
 
 Mr. Jonathan Hntcliinson mentions [Medical Press and Circular, 
 November 18, 1885) the case of a yomig medical student who had 
 fal'en at a footbah match and had knocked off the internal con- 
 dyle, which had been displaced downwards close to the side of the 
 olecranon. The condyle was absent from its proper position. 
 
 Displacement backwards. — Displacement of the epiphysis directly 
 backwards is largely due to the direction of the violence, for it is 
 difficult to understand how such a displacement could be effected by 
 muscular action alone. In these cases, therefore, the ulnar nerve is 
 very liable to be injured from the direct violence which caused the 
 separation. 
 
 The author's own case is a good example of this form of displace- 
 ment. 
 
 In other instances the displacement may be more downwards 
 and but slightly backwards, so that the fragment becomes lodged in 
 the groove between the trochlea of the humerus and olecranon. In 
 the adult the fractured piece of bone has been found firmly wedged 
 in this position between the two osseous projections. 
 
 Displacement upwards can only be produced by direct violence, 
 this being directed from below upwards, as in a fall on the ground. 
 Some portions of the triceps and brachialis anticus remain 
 untorn, and act upon the fragment above, whilst the muscles 
 attached to this process below are torn across. 
 
 It will probably be found to be complicated by some other lesion 
 in the elbow-joint. 
 
 Granger found this form of displacement in one case of fracture 
 of the internal condyle in the adult. 
 
 In one of Fahier's cases, in a boy aged fifteen, the fragment was 
 displaced one and a half centimetres upwards. This was complicated 
 with dislocation, and the epicondyle was thought to have been dis- 
 placed into this position during reduction and the application of the 
 apparatus. It was felt by the finger which examined the inner 
 edge of the humerus, being arrested by it. 
 
 Another instance is quoted by Troschel {Medicin. Zeitg. des 
 Vereins filr Heilk. in Preussen, 1839, Gurlt, ii. Theil, S. 820) of a 
 youth, aged twelve, who was pushed by his comrades and fell on the 
 pavement, the arm being in a flexed position against the side of 
 the body. 
 
 The epitrochlea (internal epicondyle) was broken off and dis- 
 placed one centimetre upwards, and could be moved both back- 
 wards and forwards without giving rise to any pain. A splint was 
 applied to the limb in the semiflexed position, and at the end of 
 eight days the fragment was already found to be fixed and firmly 
 adherent, without any articular rigidity. 
 
 Out of four cases of fracture of the epitrochlea in children 
 recorded by Hamilton (' Eeport on Deformities after Fractures,' 
 Trans, of Amer. Med. Association, vol. ix. 1856, p. 133), in one 
 
INTEKXAL EPICOXDYLE OF HUMEKUS 363 
 
 instance only was the ' epiphysis ' displaced three lines upwards 
 and two backwards towards the olecranon {vide infra). 
 
 Displacement forwards. — Some authors, including Mr. Hutchinson, 
 think that the displacement of this process is usually forwards in 
 front of the joint. 
 
 In Sturrock's case (quoted below) the epicondyle was dis- 
 placed forwards and outwards, i.e. the prominence was situate in 
 front and to the outer side of the normal site of the internal epicon- 
 dyle. 
 
 Size and form of fragment. — Unless accompanied by much swell- 
 ing — which in all probability will occur if the lesion is due to 
 muscular action — or if seen before swelling has set in, the piece 
 of bone, although small, will in such cases be readily felt by the 
 examining finger and thumb. 
 
 The detached process can sometimes be felt lying over the ulnar 
 nerve. 
 
 In one case related by M. Cesar the internal epicondyloid frag- 
 ment was comminuted. 
 
 Mobility of the epiphysis. — In nearly all the published cases this 
 has been a well-marked sign. It is rare to find the epiphysis fixed, 
 without any mobility. 
 
 The epiphysis will usually be found an inch or more below and 
 in front of its normal position at the level of the articulation, and 
 rarely, as we have seen, in other positions, above or behind. It is 
 especially mobile in an antero-posterior direction, less so in the 
 vertical direction. 
 
 Its extent is influenced by the position of the elbow, being most 
 marked when the forearm is slightly flexed and supinated in order 
 to relax the epicondylar muscles, and being more fixed in the incom- 
 pletely extended and pronated position, which exists in some cases 
 complicated with dislocation. 
 
 In other examples it has been found movable in every direction, 
 vertically as well as in the antero-posterior direction. It depends 
 also in some measure upon the swelUng of the soft parts and the 
 extent of separation of the periosteum. 
 
 Coulon, in his Traite des fractures cJiez les enfants, describes 
 these injuries under the title of extra-articular fractures of the epi- 
 trochlea, and quotes three cases in children, three and a half, ten and 
 a half, and eleven years respectively, the two last being characterised 
 by the crepitus and mobility of the small fragment of this process. 
 All were caused by falls upon the elbow. 
 
 Gurlt was undoubtedly right in considering such examples as 
 separations of the internal epicondylar epiphysis. 
 
 M. Pezerat noted {loc. cit. supra) this mobihty of the fractured 
 internal epicondyle, both forwards and backwards as well as up- 
 wards and downwards, in the case of a child, aged twelve, who had 
 fallen upon the inner side of his elbow. Graduated compresses 
 
364 EPIPHYSES OF UPPEE EXTEEMITY 
 
 were applied in front and behind, consolidation took place by the 
 twentieth day ; and by the thirtieth day the natural movements 
 were completely restored. 
 
 In the following case, which came under the author's notice at 
 the Miller Hospital, the mobility of the epiphysis was most marked 
 in the antero-posterior direction ; less so from above downwards. 
 
 Ethel G., aged three years and four months, was brought to the 
 hospital by her father. About half an hour previouslj^ she had 
 fallen and struck her elbow against the edge of a drinking-fountain. 
 She was a well-nourished, healthy-looking child, without any ap- 
 pearance of syphilis or rickets. Over the situation of the internal 
 epicondyle of the left elbow there was a well-marked prominence, 
 and the skin over it was slightly contused. This was found to be the 
 epiphysis itself, which was movable readily from before backwards, 
 the motion being accompanied by pain and soft crepitus. There was 
 little or no displacement, for the epicondyles were found to be in their 
 normal position, as well as the radius and ulna. Pronation and 
 supination were painless, but on extreme flexion and extension 
 the child cried. • There was no evidence of any other epiphysial 
 separation of the lower end of the humerus. The injury was treated 
 by a rectangular splint and a short posterior one. When the author 
 saw her ten days later there was still evidence of considerable bruising 
 over the inner side of the elbow, extending upwards for two inches, 
 and great thickening over the internal condyle, extending laterally 
 about one inch and upwards a little over an inch, also a little 
 outwards towards the olecranon. There was also some synovitis 
 of the elbow-joint. 
 
 Muffled crepitus is characteristic, even if the injury occurs in the 
 first few years of life, and is associated with the inevitable fracture 
 through the cartilaginous strip which unites it in one mass with 
 the cartilaginous lower end, separating it from the trochlea. The 
 soft character of the crepitus will not, therefore, be obscured by 
 this cartilaginous fracture. 
 
 If there is much displacement it will be detected in replacing the 
 fragment in position — viz. by pressing it upwards and backwards 
 whilst the forearm is semiflexed and pronated. But crepitus, 
 though distinct at first, may be subsequently lost from the gradual 
 separation of the epiphysis by muscular action. 
 
 When displacement is absent, or but little marked, slight 
 movement of the epiphysis will readily produce it. 
 
 Impaired movement. — There is frequently some hindrance to the 
 free movements of the elbow-joint. This may be partly accounted 
 for by the swelling present, partly by the separation of the epiphysis 
 — to which some of the principal flexors and pronators of the arm 
 are attached — and partly by the tearing off of the periosteum from 
 the diaphysis, together with important muscles. 
 
 Gurlt, however, states that in these extra- articular fractures ' the 
 
INTEENAL EPICONDYLE OF HUMEEUS 365 
 
 patient can, in spite of the pain, move his arm in flexion and exten- 
 sion, as well as in pronation and supination.' 
 
 For the forearm the common position is semiflexed and semi- 
 pronated. It may be abducted to a greater extent than is normal. 
 
 Swelling and pain. — In a young subject, swelling and ecchymosis 
 on the inner side of the elbow, accompanied by acute pain in the 
 position of the internal epicondyle, and following a blow in this situa- 
 tion or a fall upon the hand or elbow, are quite sufficient to suggest the 
 occurrence of a separation of the epiphysis of the internal condyle. 
 The ecchymosis may be very extensive, extending up the inner side 
 of the arm and downwards towards the antero-internal aspect of 
 the forearm. 
 
 The pain, although persistent at this spot, is never excessive ; 
 it may be felt in the little finger from bruising of the ulnar 
 nerve. 
 
 In many cases the swelling is so great as to prevent a thorough 
 examination and exact diagnosis being made. It may extend in 
 the course of a few days down the inner aspect of the forearm in the 
 direction of the sheath of the muscles attached to the epiphysis 
 (Cesar), and assist by the course it takes in diagnosing the lesion 
 from a simple contusion of the elbow. 
 
 In Malgaigne's case, of a boy aged ten (quoted below), the pain 
 and swelling made him suspect fracture ; but the mobility was 
 doubtful, and no crepitus was perceptible. It was not until eight 
 days afterwards, when the swelling had subsided, that all doubt was 
 removed by the occurrence of distinct crepitus. There was no 
 appreciable displacement. 
 
 Complications. Injury to the ulnar nerve. — The ulnar nerve, 
 from its close proximity to the epiphysis, is exceedingly liable to 
 be injured by the direct violence which caused the separation or 
 by the displaceixient of the epiphysis — especially if this is carried 
 in a backward and downward direction by the force of the 
 violence. Granger believed that the paralysis is always due to 
 compression by the displaced fragment. In Fallier's case the vio- 
 lence was certainly indirect, the patient having fallen on the palm 
 of his hand. 
 
 But indirect violence may cause injury to the nerve, not hy pressure 
 of the displaced fragment, but rather by dragging upon it and 
 lacerating its sheath or fibres, or by mere stretching. 
 
 Cesar and Hamilton thought it exclusively due to direct injury 
 to the nerve inflicted at the same time as the process is broken off. 
 Direct contusion of the nerve probably happened in Eichet's case, 
 in which the elbow violently struck the ground. 
 
 The paralysis of the nerve may be partial or complete at the 
 time of the accident. 
 
 An accompanying dislocation will probably injure the ulnar 
 nerve much more readily than a simple separation of this process. 
 
366 EPIPHYSES OF UPPEE EXTKEMITY 
 
 Granger (loc. cit. supra) describes the following remarkable case. 
 A boy, eight years old, fell with violence, and broke off completely 
 the whole of the inner epicondyle of the right humerus. The lad said 
 he had fallen on his hand. The fragment was displaced towards the 
 hand, and severe inflammation followed, but he recovered the free and 
 entire use of the elbow-joint in three months after the accident. ISTo 
 
 splints or bandages were ever em- 
 ployed. I'rom the moment of the 
 accident, the little finger, the inner 
 side of the ring finger, and the skin 
 on the ulnar side of the hand 
 lost all sensation. The abductor 
 minimi digiti and two contiguous 
 muscles of the little finger were 
 
 Fig. P6.-DIAGEAM OF RELATION OF ULNAR ^J parah'SCd. This COUdition 
 
 NERVE TO INTERNAL EPICONDYLE -L _ -J 
 
 lasted eight or ten years, after 
 wliich sensation and motion were gradually restored to these parts. 
 As a consequence of this paralysed condition of the ulnar nerve, 
 successive crops of vesications, about the size of a split horse- 
 bean, commenced to form on the little finger and ulnar edge of 
 the hand some weeks after the accident, leaving troublesome 
 excoriations. This eruption did not entirely cease for two or three 
 months. 
 
 In two other cases Granger states that he found ' the same 
 paralysis of the small muscles of the little finger, the same loss 
 of feeling in the integuments, and the same succession of crops of 
 vesicles on the affected part of the hand, as had occurred in the 
 preceding case.' 
 
 The trophic changes were probably the result of neuritis due to 
 the direct contusion of the nerve against the internal condyle. Both 
 cases were said to have ultimately recovered. 
 
 Eichet's case of detachment of the epitrochlea, accompanied by 
 dislocation of the elbow inwards and complete paralysis of the ulnar 
 nerve, is quoted below. 
 
 Dislocation of the elbow. — Dislocation of the elbow combined with 
 separation of the internal epicondyle is not an uncommon accident. 
 Granger, in 1818, was the first to indicate this compHcation. It 
 may be produced by a direct blow upon the elbow or a fall upon the 
 hand. It will be founds to be more common from thirteen to 
 nineteen years of age. Out of forty-eight cases of fracture of the 
 epicondyle, nineteen were complicated with dislocation of the elbow 
 (EalHer). 
 
 One of Granger's patients, a boy, aged eleven, had also a 
 luxation of the elbow, which w\as reduced, but by reason of neglect 
 he failed to recover flexion and extension in the joint. AVhen the 
 swelling, which was exceedingly great, had gone down, the forearm 
 was found innnoval)ly fixed at right angles with the humerus. By 
 
INTEENAL EPICONDYLE OE HUMEEUS 3G7 
 
 means of passive motion considerable use of the elbow had been 
 regained at the end of three weeks. The patient neglected the 
 elbow for a considerable time, and the elbow was then fixed in 
 a position of complete extension, and remained immovable as before. 
 However, some improvement in flexion subsequently took place. 
 
 The dislocation maybe backwards, as in Fallier's, Debruyn's, and 
 Kocher's examples. 
 
 Seeing that the chief connections between the humerus and 
 forearm — namely, the powerful muscles and internal lateral liga- 
 ments — are set free when the internal epicondyle is detached, it 
 is surprising to find that dislocation is not more frequently present. 
 In two or three separated internal epicondyles under his care the 
 author has demonstrated very clearly the facility with which a 
 dislocation may be produced. 
 
 In all separations of the internal epicondyle, undue mobility of 
 the ulna with the forearm is a very noticeable feature, especially in a 
 lateral direction. 
 
 Hutchinson recorded {British Medical Journal, vol. ii. 1866 ; 
 Medical Times and Gazette, January 1884, p. 3) an example of this 
 complication. A young gentleman, aged sixteen, whilst playing 
 racquets, fell and struck his elbow against a w^all. He was found 
 to have ' a dislocation,' and within an hour a surgeon reduced it. 
 Nothing further was recognised at the time, but some months later 
 his father, who was a surgeon, but did not see him in the first 
 instance, found that the inner condyle had been fractured. He was 
 brought to Mr. Hutchinson six weeks later, and it was then quite 
 evident that the inner epicondyle was broken off and displaced 
 downwards, so as to rest against the inner side of the olecranon, 
 where it was fixed a year later. The elbow being examined on a 
 subsequent occasion, the condition of things was found to be exactly 
 as before. On the side of the olecranon was a lump of bone, nearly 
 as large as the end of one's thumb. If not ankylosed to the 
 olecranon, it was certainly very firmly fixed, as no movement could be 
 obtained. The origin of the flexor carpi radialis, and also, Mr. Hut- 
 chinson thought, a part of the pronator radii teres, could be distinctly 
 traced to this bone. That it was the inner condyle there could not 
 be the slightest doubt, for the part of the humerus from which it had 
 been broken still presented a rough edge, and the condyle had dis- 
 appeared. When seen two years later the patient had regained 
 almost perfect use of the joint. Mr. Hutchinson adds : ' In what 
 manner the displacement of this fragment downwards is effected 
 it is difficult to conjecture, but I have since seen another case which 
 was, in this feature, exactly like the one which I have described. 
 Possibly such a displacement can occur only when there is dis- 
 location at the joint as well as detachinent of the epicondyle. 
 Dislocation might be productive of considerable laceration of the 
 soft structures, and be attended by dragging of the epicond3de 
 
368 EPIPHYSES OF UPPEK EXTEEMITY 
 
 downwards. The nsnal position of the fragment in this accident 
 is, I think, forward in front of the joint, and this is where a know- 
 ledge of the muscular attachments would lead us to expect it.' 
 
 Manoury has recorded a case complicated by backward dislocation 
 which he called a fracture by muscular action. 
 
 Gurlt quotes a case of Senftleben's (Gurlt, Lehre von den 
 Knochenhrilchen, 11. Theil, II. Lieferung, S. 823, Case 305). A boy, 
 aged eleven years, fell and struck his right elbow. There was dis- 
 location backwards and outwards of the elbow, with the charac- 
 teristic deformity, accompanied by displacement backwards of the 
 internal epicondyle into the olecranon fossa. The dislocation was 
 reduced under chloroform, and the fragment easily replaced. The 
 fragment firmly united by the fourteenth day, and all movements 
 of the elbow-joint were ultimately perfectly free. 
 
 L. Fallier has published {Bevue des Sciences Medicales, 1890, 
 p. 265 ; ' Contribution a I'etude des fractures de I'epitrochlee, These 
 de Paris, 1889) a number of cases of fracture of the epitrochlea in 
 addition to those already recorded, and finds that they are almost 
 exclusively observed in the male sex. He also shows that when 
 they are complicated with dislocation of the elbow they are as often 
 caused by indirect as by direct violence. When the violence is 
 indirect the fracture is the result of detachment of the internal 
 lateral ligament of the elbow, and the fracture ought always to be 
 considered as a complication of the dislocation; but, on the 
 contrary, in the rare cases where the fracture is due to muscular 
 action, the dislocation should be considered as the complication of 
 the fracture. 
 
 Dislocation imuards. — Dislocation inwards is much more rarely 
 met with than dislocation outwards. Eichet has recorded a case 
 in the adult complicated with dislocation backwards and in- 
 wards, but it is probable that in this instance the trochlea itself was 
 fractured. 
 
 The following case was communicated to Dr. A. Cesar by Pro- 
 fessor Eichet. 
 
 A youth, aged about fifteen years, slipped on some ice and fell 
 upon the inner side of the elbow, the arm being away from the body. 
 M. Eichet found a fracture of the epitrochlea, with dislocation of the 
 elbow backwards and inwards. After the dislocation had been 
 immediately reduced, it was found that the ulnar nerve had been so 
 seriously contused that it was entirely paralysed, the little finger 
 being completely insensitive. At the end of a few days the arm was 
 enclosed in a splint, which was removed by M. Eichet at the end of 
 twenty days for fear of ankylosis resulting from the dislocation. 
 The insensibility remained as complete as before, and was so 
 marked that a month later the patient was able to hold his finger 
 for more than a minute in a candle flame, to the astonishment 
 of his companions, without feeling the least pain. The burn was 
 
IXTEEXAL EPICONDYLE OF HUMEKUS 
 
 369 
 
 so great that the skin frizzled and cracked and the nail ignited. 
 It took several weeks to heal, and left traces which were still recog- 
 nisable ; but after this violent cauterisation sensibility re-appeared 
 in a progressive and rapid manner. There was no vesicular 
 eruption such as Granger speaks of. 
 
 As regards the movements of the elbow, they almost completely 
 returned, with the exception of full flexion and extension. 
 
 Hamilton records (' Eeport on Deformities after Fractures,' 
 Trans, of Amer. Med. Association, vol. ix. 1856, p. 112 ; and Treatise 
 on Fractures and Dislocations) the case of a boy (F. C), aged fifteen 
 years, who had fallen upon his arm in wrestling, and the surgeon 
 found a dislocation inwards of the bones of the elbow-joint, which 
 he immediately reduced. The diastasis of the epicondyle was not 
 at that time detected, the arm being greatly swollen. No splints 
 were applied. It was three months 
 after the accident when Hamilton saw 
 him, at which time he found the in- 
 ternal epicondyle removed downwards 
 towards the hand one inch and a 
 quarter, and at this point it had become 
 immovably fixed. 
 
 Partial ankylosis existed at the 
 elbow-joint, but pronation and supina- 
 tion were perfect. 
 
 Dislocation outwards is readily ex- 
 plained by the attachment of the inter- 
 nal lateral ligament to the epicondyle. 
 It is most correctly considered as a 
 variety of dislocation backwards, for in 
 many instances, the muscles on the 
 inner side having lost their attachment 
 through the fracture of the internal 
 epicondyle, the muscles on the outer side continue to act upon the 
 forearm, and so tend to displace the bones of the forearm out- 
 wards. 
 
 Dislocation directly outwards is of occasional occurrence. 
 Fig. 97 is from an experimental preparation by Helferich (Atlas 
 der trauniatiscJien Fractu7'e?i U7id Luxationen,1895, Tab. 33, Fig. 1), 
 The ulna is in contact with the side of the capitellum and outer 
 portion of the trochlea, whilst the radial head stands out free on the 
 outer side. By means of the internal lateral ligament the internal 
 epicondyle is torn off and remains still connected with the ulna. 
 
 Fig. 98 (Helferich, ibid. Tab. 33, Fig. 2) represents a case 
 observed by Helferich during life, displaying the lesion just figured, 
 in which the characteristic projection of the olecranon in dislocation 
 backwards was entirely absent, and the other contours of the elbow 
 little altered. But on the outer side the radial head could readily 
 
 E 1] 
 
 Fig. 97. — diagram of dislocation 
 of elbow outwards, with sk- 
 paration of the internal 
 
 EPICONDYLE. (hELFERICH) 
 
370 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 Fig. 98. — dislocation outwaeds of elbow 
 accompanying separation of the inteenal 
 
 EPICONDYLE. (HELFEEICH) 
 
 be seen, and, in lifetime, felt, especially during supination and 
 pronation. 
 
 Dislocation of the elbow forwards is extremely rare. It is remark- 
 able that in all the four cases of simple dislocation forwards of the 
 
 elbow collected by Denuce in 
 1869 the injury was due to a 
 fall upon the elbow, while 
 in the following case it was 
 caused by a fall upon the 
 hand. 
 
 Poinsot has recorded this 
 case as seen by W. Dale, in 
 which a child of fourteen years 
 fell on to the palm of its hand, 
 which caused an incomplete 
 dislocation of the elbow for- 
 wards. It was noticed after 
 reduction, which was readily 
 accomplished, that the epi- 
 trochlea had been torn off at 
 its base. Recovery took place 
 without any mishap, and with absolute restoration of all movements. 
 M. Poinsot thought that this form of dislocation with the fracture 
 had been brought about by torsion and lateral bending outwards of 
 the forearm. 
 
 Dislocation of ulna backwards is produced in much the same 
 manner as dislocation of both bones backwards — viz. by over-exten- 
 sion of the forearm and lateral flexion outw^ards, as in a fall on the 
 palm of the hand. 
 
 A case of dislocation of the ulna backwards, complicated by 
 fracture of the internal epicondyle, is quoted by M. L. Fallier, seen 
 by Beaurieux, of Orleans (' Note sur un cas de luxation isolee et 
 complete du cubitus en arriere, complique d'une fracture de I'epi- 
 trochlee,' France Medicale, 25 Aout 1880). 
 
 A youth (0.), aged twelve years, had fallen (1880), while at gym- 
 nastics, upon the palm of his left hand, and had lost almost the entire 
 use of the limb. On examination two hours after the accident, the 
 forearm was found in the pronated position, the elbow semiflexed, 
 and the hand flexed at the wrist and adducted. There w^as only a 
 moderate amount of swelling around the elbow-joint. Active and 
 passive motion, especially flexion, were very painful and restricted. 
 The deformity of the joint was very distinct, for its internal angle 
 was obliterated, whilst its external angle, on the contrary, projected 
 more than is normal. On the posterior aspect of the arm, about 
 two inches above the lower end of the humerus, the upper end 
 of the ulna made a considerable projection, which was easily distin- 
 guished. The head of the radius preserved its normal relations 
 
INTERNAL EPICONDYLE OF HUMERUS 371 
 
 with the external epicondyle, and moved freely during pronation and 
 supination of the forearm. The internal epicondyle could not, 
 however, be made out, and it was only during reduction of the 
 dislocated ulna that the epitrochlea (internal epicondyle) was found 
 to be detached from the humerus. The elbow was kept flexed 
 on a splint at a right angle until the sixth day, when the apparatus 
 was removed, as there was no displacement or swelling, but 
 merely slight discoloration. All movements were easily carried out, 
 with little impediment, and the fractured epitrochlea appeared to be 
 consolidating, for neither mobility nor crepitus was present. 
 Fifteen days later the child had completely recovered, with full use 
 of its limb. 
 
 Another previously unpublished case of dislocation of the ulna 
 backwards with fracture of the internal epicondyle is recorded by 
 M. Falher. 
 
 On August 21, 1885, the patient (A. S.), aged fifteen, an iron- 
 platework apprentice, fell, whilst running, on the dorsal aspect 
 of his left wrist, the hand being bent on the forearm and the 
 forearm but sHghtly on the arm. He was seen by M. Depasse 
 immediately after the accident, and the ulna alone was found to be 
 completely dislocated backwards. The humeral trochlea projected 
 forwards in the flexure of the elbow, and the epitrochlea was 
 detached and freely movable in every direction. The head of the 
 radius rotated in its normal position. Reduction was easily effected 
 by extension and supination of the forearm and manipulation of 
 the displaced bones, and a splint was applied. On his admission to 
 the Maine Hospital at Brest, Professor Fontan found, on removino- 
 the apparatus, that the epitrochlea (internal epicondyle) was elevated 
 about one and a half centimetres, and all movements of the elbow- 
 joint could be carried out, the head of the radius still rotating 
 in its normal position. It was noted that with the forearm sHghtly 
 flexed on the arm, and the hand on the forearm, the epitrochlea 
 approached its normal site ; the Jimb was therefore put up in this 
 position. On August 25 a dorsal splint was applied, and on Sep- 
 tember 1 replaced by one of gutta-percha. On October 1 the patient 
 left the hospital cured, to resume his work. 
 
 It is not necessary here to describe in detail the symptoms of 
 each kind of dislocation which may complicate the detachment of the 
 internal epicondyle. It will suffice to say that, any of these forms 
 of dislocation having been diagnosed, it is essential that the 
 presence or absence of a detached internal epicondyle should be 
 determined from the symptoms already related. 
 
 However, in many instances complicated with dislocation it has 
 been found difficult to recognise the displacement of the fragment, or 
 any mobility or crepitus, before reduction, and it is only after this 
 has been accomplished that they have been observed. This has been 
 noticed to be the case even where little or no swelling was present. 
 
 U I! 2 
 
372 EPIPHYSES OF UPPER EXTPvEMITY 
 
 After reduction of the dislocation and before any great swelling 
 has taken place, it has been found possible to make out some 
 impediment to the movements of the elbow caused by the detached 
 epicondyle. The fragment dragged downwards and forwards by the 
 epitrochlear muscles may limit flexion, but more often pronation is 
 incomplete, partly from the acute pain experienced by the patient at 
 the seat of fracture during any attempt at this movement, and 
 partly from the loss of power due to the attachment of a portion of 
 the pronator muscles to the epicondyle, and to the neighbouring 
 periosteum, which is detached from the diaphysis. 
 
 FalHer ascertained, in ten cases of dislocation, that in only three 
 was this fracture detected, although present. Ah three were disloca- 
 tions backwards (one at the age of eleven, and two at fifteen years). 
 
 Although a separated internal condyle has sometimes been 
 recognised in dislocation backwards before reduction, it is essential 
 that in all cases of apparently uncomplicated dislocation of the elbow 
 in children careful examination of the epicondylar regions should be 
 made after reduction. 
 
 Fracture of the olecranon. — In Sir Astley Cooper's case of separa- 
 tion of the internal epicondyle the injury was compHcated with a 
 fracture of the olecranon. 
 
 Fracture of the coronoid process. — This has occurred in one in- 
 stance. 
 
 Wounds.— It is interesting to note that the author has only 
 been able to obtain one example of separation complicated with a 
 wound — viz. his own case, already quoted. 
 
 Acute synovitis. — ^Synovitis is often met with as the result of 
 implication of the synovial membrane in the laceration, or from 
 the extension of the inflammation about the epiphysial separation. 
 If not properly treated it will give rise to ankylosis later on. 
 
 Intra-articidar separations are most Hkely to occur before the 
 age of twelve to thirteen years. The fracture, separating the 
 internal epicondyle from the rest of the cartilaginous epiphysis at 
 this early age, will probably open the synovial cavity on the inner 
 side, close to the trochlea. 
 
 Although the elbow-joint may be opened during the first few 
 years of childhood, it usually escapes injury after about the twelfth 
 
 year. 
 
 Synovitis was present in the author's case of the girl aged three 
 years and four months, described above. In one of Granger's 
 cases, comphcated with dislocation of the elbow, the fracture must 
 certainly have entered the joint. 
 
 Gurlt beheved that all epiphysial separations of the internal epi- 
 condyle must necessarily be extra-capsular, but of this he had no 
 anatomical proof. 
 
 Berthomier thinks (Mecanisme des fractures du coiide chez les 
 en f ants, Paris, 1875) that the occurrence of extra-articular fracture 
 
INTEENAL EPICONDYLE OF HUMEKUS 373 
 
 of the internal epicondyle has not been sufficiently proved, and states 
 that he was unable to produce extra-capsular fracture of either the 
 internal or external epicondyle. 
 
 D. W. Cheever, Professor of Surgery of Harvard University, 
 speaks {Boston Med. and Surg, Journal, cxxviii. p. 589) of epicon- 
 dylar separations as very unimportant injuries, and as having 
 nothing to do with the joint. ' Separation of the internal epi- 
 condyle is a matter of little consequence, speedily unites, and ought 
 not to make any stiffness of the elbow, because it does not go into 
 the joint.' 
 
 Some authors believe that when the fracture is complicated with 
 dislocation of the bones of the forearm backwards and outwards it 
 communicates with the joint. 
 
 Severe inflammation is apt to take place around the seat of 
 separation when the injury has been caused by severe direct 
 violence. 
 
 Granger has carefully noted severe inflammation about the elbow 
 and forearm, involving the muscles attached to the epicondyle, and 
 producing such extensive swelling as to prevent almost completely 
 all movement at the elbow. 
 
 DIFFERENTIAL DIAGNOSIS. Fracture of the internal condyle. — 
 The character of the crepitus, the size and shape of the separated 
 epiphysis, and its causation from muscular action alone in many 
 cases — with, consequently, less swelling and ecchymosis present — are 
 the only guides we have to distinguish it from fracture of the internal 
 condyle. 
 
 "Where the injury is complicated by dislocation, &c., in which 
 there is great swelling and laceration of the soft parts, the diagnosis 
 from fracture is rendered even more difficult. 
 
 Severe contusion on the inner side of the elbow may completely 
 prevent a minute examination of the epicondylar region, thus 
 causing a separation of this process to be unrecognised. This may 
 be especially true when a dislocation complicates the case. 
 
 Until the dislocation has been reduced no precise diagnosis can, 
 as a rule, be made ; and even then it may be undetected for some 
 days or weeks, on account of the peri-articular inflammation. It 
 should, however, be recognised as soon after reduction as possible, 
 on account of the consequences that may follow. 
 
 If no dislocation be present, the swelling, pain, and bruising will 
 disappear in a few days, and permit a complete exploration of this 
 region. 
 
 In all cases for an e>:act diagnosis to be made an ana?sthetic 
 must be given, although in many of the uncomplicated cases it is 
 quite evident that one, more or less satisfactory, might be arrived at 
 without its use. 
 
 PROGNOSIS AND RESULTS. Rigidity and impairment of move- 
 ment. — Where there is no displacement of the epiphysis, and the 
 
374 EPIPHYSES OF UPPEE EXTEEMITY 
 
 separation is therefore extra-articular, the rigidity is hkely to be only 
 temporary and the movements of the joint completely restored in a 
 short time, provided that proper treatment is adopted and the arm 
 not confined too long in the flexed position. 
 
 Granger, Cesar, and Hamilton agree that it is rare to find much 
 articular rigidity in simple fracture of the epicondyle. 
 
 In one out of four cases of separation of the internal epicondyle 
 recorded by Hamilton {Trans, of Amer. Med. Association, vol. ix. 
 1856, p. Ill) the result was perfect. 
 
 A boy (C. F.), aged eleven, fell and struck the internal condyle 
 of the left humerus. He was seen immediately, when the internal 
 condyle was found to be loose and motion produced a distinct 
 crepitus. Hamilton did not think the fracture extended into the 
 joint. The patient could flex and extend the arm perfectly, and 
 rotate the forearm. A right-angled splint was applied for five 
 weeks. Three months afterwards he could nearly straighten the 
 arm, and all movements were almost perfect. 
 
 Even where displacement exists and the deformity is permanent, 
 as in some of Granger's cases, flexion and extension of the elbow 
 have been perfect. In others the movements of the elbow have been 
 but little interfered with. The muscles attached to the displaced 
 epiphysis soon regain their natural power, and are seldom per- 
 manently affected. In all of Coulson's cases the movements of the 
 joint were almost perfectly recovered. Gurlt also mentions another 
 similar example observed by Troschel. 
 
 Cesar believed that the epicondyle was often imperfectly united 
 by fibrous tissue, and it is probably true that in the majority of 
 cases in which displacement of this process has taken place the 
 union is a fibrous one. 
 
 In the more uncommon cases of separation, with little or no 
 displacement, union by bone is probably not an unusual result. 
 
 Stimson saw two cases : one in a girl aged thirteen, and the 
 other in a boy aged eleven years. In both the internal epicondyle 
 was movable, and ended in complete recovery without interference 
 with the movements of the joint. In the latter case the fragment 
 united, with displacement downwards to the distance of a quarter 
 of an inch, and it was thought that the lesion was associated with a 
 separation of a part of the lower epiphysis of the humerus or of its 
 trochlear portion. 
 
 Mr. Jonathan Hutchinson junior mentions (British Med. Journal, 
 January 16, 1892, p. Ill) five cases, and alludes to others, in which 
 practically complete recovery of power in the elbow took place, 
 although the epicondyle remained united to the humerus only by 
 fibrous tissue. 
 
 Case I. E. E., a boy aged ten, fell on the curbstone, the point 
 of his right elbow striking the ground. A backward and outward 
 dislocation of the radius and ulna was thus produced, with detach- 
 
INTERNAL EPICONDYLE OF HUMERUS 375 
 
 ment of the internal epicondyle, Reduction was effected and an 
 outside angular splint applied. Three weeks later the epicondyle 
 was found displaced slightly downwards and backwards. Both 
 flexion and extension were somewhat limited, but the patient 
 recovered completely under passive motion. 
 
 Case IL H. T., aged eleven, had his epicondyle detached by a 
 fall on to the hand ; he was positive that the elbow had not been 
 struck. The epicondyle could be readily felt and moved laterally ; 
 full relaxation of the flexor muscles had no effect upon the displace- 
 ment, which was chiefly downwards. An outside angular splint was 
 applied with a circular pad over the fractured part. Ultimately 
 fibrous union, but with almost perfect use of the joint, was obtained. 
 
 Cases III. and IV. In both these cases (young boys) the fore- 
 arm was dislocated outwards at the same time that the epicondyle 
 was dragged off by the traction on the internal lateral ligament. In 
 both, the small fragment of bone was drawn under the trochlear 
 surface, and was not detected in one until the dislocation had been 
 reduced. 
 
 Case V. B. B., aged fourteen ; one arm ' gave way ' as he was 
 crawling on hands and knees. Dislocation of the forearm outwards 
 resulted, with detachment of the epicondyle. At the end of four 
 weeks' treatment the latter remained in a position close to th.e 
 coronoid process, united only by fibrous tissue to the humerus. 
 Extension was less by 15 degrees than on the other side. Eighteen 
 months later, on carefully examining the elbow again, the epi- 
 condyle was found (two centimetres in long diameter) still quite 
 movable. The elbow was considered as strong as the other one, 
 but in lifting weights the patient felt occasional pain in the region. 
 Out of ten cases under this surgeon's observation {Brit. Med. Journal, 
 December 30, 1893), ' almost perfect range of movement in the elbow - 
 joint was ultimately secured in the seven which were followed up 
 long enough to decide upon. Perseverance in the performance of 
 passive motion was required in nearly all for some weeks.' 
 
 Dr. C. A. Sturrock records {Edinhurrjh Hospital Beports, vol. ii. 
 1894, p. 599) an instance of perfect recovery, with bony union, four- 
 teen months after the accident. 
 
 H. Y., set. ten, was admitted to the Royal Infirmary, Edinburgh, 
 on June 6, 1892, giving a history of having fallen on his elbow, 
 and of having lost the power of his arm immediately. A deficiency 
 was noticed in the region of the internal condyle, and a prominence 
 in front and to the outer side of the normal site of the interna 
 condyle, due apparently to the displaced internal condyle, which 
 was immovable when the hand and forearm were extended. The 
 fragment could be manipulated into position, and the so-called 
 cartilaginous crepitus eHcited. On flexing the pronated forearm to 
 less than a right angle, it was found that little or "no trace of the 
 displacement remained, and the arm was accordingly retained in 
 
376 EPIPHYSES OF UPPER EXTREMITY 
 
 splints in this position for fourteen days, after which gentle passive 
 movements were commenced and continued for two months. By 
 this time free and complete movements at the elbow-joint were 
 readily performed, and, when the last observation was made, four- 
 teen months after the accident, these had been maintained, the only 
 trace of the injury being a slight amount of thickening at the base 
 of the internal condyle, which had apparently united to the shaft 
 by bony union. 
 
 In several instances of separation of the internal epicondyle 
 which have come under the author's observation at the Miller 
 Hospital, the same good result has always ultimately resulted. In 
 a few cases flexion and extension were a little limited for some 
 time, of which the following case is an example. 
 
 E. S., aged eleven, was pushed down in the road, November 11, 
 1893, and struck the inner side of his right arm. He was seen at 
 the hospital half an hour afterwards, when there was found to be 
 swelling over the situation of the epicondyle, wdth some flexion and 
 pronation of the forearm. On fixing the shaft of the humerus, 
 the epicondyle could be grasped and moved, especially from above 
 downwards, with velvety crepitus. A rectangular splint was the 
 form of splint adopted. By December 28, 1893, supination and 
 pronation were quite perfect, and extension almost complete. 
 Flexion was not quite so good, but still this could be carried 
 beyond a right angle. 
 
 If there has been much extra-articular inflammation, the muscles 
 attached to the internal epicondyle are likely to become much 
 shortened, rendering the displacement of this process quite im- 
 possible to be reduced, and considerable deformity and hindrance 
 to the proper functions of the limb will result. 
 
 Rigidity not amounting to ankylosis is due to the prolonged 
 fixation of the elbow. It must be distinguished from articular 
 ankylosis due to synovitis of the articulation, and will rapidly 
 disappear under treatment. 
 
 Ankylosis of the joint. — Severe inflammation in the neighbourhood 
 of the articulation, with contraction of the muscles and tendons 
 and deposit of new bone, caused by stripping up of the periostemn, 
 will all tend to produce more or less ankylosis. 
 
 In one of Hamilton's cases there was partial ankylosis three 
 months after the accident, but pronation and supination were 
 perfect. 
 
 Even when the injury has been complicated with a dislocation, 
 the impairment of the movements of the joint has not been 
 permanent to any great extent. 
 
 Hamilton remarks that ' we might, therefore, reasonably conclude 
 that, where the accident has been properly treated, permanent 
 ankylosis would be the exception, and not the rule.' On the other 
 hand, Malgaigne and others have thought that articular rio-iditv with 
 
IKTEEXAL EPICOKDYLE OF HUMEEUS 377 
 
 serious impairment of movement is almost inevitable — even ankylosis 
 in many cases. It is certain that in many of the recorded cases the 
 diminished extent of range of movement is very disproportionate to 
 the apparently small amomit of injury. 
 
 Malgaigne {Treatise on Fractures) mentions the case of a boy, 
 aged ten, who fell on the path, the inner side of his elbow being 
 driven into the gravel. No crepitus was at first present, and owing 
 to the swelling no diagnosis was made until the eighth day, when 
 the epitrochlea was plainly made out to be broken off, but without 
 marked displacement. The forearm was kept flexed on a splint, 
 and some pressure made on the epitrochlea ; passive motion was 
 begun at the end of a fortnight. Little inflammation was present ; 
 yet, after two months and a half had elapsed, Malgaigne states that 
 flexion could only be obtained between 80 and 1 40 degrees. 
 
 Without going so far as this surgeon, it must be said that 
 ankylosis, partial or complete, is inevitable in certain cases. 
 Especially when the articulation of the elbow-joint is involved in 
 the injury, the results are very grave. 
 
 In one of Granger's cases, the patient, through neglect, never 
 recovered flexion or extension of the elbow-joint, and Hamilton says 
 that he had only once found any considerable ankylosis of the joint 
 after the lapse of a few years. 
 
 Jonathan Hutchinson junior also records (loc. cit. supra) 
 another example of partial ankylosis. 
 
 W. W., aged seven, fell on the right arm, and separated the 
 internal epicondyle, dislocating the forearm backwards. He came to 
 the clinic two days later, when the swelling was very great. Under 
 anaesthesia, however, the diagnosis could be effected and reduction 
 made. A plaster-of-Paris bandage was employed. He was sent out 
 of hospital, and told to return in a fortnight ; unfortunately he did 
 not do so for several weeks, by which time movement in the joint 
 had become much impaired, and it did not improve greatly. 
 
 Union of epiphysis. — If the epiphysis is but little displaced, there 
 is every reason to believe that it will unite by osseous material, for 
 of this the author has seen several instances. Sturrock's case 
 (quoted above) illustrates this point. 
 
 Still, it is somewhat surprising that in the larger proportion 
 of cases of detachment with displacement, this epiphysis, unlike 
 most of the other epiphyses in the body, does not unite by bone, 
 but by fibrous tissue. 
 
 There is frequently no large amount of callus about the detached 
 epicondyle, such as we find in other epiphysial separations. This 
 is probably due not so much to the displacement as to the laceration 
 of the periosteum connecting it with the rest of the internal 
 condyle. 
 
 Deformity. — According to some surgeons, no deformity should be 
 expected, although Gross says of this form of fracture that ' few 
 
378 EPIPHYSES OF UPPER EXTEEMITY 
 
 cases recover without a certain degree of deformity, or even 
 ankylosis.' 
 
 Of ten cases recorded by Dr. C. A. Powers {New York Medical 
 Becord, December 22, 1888) — eight in children and two in adults — ■ 
 nine regained the functions perfectly ; the other was lost sight of at 
 the end of the second month. In none was there resulting deformity. 
 On the removal of the splint, the average range of motion found was 
 35 degrees, and this generally improved in direct proportion to 
 the intelligence and faithfulness with which the patient followed 
 directions. 
 
 The epicondyle was found by Hamilton in one case displaced 
 downwards for a distance of one inch and a quarter, and immovably 
 fixed, three months after the accident. 
 
 In M. Paulet's specimen, and in M. Fallier's case, the fragment 
 was still displaced downwards and freely movable eight months 
 after the accident. 
 
 In others it has remained fixed in its displaced position. 
 
 Displacement doionioards and backwards. — In another case of 
 Hutchinson's it was found after a year displaced downwards and 
 backwards, and very firmly fixed against the inner side of the 
 olecranon. This case had been originally complicated with a dis- 
 location. 
 
 Packard has {International ■ Cyclopcedia of Surgery, vol. iv. 
 p. 137) unfortunately placed under fractures of the epitrochlea 
 (internal epicondyle) eleven cases of fracture of the trochlea and 
 internal condyle recorded by Hamilton. The following is what 
 Hamilton says of these cases in his ' Report on Deformities after Frac- 
 tures ' {Trans. Amer. Med. Association, vol. ix. 1856, pp. 114, 133) : 
 
 ' The eleven fractures of the internal condyle (' trochlea and epi- 
 trochlea ' of Chaussier) occurred in children between the ages of six 
 years and eighteen. Of the whole number, fonr are known to have been 
 fractures of the condyle outside of the joint, or fractures of the apo- 
 physis (' epitrochlea '), and four are known to have entered the joint 
 (fractures of the ' trochlea '). Of the fractures of the apophyses, two are 
 recorded as imperfect, because there remains a partial ankylosis, and 
 two as perfect, because no ankylosis exists. In three of the four cases 
 there was, however, a permanent displacement of the apophysis. 
 In one instance it was displaced slightly upwards and backwards, 
 and in two cases it was very much displaced downwards.' 
 
 The two cases of displacement downwards were : 
 
 I. Boy (F. C), aged fifteen (case reported above). Three months 
 after accident the apophysis of the internal condyle was found to be 
 broken off and removed downwards towards the wrist one inch 
 and a quarter, where it was immovably fixed. The elbow was partially 
 ankylosed, so that it could not be straightened completely nor flexed 
 to a right angle. Pronation and supination were perfect. 
 
 II. 'Boy (F. B.), aged nine, fell and broke left internal condj^le. 
 
INTERNAL EPICONDYLE OF HUMERUS 379 
 
 Six years after the accident, when the patient was a student of 
 medicine, the internal condyle was found to be displaced downwards 
 towards the wrist half an inch. Cannot straighten the arm com- 
 pletely. Can only flex it slightly, the elbow being fixed at an obtuse 
 angle. The power of pronation and supination imperfect. He 
 thinks the arm is as strong as before.' 
 
 In 1859 Coulson stated at the Royal Medical Chirurgical Society 
 that he had seen a great many cases of fracture of the internal 
 condyle in boys, and thought that they were almost always followed 
 by deformity. He quoted the case of a boy in which Mr. Key 
 refractured the part for fixation of the elbow. The boy ultimately 
 recovered good movement. 
 
 Displacement forwards. — If the epiphysis be displac3d forwards 
 it may unite with the lower end of the shaft, and very considerably 
 hamper the proper movements of the joint. 
 
 Mr. Hutchinson describes {Brit. Med. Journal, 1886, July 24) 
 a case in which he found this epicondyle displaced forwards 
 twenty months after the injury. A girl, aged four years, fell 
 while in the care of a nurse, but it was not known precisely of 
 what kind the violence had been. The elbow was bruised and 
 swollen for some time. She was treated by means of a plaster-of- 
 Paris case, and subsequently by a hinged splint. On examination 
 twenty months afterwards the elbow could not be flexed quite to a 
 right angle, nor could it be straightened. Slight flfexion only was 
 permitted, but pronation and supination were quite free. The 
 arm was strong, and the child used it for almost anything, yet 
 could not raise it to the mouth. It appeared probable that the 
 injury had been complicated. The head of the radius projected 
 strongly, as if almost, though not quite, free from the external 
 condyle, so that the finger could be placed in the outer two-thirds 
 of the cup of the radius ; still, it certainly had not wholly left the 
 condyle. The distance between the radius and ulna was much 
 increased, and no doubt the articular ligament was completely torn. 
 The inner condyle was lost, the inner side of the ulna being in the 
 same plane, or nearly so, as the inner edge of the humerus. There 
 was thickening in front of the humerus in this position, making it 
 seem possible that the epicondyle had been broken off and displaced 
 forwards. The thickening in front of the lower part of the humerus 
 was, however, not nearly so great as is usual in separation of the 
 whole lower epiphysis. Under an ansesthetic the elbow was bent 
 up to an angle of 45 degrees, and very nearly straightened. 
 Systematic and vigorous movements of the joint were advised, and 
 in the course of a few years its use would be alinost perfect. 
 
 Displacement upwards. — In only one instance out of four recorded 
 by Hamilton was the fragment displaced permanently upwards and 
 backwards. A boy (G. B.), 'aged six, fell and separated the 
 apophysis from the internal condyle of the right humerus. The 
 
380 EPIPHYSES OF UPPEE EXTEEMITY 
 
 fracture did not extend into the joint. When examined seven 
 years after the accident the arm was perfect in every respect, except 
 that the apophysis was carried backwards about two hnes, and 
 upwards towards the shoulder about three hnes ; and it was a httle 
 more prominent than the apophysis on the opposite arm, the right 
 elbow measuring three and three-quarter inches in its transverse 
 diameter, and the left three and a half,' 
 
 Injury to the ulnar nerve, paralysis, &c. — In Granger's case loss of 
 sensation over the distribution of the ulnar nerve, and paralysis of 
 the abductor minimi digiti and two contiguous muscles of the little 
 finger, lasted for eight or ten years, after which sensation and motion 
 were gradually restored to these parts. As a consequence of the 
 paralysis of the ulnar nerve, trophic changes took place in the skin, 
 and successive crops of vesications formed on the little finger and 
 ulnar edge of the hand some weeks after the accident, leaving 
 troublesome excoriations, and did not entirely cease for two or three 
 months. 
 
 These vesications, noticed by Granger in his three cases, on the 
 inner side of the hand have not been found in any of the other 
 examples of paralysis of the ulnar nerve subsequently met with. 
 
 In one of Cesar's cases the injury to the ulnar nerve was com- 
 phcated with dislocation inwards of the elbow, but the sensibifity of 
 the nerve gradually returned. 
 
 Compression of the ulnar nerve may be produced by the 
 pressure of the epicondyle united in a bad position. In one instance 
 it is stated that the nerve was found ' hypertrophied and in contact 
 with an osseous spine, produced by the epicondyle consohdated in 
 faulty position.' 
 
 In a case of Denuce's, resection of the x^rojecting spine-hke 
 process of bone, for neuralgia produced by pressure upon the ulnar 
 nerve, was foUowed by loss of the nerve symptoms. It occurred to 
 a man who had fallen upon his elbow three months previously. 
 
 Sir Astley Cooper {Fractures and Dislocations, 1842, p. 466) relates 
 the case of a girl who, by a fall upon her elbow, had fractured the 
 olecranon, and also the internal epicondyle of the humerus. The 
 point of the broken bone had almost penetrated the skin. The 
 cubital nerve had also been injured, for the Httle finger and half the 
 ring finger were benumbed. 
 
 Mr. Jonathan Hutchinson junior pubHshes {Transactions of the 
 Hunterian Society, 1891, p. 110) a parallel case where flexion was 
 limited to 10 degrees, and the muscles supplied by this nerve were 
 wasted with angesthesia. He removed the epicondyle after opening 
 the elbow-joint ; sensation returned, and flexion was increased to 50 
 degrees, with a useful arm. The following are the particulars of the 
 case (Brit. Med. Journal, January 16, 1892, p. 113) : 
 
 H. W., aged thirteen, whilst ' turning cart wheels ' on his hands, 
 fell and detached the epicondyle of one humerus. He was treated 
 
INTEENAL EPICONDYLE OF HUMERUS 881 
 
 at Guy's Hospital in the most thorough manner, and from par- 
 ticulars which Mr. Hutchinson junior was fortunate enough to obtain 
 from one of the dressers who had attended to him, it was ascertained 
 that passive motion was tried for long, and that he was twice 
 auEBsthetised with the view of overcoming the rigid extension of the 
 elbow. When he came to the London Hospital at the end of some 
 four or five months, the condition was as follows : his left arm was 
 practically useless, since he could not bend the elbow more than a 
 few degrees, and he complained of great pain if any attempt were made 
 to increase this limit. Further, there was evidence of serious injury 
 to the ulnar nerve. The little finger and half the ring finger were 
 anesthetic, there was wasting of the short muscles of the former 
 and of the adductor pollicis, and the interossei would hardly act at 
 all. The epicondyle was readily felt to be drawn downwards and a 
 little backwards, and that region was very tender to palpation. 
 Seeing that all ordinary means had failed and that the muscles 
 were wasting, it was thought advisable to relieve the condition by 
 operation, to which the parents readily consented. Under antiseptic 
 precautions the epicondyle was cut down upon and found to be 
 firmly fixed in the position described, with the ulnar nerve stretched 
 over its posterior and outer surface. The nerve was not dis- 
 tinctly made out to be inflamed. It seemed unadvisable to fix the 
 epicondyle in position, as it would have been necessary to divide all 
 the muscles and ligaments attached to it ; so it was carefully excised. 
 The elbow-joint was, of necessity, opened. The boy made a good 
 recovery, with the exception that a small abscess (probably not in the 
 joint) formed and had to be drained. The ultimate functional result 
 was very satisfactory. Sensation returned in the anaesthetic area 
 within a few weeks ; power was regained over the interossei, &c., and 
 he was able to bend the elbow to about 50 degrees. Some six months 
 later, although slight limitation of both flexion and extension 
 remained, the arm was thoroughly useful, all pain on movement 
 had disappeared, and the patient considered the arm practically as 
 strong as the other. 
 
 A second almost identical case was operated upon by the same 
 surgeon with an equally satisfactory result {Brit. Med. Journal, 
 December 30, 1893, p. 1419) : 
 
 W. E., aged ten years and six months, fell on his right elbow 
 across a bar ; he stated that he struck the outer side, but this was 
 doubtful. The result was that the internal epicondyle was 
 separated ; an internal angular splint was applied. On examination 
 twelve days later complete absence of the normal projection of the 
 epicondyle was extremely marked. The detached piece of bone was 
 displaced backwards and downwards, and was fairly fixed in its new 
 position. The elbow had been kept at a right angle, and the 
 patient resisted efforts to extend it further than a few degrees 
 beyond this. As he had considerable pain during the last few days 
 
382 EPIPHYSES OF UPPEE EXTEEMITY 
 
 (the splint having been left off, and the imperfectly fixed fragment 
 no doubt irritating the ulnar nerve), it seemed best to re-apply the 
 splint for a short time longer before beginning passive motion. At the 
 end of three weeks passive motion was instituted, but the boy would 
 not move the elbow at all himself, and as it was very stiff, he was 
 anaesthetised for the purpose of breaking down any adhesions that 
 might be present. It was interesting to note that the greater part 
 of the stiffness was purely due to tonic muscular contraction ; 
 for whilst the range of flexion had before been limited to about 
 15 degrees, under the anaesthetic a range of at least 90 degrees was at 
 once obtained without the least force. Evidently, however, some 
 fibrous adhesions (? extra-articular) were responsible for some of the 
 limitation, as when the arm was fully extended or flexed they were 
 felt to give way. The epicondyle, as previously noted, was drawn 
 downwards and fairly fixed ; its lower point must have been close 
 to the coronoid process. A regular course of passive motion was 
 instituted, but great difficulty was experienced in obtaining the 
 power of flexion, any attempt at this causing pain. Mr. Hutchinson 
 was not able to state that this patient perfectly recovered. His case 
 made it quite clear that the chief difficulty to be met lay in the 
 pressure on the ulnar nerve, for nothing else would account for 
 such reflex spasm disappearing almost entirely under the anaesthetic. 
 In another subsequent case, under the same surgeon, the cause was still 
 more obvious ; indeed he believes that the difficulty in obtaining good 
 movement after this accident was largely due to the fact that every 
 attempt at flexion of the joint increased the pressure upon the 
 nerve. 
 
 The following example of atrophy of muscles and loss of sensation 
 of the parts supplied by the ulnar nerve is recorded by M. Fallier. 
 The injury was complicated by dislocation backwards and outwards 
 of the elbow, which occurred twice. 
 
 J. P., a mechanical workman, fell on October 22, 1888, on board 
 ship, with his hands carried forwards against the bridge. There was 
 a complete dislocation of the left elbow backwards and outwards, 
 whilst there was considerable projection forwards and inwards of the 
 humeral trochlea, with backward and outward displacement of the 
 olecranon and head of the radius. Tne forearm was semipronate. 
 Reduction was easily effected, and the arm kept in a sling. Three 
 weeks later the sling was removed and passive motion commenced ; 
 the ship's doctor then recognised a fracture of the epitrochlea and 
 disturbances in function of the ulnar nerve, and the patient experi- 
 enced acute pain in the epitrochleo-olecranon hollow. Treatment 
 by electricity was now commenced, and by the end of a month 
 the pain had quite disappeared and the movements of the forearm 
 had become almost complete, there being but slight weakness of limb 
 and loss of sensation on the inner border of the hand and little 
 hnger ; also, the little and ring fingers were contracted in a claw- 
 
INTEENAL EPICONDYLE OF HUMEEUS 383 
 
 like manner. The patient resumed his occupation ; but two days 
 afterwards, in hfting a large piece of wood, he experienced severe 
 pain on the inner side of the elbow, which again became 
 dislocated. The dislocation was readily reduced, but the patient 
 was unable to resume work on account of the loss of power of 
 the arm and the paralytic condition of the ulnar nerve, which 
 increased in spite of the continued electrical treatment. On 
 April 1 he was sent to the Maritime Hospital at Brest, under the 
 care of Professor Guyot. A transverse fracture of the epitrochlea 
 was immediately detected, the upper fourth remaining as a sharp 
 projection attached to the humerus, corresponding to the upper 
 angle of this process, and the lower three-fourths, nearly two centi- 
 metres in diameter, had been dragged downwards and inwards by 
 the epitrochlear muscles. Between these two fragments a depression 
 a finger's breadth in width could be felt, with the trochlear surface 
 of the humerus at its bottom. The lower fragment was lying more 
 than one and a half centimetres to the front and inner side of the 
 lowest part of the inner border of the olecranon, freely movable from 
 before backwards — especially when the forearm was semiflexed and 
 semipronate — and also slightly movable from below upwards, when 
 distinct crepitus was elicited. Flexion of the forearm was complete, 
 while extension could only be carried to 140 degrees. Pronation and 
 supination were normal. Flexion of the hand could not be effected to a 
 right angle, and its adduction caused slight pain at the inner aspect 
 of the elbow. The epitrochlear muscles attached to the displaced 
 fragment were clearly atrophied, and the forearm diminished in 
 muscular power. The inner border of the forearm, which was said 
 by the patient to have been insensitive at the commencement, was 
 now normal ; however, there was some loss of sensation at the 
 inner side of the wrist, and complete anassthesia on the palmar 
 aspect of the hand over the hypothenar eminence and all the palmar 
 aspect of the little finger. Around this area was a zone of diminished 
 sensibility, and the dorsal and lateral aspects of the little finger were 
 completely insensitive. The little and ring fingers were both in a 
 claw-shaped position (the first phalanges extended and the second 
 flexed), and the only voluntary movements these were capable of 
 effecting were flexion and extension of the first phalanges upon the 
 metacarpus. The separation of the middle and index fingers from 
 their neighbours could not be carried out, and adduction of the 
 thumb was weak. The rest of the movements of the fino-ers 
 appeared to be normal. Atrophy of the muscles of the hypothenar 
 eminence was also very evident, as well as that of the interosseous 
 muscles and of the adductor of the thumb. At the end of May the 
 portion of the epitrochlea attached to the humerus appeared to be 
 rounding off gradually, and the lower fragment became more and 
 more fixed, with loss of the crepitus. The Faradaic current was 
 employed without any great improvement in the paralytic condition 
 
384 EPIPHYSES OF UPPEE EXTEEMITY 
 
 of the ulnar nerve up to June 15. The termination of the case has 
 not been pubHshed. 
 
 This case was rather a fracture than an epiphysial detachment, 
 for the inner and lower borders of this process were believed to have 
 been alone torn off, leaving the rest of the epicondyle projecting the 
 same as on the opposite side, although it was sharp and pointed and 
 smaller in its other dimensions. 
 
 The paralytic condition may be of considerable duration, but is 
 very variable. 
 
 In one of Granger's cases sensibility and contractility only com- 
 menced to appear at the end of seven years, in Ealher's case at 
 the end of eight months, and in Eichet's case at the end of several 
 months. 
 
 Atrophy of epicondylar muscles. — Cesar mentions this atrophy of 
 7miscles connected with the epicondyle in three of his cases : indeed he 
 was the first to draw attention to this condition, and discusses at 
 length in his thesis the causes which may produce it. In all three 
 the fragment consolidated without displacement. 
 
 M. Eichet observed in two cases rapid atrophy and paralysis of 
 the muscles attached to the inner condyle. One of them was the 
 case mentioned above, in which the trochlea was also fractured and 
 the joint became ankylosed. He attributed the paralysis to con- 
 tusion of the ulnar nerve at the time of the accident. But in none 
 of these was there any known lesion of the ulnar nerve, nor did the 
 muscular atrophy include the flexor profundus and flexor carpi ulnaris 
 supphed by this nerve. 
 
 Separation with dislocation of elbow-joint. — Unfortunately, it has 
 occasionally happened that the dislocation has been immediately 
 reduced but the detachment of the epicondyle overlooked. In 
 Hamilton's case (boy aged fifteen) the fracture had remained unre- 
 cognised for three months, when he came under his care ; and in 
 Ealher's case it was only noticed on removing the spHnt after 
 more than three weeks. 
 
 Where the fracture has been entirely overlooked, the displace- 
 ment of the fragment becomes greater, the articulation more or less 
 stiff and weak or useless, and there may even occur a fresh dislocation. 
 
 Under these complicated circumstances the swelling will diminish 
 rapidly and complete consolidation quickly follow, provided the 
 fracture has been recognised at the time of the accident, or imme- 
 diately after reduction. If properly treated, complete recovery of the 
 function of the arm will follow. Consolidation has taken place even 
 after some delay in the recognition of the fracture. Yet in other 
 instances incomplete movements of flexion and extension may be the 
 result, as in Granger's and Eichet's cases. 
 
 In a case of Langenbeck's quoted by Gurlt (Langenbeck's 
 Archiv filr klin. Ghir. Bd. iii. 1862, S. 123, No. 3), ankylosis with 
 partial displacement backwards of the elbow, associated with separa- 
 
INTBENAL EPICONDYLE OF HUMEEUS 
 
 38; 
 
 tion of internal condyle, was seen in a boy aged sixteen years. The 
 elbow had been injured by a fall on the ground six months previously. 
 Some improvement in the movement of the joint took place after 
 forcible flexion under chloroform. 
 
 TREATMENT. — An attempt should be made to replace the dis- 
 placed epiphysis ; but this can seldom be retained perfectly in 
 position, on account of its small size and the numerous muscles 
 attached which tend to displace it. The elbow, as well as the 
 wrist and fingers, should be semiflexed to relax these muscles as 
 completely as possible, and the epicondyle replaced in its position, as 
 
 Fig. 99. — flexible metal splint with folded edges for separated internal 
 epicondyle or other milder cases of injury near the elbow-joint ' 
 
 Fig. 100. — wrenches used 
 at the city orthopedic 
 hospital 
 
 Fig. 101. — METHOD of applying wrenches for BENDING 
 METAL SPLINTS OF ALL KINDS TO FIT ACCURATELY THE 
 shape of the JOINTS IN ANY POSITION 
 
 far as practicable, by the fingers. An anterior angular splint of 
 wood, metal, or other material should then be put on to maintain the 
 parts at rest, and a bandage carefully applied. Any subsequent 
 inflammation of the joint or injured structures should be treated by 
 
 ' This si^lint when bent into the required position may be applied to the front or back 
 of the elbow, or be combined with a short wooden splint on the opposite side of the arm or 
 forearm. Ordinary flexible band or hoop iron, one and a half to two inches wide, such as 
 may be obtained at any ironmonger's or blacksmith's, is equally serviceable. With the 
 use of a file, hammer, and ordinary wrenches, almost any form of splint for the upper 
 extremity can be readily made. 
 
 C C 
 
386 EPIPHYSES OF UPPEE EXTEEMITY 
 
 appropriate evaporating lotions. Especial care should be taken that 
 the bandage is not applied too tightly, for fear of gangrene or of 
 increasing the inflammation. 
 
 The elbow should always be put up in a semiflexed position, as 
 that is the most useful position of the joint should ankylosis subse- 
 quently take place. Malgaigne recommended this position. 
 
 In Cesar's thesis, in 1876, Malgaigne's view is supported, inas- 
 much as the trochlear muscles are flexors — viz. that the forearm 
 nhould be flexed upon the arm, and the fingers also flexed, so that 
 the displaced fragment may be more readily replaced. 
 
 Granger's observations in 1818 as to the difficulty of maintain- 
 ing the fragment in position are very accurate. He says : "I have 
 purposely avoided saying one word about replacing the detached 
 condyle, and for these reasons : during the state of tumefaction of 
 the limb, no means could be adopted for confining the retracted con- 
 dyle in its place beyond that of the relaxation of the muscles ; 
 and both before the tumefaction has commenced, and after it has 
 subsided, all endeavours to replace the condyle, or even change the 
 position of it, have failed.' He discarded the use of all splints and 
 bandages, following his predecessors from the earliest history of 
 medicine. 
 
 However, a cone-shaped compress of lint or cotton-wool placed 
 over the epicondyle will often assist materially in maintaining this 
 process in position, or a horseshoe-shaped piece of wadding placed 
 below it, after reduction, according to Eichet's plan, and kept in 
 position by strapping ; or a moulded inside spHnt of poroplastic felt 
 or other material may be employed, with a gap over the situation of 
 the internal epicondyle. 
 
 Pingaud (art. ' Coude,' Dictionnaire encyclopedique cles sciences 
 medicales, 1878) agrees with Granger's views that no attempt at 
 fixation should be made, but that the limb should be placed in a 
 simple trough splint, on account of the danger of articular ankylosis. 
 
 As to the rest of the treatment advocated by Granger, it is 
 impossible to agree with him in recommending passive movement 
 to be commenced from the time of the accident. He says that 
 ' while attention ought to be given to the reduction of the inflamma- 
 tion by appropriate means, we ought, nevertheless, to instruct the 
 patient to flex and extend the arm daily from the moment the 
 accident occurs until the cure is completed, and without any regard 
 to the consoHdation of the fragment.' ' The exercise of the joint in 
 this manner must constitute the principal occupation of the patient 
 for several weeks, and should it be remitted during the formation 
 and consolidation of the callus, much of the benefit which may 
 have been derived from this practice will be lost, and will with 
 difficulty be regained.' 
 
 Granger's views in considering that it was of no consequence 
 whether the internal epicondyle united or not will hardly be accepted 
 
INTEENAL EPICONDYLE OF HUMEEUS 387 
 
 by the majority of British surgeons, even though in many cases the 
 union be a fibrous one. 
 
 Another plan is for the forearm to be secured in the semiflexed 
 and semipronate position by means of pasteboard spHnts secured 
 with a roller bandage and a pad of cotton wool or tow below the 
 epicondyle after reduction. The fingers may be also semiflexed on a 
 pad of tow. Other surgeons prefer an outside angular splint. 
 
 M. Coulon {TraiU clinique et pratique des fractures chez Us 
 enfants, Paris, 1861) in all his cases fixed the arm in the bent 
 position, but in only -two out of eight was the result very successful, 
 and these he believed were of the extra-articular variety. 
 
 The following is an example of many others which have come 
 under the author's own observation at the Miller Hospital, treated 
 by rectangular splints with excellent results. It was one of displace- 
 ment downwards and forwards of the internal epicondyle. 
 
 J. F., aged seventeen, on June 10, 1894, whilst riding a bicycle, 
 fell, striking his elbow and side. He came to the hospital soon 
 after, holding the injured arm with the other. On examination, 
 flexion and extension could be carried out without much pain, but 
 pronation and supination were much more painful. There was 
 considerable extravasation of blood over the situation of the normal 
 internal condyle, extending down the inner side of the forearm. 
 The small movable fragment of the internal epicondyle could 
 be distinctly felt below and in front of the normal situation of 
 this epiphysis. By means of manipulation in the flexed position, 
 the detached epiphysis could be brought into accurate apposition 
 with the internal condyle. The elbow was therefore put up in the 
 flexed position on a posterior rectangular splint. On the second day 
 the sphnt was re-adjusted, and the bone found to have retained its 
 excellent position. On the fifth day the swelling began to diminish, 
 and five days later passive movements were commenced, and so 
 successfully that on the eighteenth day active and passive movements 
 were almost perfect. By July 7th the functions of the elbow were 
 perfect ; there was no deformity, and the epicondyle had united by 
 osseous union. 
 
 The author thinks that a separated epicondyle is best replaced by 
 flexion to within a right angle, and treated in this position according to 
 the plan advocated above - at any rate, all those cases in which the dis- 
 placement is downwards and forwards— so as to relax the epitrochlear 
 muscles. The fingers and hand may also be flexed with advantage, 
 in order to relax the flexors attached to the epiphysis. 
 
 M. Pezerat, in 1832, was one of the first to reintroduce the 
 extended position, but at that time his views were severely criticised 
 by Malgaigne and others. Eecently Dr. L. C. Lane, of San Fran- 
 cisco, Dr. Bardenheuer, and Dr. Frere have insisted upon it. 
 
 Berthomier, in an article on the mechanism of fractures about 
 the elbow in children {Gazette des hopitaux, 1876, p. 21), also recom- 
 
 c c 2 
 
388 EPIPHYSES OF UPPEE EXTEEMITY 
 
 mends treatment of separation of the epitrochlea by extension, 
 combined or not, according to the case, with moderate traction. 
 In fact, he thinks that all fractures about the elbow should be 
 fixed in the extended position, wdth the exception of separation of 
 the epiphysis of the epicondyle (external epicondyle). 
 
 This w^riter treated several cases of fracture of the internal 
 epicondyle, and obtained much better results than by the flexed 
 position. He says that accurate adaptation of the fragments can 
 only be obtained by the straight position. 
 
 In three cases seen by Hamilton, a displacement of the fragment, 
 either forwards or backwards, occurred whenever the arm was 
 flexed, and it was necessary, therefore, to treat the case with the 
 arm in a straight position. 
 
 A. Hanbury Frere, of Frizinghall, advocates (Brit. Med. Journal, 
 January 23, 1892, p. 195) the extended position in the following 
 words : 
 
 ' I may,' he says, ' perhaps be permitted to point out that, Vvdth the 
 arm at a right angle, it is possible for the detached fragment to move 
 about in many directions ; in fact, we have no control over it what- 
 ever. At the same time, the ulnar nerve is almost certain to become 
 entangled in the effusions or the callus. On the other hand, with the 
 arm extended, we can see and feel in what direction the fragment is 
 displaced. We can more easily manipulate it into its proper place ; 
 and when once w^e have got the fragment into good position, it can 
 easily be retained there by an immovable dressing. "With the arm 
 straight, the skin and tissues around the fragment, being somewhat 
 tense, would of themselves almost keep it in place. At any rate, 
 the only possible movement would be downwards from the action 
 of muscles ; but I believe that, in elbow fractm'e, muscular 
 action has not nearly so much to do with displacement of the 
 fragments as is generally believed. If in this way the fragment is 
 kept in pro]3er position, there is no reason why bony union should 
 not take place. I suppose the chief fear of downward displacement 
 would be from the action of the pronator, and therefore, I say, dress 
 the limb in the extended position, with the forearm prone. 
 Berthomier dressed the arm "in the extended and supine position, 
 and I consider his results are better than any that have been 
 obtained in the bent position ; and therefore I wish to take this 
 opportunity of suggesting that our hospital surgeons should give the 
 straight position a fair trial, seeing that those who have done so 
 have found that by dressing the limb straight they can be certain of 
 accurate coaptation, and they therefore obtain a much earlier 
 return to usefulness ; and, above all, obviate deformity, w^hich is so 
 common after the present treatment of elbow fracture in the bent 
 position.' 
 
 Guedeney relates {Du traitement des fractures du coude chez 
 Venfant, Lyon, 1893) nine cases from M. Vincent's clinic at Lyons, 
 
INTERNAL EPICONDYLE OF HUMERUS 389 
 
 six of which were treated successfully by fixation in the extended 
 position alternating with flexion, both in the supine position. 
 
 (1) Boy, aged thirteen and a half ; internal epicondyle dis- 
 placed backwards and a little downwards, with a depression at side 
 of epicondyle. Fall from height on elbow. (2) Boy, aged ('?). 
 Detachment of internal epicondyle; swelling on inner side of 
 elbow. (3) Boy, aged twelve. Detachment of the internal epi- 
 condyle, with displacement of ulna backwards and outwards and 
 laceration of internal lateral ligament. Epicondyle felt below the 
 trochlea movable with crepitus, but the apex of the olecranon 
 on the outer side a Httle above the capitellum. (4) Boy. Fall 
 on right elbow. Detachment of external epicondyle. (5) Boy, 
 aged thirteen years. Swelling of elbow. Detachment of internal 
 epicondyle. Great looseness of joint. (6) Boy, aged ten and a 
 half. Fall on elbow. Detachment of internal epicondyle, which 
 was movable, and laceration of external lateral Hgament. (7) Boy, 
 aged ten. Fall on left elbow (treated by flexion). (8) Boy, aged 
 thirteen. Fall on elbow. Treated for eight days by bone-setter. 
 Extensive ecchymosis and internal epicondyle separated from 
 humerus for one centimetre. Deformity and loss of movement 
 remained in spite of treatment in the extended position. (9) Gn4, 
 aged six. Two months before fell from a donkey. The detachment 
 of the internal epicondyle was accompanied by subluxation and a 
 deposit of vicious callus in the bend of the elbow, which limited 
 movements. After manipulation, the elbow was kept fixed in the 
 flexed position. Child still under treatment. 
 
 Passive motion.— This should be commenced from the seventh to 
 tenth day and earned out daily for some weeks. If delayed later, 
 ankylosis or articular rigidity may ensue. As already stated, 
 Granger trusted entirely to passive motion without the use of 
 splints. 
 
 Some modern surgeons, however, have thought not only that 
 early passive motion is unnecessary to prevent stiffness of the joint, 
 but that it may be actually harinful by increasing the amount of 
 inflammation. It should always be of the gentlest kind, and so slight 
 as not to cause pain. 
 
 At the end of a fortnight the arm may be carried in a sling 
 without any splint. 
 
 The sphnts should be removed and flexion and extension carried 
 out thoroughly every day and the patient be kept under obser- 
 vation for some months. 
 
 Complications. — A separated epicondyle will only render a disloca- 
 tion diflicult of reduction when it has become impacted between 
 the articular surfaces. When this is recognised, resection of the 
 epiphysis should be performed immediately. 
 
 The rules for reduction of dislocation in the more simple cases 
 need not be alluded to in this place. After its accomplishment 
 
390 EPIPHYSES OF UPPEE EXTREMITY 
 
 some surgeons recommend the arm to be simply placed in a sling 
 until the swelling has subsided in a week's time, when the dis- 
 placed fragment may be brought into position as advocated above. 
 As far as children are concerned, this is not to be recommended, 
 consoHdation commencing in them within a few days ; the fragment 
 should be replaced at once. 
 
 Articular rigidity.— The slight articular rigidity which remains 
 will usually yield to gentle massage, exercises, and shampooing. 
 These, with the addition of the Faradaic current, will be found bene- 
 ficial in preventing the wasting of the muscles. 
 
 Should the ulnar nerve be paralysed, the continuous current 
 must be used. 
 
 Primary operation for displacement.— It has been suggested to fix 
 the epiphysis in good position after displacement in order to obtain 
 osseous union. As yet this plan has not been attempted. The pin 
 should be removed in about two weeks. 
 
 Excision of epicondyle. — When the displaced epiphysis appears to 
 be the cause of the limitation of the movements of the elbow, or 
 when there are symptoms of pressure upon the ulnar nerve — 
 especially if it is beheved that such is not due to recent callus 
 and that the pressure symptoms are not likely to disappear — 
 excision of this process should be carried out under strict antiseptic 
 precautions on account of the probability of opening the joint. 
 
 In Mr. Hutchinson junior's case quoted above {loc. cit. supra) 
 a useful arm resulted after excision of the epicondyle had been 
 performed, although the joint was opened. He alludes to the 
 fact that Bardenheuer and other German surgeons have excised 
 the whole elbow for conditions similar to that which his patient 
 presented, an operation he considers quite unjustifiable. 
 
 Bichet successfully resected a portion of the epicondyle in a man 
 for intolerable neuralgia due to pressure upon the ulnar nerve, the 
 result of union in a bad position after a fracture of this process. 
 
 Paulyhas also {Gentralhlatt filr Chirurgie,18S2,-p. 157) removed 
 the epicondyle in the hope of diminishing the risk of excessive 
 formation of callus. 
 
 In Debruyn's case of a boy, aged eighteen, the dislocation could 
 not be reduced, the repeated attempts at reduction only rendering 
 the peri-articular swelling greater ; gangrene ensued, which neces- 
 sitated amputation, when a detachment of the internal epicondyle 
 was discovered. This did not of itself lead to the disastrous result. 
 Therefore, in complicated irreducible dislocations, or ankylosis from 
 a similar cause, resection should be performed. In some complicated 
 dislocations the internal epicondyle may be the cause of the impos- 
 sibility of reduction, by being wedged between the trochlea and sigmoid 
 cavity of the ulna, and then resection is rendered necessary. 
 
 Compound Separations. — In these ver}' rare cases excision of 
 the epicondyle will be necessary. 
 
INTEENAL EPICONDYLE OF HUMEEUS 391 
 
 As regards fixation, surrounding the joint and limb with the usual 
 dressings will, as in other compound injuries about the joint, give a 
 sufficient support to the joint. ' 
 
 Early passive movement must be instituted as soon as the con- 
 dition of the wound will permit. It may be commenced in some 
 instances a few days after the operation. 
 
392 EPIPHYSES OF UPPER EXTREMITY 
 
 CHAPTEE VII 
 
 SEPARATION OF THE EXTERNAL EPICONDYLE 
 OF THE HUMERUS 
 
 ANATOMY. — The osseous nucleus of the external epicondyle 
 appears about the thirteenth or fourteenth year in the cartilage 
 of the lower epiphysis, towards the upper and outer aspect of the 
 capitellum. 
 
 The epiphysis, when completely osseous, very rapidly joins on to 
 the capitellar portion of the articular surface — viz. about the six- 
 teenth year — and only a small portion of its upper part overlaps the 
 diaphysis. 
 
 The external epicondyle, in association with the rest of the 
 articular portions, unites with the diaphysis about the seventeenth 
 year. 
 
 Sometimes, but rarely, this process forms a separate epiphysis, 
 which joins on to the diaphysis as a distinct process. 
 
 This process, which is curved slightly forwards, is so small that, 
 with the exception just mentioned, it is impossible for a traumatic 
 separation to occur without a fracture of the cartilage or bone which 
 unites it to the epiphysis, detaching it from the capitellum. The 
 synovial membrane will most probably be implicated. This diastasis 
 may therefore be said to be intra-articular. 
 
 The size of the external epicondyle is five milHmetres in the 
 fully developed condition. 
 
 Its posterior aspect can just be detected in the child, being 
 subcutaneous and covered only by the superficial fascia and deep 
 aponeurosis of the arm and forearm, which blend together here. 
 
 It presents neither such a pyramidal shape, rough appearance, 
 nor anterior cavity as is met with in the adult. 
 
 At the fourteenth year its apex is nearly one and a half centi- 
 metres above the radial cup, and projects outwards and slightly 
 downwards and forwards. 
 
 In the adult the external condyle (of English writers) is formed 
 partly of the external epicondylar epiphysis, partly of a slight 
 projection of the diaphysis of the humerus, and a small part of its 
 lower end by the non-articular posterior part of the capitellar 
 portion of the lower epiphysis. 
 
 Its upper limit is the attachment of the fibres of the extensor 
 
EXTEENAL EPICONDYLE OF HUMEKUS 
 
 393 
 
 carx^i radialis brevior and the commencement of the outer supra- 
 condyloid ridge, but below and behind it extends beyond the 
 capitehum, and quite posteriorly is separated from the outer lip 
 of the trochlear groove ; so that, as M. Austric puts it, it is as much 
 post-condyloid as epi-condyloid (i.e. the condyle or capitellum). 
 
 In the adult it only projects half a centimetre beyond the level 
 of the capitellum. 
 
 To the external epicondyle are attached the extensor communis 
 digitorum (to its lower part), the extensor carpi radialis brevior, 
 the extensor carpi ulnaris, 
 and the anconeus muscles 
 (to its back part, above 
 the attachment of the ex- 
 ternal lateral ligament) ; 
 also the external lateral 
 ligament and supinator 
 brevis (at extreme lower 
 and back part). 
 
 The extensor minimi 
 digiti is only attached to 
 the external epicondyle by 
 means of the fascial apo- 
 neurosis between it and 
 the extensor carpi ulnaris 
 and extensor communis 
 digitorum on either side 
 of it. 
 
 The fibres of the cap- 
 sular ligament in front ex- 
 tend quite up to the base 
 of the external epicondyle 
 in front, beneath the fibres of the extensor carpi radialis brevior. 
 
 Belation toith synovial membrane. — There is only the thickness 
 of the fibres of the external lateral ligament and the capsular 
 ligament (anterior ligament) separating the epiphysis from the 
 synovial membrane below and in front. Behind, the posterior 
 cul-de-sac of the synovial membrane passes over the humeral 
 portion of the external condyle of the adult, which intervenes 
 between the external epicondylar epiphysis and the outer lip of the 
 trochlea. In the child, however, the synovial membrane on this aspect 
 is at a considerable distance from the epiphysis. 
 
 Of the synovial bursEE in relation with the external epicondyle, 
 those found in the adult are enumerated by M. Poirier, and quoted 
 by M. Gabriel Austric (These de Paris, 1889, No. 13, Les fractures 
 experimentales de V epicondyle) as follows : 
 
 1. Subcutaneous bursa. — Very rare, but may be developed 
 pathologically from pressure. 
 
 Fig. 102. — epiphyses of capitelluii, tkochlea, in- 
 ternal AKD EXTERNAL EPICONDYLEb, AT THE END OF 
 THE FOURTEENTH YEAR AFTER JIACEEATION. (eOYaL 
 COLLEGE OF SURGEONS MUSEUil) 
 
394 EPIPHYSES OF UPPEE EXTEEMITY 
 
 2. Bursa beneath the anconeus muscle, often (always, according 
 to Henle) communicating with the joint, was found in one out of 
 three or four cases. 
 
 3. Bursa of the extensors of the hand, between the supinator 
 brevis and radial head and the superficial extensors covering them. 
 It was discovered in about fifty per cent, of cases, and occurred 
 more often on the right than on the left side. It never communicates 
 with the joint, but may be divided into two compartments. 
 
 These bursae are important, inasmuch as they may complicate 
 separations of this epiphysis. 
 
 Effusions into the third or last bursa mentioned might be detected 
 by pronating and supinating the forearm whilst the hand is placed 
 over the situation of the bursa^viz. the radial head. 
 
 AGE. — True separation of the osseous epiphysis of the external 
 condyle can only occur from the thirteenth to about the seventeenth 
 year. Below this age this process may be detached by a fracture 
 of the cartilaginous tissue uniting it with the capitellar portion 
 of the lower epiphysis of the humerus. 
 
 The three or four pathological specimens alluded to below were 
 from the dissecting room, and can throw no light upon the question 
 of age. 
 
 Out of the six clinical cases, in one the age is not given, one 
 was aged fourteen years, one eleven and a half, two were ten, and 
 one three and a half. 
 
 ETIOLOGY. Indirect violence. — Forcible adduction of the arm is 
 believed to be the most common manner of violence indirectly 
 to the epicondyle. 
 
 M. Berthomier has experimentally produced a detachment of the 
 external epicondyle by torsion combined with traction of the fore- 
 arm, and also by violent flexion inwards, showing the great strength 
 of the external lateral ligament. 
 
 M. Barros has also produced a fracture of the lower part of the 
 external epicondyle still attached to the external lateral ligament, 
 and combined with dislocation of the radius outwards, in a child 
 aged fourteen, by means of violence applied to the palm of the hand 
 whilst the arm was in a straight position. 
 
 Direct violence. — It has been stated that direct violence is almost 
 always the cause of detachment of the external epicondyle. This is 
 probably true in the case of the adult ; but in children, the external 
 epicondyle being so little developed before the age of eight or ten 
 years, it is impossible that direct violence can come into play — at 
 any rate, from its posterior aspect. 
 
 In 1842 M. Huguier, in a thesis on the diagnosis of diseases 
 about the elbow-joint, gave special attention to fractures of the 
 epitrochlea and epicondyle, and he thought that such were pro- 
 duced by a cause which acted directly or solely on these two 
 processes. He believed that mobility was easier to obtain in these 
 
EXTEENAL EPICONDYLE OF HUMEEUS 395 
 
 than in fractures of the trochlea or capitellum, because in them the 
 ulna or radius is not compelled to be moved. The smallness of the 
 fracture he imagined would very likely lead to an error in diagnosis, 
 were it not for the fact that the articulation is not deformed, and its 
 movements free and painless comparatively to those fractures which 
 involve the joint. 
 
 In none of Berthomier's experiments at the elbow-joint in 
 children by direct violence was he able to produce a fracture of the 
 external epicondyle alone ; yet he does not deny either the possibility 
 or the frequency of such an injury. 
 
 MM. Charvot and Franchet (' Note clinique sur les Fractures 
 de I'Epicondyle,' Archives cle Medecine et de Pharmacie militaires, 
 Nov. 1888, p. 334), in relating two cases in adults, think that the 
 essential condition for the production of the fracture (which occurred 
 in the person of one of them) was one of semiflexion of the forearm 
 during a fall, for in this position the external epicondyle is sub- 
 cutaneous and uncovered by the supinator longus and extensor carpi 
 radialis longior. The external epicondyle is caught and broken off 
 backwards and displaced downwards by the action of the extensor 
 muscles of the forearm inserted into it. 
 
 In the second case the fractured epicondyle was displaced down- 
 wards and forwards, and complicated a dislocation of the bones 
 of the forearm backwards, and reduction could not be effected. It 
 was thought to be due to indirect violence {par arracliement) . 
 
 But M. Austric thinks that, on anatomical grounds, this is hardly 
 possible from the traction alone of the external lateral ligament, 
 and certainly not from muscular action in adults, while muscular 
 action alone cannot displace the fragment — at any rate, if it is 
 only the apex which is detached, only a few tendinous fibres being 
 attached to it. 
 
 PATHOLOGICAL ANATOMY.— Separation of the external e^^i- 
 condylar epiphysis is a very much rarer form of injury than 
 separation of the internal epicondyle. 
 
 Traumatic separation of the external epicondyle can only be 
 possible before the sixteenth year. 
 
 Gurlt thinks that this injury is possible up to the eighteenth or 
 twentieth year, and that it lies entirely outside the articulation. 
 
 Malgaigne, in his treatise in 1847, denied the existence of these 
 lesions in adults : ' Quelques ecrivains modernes ont parle d'une 
 fracture qui ne penetrerait pas dans 1' articulation et qui n'affecte- 
 rait que I'epicondyle ; mais personne jusqu'a present n'en a cite 
 d'exemple.' 
 
 Marjolin recognised fractures of the external epicondyle, but 
 Denuce, in the Nouv. Dictionnaire de Medecine et de Cliirurgie pra- 
 tiques, 1868, classified them under those of the lower end of the 
 humerus, and Pingaud with those of the capitellum and external 
 condyle. 
 
396 
 
 EPIPHYSES OF UPPEK EXTEEMITY 
 
 M 
 
 The latter thought that the thickening of the humerus met with 
 in these cases indicates that the original injury has been more 
 extensive. He had never met with a detachment of the epicondyle 
 alone. 
 
 M. Berthomier (These de Paris, 1875), in eighty experiments on 
 the elbows of children, never produced a fracture of the external 
 epicondyle alone ; but in those cases where he only perceived 
 abnormal mobility of the external epicondyle after simulating a fall 
 upon the elbow, and where the examination of the part was neces- 
 sarily more easy than in the living subject, he always found a 
 
 transverse fracture passing more or 
 less exactly through the diaphyso- 
 epiphysial line. 
 
 Sir Astley Cooper was the first, in 
 1823 (Treatise on Fractures and Dis- 
 locations, London 1823), to allude to 
 this class of injury. 
 
 In the case figured by Sir Astley 
 Cooper the injury doubtless occurred 
 in an adult. It was taken from a 
 specimen in St. Thomas's Hospital, 
 and is described by him as follows : 
 ' The preparation is a specimen of the 
 transverse fracture of the extremity 
 of the condyle [Sir A. Cooper com- 
 bines under this term the external 
 epicondyle and the capitellum] within 
 the capsular ligament, and not the 
 least attempt at ossific union can 
 be detected.' He continues : ' It is 
 obvious, therefore, that this principle 
 of ligamentous union extends to all 
 detached portions within a capsular 
 ligament, the vitality of the bone 
 being supported merely by the ligament within the joint.' 
 
 According to the figure here reproduced (fig. 103), the external outer 
 limit of the capitellum appears to have been involved. Whether this 
 was the extent of the original injury it is dif&cult to say. 
 
 There is no authentic specimen of separation of the external epi- 
 condyle alone in any of the London hospital museums. 
 
 Hamilton figures Qoc. cit. supra, fig. 87) a supposed fracture 
 of the entire external epicondyle — a specimen sent to him by 
 Dr. E. Zuckerkandl, of Vienna. 'It was found in the dissecting 
 room, and is unaccompanied with any clinical history ; but it is 
 evidently from a person near the twentieth year of life. There is, 
 indeed, an apparent absence of a portion of the external epicondyle, 
 and there are two ossicula, situated in the external lateral hgament. 
 
 Fig. 103. — feactuee of the exter- 
 nal EPICONDYLE AND A SMALL PAET 
 OF CAPITELLUM. (ST. THOMAS'S 
 
 HOSPITAL MUSEUM. SIR ASTLEY 
 
 COOPEE's ' FEACTUBES AND DISLOCA- 
 TIONS ') 
 
EXTEENAL EPICONDYLE OF HUMEEUS 397 
 
 with smooth, sHghtly bossellated surfaces. Dr. Zuckerkandl explains 
 the presence of two by supposing it was an exceptional process 
 of development ; but it is more difficult to explain how the epi- 
 physis should have found its way into the lower or distal portion 
 of the external lateral ligament, where he correctly states that it is 
 situated. The supposed original seat is covered in by perfectly formed 
 lamellated tissue, and underneath the situation in which the ossicula 
 are found is a deep fossa fitted exactly to receive them.' 
 
 The specimen is undoubtedly one of fracture involving the 
 diaphysis, from the appearance of the drawing which Hamilton 
 gives. 
 
 The case is described and figured by Dr. Zuckerkandl {Allgemeine 
 Wiener medizinische Zeitung, Feb. 1878), and considered by him 
 as a real epiphysiary fracture or separation in an adult. 
 
 Gurlt also figures {Ilandhuch de?- Lehre der Knochenbriichen, 
 1860, II. Theil, S. 798) another similar specimen, in the Museum 
 of Giessen, in which the fracture — an old, consolidated one — is; 
 almost strictly limited to the external epicondyle. The fracture being 
 close up to the capitellum, indicates clearly that the articulation must 
 have been involved. He remarks that the existence of this injury had 
 always hitherto been doubted, and describes another specimen at 
 Berlin. The detached epicondyle in this, like the other specimen,, 
 had united with considerable downward displacement. 
 
 Bardeleben has also verified the existence of this fracture. 
 
 McBurney (Stimson, Practical Treatise on Fractures^ p. 395) 
 states that ' he had found in the dissecting room isolated pieces 
 of bone resembling detached epicondyles, and existing symmetri- 
 cally at both elbows.' 
 
 This rendered very unlikely the idea that they were the result 
 of injury. 
 
 Hamilton says : ' It is not difficult to admit,, however, the 
 possibility of a detachment of the epiphysial portion prior to its 
 consolidation with the shaft of the humerus ; and, indeed, the 
 occurrence of such an accident would seem quite probable, yet we 
 lack any absolutely conclusive evidence that it has ever taken 
 place.' 
 
 He distinctly separates in this way disjunction of the external 
 epicondylar epiphysis from fracture of the external condyle (of 
 English anatomists) which involves the diaphysis of the humerus 
 forming part of this process in the adult. He thinks the lesion 
 quite impossible as a simple uncomplicated fracture ' unless the line 
 of fracture includes a portion of the joint, and in that case it is tO' 
 be designated as a fracture of the condyle (capitellum) and not 
 of the epicondyle (external condyle). At least I may say that no 
 satisfactory clinical example or anatomical specimen has ever been 
 presented.' 
 
 However, one of the two cases described by Bardenheuer 
 
398 EPIPHYSES OF UPPEE EXTEEMITY 
 
 {Deutsche Chirurgie, von Billroth und Liicke, 1888) proyes conclu- 
 sively that this form of fracture may occur in the adult. Direct 
 inspection of the fracture (in a woman aged sixty-eight) proved 
 that it was extra-capsular and appeared as if detached from the 
 capitellum by a gouge. 
 
 M. Gabriel Austric {Les fractures experimentales de VejpicondyJe 
 etucliees chez Veiifant et chez Vadulte, These de Paris, 1889) in some 
 experiments found that in the bodies of adults a fracture of this 
 process by direct violence may be confined to it or combined with 
 a fracture of the capitellum or outer edge or anterior aspect of the 
 humerus ; but even in the latter the greater part always belonged 
 to the external condyle. In some instances the articular edge of the 
 outer aspect of the capitellum was scarcely involved for a quarter of 
 a centimetre, which agrees with Sir Astley Cooper's and Gurlt's cases. 
 
 In similar experiments on seven children (from four to fourteen 
 and- a half years) application of direct force in the same way from 
 without inwards produced a similar division of the fractures into 
 simple separation of this process (cartilaginous or bony) or combined 
 with a fracture of parts of the humerus similar to those in the 
 adult. The bony particles in children were very frequently attached 
 to the lower aspect of the detached epiphysis. In one case in a 
 child fourteen and a half years the epiphysial fragment was split 
 into two pieces. More commonly he found that scales or small 
 portions of the diaphysis adhered to the epicondylar fragment, and 
 moreover he states that this fracture (from his experiments) is only 
 intra-articular when it involves the capitellum, as in the adult. 
 
 Injury to the joint. — Although the synovial membrane extends 
 almost up to the external epicondyle, it is probable that in a number 
 of cases the joint may escape injury, and the separation remain an 
 extra-articular one. 
 
 No direct proof of injury to the joint has yet been furnished in 
 the case of pure separation of the external epicondyle. 
 
 SYMPTOMS. — Very little has been written upon fracture of the 
 external epicondyle ; indeed, Hamilton did not think it possible to 
 diagnose the existence of a fracture of the external epicondyle. 
 
 Coulon, who was the first to cfinically study fracture of the external 
 epicondyle {These sur les fractures du coude chez les enfants, 1861), 
 quotes MarjoHn as having observed several cases (^one or more each 
 year) all produced by direct injury, and mentions the following case 
 of Marjohn's, in which a boy aged three and a half years fell from a 
 chair to the pavement. The very small broken piece of the external 
 epicondyle was distinctly felt, and could be moved by seizing it 
 between the finger and thumb. There was no displacement of the 
 fragments, but great swelling of the whole elbow with ecchymosis 
 on the outer side. The arm was simply kept on a pillow, and 
 compresses soaked in arnica applied ; consolidation had taken place 
 by the twentieth day, and all movements of the elbow joint were 
 
EXTEENAL EPICONDYLE OF HUMEEUS 399 
 
 perfect when the patient left the hospital three weeks later. The 
 external epicondyle was somewhat bulky, more rounded, and less 
 prominent than that of the opposite side. 
 
 According to Coulon, abnormal mobility and crepitus are the 
 chief signs to be relied upon. 
 
 Absence of articular rigidity after consolidation also confirmed 
 the diagnosis in Coulon's case. 
 
 Small size of fragment. — It is possible where there is little dis- 
 placement or swelling that this small nodule may be seized between 
 the finger and thumb, and moved from before backwards. 
 
 Absence of great articular pain on movement. — The pain is mostly 
 about the external epicondylar region on active or passive movement. 
 
 Considerable swelling of the postero-external aspect of the elbow 
 may be so extensive as to render a' diagnosis impossible for the first 
 few days. 
 
 Crepitus will be of the usual soft character. 
 
 Forearm semiflexed and slightly pronated, and the hand perhaps 
 held in front of the chest. 
 
 Voluntary movements will be almost entirely absent. 
 
 Passive supination will be very painful, while pronation is free ; but 
 flexion and (especially) extension somewhat limited on account of 
 the pain experienced on the outer side of the elbow. 
 
 Displacement will probably not be so great as in the adult, from the 
 thickness of the periosteum attaching the epiphysis to the diaphysis. 
 
 The fragment may not be felt for some eight days or more until 
 the swelhng has disappeared. It is possible in some cases that a 
 depression may be felt at the normal prominence of the external 
 epicondyle. 
 
 Displacement of the epiphysis may be imoards and forwards, as 
 in M. Marchand's case ; outioards and backwards, or doionwards 
 and outioards, as in Zuckerkandl's case, the fragment being lodged 
 in the external lateral hgament, or even displaced still lower below 
 the cup of the radius, or simply downwards, as in Gurlt's case. In 
 one of M. Lannelongue's and Coudray's cases the most prominent 
 symptoms were some thickening about the external epicondyle and 
 some displacement downwards of this process. 
 
 A similar case was communicated to M. Austric by M. Coudray 
 {loc. cit. supra) of a boy, aged ten years, who had fallen (May 1889) 
 on to his left elbow while alighting from a carriage. No diagnosis 
 was made at the time. When seen by M. Coudray, fifteen days after 
 the accident, the swelling of tlie elbow had completely disappeared, 
 but pain was still present and the forearm semiflexed ; in this posi- 
 tion, measuring at the posterior part of the elbow, the distance from 
 the internal epicondyle to the external epicondyle on the left side 
 was fully eight centimetres, while on the right side it was only from 
 six and a quarter to six and a half centimetres. 
 
 The antero-posterior width of the external epicondyle, which was 
 
400 EPIPHYSES OF UPPEE EXTEEMITY 
 
 placed a little lower than its normal position, was 0-03 on the left 
 and only 0-02 centimetre on the right. 
 
 The left olecranon appeared to be brought a little inwards, in 
 consequence perhaps of a slight separation of the bones of the fore- 
 arm. Flexion was limited to a right angle, and extension was not 
 permitted beyond 45°. Pronation and supination were fairly normal. 
 Forcible movement was the treatment adopted, but the subsequent 
 history of the case was not recorded. 
 
 A rticular effusion was observed after two hours in the following 
 case under M. Lannelongue's care (quoted by Austric). 
 
 A girl, aged eleven and a half years, whilst wrestling with a little 
 boy (April 1889), fell on to the palm of her left hand stretched for- 
 wards, and at the same time the boy fell against the hmb supporting 
 her in this position. She fell down and experienced acute pain in the 
 elbow and upper part of the forearm, which she kept semiflexed and 
 supported in front of the body. Two hours afterwards it was found 
 there was sweUing on the whole of the outer side of the elbow without 
 any ecchymosis. The external epicondyle was very painful, increased 
 in bulk, and somewhat lower than usual, but there was no abnormal 
 mobility or crepitation. There was also a little effusion into the 
 elbow-joint. The rest of the humerus and the bones of the forearm 
 were normal. Flexion could not be effected beyond a right angle, 
 and extensiomv as quite impossible, whereas pronation and supination 
 were almost natural. The limb was placed in the semiflexed position 
 in a sling, with a layer of cotton wool and bandage round the elbow. 
 The next day active movements were commenced and were carried 
 out twice a day for the four following days, when massage was used. 
 A month later a displacement downwards of the epicondyle for half 
 to three-quarters of a centimetre was noted, and an enlargement of 
 nearly a centimetre. The movements of the elbow were absolutely 
 normal, and the functions of the limb and muscles were perfect 
 when seen later. 
 
 Detachment without Displacement. — Displacement may not 
 occur if the periosteum remains uninjured, as in Sir Astley Cooper's 
 and M. Marchand's cases. 
 
 Swelling about the epicondyle and mobility of fragment, with the 
 joint slightly movable in a lateral direction, may be the only signs 
 that will assist in making a diagnosis. 
 
 Complications. Dislocation. — In many cases separation of the 
 external epicondyle will be complicated with a dislocation of the 
 elbow, as has been frequently found in adults (backwards or 
 laterally). Such a complication of dislocation of the elbow gives 
 rise to great obscurity of diagnosis as well as to great difficulty of 
 reduction. 
 
 S'ubluxation of the elbow oittioar els. —Qonie surgeons affirm that 
 pure luxation of the elbow cannot take place without fracture of 
 the epicondyle. This is questionable, although no doubt in lateral 
 
EXTEKNAL EPICONDYLE OF HUMEEUS 401 
 
 dislocation fracture of the external epicond3'le exists, though un- 
 recognised. 
 
 Guedeney records, in his collection of cases, the following case of 
 fracture of the external epicond^de complicated with a dislocation 
 backwards of the elbow. 
 
 A boy (J. G.) (age not stated), while climbing on a weaving frame, 
 fell (July 1890) to the ground on to his left elbow. Although there 
 was marked swelling and bruising about the elbow, the deformity 
 was very perceptible. The humerus projected in a marked manner ; 
 the ulna was very prominent behind, and the radial cup free. As 
 there was no crepitus, simple dislocation backwards was diagnosed, 
 Beduction being effected under an anaesthetic, the joint was put up 
 in the flexed position in a plaster-trough splint. On August 12 
 osseous crepitus was perceived about the epicondyle, and the limb 
 put up again in extension. On September 12 cure is said to have 
 occurred, and the epicondyle completely united. When seen on 
 February 11, 1893, the movements of the elbow were perfectly 
 recovered, extension being even a little exaggerated. There was no 
 shortening of the liinb, but the epicondyle and olecranon still projected 
 very much. Pronation and supination were normal, and there was 
 no loss of muscular power. Whilst in the hospital the patient had 
 some trophic changes — shedding of the nails and insensibility of the 
 fingers — which had now completely disappeared. 
 
 Dislocation of the radius. — Guedeney in his thesis {Du traitement 
 des fractures du coude chez V enfant, dx., Lyon, 1893) relates a case 
 of fracture of the external epicondyle with dislocation of the radius, 
 diagnosed as such by M. Vincent. 
 
 A boy (P.), aged two years, was admitted April 25, 1885. About 
 a month previously he had fallen a distance about his own height, and 
 had been treated by a bone-setter unsuccessfully. Under an an- 
 gesthetic an oblique fracture of the epicondyle was made out with clear 
 crepitus and displacement ; this displacement was accompanied by 
 dislocation of the radial head. The dislocation was reduced, the 
 fragments placed in apposition, and the arm fixed in the extended 
 position. There was neither bruising nor swelling. On May 5 fresh 
 dressings were applied, the arm being still in extension. On May 21 
 the dressing was removed, and the fracture found to be well con- 
 solidated. Child discharged cured. 
 
 It is probable that in this case the epicondyle was detached with 
 a slight portion of the capitellum, and displaced with the radius. 
 
 The difficulties of diagnosis are very great in consequence of the 
 small projection which this epiphysis presents in children. Berthomier 
 states that separation of the external epicondyle may sometimes, in 
 very young children, be mistaken for subluxation of the head of the 
 radius. 
 
 PROGNOSIS. — The epiphyses will unite by fibrous tissue if dis- 
 placed ; probably by bone where there is no displacement. Coulou 
 
 D D 
 
402 EPIPHYSES OF UPPEE EXTEEMITY 
 
 thinks the prognosis good, and that patients should get well in fifteen 
 to thirty days. In a case treated by M. Coudray the child regained 
 the complete function of its arm a month after the accident. 
 
 Supination may he limited for some time and give rise to some 
 hindrance to free movements from peri-articular inflammation, or 
 even from some localised inflammation of the radio-humeral articu- 
 lations. But it was entirely absent in Coulon's case. 
 
 The small triangular fragment may be felt in its abnormal 
 position under the skin ; but, as the articulation is not usually 
 opened, recovery with free movement of the elbow should result. 
 
 When dislocation or other lesion complicates the separation of 
 the epicondyle, the ultimate condition of the elbow appears to be a 
 more serious matter. 
 
 In M. Lannelongue's second case (quoted by Austric), which he 
 saw seven months after the accident, all movements of extension 
 were absolutely impossible, and flexion and supination were very 
 limited, but pronation was nearly normal. 
 
 A boy, aged fourteen years, fell from a trapeze (October 1889) 
 with his left upper extremity beneath him, receiving the whole 
 weight of the body. A dislocation was diagnosed, and attempts 
 at reduction made. The swelling increased during the following 
 days, and a month later, on removing the sling supporting the 
 elbow, it was found to be almost impossible to effect any move- 
 ment of extension and flexion. Thirty-five da^ys after the acci- 
 dent massage and forcible movements were attempted, for there 
 was now considerable stiffness about the elbow-joint. Seven 
 months after the accident (April 1890) M. Lannelongue saw the 
 case ; the wasting of the left upper extremity was then very 
 marked, the muscles of the forearm, arm, and shoulder being in 
 an atrophied condition. The forearm was semiflexed, and the 
 elbow held in a sling in consequence of the loss of function of the 
 limb. The rigidity of the articulation was so considerable that 
 extension was quite impossible, and flexion could only be carried 
 out up to a right angle. Supination was very limited, and pro- 
 nation was the only movement which was fairly extensive. The 
 deformity consisted- especially in a widening of the elbow, and the 
 antero-posterior diameter of the epicondyloid projection was on the 
 left 0-03 and on the right only 0-02 centimetre. Forcible move- 
 ment gradually increased, and electricity and massage improved the 
 condition considerably, so that at the end of fifteen days active 
 flexion passed beyond a right angle, and extension was almost 
 complete. Pronation and supination were also nearlj^ normal and 
 accomplished without pain. AVhen the patient was seen later the 
 condition of the limb was perfect. 
 
 M. Marchand records (Th. de Lartet, 1889 ; M. Marchand, quoted 
 by Austric, loc. cit. supra) a case of fracture of the external epicondyle 
 in which flexion of the arm was limited by an osseous mass. 
 
EXTERNAL EPICONDYLE OF HUMERUS 403 
 
 A boy (A. R.), aged ten years, had fallen (September 1887) on 
 his elbow from a height of two metres. The doctor who saw the 
 case applied traction to the arm. Fifteen days after the accident 
 the forearm was found fixed in a position midway between semi- 
 flexion and complete extension, and the hand semi-pronated. 
 Pronation and supination of the limb were painful ; all the osseous 
 prominences about the elbow were in their normal relations, with 
 the one exception of the external epicondyle, which was displaced 
 a little forwards, thickened, and painful on pressure. A very distinct 
 depression was found in the epicondyle's normal position. The 
 diagnosis of detachment of the prominence of the external epicon- 
 dyle was confirmed under chloroform when the elbow was forcibly 
 flexed and extended, with sensation of cartilaginous crepitus. 
 During flexion the radial head could now pass freely in front of the 
 osseous mass, which before was not possible, as it kept the radial 
 head back. The arm was put up in an immovable apparatus, the 
 forearm being flexed to an acute angle. This was removed after 
 fifteen days ; the movements, though fairly free, were very painfuL 
 Eight days after, some muscular contraction having occurred, 
 an ansesthetic was again administered, and the elbow freely moved. 
 Continual movement and massage were recommended. 
 
 Muscular malnutrition and atrophy, as in M. Lannelongue's 
 case, may involve all the upper extremity. They should therefore be 
 carefully guarded against by appropriate treatment. 
 
 TREATMENT. — As in the corresponding fracture of the internal 
 epicondyle, the fragment should be replaced in its normal position, 
 and a horseshoe-shaped pad of lint or other soft material, as recom- 
 mended first by M. Richet, placed and fixed below it, while the elbow 
 should be fixed by an internal lateral splint in the semiflexed position. 
 
 The extended position for three or four weeks is recommended by 
 Dr. L. C. Lane. 
 
 Seven cases are said by Guedeney to have been diagnosed 
 in M. Vincent's clinic at Lyons as fracture or detachment of the 
 external epicondyle, and treated by fixation in the extended position. 
 An eighth case in a boy, one and a half years old, although placed 
 under this form of injury, appears to have been clearly accompanied 
 by a fracture in the capitellum as well ; indeed, considering the age of 
 the patients recorded — viz. below eight years — the small size of the 
 cartilaginous nodule representing the epiphysial process in later 
 childhood, and its intimate connection with the rest of the cartilagi- 
 nous lower end of the humerus at this age, all render it extremely 
 unlikely that these cases were instances of this rare form of 
 injury — viz. simple detachment or fracture of the external epi- 
 condyle. The ages were respectively : (1) three and a half years ; 
 (2) not stated ; (8) five years ; (4) not stated ; (5) eight yciars ; 
 (6) not stated ; (7) six and a lialf years. 
 
 The presence of dislocation complicating this separation is of 
 
404 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 grave importance, for if the fragment be displaced forwards towards 
 the bend of the elbow, reduction of the dislocation and flexion of 
 the elbow will be rendered so much more difficult. 
 
 This difficulty of flexion from the abnormal position of the 
 external epicondyle was noted in M. Marchand's case. 
 
 Primary resection. — Should the freedom of movement of the joint 
 be greatly interfered with on account of some dislocation accom- 
 panying it, or on account of the great displacement of the epicon- 
 dyle, the epiphysis should be resected and the parts replaced in 
 their normal position under strict antiseptic precautions. In 
 compound separations immediate resection of the epiphysis should 
 be performed. The epiphysis will probably be found in one or more 
 
 Fig. 104. — internal rectangulae splint hollowed for right elbow 
 
 pieces ; or the small epiphysis, under aseptic measures, may be 
 fixed to the diaphysis by means of a steel pin driven through it into 
 the latter. 
 
 Passive movement should be commenced very early — on the 
 seventh or tenth day. In M. Lannelongue's patient movement of 
 the elbow was commenced on the day after the accident. 
 
 Massage and electricity, and forcible movement gradually increased 
 will tend to counteract any tendency to muscular atrophy. 
 
 Should the formation of callus prevent complete flexion of the 
 joint, the ankylosis must be carefully broken down and the joint 
 moved with caution. 
 
 Operative treatment of faulty union. — Brun-Bourgeret, in a recent 
 thesis (These de Bordeaux, 1892), recommends linear osteotomy as a 
 treatment for vicious consolidation of fractures of the external 
 epicondyle. 
 
405 
 
 CHAPTEE VIII 
 
 SEPABATION OF THE TROCHLEA WITH INTERIirAL 
 
 EPICONDYLE (EPICONDYLO-TBOCHLEAR SEPARATION) 
 
 OP THE HUMERUS 
 
 AND 
 
 SEPARATION OP THE TROCHLEA WITH PRACTURE OP 
 
 INTERNAL CONDYLE (CONDYLO-TROCHLEAR PRACTURE) 
 
 OP THE HUMERUS 
 
 A TEUE separation of the trochlear and internal epicondylar epi- 
 physes of the humerus in one piece can only take place before the 
 period at which the internal epicondyle becomes a distinct epiphysis. 
 
 The line of separation will pass through the base of the internal 
 epicondyle, obliquely downwards and outwards, through the lower 
 limit of the coronoid and olecranon fossse to the middle of the 
 trochlear articular surface. 
 
 Such a separation is rare compared with separation of the 
 trochlear portion, conibined with fracture of the internal condyle. 
 In this case it is a partial separation accompanied by intra-articular 
 fracture and fracture of the diaphysial portion of the internal 
 condyle. 
 
 ETIOLOGrY. — Direct blows upon the elbow are the most frequent 
 cause. 
 
 It is quite possible that muscular violence, which can tear off the 
 internal epicondyle, may also detach the trochlear epiphysis with it, 
 by means of the leverage of the upper end of the ulna. 
 
 Indirect violence is often noted, from falls upon the hand or elbow. 
 
 In the typical ' oblique internal trochlear fracture,' indirect 
 violence is almost invariably the cause. 
 
 In a fall upon the elbow the posterior aspect of the upper end 
 of the ulna strikes the ground, the violence being transmitted to the 
 bottom of the trochlear surface by the articular convex ridge of 
 the sigmoid cavity, which acts as a wedge, the internal lateral 
 ligament also playing an important part through its attachment to 
 the internal condyle. 
 
 The violence, again, may act in the long axis of the ulna, 
 thereby displacing the trochlear fragment upwards or upwards and 
 backwards. 
 
 Finally, the violence acting upon the ulna may be more lateral, 
 
406 
 
 EPIPHYSES OE UPPEE EXTEEMITY 
 
 acting upon its outer or inner side. If in the latter direction, the 
 forearm is thrust towards the uhiar side; the XDOwerful internal 
 lateral hgament will cause detachment of the condylo-trochlear 
 fragment, which is thus displaced downwards, and probably accom- 
 panied by a complete or partial dislocation of the bones of the 
 forearm described below. 
 
 AG-E. — Among eight chnical cases of condyle- and epicondylo- 
 trochlear fracture in children, one was stated to be at twelve years 
 of age, one at eleven, two at ten years, one at nine, one at four, and 
 in two cases the age was not stated. 
 
 PATHOLOGICAL ANATOMY. — There is no authentic specimen of 
 separation of the epicondylo-trochlear ejDiphyses. 
 
 The lesion would correspond exactly to the simultaneous fracture 
 of the internal condyle and inner half of the trochlea, which is not 
 infrequently met with in aduEs. Such cases have been recorded by 
 Sir Astley Cooper, Th. i\Iarko3, Hugo Senftleben, Gurlt, Ch. Bell, 
 Desault, Malgaigne, and Gueneau de Mussy in 1837, and specimens 
 are to be seen in several museums, e.g. the Museum of the Edinburgh 
 L'ni versify and Musee Dupuytren. 
 
 Sir A. Cooper adds in his description that these fractures were 
 especially frequent in children. Malgaigne, however, thought they 
 were exceedingly rare. 
 
 Out of eight cases observed by Markoe and Senftleben, five were 
 in children — one at ten, another at eleven, another at fourteen, and 
 two at sixteen years of age, and all in male subjects. 
 
 The ' fracture trochleenne oblique interne ' of Denuce, in which 
 the inner half of the trochlear articular surface and more or less 
 
 of the internal condyle of the humerus 
 are detached in one piece, crosses the 
 outer portion of the olecranon fossa, 
 and terminates on the outer side of the 
 trochlear groove. So that in the adult 
 a considerable portion of the diaphysis 
 is always detached, and the line of 
 fracture ra&y even traverse the coronoid 
 and olecranon fossse. 
 
 The authors, Markoe, Senftleben, 
 and Astley Cooper, have noted displace- 
 ment hackioards of the fragment in these 
 cases, and with it the ulna and radius. 
 
 The ulna is firmly bound to the epi- 
 physial fragment in its normal relation 
 especially by means of the internal 
 lateral ligament, and the radius will 
 also accompany the ulna if the orbicular 
 ligament be not torn across ; the ulna, with the forearm, conse- 
 quently being displaced with this fragment. So that it is more 
 
 Fig. 105. — i-ractdre of the rs"- 
 
 TEKXAL COXUYLE AXD TROCHLEA ; 
 UISPLACEITEXT Ui'WARDS OF FRAG- 
 MENT. BEESLAU MUSEL'JI. (aFTER 
 
 gtjelt) 
 
CONDYLO-TEOCHLEAE FEACTUEE & SEPAEATION 407 
 
 than probable that a dislocation either backwards or backwards 
 and inwards will be immediately diagnosed, and the fracture or 
 separation overlooked. 
 
 A condylo-trochlear fractm^e is figured by Gurlt, from the 
 Anatomical Museum of Breslau. The fractured part, composed of 
 the internal condyle and a portion of the trochlear surface of the 
 humerus, has been displaced upwards, and united in this position, 
 so that the lower end of the humerus is very obHque (see fig. 105) . 
 
 SYMPTOMS. — The symptoms of separation of the epicondylo- 
 trochlear epiphyses are almost identical with those of fracture of 
 the internal condyle traversing the diaphysis from above the base 
 of this process, obHquely downwards and outwards through the 
 olecranon and coronoid fossae to the groove of the trochlea. The 
 latter is a very common accident in children. 
 
 Out of twenty cases of this fracture seen by Hamilton, only 
 two were after the eighteenth year of life. Malgaigne, Sir Astley 
 Cooper, South, Gurlt, E. Adams, have all recorded cases in children. 
 
 Crepitus is of the characteristic muffied character when the separa- 
 tion is pure, but is more likely to be of a rougher character if the 
 separation traverses any part of the diaphysis. 
 
 It may be felt either on grasping the portions of the lower end 
 of the humerus on either side and imparting some lateral motion, 
 or on grasping the internal condyle and trochlea with one hand and 
 flexing and extending the forearm with the other. 
 
 Mobility of the internal condyle, especially in the antero-posterior 
 direction, may be detected when this process is grasped between the 
 finger and thumb whilst the rest of the elbow is fixed. It can also 
 be felt on flexion and extension of the elbow-joint. 
 
 If there is displacement of either or both bones of the forearm, 
 unnatural mobihty wih be felt on reduction ; in this case the dis- 
 placement will be found to be readily reproduced. 
 
 Displacement.— There may be fittle or no deformity, from the 
 fragment being held in position by the periosteum and other 
 ligamentous structures. 
 
 The precise appearance of the elbow will be determined by the 
 position of the displaced fragment, so that the forearm may be 
 adducted or abducted, pronated or supinated. 
 
 Upwards and backivards, and perhaps a little inwards, will be the 
 usual form of displacement. 
 
 It win be recognised by carefully ascertaining the relations of the 
 internal epicondyle with the olecranon and with the external epicon- 
 dyle, as compared with the uninjured side. This relationship should 
 be determined both before and after reduction of the displacement. 
 
 It should be also remembered that, normally, in full extension 
 of the elbow, a fine joining the two epicondyles behind will cross 
 the tip of the olecranon. 
 
 Increase of breadth between the cpicoiuhjlcs of the humerus.— This 
 
408 EPIPHYSES OF UPPEE EXTEEMITY 
 
 increase in the transverse diameter of the lower end of the humerus 
 may be masked, to a great extent, by the swehing and ecchymosis 
 present. 
 
 Prominence of ulna behind when the forearm is extended, so that it 
 appears dislocated, the ulna projecting backwards with the fractured 
 portion of the humerus, and the relation between the olecranon and 
 the internal epicondyle being altered as compared with the opposite 
 side. The ulna is restored to its normal position on again flexing the 
 forearm. The distance is widened or shortened according to the 
 form and degree of displacement. 
 
 Projection of loiuer end of humerus in front, ujron the anterior 
 aspect of the elbow-joint, on extreme extension. 
 
 Forearm deflected to ulnar side, in extreme extension, when the 
 ■-fragment has been displaced upwards. 
 
 The deformity is immediately reproduced when the parts are left 
 to themselves after reduction. 
 
 The displacement may be doionwards, from indirect violence, 
 or even di\Teci\y forwards. 
 
 Swelling. — The amount of ext'ravasated blood in the surrounding 
 tissue and the distension of the joint may be so excessive as to 
 render an accurate diagnosis impossible until these have subsided. 
 
 Complications. — Dislocations of elbow, either backwards or back- 
 wards and inwards, are frequent complications. If the trochlea and 
 internal condyle be displaced, the ulna at any rate will follow the 
 fragment ; but it may occasionally happen that both bones of the 
 forearm will be displaced. 
 
 Dislocation of radius backwards, in association with the analogous 
 fracture in adults, has been especially noted by Gurlt {Hand- 
 bitch der Lehre von den Enochenbrilchen, 1863, S. 822), Markoe, 
 Hamilton, and others, and presents a most serious complication. 
 Dr. Markoe, indeed, believes that dislocation of the radius seldom 
 or never occurs without a fracture of the internal condyle (i.e. 
 internal condyle with trochlea). He claims to have been the first, 
 in 1855, to have directed attention to the importance of this 
 complication. 
 
 In this complication tbe radius, ulna, and internal condylar 
 fragment of the humerus preserve their normal relation to one 
 another. 
 
 It will closely resemble simple dislocation of both bones backwards, 
 with this difference — that the internal epicondyle preserves its 
 normal relation with the olecranon, and that mobility of the frag- 
 ment is present, accompanied by crepitus ; but in both the head 
 of the radius will be felt behind and below the external epicondyle. 
 
 The reduction in this form of separation with dislocation of the 
 radius will be easily effected, but is immediately reproduced. 
 
 To these signs Markoe {New York Medical Becord, 1880, 
 vol. xviii. p. 119, ' On Fracture of the Internal Condyle of the 
 
CONDYLO-TEOCHLEAE FEACTUEE & SEPAEATION 409 
 
 Humerus, with Dislocation of the Head of the Eadius ') adds the 
 following, viz. that on the anterior aspect of the joint a somewhat 
 sharp protuberance can be felt, which is the end of the humerus 
 from which the internal condyle has been detached. 
 
 This surgeon gives the following case from his notebook : 
 
 ' M. L., aged ten, was admitted to the New York Hospital, 
 October 11, 1859. Five days before he had fallen from a horse, 
 striking his left side, with his arm twisted behind him. Great 
 swelling and ecchymosis took place immediately, so that a thorough 
 examination could not be made. On the 17th the swelling had so 
 far subsided as to give us a chance to examine the fracture. The 
 internal condyle and the olecranon were in proper relation to one 
 another, while the head of the radius had left the external condyle 
 and was easily felt rotating behind and to the outside of it. The 
 whole aspect of the elbow was that of dislocation backwards, the 
 end of the olecranon projecting about an inch backwards, and 
 the end of the humerus making a rounded projection on the anterior 
 aspect of the joint. The parts were so easily movable that it could 
 further be distinctly made out that a considerable fragment of the 
 internal condyle, broken from the shaft of the bone, remained 
 attached to the olecranon and moved with it. The whole displace- 
 ment could be easily reduced and the deformity removed, while on 
 letting go the limb it was immediately reproduced. Dr. Van Buren 
 saw the case, and agreed in the diagnosis of fracture of the internal 
 condyle, involving so much of the basis of support of the olecranon 
 as to allow of its displacement backwards to a sufficient extent to 
 permit the head of the radius to be also backwards, as in ordinary 
 luxation. The displacement was reduced, and the arm placed at an 
 angle less than a right angle, and so retained by an angular tin 
 splint, a firm pad being placed on the prominent end of the humerus 
 to keep it in place. On the 30th the apparatus was removed, and it 
 was reported that union of the detached fragment was firm and the 
 joint in good shape. The patient was discharged the following day.' 
 
 Stripping of periosteum from the diaphysis gives rise to great 
 swelling around and above the joint. 
 
 Acute synovitis, more or less intense, is inevitable from the separa- 
 tion involving the articular surface. 
 
 Injury to the ulnar nerve. — The ulnar nerve may be pressed upon 
 and injured by displacement of the fragment, giving rise to paralysis 
 or impaired motion on the inner side of the forearm and hand, or to 
 loss of sensation in the same parts, or pain or numbness of the little 
 finger. 
 
 Senftleben once observed paralytic symptoms from injury to the 
 ulnar nerve follow violent attempts to place the limb in the flexed 
 position. They, however, gradually disappeared. 
 
 Sir Astley Cooper saw a girl who, by a fall upon her elbow, had 
 fractured the olecranon, and also broken the internal condyle (i.e. 
 
410 EPIPHYSES OF UPPEK EXTEEMITY 
 
 trochlea and internal condyle) of the humerus, the point of the broken 
 bone having penetrated the skin ; the cubital nerve had also been 
 injured, for the little finger and half the ring finger were benumbed. 
 Cooper says : ' The cause of this accident is a fall upon the point of 
 the elbovy. It usually occurs in j^outh before the epiphysis is com- 
 pletely ossified ; although I have seen it, but less frequently, in old 
 age. It is often mistaken for dislocation.' 
 
 The precise lesion in this instance is obscure, for Packard places it 
 under the heading of fracture of the epitrochlea ; while Sir Astley 
 Cooper places it under fracture of the internal condyle (i.e. epicondyle 
 and trochlea), and presents a diagTam of the lesion. 
 
 Rupture of bracMal artery. — A case of oblique fracture through 
 the lower epiphysis of the left humerus into the elbow-joint (invol- 
 ving the internal cond5de, trochlea, and capitellum), with rupture 
 of the brachial artery, is given by Mr. George Lawson {Lancet, 
 December 1, 1894, p. 1277). At first no fracture was detected; but 
 at the end of a fortnight, when the swelling from the extravasated 
 blood began to subside, the deformity about the elbow became mani- 
 fest, and the arm was found shortened three quarters of an inch, 
 measuring from the coracoid process to the olecranon, and a shorten- 
 ing, though to a less extent, from the coracoid to the internal condyle ; 
 but none was discovered from the coracoid process to the external 
 condyle. Flexion and extension were very considerably impaired, 
 whilst pronation and supination were not interfered with. At the 
 end of seven weeks flexion could be carried out to a right angle, 
 whilst extension was nearly perfect. The swelling from the ruptured 
 vessel had then completely subsided. 
 
 DIAGNOSIS. Fracture of the coronoid process of the ulna witli dis- 
 location backwards will simulate in some respects epicondylo-trochlear 
 separation complicated with dislocation of th.e. radius. For in 
 both there may be some lateral inclination of the forearm on forcible 
 extension with lateral mobility and crepitus. 
 
 But in the former the precautions necessary to effect the reduc- 
 tion of the dislocation backwards, the ease with which the displace- 
 ment is immediately reproduced, together with the loss of the proper 
 relations of the olecranon to both the epicondyles, are quite sufficient 
 to distinguish it from the latter. 
 
 PROGNOSIS AND RESULTS. — In the more simple cases, without 
 much displacement, a good and useful joint may be expected in five 
 or six weeks, provided careful treatment has been carried out and 
 passive motion commenced early. 
 
 There is sure to be a good deal of new periosteal deposit around 
 the condyle and low^er end of the humerus from the stripping up of 
 the periosteum, but this will mould in the course of years to the 
 natural shape of the limb, and almost perfect restoration of utility 
 of the limb may be expected. 
 
 Impaired movement will be inevitable in certain cases where 
 
CONDYLO-TKOCHLEAR FEACTUEE & SEPAEATION 411 
 
 complication exists, and has resulted at times in apparently more 
 simple cases. 
 
 The lesion is always of a serious nature, inasmuch as the fracture 
 extends into the joint, and is therefore attended with more or less 
 inflammation and consequent impairment of the mobility of the 
 articulation. Moreover, articular extravasation of blood will also 
 tend to ankylosis, whilst the callus may be excessive and occur in 
 a position likely to greatly restrict the movements of the joint. 
 
 Besides, as the humero-ulnar articulation forms the principal 
 physiologicil portion of the elbow-joint, any interference with the 
 relation or normal position of its humeral portion, such as we find 
 in this injury, must result in impairment of function of this joint. 
 
 The epiphysial fragment will usually unite firmly with the shaft, 
 although in a displaced position. Coulon {Fractures cliez les enfants, 
 Paris, 1861, p. 159) gives the following example of this injury, 
 which is scarcely typical, in a child, four years old, who was brought 
 to the hospital two hours after she had fallen down a staircase. 
 The elbow was swollen, the forearm slightly flexed upon the arm, and 
 the relations between the olecranon and epicondyles normal. Pres- 
 sure upon the epitrochlea produced crepitus, but the swelling made 
 it impossible to recognise the size of the fragment or the extent of 
 the mobility. Flexion and extension were rendered almost impos- 
 sible by the swelling and pain. The limb was partly flexed and 
 fastened on a cushion, and on the fifth day placed in a gutta-percha 
 splint. On the twenty-first day passive motion was commenced. At 
 the end of the month the patient left the hospital ; the arm could 
 then be flexed to a right angle, and extended to an angle of 140° ; the 
 epitrochlea was displaced inw^ards and forwards, and the fragment 
 could be felt to be voluminous. Two and a half months later the con- 
 dition was said to be the same. 
 
 Mr. Durham had under his care at Guy's Hospital in October, 
 1885, a case of considerable deformity of the elbow-joint after partial 
 separation of the trochlea. 
 
 John S., aged ten, while running along the top of a wall, fell off 
 and injured his elbow. There was considerable swelling, great 
 pain, and loss of power in the elbow. He had been treated for three 
 weeks with a gutta-percha splint. This was removed at the end of 
 this time, and the arm was found to be useless. There was consider- 
 able deformity of the left elbow, and flexion and extension were both 
 incompletely performed. The head of the radius rotated on the capi- 
 tellum, but the external condyle appeared to be much more prominent 
 than usual. The relations of the radius and ulna were not disturbed. 
 The distance between the inner border of the olecranon and the 
 inner side of the inner condyle was increased by nearly half an inch as 
 compared with the right side. It seemed certain that the original 
 injury was one of separation of the trochlear epiphysis with displace- 
 ment inwards of this process. 
 
412 EPIPHYSES OF UPPEE EXTEEMITY 
 
 Powers relates the case of a boy (T. D.), aged nine years, who 
 fell forcibly on the sidewalk, striking the left elbow. Examination 
 revealed all the evidences of fracture through the internal condyle and 
 trochlea. There was no tendency to posterior displacement of the 
 condyle, but when the forearm was in extension it made the normal 
 angle with the arm. The elbow was placed at 90 degrees, midway 
 between pronation and supination, and the condyle drawn a little 
 forward to correct its displacement. A plaster splint was applied for 
 twelve days, and then re-applied and left on till the twenty-eighth 
 day, when the elbow was painless and but slightly enlarged. The 
 range of motion was from 80° to 150°, pronation and supination were 
 all but perfect, and there was no apparent deformity. At the end of 
 the third month the functions were completely restored. There was 
 moderate thickening at the side of the fracture, but no real deformity. 
 
 Gurlt quotes a case from Senftleben, in which the result is said 
 to have been good : it was that of a boy, aged eleven. In four other 
 cases ankylosis ensued ; one was at an angle of 140°, in which 
 death ensued after resection by Langenbeck. In another case com- 
 plicated by dislocation ankylosis followed (Langenbeck's Archiv, 
 Bd. iii., 1862, S. 311, No. 139) ; excision was performed seven months 
 afterwards, and this direct examination showed the fragment of the 
 internal condyle lying in the olecranon fossa. 
 
 At the Societe de Chirurgie, Paris, in 1861 (Langenbeck's 
 Archiv, Bd. xxi. S. 237) M. Marjolin showed a boy, aged twelve, 
 in whom rectangular ankylosis of the elbow occurred after detach- 
 ment and displacement forwards of the trochlea with the internal 
 condyle (internal condyloid fracture of the French). Passive motion 
 under an ansesthetic was proposed. 
 
 Deformity will probably be great where the separation has been 
 complicated with dislocation. 
 
 Displace)7ient upwards.^ln severe cases a reversal of the normal 
 elbow obliquity has been found. This is known in America 
 as the ' gunstock ' deformity, from the elevation of the internal 
 condyloid fragment and inward deflection of the normal axis of Ithe 
 extended forearm. The normal humero-ulnar or ' carrying angle ' 
 becomes reversed, giving rise to the deformity known as cubitus varus. 
 
 G. A. "Wright, of Manchester, figures (Ashby and Wright, 
 Diseases of Children, 3rd edition, 1896, p. 764) an example of 
 separation of the trochlear epiphysis of the humerus, showing adduc- 
 tion of the forearm with loss of this ' carrying angle ' (see fig. 106). 
 
 Out of twelve cases of fracture of the internal condyle entering 
 the joint seen by Powers in children and adults, nine perfectly 
 recovered their functions ; in one all motions became complete 
 except extension, this being five degrees short ; one was perfect, 
 and one was still under treatment. In none was there deformity. 
 From the brief account Powers gives of these cases they appear to 
 have been unusually mikl. But little of the articular surface could 
 
CONDYLO-TKOCHLEAE FEACTUEE & SEPAEATION 413 
 
 have been involved to leave such a complete restoration of function 
 without deformity. 
 
 The displacement of the epiphysial fragment should never be 
 permitted to be permanently so great as to prevent complete or 
 almost complete loss of movement of the elbow-joint due to the 
 locking of the radius or ulna against the displaced fragment. Such 
 deformity ought never to be met with ; the instances in which it 
 occurred ought to have been operated upon and reduced. 
 
 It is well to repeat here that deformity at the elbow cannot be accu- 
 rately judged when the joint is flexed ; it is only in an extended 
 position that its presence can be made out with any accuracy. 
 
 Fig. 106. — cubitus vaeus following separation of the teochleae epiphysis 
 
 OF THE HUMERUS. (ASHBY AND WRIGHT) 
 
 Osseous ankylosis has ensued in cases of fracture in this position 
 from improper treatment. 
 
 Exuberant callus. — The danger from an excessive production of 
 callus is very great. Seeing that the separation is an intra-articular 
 one, the movements of the joint are in great danger of being much 
 restricted from this cause alone. 
 
 Paralysis or neuralgia of ulnar nerve. — From pressure of exuberant 
 callus in conjunction or not with displacement of the condylar 
 fragment. 
 
 Agnew has recorded a case of the kind in the adult, and 
 "Weir Mitchell has added a second, occurring seven years after a 
 fracture. 
 
414 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 Arrest of growth. — A slight amount of arrest of growth of the end 
 of the humerus may result, and give rise to permanent and very- 
 singular alterations in the form of the limb. 
 
 TREATMENT. — Where there is little or no displacement the 
 elbow should be fixed at once at a right angle by means of a 
 posterior angular splint. This should extend along the back of the 
 arm and forearm as far as the wrist. The splint should not as a rule 
 be applied on the front or the side. The posterior splint presses 
 the olecranon forwards and helps to support the separated frag- 
 ment. Evaporating lotions, lead and opium lotions, &c., should be 
 _ applied to allay the in- 
 
 evitable inflammation and 
 synovitis of the elbow. 
 
 After the swelling has 
 subsided the elbow should 
 be put up in the rectangu- 
 lar position, with the hand 
 supine, in a plaster-of- 
 Paris, leather, poroplastic, 
 or other form of casing 
 until a week or ten days 
 has elapsed from the time 
 of the accident. Gentle 
 passive movemsnt should 
 then be commenced. For 
 the first day or two only 
 movements of pronation and supination should be performed, and 
 later on flexion and extension. The utmost care should be taken 
 to prevent any. yielding of the soft material uniting the fragment 
 to the shaft. It should be repeated daily for several weeks to lessen 
 the. stiffness which always follows this injury. 
 
 The plaster-of-Paris splint in the form known as 'Croft's' is 
 superior to all other splints ; the effusion, both intra- and extra- 
 articular, subsiding more rapidly when it is employed. It makes equal 
 pressure all over the joint, and keeps the joint and fragments abso- 
 lutely at rest. Plaster-of-Paris bandages should never be employed. 
 The lower forearm piece should not be in a line with the upper 
 arm piece, but make with it an angle outwards, which should vary 
 according to the age of the child, so as to preserve the normal 
 oblique direction of the axis of the joint. 
 
 Hamilton's rules for treating similar fractures in this situation 
 apply with equal force to epiphysial separations. ' Considerable 
 swelling is almost certain to follow, and no surgeon ought to hazard 
 the chances of vesications, ulcerations, &c., by neglecting to open 
 or completely remove the dressings every day. Within seven days, 
 and perhaps earlier, passive motion must be commenced, and 
 perseveringly employed from day to day until the cure is accom- 
 
 FlG. 107. — POSTEMOK KECTANGULAR ANB HOLLOWED 
 
 SPLINT FOR LEFT ELBOW, AS USED BY AUTHOR. 
 THE ANGLE IS OBLIQUE AND THE FOREAEM PIECE 
 DEFLECTED OUTWARDS 
 
CONDYLO-TKOCHLEAE FEACTUEE & SEPAEATION 415 
 
 plished ; indeed, in many cases it is better not to resume the use of 
 splints after this period, for although no bony union has taken place, 
 yet the effusions have somewhat steadied the fragments, and the 
 danger of displacement is lessened, while the prevention of ankylosis 
 demands very early and continued motion.' 
 
 To this it may be added that all violent movements should be 
 carefully avoided ; passive motion should only be undertaken by 
 skilful hands. 
 
 Displacement. — The reduction of the displaced epiphyses should 
 be immediately effected, as well as that of any associated dislocation, 
 and the arm and forearm fixed in an internal or posterior rectangular 
 position, as recommended above, taking care to preserve the outward 
 deflection of the forearm, and the hand in the supine position. 
 
 But many modern writers now agree that the results from the 
 flexed position are not satisfactory in a large proportion of cases, on 
 account of the malposition of the fragment and more or less loss of 
 function of the joint. 
 
 Dr. 0. H. Allis, of Philadelphia, goes so far as to say that with 
 the splint at this angle the ulna and the attached condyloid fragment 
 are actually pressed out of position in an upward direction and 
 give rise when the forearm is fully extended to deviation inwards 
 of the latter, and to gunstock deformity. 
 
 In the case of similar fractures in adults Stephen Snxith 
 recommends the elbow to be kept fixed (in the straight position) 
 until union is complete, when passive motion is to be commenced, 
 and voluntary efforts of the patient gently attempted, under the 
 influence of fomentations. 
 
 At any rate, in the case of children, where union is more rapid, 
 so prolonged a time is not only unnecessary, but rather tends 
 to fixation and ankylosis of the joint, which will cause the useful- 
 ness of the joint to be regained only at the expenditure of a con- 
 siderable amount of time and treatment on the part of the surgeon. 
 
 The bad results of many cases treated in the rectangular 
 position are probably due to the fact that the elbow has not 
 been placed in its normal position. The axis of the joint is not 
 perpendicular to the long axis of the humerus, but is inclined to it 
 at an angle which varies with the age and with the individual. This 
 is best observed when the arm is extended, when the forearm is seen 
 to be directed away from the side of the trunk, as in carrying. The 
 anterior crease in the flexure of the elbow corresponds in direction 
 and obliquity with the axis of the joint. 
 
 The ulna remaining attached to the epiphysial fragment of the 
 forearm is not placed in its normal position with the axis of the 
 joint oblique ; it will, if put up with this at right angles to the long 
 axis of the humerus, as is the case with the common rectangular 
 splints, cause displacement upwards of the fragment, or tend to 
 keep up this displacement if it has already occurred. The hand and 
 
416 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 forearm should therefore be shghtly directed outwards. By means of 
 Physick's rectangular splint, or of those devised by the author with an 
 angle opening outwards, the normal oblique direction of the articular 
 surface of the humerus to that of the vertical axis of the shaft is 
 well preserved. 
 
 J. S. Dorsey, in 1823 {Elements of Surgerij, vol. i. 1823, 
 p. 168), was one of the first to describe accurately this angu- 
 lar projection of the elhoio outwards, resulting from fracture of 
 either condyle penetrating the elbow-joint. In the cases now 
 under consideration it is this internal condyloid fragment with the 
 trochlea which ascends and causes the axis of the forearm to be 
 displaced inwards. He recommended treatment by the flexed 
 position at a right angle, which, he said, was complete!}^ successful 
 in preventing deformity. 
 
 Fig. 103. — asteeioe kectangxjlak splint fok lett elbos^ as used by 
 
 AtJTHOE. DEFLECTION OUTWAEDS. THE DOTTED IIXES INDICATE THE 
 EOKEAEM PIECE IM A STEAIGHT LINE ^^ITH THAT OF THE AEil. THE 
 ANGLE AT A SLOPES OBLIQUELY DOWNWAEDS AND INWARDS, COEEESPONDING 
 WITH THE AXIS OF THE JOINT. THE POSTEEIOE EECTANGULAK SPLINT HAS 
 THE SAIIE DEFLECTION OUTWARDS OF THE FOBEAEII PIECE AND THE SAME 
 OBLIQUITY COEEESPONDING TO THE FLESUEE OF THE JOINT (see fig. 107) 
 
 Normally, the axis of the elbow-joint is not perpendicular to 
 that of the axis of the arm, but forms an angle with it, so that the 
 forearm is deflected outwards away from the trunk at a vaiying 
 angle; 170^ (Denuce). 
 
 Packard says (Keatiiig's Cyclopcedia of Diseases of Children, 
 vol. iii., part ii., p. 1073) : ' One point should never be overlooked in 
 any case of fracture at the lower end of the humerus, but especially 
 in separation of the trochlea ; there is apt to be caused a change in 
 the relation of the arm with the forearm, which seriously impairs not 
 only the shape, but also the usefulness, of the limb. Xormalh", if 
 the elbow is extended with the hand in supination, the forearm 
 forms with the arm an obtuse angle salient inwards, towards the 
 median line of the body, and the fold of the elbow in front curves 
 obliquely downwards and inwards. The reason of this is the 
 
CONDYLO-TEOCHLEAR FRACTURE & SEPARATION 417 
 
 obliquity of the trochlea. If, now, a splint is applied which presses 
 straight across, it pushes up the lower and more movable fragment, 
 and the result is that the forearm either comes into a straight line 
 with the arm, or even makes with it an angle salient outward. 
 Union taking place under such circumstances — as pointed out long 
 ago by Dorsey, and later very forcibly by AUis {Annals of the 
 Brooklyn Anatomical and Surgical Society, August 1880) — there 
 will be at all times a very notable awkwardness in the limb, besides 
 marked interference with its strength and usefulness in many of its 
 functions. In order to obviate this difficulty, Allis and others have 
 proposed treating these fractures with the limb in the straight 
 position. I think the better plan is to make a splint which' shall 
 conform to the normal shape of the joint, and to keep the hand 
 away from the body. This is not always easy to do, and indeed 
 
 Fig. 109. — lateral external tin splint for the right elbow, treatment 
 N the fixed rectangular position, interruption at elbow-joint ^\-ith 
 
 LATER.AL MOVEMENT OP FOREARM UPON ARMPIECE TO PRESERVE THE NATURAL 
 obliquity OF THE FOREARM OUTWARDS 
 
 one may often see these fractures dressed not with the hand 
 in supination, but with the forearm carefully drawn forward and slung 
 as close to the front of the body as possible.' 
 
 The truth of these remarks must be evident to every one, viz. that 
 unless properly guarded against, as Packard suggests, the trochlea 
 will be forced upwards beyond the separated surface on the end 
 of the diaphysis. 
 
 Deformity in this respect, it must be admitted, will be consider- 
 ably lessened, if not entirely avoided, by the extended position, for in 
 this way the elbow may be made to assume any degree of obliquit3\ 
 
 Straight position of limb with forearm away from side. — Complete 
 extension of the elbow has been much employed of late years for 
 these as well as for other forms of injury to the elbow-joint. 
 
 It is said by the advocates of the extended position that, with 
 the head of the radius resting firmly against the capitellum, the 
 
 E E 
 
418 EPIPHYSES OF UPPEK EXTEEMITY 
 
 internal condylar fragment can be brought fully down by fixing the 
 arm and drawing the wrist gently outwards, and that so long as the 
 forearm is kept in this position the internal condyle cannot rise. At 
 the same time it is admitted that the forward and backward dis- 
 placement is not corrected by this means. 
 
 Stephen Smith adds to the same effect : ' A fact of much 
 importance in the treatment of fractures of the condyles (internal 
 oblique trochlear and capitellar fractures) relates to the preservation 
 of the normal angle of the forearm with the arm, which gives to the 
 entire limb its "carrying function." This angle is such as to give 
 an outward position of the hand when carrying a weight, the elbow 
 resting naturally on the thigh. This angle may be lost either by the 
 ascent of the internal condyle {sic), or by the descent of the 
 external condyle (sic), and constitutes, in the opinion of Dr. Allis, 
 the usual deformity after fractures of the condyles (sic). To 
 prevent or overcome this displacement, which Dr. Allis attri- 
 butes in part to the flexed elbow and the bandages and splints 
 ordinarily used, he places the whole limb in a straight position. 
 The radius and ulna at the elbow-joint then tend to bring the 
 internal condyle into position and retain it there, the internal 
 lateral ligament attached to the condyle and ulna aiding much to 
 effect this result. The dressings are now applied, it being borne in 
 mind that " the perfection of the cure will depend wholly upon the 
 natural position assumed by the limb while the dressing is applied." 
 Dr. Allis advises that the patient be placed on his back and both 
 arms stripped, in order that the sound arm may be a guide in fixing 
 the final position of the injured arm. The sound arm is to be placed 
 in a supine position, with the thumb looking outwards, and the 
 injured arm is to be placed in the same position. The forearm of 
 the injured limb must form the same obtuse angle with the arm at 
 the elbow as is noticed in the sound arm. In that position, con- 
 stantly maintained, the dressings are to be applied, and, if plastic, 
 allowed to become firm. Dr. Allis prefers immovable dressings or a 
 moulded splint. He applies a temporary dressing for a week, the 
 patient being in a recumbent position ; then he proceeds to the 
 permanent dressing, as follows : (1) an envelope of cotton, an inch 
 thick, extends from the shoulder to the wrist, thickest at the bend 
 of the arm ; (2) a layer of bandages applied sufficiently tight to 
 compress the cotton and afford support ; (3) the stiffening material 
 selected — starch, plaster of Paris, &c. — is rubbed in, and a second 
 and third layer of bandage is applied in the same way. The arm is 
 kept in an easy position until the dressing is perfectly hard. He 
 gives a simpler form of dressing as a substitute. Envelop the arm 
 with cotton and then apply a single covering of bandage ; cover the 
 whole of this with adhesive plaster. This dressing may be applied 
 from first to last ; it has the advantage that it permits the patient 
 to flex the joint a little.' 
 
CONDYLO-TEOCHLEAE FEACTUEE & SEPAEATION 419 
 
 Dr. L. C. Lane, of San Francisco, also recommends {Trans. 
 American Surgical Association, vol. ix., 1891) the extended position 
 secured by a straight splint of pasteboard, felt, or tin. On the 
 second day passive motion with rotation of the forearm should, he 
 holds, be commenced, and 'it should be continued with scrupulous 
 fidelity for many weeks.' 
 
 One disadvantage of the extended position is that if the extension 
 be too great the epiphysial fragment will be tilted and thrown for- 
 wards by the olecranon impinging upon it from behind. Another 
 is that the limb, which is usually in a dependent position, has a ten- 
 dency to swell and cause great discomfort to the patient. 
 
 Incomplete extension.— Some surgeons prefer incomplete extension 
 — that is to say, 30° or 40° short of full extension — while others modify 
 the extended position by putting the elbow in this position for a 
 limited period, ten to fourteen days, when it is put up again in the 
 rectangular position. It is said that, the displacement having been 
 corrected, the amount of union which has then taken place is suffi- 
 cient to prevent any recurrence of the deviation from the natural 
 position. 
 
 Passive motion. — In 1848 Dr. J. C. Warren, of Boston, U.S.A. 
 {Trans, of American Med. Association, vol. i. 1848, p. 174), and 
 some modern French surgeons more recently, in order to prevent 
 ankylosis after treatment by angular splints, in fractures of the 
 condyles of the humerus, recommend early and daily passive move- 
 ments without the application of any splints. 
 
 The former probably hits the right mark when he adds that the 
 accomplishment of this process is so very painful that few patients 
 have courage to submit to it, and few surgeons firmness to prosecute it. 
 
 Passive motion should be commenced on the twelfth or fourteenth 
 day, and should be of the most gentle character.. 
 
 It should be carried out daily, and increased on each occasion, 
 provided it is painless and accomplished with6ut difficulty ; anything 
 like forcible movement at this early stage is to be strongly con- 
 demned. Movements of pronation and supination should be com- 
 menced before those of flexion and extension. 
 
 After the lapse of four weeks the movements should be more 
 extensive. If, however, the movement be carried out early and 
 gently, there will be no necessity for the very violent efforts which 
 are sometimes resorted to in the later stages to break down the intra- 
 articular adhesions which have formed. 
 
 Objections have been raised to passive motion being undertaken 
 in the early stages on account of the possibility of increasing and 
 prolonging the articular inflammation, and thereby causing ankylosis 
 of the joint. These are not borne out in practice, provided the move- 
 ment be of the most gentle description, while on the contrary there 
 are plenty of cases on record where rigidity has resulted, although 
 no passive movement was carried out in the earlier stages. 
 
 E F, 2 
 
420 EPIPHYSES OF UPPEE EXTEEMITY 
 
 Massage will do much towards hastening the absorption of 
 excessive inflammatory material and promoting the functional 
 activity of the limb. 
 
 Complications. — Where dislocation complicates the separation 
 great difficulty will be experienced, not only in replacing the bones 
 in their normal relations, but also in retaining them in this position 
 after reduction. 
 
 In nearly all instances it may be found impossible to satis- 
 factorily treat them except in the semiflexed position, in order to 
 prevent the constant recurrence of the dislocation and deformity. 
 Even the advocates of the extended position do not recommend this 
 position when dislocation is present. 
 
 A well-moulded posterior splint is the best kind of dressing. 
 
 Passive motion should be delayed a little longer in these com- 
 plicated cases. It may be attempted in a very gentle manner about 
 the third week. 
 
 Eecent Ieeeducibility of Defoemity feom Displacement of 
 Eeagments. — The displacement of the fragments must be reduced 
 immediately. It is a mistake to suppose that the fracture may be 
 put up temporarily, and that as time goes on the displaced fragment 
 may be gradually pushed into position. 
 
 In all cases where the fragments are so misplaced that they cannot 
 be reduced by manipulation, an incision should be made under strict 
 aseptic precautions, and the fragments reduced and wired in position. 
 
 Resection of part or the whole of the elbow-joint. — After all the ordi- 
 nary means of reduction have been attempted and have failed, in 
 severe displacements and complicated injuries, this last operative 
 resource will be the best and safest for the future welfare of the limb. 
 In many cases removal of the separated fragment or fragments with 
 the rest of the lower end of the humerus will be all that is required. 
 It should be performed at once. It will not be desirable, as a rule, to 
 wait until the swelling and inflammation have subsided. 
 
 The same treatment may be found necessary where the parts after 
 reduction cannot be maintained in position. 
 
 Compound Sepaeations should be carefully explored by means 
 of an incision, the fragments wired in position, or, if necessary, 
 the fragments removed and the joint partly or wholly excised. 
 
 The author, in conclusion, quotes the trite remarks of Dr. 
 H. E. Wharton, of Philadelphia {International Clinics, 2nd Series, 
 1892, vol. iv. p. 217), when describing an intercondyloid fracture 
 of the humerus in a young patient : ' There is probably no class 
 of cases that has caused surgeons as much trouble as these 
 injuries at the elbow-joint, for these are the cases which are con- 
 stantly brought into the courts for damages from the attending 
 surgeon for maltreatment. It is very important on taking charge 
 of any case with this injury that the surgeon should be extremely 
 careful as to the examination and the prognosis.' 
 
421 
 
 CHAPTEK IX 
 
 SEPARATION OF THE CAPITELLAR AND EXTERNAL EPI- 
 CONDYLAR EPIPHYSES AND EPICONDYLO-CAPITELLAR 
 AND CONDYLO-CAPITELLAR FRACTURES 
 
 ANATOMY. — The anatomy of the capitellar and external epi- 
 condylar epiphyses has aheady been sufficiently described when 
 speaking of the lower epiphyses of the humerus and its epicondylar 
 epiphyses (see Chapter lY. of Part 11.) . 
 
 Fig. 110. — SAGITTAL SECTION THROUGH THE 
 OUTER PORTION OP THE ELBOW-JOINT, 
 SHOWING THE RELATION OF THE SYNOVIAL 
 MEMBRANE TO THE EPIPHYSIAL LINES OF 
 THE BONES (rADIO-HUMERAL ARTICULA- 
 TION), IN A YOUTH AGED FIFTEEN AND A 
 HALF YEARS 
 
 Fig. 111. — DETACHMENT OF THE CAPITELLAR 
 AND EXTERNAL EPICONDYLAR EPIPHYSES 
 PRODUCED BY MACERATION AT THE FIF- 
 TEENTH YEAR. (^ size) 
 
 The synovial membrane extends for a short distance above the 
 epiphysial junction of the capitellum with diaphysis in front, while 
 behind it does not reach up to this level. On the outer side the 
 synovial sac just gains the lower limit of the external epicondyle. 
 
422 
 
 EPIPHYSES OF UPPEE EXTKEMITY 
 
 ETIOLOGY. — From the records it appears that separations of 
 these epiphyses are a much more common in]\iry than the corre- 
 sponding separations on the inner side. 
 
 They have been experimentally produced by H. Senftleben. 
 Indirect violence. — Indirect violence is the most frequent cause. 
 For in falls u^on the hand it is clear that the force of the con- 
 cussion would be carried from the wrist mainly by the radius to 
 the capitellum. 
 
 Again, if the forearm is flexed upon the arm and a blow is 
 received upon the lower part of the hack of the ar^n, these processes 
 may be detached and displaced backwards by the head of the 
 radius, for during flexion of the forearm the capitehum receives 
 from in front backwards the direct thrust of the radius when a retro- 
 humeral blow is made. 
 
 Again, in forcible bending inwards of the forearm upon the arm 
 it is possible to produce this fracture, from the attachment to the 
 external epicondyle of the muscles tending to drag off this process, 
 combined with the pressure of the concave ridge of the sigmoid 
 cavity on the bottom of the trochlear groove — a fracture 'par 
 pression et arrachement ' of the French writers. 
 
 More direct violence may also cause this separation, generally by 
 a fall upon the elbow on the inner and posterior aspect, the ulna 
 being driven from within outwards and impinging against the outer 
 portion of trochlea and capitellum, as in the corresponding separa- 
 tion of the trochlea together with the internal epicondyle or 
 
 internal condyle. But here, the 
 violence being received on the 
 posterior aspect of the ulna, 
 the arm is at the time of the 
 accident close to the body (Mal- 
 gaigne), whilst in the case of 
 the trochlea and internal con- 
 dyle the arm is, on the contrary, 
 away from the trunk in the 
 position of abduction, according 
 to Bernard and Denuce. 
 
 Pingaud produced this frac- 
 ture many times in attempting, 
 on the dead subject, to dislocate 
 the bones of the forearm directly 
 inwards. 
 
 Farabeuf says that the best 
 way to produce this lesion, which he places under the head of sepa- 
 ration of the lower epiphysis of the humerus, is by a retro-humeral 
 blow whilst the forearm is flexed, with the hand resting on a table 
 or on the ground as in the accompanying sketch, by which he shows 
 how he succeeded in his experiment on the body of a boy aged 
 
 ^^ H 
 
 Fig. 112. — vertical antero-posteeior section 
 op the flexed humero-radial articula- 
 tion at the age of thirteen years. two 
 
 FORCES ACTING IN OPPOSITE DIRECTIONS (liKE 
 THE arrows) PRODUCE SEPARATION OF THE 
 condyloid EPIPHYSIS C. (aFTER FARABEUF) 
 
 H, humerus ; B, radius 
 
EPICONDYLO-CAPITELLAE FKACTUEE 423 
 
 thirteen years. The radius causes the capitellar epiphysis to be 
 detached obhquely, carrying with it more or less of the epicondyle 
 and of the cartilaginous substance of the trochlea. 
 
 He continues : ' Although the radius, when flexed and supported, 
 can effectually contribute to separation of the epiphysis, it is not 
 the same with the ulna, whose coronoid hook, during flexion, 
 advances in such a manner as to support itself against the 
 diaphysial part of the trochlea.' 
 
 M. Champenois has reported a case of this fracture in a child 
 aged nine years, who had fallen from a horse on to the left side with 
 the forearm entangled behind the back. The fracture was ac- 
 companied by incomplete dislocation of the bones of the forearm 
 inwards. 
 
 Sir Astley Cooper, in describing this form of injury, says : ' This 
 accident usually happens in children by falls upon the elbow ; at 
 least, in my observation, a very large proportion of them have been 
 in young persons. I have seen it occur in the adult, but very 
 rarely in advanced age.' 
 
 AG-E. — In the tiuo pathological specimens of old date the age is 
 not stated ; in one complicated recent one it is given as ten. 
 Of the eight simple cases two were at eleven, one at seven, one at 
 five and a half, two at five, and two at four years of age. 
 
 PATHOLOGICAL ANATOMY.— The line of separation in a pure 
 example passes from just above the base of the external epicondyle 
 downwards and inwards, skirting the lower edge of the radial and 
 outer part of the olecranon fossa, and terminating at the middle of 
 the trochlear surface, thereby separating the outer part of the 
 trochlear surface which belongs to the capitellar epiphysis. 
 
 In this true form it can only occur before the fifteenth to 
 sixteenth year, the period of junction of this epiphysis with the rest 
 of the trochlea. 
 
 In early years there may be a fracture through the cartilaginous 
 epiphysis, and in later years one in the same position, i.e. where 
 the junction takes place. 
 
 Several specimens show the exact nature of this injury. 
 
 The analogous fracture in the adult (fracture oblique externe) 
 was well recognised and described by Malgaigne. Malgaigne, 
 Bernard, Sir Astley Cooper, F. Schmitz, and others give figures 
 of this injury. 
 
 Gurlt figures a specimen from the Giessen collection — 
 more a fracture than an epiphysial separation, for the detached 
 portion comprises the external epicondyle and a portion only 
 of the capitellum. There was considerable loss of function of 
 the limb ; the only possible movements were those of rotation of 
 the radius, and the forearm was immovably fixed at an obtuse 
 angle. 
 
 According to Giraldes, in a considerable number of cases of injury 
 
424 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 to the lower end of the humerus, ' the trochlea is seen, on the one 
 hand, to be still attached to the lower extremity of the diaphysis, 
 and its proper relationship preserved with the ulna, whilst the 
 condyle (capitellum) , the epicondyle (external epicondyle), and the 
 radius are detached and displaced. The radius, with the epiphysial 
 fragment which it supports, is displaced either forwards or back- 
 wards according to the direction of the violence causing the injury,' 
 Displacsment. — Judging by the description which Gurlt gives of 
 more than one specimen, displacement usually takes place, and the 
 periosteum is only partially lacerated. 
 
 It will be found that according as the periosteum remains intact 
 or is a]3preciably lacerated, so will the detached capitellar epiphysis 
 remain in position or be displaced to a greater or less extent. The 
 epiphysial fragment may be displaced in any direction and rotated 
 on any one of its axes. 
 
 Displacement upwards and outwards is the most common 
 direction for the separated epiphyses to take. 
 
 In the Museum of the Eoyal College of Surgeons there is a 
 specimen, No. 945a, of the articular ends of bones forming the 
 elbow-joint removed by excision {Catalogue of the Museum of the 
 Boijal College of Surgeons, Appendix I., p. 30) presented by Mr 
 John Wood (1885). 
 
 It shows a separation of the epiphyses of the capitellum and 
 external epicondyle in one piece, which has been displaced outwards, 
 
 and is united to the shaft 
 in that position. The head 
 of the radius is still in con- 
 tact with the capitellum, 
 and the articular surface 
 of the ulna, being carried 
 with it, lies in a rough 
 saddle-shaped surface in- 
 tervening between the 
 displaced capitellum and 
 trochlea. The ulna was 
 fixed in a semiflexed 
 position, movement being 
 prevented by ridges of 
 callus in front and behind 
 it. 
 
 In other instances the separation does not pass through the 
 epiphysial junction of the external epicondyle, but as a fracture 
 traversing the diaphysial portion of the external condyle. The 
 fracture in this injury will commence above at the lower part of the 
 external supra-condyloid ridge, through the coronoid and outer part 
 of the olecranon fossa, traversing the epiphysial hne of the capitellar 
 epiphysis^ 
 
 Fig. 113. — sepaeatiox of epiphyses of capitellum 
 
 AND EXTEENAL EPICONDYLE. (eOYAL COLLEGE OF 
 SURGEONS JIUSEUM) 
 
EPICONDYLO-CAPITELLAE FKACTUEE 425 
 
 It is by far the more common form of injury, and is identical 
 with a pure fractare of the external condyle and capitellum and 
 outer part of the trochlea — so commonly met with in children. 
 
 Writing in 1884, Hamilton says of twenty-nine fractures of the 
 external condyle (external condyle and capitellar and outer trochlear 
 portions of the articular surface) of which he had a record, twenty- 
 seven were in patients under fifteen years of age. 
 
 Sir Astley Cooper figures {Fractures and Dislocations, 2nd edition, 
 1823, p. 491) an excellent specimen of this kind from the Museum 
 of St. Thomas's Hospital. 
 
 ' In this preparation, in which the external condyle (i.e. the 
 external condyle and capitellum) is split obliquely, the bone 
 is somewhat thickened ; but although this accident had obviously 
 happened long before death, no union but that by ligament had 
 been produced.' 
 
 A well-marked specimen which was found on a skeleton supplied 
 to the author by an anatomical dealer in Vienna shows this injury 
 in a very. clear light. The skeleton was of a well-made and evidently 
 muscular youth, aged eighteen. Unfortunately, no clinical history 
 could be obtained ; but from the condition of the bones and the 
 considerable remodelling of the parts, it could fairly be presumed 
 that the injury had taken place some years before death. The 
 capitellar epiphysis and outer part of the trochlear surface had 
 evidently been separated through the epiphysial line. This portion 
 of the articular surface with the external condyle was displaced 
 slightly outwards and upwards, and rotated somewhat on its trans- 
 verse axis, so that the groove between the capitellar and trochlear 
 surfaces, instead of being vertical, ran obliquely downwards and 
 outwards. The line of union of the fracture through the diaphysis 
 could be traced through the radial and outer part of the olecranon 
 fossae, which were thereby almost obliterated. Between the capi- 
 tellar epiphysis and the inner margin of the trochlea was a huge 
 gap I inch deep, and about the same size in width ; with this the 
 sigmoid cavity and coronoid process of the ulna articulated. The 
 remaining horizontal portion of the trochlear surface had quite 
 disappeared, probably from the pressure of the ulna, leaving the 
 inner edge of the trochlea very prominent. 
 
 This remaining portion of the trochlea, by means of a large facet 
 on its outer side, articulated with a similar facet on the inner side 
 of the coronoid process, and its lower margin nearly reached {\ inch 
 distant) the posterior border of the ulna when the elbow was placed 
 at a right angle. 
 
 The movements were very restricted even in the dried condition 
 of the bones ; extension could only be effected to an angle of 125 
 degrees on account of the olecranon coming in contact with the pos- 
 terior aspect of the humerus. It was the upward displacement of the 
 whole of the ulna which prevented full extension, as well as some 
 
426 EPIPHYSES OF UPPEK EXTEEMITY 
 
 osseous deposit, which partially filled the upper and outer portion of 
 the olecranon fossa. Flexion was impossible beyond an angle of fifty 
 degrees, the coronoid process of the ulna coming in contact with some 
 deposit of new bone just below the coronoid fossa, which was not 
 obliterated, A facet was situated immediately above the outer 
 margin of the trochlea for articulation with the inner side of the 
 coronoid process. 
 
 There was increase of tvidth of the lower end of the humerus ; 
 the distance between the two epicondyles on the left side being Sc- 
 inches, and on the right side nearly 2| inches. 
 
 There was a diminution of rather less than ^ inch in the distance 
 between the internal epicondyle and the inner side of the olecranon 
 as compared with the sound side ; whereas between the external 
 epicondyle and the outer side of the olecranon there was an in- 
 creased difference of ^ inch, the left side measuring 1^ inches and 
 the right 1^ inches. In each case the elbow was flexed to a right 
 angle. 
 
 The head of the radius had clearly accompanied the fragment. 
 The inner part of the humerus and the inner aspect of the 
 trochlea were quite normal. 
 
 Another sign was present which the author has not seen alluded to 
 by any writer, either in recent or old injuries, viz. the upicard displace- 
 ment of the whole upper end of the ulna. In this specimen it was a 
 very marked feature. Although a considerable amount of this dis- 
 placement was probably caused by the subsequent absorption of the 
 remaining horizontal portion of the trochlea, yet this portion of the 
 trochlear epiphysis from its small size cannot prevent this displace- 
 ment in recent injuries when such a gap is produced between the two 
 portions of the trochlea by the displacement upwards and outwards 
 of the capitellar epiphysis, which the ulna accompanies to some 
 extent. 
 
 On comparing the measurement between different points of bone 
 the upward displacement of the ulna was found to be f inch. 
 
 The distance round the lower part of the elbow over the olecranon 
 from one epicondyle to the other on the right side was 4| inches, and 
 on the left 4 inches, the forearm being at right angles. Measuring from 
 the lowest margin of the trochlear surface to the posterior border of 
 the olecranon (the elbow at right angles), on the left side it was 
 ^ inch, on the right f inch. 
 
 The forearm being in the same position, the distance from the 
 outer limit of the upper epiphysial line of the humerus to the posterior 
 border of the olecranon, on the right side, was 14 inches, on the left 
 13| inches. There was no deflection to the radial side on extension. 
 On testing by Wright's hne {Guy's. Hospital Beports, 3rd Series, 
 vol. xxiv., 1879), the elbow being in the extended position — that is, 
 by a line drawn from the most prominent point of the internal epi- 
 condyle, obliquely downwards and outwards to the head of the 
 
EPICONDYLO-CAPITELLAR FRACTUEE 
 
 427 
 
 radius — the upper border of the olecranon, instead of being on a 
 level with it, was | inch above it. 
 
 Again, when a horizontal line was drawn across the back of the 
 joint in full extension (as far as it was possible) from the external to 
 the internal epicondyle, the upper border of the olecranon was ^ inch 
 above this line, which in the normal condition passes just above the 
 olecranon. 
 
 There was no difference on the two sides, measuring from the 
 epicondyles to the styloid process of the ulna and radius respectively. 
 
 Fig. 114. — lower end op eight humerus ; 
 uninjured. same subject as the next 
 
 FIGURE. (i NATURAL SIZE) 
 
 Fig. 115. — displacement of the capitel- 
 
 LAR AND external EPICONDYLAR EPIPHYSIS 
 OF LEFT HUMERUS, WITH FRACTURE OF 
 SMALL PART OF DIAPHYSIS. UNITED. FROM 
 A LAD AGED EIGHTEEN YEARS. (^ NATU 
 RAL size) 
 
 On the posterior aspect of the humerus towards the outer side 
 there was some evidence of old osseous deposit for two inches upwards, 
 probably the result of periosteal detachment. 
 
 The inner remaining portion of the trochlea and the articular 
 surfaces of the ulna and radius, and contiguous portions of these 
 bones, appear to be somewhat hypertrophied. A similar enlargement 
 in this form of fracture is noted and figured by Malgaigne. 
 
 Franz Schmitz gives {Ein Beitrag zur chirurgisclien PatJwIogie 
 des ElhogengelenJcs, Munich, 1880, S. 27) drawings, after dissec- 
 tion, of two cases (in adults) in which there was extreme displace- 
 
428 
 
 EPIPHYSES OE UPPEE EXTEEMITY 
 
 ment outwards and upwards. In one the outer condyle (condyle 
 and capitellum) was ununited. Flexion and extension limited to 
 the arc between 105° and 140° ; pronation and supination perfect. 
 A neuritis of the ulnar nerve had been excited by its overstretching 
 and had led to paralysis of the corresponding muscles. The second 
 
 case was found in the dissecting 
 room, with no history, and no 
 appearance of nerve trouble. 
 
 An exactly similar lesion 
 was under the author's care at 
 the City Orthopaedic Hospital 
 in April 1895. The fragment, 
 consisting of the capitellar por- 
 tion of the lower epiphysis and 
 a portion of the outer part of 
 the diaphysis, remained con- 
 nected with the radius, but quite 
 ununited to the diaphysis. 
 
 The boy (W. T.) was at this 
 time aged nine years. Six years 
 before he had slipped down in- 
 doors, and fell on to his left 
 elbow. He was treated at the 
 German Hospital, London, and 
 the limb put up in plaster-of- 
 Paris bandages for six weeks. 
 Passive motion was then com- 
 menced ; after a week the elbow 
 could be used, but stiffly. When 
 the patient came under observa- 
 tion he could use his arm very 
 well, but it was weaker than 
 the other. Flexion, extension, 
 pronation, and supination were 
 good. From the front as well as the back the elbow looked widened. 
 On the outer side there was a fragment of the outer portion of the 
 lower end of the humerus freely movable on the shaft. With this 
 the radius was still connected, and on this it rotated. The distance 
 between the epicondyles behind was an inch and a quarter more 
 than on the uninjured side. During flexion the olecranon was in 
 the same plane as the epicondyles, having passed upwards and 
 outwards between the two fragments of the lower end of the 
 humerus ; so that when the elbow was placed in this position 
 on a table, each of these osseous projections touched the surface of 
 the table. 
 
 The accompanying skiagraph, kindly taken by Mr. Thos. Moore 
 in December 1896, shows clearly the condition of the bones, as well 
 
 Fig. 116. — cubitus valgus, with ununited 
 
 CONDYLO-CAPITELLAK FEACTUBE. AUTHOll's 
 CASE 
 
CTTBITUS VALaUS, WITH UNIINITED CONDYLO-OAPITELLAR PRACTUKE. 
 Author's case. Taken by Jlr. Thomas Moobe. 
 
% 
 
EPICONDYLO-CAPITELLAE FKACTUEE 429 
 
 as some dark spots, which represent calcareous nodules m the 
 subcutaneous tissue.' 
 
 That the head of the radius does not always accompany the 
 fragment in its displacement is proved by a specimen in Professor 
 Annandale's collection in Edinburgh, which he kindly gave the author 
 the opportunity of examining. There was displacement backwards of 
 the outer half of the epiphysis ; but the head of the radius was in 
 contact in front with the lower end of the diaphysis. There was a 
 considerable deposit of new bone round the lower end of the humerus, 
 especially in the olecranon fossa. The condition of the elbow 
 rendered excision necessary. 
 
 Annandale (' On some Injuries implicating the Elbow-joint,' Edin- 
 hurgh Medical Journal, Feb. 1885, p. 685) subsequently published 
 the case. A boy, about six years old, injured his elbow by a fall, and 
 this was followed by ankylosis, making the arm very useless. Ex- 
 cision of the joint was performed, and an examination of the parts 
 excised disclosed an oblique fracture through the condyles of the 
 humerus, completely separating the outer half of the epiphysis, 
 together with the external condyle. This portion of bone was dis- 
 placed upwards and backwards, and also slightly rotated outwards, 
 and was attached by osseous material to the posterior aspect of the 
 humerus immediately above the articular surface. The olecranon 
 fossa was filled up by osseous material, and the olecranon itself was 
 displaced slightly backwards from its normal position by this new 
 material. The posterior margin of the head of the radius was dis- 
 placed a little upwards and forwards, its posterior margin resting 
 against the epiphysial line from which the external condyle had been 
 separated. 
 
 Complications. — Dislocation of elbow is one of the most common 
 lesions accompanying this injury. It might be laid down as a rule 
 that dislocations at the elbow in children are almost all complicated, 
 the complication usually being a partial separation of the lower 
 epiphysis of the humerus. 
 
 Dislocation of the elbow outwards or outwards and backwards 
 has been observed in the six specimens of this fracture recorded by 
 Gurlt. 
 
 There is in the Guy's Hospital Museum a specimen, No. 1306^^, 
 showing the portions of bone forming the elbow removed by excision. 
 On carefully dissecting out the parts, and removing the fibrous 
 tissue which united the ends of the bone, the author was able to 
 make out the precise condition of the fragments, which he notes 
 below. For the opportunity thus afforded the author, he is indebted 
 
 ' These nodules were very numerous all over the body, but most marked on the fore- 
 arms and legs, and felt like shot, freely movable beneath the skin. The skin was 
 generally atrophied and extensible. The nodules were probably phleboKtes, for there were 
 traces of a congenital and universal nsevoid condition. The author removed a pendulous 
 mass of nnsvoid tissue at the back of each heel, which had undergone cystic and fatty 
 degeneration, and prevented the boy wearing boots. 
 
430 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 to Mr. Bryant. The specimen is figured by Mr. Bryant {Practice of 
 Surgery, 1884, vol. ii. p. 425, fig. 486a). 
 
 G. L. S., aged ten years, fell from a horse on to his right side, 
 with his arm extended under him, and he then rolled over on to his 
 face. There was mobility about the lower end of the humerus, and 
 it was considered by the surgeon as a T-shaped fracture and treated 
 with splints. When admitted under the care of Mr. Bryant at 
 Guy's Hospital in August 1883, six weeks after the injury, a dis- 
 location of the elbow was detected, and great impairment of move- 
 ment. Th-^ elbow was kept flexed at an angle of 145 degrees, and 
 active and passive movement of flexion could only be effected through 
 10 degrees from that point. Pronation and supination were good. 
 The distance between the external epicondyle and the outer edge of 
 the olecranon was If inches, and on the left side 1 inch. The articular 
 cup of the head of the radius could be felt behind and somewhat 
 
 below the level of the external 
 condyle, and it rotated freely. 
 There was a remarkable promi- 
 nence of the olecranon on the 
 inner side, looking not unlike 
 the internal epicondyle. After 
 an unsuccessful attempt to re- 
 place the bones, excision was 
 performed. The capitellar epi- 
 physis, including the outer part 
 of the trochlea, was found to be 
 separated, and had undergone 
 rotation into an almost vertical 
 position, the capitellar portion 
 being the lower part. The 
 radius and ulna were dislocated 
 inwards and locked in that 
 posiiion, the coronoid process being in contact with the lower aspect 
 of the internal condyle, and its outer edge lying against the inner 
 margin of the trochlea. The head of the radius was in contact with 
 the inner portion of the trochlear surface, and the internal epicondyle 
 was completely detached, displaced forwards, and united by fibrous 
 tissue on to the front of the humerus, to the outer side of the 
 trochlea. Complete recovery with good movement ensued. 
 In other instances the dislocation may be only a partial one. 
 .Dislocation of the radius alone may be present, especially in the 
 outward direction. However, of this there is no specimen recorded. 
 Detachment of periosteum. — The periosteum will probably not be 
 torn to any serious extent, except when the displacement is very great. 
 Wounds. — This fracture may be complicated, though very rarely, 
 by a wound. 
 
 Gurlt relates the case of a child, eleven years old, whose arm was 
 
 Fig. 117. — semidiagrammatic, from guy's 
 hospital museum (excision of elbow). 
 partial dislocation inwards of radius 
 and ulna, with separation and outward 
 rotation of capitellar portion of epi- 
 physis, detachment of portion of in- 
 ternal epicondyle. author's dissection 
 
EPICONDYLO-CAPITELLAB FEACTUKE 431 
 
 caught by a machine in motion and extensively lacerated from the 
 middle of the forearm to the insertion of the deltoid. Through one 
 of the lacerations the capitellar (external condylar) portion of the 
 humerus was seen to be detached, but still adherent by some 
 muscular or aponeurotic fibres. The osseous fragment was drawn 
 up into position, and the limb fixed at a right angle, with the result 
 that at the end of four months recovery took place, with the fore- 
 arm ankylosed at a right angle, but the movements of pronation 
 and supination were preserved. 
 
 Desault also has reported a case of this fracture complicated 
 with a wound and terminating in recovery. 
 
 SYMPTOMS. Separation without Displacement. — In many 
 instances of this injury there will be found no displacement, or so 
 little displacement as to be quite inappreciable, the periosteum being 
 but little torn. 
 
 The injury may then be detected by the following signs : 
 Mobility. — Before swelling has occurred the external epicondyle 
 may be grasped between the finger and thumb, and this process, 
 with the separated capitellar epiphysis, moved in a forward and 
 backward direction. Some mobility of the fragment will occa- 
 sionally be detected on extreme pronation, through the action of 
 the supinators and carpal extensors ; this is likely to be the case if 
 the separation is really at its upper limit a fracture of the lower 
 part of the supracondyloid ridge of the diaphysis. 
 
 Muffled crepitus will usually be perceived during the manipula- 
 tion just mentioned, and is very distinct. 
 
 It can also be easily obtained on rotating the radius and on 
 extreme pronation. 
 
 Pain is usually considerable over the seat of injury, and on 
 iextreme flexion and extension of the elbow. 
 
 Swelling rapidly ensues, from the bruising of the soft structures 
 and the injury to the articulation. It may sometimes be so great as 
 to render the osseous prominences quite indistinguishable. 
 
 Occasionally an opportunity is afforded of examining the elbow 
 a few minutes or directly after the accident, and even then some 
 fulness may be found over the synovial membrane on either side 
 of the olecranon, indicating the presence of blood in the joint. 
 
 Impaired movement of joint. — The movements of the elbow-joint 
 are more or less restricted, and executed with great pain. The 
 forearm is in a semiflexed and pronate position. 
 
 The two following cases, which came under the author's care, 
 are good examples of this form of injury. 
 
 No. 1. — Walter E., seven years old, was knocked down by 
 another boy, and fell on his left elbow. On examination, within 
 half an hour of the accident (May 7, 1887), there was no deformity, 
 but soft crepitus on flexion and extension, most marked on extreme 
 extension. Slight mobility of the external epicondyle was detected 
 
432 EPIPHYSES OF UPPEE EXTEEMITY 
 
 on grasping this process between the finger and thumb, and also on 
 pronation and supination. The greatest pain experienced was during 
 extreme extension. The prominences about the elbow-joint were in 
 normal relationship, and the radius and ulna intact. The elbow was 
 put up in a plaster-of-Paris dressing in the semiflexed position, and 
 complete recovery subsequently ensued. 
 
 ISIo. 2. — Amelia H., aged five years and six months, had been 
 knocked down and had fallen upon her left elbow. She was brcught 
 to the Miller Hospital twenty minutes later, and the following signs 
 were found : mobility and soft crepitus on seizing the external 
 epicondyle, the movement taking place from before backwards. 
 There was no appreciable displacement ; the external epicondyle 
 appeared to project very slightly backwards. Rotation of the radius 
 produced the characteristic crepitus, without pain. Pain was 
 experienced on extending the elbow beyond an angle of 125 degrees, 
 and on extreme flexion. There was considerable swelling over the 
 lower end of the humerus, especiallj^ towards the outer side, and on 
 either side of the olecranon, from effusion of blood into the synovial 
 cavity. 
 
 Of fractures generally of the external condyle and capitellum Sir 
 Astley Cooper states that the ' accident is readily detected by the 
 following symptoms : there is some degree of swelling upon the 
 external condyle [i.e. external condyle and capitellum], and pain 
 upon pressure ; the motions of the elbow-joint, both of exten- 
 sion and flexion, are performed with pain ; but the principal 
 diagnostic sign is the crepitus produced by the rotatory motion 
 of the hand and radius. If the portion of the fractured condyle 
 be large, it is drawn a little backwards, and carries the radius with 
 it ; but if the portion be small, this circumstance does not exist.' 
 
 It is only by carefully examining the relationships of the various 
 osseous projections that a diagnosis can be made with any certainty, 
 but the discrimination of these points about the joint often becomes 
 a matter of great difficulty, on account of the amount of blood 
 extravasated into the aiticulation, as well as into the tissues sur- 
 rounding it. 
 
 Separation with DisPLACE^kiEXT. — Although, as a rule, the 
 displacement is very inconsiderable, the fragment and with it the 
 head of the radius are very liable to be displaced backwards, back- 
 wards and outwards, or forwards. 
 
 Displacement backwards. — When the epiphysial fragment is dis- 
 placed backwards the head of the radius will usually accompany it. 
 The foreariTL is placed in the prone position. Even if the displace- 
 ment is great, there will be no difference in the distance on the two 
 sides between the external epicondyle and styloid process of the 
 radius so characteristic of dislocation. 
 
 Frojection of lower end of diapliijsis. — On extreme extension of 
 the elbow with the forearm pronated, the lower end of part of the 
 
EPICONDYLO-CAPITELLAK FEACTUKE 
 
 433 
 
 diaphysis or upper fragment may be felt in front of the joint ; that 
 is, when the epiphysial fragment is much displaced backwards. This 
 may persist even after consolidation. At other times it is so slight 
 that it disappears when the elbow is flexed. 
 
 It is possible for the olecranon and ulna to he displaced backivards 
 to a shght extent, along with the epiphysial fragment and radius. 
 It is best detected by extending the forearm on the arm ; the ole- 
 cranon will then become prominent behind. 
 
 Fig. 118. — line of feactuke through 
 epiphysial line 
 
 Fig. 119. — separation of external epicon- 
 
 DYLAR AND CAPITELLAB EPIPHYSES 
 
 Fig. 120. — external diaphysio -trochlear 
 fracture. separation of capitellar 
 epiphysis with fracture of exter- 
 nal CONDYLE OR DIAPHYSIS THROUGH 
 SUPRA-CONDYLOID RIDGE 
 
 Fig. 121. — diaphysio-capitellar fracture, 
 fracture between capitellum and 
 trochlea and through diaphysis, 
 traversing or passing above radial 
 
 FOSSA 
 
 DIAGRAMS OF THE MORE COMMON FORMS OP FRACTURE ON THE OUTER 
 SIDE OF THE LOWER END OF THE HUMERUS 
 
 The whole ulna is also displaced upwards in the direction of the 
 axis of the humerus, so that there will be more or less diminution in 
 the distance from one epicondyle to the other over the posterior 
 aspect of the olecranon, the forearm being held at right angles. 
 This displacement is brought about by the direction of the violence, 
 which is applied directly to the olecranon, and by the action of the 
 triceps, biceps, brachialis anticus, and other powerful muscles passing 
 from the arm to the forearm. 
 
 Sir A. Cooper says that the appearance presented in this injury is 
 similar to that of dislocation of the radius backwards. 
 
 Displacement upwards and outwards, and inclined slightly backwards, 
 
 F F 
 
434 EPIPHYSES OF UPPEE EXTEEMITY 
 
 is the more common form of displacement of the fragment. The 
 prominent signs are as follows : 
 
 Loss of relation of the external epicondyle and the olecranon. 
 Slight displacement of olecranon backwards, so that when the 
 forearm is fully extended the ulna projects behind the humerus. 
 
 Displacement of ulna upioards as measured by the distance from 
 epicondyle to epicondyle, as in the last-mentioned form of displace- 
 ment. 
 
 This upward and backward displacement of the ulna can readily 
 be ascertained also by Wright's line passing from one epicondyle to 
 another. The upper border of the olecranon, which should normally 
 be on a level with this, will be considerably above it. 
 
 Widening betiveen the epicondyles of the humerus. The trans- 
 verse measurement between the epicondyles is increased from the 
 displacement outwards of the fragment. 
 
 Displacement forwards. — This displacement of the epiphysial 
 fragment is accompaiiied by supination of the forearm and loss of 
 relation of external epicondyle and olecranon. The epicondyle 
 preserves its normal relation with the head of the radius, and the 
 radial head may be felt, if the sweUing be not too great, to rotate at 
 the normal distance below the external epicondyle. 
 
 Displacement downwards is rarely met with, although Hamilton 
 and others think this the more common form of displacement in 
 adults, on account of the action of the supinator and extensor muscles 
 attached to the fragment. This, however, does not apply to pure 
 epicondylo-capitellar separations in children. 
 
 Some deflection of forearm inwards will probably exist. 
 
 The following signs are common to all the varieties of displace- 
 ment : 
 
 Mobility of the epiphysial fragment, whilst the remainder of the 
 joint is fixed even after the fragment has been replaced. Pronation 
 and supination of the forearm will, through the radius, cause some 
 movement of the fragment with crepitus. 
 
 Soft crepitus is found when the separation is pure, but is of a bony 
 character when the separation is accompanied with a fracture of the 
 supracondyloid ridge of the diaphysis. It is readily felt in detecting 
 mobihty, or on rotating radius, or on pronation. 
 
 Pain is very great on the slightest movement. Sometimes it is 
 hmited to the region just above the external epicondyle. 
 
 Swelling from injury to the joint is very great. 
 
 Ecchymosis. — Extravasation of blood into the interior of the joint 
 as well as into all the tissues round the joint is very considerable. 
 
 Impaired movement of elbow. 
 
 Deflection of forearm to radial or to the ulnar side when the 
 forearm is fully extended on the arm. This is in accordance with 
 the severity of the displacement of the epiphysial fragment upwards 
 or downwards. 
 
EPICONDYLO-CAPITELLAK FEACTUKE 435 
 
 Hamilton met with deflection downwards three times in children 
 mider three years of age ; in one of whom he could not discover that 
 the condyle (capitellmn and external epicondyle) was carried towards 
 the shoulder, but only outwards ; in each of the other cases the 
 fragment had united by ligament. 
 
 Reproduction of deformity is particularly marked when much dis- 
 placement is present with partial or complete dislocation of the bones 
 of the forearm backwards and outwards, the deformity being re- 
 produced with the greatest ease directly after it has been corrected. 
 
 Indeed, in dislocations backwards and outwards in children which 
 at first appear to be simple, but which are immediately reproduced 
 after reduction, the surgeon should consider the probability of the 
 occurrence of this form of epiphysial separation. A careful exami- 
 nation of the various prominences will probably reveal one or other 
 form of displacement of the epiphysial fragment. 
 
 Complications. — Dislocation of elbow outwards or backivards and 
 outwards is the most usual complication. 
 
 Dislocation of elhoio inwards has only been met with in a few 
 instances, e.g. Champenois's and Bryant's, already described. 
 
 Dislocation of the radius. — This complication has only been 
 observed once by Hamilton, the radius being completely separated 
 from the capitellar fragment. It must be considered quite an ex- 
 ceptional instance ; for the head of the radius always goes with the 
 fragment, which includes the external epicondyle, and is therefore in 
 normal relation with it. 
 
 'A boy (F. K.), aged eleven, fell from a load of hay, and he is 
 confident that he struck the ground with the back of his elbow. 
 When seen, six hours after the accident, the arm was much swollen, 
 and the external condyle (i.e. external epicondyle andcapitellum) could 
 not be distinctly felt ; but when pressure was made directly upon it, 
 crepitus and motion became manifest. The head of the radius was 
 at the same time dislocated backwards, and separated entirely from 
 the condyle, its smooth buttonlike head being very prominent. 
 It is difficult to conceive how a blow from behind should leave 
 the head of the radius dislocated backwards, or how the radius could 
 have separated from the broken condyle ; but as the examination 
 was repeated several times and while the patient was under the 
 influence of ether, Hamilton had no doubt of the fact. The disloca- 
 tion of the radius was reduced, but it would not remain in place a 
 moment when pressure or support was removed. The lad recovered 
 with a very useful arm, the motions of flexion and extension, 
 with pronation and supination, after the lapse of a year, beint>- 
 nearly as complete as before the accident, the radius remaining 
 unreduced.' 
 
 DIFFERENTIAL DIAGNOSIS. —A pure separation of the capitellar 
 and epicondylar epiphyses is distingaished from vertical or oblique 
 fracture of the external condyle into the trochlear or capitellar 
 
436 
 
 EPIPHYSES OF UPPEK EXTKEMITY 
 
 surface by (1) the projection forwards of the lower end of diaphysis on 
 extension of the elbow, and (2) the mufiled crepitus. 
 
 Separation of the capitellum loith fracture of the external condyle 
 is indistinguishable from true fracture traversing the parts mentioned, 
 inasmuch as the tracks are almost exactly the same. 
 
 G. A. Wright gives (Guy's Hospital Beports, 1879, p. 55) two 
 useful test lines in the diagnosis of injuries about the elbow. He 
 says : ' It will be found that a line can be drawn in all positions of the 
 joint, from the most prominent point of the internal condyle, through 
 the upper border of the olecranon, obliquely downwards and outwards 
 to the head of the radius, and that such line is bisected at a point 
 corresponding to the superior and external angle of the olecranon. 
 Hence any displacement of any one of these points will be mani- 
 fested along this line.' 
 
 As to the second test he says : ' If also a line be drawn across 
 the back of the joint in full extension, from the external to the 
 internal condyle, or vice versa, that line will lie above the upper 
 border of the olecranon, or, in other words, the angle it forms with 
 the first test line will be on the distal side of the intercondyloid line. 
 This line is most conveniently taken by extending the arm horizon- 
 tally, with the humerus rotated so that the bicipital or anterior 
 aspect looks towards the middle line of the body, and by then drop- 
 ping a perpendicular through the condyles.' 
 
 PROGNOSIS AND RESULTS.— Like all other epiphysial separa- 
 tions, this injury without displacement, or with only slight displace- 
 ment, will readily unite firmly 
 by callus under appropriate 
 treatment, although many cases 
 of ununited fracture or fibrous 
 union only are recorded in the 
 case of adults. The functions 
 of the limb, except in cases of 
 great displacement and with 
 complications, are not likely to 
 be permanently affected. 
 
 Even when displacement is 
 considerable, union will still 
 take place, though at a later 
 period. 
 
 Speaking of this form of 
 fracture. Sir Astley Cooper says 
 that if the fracture be very 
 obhque, a considerable portion 
 being external to the capsular 
 ligament, a steady and long- 
 continued support of the part will occasion it to unite, but 
 that if the whole extent of the fracture b§ within the Hga- 
 
 FiG. 122. — fkactuhe of the outer condy- 
 loid (capitellar) portion of the humerus. 
 
 UNUNITED. (after SIR ASTLEY COOPER.) 
 (ST. THOMAS'S HOSPITAL MUSEUM) 
 
EPICONDYLO-CAPITELLAE FEACTURE 437 
 
 ment it does not unite by bone, whatever may be the means 
 employed. 
 
 In two out of three cases of fracture in this position in 
 children under three years of age Hamilton found the fragment 
 united by ligament. 
 
 A girl, aged three, fell and broke the external condyle (i.e. capi- 
 tellum and external epicondyle) of the left humerus, the fracture ex- 
 tending freely into the joint ; crepitus was distinct, and the forearm 
 slightly flexed and prone. The lesser fragment was displaced outwards 
 and a little backwards, carrying with it the radius. On the second day 
 Hamilton was dismissed on account of the unfavourable prognosis 
 which he gave — or, rather, because he refused to guarantee a perfect 
 limb — and a quack was called in. Several months after the accident 
 the father brought the patient for examination. There was no 
 ankylosis, but the lesser fragment had never united, unless by liga- 
 ment, moving freely with the head of the radius. When the forearm 
 was straightened upon the arm it fell strongly to the radial side, but 
 resumed its natural relation again when the elbow was flexed. 
 
 Deformity. — Where there has been but little displacement the 
 slight deformity will be quite indistinguishable in the course of a 
 year or more, from the remoulding of the parts. 
 
 In other cases the deformity will be very noticeable, when the 
 fragment has united in a bad position and the bones of the forearm 
 have remained somewhat displaced. 
 
 In a case shown by L. A. Bidwell {Lancet, May 4, 1889 ; Hun- 
 terian Society's Transactions, 1890, p. 62) to the Hunterian Societ}^, 
 a boy, aged five, had had a fall on the hand thirteen weeks pre- 
 viously. He was said to have dislocated the elbow, and splints 
 were applied for a few days only. There was deformity, increase 
 in circumference of the elbow by | inch, wasting of the arm, 
 and very little motion — extension not being permitted at all. 
 There was an increase in the width of | inch between the 
 condyles of the humerus. The outer half of the articular surface 
 of the humerus, displaced somewhat forwards and outwards, was 
 firmly united, and the ulna was in normal relation to the humerus. 
 The probable injury consisted in a fall upon the radial side of the 
 hand, pushing up the radius against the capitellum and causing 
 a fracture running from just above the external condyle to the 
 middle of the articular surface. Excision of the joint was pro- 
 posed. 
 
 The author's case, already narrated, is a notable example of 
 cubitus valgus due to an ununited condylo-capitellar fracture. 
 
 Hamilton has noted in several instances of fracture of the 
 capitellum and external condyle in children the existence of lateral 
 inclination towards the radial side on extending the arm, its natural 
 relation nevertheless being resumed when the elbow was flexed. 
 
 In one case, however, the deflection was to^^'ards the opposite 
 
438 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 side. Hamilton examined the child one year after the accident, the 
 patient being then five years old, and fonnd the external condyle (i.e. 
 capitellum and external condyle) very prominent and firmly united, 
 but not apparently displaced in any direction except outwards. The 
 radius and ulna had evidently suffered a diastasis at their upper 
 ends, but all the motions of the joint were free and perfect. 
 
 Fig. 123. — natueal cakeying angle 
 of elbow. 170° outwaeds 
 
 Fig. 124. — cubitus v^ulgus following feactuee 
 
 INTO elbow-joint. EXCESS OF CABEYING ANGLE 
 
 Coulon reports two other instances of what he calls intra- 
 articular fractures of the epicondyle, one in a boy six years old, 
 another in a boy of fourteen. Both these cases resulted in serious 
 deformity and disability. 
 
 Descent of the external condyloid fragment with the capitellum 
 will cause the normal axis of the forearm outwards in the extended 
 position to be substituted for a more inward position, so that the 
 elbow will then project outwards, The deformity will, in this case, 
 
EnCONDYLO-CAPITELLAK FKACTUKE 
 
 439 
 
 be precisely similar to that so frequently met with after separation of 
 the trochlea and internal condyle. 
 
 Sir William MacCormac, in speaking of injm-ies involving the 
 elbow-joint {Clinical Journal, October 10, 1894, p. 383), says : 'In 
 many of these cases the change in the shape of the surface of the 
 articulation as the result of fracture in itself greatly militates 
 against a satisfactory result as regards function, and in many cases, 
 whatever the treatment be, a great deal 
 of alteration in the shape of the joint 
 may ensue.' 
 
 Cubitus varus and valgus may also 
 be . brought about by irregular growth 
 at the epiphysial line of the humerus 
 without any displacement of the epi- 
 physis having occurred. 
 
 An injury to the conjugal cartilage 
 in early childhood may cause an early 
 ossification or destruction of the con- 
 jugal cartilage and arrest of growth of 
 a part of the growing end of the bone, 
 and thereby produce considerable defor- 
 mity of the joint in after years. 
 
 Ankylosis. — From the intra-articular 
 nature of the injury some degree of 
 temporary ankylosis must result, but 
 it will usually disappear entirely at the 
 end of some months under proper treat- 
 ment. 
 
 The permanent stiffness which is 
 met with does not arise so much from 
 arthritis as from the intervention of the 
 separated fragment, or the improper 
 reduction of the fragment, giving rise 
 to alteration of the normal articular 
 surfaces. 
 
 In some instances the olecranon fossa 
 may be filled up with inflammatory or 
 osseous material, and greatly hamper 
 or entirely prevent the movements of 
 
 the joint. This has led the advocates of the treatment by the 
 extended position to insist upon this method, as in the flexed position 
 this great hollow is left unoccupied by the olecranon. 
 
 In other instances, as in the author's, there will be, from the nature 
 of the lesion and from the obliteration of the articular cavity by 
 inflammation, some permanent ankylosis. In Bidwell's case no 
 extension of the arm was permitted. 
 
 Malgaigne saWj in consultation with M. Amussat, a child of 
 
 Fig. 125. — cubitus vaeus. an 
 angle of 170° inwards 
 
440 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 twelve years, who for nearly two months had had a fracture of the- 
 external condyle (i.e. capitellar epiphysis and external epicondyle), and 
 as yet no consolidation. The space between the two tuberosities 
 was increased by six or seven millimetres ; the upper end of the 
 fragment projected forwards, its lower part about two millimetres 
 backwards ; motion was much impeded, and there was still pain in 
 the elbow ; it was thought that the joint would never w^holly 
 
 Axis of Humerus 
 A 
 
 B 
 
 Line perpendicular to A. and 
 passing through epicondyles 
 
 Aa;is of articular surf ace 
 of elhcnv Joint. 
 
 \ 
 
 D 
 
 Axis of forearm 
 
 170° with aocls of Humerus. 
 
 Fig. 126. — diagram showixg the natueal deviation of the left forearm outwards, 
 
 AND the relation OF THE AXIS G OF THE ELBOW-JOINT TO THAT OF AXIS A OF THE 
 HDJIERUS 
 
 B, a line drawn at right angles to A through the epicondyles (fifteen years of age) ; 
 D, axis of forearm at an angle of 170° with A 
 
 recover its mobility. However, by carefully directed exercise the 
 movement gradually increased, and when Malgaigne again saw the 
 child, nearly two years afterwards, flexion, pronation, and supina- 
 tion were complete, extension was only to the amount of a few 
 degrees, and there was every promise of its full restoration. The 
 only remaining annoyances from the fracture were the persistent 
 deformity of the elbow, a slight displacement of the head of the 
 
SEPARATION OP THE OAPITELLAR AND EXTERNAL EPICONDYLAR PORTION OP THE 
 LOWER HUMERAL EPIPHYSIS WITH DISPLACEMENT DOWNWARDS AND IK WARDS. 
 
 Severe cubitus varus three and a half years after a faU on the right elbow." 
 Movements of the elbow joint perfect. 
 
 Mr. T. F. Raven's case. 
 
 Taken by Mr. A. F. Stanley Kent. 
 
EPICONDYLO-CAPITELLAR FEACTUEE 441 
 
 radius backwards during extreme extension, and occasional pain 
 about the elbow. 
 
 Pingaud has stated that the ultimate result of this form of 
 fracture differs entirely from that of the corresponding internal 
 trochlear fracture on the inner side, and that the latter frequently 
 ends in ankylosis, whilst the former frequently terminates in the 
 formation of a false joint. 
 
 The greater difficulty in rendering immovable the capitellar 
 fragment — which is moreover connected with a very movable bone 
 (the radius) — no doubt, in the adult, renders these fractures more 
 liable to be followed by a false joint, but in the case of children 
 such circumstances do not carry so great weight. In fact the author 
 knows of no case of this kind followed by a false joint in children 
 which has been recognised and undergone appropriate treatment. 
 In children the ultimate result, as regards the function at any 
 rate, may be said to be good. Even if stiffness of the joint has 
 remained for several months, it will in the majority of cases, with 
 appropriate treatment by massage, &c., gradually become less, and 
 at the end of a year or two completely disappear. 
 
 In the case of a boy, aged five years, seen by Powers, a fracture 
 of the external condyle extending to the trochlear surface, and 
 exhibiting all the usual signs and slight posterior displacement, 
 was treated by plaster-of-Paris splint, with the result that all 
 the motions of the elbow were satisfactory and union was complete, 
 with thickening and widening of the condyles. The forearm, 
 however, was more nearly in a straight line with the arm than on 
 the opposite side. 
 
 Of fifteen cases of this form of fracture in adults and 
 children, Powers found that nearly all presented some deformity, 
 due to the marked prominence of the condyle and its slight back- 
 ward displacement ; but the functions were a very little short of 
 complete. 
 
 Mr, Hutchinson relates {British Medical Journal, July 24, 188G) 
 the case of a boy, aged ten, in whom full freedom of all motion had 
 been rapidly restored. It was only nine weeks since the accident, 
 yet there was not the slightest swelling, and he could flex and 
 extend almost perfectly, and pronation and supination were equally 
 free. The external condyle, together with the articular surface 
 for the radius, was visibly displaced, and very conspicuous. Some 
 surgeons who examined it thought that it was still movable. The 
 internal condyle was almost, if not quite, in due relation with the 
 olecranon ; but there was some thickening of the humerus, and 
 the olecranon did not seem to project so much as usual. Mr. 
 Hutchinson's impression was that the end of the shaft was dis- 
 placed a little backwards, but he had not an opportunity for forming 
 a deliberate opinion. The wonder was that there could be such 
 displacement with perfect motion. 
 
442 
 
 EPIPHYSES OE UPPEE EXTEEMITY 
 
 Irregular growth of the humerus from injury to this part of the 
 epiphysial junction may subsequently ensue, but will be trifling 
 compared with the deformity from displacement. 
 
 TREATMENT.— The elbow should be flexed to a right angle, 
 with the forearm in the position of supination, an anterior or 
 posterior rectangular splint applied from the shoulder to the wrist, 
 and the fragment, if displaced, restored to its proper position. The 
 posterior splint with outward deviation of the forearm piece is the most 
 efficient. A cotton pad over the detached fragment will assist in 
 
 1 1 ! 1 
 
 ^. ,^.-[,v."Vt 
 
 ,...,,y.,.^ !■ - 
 
 > 
 
 ' 4 ^ - ■ 
 1 
 
 ^ 
 
 i 
 
 ] < 
 
 
 O/ncheS. 5 /O />5 // 
 
 Fig. 127. — pattern for posterior pieces of anteko-posterior splints (croft's) 
 
 WITH elbow at a right ANGLE. FOR A BOY OF FIFTEEN YEARS 
 
 Keduced to one quarter size on scale of inches 
 
 ■ ch 
 
 -■& 
 
 O inches. 5 JO /£> 
 
 Fig. 128. — pattern for anterior pieces of antero-posterior splints 
 Size as above 
 
 /d 
 
 keeping it in position ; or one may be necessary over the lower end 
 of the upper fragment of the diaphysis, which tends to be thrown 
 forwards. 
 
 At all times there is but little hold to be obtained on the capi- 
 tellar fragment, so that it would appear to be impossible to secure 
 much direct pressure upon it. Care should therefore be taken to fix 
 the radius securely. When the fragment is clearly displaced in a 
 downward direction, the forearm should be extended and abducted 
 into its normal outward deviation, and, with some manipulation of 
 
EPICONDYLO-CAPITELLAE FEACTURE 443 
 
 the fragment, the reduction of the displacement will usually be 
 effected. 
 
 At the end of ten to fourteen days, or earlier, a modified 'Croft's ' 
 splint, consisting of anterior and posterior pieces of plaster of Paris, 
 will be found of the greatest service, and allow the daily examina- 
 tion of the elbow without the risk of displacing the fragment. It is 
 often preferable from the commencement of treatment to apply this 
 splint instead of wooden ones on the anterior or posterior aspect. A 
 poroplastic, leather, gutta-percha, or other moulded splint may, like 
 the latter, be applied directly after the accident. The limb should 
 under these circumstances be in the semiflexed position, midway 
 between pronation and supination. 
 
 Fig. 129. — croft's anteeo-posteeiok splints of plastek of pabis 
 
 APPLIED TO LEFT FOllEAKM 
 
 In cases of shght displacement the treatment merely consists ni 
 keeping the elbow semiflexed with a starch, plaster-of-Paris, or 
 other immovable apparatus. 
 
 Malgaigne treated a case of shght displacement in a boy nme 
 years old by applying a starch bandage, and putting a graduated 
 compress in front of the elbow, to push backwards the upper end 
 of the fragment, which tended to start forwards. The union was 
 easy and perfect. 
 
 Sir Astley Cooper recommends for this injury in children an 
 angular splint to be applied to the back of the arm, elbow, and 
 forearm. He says : ' It may be made of stiff pasteboard bent to the 
 shape of the elbow ; but the best mode for its apphcation is to dip 
 it in hot water and apply it wet, so that it may exactly adapt itself 
 to the form of the limb.' 
 
 Hamilton says ; ' Generally the forearm ought to be flexed upon 
 
444 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 the arm, especially with a view to overcome the usual tendency* 
 in the upper end of the lower fragment to pitch forwards, which 
 form of displacement is greatly increased by straightening the 
 arm.' He mentions an exception (one of two cases which he had 
 seen) to this rule. 
 
 J. C, a boy aged six, was brought to him, having, a few minutes 
 before, fallen from a height of four or five feet to the ground. His 
 father said the elbow had been broken at the same point two years 
 before, and from that time had remained stiff and crooked. The 
 
 Fig. 130. — the same, with the anteriob piece laid to the oujeh side afteu 
 cutting through the muslin along the whole of the gap on the innkll side 
 and through part of the gap on the outer side 
 
 external condyle (i.e. capitellum and external condyle) was found to be 
 broken off, and, with the head of the radius, carried backwards. 
 This was the position which it occupied constantly, although it 
 was easily restored and maintained in position when the arm was 
 straight, but not by any possible means when the elbow was flexed. 
 The arm was therefore put up in the extended position in a long 
 felt splint, and the fragments remained well in place till a cure was 
 accomplished. 
 
 Mason's elbow splint, as used for excision, has sometimes been 
 employed, as it enables not only flexion and extension, but also 
 pronation and supination, to be carried out while it is on the 
 limb. 
 
EPICONDYLO-CAPITELLAE FRACTUEE 445 
 
 The extended position is recommended b}^ Dr. L. C. Lane for 
 fractures in this situation : 
 
 ' Adjustment and co-aptation must first be carefully done, and 
 then the splint applied while the arm is extended in supination. In 
 the supine and straight position the biceps and pronator radii teres 
 muscles tend to prevent the radius and its fragment from deviating 
 backward, in which direction displacement normally occurs. Should 
 there be a tendency to displacement of the fragment or of the head 
 of the radius after ihey have been reduced to their proper site, then 
 compresses should be so placed as to correct and prevent such dis- 
 placement. Passive motion must be commenced early and continued 
 until satisfactory motion is obtained ; and the guide should not be 
 the number of weeks occupied, but the work should be continued 
 until freedom of movement is obtained.' 
 
 Guedeney briefly records {Die traitement cles fractures du coude 
 chez Venfant, Lyon, 1893) two cases of fracture of the external 
 epicondyle with fracture of the capitellum (condyle). Both occurred 
 in girls aged four years, who had fallen their own height on to the 
 elbow. There was slight swelling and clear crepitus in each. In 
 one there was pain on moving the forearm laterally. A diagnosis 
 of fracture of the humeral external epicondyle and of the capi- 
 tellum was made. The latter remained fixed to the radius in 
 both cases. Both were treated by fixation in the extended position. 
 Some weeks later, on removal of the bandage, there was found to be 
 complete consolidation, and the movements of the limb were entirely 
 preserved in both cases. 
 
 Allis also recommends this position. For a further description 
 of this subject the author must refer the reader to Chapters IV. and 
 VI. of Part II. 
 
 Yet it must not be forgotten that if an ankylosed joint follows 
 treatment in the extended position, the limb will be rendered almost 
 useless. 
 
 "When a dislocation is also present, the greatest difficulty is to 
 maintain the bones in position after reduction. The displaced 
 capitellar fragment, in its position backwards, forwards, or outwards, 
 may then be detected for the first time. An attempt should be 
 made to replace it by pushing it back by its apex into its normal 
 position. 
 
 The extended position is quite unsuited to cases complicated by 
 dislocation, for in these the dislocation will be reproduced in this 
 position. 
 
 Passive motion should be commenced early — on the eighth to 
 tenth day — and performed daily with great gentleness. 
 
 Sir Astley Cooper recommends the ' splint to be worn for three 
 weeks, when passive motion is to be begun ; it must be very gentle 
 at first, and may be gradually increased as the pain and incon- 
 venience attendino- it subside.' 
 
446 EPIPHYSES OF UPPEK EXTEEMITY 
 
 Passive movement and massage should be commenced early, on 
 accomit of the damage to the joint. Hitherto it has been the 
 practice to delay these for fear of non-union of the fracture. 
 
 Bigid and stiff limbs and joints are far more frequent than non- 
 union of fracture ; indeed, the latter in children are exceedingly 
 rare. 
 
 Inflammation of the joint and surrounding structures is to be 
 treated by the use of lead, spirit, or other suitable application. 
 
 Resection of the whole joint, or partial resection, i.e. of the humeral 
 fragment alone, may be rendered necessary in exceptionally compli- 
 cated cases of great and irreducible displacement or rotation of the 
 epiphysial fragment or dislocation of the elbow. It is always 
 best, if possible, to leave the radius and ulna intact. The resection 
 may be performed at the time of the accident, or preferably at a 
 later period. 
 
 But where reduction simply cannot be efficiently and fully carried 
 out, then incision and replacement and wiring or suturing of the fragments 
 in position should be undertaken with proper aseptic precautions. 
 Indeed, in all cases in which it is found to be impossible to reduce 
 the displacement by manipulation, it may be carried out in hospital 
 practice. 
 
 Partial resection in old cases of dislocation backwards of forearm. — 
 F. Fischer has recorded {Deutsche Zeitsclir. f. Chir., 1889, T. 29, 370, 
 and Archives Generates de Medecine, 1889, vol. ii. p. 235) three 
 cases, two of them in girls, aged sixteen and ten years, and one 
 in a boy, aged fifteen years, from Liicke's clinic at Strasburg. In 
 each case the joint was fixed at an angle of 170° to 180° ; flexion 
 impossible. Pronation and supination only slightly marked in one 
 case. Partial resection, consisting of removal of the olecranon and 
 a small portion of the radius, was followed by very satisfactory results. 
 The girl, aged sixteen, could follow her occupation of domestic 
 servant, and extension of the arm was the only movement that might 
 have been more complete. In the other two patients the elbow 
 could be used perfectly, all active movements being very easily 
 carried out. In all these cases the dislocation of the bones of the 
 forearm backwards was complicated with a fracture of the epicon- 
 dyle, the track of which extended obliquely from the posterior aspect 
 of this process towards the outer side of the trochlea. 
 
 Fischer adds some remarks upon the mechanism of this injury, 
 experimental and otherwise. The injury, he says, is usually produced 
 by forcible over-extension of the forearm whilst in the pronate 
 and abducted position, and at the same time the arm is brought 
 nearer to the trunk, producing a violent twisting force at the 
 elbow. Direct violence — viz. a kick on the elbow — was added to 
 the other etiological conditions in the case of the boy aged fifteen. 
 Fischer thinks that the dislocation occurs first during the accident, 
 and that the fracture of the epicondyle is caused by the impingement 
 
EPICONDYLO-CAPITELLAR FRACTURE 447 
 
 of the radial head against the posterior aspect of this process while 
 the forearm is abducted and the arm adducted. On the other hand, 
 in experiments on the dead body, fracturing first the epicondyle by 
 direct violence or by abduction and forcible pronation of the forearm, 
 he never succeeded in producing a dislocation backwards, but always 
 outwards. 
 
448 EPIPHYSES OF UPPEPv EXTEEMITY 
 
 CHAPTEE X 
 
 Separation of the Trochlea of the Humerus — Separation of the Capi- 
 TELLUM — Separation of the Capitellar and Trochlear Epiphyses 
 
 SEPARATION OF THE TROCHLEA 
 
 ANATOMY. — Between the eleventh and twelfth years the nucleus 
 or nuclei, for there are often two, appear first towards the prominent 
 part of the inner edge of the trochlea. 
 
 About the thirteenth year the internal epicondyle is completely 
 separated from the trochlear surface by the growth downwards and 
 inwards of the diaphysis, and becomes a distinct epiphysis. This 
 inner portion of the trochlea, when fully ossified, unites with the rest 
 of the articular surface about the fifteenth to sixteenth year. 
 
 M. Mayet describes {Bulletins de la Societe anatomique de Paris, 
 Avril-Mai 1895, p. 375) accessory points of ossification occasionally 
 met with in addition to the chief centre of the trochlea : one an 
 inner marginal (appearing at twelve years of age), situated on the 
 inner aspect of the trochlear projection and blending w^ith the dia- 
 physis, and the others, tw^o or three in number, at the bottom of the 
 trochlear groove (appearing at twelve and a half years of age, and 
 joining at fourteen to fifteen with the neighbouring centres). 
 
 AGE. — In one old and doubtful pathological specimen the age was 
 stated to be ten years. 
 
 Of the two clinical cases, one was aged eleven years and the 
 other seventeen — the latter age certainly the utmost limit at which the 
 trochlear portion of the epiphysis remains a distinct portion uncon- 
 nected with the rest of the trochlear surface. 
 
 PATHOLOGICAL ANATOMY.— A pure separation of the trochlear 
 epiphysis can only, on anatomical grounds, occur between the 
 thirteenth, sixteenth, and seventeenth years ; for before this period 
 the internal epicondyle is still connected with it, and after the 
 sixteenth year it is blended with the rest of the articular surface. 
 However, before or after this period, separation with a fracture 
 detaching it from either of these parts is even more likely to 
 occur than a pure separation. 
 
 Professor Laugier was the first, in 1853, to assert the possibility 
 of a fracture in the adult involving the trochlea alone, but he was 
 unable to furnish any proof of his statement. 
 
SEPAKATION OF THE TROCHLEA 449 
 
 Pingaud states that there exists in the Museum of Breslau a 
 specimen (No. 1116) of an old fracture of the lower extremity of the 
 humerus, in which the principal lesion appears to have been in 
 the trochlea, which was atrophied and displaced upwards. 
 
 The only uncomphcated case the author can find verified by 
 actual inspection is the case of a boy aged ten years, quoted by 
 Gurlt from Langenbeck. The elbow was ankylosed, and on resec- 
 tion the broken condyle (trochlea) was found in the olecranon fossa. 
 Death ensued from pyeemia. 
 
 Complications. — Dislocation of the elbow hachioards, hacJctoards 
 and imvards, or hachioards and outwards, is very likely to com- 
 plicate a separation of the trochlear epiphysis. 
 
 Packard, writing in Keating's CycIo2J(Bdia of Diseases of CJdldren 
 (vol. iii., part ii., p. 1072), states that in the Warren Museum (Cata- 
 logue, p. 172) there is a specimen from a girl aged sixteen, who had 
 a fracture of the inner condyle (trochlea) with dislocation backwards 
 and outwards of the elbow. Sloughing ensued, and amputation was 
 performed on the forty-sixth day. ' The condyle is seen to have 
 undergone considerable change, as have also the other bones, more 
 or less.' 
 
 ETIOLOGY. — But little is known of the etiology and mechanism 
 of this separation. 
 
 Direct blows, such as a fall upon the elbow. 
 
 Indirect violence. — Falls upon the palm of the hand, as in 
 Laugier's case, in which there was entire absence of evidence 
 of direct injury to the elbow — the forearm being semiflexed, and 
 the ulnar hook formed by the coronoid process dragging off this 
 process. 
 
 SYMPTOMS. — It is possible for the trochlea to be separated 
 witJiout any displacement, the detached portion remaining entirely 
 within the joint. 
 
 Some pain on movement of the joint, with imjmired use of the 
 limb, and possibly crepitus, will assist in forming a correct dia- 
 gnosis. 
 
 The injury will often be rendered more obscure by the swelling 
 which rapidly ensues after the accident between the internal epi- 
 condyle and the inner side of the olecranon, where the injury has 
 been caused by more direct violence to the elbow. 
 
 Mobility of a loose body on the inner side of the elbow-joint. 
 
 Lateral movement inwards of trochlea with the ulna when the 
 ulna is held firmly at the level of the coronoid process. 
 
 Ulna and epicondyles intact, and no loss of relationship between 
 these processes. The epicondyles are not movable on the humerus 
 or between one another, and there is no displacement of the ulna 
 backwards or inwards. 
 
 Laugier sums up the signs of this fracture by the following 
 characteristics : 
 
 G G 
 
450 EPIPHYSES OF UPPER EXTREMITY 
 
 1. Passive movements of flexion and extension of the elbow to 
 their full extent, and there is even the possibility of passive mobility 
 beyond the physiological limits. 
 
 2. The internal lateral inclination of the forearm in extension 
 of the limb, the forearm forming with the arm an angle, opening 
 inwards, whose apex is below the epitrochlea. 
 
 3. The possibility of detecting abnormal lateral mobility on 
 forcible extension, and at the same time producing crepitus. 
 
 4. The immobility of the rlifferent osseous processes and the 
 preservation of their normal relations. 
 
 5. No mobility of the epicondyles, either on the humerus or 
 between themselves. 
 
 J. H. Packard, in speaking (Ashhurst's International Ency clop cBcJia 
 of Surgery, ' Injuries of Bones,' p. 138) of disjunction of the lower 
 epiphysis of the humerus, says : ' I think the fracture may concern 
 a portion only of the epiphysis, and then be entirely within the joint. 
 The cases of this kind which have come under my notice have been 
 in children, and the mechanism of their production was not known. 
 On passive motion of the elbow, distinct crepitus was elicited, and 
 no other sign of fracture existed except loss of power in the limb 
 and pain, aggravated by handling ; there was no perceptible 
 deformity. In the two cases of which I have kept notes, complete 
 recovery ensued in about six weeks.' 
 
 An example was seen by M. S. Laugier {Arch. Gen. de Medecine, 
 1853, vol. i. p. 45, ' Sur une variete de la fracture de la trochlee 
 humerale ') in a girl seventeen years old, who had fallen upon the 
 palm of her hand, without directly injuring the elbow itself. It was 
 not followed by swelling or bruising about the elbow, or by effusion 
 into the joint. Laugier considered it undoubtedly a fracture of the 
 trochlea alone ; but the exact line of separation does not appear to 
 have been clearly established. 
 
 Voluntary movements were painful, and therefore difficult ; but 
 passive flexion and extension, pronation and supination, could be 
 carried out to their fullest extent, though accompanied by pain. 
 The rotation of the radius during pronation and supination was at 
 times accompanied by intra-articular crepitus, but this was most 
 evident on inclining the forearm inwards while it was fully ex- 
 tended on the arm ; and in bending it in the same position and 
 direction, viz. inwards towards the ulnar side, a very obtuse angle 
 was produced on the inner side at the elbow-joint. Together with 
 the crepitus, some lateral mobility was always felt in these move- 
 ments, caused by the gliding of the trochlea upon the humeral 
 diaphysis, in an inward and outward direction, and produced by 
 means of the ulna. 
 
 The epitrochlea and epicondyle were quite immovable on the 
 humeral diaphysis, as well as between themselves. 
 
 The treatment consisted in rest, the forearm being slightly 
 
SEPAEATION OF THE TROCHLEA 451 
 
 flexed and pronated. In a few weeks recovery took place, with 
 complete restoration of the functions of the arra. A slight greenish 
 discoloration on the inner and posterior aspect of the elbow was the 
 only evidence of injury to the joint, there being no effusion into it. 
 
 Dr. Charles A. Powers {Neio York Medical Becord, March 17, 1888, 
 p. 311) diagnosed the following case of separation of the trochlear 
 epiphysis of the humerus : 
 
 The boy, aged eleven, fell from a wagon, striking the inner 
 aspect of the left elbow. Immediately after there was found to 
 be almost complete disability at the elbow, very much pain, and 
 moderate swelling at the inner aspect of the joint. There was 
 no fracture through either condyle, or through their bases, and 
 the ulna was intact. There was no difference in the contour of the 
 epicondyles on comparison with the opposite side. Between the 
 internal epicondyle and the inner aspect of the olecranon lay a loose 
 body about the size of a bean ; it was freely movable, and could be 
 made to grate on the adjacent bone. When the ulna was firmly 
 grasped antero-posteriorly at the coronoid process, it could be made 
 to slip internally on the humeral trochlea, and in so doing carried 
 with it the loose fragment. The inner edge of the trochlear surface 
 could not be felt. The examination was made under ether. From 
 the preservation of the contour of the internal condyle, and the free 
 lateral movement of the ulna. Dr. Powers concluded that this frag- 
 ment could come only from the inner trochlear surface of the 
 humerus. 
 
 The forearm was flexed at ninety degrees, midway between 
 pronation and supination, and a plaster-of-Paris splint was applied 
 and kept in place four weeks, at the end of which time the 
 condition noted was as follows : ' Moderate thickening at the inner 
 aspect of the humerus below and without the internal epicondyle ; 
 flexion to 80 degrees, extension to 120 degrees ; pronation and 
 supination almost complete. 
 
 ' The functions gradually returned, and six months later all were 
 complete except extension, which was ten degrees short of normal.' 
 
 Complications. — Dislocation of elbow. Gurlt reports the case of 
 a boy, aged seven, in whom the luxation was reduced, but the joint 
 was permanently stifl^ened. 
 
 DIAGNOSIS. — Separation of the trochlea alone has a close 
 relationship with separation of the trochlear and internal epicondylar 
 epiphyses, or with a separated trochlea accompanied by a fracture of the 
 internal condyle. But both the latter have very marked differences 
 which should prevent them being confused — viz. the mobility of the 
 internal condylar process, projection of the olecranon backwards, 
 the ulna being displaced backwards with the detached fragment, 
 simulating dislocation (Sir A. Cooper), and projection of the upper 
 or humeral fragment forwards. 
 
 None of these are present in separation of the trochlea alone. 
 
 G G 2 
 
452 EPIPHYSES OF UPPEE EXTEEMITY 
 
 There is no mobility of the epicondyle, or appearance of dislocation 
 of the ulna backwards or inwards. 
 
 On the other hand, in both injuries the forearm will incline 
 inwards during forcible extension of the limb, and at the same time 
 some lateral mobility and crepitus may be felt. 
 
 TREATMENT. — Evaporating lotions are recommended by some 
 to be applied for the first few days, with or without the use of a 
 splint, especially when great swelling and ecchymosis exist. 
 
 If displaced, the epiphysis should always, if possible, be replaced 
 at once. The elbow should then be put up in the flexed position in 
 a leather or other moulded splint for the next ten days, after which 
 time passive movement should be resorted to and gently carried out 
 every day. 
 
 A posterior angular splint, if preferred, will tend to support 
 the olecranon and prevent any displacement backwards of the 
 trochlea. 
 
 SEPARATION OF THE CAPITELLUM 
 
 ANATOMY. — The nucleus of the capitellum is the first of the 
 osseous centres of the lower end of the humerus to appear. It does so 
 during the third year, and rapidly spreads throughout the whole of this 
 process, and extends inwards to form the outer half of the trochlea — 
 that is, as far as the trochlear groove. About the fifteenth or six- 
 teenth year the capitellar surface, including the outer half of the 
 trochlea, unites with the inner part of the trochlea, and soon 
 afterwards the external epicondyle, now completely osseous, joins the 
 upper and outer aspect of the capitellar epiphysis. 
 
 The entire lower epiphysis of the humerus thus formed joins the 
 shaft at the seventeenth year. 
 
 The fully formed epiphysis is somewhat triangular in shape ; its 
 upper, slightly concave, surface sloping downwards and inwards. The 
 base of the triangle on the outer side is almost as thick as the whole 
 transverse length of the capitellum ; it is thin on the inner side, where 
 the diaphysial end has penetrated the inner portion of the cartila- 
 ginous end of the humerus. 
 
 From the anatomical condition of the bone, the external epi- 
 condyle being so largely connected with the capitellar epiphysis, 
 it is improbable that separation of the capitellum alone will be a 
 frequent accident. The external epicondyle, when fully ossified, is 
 only in contact with the diaphysis of the humerus to a very small 
 extent, and very rapidly after its complete formation blends with 
 the capitellar epiphysis. Before the thirteenth or fourteenth year, 
 when this centre of the external epicondyle appears, this cartilaginous 
 process is merely a part of the cartilaginous lower end of the 
 humerus. 
 
SEPAEATION OF THE CAPITELLUM 453 
 
 AGE. — In the only clinical case recorded, and it is a doubtful one, 
 the age is given as seven years. 
 
 PATHOLOGICAL ANATOMY. — From pathological specimens 
 which have been recently recorded, it is quite possible for the 
 capitellum to be alone separated. 
 
 The separation of this epiphysis will be entirely within the 
 capsule. 
 
 Hahn, of Stuttgart, has recorded an interesting fracture of this 
 process in an old woman, aged sixty-seven. The elbow had been 
 injured four years previously, when she was in a state of intoxica- 
 tion, so that no account could be obtained of the circumstances of 
 the accident. 
 
 The olecranon and coronoid fossae were filled up by new osseous 
 material. The capitellum was separated at its base from the epi- 
 condyle and from the external aspect of the trochlea ; it was displaced 
 forwards and upwards, and formed with the epicondyle an almost 
 right angle ; at its upper border it adhered and became blended with 
 the osseous mass which filled the radial depression of the humerus. 
 The anterior aspect of the epicondyle and the posterior aspect of 
 the detached fragment limited an excavation in which the radial 
 head lodged. The latter was in its normal position, and was held 
 in relation with the lesser sigmoid cavity of the ulna by means of the 
 annular (orbicular) ligament. The humerus was also in contact with 
 the great sigmoid cavity of the ulna. From the anterior aspect of the 
 epicondyle there projected an osseous plate (lamella), which passed 
 in front and to the inner side of the capitellum without touching it. 
 A similar plate stood out from the anterior aspect of the epitrochlea, 
 and extended downwards and inwards towards the coronoid process. 
 
 Gurlt also met with a specimen in an adult in which the capi- 
 tellum was broken off, displaced upwards, and united to the radial 
 depression. The injury was not diagnosed during life. 
 
 In a case recorded by G. A. Wright {Guy's Hospital Beports, 
 1879, 3rd Series, vol. xxiv. p. 53) a strumous boy, aged twelve, had 
 a fracture detaching the capitellum. He had fallen down, striking 
 the right elbow against a wall in his fall, the arm at the time being in 
 a flexed position. No fracture or dislocation was discovered. There 
 ensued pulpy degeneration of the joint, which demanded excision. 
 On opening the joint it was discovered that there had been a fracture 
 of the capitellum, which had been chipped off ; the part separated 
 appeared from its size to represent only a portion of the epiphysis 
 developed from the capitellar centre of ossification. It was, therefore, 
 a true fracture, and not analogous to the separation of an epiphysis. 
 
 The capitellum may be rotated round its vertical or transverse 
 axis, as well as displaced in either direction, as in Mr. Bryant's case 
 of separation of external epicondyle and capitellum complicated with 
 dislocation. Mr. Jonathan Hutchinson junior, ' assisted at an opera- 
 tion on a case of this kind performed by Mr. Treves several months 
 
454 EPIPHYSES OF UPPEE EXTEEMITY 
 
 after the accident {Brit. Med. Journ., November 3, 1894, p. 967) 
 in which the capiteUum was found to be completely tm:ned romid, 
 so that its normal lower smrface faced upwards, and in which con- 
 siderable improvement followed its removal.' 
 
 ETIOLOG-Y. — The violence may be direct or indirect, as in falls upon 
 the radial side of the hand. 
 
 Hahn attributed to a fall upon the hand, wdien the forearm w'as 
 flexed, his specimen of fracture of the condyle (capitellum) ; but it 
 is difflcult to see how the fragment could have been driven upwards 
 by the radius unless the forearm was in the extended position at the 
 time of the accident. 
 
 SYMPTOMS. — When the epiphysis is but little displaced, an exact 
 diagnosis is almost impossible, as there is no deformity. 
 
 Crepitus on rotation of the radius or during extreme pronation 
 and supination will be the most constant sign ; indeed, this, 
 together v^ith pain, especially on manipulation, and some loss of 
 active movement of the elbow^ are the only iinmediate signs of 
 fracture. 
 
 Pain on rotation of the radius is often considerable. 
 
 Swelling and synovitis rapidl}^ ensue, as the injury is entirely 
 wdthin the joint, while impaired movement of limb is a noticeable sign. 
 
 In Hahn's case the symptoms presented by the patient the day 
 after the accident were as follows : Voluntary movements absent ; 
 passive movements limited and very painful ; forearm bent almost 
 to a right angle ; distinct crepitus below the external condyle (epi- 
 condyle) . The olecranon, coronoid, epicondyle, and epitrochlea were 
 in their proper position and immovable. In front of the external 
 condyle (epicondyle) there was an abnormal and rounded projec- 
 tion, which at first was taken for the dislocated head of the radius ; 
 but as this projection remained immovable during pronation and 
 supination of the forearm, and when, in displacing it with the 
 fingers, crepitus could be detected, the diagnosis of fracture of the 
 neck of the radius was made out. The patient recovered very well, 
 vdth only some hampering of movements of flexion and extension of 
 the forearm. The exact condition of the parts was disclosed by the 
 autopsy four years later (see above) . 
 
 Mr. L. A. Dunn showed, at the Clinical Society, November 25, 
 1892 {Lancet, December 3, 1892, p. 1273), a boy, aged seven, who 
 had a piece of loose bone in his elbow-joint. He had fallen down 
 and injured the elbow three years previously. The part separated 
 seemed to be the capitellum of the humerus, which had become 
 loosely attached to the head of the radius. It w^as situated between 
 the head of the radius and the lower extremity of the humerus. It 
 was somewhat disc-shaped, and measured 1^ inches in diameter and 
 \ inch in depth, quite movable apart from both humerus and 
 radius, although more nearly connected with the latter. All the 
 movements of the normal elbow could be perfectly performed. 
 
SEPAKATION OF THE CAPITELLUM 455 
 
 Eotation of the capitellar fragment in this injury, as well as in 
 epicondylo-capitellar fracture, is probably more frequent than is 
 generally supposed. It is caused by extreme flexion of the forearm 
 in the semipronate position. 
 
 Complications. — Dislocation of elbow is probably not an un- 
 common complication. 
 
 In Wright's case the inflammation of the elbow-joint led to a 
 more serious result — viz. pulpy disease, for which excision of the 
 joint was performed. 
 
 PROGNOSIS. — Deformity may not be great, yet ankylosis will be 
 inevitable if sufficient and appropriate treatment be not employed, 
 while arrest of growth of the outer part of the humerus will be slight. 
 
 TREATMENT. — The flexed position of the elbow is the best 
 after reduction of the displaced capitellum. Anterior or posterior 
 angular wooden splints or moulded casing are equally serviceable. 
 Inflammation of the joint should be subdued by appropriate appli- 
 cations. 
 
 Passive motion should be commenced early, about the tenth day, 
 and gently continued each day until the cure is effected. 
 
 SEPARATION OP THE CAPITELLAR AND TROCHLEAR 
 EPIPHYSES OP THE HUMERUS (INFRA-EPICONDYLOID 
 SEPARATION OP THE LOWER EPIPHYSIS OP THE 
 HUMERUS) 
 
 It cannot be supposed that such a diastasis entirely within the 
 joint could occur without being accompanied by that of the external 
 epicondylar epiphysis. This would then be a separation of the 
 lower epiphysis after puberty. 
 
 By the time the internal epicondyle is completely separated 
 from the rest of the lower end of the humerus, the external epicon- 
 dyle is firmly blended with the capitellum, but a small portion of 
 the latter is in relation with the outer part of the humeral 
 diaphysis. 
 
 Pingaud states that the Pathological Museum of Josephine in 
 Vienna possesses a very remarkable specimen of simultaneous 
 fracture of the trochlea and condyle (capitellum), which have been 
 carried in one mass forwards and upwards ; but the detached 
 fragment, instead of slipping upwards parallel to its great axis, has 
 rotated for almost a quarter of an inch, so that the articular cylin- 
 drical mass was almost parallel to the general direction of the 
 humerus. 
 
 In this position the condyle (capitellum) was joined above to the 
 coronoid fossa, whilst the trochlea, which was free below, chiefly 
 covered it without adhering to it. 
 
456 EPIPHYSES OF UPPEE EXTEEMITY 
 
 Guiit has had such a specimen in an adult. 
 
 Hohnes says : ' It is quite conceivable, and may be true, that 
 fractm-e might occur through the hue of junction of the trochlea 
 and capitellum below with the shaft and condyles above, but in 
 order to prove the reality of this injury, anatomical examination is 
 absolutely necessary.' 
 
 Other writers also mention that, exceptionally, the capitellum 
 and trochlea alone are separated, the condyles remaining i)i situ, 
 and designate it infra-condyloid separation of the epiphysis. 
 
 This lesion corresponds to Professor R. W. Smith's separation of 
 the lower epiphysis of the humerus. It is only necessary, therefore, 
 to refer the reader to Chapter V., Part II. 
 
457 
 
 CHAPTEE XI 
 
 Separation of the Olecranon Epiphysis and of the Cartilaginous Upper 
 End of the Ulna — Separation of the Upper Epiphysis (Head) of the 
 Eadius — Separation of the Bicipital Epiphysis of the Kadius 
 
 SEPARATION OP THE UPPER EPIPHYSIS OP THE ULNA 
 
 ANATOMY. — The cartilaginous upper end of the ulna at birth, 
 and for the first few years of life, is seen to include nearly the upper 
 half of the olecranon process, and a strip of cartilage passes down 
 the front articular aspect of the olecranon, covering the upper aspect 
 of the coronoid process as a thin lamella. 
 
 This strip of cartilage gradually disappears by the upward growth 
 of the olecranon and shaft of the ulna, so that by the eighth year 
 almost all that remains is the epi- 
 physis of the olecranon process. The 
 greater part of the olecranon is thus 
 formed by the upward growth of the 
 shaft. But often as late as the 
 tenth year, and later, a portion of 
 cartilage may still be found forming 
 the summit of the coronoid process ; 
 it disappears during the growth and 
 development of the coronoid, without, 
 as a rule, undergoing any ossification. 
 
 Some anatomists have described 
 a separate nucleus for the coronoid 
 process, but this has not been gene- 
 rally confirmed nor has the author 
 met with it. 
 
 The olecranon epiphysis is but a 
 small process, occupying little more 
 than a third of the whole olecranon 
 
 at about the tenth year. In this cartilage ossification appears at 
 the summit of the olecranon as a single nucleus usually at this 
 period — in rare cases a year or two sooner, more often a little later — 
 and rapidly invades the whole. 
 
 A second nucleus is very often seen, it may be as early as the 
 fifth year, and forms the outer side of the upper part of the sigmoid 
 
 Fig. 131. — sagittal section of uppek 
 end of ulna at the age of seven 
 yeaes. the osseous centre for 
 the summit of the olecranon has 
 not yet appeared 
 
458 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 Fig. 132. — upper end of ulna at 
 
 ABOUT THE TWELFTH YEAE. (aETEE 
 EAMBAUD AND EENAULt) 
 
 cavity and the tip or beak of the olecranon, and a small portion 
 
 of the inner side of the sigmoid cavity (upper part) . This nucleus 
 
 ^ encroaches but little on the posterior 
 
 aspect, and unites v^ith the rest of the 
 
 epiphysis soon after the commencement 
 
 of the ninth year. 
 
 In the fully ossified state, at the 
 fifteenth year, the epiphysis comprises 
 Dhe upper aspect of the olecranon v^ith 
 the insertion of the triceps, part of the 
 attachment of the posterior ligament 
 of the elbow-joint, and a small portion 
 of the upper part (less than a quarter 
 of an inch) of the triangular subcuta- 
 neous surface posteriorly ; on the inner 
 side it is above the tubercle for the 
 flexor carpi ulnaris. 
 
 This epiphysis, with its forward 
 projection, enters very little into the 
 formation of the elbow-joint. 
 
 The chief part of the olecranon is formed by the upward extension 
 of the diaphysis, so that it is quite incorrect to state, as most text- 
 books do, that the union of this epi- 
 physis with the shaft is marked by a 
 constriction below the centre, at the 
 base, of the olecranon — the usual situa- 
 tion of fracture of the olecranon. 
 
 The epiphysial line slopes obliquely 
 downwards and backwards from the ar- 
 ticular surface in front — viz. the upper 
 part of the sigmoid cavity. At the age 
 of fourteen and a half years the whole 
 of the olecranon is about one inch long, 
 and the epiphysis, which is now largely 
 composed of osseous tissue, is rather 
 more than three-eighths of an inch long 
 (ten millimetres), so that this process 
 forms slightly more than a third of the 
 whole olecranon. The epiphysis at 
 this age is fifteen millimetres in width 
 laterally, and thirteen millimetres thick 
 antero-posteriorly. 
 
 This epiphysis unites with the shaft 
 at the seventeenth year. Some anato- 
 mists state that it may remain disconnected throughout life, but the 
 author has been unable to find any specimen to confirm this. The 
 union is generally effected before that of the lower end of the humerus. 
 
 Fig. 133. — ossification of olecea- 
 non epiphysis almost cobiplete 
 
 AT the FOUETEENTH YEAE 
 
 (Specimen, Royal College of 
 Surgeons Museum) 
 
SEPAKATION OF UPPEK EPIPHYSIS OF ULNA 459 
 
 The anterior surface of the olecranon epiphysis — viz. the extreme 
 upper part of the sigmoid cavity — forms but a small part of the 
 articular surface. A small process of the synovial membrane over- 
 laps its upper edge in front of the attachment of the posterior 
 ligament of the elbow-joint. 
 
 The epiphyses of the bones of the arm and forearm at the elbow- 
 joint commence to ossify later, but join their respective diaphyses 
 earlier, than the epiphyses at the opposite ends of these bones ; 
 while the epiphyses of the femur and tibia (the upper epiphysis 
 of the fibula being exceptional) 
 
 at the knee-joint are the earliest 
 to ossify and the latest to join 
 with their diaphyses. 
 
 Berard's law is thus verified, 
 as in the humerus, radius, and 
 ulna the nutrient canals are 
 directed toioards the elbow ; in 
 the femur and bones of the leg 
 they are directed aioay from 
 the knee. 
 
 PATHOLOGICAL ANATOMY. 
 Separation of the olecranon epi- 
 physis is one of the rarest forms 
 of epiphysial detachment. The 
 only specimens in the London 
 museums occurred in infancy, 
 while this epiphysis is still car- 
 tilaginous, and both were the 
 results of direct violence. 
 
 In the one, the whole carti- 
 laginous end was detached ; in 
 the other, only the olecranon 
 portion. 
 
 The specimen in St. Mary's 
 Hospital Museum, No. 97 (Cata- 
 logue of Pathological Museum 
 of St. Mary's Hospital, 1891, 
 p. 10), shows a separation of the whole cartilaginous upper end of the 
 ulna, including the upper surface of the coronoid process, in one piece. 
 
 It was held to the diaphysis merely by a tag of periosteum at 
 the posterior part, and there was present also a greenstick fracture 
 of the shaft one and a quarter inch below the coronoid process. 
 
 The child, aged about three years, was admitted with compound 
 dislocation of the elbow-joint. There was also much laceration of 
 the soft parts, and division of the ulnar artery and nerve, in addition 
 to the fractures just mentioned. Amputation was performed at 
 the elbow-joint by Mr. Owen, and the patient made a good recovery. 
 
 Fig. 134. — complete separation of the 
 
 WHOLE CAETILAGINOUS UPPEE END OF THE 
 ULNA IN A CHILD AGED THREE YEARS 
 
 (St. Mary's Hospital Museum. Natural 
 size) 
 
460 EPIPHYSES OF UPPEE EXTEEMITY 
 
 The other specimen in St. George's Hospital Museum, Series 1, 
 No. 110 {Catalogue of St. George's Hospital Museum, 1866, p. 37), is 
 figured by Holnies {Surgical Diseases of Children, 1868, p. 264, 
 fig. 48), and shows the Hne of fracture traversing the cartilaginous 
 base of the olecranon in a child aged two years. There was also a 
 compound dislocation of the radius forwards (the head of the bone 
 lying exposed in a large lacerated wound), but the shaft was entire. 
 The ulna was fractured below its middle. The injury, which had 
 been caused by a carriage-wheel passing over the arm, proved fatal 
 from pygemia. 
 
 In the author's case, which occmTed at the Miller Hospital in 
 1893, the specimen is probably a unique one. The separation of 
 the olecranon process was a pure one, and took place at the age of 
 six years ; it was accompanied by fractm'e immediately above the 
 lower epiphysial line of the humerus, whose lower epiphysis was 
 displaced forwards (see Part II., Chap. lY., page 280, and fig. 71). 
 The olecranon epiphysis is seen (three months after the accident) 
 to be displaced backwards off the ulna and firmly united to the 
 posterior aspect of the lower end of the humeral diaphysis. 
 
 Helferich represents a separation of the olecranon epiphysis with 
 longitudinal fracture of the upper end of the ulna, which complicated 
 a partial separation of the lower epiphysis of the humerus, the result 
 of a severe machine accident (see page 275). 
 
 Once, in his experiments, Cruveilhier detached the olecranon 
 epiphysis with the cartilaginous upper end of the coronoid process, 
 to the latter of which some osseous granules adhered. 
 
 Berthomier found, in his experiments on the elbows of children, 
 that displacement of the epiphysis of the olecranon was excessively 
 rare on account of its being held in position by the triceps and 
 internal lateral ligament. 
 
 The author has, however, on more than one occasion detached 
 and displaced this process on the dead subject, by extreme extension 
 of the elbow. 
 
 Compound separation of olecranon epiphysis without displacement. — In 
 October 1883 a case came under the care of Mr. Bryant at Guy's 
 Hospital in which the author had the opportunity of dissecting the 
 specimen. He (the author) came to the conclusion that it was 
 a case of partial separation without displacement, but complicated 
 with a wound leading to suppuration of the joint and destruction of 
 part of the cartilaginous portion of the epiphysis. 
 
 Jas. P., aged fourteen, slipped and fell with some violence on 
 his right elbow, causing a small wound over the olecranon, which 
 bled profusely at the time. Two days later he was admitted into 
 the hospital with suppuration of the wound and extensive inflam- 
 mation of elbow and forearm. Suppuration of the joint ensued, and 
 an incision was made, evacuating pus and revealing the presence of 
 necrosis about the olecranon. Two months after the accident 
 
SEPAEATION OF UPPEE EPIPHYSIS OF ULNA 461 
 
 excision was performed on account of disorganisation of the joint. 
 The olecranon epiphysis was then quite loose, the cartilage sur- 
 rounding the exposed osseous nucleus much eroded, and over the 
 olecranon a deposit had been made of new bone from the periosteum. 
 
 AGE. — Separation of the whole cartilaginous upper end of the 
 ulna is possible only before the eighth year or thereabouts, and pure 
 separation of the olecranon epiphysis can only occur from about the 
 tenth year to the seventeenth or eighteenth, the time of junction 
 with the epiphysis. 
 
 Of the nine cases recorded, three recent pathological sjjecimens 
 occurred in patients at the age of two, three, and six respectively, 
 while in one somewhat older pathological specimen the injury 
 occurred about the sixteenth year. 
 
 Of the two compound separations the age is given only in one — 
 viz. at fourteen years. 
 
 Of the three simple cases one was at eight, one at seven, and one 
 at four years of age. 
 
 ETIOLOGY. — The rarity of this injury in children, as compared 
 with fractures of the olecranon process in adults, may be accounted 
 •for, to some extent, by the small size and less prominent projec- 
 tion of this process in the former. 
 
 The posterior aspect of this epiphysis in children before the 
 fourteenth year is on a plane anterior to that of the epicondyles and 
 posterior aspect of the diaphysis of the humerus when the elbow is 
 at a right angle. Consequently, in falls upon the elbow and in 
 other injuries the force of the blow is much more likely to be 
 received by the epicondyles than by the olecranon. 
 
 Cheever says that ' the olecranon epiphysis is easily separated in 
 childhood.' 
 
 Gueretin was able to separate this epiphysis on the dead subject 
 only by forcible hyperextension, but the lower epiphysis of the 
 humerus usually gave way in this manner. 
 
 Colignon was unable to produce a separation of this epiphysis. 
 
 Direct violence. — The injury is commonly caused by a fall upon 
 the back of the elbow while the elbow is in a flexed position, or 
 by some other direct blow. 
 
 Direct violence was the cause of separation in Eames's case. 
 
 In 1885 at Guy's Hospital Mr. Davies-Colley diagnosed a 
 separation of the point of the olecranon, which was also broken in 
 two, in the case of a boy, aged eight, who had fallen a distance of 
 forty feet from a bridge over a railway line. There was also 
 separation of the lower epiphysis of each radius. The patient did 
 well, but flexion and extension of the elbow were somewhat limited. 
 
 At this early age the epiphysis has not any trace of ossification ; 
 it is more usual for its osseous nucleus to appear after the tenth 
 year than at an earlier period. In this instance, therefore, it is 
 more probable that the upper cartilaginous end was much com- 
 
462 EPIPHYSES OF UPPEE EXTEEMITY 
 
 miimted by direct violence than that a true fracture of this process 
 had occurred combined with separation. 
 
 Indirect violence. — Extreme flexion of the elhoio may cause separa- 
 tion. 
 
 In Hamilton's case of old dislocation of the elbow in a boy, aged 
 seven, forcible flexion produced this lesion. 
 
 Hyperextension maj^ likewise produce it, as shown by the post- 
 mortem experiments of Salmon and many observers. The author has 
 readily effected it in this way on three occasions. During this over- 
 extension the apex of the olecranon impinges against the posterior 
 aspect of the lower end of the humerus and breaks off the epiphysis 
 of this portion of the bone. 
 
 An experimental specimen in the Eoyal College of Surgeons 
 Museum (No. 946a), by Mr. Jonathan Hutchinson junior, 1889, 
 gives the posterior view of the elbow- joint of a child, aged nineteen 
 months, in whom forcible hyperextension after death resulted in 
 separation and backward displacement of the olecranon epiphysis, 
 which is seen by section to be wholly cartilaginous. The attach- 
 ment of the triceps to the epiphysis is shown, and the periosteum is 
 stripped off the shaft for about an inch. 
 
 Lonsdale was the first to suggest this mode of fracture of the 
 olecranon in the adult. 
 
 Muscular action. — It has been supposed that separation may also be 
 occasioned by the violent contraction of the triceps during extension 
 of the forearm. It is, however, questionable whether in children 
 the action of this muscle is sufficiently powerful to detach this 
 process, unless it be combined with one or other of the causes men- 
 tioned above. 
 
 SYMPTOMS. — The symptoms are almost the same as those of 
 fracture of the olecranon. As in fractured olecranon, the thick 
 periosteum and'' tendinous structure prevent any extensive dis- 
 placement. 
 
 Sepaeation without Displacement. — In some instances there 
 may be no displacement of the fragment whatever, from its beiog 
 held in position by the periosteum and ligamentous structures, 
 and by the tendinous expansion of the triceps being attached to the 
 lateral margins and posterior aspect of the olecranon process, as 
 well as (the thick part of its tendon) fixed into the posterior part 
 of its upper sm-face, not into the beak-like tip of this process. 
 
 Pain, swelling, and mobility are the chief signs, v/hile crepitus may 
 be often perceptible. 
 
 Surgeon William Eames records {British Medical Journal, July 
 16, 1887, p. 124) a fracture of the olecranon in a child of four years 
 which was doubtless one of separation of this epiphysis. The boy 
 (P. A.), whilst walking, slipped and fell with the whole weight of 
 his body on the point of his right elbow. On examination there 
 was some fulness over the olecranon, and a fracture of the upper 
 
SEPAEATION OF UPPEK EPIPHYSIS OF ULNA 463 
 
 half of the olecranon was found, the upper fragment being freely 
 movable, with soft cartilaginous crepitus in a lateral direction, but 
 with no separation to be detected between the fragments. There 
 was inability to extend the arm, and flexion was partially impaired. 
 The limb was treated by being placed in a long splint in the fuUy 
 extended position. 
 
 Separation with displacement. Deformity. — In other instances 
 the displacement of the epiphysis may be considerable and tipioards, 
 not so much owing to the action of the triceps muscle as to the 
 displacement of the lower fragment away from the upper. Below 
 the detached epiphysis a depression will be felt at the back of the 
 elbow- joint, which can be rendered more distinct on flexing the 
 forearm, and be diminished by extending it. 
 
 Hamilton relates the case of a boy, aged seven years, who had 
 an unreduced dislocation of the radius and ulna backwards of 
 nine weeks' standing. "While reducing this dislocation, it became 
 necessary to flex the arm forcibly. The epiphysis constituting the 
 olecranon process gave way, and became separated from one half to 
 three quarters of an inch. This is the only example of separation 
 of this epiphysis which had come to his knowledge. 
 
 A case of fractured olecranon in a young girl recorded by Sir 
 Astley Cooper has been quoted on insufficient grounds as a case of 
 separation of the olecranon epiphysis. 
 
 Marked displacement may not be present directly after the 
 injury. A mere chink or depression just sufficient to admit the 
 finger-nail is all that may be detected at first at the back of the 
 elbow. After the lapse of a day or two we may detect the separa- 
 tion and place the finger between the fragments. 
 
 The action of the triceps in causing separation of the epiphysis 
 is even less efficient than in fracture in adults. It is, however, a 
 very important factor in maintaining the displacement of the epi- 
 physis when once this has taken place. 
 
 Mobility of epiphysis. — This epiphysis is so small a shell of bone 
 that it can be grasped with difficulty if much swelling be present. 
 It will be found to be movable from side to side. If it has been 
 displaced, it will be discovered immediately above the depression at 
 the upper end of the triangular subcutaneous surface of the olecranon 
 by extending the forearm, which will bring the fragments together. 
 
 Muffled crepitus. — This will be easily detected during the lateral 
 movement of the epiphysis, but when displacement has taken place 
 it can only be discovered by extending the forearm and approximating 
 the fragments. 
 
 Ecchymosis and swelling-. — The former is less marked in cases 
 caused by indirect violence than direct violence ; but at times the 
 swelling about the elbow will be so great as to entirely obscure the 
 outline of the olecranon and the gap between the fragments. In 
 such cases it will be better to wait till this has subsided before 
 
464 EPIPHYSES OF UPPEE EXTEEMITY 
 
 expressing a definite opinion on the character of the injury — i.e. if 
 an examination under an anaesthetic has been refused. 
 
 Pain. — The pain is not very great, except when the patient or 
 surgeon attempts to flex or extend the elbow. It is most acute over 
 the upper end of the olecranon process. 
 
 Synovitis. — There is sure to be more or less effusion into the joint 
 as the separation passes into the articular cavity. It will be con- 
 siderable when the joint is freely opened in displacement of the 
 epiphysis, which lacerates the synovial membrane at the posterior 
 part. 
 
 When the effusion of blood and fluid in the joint is great, it may 
 tend to keep the fragments from being brought together. 
 
 Loss of power of the forearm, especially in extension by the 
 patient, will be present to a greater or less extent according to the 
 amount of displacement, whereas flexion can be readily effected. 
 In many instances where the displacement is slight and the triceps 
 expansion incompletely lacerated, the power of extension will be 
 retained to a considerable degree. 
 
 Flexion of the elbow gives rise to great pain at the seat of the 
 disjunction. 
 
 DIFFEEENTIAL DIAGNOSIS. Fracture of the olecranon.— In 
 epiphysial separation the character of the C7'epitus and the form and 
 situation of the separated fragment are sufficient to render it dis- 
 tinguishable from fracture of the olecranon. 
 
 Hamilton falls into the common error in supposing that the place 
 where the epiphysis joins the shaft is below the centre of the ole- 
 cranon, the most common situation for fracture ; he says : ' Fractures 
 of the middle (of the olecranon) are generally transverse, and only 
 slightly oblique, occurring in the line of the junction of the epiphysis 
 with the diaphysis.' 
 
 On the other hand, the annual surgical reports of several of the 
 London hospitals mention in their statistics numerous cases of 
 fracture of the olecranon before adolescence, many of which were 
 probably examples of epiphysial separation. 
 
 Guedeney {Dio traitement des fractures du coude chez l' enfant, &c., 
 Lyon, 1893), while stating that fracture (sic) of the olecranon is 
 rare in children, was able to record four cases out of sixty inju- 
 ries to the elbow-joint in these young subjects. A fifth is classed as 
 a separation of the olecranon epiphysis with laceration of the internal 
 lateral ligament, but neither the age nor any other details are given of 
 this case. Of the four cases of fracture, the first was a boy (J. B.), 
 aged ten and a half. There was enormous swelling and great extra- 
 vasation of blood even into the joint, with abnormal mobility and crepi- 
 tus. The joint could be moved laterally, showing that the internal 
 lateral ligament had been lacerated. In the second, a girl (J. M.), 
 aged eight and a half, had a blow against a door a month previously. 
 The fracture of the olecranon was accompanied by juxta-epiphysial 
 
SEPAKATION OF UPPEK EPIPHYSIS OF ULNA 465 
 
 sprain of the radius with periostitis; also great swelhng of the 
 forearm. In the third case, of a boy (F. T.) aged (?), the frac- 
 ture of the olecranon was incomplete and accompanied by laceration 
 of the internal lateral ligament. In the fourth case, of a boy {(). D.), 
 eleven and a half years, the detacliment of the olecranon was com- 
 plicated by complete dislocation backwards of the bones of the fore- 
 arm. Crepitus was clearly made out. There were, besides, fracture 
 (sic) of the lower end of the radius, with ' back of fork ' deformity, 
 detachment of the styloid process of the ulna, and abnormal 
 mobility of the wrist. These lesions had been caused by a simple 
 fall from the boy's own height on to the dorsal aspect of the hand. 
 
 All the above five cases were treated by a plaster splint in the 
 extended position with a successful result, especially as regards the 
 free movement of the joint. 
 
 The age of the patient will not assist us greatly ; for although 
 Hulke (Holmes's System of Surgery, 1882, vol. i. p. 961) says that 
 fracture of the olecranon is almost unknown before the age of 
 fifteen, cases have been recorded by Hamilton in a boy aged fourteen 
 years, and in the Warren Museum, according to Packard, there is a 
 specimen removed by excision of the elbow from a patient at the 
 age of twenty-three years who had injured his elbow when eight 
 years old. 
 
 Fletcher has reported {Medical Times and Gazette, 1851, vol. ii. 
 p. 173) a case of complete osseous union of fracture of both olecranons 
 in a boy aged sixteen years,, who had fallen over some timber a short 
 time before. There was separation to the extent of a finger's 
 breadth on both sides. Swelling not great. Fragments loose and 
 movable in any direction. Full use of both arms took place after 
 treatment in the extended position. Death occurred ten months 
 later from phthisis. On dissection the signs of fracture were an 
 irregular furrow on the surface of each sigmoid cavity two lines 
 wide, along which the articular cavity was entirely wanting. On 
 the right olecranon this furrow was three-eighths and on the left 
 five-eighths of an inch from the humeral end. Posteriorly there 
 was no furrow or projection, but a slight deviation from the normal 
 line beginning about an inch from the humeral extremity. On 
 section, the cancellated structure above the line of fracture ' was 
 slightly condensed, but all remains of the callus seem to have been 
 removed.' 
 
 Professor Annandale (' On some Injuries implicating the Elbow- 
 joint,' Edinburgh Medical Journal, February 1885, vol. xxx. part ii. 
 p. 688) records another instance of fractured olecranon in a boy 
 aged sixteen in which he resected the ends of the fragments and 
 successfully wired them together. The elbow had received a kick 
 from a horse five months previously. 
 
 PROGNOSIS.— Bony union should always be expected when the 
 fragment has been properly reduced, and if passive movements 
 
 H H 
 
466 
 
 EPIPHYSES OF UPPEPv EXTREMITY 
 
 be carried out at an early period the limb will entirely recover its 
 functions. 
 
 Should fibrous union occur from the displacement of the upper 
 fragment, and leave onlj^ a short gap between the fragments, the 
 utility of the elbow will be but little impaired. 
 
 In one case out of three of fracture of the olecranon process 
 Hamilton found osseous union. A boy (P. C), aged fourteen, fractured 
 his olecranon. Sixty-nine years after the accident — he being then 
 eighty-three years old — the olecranon process united by bone. He 
 
 could not, however, straighten the arm 
 completely nor supine it freely. In the 
 other two cases the bond of union was 
 ligamentous. J. C, aged eighteen, frac- 
 tured his right olecranon process. It 
 was treated with a straight splint. Kine 
 3"ears later the process was united by a 
 ligament half an inch in length, and 
 he could nearly, but not entirely, 
 straighten the arm. In all other re- 
 spects the functions and motions of the 
 arm were perfect. The other case was 
 a lad aged fifteen, whose olecranon 
 process had been broken by a fall six 
 months previously, and at the same 
 time the head of the radius had been 
 dislocated forwards. Hamilton found 
 the radius in place, and the olecranon 
 process united by a ligament about half 
 an inch in length. The patient was 
 not able to straighten the arm com- 
 pletely, the forearm remaining at an 
 angle of fortj^-five degrees with the arm. 
 Ankylosis is a serious occurrence, 
 from adhesions taking place wuthin the 
 joint. It may occur from neglect to 
 move the joint. Permanent ankylosis 
 is unlikely to result when this has been 
 prox^erly performed, whether the elbow be kept in the extended or 
 flexed position 
 
 TREATMENT. — All cases should be put up at once in the com- 
 pletely extended position, and maintained in that positioii bj' a long 
 anterior straight splint, or other suitable apparatus, extending from 
 the shoulder to the end of the metacarpal bones. The olecranon 
 must be secured in its natural position. 
 
 We must not wait until swelling has subsided, as recommended 
 by some surgeons, for it will be found very much more difficult to 
 straighten the forearm subsequently than it would have been at 
 
 IG. 13-5. STEAIGHT AXTERIOK 
 
 SPLINT (gOOCH's SPLIXTrXG) FE03I 
 SHOULDER TO WEIST FOE SEPAEA- 
 TION OF THE QLECEAXO^" 
 
 A bandage is applied in oblique 
 turns to the elbow-joint above 
 and below the olecranon to 
 prevent displacement of its 
 epiphysis. (After Spence) 
 
SEPAEATION OF UPPER EPIPHYSIS OF ULXA 467 
 
 first, and there will be the risk of the olecranon becoming displaced, 
 if this had not occurred already. Should displacement of the olecranon 
 have taken place, it will be still further drawn up and fixed in that 
 position. The synovial fluid, being in contact with the fractured 
 ends of the bone, will not only tend to prevent the accurate apposition 
 of the fragments, but, by lining the surfaces with synovial lymph, 
 may entirely stop the formation of osseous union between the 
 fragments. 
 
 This position has been almost universally adopted for fractured 
 olecranon in England since the time of Sir A. Cooper, and in France 
 also — following the authority of Boux, Malgaigne, and Dupuytren, 
 
 Where disiolacement has occurred, the exact apposition of the 
 fragments^the most important factor in the treatment, which should 
 be aimed at in all cases — ^can only be brought about by extension of 
 the arm. In this position only can the triceps be relaxed, and the 
 descent of the epiphysis permitted. 
 
 The circular and transverse bandages of Sir iVstley Cooper, above 
 and below the olecranon, with lateral tapes to draw them together, 
 to which also a straight anterior splint is added, will be found 
 sufficient in some cases to bring the fragments into contact where 
 there is little displacement. 
 
 The descent of the olecranon may be aided by the fingers, and a 
 pad of lint placed above the process. 
 
 In the eighteenth century, Camper was the first to tr}^ fixation 
 of the fragments in fracture of the olecranon, but he appears to have 
 soon abandoned this method and followed all his early predecessors 
 by treating these injuries without any immobilisation. 
 
 Some modern surgeons have recommended the limb to be placed in 
 a semiflexed position, in the opinion that, should ankylosis occur, the 
 arm will be in its best position for the performance of all its func- 
 tions. This is met by the statement that ankylosis is rarely ob- 
 served when the arm is treated by extension or flexion in a proper 
 manner, and that it is only in exceptionally severe and complicated 
 cases, or where the proper movement of the joint has been neglected, 
 that ankylosis has been met with in the adult. 
 
 Aspiration of the joint. — This may be necessary when the effusion 
 of blood and serum due to the lacerated synovial membrane of the 
 joint prevents the fragments being brought together. It should be 
 performed only in exceptional cases to secure exact apposition of the 
 fragments : the intra-articular effusion in this case being so great as 
 to prevent the fragments being brought together. 
 
 The splint described as follows b}' Hamilton for fractures of the 
 olecranon with great displacement appears to be at once effectual 
 and simple. 
 
 ' The surgeon will prepare — extemporaneously always, for no 
 single pattern will fit two arms — a splint from a piece of thin light 
 board. This must be long enough to reach from near the wrist-joint 
 
468 EPIPHYSES OF UPPEE EXTBEMITY 
 
 to within three or four inches of the shoulder, and of a width nearly 
 or quite equal to the widest part of the limb. Its width must be 
 uniform throughout, except that, at a point corresponding to a point 
 three inches, or thereabouts, below the top of the olecranon process, 
 there shall be a notch on each side, or a slight narrowing of the 
 splint. One surface of the splint is now to be thickly padded with 
 hair or cotton-batting, so as to fit all the irregularities of the arm, 
 forearm, and elbow, and the whole covered neatly w^ith a piece of 
 cotton cloth, stitched together upon the back of the splint. Thus 
 prepared, it is to be laid upon the palmar surface of the limb, and a 
 roller is to be applied, commencing at the hand and covering the 
 splint, by successive circular turns, until the notch is reached, from 
 which x^oint the roller is to pass upwards and backwards behind the 
 olecranon process and down again to the same point on the opposite 
 side of the splint ; after making a second oblique turn above the 
 olecranon, to render it more secure, the roller may begin gradually 
 to descend, each turn being less oblique, and passing through the 
 sam.e notch, until the whole of the back of the elbow-joint is covered. 
 This completes the adjustment of the fragments, and it only remains 
 to carry the roller again upwards, by circular turns, until the whole 
 arm is covered as high as the top of the splint. The advantages of 
 this method are apparent. 
 
 ' It leaves, on each side of the splint, a space upon which neither 
 the splint nor bandage can make pressure, and the circulation of the 
 limb is therefore unembarrassed, while it is equally effective in 
 retaining the olecranon in place, and much less liable to become 
 disarranged. 
 
 ' We must always keep in mind the fact that, the fracture being 
 usually the result of a direct blow, considerable inflammation and 
 swellino- around the joint are about to follow rapidly; and on each 
 successive day, or oftener if necessary, the bandages must be examined 
 carefully and promptly loosened whenever it seems to be necessary. 
 For this purpose it is better not to miroll the bandages, but to cut 
 them with a pair of scissors along the face of the splint, cutting only 
 a small portion at a time, and, as they draw back, stitch them together 
 acyain lightly ; aiid thus proceed until the whole has been rendered 
 sufficiently loose.' 
 
 Plaster-of-Paris bandages should be avoided if possible. 
 
 Extension of the arm hij a weight in bed has been advocated, but 
 has not proved very satisfactory, in fracture of the olecranon. 
 
 Passive motion. — Passive motion should be commenced' about the 
 fourteenth day. If there is much effusion into the joint, this may be 
 delaved a little longer. The finger and thumb should be placed above 
 the olecranon epiphysis, and pressure made upon it downwards. The 
 elbow should then be gently flexed to a very slight extent, and the 
 limb replaced on the straight splint. This should be continued daily 
 until the third week, when the straight s])lmt should be replaced ]\v 
 
SEPAEATION OF UPPEE EPIPHYSIS OF ULNA 469 
 
 an angular one, or by an immovable moulded splint flexed to a right 
 angle or less. From this time the flexion may be daily increased 
 until consolidation has taken place, or, at least, it may be carried as far 
 as the inflammatory condition will permit. 
 
 The angle of the splint should be changed from time to time. 
 
 After the fragment has firmly united, and all fear of separating 
 the epiphysis has vanished, the patient should commence to use the 
 limb, and passive motion should be continued for a considerable time. 
 
 Extra-articular suture. — Mr. Mayo-Iiobson's plan of fixing {Clinical 
 Society's Transactions, 1889, p. 286) the fragments in position by 
 means of extra-articular pins is at once simple and effectual in certain 
 cases when other means have failed to bring the fragments into 
 apposition. 
 
 Carefully cleansed steel pins are passed, under antiseptic pre- 
 cautions, through the skin and triceps above the uppt r fragment, and 
 another below the upper end of the lower fragment through the skin 
 and dense structures over the back of the olecranon, and a figure-of- 
 eight asepticised silk is passed over the ends of the pins (not over 
 the olecranon, the pins being drawn together by gentle traction) and 
 an anterior straight splint applied. Antiseptic dressings are then 
 applied and left on for about two weeks. 
 
 By this method Mr. Eobsoh, in a case of fractured olecranon, 
 apparently secured bony union without any stiffness of the elbow- 
 joint. 
 
 Wiring' of the fragments in position. — This should only be under- 
 taken in cases of compound separation und^eT strict antiseptic 
 precautions, and in other extreme and quite exceptional cases of non- 
 tiwion of the epiphysis in childhood, the patient being thereby 
 incapacitated from using his arm and unable to gain his livelihood in 
 later life. 
 
 This operation may also be necessary after ununited fractures of 
 the olecranon in older subjects just about the tiixie of union of the 
 epiphysis with the upper end of the bone. 
 
 Dr. A. E. Morison {Lancet, November 23, 1896, p. 1531) wired 
 the olecranon of a boy, aged sixteen, who had fallen on his elbow 
 five months previously. The olecranon was freely movable, and 
 separated three-quarters of an inch from the upper end of the ulna. 
 There being inability to extend the forearm, with much weakness 
 and wasting of the muscles, especially the triceps, a longitudinal 
 incision was made over the elbow posteriorly, and the ends of the 
 upper and lower fragments were sawn off, opening the elbow-joint. 
 The bones were brought into apposition by two strands of silver wire 
 passed through a hole drilled in each, and the wound closed without 
 drainage. In ten days it was entirely healed. The movements of 
 the arm were now perfect, but the joint a little weak. The union 
 was so firm that it would have been regarded as bony if skiagraphs 
 had not shown a clear line at the junction of the apposed surfaces. 
 
470 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 This was considered to be cartilage, and would ultimately become 
 bone. 
 
 Mr. G. A. Wright, of Manchester, once wired (Ashby and 
 Wright, Diseases of Children, Medical and Surgical, 2nd edit., 
 1892, p. 707) a case of compound separation of the upper epiphysis 
 of the ulna with a good result. 
 
 Compound Sepaeations. — The wound must be thoroughly 
 cleansed, and all portions of soiled tissue removed. 
 
 The joint should be carefully washed out with some antiseptic 
 lotion, and the fragments brought together w^ith wire or carbolised silk. 
 
 Ankylosis should be very carefully guarded against, and measures 
 taken to combat the articular inflammation which must result from 
 the opening of the joint. 
 
 Should the bone be much comminuted, or the wound improperly 
 treated from the first, and asepticism neglected, excision of the joint, 
 as probably affording a better and more speedy recovery, should not 
 be delayed as a secondary procedure. To secure a useful limb is cer- 
 tainly preferable to risking a patient's life from prolonged suppuration 
 of the joint, or even from pyaemia. The operation unperformed would 
 involve, at the best, a very protracted recovery, with the certainty of 
 ankylosis ensuing. 
 
 SEPARATION OF THE UPPER EPIPHYSIS (HEAD) 
 OF THE RADIUS 
 
 ANATOMY. — The osseous nucleus for the head of the radius 
 appears in the centre of the cartilaginous upper end at the com- 
 mencement of the sixth year. 
 
 At the tenth year it is of a 
 circular shape, about a centimetre 
 in diameter, and placed rather to 
 the outer and posterior side of the 
 centre of the diaphysis, towards 
 the part where the upper end of 
 the diaphysis somewhat projects. 
 
 Bambaud and Renault describe 
 a number of accessory osseous 
 nuclei which are placed in a re- 
 markable manner round the prin- 
 cipal central plate, and, when 
 joined together and to the central 
 portion, form the characteristic concavity of the epiphysis. These 
 pieces have each a triangular shape ; their bases are turned out- 
 wards and constitute the rim of the cup ; and together they make up 
 
 Fig. 136. — rppER end of radius at the 
 
 SIXTH YEAR ; MOSTLY CARTILAGE. ONE 
 ELONGATED OSSEOUS NUCLEUS ONLY 
 VISIBLE. (actual SIZe) 
 
SEPAEATION OF UPPEK EPIPHYSIS OF EADIUS 471 
 
 an osseous crown bevelled off inwards. This part insinuates itself 
 beneath the median disc, which is completely plane on both sides, 
 and finally blends with it, forming one osseous mass. 
 
 About the sixteenth year the upper epiphysis is fully ossified, 
 and towards the end of this, or the early part of the seventeenth, 
 year joins the diaphysis ; at times a little later. The upper 
 extremity of the radius is there- 
 fore remarkable as being, of all 
 the epiphyses of the long bones, 
 the last to become osseous and 
 the first to unite with the shaft. 
 The outer portion being the 
 part to synostose first, the inner 
 half of the epiphysial line, cor- 
 responding to the lesser sigmoid 
 cavity of the ulna, often remains 
 distinct for a considerable time 
 after the outer portion is quite ^ig. 137.-upper end of eadius at the 
 
 •^ -^ SIXTEENTH TEAR, AFTER RAMBAUD ANI) RENAULT 
 
 obliterated. 
 
 This epiphysis is of a bi-concave shape, narrower on the outer 
 than the inner side, and includes only the upper part of the head — 
 viz. the whole of the cartilage-clad area, part of which, round the 
 inner edge, articulates with the lesser sigmoid cavity of the ulna, 
 while the rest of the edge, the narrower portion, is surrounded by 
 and rotates within the orbicular ligament. 
 
 The lower part of the head and the neck are ossified from the 
 shaft. 
 
 In the fully formed epiphysis the depth (vertically) in the centre 
 is only two millimetres, on the outer side five millimetres, while 
 on the inner side it is one centimetre. At the fourteenth year it is 
 three and a half millimetres on the outer side, and five and a half 
 millimetres on the inner side. 
 
 In width laterally, at the fourteenth year it is sixteen milli- 
 metres, and at the time of union with the shaft twenty-one 
 millimetres. 
 
 The epiphysis is completely intra-articular. 
 
 The synovial membrane of the elbow- joint extends far beyond 
 the epiphysial boundary of the head of the radius ; completely lining 
 the entire inner surface of the orbicular ligament, it passes off to 
 blend above with the epiphysis of the head by a funnel-shaped 
 process, being attached to the radius only by weak areolar tissue. 
 Although highly probable, it is not absolutely necessary, that lacera- 
 tion of the synovial membrane should accompany epiphysial separa- 
 tion, since this synovial sac is so readily detached from the neck of 
 the bone ; yet by reason of its extent it must be especially liable to 
 injury. 
 
 This epiphysis has no ligaments or tendons attached to it. 
 
472 EPIPHYSES OF UPPEE EXTEEMITY 
 
 ETIOLOGY. Direct violenee.— It might at first be supposed that 
 separation of this epiphysis could only occur as the result of direct 
 violence, as in Mr. MayoRobson's and Mr. Mansell Moullin's 
 cases. Yet from the record of other cases it appears that indirect 
 violsnce is more frequent, such as occurs in seizing the hand or fore- 
 arm of a child when falling, and twisting it. 
 
 Dr. A. Foulerton gives {Lancet, October 2, 1886, p. 627, and 
 October 30, p. 816) a note of a double fracture of the upper limb of 
 a child by indirect violence. One fracture was through the upper 
 epiphysial line of the radius, and the other through the clavicle. 
 
 ' A child, aged nineteen months, was being led along the street 
 by his mother, who was holding his right hand. The child stumbled, 
 fell with a jerk, and was dragged up again — roughly, probably— 
 by his mother, who, however, never let go his hand. She then 
 noticed that the boy's arm was quite powerless, and hung loosely by 
 his side. Shortly afterwards the child was brought to the Royal 
 Isle of Wight Infirmary, where it was found that two fractures had 
 occurred, one through the upper epiphysial line of the right radius, 
 the other at the junction of the middle with the acromial third of 
 the right clavicle. One would certainly have expected dislocation 
 rather than fracture as the result of such an accident occurring in 
 so young a child, and Dr. Foulerton was unable to offer any exact 
 explanation as to the mechanics of the lesion. 
 
 The signs upon which Dr. Foulerton based his diagnosis of epi- 
 phj^sial separation were as follows : genuine crepitus ; some slight 
 displacement of the upper end of the shaft, which displacement, 
 having been once reduced, could without the exercise of any force 
 be reproduced ; non-participation of the head of the radius in move- 
 ment communicated to the lower end. Beyond this, when the 
 fracture apparatus was removed, there was an irregular thickening 
 around the upper end of the bone, which was believed to be callus. 
 
 Dr. Foulerton says that the age of the patient (nineteen months) 
 and the nature of the accident (forcible traction on the arm) were 
 both, it is true, against the prohahility of the lesion having been a 
 fracture, but after careful examination no doubt was entertained 
 as to the accuracy of the diagnosis. 
 
 AGE. — Of the two recent pathological specimens, in only one is the 
 age stated — namely, at thirteen years. 
 
 Of the five simple cases the age is given in four — at twelve, eight, 
 six years, and nineteen months of age. 
 
 PATHOLOGICAL ANATOMY.— The only specimen known to the 
 author is in the London Hospital Museum {London Hospital Museum 
 Catalogue, 1890, p. 96), No. 404a. It is a compound separation 
 caused by direct violence. The upper epiphysis of the radius is clearly 
 detached at the epiphysial line, and remains partly within the grasp 
 of the orbicular ligament, the diaphysis projecting somewhat behind 
 it. The diaphysis is otherwise not injured, though the orbicular 
 
SEPAEATION OF UPPER EPIPHYSIS OF RADIUS 473 
 
 ligament is torn away. The synovial membrane of the joint still 
 retains its connection to the head of the radius. The epiphysial disc 
 remains with the epiphysis. The outer side of the elbow-joint has 
 evidently borne the whole of the violence, as the capitellum is 
 partially divided by a line of fracture passing downwards and inwards, 
 in addition to the small epiphysis of the outer epicondyle and the 
 adjaining part of the capitellum being torn off. The periosteum is 
 only slightly detached at the anterior margin of the end of the shaft. 
 
 The patient was a lad aged thirteen years, who fell between a 
 train and the platform, tearing off the skin of the forearm and lacera- 
 ting the muscles. Primary amputation above the elbow-joint was 
 performed, and he rapidly recovered. The case is reported by 
 Mr. C. Mansell-Moullin in the Pathological Transactions for 1888, 
 p. 242, and the specimen is figured by this surgeon (Mansell-Moullin, 
 Surgery, 1891, fig. 118, p. 444). 
 
 Mr. Hutchinson junior, however, says {British Medical Jour.ial, 
 March 31, 1894, p. 669) there was another case at the London 
 Hospital under his father (also from severe crushing force). 
 
 In both these instances the epiphysis lay loose in the elbow- 
 joint. 
 
 SYMPTOMS. Impaired movements of elbow-joint. — When there is 
 no displacement, all the movements of the joint will be found to 
 be free. 
 
 When displacement has occurred, pronation and supination will 
 be imperfectly performed, and complete extension and flexion not 
 permitted. 
 
 Poucel ('Considerations sur les Disjonctions epiphysaires a propos 
 d'une Observation de Disjonction traumatique de I'Epiphyse radiale 
 superieure ; ' Marseille Med. 1869, vi. 847-858) has published a case 
 of this injury, while Portal, in his Anatomie medicale, 1803, t. i. 
 p. 424, alludes to separation of the upper epiphysis of the radius as of 
 frequent occurrence and often mistaken for fracture. This author 
 {Anat. Med. t. ii. p. 31) has also recorded an example. 
 
 Yet Hamilton {Fractures and Dislocations, 1884, 7th edit. p. 355) 
 says that he had not met with any recorded examples of separation 
 of the upper epiphysis of the radius. 
 
 Separation without Displacement. — There need be no de- 
 formity in any case if there has been no displacement. 
 
 The following example came under the author's treatment at 
 the Miller Hospital in 1889. 
 
 Charles H., eight years old, had fallen down on his back with 
 his right arm twisted behind. On lifting the child up, his mother 
 heard a distinct crackle at the elbow. 
 
 On examination a few days after the injury, there was much 
 effusion into the right elbow-joint, which considerably limited 
 extension and to some extent flexion. The epicondyles were in 
 normal relation with the olecranon, but on grasping with the finger 
 
474 EPIPHYSES OF UPPEK EXTEEMITY 
 
 and thumb the small head of the radius, which was in the normal 
 position, and rotating the radius with the opposite hand, the head 
 did not rotate with the diaphysis. This movement was accompanied 
 by the usual muffled crepitus. On further examination, some un- 
 natural mobility was detected between the epiphysis and shaft. 
 There was no displacement of the bone. The patient could only 
 slightly pronate the forearm, but not supinate in the slightest degree 
 on account of the great pain which it caused him. Great pain was 
 produced by pressure over the situation of the epiphysial line. 
 
 Displacement op the Diaphysis foewaeds. — This is the 
 most likely form of displacement to occur : a gap will then be felt 
 below the head of the radius, which retains its noi'vial position with 
 the external epicondyle and capitellum. The shaft of the radius will 
 be directed somewhat forwards, and will be felt to be somewhat 
 closer than natural to that of the ulna. 
 
 When the diaphysis has completely cleared the epiphysis, the 
 latter will be loose in the joint, being held only by the thin periosteum 
 and synovial membrane covering the head and neck of the bone. 
 
 Unnatural mobility will be felt, but in the lateral direction, on 
 seizing the small epiphysial head of the radius and grasping the 
 shaft of the radius, also on rotation the former will be found to 
 be motionless. 
 
 Pressure may likewise displace the separated head. 
 
 Muffled crepitus may be felt on bringing the diaphysis into its 
 normal position with the head. 
 
 Pain on extreme extension and flexion, and on pressure over the 
 situation of the head, will be found to be a constant sign. 
 
 Effusion into the elbow-joint will ensue with great rapidity, on 
 account of the intra-articular character of the lesion. 
 
 PROGNOSIS.— If properly treated, all movements of the limb will 
 be entirely recovered. 
 
 Mr. A. W. Mayo-Eobson, however, gives {Lancet, March 21, 1885, 
 p. 518) the following account of a boy, aged six, who was admitted 
 into the Leeds General Infirmary with loss of supination, although 
 the other movements of the forearm were perfect and the diaphysis 
 greatly displaced. The parents stated that they had noticed im- 
 paired movement in the arm during the last four months, but on 
 closer inquiry it was elicited that he had been run over by a cart 
 four years before, and had been treated at the time for a bruise of 
 the arm. On examination he complained of no pain, could flex, 
 extend, and pronate the forearm completely, but could not supinate 
 more than to place the hand vertical with the floor. The ulna could 
 be traced along its whole length, and the olecranon bore a proper 
 relation to the condyles, which were normal. The head of the radius 
 was in position, but immediately below it was a hollow. The radius 
 could be traced obliquely across the front of the forearm, from below 
 upwards and inwards, ending in a hard bossy mass, apparently callus, 
 
SEPAEATION OF UPPEE EPIPHYSIS OF RADIUS 475 
 
 in front of and below the internal condyle of the humerus, where it 
 rotated in its new position. It was diagnosed from dislocation of 
 the head of the radius forwards by the detached head being felt in 
 its normal position, and by the ability to completely flex the forearm. 
 No treatment was recommended. 
 
 DIFFERENTIAL DIAGNOSIS.— Partial dislocation of the head cf 
 the radius in infants, or subluxation of the orbicular ligament. In- 
 complete dislocation has been recently brought forward by several 
 writers as a new form of injury, though Nelaton, Sir Astley Cooper, 
 Goyrand, Malgaigne, Hamilton, and others have described and dis- 
 cussed cases of this kind in children. 
 
 As long ago as 1837 M. G. Goyrand {Gazette Medicate de Paris, 
 Fevrier 1837, t. v. p. 115) treated of incomplete dislocation of the 
 upper end of the radius forwards, and its accompanying signs and 
 treatment. He moreover states that it is by no means a rare 
 accident from eighteen months to three years of age. 
 
 M. Pingaud has given {Diet. Encycl. des Sc. Med. 1^'® section, t. xxi. 
 1878, p. 575) a very exhaustive account of these injuries in children, 
 and figures the displacements which may occur to the head of the 
 radius from the slipping upwards of the orbicular ligament. 
 
 In this country Mr. Jonathan Hutchinson junior has again 
 drawn attention {Annals of Surgery, vol. ii. 1885, p. 91) to these 
 cases, which he calls ' elbow sprain ' or * pulled elbow,' in infants and 
 young children. They are caused by the child being dragged along 
 by the arm, lifted by the hand or wrist, and swung round by the 
 arm, or may be the result of a fall. The head of the radius slips 
 below from beneath the orbicular ligament, and is partially displaced 
 forwards. The ligament rests in the angle between the radius and 
 capitellum. 
 
 This injury, he says, in the majority of cases is diagnosed as separa- 
 tion of the upper epiphysis of the radius, or fracture of the radial neck, 
 on account of the snapping sound produced either on reduction or at 
 the time of the accident, but this error is hardly possible if sufficient 
 care be taken, as in this injury the head of the radius lies free, and 
 can be felt in its abnormal position. All movements are free except 
 complete extension and supination, and a distinct click is heard at 
 the time of injury and on reduction. The forearm is generally 
 pronated and semiflexed. The subluxation is easily reduced by 
 flexion and full pronation of the forearm, and is accompanied by a 
 sound which might easily be mistaken for the cartilaginous crepitus 
 of the epiphysis upon the shaft. 
 
 This injury, Mr. Hutchinson thinks, never happens after five years 
 of age, because the head of the radius then becomes bony, and is no 
 longer elastic. 
 
 Van Arsdale reports {Annals of Surgery, 1889, vol. ix. p. 401) 
 one hundred cases of subluxation of the head of the radius in 
 children, and draws the following conclusions : 
 
476 EPIPHYSES OF UPPEK EXTREMITY 
 
 (1) The injury frequently occurring in cliilJliood and called sub- 
 luxation of the head, or displacement by elongation of the radius, is 
 a well-defined typical injury, with well marked constant symptoms, 
 and is due to the same anatomical lesion in every case. 
 
 (2) The frequency is over one per cent, of surgical injuries in 
 children. 
 
 (3) It occurs in children under nine years of age. 
 
 (4) The most frequent exciting cause is sudden traction by the 
 hand or forearm, or more rarely a fall. 
 
 (5) The principal symptoms of the injury are absence of 
 appreciable deformity ; loss of function of the arm ; localised pain 
 over the head of the radius on pressure ; pronation of the hand ; 
 slight flexion of the elbow ; crepitation or snapping upon forced 
 supination, with restoration of function. 
 
 (6) Treatment with a splint is advisable, in order to prevent 
 recurrence. 
 
 (7) The anatomical lesion causing the injurj' is not yet satis- 
 factorily established. 
 
 In these cases this false crepitus may also be obtained by 
 alternately pronating and supinating the forearm. The diagnosis 
 will be made clear by the fact that the head of the radius will rotate 
 with the shaft in cases of subluxation. 
 
 Again, in subluxation, after the reduction of the displacement, 
 pain will be sooner removed and the joint become more quickly 
 movable than in epiphysial separation, and in a short space of time 
 little or no trace of the injury will be detected after subluxation. 
 
 Fracture of neck of radius may closely simulate epiphysial separa- 
 tion, especially if it be broken at its upper part. 
 
 The skiagram here reproduced of a fracture of the neck of the 
 radius, complicated with a dislocation of the ulna backwards, was 
 kindly placed at the author's disposal by Mr. Thomas Moore, of Black- 
 heath, under whose care the patient was in June 1896. There was 
 great displacement and rotation of the upper fragment of the radius. 
 Another skiagram was taken by Mr. Moore after reduction of the 
 dislocated ulna, which showed most clearly this bone in position, 
 but the displacement of the head of the radius was then even more 
 marked. 
 
 TREATMENT. — Eeplace the diaphysis and place the forearm in 
 the flexed position by means of an anterior angular splint, to pre- 
 vent the biceps displacing the diaphysis forwards. Antiphlogistic 
 measures should be taken to subdue the inflammation of the elbow- 
 joint. 
 
 Bardenheuer and Dr. L. C. Lane recommend extension for 
 fractures of the upper end of the radius. 
 
 Passive motiou at the end of the fourteenth day should be very 
 cautiously commenced, on account of the contracted condition of 
 the biceps. 
 
FRACTURE OF NECK OF RADIUS, AVITH DISLOCATION OF THE ELROAV BACKWARDS. 
 
 The upper fragment of the radius, consisting of the epiphysis head and of the uppei' part of the neck of the bone, 
 
 is greatly displaced and rotated, 
 ilr. Thomas Moore's case. Taken by ilr. Thomas Moork. 
 
T.r^ roUmsi 
 
 THE SAME CASE AFTER REDUOTION OP THE DISLOCATION OP ELBOW. 
 Takea by Mr. Thomas Moore. 
 
SEPAEATION OF UPPEK EPIPHYSIS OF EADIUS 477 
 
 Guedeney records {Du traitement des fractures dii coude chez 
 Venfant, Lyon, 1893) the two following cases which were diagnosed 
 by M. Vincent as separation of the upper epiphysis of the radius, 
 and treated by fixation in the extended position. 
 
 I. A boy (J. G.), aged (?). Separation of the upper epi- 
 physis of the right radius. The part was painful and swollen, and 
 crepitus was present. Pronation and supination could not be 
 effected, while the other movements of the joint were free. The 
 ulna and humerus were intact. The radius was replaced in its 
 normal position, and the limb fixed in the completely extended and 
 supine position by means of a plaster splint. Four months later 
 tuberculous disease developed, and flexion in a silicate splint was 
 employed for two months after. At the end of thirteen months the 
 movements were still imperfect, and a fistulous track remained with 
 enlargement of the end of the bone. 
 
 II. Epiphysial fracture of the upper end of the radius, with dis- 
 location of the elbow. A boy (L. 0.), aged twelve years, fell from 
 a crossbar on to the left arm, which was bent back. This was 
 immediately followed by pain and loss of power. The child was 
 admitted into hospital at the end of sixteen days, when extension 
 was found to be free, while flexion was limited to a right angle. 
 Pronation and supination could not be effected without pain, being 
 prevented by muscular contraction. There was considerable increase 
 in thickness at the level of the radial head — two centimetres thick 
 on the right and three and a half on the left. This increased bulk 
 was due to the diaphysial fragment causing a projection of the 
 orbicular ligament, in which the radial cup still remained engaged. 
 The swollen and puffy condition of the part was considerable, 
 and interfered with examination. Reduction was effected under 
 chloroform, and the limb put up in the complete extended and 
 supine position. The ulterior results were unknown. 
 
 SEPARATION OF THE BICIPITAL EPIPHYSIS OP THE 
 
 RADIUS 
 
 About the sixteenth year a small epiphysial plate is developed, 
 which rapidly joins with the tuberosity. 
 
 It might be supposed that violent muscular action of the biceps 
 would be sufficient to cause separation of this epiphysis, but as yet 
 no case has been observed. 
 
 In the adult the biceps tendon has been torn from the radius and 
 successfully wired to the periosteum on either side of the tuberosity 
 (Johnson, New Yorh Medical Journal, August 21, 1897, p. 261), 
 
478 EPIPHYSES OF UPPEE EXTEEMITY 
 
 CHAPTEE XII 
 
 SEPAHATION OF THE LOWER EPIPHYSIS OP 
 THE RADIUS 
 
 ANATOMY. — Towards the end of the second year the osseous 
 nucleus of the lower epiphysis of the radius appears above the 
 scaphoid facet. Sometimes two granules appear, which rapidly 
 blend together and form a plate projecting towards the borders of 
 the epiphysis. This becomes much thicker towards the outer part, 
 where it extends from about the sixth year to form the styloid 
 process. By the tenth year the styloid process and lower epiphysis 
 are almost entirely invaded by the osseous centre. Between the 
 fourteenth and fifteenth years the external, middle, and internal 
 thecal tubercles begin to project and extend upwards from the 
 posterior aspect of the epiphysis. 
 
 This epiphysis is not united to the shaft till the nineteenth or 
 twentieth year. Union takes place first towards the middle of the 
 epiphysis — its thinnest part. 
 
 M. Voillemier has quoted instances in which the conjugal carti- 
 lage still persisted in subjects aged twenty-four and twenty-five years. 
 
 The fully formed epiphysis is of an irregular quadrilateral shape, 
 concave at the articular surface, which is formed into an outer tri- 
 angular facet for the scaphoid and an inner quadrate facet for the semi- 
 lunar bone. Its upper mamillated surface is also slightly concave, but 
 more flattened than most of the diaphysial surfaces of the epiphyses, 
 and accurately fits the quadrilateral convex end of the diaphysis. 
 
 Upwards it is limited in front by the anterior epiphysiary crest, 
 and between this crest and the border of the scaphoid facet is a 
 rough area — of a triangular shape for the attachment of the anterior 
 ligament of the wrist-joint, and somewhat bevelled off to permit of 
 flexion of the scaphoid. 
 
 On the inner side it forms the whole of the sigmoid cavity or 
 sinus lunatus, which is transversely concave, coated with cartilage 
 for the convex articular head of the ulna. 
 
 The lower margin of this is separated from the inferior articular 
 surface by a thin edge, to which is attached the thin base of the 
 triangular fibro-cartilage of the wrist-joint. 
 
 The anterior epiphysiary crest ends at the outer side towards the 
 
SEPAEATION OF LOWEE EPIPHYSIS OF KADIUS 479 
 
 base of the styloid process in a sharp tubercle, which is the lower 
 end of the pronator crest on the diaphysis, and which limits the 
 lower and outer part of the pronator quadratus. Posterior to this 
 is a shallow groove divided into two for the tendons of the extensor 
 ossis metacarpi pollicis and the extensor primi internodii pollicis. 
 
 Behind the groove is a ridge, the external thecal tubercle, passing 
 downwards to the apex of the styloid process. Into the lower end of 
 the pronator crest, and the surface of bone running backwards to 
 this ridge, the supinator longus is inserted. Posterior to the external 
 thecal tubercle is another broad shallow groove, divided into two by 
 a slight ridge, for the transmission of the tendons of the extensor 
 carpi radialis longior and extensor carpi radialis brevior. Still more 
 internal to this on the posterior 
 surface of the epiphysis is the 
 prominent middle thecal tubercle, 
 on the inner side of which is a 
 deep oblique narrow groove for 
 the extensor secundi internodii 
 pollicis tendon. This prominent 
 ridge, therefore, forms a good 
 guide to the epiphysial line on 
 this aspect of the bone, the line 
 running across the bone an eighth 
 of an inch below the posterior 
 end of the ridge. The inner ridge 
 of this groove is the less promi- 
 nent internal thecal tubercle. 
 Between this and the posterior 
 extremity of the sigmoid surface 
 is the wide groove for the tendons 
 of the extensor indicis and the 
 extensor communis digitorum. 
 
 The epiphysis, as seen at the 
 seventeenth to eighteenth year of 
 age, is 1^ inch (3 centimetres 
 2 millimetres) in width from side 
 
 to side, and rather more than | inch (2 centimetres) in width antero- 
 posteriorly ; -i% inch in thickness about its centre. Its anterior lip 
 is rather less than ^ inch (6 millimetres) in depth about the middle, 
 and the posterior lip more than | inch (10 millimetres) at the same 
 point ; in the centre it is 5 millimetres thick vertically. On the 
 outer side from the epiphysial line of cartilage to the apex of the 
 styloid process it measures rather more than | inch (2 centimetres). 
 At its ulnar border, the sigmoid cavity, it is nearly ^ inch (G milli- 
 metres) thick vertically. 
 
 At fourteen years of age the vertical measurements are from the 
 epiphysial cartilage, outer side, to apex of styloid process, 7 milli- 
 
 FlG. 138. — SECTION OF R4JDIUS AND ULNA AT 
 THE EIGHTEENTH YEAR. RELATION OF THE 
 EPIPHYSES AND EPIPHYSIAL LINES. STRUC- 
 TURE OF THE ENDS OF THE BONES. (aCTDAL 
 
 size) 
 
480 
 
 EPIPHYSES OF UPPEK EXTEEMITY 
 
 metres; ulnar border, 4^ millimetres ; anterior lip, 6 millimetres ; pos- 
 terior lip, 9 millimetres, each about the middle. 
 
 To the apex of the styloid process is attached the external lateral 
 ligament of the wrist-joint, and to the posterior border of the epi- 
 physis the posterior ligament of the wrist. 
 
 De Paoli gives the following table of measurements of the lower 
 epiphysis of the radius and ulna at different ages : 
 
 Age 
 
 
 Radiu 
 
 3 
 
 
 TJlxa 
 
 
 Height 
 
 
 Breadth 
 
 Height 
 
 Breadtli 
 
 styloid 
 Process 
 
 About the 
 middle 
 
 Internal 
 edge 
 
 Before birth 
 
 5 mm. 
 
 4 mm. 
 
 3 mm. 
 
 10 
 
 6-5 
 
 6 
 
 Twenty montha . 
 
 8 „ 
 
 5 „ 
 
 4 „ 
 
 12 
 
 7 ■ 
 
 11 
 
 Two years . 
 
 . 4 „ 
 
 4 „ 
 
 3-5 „ 
 
 12 
 
 6 
 
 — 
 
 Four years . 
 
 8 „ 
 12 „ 
 
 5 
 
 6 „ 
 
 3 
 3 
 
 21 
 22 
 
 5 
 6 
 
 13 
 14 
 
 Five years . 
 
 11 „ 
 
 5 „ 
 
 3 
 
 24 
 
 5 
 
 14 
 
 Six 3'ears 
 
 12 „ 
 
 5-5 „ 
 
 4 
 
 22 
 
 5 
 
 12 
 
 Seven years 
 
 7 „ 
 
 3-5 „ 
 
 4 
 
 16 
 
 5 
 
 — 
 
 Nine years . 
 
 13 „ 
 
 6 
 
 5 
 
 — 
 
 5 
 
 — 
 
 11 „ 
 
 5 
 
 4 
 
 
 5 
 
 — 
 
 
 14 „ 
 
 6 „ 
 
 4 „ 
 
 23 
 
 6 
 
 14 
 
 Ten years . . 
 
 14 „ 
 
 5 „ 
 
 4 „ 
 
 21 
 
 8 
 
 13 
 
 Foiirteen years . 
 
 15 „ 
 
 7 
 
 6 
 
 26 
 
 8 
 
 — 
 
 Fifteen years 
 
 16 „ 
 
 7 „ . 
 
 
 
 29 
 
 8 
 
 — 
 
 Sixteen j-ears 
 
 15 „ 
 
 5 „ 
 
 4 
 
 29 
 
 8 
 
 16 
 
 Seventeen years . 
 
 17 ,, 
 
 7 „ 
 
 5 „ 
 
 27 
 
 8 
 
 12 
 
 Nineteen years . 
 
 16 „ 
 
 8 „ 
 
 5 
 
 28 
 
 7 
 
 15 
 
 The synovial membrane of the wrist- joint does not come into 
 relationship with the epiphysial line of the radius, nor with that of 
 the ulna, which forms no part of the articulation. 
 
 Erom the margin of the articular surface of the epiphj'sis springs 
 the synovial membrane of the wrist-joint, but it does not pass 
 upwards either on the anterior or posterior aspects. 
 
 Although the synovial membrane of the inferior radio-ulnar 
 articulation forms a loose pocket— the membrana succiformis — 
 upwards between the radius and ulna above their epiphj^sial 
 boundaries, it is but loosely connected with the diaphyses. Below, it 
 is firmly connected with the .epiphyses. 
 
 Laceration of the synovial pouch is possible, but not abso- 
 lutely inevitable, in epiphysial separations. 
 
SEPAEATION OF LOWEE EPIPHYSIS OF EADIUS 481 
 
 ETIOLOG-Y. Indirect violence. — Separation of this epiphysis is 
 nearly always produced by indirect violence, such s^s falls froin a height 
 on to the outstretched hand. 
 
 In analysing the cases the author has collected, v^e find that of 
 the thirteen museum sj^ecimens the cause of the injury is given in 
 nine. In all of these the lesion 
 was produced in precisely the same 
 manner — viz. a fall from a height, 
 in some instances a distance of 
 fifty-five, thirty, and twelve feet 
 on to the ground, in others a fall 
 from a second or third story win- 
 dow or a fall from a tree. In two 
 cases it is noted that the fall was 
 probably upon the outstretched 
 hand. 
 
 Again, we find the cause given 
 in eight out of ten cases of com- 
 pound separation with the same 
 uniformity — viz. a fall from a 
 height in seven cases, as follows : 
 
 Fall from a tree, twenty-six 
 feet ; off a parapet, fifteen feet ; 
 fall from crags ; from third story 
 (one) and from fourth story (one) ; 
 and down a flight of stairs. In one 
 instance only entanglement of the 
 arm in the band of a machine. 
 
 In nineteen cases out of thirty-five inspected anatomically De 
 Paoli found the same cause — a fall from a great height, from second 
 and third floors, in one a distance of forty feet. In two cases only 
 it was a simple fall to the ground while walking, in one case a fall 
 from a horse. 
 
 Colignon notes that one half of his cases were due to a fall from 
 a height upon the hand. 
 
 In eight out of nine cases of simple separation verified by an 
 autopsy, and in w^hich the cause is recorded, all were due to the 
 same accident — viz. a fall from a considerable height, thirty to fortj^ 
 feet, from a scaffold or tree (two instances), or from a second story, 
 third story, &c. 
 
 In fourteen out of sixteen simple cases the cause is noted, and, 
 with one exception, all were from a fall upon the outstretched hand. 
 In some the fall was from a height, as from a trapeze, balcony, tree, 
 or out of a warehouse window, but in many of these instances the 
 fall was a shorter distance. Thus in two cases the youths fell from 
 a cart on to some grass, and in a few cases there had been only a 
 simple fall, as in slipping whilst walking. 
 
 II 
 
 Fig. 139. — frontal section through the 
 
 BOXES of the wrist AND HAND IN A 
 youth AGED EIGHTEEN TEARS. (-| SIZE.) 
 RELATION OF THE SYNOVIAL JIEMBKANES 
 TO THE EPIPHYSIAL JUNCTIONS 
 
482 EPIPHYSES OF UPPER EXTREMITY 
 
 In these falls from a height the whole weight of the body is 
 received upon the palmar aspect of the outstretched and pronated 
 hand, and by the direction of the violence through the ball of the 
 thumb nearly the whole of it is sustained by the lower end of the 
 radius. The muscles assist very materially by their contraction in 
 giving fixation to the bones, and allow the greater portion of the 
 impulse of the violence to be received on the posterior border of the 
 epiphysis, which is forced backwards. The epiphysis is thus dis- 
 placed in a backward direction. The numerous strong anterior 
 carpal ligaments and flexor tendons on the front, binding" the 
 epiphysis to carpus, are put violentlj^ on the stretch. The epiphysis 
 is consequently VTrenched off and tilted backwards, so that the aspect 
 of its carpal surface, and with it the carpus and hand, is altered in a 
 greater or less degree, and a gap is left between the fragments in front. 
 M. J. Cloquet {loc. cit. infra) dissected a separation of the lower 
 epiphysis of the radius in a child of twelve years, who had fallen 
 from the top of a tree. 
 
 M. Rognetta gives {loc. cit. supra) a similar case, occurring in a 
 subject fifteen years old. 
 
 Cruveilhier, in his experiments on the dead body, almost always 
 produced separation of this epiphysis by acting upon the carpus, 
 either from the weight of the whole body or by a sharp blow from a 
 hammer. In this way sometimes the lower epiphysis of the ulna was 
 detached at the same time, but more frequently the epiphysis of the 
 radius was separated alone. 
 
 Packard, writing in 1890, says that ' when the radius is broken 
 near its lower extremity, it is almost invariably by a fall on the 
 hand. These fractures are generally said to be infrequent in early 
 life, but I recently had, at the Pennsylvania Hospital, within forty- 
 eight hours four cases of Colles's fracture in patients between five and 
 twelve years of age. All these were from simple ordinar}^ falls on 
 the hand ; there was no ice (it was in October) or any other circum- 
 stance to account for the coincidence. I have repeatedly seen this 
 injury on both sides, from falls from greater or less heights. In one 
 case, many years ago, a boy, about ten years old, fell five stories, 
 with no other damage ; he made a good recovery. Sometimes, no 
 doubt, the portion separated is the epiphysis, but I think this is 
 very rare.' 
 
 This lesion, like Colles's fracture, may be brought about, as 
 mentioned by Malgaigne, by backward over-extension of the hand at 
 the wrist-joint ; the carpus being thrust violently backwards puts the 
 anterior ligaments of the wrist-joint on the stretch, and these, by 
 their forcible traction on the epiphysis, produce separation by ' cross 
 strain ' {arrachement) . 
 
 This was probably the cause of the separation in Ozenne's case 
 mentioned below, and it has evidently been the mode of production 
 in other instances. 
 
SEPARATION OF LOWER EPIPHYSIS OF RADIUS 488 
 
 Experimentally, it is very easy to produce this separation by 
 forcible extension of the hand, also by torsion of the hand. 
 
 Bahr concludes, however, from his recent experiments {Central- 
 hlattfilr Ghir. 1894, No. 36) that this, as well as many other typical 
 forms of fracture of the radius, may be explained by the impact of 
 the upper carpal row upon the lower end of the radius. 
 
 Sir A. Cooper, in 1833, made experiments on the dead body, 
 carrying the hand into extreme extension ; the radius gave way, in 
 one instance, at the epiphysis, in the other just above that point. 
 
 Rognetta produced the lesion by violent traction, and Anger by 
 torsion or rotation of the hand. 
 
 M. L. Voillemier was the first to clearly point out {Glinique 
 Chirurgicale, 1861, p. 33) the occurrence of separation of the 
 lower epiphysis of the radius by cross strain {par wrrachement) 
 during over-extension, as in falls upon the hand. He believed that 
 these separations only took place in this manner. Previous to 
 M. Anger's similar experiments on the dead subject, M. Voillemier 
 produced separation by forcible flexion and extension of the wrist, 
 not only in young subjects, but also on a man, aged twenty-four, 
 with a powerful physique. 
 
 This mode of production is supported by records of many 
 clinical cases. 
 
 In nine out of seventeen cases, chiefly of incomplete separation, 
 De Paoli noted that the cause of the injury was a simple fall, met 
 with in running or walking, but that in seven others the violence 
 was greater — ^viz. a fall from a height. In sixteen cases the cause 
 was indirect, and acted upon the hand ; in one only — a fall from a 
 height of four metres on to the rung of a ladder — the force seems to 
 have acted directly on the epiphysis, which was displaced forw^ards. 
 
 Bruns, in speaking of the lesser degree of violence sufficient to 
 detach the epiphysis in simpler cases, alludes to the case of a boy, 
 aged (?), in whom he recognised an undoubted separation of the 
 lower end of the radius after a fall from a low ladder. 
 
 The following case, under the care of Mr. Howse at Guy's 
 Hospital in 1888, was probably due to indirect violence or separation 
 by ' cross strain.' 
 
 The boy (Michael G.), aged fifteen years, whilst swinging on a 
 chain, fell off on to the ground, his head striking the ground, and 
 his left arm doubling up under and behind him. Separation of the 
 lower epiphysis of the left radius was found with the usual 
 deformity. A Carr's splint was applied after reduction, and he 
 was able to leave the hospital after seventeen days with the wrist 
 and forearm in good position. 
 
 Packard, in an excellent article on ' Fractures of the Lower End 
 of the Radius ' {American Journal of Medical Science, Hays, n.s., 
 Philadelphia, 1879, p. 123), states that the great majority of these 
 fractures are more or less transverse and are produced by leverage. 
 
 I I '2 
 
484 EPIPHYSES OF UPPEE EXTKEMITY 
 
 Coulon, in his work on Fractures in Children, while discussing 
 the rarity of fractures of the lower end of the radius in children as 
 compared with the adult, says that a fall upon the palm of the hand in 
 a child usually produces a fracture of the forearm, and not, as in 
 the adult, a fracture of the lower end of the radius. However, he 
 makes an important statement that when such a fracture does 
 occur, it is almost always in children thirteen or fourteen years of 
 age and but rarely before the tenth year. 
 
 He quotes three cases in children, twelve, twelve, and thirteen 
 years respectively, with the characteristic deformity. 
 
 In one of the cases recorded by Rognetta this lesion was 
 produced in a child, aged five years, by its being dragged violently 
 about by the hand. In this case, however, there was apparently 
 very little displacement of the fragments. 
 
 M. B. Anger mentions the case of a separation of the lower end 
 of the radius in a young man whose hand had been seized in a 
 machine. 
 
 In many instances it is probable that the mechanism of the 
 injury is one composed of both factors — viz. a combination of cross 
 strain or hyper-extension, and of the direct thrust of the violence 
 displacing the epiphysis backwards, the bone yielding at its weakest 
 point. 
 
 Separation of this epiphysis is very unlikely to be the result of 
 muscular action alone, although it is a very important factor in 
 maintaining the deformity or displacing the epiphysis after it has 
 been separated at the time of the accident. 
 
 After reduction of the displaced epiphysis the muscles have 
 but little tendency to reproduce the deformity. 
 
 Callender has recorded a case of fracture of both radii just above 
 the epiphysis in a boy, aged fourteen years, which was pro- 
 duced by violent muscular efforts excited by a strong galvanic 
 current. 
 
 Direct violence from a blow or passage of a wheel over the wrist. 
 
 The epiphysis in one of the London Hospital specimens was 
 probably torn off by a toothed machine. 
 
 J. Hutchinson junior relates (British Medical Journal, March 31, 
 1894, p. 670) the curious case of a lad who was incautiously lying 
 on the ground resting his head upon his hand underneath a lift. 
 He happened to raise his head, and at that moment the lift descended, 
 striking the front of his hand and forcing backwards his radial 
 epiphysis. 
 
 Sepaeation with Displacement foewards. — Professor J. B. 
 Roberts {A Clinical, Pathological, and Experimental Study of 
 Fracture of the Lower End of the Badius, with Displacement of the 
 Carpal Fragment toioards the Flexor or Anterior Surface of the 
 Wrist, Philadelphia, 1897, p. 42) has experimentally, in one instance, 
 produced epiphysial separation with anterior displacement by extreme 
 
SEPAEATION OF LOWEE EPIPHYSIS OF EADIUS 485 
 
 flexion of the wrist. He did this on the amputated forearm of a 
 boy of fourteen years. 
 
 AGE. — In analysing the cases in which the age is recorded in 
 the forty pathological specime7is, we must exclude twelve in which 
 it is not stated, twp in young men, and one in a lad below 20 years. 
 The age is definitely given in twenty-eight. In four the separation 
 occurred at 18 years of age, four at 16, four at 15, five at 14, one 
 at 13^, one at 13, four at 12, one at 9, one at 8, one at 7, and one 
 at 3 years of age, and one doubtful case of detachment of only a 
 small part of the epiphysis at 1 year. Of these, the larger number, 
 twenty-three, occurred between 18 and 12 years of age. 
 
 I7i six pathological specimens, showing dwarfing, &c., in three the 
 age is not given, in one it is said to have occurred in boyhood, and in 
 one case some years prior to the twentieth ; in one case at 5 years. 
 
 Taking the fourteen cases of compound separation, the age is 
 not stated in three, but is noted in eleven, one at 18, one at 17, one 
 at 16, one at 15, three at 14, two at 12, one at 8, and one at 6 ; 
 nine of these, therefore, were between 12 and 18 years of age. 
 
 Putting all the cases together which loere verified by direct 
 examination, sixty in number, we find that the age is stated in 
 forty ; the remainder are too inaccurately stated to be of any use. 
 Five were at 18, one at 17, five at 16, five at 15, eight at 14, one at 13|, 
 one at 13, six at 12, one at 9, two at 8, one at 7, one at 6, one at 
 5 years, one at 3, and one at 1 year. 
 
 Of these forty, by far the greater number, thirty-two, were from 
 18 to 12 years of age ; out of these thirty-two, twenty-six were 
 between ]6 and 12 years of age. 
 
 The average age of the cases must be just about the fourteenth 
 year. 
 
 In De Paoli's figures, the age of the patients was in one case 7 
 years, in three 13, in two 15, in five 18, and in one 20 ; in ten it was 
 unknown. 
 
 Among the clinical cases, of which there are fifty-two, the age 
 is omitted in nine ; two were said to have taken place in infancy, 
 another in a child, one in a young man, and one in a youth, and in 
 the other four it is not stated at all. Of the remaining forty-three cases 
 in which the age is recorded, one was at 20, one at 19, one at 18^, one 
 at 18, three at 17, three at 16, one at 15^, three at 15, four at 14, 
 two at 13, two at 12, three at 11, six at 10, one between 10 and 12, 
 two at 9, four at 8, one between 7 and 8, one at 5, two at 4, and one 
 at 3 years of age. The greatest number, eighteen, were between 17 
 and 12 years of age. 
 
 Patting together the whole total, 112 cases of injury to the lower 
 epiphysis of the radius, the age is not given in twenty-nine. Of the 
 remaining total, eighty-three, no less than fifty-one occurred between 
 the ages of 12 and 18 years, and of these thirty-nine were between 
 14 and 18. 
 
486 EPIPHYSES OF UPPEE EXTEEMITY 
 
 From the notes which De PaoH took of seventeen cases under 
 his care, his experience was the same — viz. that they occur much 
 more frequently in the second decade of Hfe, and represent about 
 one half of the solutions of continuity of the bones which occur 
 between the ages of ten and twenty. 
 
 Manquat puts the most frequent period for this separation at ten 
 to fifteen years, but he adds that it is very often met with still later. 
 
 Among the fifty-four cases of separation of this epiphysis collected 
 by Jonathan Hutchinson junior, seventeen of which were under his 
 own observation, the age of the patient ranged from three years to 
 twenty, the majority being over ten years, and quite a number of 
 them seventeen or eighteen years. 
 
 D'Arcy Power {Surgical Diseases of Children, 1895, p. 182) thinks 
 that with the increase of bicycling it is becoming rather more fre- 
 quent in young adults. 
 
 SEX. — The sex is stated in nineteen of the thirty-two pathological 
 cases, eighteen being boys and one a girl ; but of the remaining cases, 
 from the occupation in which the patients were engaged at the 
 time of the accident, it is probable that the greater proportion were 
 males. But in the total sixty cases verified by anatomical examina- 
 tion, the sex is given in forty-five — viz. forty-one in males and four in 
 females. All the girls were at or below five years of age. 
 
 Out of sixteen clinical cases, thirteen are recorded as having 
 occurred in boys and two in girls, and in one the sex is not stated. 
 But in the total fifty-tioo simple cases, the sex is stated in forty-four. 
 Of these, thirty-eight occurred in males and only six in females. All 
 the girls were below fourteen years of age. 
 
 Out of the grand total of 112 cases, the sex is given in eighty- 
 nine instances as seventy-nine in males and ten in girls — the whole 
 of the latter being at or below fourteen years of age. 
 
 PATHOLOGICAL ANATOMY.— From the number of cases of 
 traumatic separation of the lower epiphysis of the radius in which a 
 direct anatomical examination was practicable, it would appear that 
 they are more numerous than those of any of the other epiphyses. 
 
 Yet Hamilton, writing in 1884, says : ' The examples of separa- 
 tion of the lower epiphysis of the radius have seldom been clearly 
 made out.' 
 
 Gurlt, in his treatise on fractures {Handbicch der Lehre von 
 den KnochenbrilcJien, Hamm. 1862), collected all the known cases of 
 epiphysial separation to the number of eighteen, four of which were 
 of the lower end of the radius ; and Bruns collected twenty- 
 five cases of separation of the lower end of the radius — verified 
 by direct inspection — out of a total of eighty cases of epiphysial 
 detachment. Since that time, 1882, the author has been able, as 
 we have just seen, to bring together a considerable number. 
 
 Malgaigne observed that it was perhaps the most common of all 
 epiphysial separations, but he has not given any description of its 
 
SEPAKATION OF LOWEE EPIPHYSIS OF KADIUS 487 
 
 pathological characters or of its symptoms, dismissing the subject by- 
 saying that the causes, symptoms, and treatment are identical with 
 those of fracture. He merely alluded to the cases described by 
 J. Cloquet, Eoux, and Johnston. Although Koux ascertained the 
 existence of the lesion in his case, he did not give the age of the child. 
 
 Dupuytren was the first to point- out, 1834 {Lego)is orales de 
 clinique chirurgicale, 1834, t. iv. p. 183), that in young subjects 
 epiphysial separation was more likely to occur than fracture of the 
 lower end of the radius. 
 
 Colignon, in his thesis, 1868, commences a chapter on traumatic 
 separation of the lower epiphysis of the radius by stating that all 
 authors agree in recognising this form of epiphysial separation as 
 the most common. 
 
 From De Paoli's statistics (Del distacco traumatico delle epifisi, 
 Torino, 1882, p. 105) of thirty-five cases directly examined, it appears 
 that the separation was complete in twenty-three cases, incomplete 
 in one only, and in four cases bilateral. 
 
 In eight cases small fragments of the cortical substance of the 
 diaphysis adhered to the epiphysis ; in twenty cases the separation 
 had occurred above the conjugal cartilage ; in three cases only, small 
 strips of this cartilage adhered to the lower surface of the diaphysis ; 
 and in one the epiphysial separation was accompanied by a fracture 
 of the epiphysis penetrating into the articulation. 
 
 J. Colignon was able to collect eighteen cases in his thesis 
 {loc. cit. supra). 
 
 Bardenheuer (Deittsche Chirurgie, Billroth und Liicke, 1888, 
 II. Theil, S. 238) agrees with Bruns in believing that it is the most 
 common epiphysial injury after that of the lower end of the femur. 
 
 Gurlt thought the frequency of separation of the lower radial 
 epiphysis in children beyond infancy was due to the fact that this 
 epiphysis does not diminish in size, relatively to the rest of the 
 growing bone, to such an extent as other bones — those, for instance, 
 at the lower end of the humerus. 
 
 The great frequency is rather due, in all probabiHty, to the 
 anatomical characteristics of the epiphysis, and to its situation in 
 the skeleton. Besides, this epiphysis is one of the last bones to 
 join on to its diaphysis. 
 
 Its superficial position also renders separation more easy of 
 detection than is the case with many of the other epiphyses. 
 
 Bardenheuer {loc. cit. supra) figures a specimen from a child one 
 year old, which he gives as an example of epiphysial separation, 
 although only portions of the epiphysial end were torn away. The 
 styloid process, and the whole of the marginal portion of the articular 
 surface of the radius, were separated, leaving the central portion 
 uninjured. There were also fractures of the cuneiform bone and of 
 the styloid process of the ulna. 
 
 In Bceckel's case the separation appears to have passed through 
 
488 EPIPHYSES OF UPPEE EXTEEMITY 
 
 the midst of the conjugal cartilage, for the protruding diaphysial 
 end of the radius was said to have been covered with a layer of 
 cartilage, which led the doctor who first saw the case to mistake 
 it for a dislocation, and reduce it. 
 
 Displacement backwards. — Displacement in the backward direction 
 has occurred in all the museum specimens. On carefully examining 
 the condition of the bones it is seen to vary much in its degree ; thus, 
 in one of the specimens in St. George's Hospital and in one at the 
 Royal College of Surgeons the epiphysis is almost completely displaced 
 off the diaphysis ; and Professor E. W. Smith found the epiphysis in 
 one of his cases dis^Dlaced directly backwards so far as to have nearly 
 cleared the extremity of the upper fragment, and in another of his 
 cases it was carried backwards for three-eighths of an inch. In the 
 Guy's Hospital specimen, and in that of Professor Annandale, it was 
 more than halfway off the diaphysis, and in one of the St. Bar- 
 tholomew's Hospital specimens two-thirds of the way. In the 
 specimen in King's College Hospital, and in one of those in St. 
 George's Hospital, there is only very slight displaceiXLent backwards. 
 In Mr. Shattock's specimen the epiphysis is described as being dis- 
 placed backwards and forming an obtuse angle with the shaft. 
 
 Displacement backwards, without fracture of the diaphysis. — Several 
 specimens in the London museums show the occurrence of pure 
 separations through the epiphysial junction. 
 
 The conjugal cartilage in nearly every instance has remained 
 with the epiphysis, but in some rare examples it is probable that the 
 separation has taken place through the cartilage itself. 
 
 In Eichet's case the end of the radius, after removal, was found 
 to be covered with several thin lamellas of the epiphysial cartilage, 
 so that the separation was thought to have occurred through the 
 epiphysial layer. The same condition is mentioned by M. Manquat 
 in Pean's case. In one of the London Hospital museum specimens 
 two small patches of the epiphysial cartilage remain on the extremity 
 of the shaft, and in the compound diastasis mentioned by Gripat the 
 diaphysial end presented some small particles of cartilage. 
 
 In the museum of King's College Hospital is a specimen, 
 No. 644, from a child, aged twelve, presented by Professor Partridge. 
 The lower radial epiphysis is separated exactly at the epiphysial 
 line, and displaced slightly towards the dorsal aspect of the shaft, so 
 that the anterior margin of the lower end of the latter projects but 
 little. The periosteum is torn upwards from the front of the shaft 
 for three-quarters of an inch. The styloid process of the ulna and 
 triangular fibro-cartilage are uninjured. Death resulted from fracture 
 of the skull. 
 
 M. Jules Cloquet ascertained by dissection {Diction, de Medecine, 
 vol. ix. 1824, p. 448) the existence of a complete separation in a 
 boy aged twelve years. Death occurred from fracture of the skull 
 three days after a fall from a tree. The epiphysis of the right 
 
SEPAEATION OF LOWEE EPIPHYSIS OF EADIUS 489 
 
 radius was completely separated, and a quantity of blood extra- 
 vasated into the deeper parts of the palmar region beneath the 
 flexor tendons of the fingers. Dupuytren quotes the case in his 
 Legons orales, 1834, t. iv. p. 183. 
 
 Eognetta quotes M. Flaubert (of Eouen) as having seen a 
 similar case which had been treated as a simple contusion of the 
 wrist-joint. The specimen was in the Anatomical Museum of the 
 Hotel-Dieu in Paris, and is also quoted by M. Malgaigne as having 
 been treated for a simple dislocation of the wrist. 
 
 B. Anger figures {Traite ico^iograpliiq^ue des 7naladies chirurgi- 
 cales, 1865, p. 197) the only specimen of separation of the lower 
 end of the radius which he had been able to observe anato- 
 mically. It was taken from 
 a youth, a printer, whose 
 hand had been caught in 
 a machine. The lower epi- 
 physis of the radius was 
 separated, and from the 
 backward projection of the 
 lower end of the bone the 
 deformity in every respect 
 was similar to that of frac- 
 ture of the lower end of the 
 radius. From the figure 
 it appears that the styloid 
 process of the ulna was 
 uninjured, that the perios- 
 teum in front is torn across 
 at the level of the lower 
 end of the diaphysis, and 
 that scarcely any displace- 
 ment had occurred. 
 
 Ihe specimen m Gruy s pj^ 140.— puke separation of lower epiphysis 
 Hospital, described below, 0^ eadius with slight displacement backwards 
 
 is also an example of sepa- ^' ^^7^ok\ process of radius ; b, head of ulna ; 
 . - ^ c, styloid process of ulna; 1, pronator qua- 
 
 ration without fracture of dratus ; 2, interosseous ligament. (Anger) 
 
 the diaphysis. 
 
 Athol A. Johnson, in a clinical lecture at the Hospital for Sick 
 Children {British Medical Journal, January 21, 1860, p. 44), refers 
 to a preparation with laceration of the inferior epiphysis of the 
 radius, but the exact age of the patient is not known. 
 
 In Hartmann's case the separation on each side was perfectly 
 clean and transverse, and without the slightest indication of an 
 osseous particle. 
 
 St. Bartholomew's Hospital Museum (Catalogue of Pathological 
 Museum, St. Bartholomew's Hospital, Addenda 1881-93, 1894, p. 44) 
 contains a specimen. No. 758b, one half (posterior) of the lower end 
 
 B- 
 
490 EPIPHYSES OF UPPEE EXTEEMITY 
 
 of the radius and ulna which have been sawn through longitudinally, 
 showing, as the result of an accident, the separation of the lower 
 epiphysis of the radius from the shaft. It was obtained from a boy, 
 aged sixteen, who was brought dead to the hospital. The epiphysis 
 of the right radius is seen to be displaced backwards almost com- 
 pletely off the diaphysis. The triangular fibro-cartilage and wrist- 
 joint are intact, while the periosteum is stripped up on the dorsal 
 aspect for one and a quarter inches. The styloid process of the ulna 
 is broken off, but the bone is otherwise uninjured ; its lower end is 
 very prominent. There is no fracture of the diaphysis of the radius 
 
 One of the earliest cases of compound separation of this 
 epiphysis is recorded by Mr. John Hilton {Guy's Hospital Reports, 
 3rd series, vol. xi. 1865, p. 338-44). There was compound separa- 
 tion of the carpal epiphyses of both radii from the shafts of the 
 bones ; tetanus ensued on the sixth day, and terminated in death 
 the following day. 
 
 The patient (B. B.), aged fourteen, a bricklayer's labourer, was 
 admitted into Cornelius Ward, under the care of Mr. Hilton, on 
 December 13, 1864. He had fallen from a scaffolding half an hour 
 previously, a distance of about forty feet, and had aHghted on a heap 
 of bricks with his face downwards, and both arms and hands 
 stretched out after a kind of spreadeagle fashion. There was a 
 contused lacerated wound of the forehead and concussion of the 
 brain. The continuity of the right radius was destroyed at the 
 junction of the lower epiphysis with the shaft, the distal portion 
 being displaced backwards ; the ulna of this side seemed to be 
 entire. There were two transverse slits in the skin over the 
 anterior surface of the same wrist, laying bare the flexor tendons, 
 but not exposing the bone. Only one could have been caused by 
 the protrusion of the broken radius ; the other was probably 
 produced by extreme flexion of the hand backwards, causing great 
 tension of the skin in front, which then gave way. The haemor- 
 rhage from these wounds was trifling. The displacement was 
 readily reduced by extension, and was accompanied with a feeling 
 of crepitus over the region of the fracture. 
 
 The left radius was fractured similarly to the right, with a 
 corresponding displacement ; only in this case the end of the 
 diaphysis projected through a wound anteriorly, and there was 
 more haemorrhage. On feeling the exposed end of the bone it was 
 noticed to be comparatively smooth, and suggested to the house 
 surgeon a separation of the epiphysis from the shaft. The dis- 
 placed extremity of the bone was fixed with considerable firmness 
 in its abnormal position, and there was much difficulty in getting 
 the fragments into good position. The projecting bone had passed 
 between the closely grouped and tense tendons, indicating that 
 great force had been expended in producing this separation of the 
 epiphysis. The radial artery, but not the ulnar, could be distinctly 
 
SEPAEATION OF LOWEE EPIPHYSIS OF EADIUS 491 
 
 felt. After ' the setting ' of the fractures a pistol-shaped splint was 
 put on the outer side of each forearm and hand. 
 
 As Mr. Hilton says : ' These splints were wrong and unnecessary, 
 and were applied by the dresser, who thought he had two instances 
 of Colles's fracture to deal with. The median nerve could scarcely 
 have escaped injury at the time of the accident, lying, as it did, in 
 the midst of the tendons through which the fractured bone protruded. 
 
 ' On December 19, six days after the accident, the patient com- 
 plained of a little soreness about the throat, and of stiff neck. On 
 the 20th, 8 a.m., the corrugatores superciliorum were contracted, 
 the lower jaw fixed, neck rigid, and abdomen hard ; at 3 p.m. he had a 
 severe opisthotonic spasm, and his chest became rigid. The spasms 
 became more severe, and recurred frequently till 5.35 p.m., when 
 he died of tetanus, caused, Mr. Hilton thought, by injury to the 
 median nerve. At the auto'psy only the wrists were allowed to be 
 examined. As soon as the splints were removed the displacements 
 recurred. At the right wrist the radial epiphysis was found sepa- 
 rated from the shaft of the bone, but the wrist-joint was uninjured. 
 There was no suppuration about the fracture. On the left side 
 a similar displacement was found, and also an oblique fracture of 
 the ulna about an inch and a half above the wrist-joint. Suppura- 
 tion existed about the fractured bones, which were bloodless and 
 saturated with fetid pus. The periosteum of the shaft of the radius 
 was stripped off to a considerable extent.' 
 
 Mr. Jonathan Hutchinson, in his report as chairman of the 
 committee of the International Medical Congress Museum of 1881 
 {Transactions of the Liter national Medical Congress, London 1881, 
 vol. i. p. 116), says: 'An excellent specimen of separation of the 
 carpal epiphysis of the radius was lent from the Dublin College of 
 Surgeons, in which was shown the precise condition of parts in a 
 complete separation, with complete dislocation of the epiphysis on 
 the dorsal aspect of the radius. I was able to supplement this by 
 a drawing from a precisely similar case, showing the appearance 
 presented by the hand immediately after the accident. It is quite 
 possible that specimen and drawing may each be unique, for this 
 accident, with this degree of displacement, is certainly very rare, 
 and I have never myself, until this occasion, had an opportunity of 
 examining a preparation. Dr. Geoghegan's patient died of injuries 
 received in a fall from a scaffolding ; in mine, reduction was found 
 exceedingly difficult, and suppuration subsequently occurred, but the 
 arm was saved.' 
 
 Korte mentions a specimen, alluded to later on, from a boy, aged 
 eighteen years, in which the lower radial epiphysis was completely 
 separated, although it was still connected with the diaphysis by 
 means of the periosteum. 
 
 Displacement backwards with fracture of the diaphysis. — Many 
 specimens in which dorsal displacement occurred show the existence 
 
492 EPIPHYSES OE UPPEE EXTEEMITY 
 
 of a slight fracture of the diaphysis. In the majority of cases some 
 small osseous scales adhere to the posterior margin of the epiphysis. 
 
 The fragment is almost always from the back of the diaphysis. 
 
 A specimen, ISTo. 758a, m the museum of St. Bartholomew's 
 Hospital {St. Bartholomew's Hospital Beports, 1887, vol. xiii. 
 p. 367 ; Catalogue of the Anatomical and Bathological Museum of 
 St. Bartholomeio' s Hospital, Addenda 1881-93, 1894, p. 43), a 
 section of the lower end of the radius of a child, is described 
 as an incomplete separation of the lower radial epiphysis, or 
 separation combined with fracture of the diaphysis, the separation 
 being complete along the radial border, but towards the ulnar side 
 the line of injury running obliquely, and consequently the bone has 
 been fractured above the epiphysis. On examining the specimen, 
 however, it a^Dpears that this small shell of the shaft adhering to 
 the epiphysis is on the dorsal aspect, towards which the epiphysis 
 has been displaced two-thirds of the way off the diaphysis. 
 The periosteum is torn through at the anterior aspect, and the 
 diaphysis, which is quite devoid of cartilage, projects at this point. 
 
 The specimen was from a girl, aged three years, who fell from a 
 height of thirty feet on to the pavement, and died two days after 
 the injury. 
 
 Another specimen, No. 39a, in St. George's Hospital Museum 
 {Catalogue of Museum of St. George's Hosp)ital, 1882), is figured 
 by Holmes {Surgical Diseases of Children, 1868, p. 255, figs. 
 42, 43), in which some displacement backwards of the epiphysis 
 has taken place, and the diaphysis, in the description of the specimen, 
 is stated to be displaced by the action of the pronator quadratus ; 
 but an examination of the specimen show^s that the periosteum is 
 torn off, together with the lower part of the pronator quadratus, 
 from the anterior aspect of the lower end of the diaphysis, so that 
 the bare end of the diaphysis protrudes. The separation is clean 
 through the epiphysial junction, with the exception of the posterior 
 margin of the end of the diaphysis, which is broken off as a rim of 
 bone situated ju.st a quarter of an inch above the epiphysial line 
 and still adherent to the epiphysis. The symptoms during life are 
 not recorded. 
 
 A similar specimen is in the London Hospital Museum, No. 404 
 {London Hospital Museum Catalogue, 1890, p. 96), and is figured 
 and described by Mr. Hutchinson {Pathological Society's Trans- 
 actions, vol. xiii. 1862, p. 182, fig. 1, plate xi. ; and London Hospital 
 Beports, vol. i. p. 89). It shows complete detachment of the carpal 
 epiphysis of the radius, with the exception that, on its dorsal aspect 
 at the inner side, a small portion of bone has been broken from the 
 extremity of the shaft and carried along with the epiphysis. The 
 lower extremity of the shaft presents no cartilaginous covering, but 
 shows numerous rounded elevations which had fitted into corre- 
 sponding depressions in the cartilage of the epiphysis. Its surface 
 
SEPARATION OP THE LOWER EPIPHrSIS OP THE RADIUS, WITH ALIIOST COMPLETE DISPLACEMENT 
 BACKWARDS AND TO THE OUTER SIDE. 
 
 The backward displacement was well shown in another skiagram taken laterally. A flake is detached from the posterior aspect 
 
 of the diaphysis of the radius. The ulnar epiphysis appears to be uninjured. From a boy aged eleven years. 
 
 Another skiagram of the same case after reduction showed the epiphysis in exactly normal position. 
 
 Mr. Thomas Moore's case. 
 
 Taken by Mr. Thojias Moore. 
 
SBPAEATION OF LOWEE EPIPHYSIS OF KADIUS 493 
 
 is entire and unbroken, excepting at the back, from which the small 
 fragment of bone has been detached. The detached epiphysis is 
 everywhere covered with cartilage, and is in normal relation with 
 the carpal bones. None of the ligaments are injured. The head 
 of the ulna having been removed, it was impossible to state 
 whether or not the styloid process of that bone, or the triangular 
 ligament connecting it with the radius, had been injured. 
 
 The specimen was taken from a boy aged sixteen years, who 
 died a few days after admission from various severe injuries sustained 
 in a fall. The symptoms of the epiphysial injury during life are 
 unfortunately not given. 
 
 The same museum contains another preparation. No. 405 {London 
 Hospital Beports, vol. iii. 1866, p. 401), consisting of the radius and 
 ulna of a young subject, whose left arm was removed by primary 
 amputation. The carpal epiphysis of the radius has been detached, 
 and almost the whole of the epiphysial cartilage has gone with it ; 
 but two small patches remain on the extremity of the shaft. The 
 end of the shaft at its margins is a little splintered, but there is no 
 material fracture. On the palmar aspect, about a quarter of an inch 
 from the outer border, is a linear fracture about an inch long, the 
 upper end of which looks as if a tooth of some machine had entered 
 the bone. This linear fracture does not involve the whole thickness 
 of the bone, and consequently does not permit of motion ; possibly 
 it is only a scratch, and if so the epiphysis was probably pulled off 
 by the tooth which inflicted it. Unfortunately, the carpal end of 
 the bone has not been kept. The ulna presents a dentated, almost 
 transverse, fracture an inch and a quarter from the extremity of the 
 styloid process. 
 
 Mr. Jonathan Hutchinson junior's specimen in the Eoyal College 
 of Surgeons Museum presents a traumatic separation of the lower 
 radial epiphysis with great 
 displacement and slight dia- 
 physial fracture from a fall 
 on the hand. 
 
 The patient was probably 
 aged about sixteen years. 
 The lower radial epiphysis 
 has been displaced com- 
 pletely backwards, so that 
 the anterior margin is about Fig- 141. — showing epiphysis feom outer 
 
 1 1 'fl ill /I' 'K '1 ^^^^ DISPLACED BACKWAEDS WITH PERIOSTEUM. 
 
 on a level witii tne aiapnysiai seen from the inner side the displace- 
 end and looking downwards, ^i^nt appeared much greater 
 
 still adhering to the shaft by ^^°^^^ ^°^^'Se of Surgeons Museum, No. 956c) 
 the periosteum. The separation has occurred exactly at the epi- 
 physial Hue, except on the posterior aspect, where a small ridge of 
 bone has been torn off the diaphysis. The top of the styloid process 
 of the ulna is broken off, but the conjugal line is uninjured. 
 
494 EPIPHYSES OE UPPEE EXTEEMITY 
 
 An interesting recent specimen in the Pathological Institute of 
 the University of Turin is figured and described by Dr. De Paoli 
 (loc. cit. sui^ra). It was taken from a boy aged nine years, who had 
 fallen from a great height, and died from fracture of the skull and 
 visceral lesions (figs. 142 and 143). 
 
 A little above the radio-carpal articulation there was to be seen 
 issuing through a transverse laceration of the anterior part of the 
 periosteum and lower part of the pronator quadratus, the quadrangular 
 lower end of the diaphysis of the i^'adius, with its somewhat rounded 
 corners. Its lower aspect was slightly granular, and showed here 
 and there a scale of cartilaginous tissue ; its anterior surface, 
 especially towards the inner side, is deprived of its periosteum for a 
 distance of seven to eight millimetres, but a little higher up it is 
 covered by the periosteum and pronator quadratus. The small 
 portion of the periosteum stripped from the diaphysis here in front 
 is still adherent to the upper margin of the epi]_3hysis, and covered 
 by the lower part of the pronator quadratus. The upper aspect of 
 the epiphysis was principally covered by the conjugal cartilage, 
 although a thin scale or two of the osseous tissue of the diaphysis 
 still clung to it. 
 
 Posteriorly, the periosteum remained intact, although stripped for 
 a distance of about one and a half centimetres from the posterior 
 and inner aspect of the diaphysis, a very thin strip of which remained 
 adhering to it. 
 
 The displacement of the epiphysis was not completely off the 
 epiphysis, but it could be readily accomplished, and reduction was 
 then found to be almost impossible in the preparation. The ulna 
 was partially displaced below and in front, and the internal lateral 
 ligament and the posterior part of the articular capsule presented 
 lacerations ; that of the latter opened the radio-ulnar articulation. 
 
 There was also an incomplete fractm^e of the diaphysis of the 
 radius about its middle, the periosteum and posterior half of the 
 bone being involved. The bone was bent at an angle of about 120°. 
 
 De Paoli in 1877 dissected a similar specimen taken from the 
 body of a mason's apprentice, aged fom'teen, who had fallen from 
 a third floor and died of severe abdominal lesions — lacerated 
 kidneys, &c. 
 
 There was the usual projection in front of the forearm, about 
 one centimetre above the radio-carpal articulation, and a correspond- 
 ing depression behind. The hand was in a lijqDer-extended position 
 and the styloid processes in their normal relations, and there was some 
 effusion of blood on the palmar aspect of the forearm. 
 
 The radial epiphysis was found almost cleanly separated from 
 the diaphysis, and covered with the conjugal cartilage ; while 
 posteriorly and internally the periostemn was stripped for a 
 distance of about two centimetres off the outer surface of the 
 diaphj^sis, many small particles of the compact substance of which 
 
SEPAEATION OF LOWEE EPIPHYSIS OF KADIUS 495 
 
 adhered to it. Anteriorly the periosteum was lacerated, and remained 
 adherent to the epiphysis. The diaphysis which protruded throagh 
 this laceration had its anterior surface somewhat rotated back- 
 wards towards the inner side, and the epiphysis, on the other 
 hand, was turned slightly outwards and backwards ; which facts led 
 De Paoli to suppose that the lesion had been produced by violent 
 extension and supination of the radio-carpal articulation, such as 
 would be produced by the boy falling on his outstretched hand with 
 the forearm pronated. The radio-ulnar joint was intact. 
 
 M. Johnston describes (Bullet, de la Soc. Anat. 1839, p. 184) a 
 specimen of perfect separation of this epiphysis, with the exception 
 of a very small fractured fragment which had been detached from 
 the posterior margin of the diaphysis, and still adhered to the 
 
 ^ 
 
 Fig. 142. — dissection of teaumatic separation op the lower epiphysis of 
 the radius, and dislocation of the ulna. (anterior view) 
 
 (Specimen in the Pathological Institute, University of Turin) 
 
 Fig. 143. — the same, (lateral view.) (de paoli) 
 
 posterior border of the epiphysis. The periosteum was stripped up 
 from the dorsal aspect of the diaphysis, was thickened and markedly 
 injected, and completely torn through in front. The epiphysis was 
 displaced backwards, and the diaphysial end projected forwards 
 beneath the flexor tendons. There was said to be also a tendency 
 to displacement outwards from the action of the radial muscles. 
 
 The articular ligaments uniting the ulna to the carpus were 
 lacerated behind, and the head of the ulna projected strongly below 
 through the inclination of the carpus outwards, but was not displaced 
 off the carpus. On the opposite, the left, side there was a precisely 
 similar, though less marked fracture. 
 
 During life the injury was thought to be a fracture of the lower 
 end of the right radius, as all the signs of this injury were said to 
 
496 EPIPHYSES OF- UPPEE EXTREMITY 
 
 be present. There were several other bones fractured, inchiding the 
 femur. The lesions resulted from a fall from a height of about 
 thirty or forty feet. 
 
 The patient, a lad aged eighteen years, died, on the fifth day after 
 the accident, from gangrene following laceration of the popliteal 
 artery and vein. 
 
 J. Colignon describes {Disjonction traumat. cles epiph., These de 
 Paris, 1868, p. 72) an almost perfect separation of the lower radial 
 epiphysis, to which adhered some osseous scales, broken from the 
 posterior margin of the diaphysis. There was extensive separation 
 of the periosteum from the diaphysis, and two fringe-like processes 
 of the former remained adherent to the epiphysis. There was a little 
 extravasated blood in the situation of the epiphysial cartilage ; the 
 ulna was intact. 
 
 The patient, a boy aged seven years, died from severe injuries to 
 the head thirteen days after a fall from a second story, and was 
 under the care of M. Marjolin at the Hopital St. Eugenie in 1868. 
 
 During life the left forearm was much deformed, swollen, and 
 somewhat shortened. The ' fork-back ' deformity described by 
 Velpeau in cases of fracture of the lower end of the radius was well 
 marked. The styloid process of the radius was on the same level as 
 that of the ulna, which projected more than in the natural condition. 
 The hand appeared to be somewhat thrown towards the radial side ; 
 the forearm consequently presented a slight incurvation at its lower 
 part. The form of the projecting lower end of the diaphysis, with 
 its abrupt ridge, could be easily made out, about a centimetre above 
 the intra-articular interline. Mobility from before backwards was 
 distinctly felt, and a smooth soft crepitus which did not permit of 
 any doubt as to the true nature of the lesion. The. pain was very 
 great on the slightest movement, and the limb quite powerless. M. 
 Marjolin readily reduced the fragments by means of extension and 
 manipulation, but the deformity was almost immediately reproduced. 
 
 In Gripat's and in one of R. W. Smith's cases the separation 
 was accompanied by a slight fracture of the diaphysis; this also 
 existed in Boeckel's case. 
 
 Occasionally it is noted that fragments of the diaphysis are torn 
 away from its anterior aspect, and it is probable, as De Paoli remarks, 
 that the lesion has occurred nearly at the period of complete develop- 
 ment and union of the epiphysis with the shaft. This view is further 
 supported in the recent specimen figured by De Paoli, by the fact 
 that the ulnar epiphysis has almost completely ossified to the shaft, 
 and that the measurements of the displaced portion of the radius are 
 those of the fully formed epiphysis (being sixteen millimetres in 
 depth at the styloid process) . 
 
 The lower end of the ulna was fractured at the middle in an antero- 
 posterior direction, detaching on the inner side the styloid process 
 and a portion of the diaphysis, and on the outer side the head of the 
 
SEPAEATION OF LOWER EPIPHYSIS OF EADIUS 497 
 
 bone at the upper level of the epiphysis, together with a small portion 
 of the diaphysis behind (see fig. 144). 
 
 The two portions detached from the compact layer of the lower 
 end of the diaphysis of the radius were, posteriorly, nine millimetres 
 in length, and remained attached to the upper margin of the epiphysis, 
 while on the inner side of the anterior aspect some irregular pieces 
 of the diaphysis, five to six centimetres in depth, also adhered to the 
 epiphysis. The epiphysis 
 was displaced backwards. 
 
 Complications. Sepa- 
 ration with fracture of the 
 epiphysis. — From the thin- 
 ness of the epiphysis, espe- 
 cially about the middle, it 
 might be supposed that 
 fracture of the epiphysis 
 in this position would be 
 of frequent occurrence, but 
 an examination of the 
 records shows that this is 
 not the case. Several 
 museum specimens de- 
 monstrate its existence, 
 however. 
 
 The epiphysis is more 
 solid than the lower end 
 of the bone of the adult, 
 and by this means escapes 
 the fracture, comminution, 
 or even impaction which 
 are so frequent in later life. 
 
 The specimen. No. 931, 
 in the museum of St. 
 Bartholomew's Hospital 
 {Catalogue of the Anato- 
 mical and Pathological Museum of St. Bartholo7neio' s Hospital, 
 vol. i. p. 134) of separation of the lower epiphysis of the left radius 
 is of considerable interest. The separation from the shaft has taken 
 place almost quite cleanly at the epiphysial line, and a fracture 
 extends vertically through the middle of the epiphysis into the 
 wrist-joint. The periosteum with a small flake of the diaphysis is 
 torn upwards for half an inch on the dorsal aspect, and the lower 
 end of the ulna is fractured above the epiphysial line. The styloid 
 process of the ulna is also broken off. 
 
 On the right side (specimen No. 932) the radius is fractured 
 transversely an inch and a quarter from its articular surface. The 
 shaft was driven into, and firmly impacted in, the cancellous tissue 
 
 K K 
 
 Fig. 144. — recent teaumatic separation of the 
 lower epiphysis of the radius, and separation 
 with fracture of the lower epiphysis of the 
 
 ULNA. (dE PAOLI) 
 
 E, epiphysis of the radius ; O, fragments of the 
 compact tissue of the posterior part of the dia- 
 physis adhering to the epiphysis ; D, diaphysis 
 of radius ; E', epiphysis of ulna ; D', diaphysis 
 of ulna 
 
498 EPIPHYSES OF UPPEK EXTEEMITY 
 
 of the lower extremity, which was displaced backwards, the epiphysial 
 line below being intact. The epiphysis of the ulna is separated 
 from the diaphysis and broken into several pieces. The intra-articular 
 fibro-cartilage is still attached to one of the larger pieces comprising 
 the head of the ulna on the inner side. The shaft of this bone is 
 uninjured. Owing to the impaction, no crepitus could be felt, even 
 after the removal of the surrounding soft parts. The specimens were 
 taken from the body of a boy aged fourteen years, who fell from a 
 window and died, a few hours after, from injuries to the head. 
 
 Callender ('Fractures injuring Joints,' St. Bartholomew's Hospital 
 Beports, vol. i. 1865, p. 281) alludes to the same case in St. 
 Bartholomew's Hospital museum. The right radius, he adds, was 
 deformed through the projection of the lower end of the bone. 
 
 The bone was broken transversely at a point one inch from its 
 articular surface. The shaft was impacted and driven into the 
 cancellous tissue of the carpal extremity, so that the latter was dis- 
 placed backwards and fixed at an angle of 160 degrees with the 
 shaft. 
 
 In 1884 Professor Annandale, of Edinburgh, showed the author 
 an almost precisely similar specimen in his pathological collection in 
 the Edinbvirgh Infirmary. The lesion had been a compound one. 
 The lower epiphysis of the radius was displaced backwards halfway 
 off the diaphysis, and there were one or more fissures extending 
 through the epiphysis into the wrist-joint. Primary amputation of 
 the forearm was performed, and the patient recovered. 
 
 In the Musee de la Societe de Chirurgie de Paris {Bullet, de 
 la Soc. de Chiriirg. 1865, 1866, 2 Ser. vi. p. 524, and Gazette des 
 Hopit. 1865, pp. 145-147) there are specimens presented by 
 M. Dolbeau of almost perfect separation of the lower epiphysis of 
 the radius and ulna on the left side and of the radius alone on 
 the right. On this side (the right) the aponeurosis of the forearm 
 was torn, and the flexor muscles formed a kind of buttonhole, 
 which was placed between the diaphysis and the epiphysis. The 
 epiphysial cartilage still adhered to the right epiphysis together 
 with a thin flake from the posterior margin of the diaphysis, and the 
 separation on the left side was moreover complicated with a fracture 
 of the epiphysis penetrating the wrist-joint ; otherwise the wrist-joint 
 on each side was intact. The specimens were taken from a child 
 thirteen years old, who died nineteen days after from fracture of 
 the skull, the result of a fall from a second story. 
 
 E. H. Bennett describes {British Medical Journal, vol. i. 1880, 
 p. 759) casts and specimens taken from the limbs of a boy who died 
 from injury to the skull a few days after a fall from a height. On 
 the one side the displaced epiphysis was comminuted, with detach- 
 ment of a small scale of bone from the diaphysis ; on the other the 
 separation was simple. There was to be noticed the contrast of 
 deformity with Colles's fracture in the transverse features of their 
 
SEPAEATION OF LOWEE EPIPHYSIS OF EADIUS 499 
 
 dorsal and palmar projections, the folding of the skin in the palmar 
 depression, absence of abduction of the hand, easy reduction, and 
 the facility of obtaining crepitus, as well as of keeping fragments in 
 position. 
 
 In an article upon ' Clinical Observations on Disjunction of the 
 Lower Epiphysis of the Eadius ' (Dublin Hospital Gazette, vol. vii. 
 1860, p. 49) and in his ' Address in Surgery ' (British Medical 
 Journal, vol. ii. August 17, 1867, p. 123 ; and in the Proceedings of 
 the Pathological Society of Dublin, N.s. vol. i. 1862, p. 126), Professor 
 E. W. Smith describes a case in which the diagnosis made during 
 life was confirmed by an autopsy. The separation was bilateral, and 
 on one side the epiphysis was comminuted. 
 
 A lad, under twenty years of age, was admitted into the 
 Eichmond Hospital, Dublin, having fallen from a considerable 
 height. He sustained a very severe injury of the head, and in each 
 forearm the radius was broken close to the wrist-joint. The ex- 
 ternal characters of the fracture were as nearly as possible alike upon 
 each side. In the left forearm two projections were visible im- 
 mediately above the radio-carpal articulation, one upon the dorsal, 
 the other upon the palmar surface of the limb, the latter being the 
 more distinctly circumscribed. Their outline was directed trans- 
 versely, but neither of them extended across the entire breadth of 
 the forearm. They were limited to the transverse extent of the 
 radius, and were not placed directly opposite to each other, the lower 
 boundary of the anterior corresponding to the superior margin of 
 the posterior. Immediately below the abrupt termination of the 
 anterior projection there was a deep transverse sulcus, in which the 
 integuments presented a few transverse folds, as if relaxed. Upon 
 the right side, although there existed a greater amount of deformity, 
 the peculiar signs which characterise the injury under consideration 
 were not so distinctly marked. Owing to the comminution of the 
 lower fragment of the radius, the neighbourhood of the wrist here 
 presented a combination of the signs of Colles's fracture with those 
 of disjunction of the radial epiphysis, but the peculiar twisted 
 appearance which forms so striking a feature in the former injury 
 was entirely wanting. Upon both sides the antero-posterior diameter 
 of the limb was increased, and the sharp margin of the superior 
 fragment of the radius could be very distinctly felt. The diagnosis 
 made was ' separation of the lower epiphysis of the radius upon 
 each side.' The patient died from the injury to the head a few days 
 after the accident, the symptoms having been those of compression 
 of the brain. 
 
 The examination of the bones after death demonstrated the 
 correctness of the opinion which had been formed as to the nature 
 .of the injuries sustained, the epiphysis being found separated from 
 the shaft of the radius upon each side, and carried backwards along 
 with the carpus to the extent of about three-eighths of an inch. 
 
 K K 2 
 
500 EPIPHYSES OF UPPEE EXTKEMITY 
 
 Upon the left side there was no other injury, but upon the right a 
 thin scale of bone was detached along with the periosteum from the 
 posterior surface of the shaft, and the epiphysis was broken into 
 four pieces. There was no injury of the ulna upon either side. 
 
 Laceration of pronator quadratus, &c. — This small muscle can exert 
 but little influence on the lower fragment or epiphysis, or cause any 
 displacement inwards, for only a few fibres of this muscle are attached 
 to the epiphysis, and these are usually torn across. 
 
 The action of this muscle would only tend to draw the shaft of 
 the radius towards the ulna, but there is really no interosseous space 
 in epiphysial separation into which the diaphysis may fall, and its 
 displacement in this direction therefore becomes impossible. 
 
 In the Guy's Hospital specimen dissected by the author, the 
 anterior margin of the diaphysis is seen protruding for three-eighths 
 of an inch beyond the transverse laceration in the lower third of this 
 muscle. 
 
 The same laceration of the pronator quadratus exists in both 
 of the specimens in St. Greorge's Hospital Museum and in that 
 in the University of Turin. 
 
 In Johnston's case this muscle was found to be infiltrated with 
 blood, and in the author's specimen the effusion of blood around 
 the lacerated muscle in front of the diaphysis was a noticeable feature. 
 This effusion has been remarked in many of the other specimens. 
 
 The interposition of the flexor tendon (profundus) of the middle 
 finger prevented reduction in Hartmann's case. 
 
 Injury of wrist-joint. — The wrist-joint frequently escapes injury, 
 and in this respect separation of the lower epiphysis of the radius 
 differs very considerably from Colles's fracture in the adult. 
 
 In many instances, e.g. Boeckel's, it is distinctly stated that on 
 dissection of the specimen the wrist-joint was uninjured. 
 
 Detaclunent &c. of periostenm. — In displacement backw^ards the peri- 
 osteum is usually torn through at the anterior aspect, about on a 
 level with the conjugal cartilage, and more or less extensively stripped 
 up from the dorsal aspect of the diaphysis in the majority of the 
 dissected specimens, but it is not usually lacerated in this latter 
 direction. 
 
 De Paoli notes this laceration of the periosteum at the anterior 
 part, with displacement of the diaphysis forwards, in ten out of his 
 thirty-five cases, while in Boeckel's case a small strip of periosteum 
 on the dorsal aspect was the only part remaining intact. 
 
 In the Guy's Hospital specimen the periosteum is torn off for a 
 distance of three-quarters of an inch, and the space between it and 
 the shaft is occupied by blood clot ; in front it is lacerated in the 
 usual way transversely across at the level of the anterior margin of 
 the diaphysis. Precisely the same condition is described by John- 
 ston {loc. cit. supra). 
 
 Dorsal detachment of the periosteum is also noted in one of 
 
SEPAEATION OF LOWEE EPIPHYSIS OF RADIUS 501 
 
 E. W. Smith's cases {loc. cit. siqna), and also by other surgeons. 
 In Colignon's case the separation of the periosteum from the dia- 
 physis was described as extensive. 
 
 In one or two rare examples the periosteum has been found 
 stripped from the front of the diaphysis. Thus in one of the specimens 
 in St. George's Hospital the periosteum, together with the lower part 
 of the pronator quadratus, was torn off the anterior aspect of the 
 lower end of the diaphysis, and in the King's College Hospital 
 specimen it is torn upwards for three-quarters of an inch from the 
 front of the diaphysis. 
 
 Fracture of the styloid process of the ulna. — The frequency of 
 fracture of the styloid process in CoUes's fracture has been noted by 
 Malgaigne, Cameron, Bennett, Lucas, and others, and the same 
 lesion is not uncommonly found to exist in separation of the lower 
 radial epiphysis. 
 
 At the Pathological Society in 1890 Mr. S. G. Shattock {Transac- 
 tions of the Pathological Society, vol. xH. 1890, p. 236 ; St. Thomas's 
 Hospital Museum, No. 115a) showed a specimen in which the 
 lower epiphysis of the radius was clearly detached along its plane of 
 junction with the shaft, and displaced backwards at an obtuse angle 
 about a quarter of an inch off the diaphysis, precisely as the lower 
 fragment commonly is in a Colles's fracture, rendering the head of 
 the ulna very prominent. The styloid process of the ulna was also 
 Broken off. The injury probably resulted from the shock of the fall 
 having been received by the outstretched hand. The boy, eight 
 years of age, had faUen from a window a height of about twelve 
 feet, and was supposed to have struck an anvil which was lying in 
 the yard below. He sustained at the same time a rupture of the 
 small intestine. For this a partial but unsuccessful enterectomy was 
 performed on the day following the accident. 
 
 In a specimen in St. George's Hospital Museum, No. 3424 (1145) 
 {Catalogue of the Pathological Museum of St. George s Hospital, 1882, 
 p. 7), the lower radial epiphysis is displaced upwards and backwards 
 almost off the diaphysis, and the apex of the styloid process is 
 broken off. The ligaments of the left wrist were said to have been 
 torn and the diaphyses of the bones uninjured. 
 
 In the description of the specimen it is stated that the lower end 
 of the radial diaphysis may be seen protruding through the lacerated 
 anterior ligament. If by this is meant the true anterior ligament of 
 the wrist-joint, it is quite impossible to see how tliis could occur ; 
 but, on the contrary, on examining the specimen it is clearly seen 
 that the end of the diaphysis has lacerated the periosteum and lower 
 part of the pronator quadratus, and protrudes in front through 
 the fibres of this muscle. The patient, a boy aged fifteen, had 
 fallen fifty-five feet, and fractured both his skull and his right 
 clavicle. 
 
 In one of the specimens in St. Bartholomew's Hospital mentioned 
 
502 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 above, the styloid process was fractured, as well as the lower end of 
 the ulna above the epiphysial line. 
 
 In 1883 the author made the following dissection of a case of 
 separated lower epiphysis of the radius which simulated a Colles's 
 fracture. The specimen is in the Guy's Hospital Museum, 
 No. 1117^^, and the specimen No. 956b in the Eoyal College of 
 Surgeons museum is the inner portion of the same after- vertical 
 section. It is also figured by Mr. Bryant in his ' Practice of Surgery,' 
 and by the author in ' Pediatrics,' New York and London, 1897, iv. 
 p. 49. 
 
 The patient was a boy (Jas. H.), aged twelve, who, in sliding 
 down the banisters of a warehouse, overbalanced and fell from the 
 third story. Death ensued on the second day from fracture of the 
 
 Fig. 145. — author's dissection of specimen in guy's hospital museum, from a 
 lad aged twelve years 
 
 A, diaphysis of radius ; B, carpal epiphysis of radius incomxiletely ossified ; C, flexor 
 tendons displaced forwards ; D, pronator quadratus lacerated by anterior margin 
 of end of radial diaphysis ; E, periosteum stripped off dorsal aspect of diaphysis ; 
 F, blood clot filling space between periosteum and diaphysis ; G, scaphoid 
 
 anterior fossa of the skull. The characteristic deformity of a Colles's 
 fracture was still present after death, but crepitus was not felt. 
 
 The lower radial epiphysis was displaced more than halfway off, 
 towards the dorsal aspect of the diaphysis, carrying with it the 
 carpus and hand. It made an angle of forty-five degrees with the 
 dorsal aspect of the shaft, the anterior third of its separated epi- 
 physial surface being still in contact with the posterior or dorsal 
 edge of the lower end of the diaphysis. The anterior margin of 
 the latter had completely torn across the lower third of the 
 pronator quadratus, and projected three-eighths of an inch beyond 
 the lower portion of this muscle. This projecting margin of the 
 diaphysis covered by the flexor tendons gave rise to the prominent 
 convexity on the anterior aspect of the forearm above the wrist. 
 
SEPAEATION OF LOWEE EPIPHYSIS OF EADIUS 508 
 
 The periosteum was stripped off the dorsal aspect of the shaft 
 to the extent of three-quarters of an inch upwards, and a triangular 
 interval was thereby left between it and the diaphysis, which was 
 occupied by firm blood clot. On the palmar aspect the periosteum 
 binding the epiphysis to the diaphysis was entirely ruptured across. 
 
 The styloid process of the ulna was broken off, and together 
 with the internal lateral ligament of the wrist-joint, which still 
 remained connected with it, displaced for a distance of half an inch 
 upwards and backwards. The lower end of the ulna, with its 
 fractured styloid surface, projected prominently on the inner side of 
 the wrist, but the dorsal branch of the ulnar nerve was uninjured, 
 although the periosteum and ligamentous tissues were detached 
 from the dorsal aspect of the ulna for a distance of three-quarters of an 
 inch upwards. The triangular fibro-cartilage had its apex torn from 
 the ulna, but a few fibres still remained attached to the root of the 
 styloid process, and the cartilage was displaced backwards with it.^ 
 
 Fig. 146. — compound separation of lower epiphysis of radius, with fracture _ 
 
 OF STYLOID PROCESS OF ULNA. (gUY'S HOSPITAL MUSEUM) 
 
 This inner portion of the wrist-joint (articulating with the cuneiform 
 bone) was full of blood. The inferior radio-ulnar joint also con- 
 tained some blood. The capsular ligament of the wrist- joint and 
 the diaphyses of the bones of the forearm were uninjured. 
 
 The tendon of the extensor carpi ulnaris on the posterior aspect 
 of the wrist was exceedingly tense, and on the outer side the 
 supinator longus, still attached to the displaced epiphysis, was in a 
 like condition. These, as well as the other extensor tendons passing 
 through the thecal grooves at the back of the epiphysis, largely con- 
 tributed by their action to the maintenance of the displaced condition 
 of the fragment, and no doubt afforded considerable hindrance to 
 the proper reduction of the deformity. 
 
 The accompanying drawing is from a case in Guy's Hospital 
 Museum, No. 5^^ in which primary amputation was performed by 
 Mr. Hilton in July 1865. There was a compound separation of 
 the lower radial epiphysis, with great displacement backwards of the 
 
 ' Differing from many instances of rupture of the fibro-cartilage in CoUes's fracture, 
 which takes place at its attachment to the inner margin of the radius. 
 
504 EPIPHYSES OF UPPEE EXTEEMITY 
 
 carpus and hand. The styloid process was broken off, and the ends 
 of the radius and ulna projected for some distance through the rent 
 in the skin in front above the wrist-joint. The end of the radial 
 diaphysis has the appearance as if it were fissured upwards about its 
 centre. 
 
 This specimen is also figured by Bryant. 
 
 Separation of the lower epiphysis of the ulna. — The lower epiphysis 
 or head of the ulna is but rarely detached. Its styloid process or its 
 diaphysis, three-quarters of an inch above the lower end, gives way 
 more frequently. 
 
 Barbarin mentions {Lesfract. cliez les enfants, These de Paris, 1873, 
 p. 34) the case of a youth, eighteen years of age, in whom amputa- 
 tion of the shoulder-joint was performed on account of gangrene. 
 He had fallen from a tree, and there was found a very clean separa- 
 tion of the radial epiphysis, to which the conjugal cartilage still 
 adhered. There was also on the same side a separation of the lower 
 epiphysis of the ulna. The patient was under the care of M. 
 Oilier" 
 
 Professor Annandale, of Edinburgh, informed the author in 1884 
 of a case in his practice of compound separation of the lower radial 
 and ulnar epiphj'ses. A boy, aged about fifteen years, fell from 
 some crags when bird-nesting. There was a lacerated transverse 
 wound across the lower end of the forearm on the. palmar aspect ; 
 the tendons w^ere not torn, but the ends of the shafts of the 
 radius and ulna protruded and were bruised and covered with dirt. 
 The epiphyses remained in position. Mr. Annandale excised the 
 protruding portions of the radius and ulna, and also removed the 
 epiphyses. The result was a good recovery, with a movable wrist 
 and fairly strong hand. 
 
 Dr. C. A. Sturrock records {Edinhurgh Hosjntal Beports, vol. ii. 
 1894, p. 602) a case from Mr. Annandale's wards at the Eoyal In- 
 firmary, Edinburgh. A boj^ of fourteen sustained a compound separa- 
 tion of the lower epiphyses of the radius and ulna, the result of a 
 machinery accident. The shafts of both bones, which protruded and 
 were partially stripped of periosteum, were tightly gripped by the flexor 
 muscles of the fingers. It was found to be impossible to reduce the 
 displacement, and accordingly Dr. E. J. A. Berry, after enlarging the 
 wound, removed about three-quarters of an inch of the shafts of the 
 radius and ulna, replaced the bones in position, and sewed up the 
 wound. The patient made a rapid recovery, and when seen some 
 fifteen months after the accident w^as found to have regained almost 
 completely the movements at the wrist, and to suffer from little or 
 no shortening. 
 
 In one of De Paoli's specimens figured above (fig. 144) there 
 existed a separation and a fracture of the lower epiphysis of the ulna. 
 He has noted the existence of separation of the ulnar epiphysis in 
 three other instances. 
 
BEPAKATION OF LOWEE EPIPHYSIS OF RADIUS 505 
 
 Mr. E. Percy Paton {Transactions of the Pathological Society, 
 vol. xlviii. 1897, p. 191) showed at the Pathological Society of 
 London, on January 19, 1897, a specimen of fracture of the ulna 
 and radius at the epiphysial lines. 
 
 Mr. Stonham kindly placed the specimen at the author's disposal 
 for the purpose of the accompanying drawing. 
 
 Fig. 147. — compound sepaeation 
 ulna. (westminster hospital 
 physes have been rotated in 
 
 A, diaphysis of radius bereft of 
 osteum ; jB, epiphysis of radius 
 by suppuration ; C, diaphysis 
 cartilage intact ; F, periosteum 
 
 OF THE LOWER EPIPHYSES OF THE RADIUS AND 
 MUSEUM.) SUPPURATIVE PERIOSTITIS. THE EPI- 
 ORDER TO SHOW THEIR DIAPHYSIAL SURFACES 
 
 periosteum ; E, new osseous deposit from peri- 
 with conjugal cartilage almost entirely destroyed 
 of ulna ; D, epiphysis of ulna with conjugal 
 stripped off the diaphysis of ulna 
 
 For the following notes of the case the author is indebted to 
 Mr. Paton. 
 
 D. S., aged fourteen, plumber's mate, was admitted into West- 
 minster Hospital under Mr. Stonham on December 11, 1896, having 
 just fallen twenty feet from a ladder. He was found to have a 
 transverse wound from two to three inches long on the flexor aspect 
 of the right forearm just above the wrist-joint. It was begrimed 
 with dirt, and from it protruded the lower end of the diaphyses of 
 both radius and ulna. An angesthetic was given, and the bones and 
 wound were thoroughly cleansed by the house surgeon. The bones 
 were then reduced without difficulty and the wound sutured, the hand 
 and arm being put in a splint. The temperature rose somewhat 
 during the next day or two and the wound suppurated, but not very 
 
506 EPIPHYSES OF UPPEE EXTKEMITY 
 
 extensively ; all stitches were taken out and the hand transferred 
 to an arm-bath, the deformity being still controlled by a splint. On 
 December 18 signs of tetanus set in at 6 a.m. (trismus and some 
 dorsal spasm). This was treated with large doses of chloral and 
 bromide, scraping of the wound under an anaesthetic, irrigation 
 with oxygen gas, and the injection of anti-tetano-toxin, obtained 
 from the Institute of Preventive Medicine, in three doses to the 
 amount of 35 c.c, but the boy died at 2 p.m. on December 19, in an 
 acute spasm. 
 
 Nothing special was found at the autopsy but the injury shown 
 in the specimen. 
 
 The carpal epiphyses of the radius and ulna were cleanly separated, 
 with the exception of a few osseous granules from the posterior 
 margin of the end of the diaphysis of the radius. The conjugal 
 cartilage of this bone had been almost entirely destroyed by suppura- 
 tion — a few flakes only remained attached to the inner part of the 
 epiphysis — while that of the ulna was still intact, adhering in its 
 entirety to the epiphysis. The styloid process of the ulna and 
 wrist-joint were uninjured. The periosteum was stripped for two 
 and a half inches from the whole circumference of the shaft. 
 Above this, new periosteal deposit extended upwards for some 
 distance. The periosteal sheath of the ulna was much thickened 
 and inflamed, and detached for two and a half inches upwards from 
 the outer half of the circumference of the shaft. 
 
 At Guy's Hospital in 1880 Mr. Cooper Forster had under his 
 care the case of a boy (Henry T.), aged fourteen years, who had 
 fallen through the stair-rails the height of the flight of stairs on to 
 his hands. There was found compound separation of the lower 
 epiphyses of the radius and the ulna, with displacement of the radial 
 epiphysis. Mr. Forster resected half an inch of the lower end of the 
 diaphysis of the radius by means of a saw, and reduced the displace- 
 ment. This was followed by some necrosis of the diaphysis and 
 by recovery. Dislocation of the elbow backwards was also present. 
 
 At the museum of the International Medical Congress, London, 
 in 1881 {Museum Catalogue of International Medical Congress, 
 London 1881, p. 52, No. 550) Dr. Geoghegan exhibited a specimen, 
 from the Eoyal College of Surgeons, Ireland, of separation of the 
 epiphyses of the radius and ulna. The subject from which this 
 specimen was taken was a young man who died of injuries received 
 in a fall from scaffolding. 
 
 M. Voillemier gives an example in a child aged fourteen years, 
 who had fallen a height of eight feet on to the palm of the hand. 
 
 Besides the detachment of the lower epiphysis of the radius, 
 there was a fracture of the ulna which involved two thirds of its 
 thickness at the union of its lower epiphysis with the shaft. But 
 this author makes no further allusion to the subject in his valuable 
 memoir on fractures of the lower end of the radius. 
 
SEPAKATION OF LOWEK EPIPHYSIS OF EADIUS 507 
 
 Fracture of shaft of ulna. — Fracture of the ulna is of frequent 
 occurrence towards its lower end. 
 
 In a child of about fifteen the weakest and smallest part of the 
 diaphysis is three-quarters of an inch above the lower end. 
 
 In Koux's specimen the ulna was fractured in its lower fourth, 
 but in this case the radial epiphysis was displaced forwards. 
 
 De Paoli, in four cases, found this separation accompanied by 
 fracture of the ulnar diaphysis near its lower extremity. 
 
 In Hilton's case of compound separation of both radial epiphyses, 
 on the left side there was also an oblique fracture of the ulna an 
 inch and a half above the wrist-joint ; on the right side the ulna was 
 uninjured. 
 
 The ulna was fractured, in Boeckel's case, three centimetres 
 above its lower end. 
 
 An interesting case of epiphysial separation of the lower end of 
 each radius — compound on the right side, with fracture of the ulna 
 a little above its lower end — is recorded at length by H. Hartmann 
 {Bulletins de la Societe anatomique, Paris, July 1883, p. 328). 
 Fracture of the right femur, rupture of the left kidney, and multiple 
 contusions complicated the injury and led to death on the thirty- 
 fourth day from general infection and suppuration of all the seats of 
 injury. 
 
 (C), a boy, aged twelve years, was admitted on June 8, 1883, 
 under the care of Dr. Terrier, into the Bichat Hopital, having 
 fallen that afternoon from the top of the ramparts while at play. 
 There was a contused wound of the forehead and slight contusion of 
 the nape of the neck, fractm'e of the lower part of the left forearm 
 (with displacement backwards of the hand, which was easily 
 reduced, and a posterior plaster splint applied), and fracture of the 
 right thigh at the junction of the upper with the lower thirds 
 (which was treated by continuous extension). At the inner and 
 front aspect of the right forearm there was a wound, through which 
 protruded the lower end of the radius, displaced forwards and 
 inwards off the epiphysis. Its surface displayed a slightly mam- 
 millated appearance, without any trace of spongy tissue or osseous 
 roughness, and was more like the articular end of the bone than a 
 fractured one. The styloid process held its normal relations. The 
 radius was irreducible on account of the interposition of the 
 tendons and its embracement by the skin wound, and the urine was 
 found to contain blood. The following day, under an anaesthetic, 
 reduction was somewhat difficult, for the middle finger, which was 
 kept flexed, could not be extended, whilst all the other fingers could 
 be, with ease ; this was caused by the tendon of the flexor profundus 
 to the middle finger being interposed. After this had been drawn 
 aside and disengaged the radius was placed in position. Lister's 
 dressings were employed, and a posterior splint applied. 
 
 On June 10 an external splint was applied to the thigh. On 
 
508 EPIPHYSES OF UPPEE EXTEEMITY 
 
 June 16 some sloughs began to separate from the wound of the 
 forearm, and two days later a blackish slough the size of the 
 palm of the hand formed on the right buttock, and haemorrhage 
 took place from the ulnar artery, which necessitated ligature of the 
 two ends in the wound. On June 22 the patient, in his delirium, 
 had a second time taken off the dressings, and there was noticed at 
 the upper and inner part of the wrist a wound in which the end of 
 the fractured ulna presented itself with an oblique (inward) division 
 and very sharp end. There was also oedema of the abdominal wall 
 and pain in the left flank. On June 27 a small purulent collection 
 in nape of neck opened at the site of a contusion. The following 
 day it was noted that the swelling of the right thigh had increased the 
 last few days, and a puncture let out a quantity of gas and foetid pus. 
 On the 29th a small abscess opened at the level of the frontal wound. 
 On the 30th an incision above the left crural arch evacuated a very 
 large quantity of serous and brownish pus. T. 101°. On July 1 the 
 right radius again became displaced, and projected between the 
 muscles in front of the forearm. The slough of the right buttock was 
 detached, leaving a vast wound. Emaciation increasing, tongue dry, 
 eyes sunken, T. 101-4° F. Death ensued on July 12. Temperature 
 rose gradually the last fom^ days to 105-2° F. At the autopsy a large 
 wound was seen on the anterior aspect of the right forearm, through 
 which there protruded the lower part of the radius. It was directed 
 obliquely downwards, forwards, and inwards, ending immediately 
 above the pisiform bone. The whole mass of the flexor tendons 
 was situate on its outer side, and prevented it being replaced in 
 position. Its end presented a very abrupt, slightly mammillated, 
 and black appearance. The bone was denuded for about three 
 fingers' breadth, with a reddish, mottled, and slightly rough look. 
 On dividing and removing the anterior tendons the radial epiphysis 
 was seen to be in position, and the styloid process preserved its 
 proper relations. The epiphysis had the appearance of a plate 
 about a millimetre and a half thick, rising up at its outer part to 
 constitute the styloid process. The cartilages were destroyed. The 
 ulna presented a dentate fracture just above its lower end, passing 
 obliquely downwards and inwards, so that the upper fragment was 
 displaced in the same direction, overlapping the lower fragment 
 (backwards and inwards), and was pointed at the inner side. The 
 lower fragment occupied its normal position, while the upper was 
 denuded for two centimetres in extent on its inner side, and pro- 
 jected through the integuments. No union was present, but sup- 
 puration was limited to the seat of fracture. The cartilages of the 
 medio-carpal articulation and of the carpo-metacarpal articulation of 
 the second and third metacarpal bones had disappeared, while the 
 trapezo-metacarpal and two last metacarpal joints were healthy. 
 At its upper part the synovial sheath of the flexor tendons was 
 obliterated at the level of the wound by a greyish mass, the palmar 
 
SEPAEATION OF LOWER EPIPHYSIS OF RADIUS 509 
 
 portion presenting its normal pearly aspect. On the posterior 
 aspect the extensor tendons in the whole of their extent were clear 
 and shining. On the left forearm there was an extensive purulent 
 collection extending between and separating the muscles, which did 
 not appear to be very much altered. The bones were in their normal 
 relations. The radial epiphysis was separated ; the end of the upper 
 fragment presented a general transversely divided and slightly mam- 
 millated appearance, while the lower fragment presented precisely 
 the same appearance as that of the right side. The ulna was not 
 fractured, and occupied its normal position ; its small denuded head 
 was surrounded by a deep furrow consequent on the partial destruc- 
 tion of the conjugal cartilage by the suppuration. The cartilages 
 of the medio-carpal joint were destroyed. The synovial sheaths of 
 the flexor and extensor tendons were intact. 
 
 On the right thigh there was a transversely dentate subtro- 
 chanteric fracture of the femur. The lower fragment was parallel 
 to, but surmounted, the upper on its outer aspect for about three 
 fingers' breadth. There was no trace of union between the ends, 
 which were contained in a fairly large but limited collection of pus. 
 Nephritic abscess and rupture of the left kidney. At the upper part 
 of the left thigh, from four fingers' breadth below the crural arch, 
 there was a large purulent collection extending upwards in the 
 sheath of the psoas muscles into the abdominal cavity. The 
 peritoneum was not opened." There was also a large lumbar 
 abscess destroying the iliacus muscle, at the upper part of which 
 the kidney was torn in two by a transverse rent at the level of the 
 lower part of the hilus. The two parts were only held together by 
 some tags at the posterior part, which appeared to be formed by 
 some debris of the capsule. The lower part was surrounded by 
 the abscess cavity. The whole of the hilus was completely torn 
 through. The ureter was partially torn at the inner side. Inter- 
 stitial nephritis, with foci of fatty granular degeneration, was 
 present in the lower half of the lacerated kidney. 
 
 M. Hartmann draws attention to the slight displacement of the 
 radius on the one side, while the upper fragment of the radius on 
 the other side protruded through a wound, and to the difficulty of 
 reduction and maintaining it in position after replacement, which he 
 thought attributable to muscular action and to the absence of denta- 
 tion, which permitted the easy reproduction of the displacement. 
 He also remarks upon the suppuration of all the seats of injury and 
 of these alone ; he therefore considered the case a good example 
 of those auto-inoculations so well described by Professor Verneuil. 
 
 Professor R. W. Smith [Fractures and Dislocations, Dublin, 1847, 
 p. 164) figures and describes the condition of the forearm before 
 and after dissection. 
 
 The patient, a young man, fell from a scaffold, and in addition 
 to the fracture of the forearm, received other injuries, of which he 
 
510 
 
 EPIPHYSES OF UPPEH EXTKEMITY 
 
 died in a few hours. No attempt was made to reduce the displace- 
 ment consequent upon the fracture. When the Hmb was examined 
 after death the radius was fou.nd fractured transversely through the 
 line of its inferior epiphysis, and the lower fragment displaced 
 directly backwards, so far as to have very nearly cleared the 
 extremity of the upper fragment ; the lower extremity of the ulna 
 was broken a short distance above the line of junction with its 
 epiphysis ; this fracture was oblique from above and before down- 
 wards and backwards ; the extremities of the two fragments formed 
 with each other an angle salient in front ; the radio-carpal articulation 
 
 Fig. 148,- 
 
 -SEPAEATION OF LOWER EPIPHYSIS OF EADIUS, WLTK FEACTUEE OF ULNA. 
 (aFTEE E. W. smith.) appearance BEFOEE DISSECTION 
 
 Fig. 149. — separation of the lower epiphysis of the radius, with 
 fracture of the ulna. (e. w. smith) 
 
 Fig. 150. — the same, outee side, (e, w. smith) 
 
 was uninjured, and the carpus accompanied the lower fragment of 
 the radius in its displacement backwards. 
 
 The same author describes {DuhJin Jommal of Medical Science, 
 vol. Ivi. 1873, p. 424 ; Proceedings of the Pathological Society of 
 Dublin, N.s. vol. v. 1874, p. 245) the fohowing case of compound 
 disjunction of the lower epiphysis of the radius accompanied with 
 fracture of the ulna. The patient, a boy aged twelve years, fell off 
 a parapet fifteen feet high, sustaining very extensive compound 
 fractures of the skull and laceration of the brain, from which he 
 died. 
 
SEPAEATION OF LOWEE EPIPHYSIS OF EADIUS 511 
 
 The lesion was situated in the immediate vicinity of the radio- 
 carpal articulation ; a large lacerated wound existed here upon the 
 palmar surface of the limb, through which rather more than half an 
 inch of the radius protruded ; it was disjointed from its epiphysis. 
 The axis of the bone was directed forwards and considerably inwards 
 towards the lower end of the ulna. The radial border of the forearm 
 presented a very striking curve, the concavity of which (supposing 
 the arm to hang by the side) was directed forwards, while along the 
 ulnar margin was seen an equally remarkable convexity. The hand 
 and carpus were in the position of extreme abduction. The dorsal 
 surface of the limb presented equally remarkable features. It was 
 curved to a great degree ; the hollow of the curve (the limb 
 being in the position mentioned above) was directed backwards. 
 Above, it faded away insensibly, but below it ended abruptly at 
 the margin of a tumour, which, extending from the radial to the 
 ulnar border of the limb, constituted a most striking feature of the 
 injury, and was, of itself, diagnostic of the nature of the injury 
 
 Fig. 151. — Compound separation of the 
 lower epiphysis of the eadius, with 
 feactuee of the ulna. palmar aspect 
 (after e. w. smith) 
 
 Fig. 152. --the sajie, dorsal aspect 
 (r, w. smith) 
 
 which the bones had sustained. This tumour gave to the back of 
 the hand an elongated appearance. 
 
 The condition of affairs disclosed by dissection was as follows : 
 The radial epiphysis was found still connected with the scaphoid 
 and lunar bones. The ulna was fractured directly above its 
 epiphysis, and the lower fragment displaced backwards in such 
 a manner as to form with the upper an angle salient in front. The 
 dorsal tumour was thus constituted by the carpus, the radial 
 epiphysis, and the lower fragment of the ulna, forming one system 
 of parts, carried backwards, and giving to the hand its lengthened 
 appearance and its resemblance to a luxation of the carpus in that 
 direction. In the sulcus which marked the termination of the 
 posterior curvature and the commencement of the dorsal tumour, the 
 relaxed integument was thrown into transverse curved creases, whose 
 concavities were directed downwards towards the hand. They closely 
 resembled the crescentic folds seen above the displaced phalanx in 
 many cases of Hey's luxation of the thumb. 
 
 In a case mentioned by E. H. Bennett the separated radial 
 epiphysis was accompanied by a fracture of the ulna close above 
 
512 EPIPHYSES OF UPPER EXTREMITY 
 
 the epiphysial hne, and a similar fracture is present in one of the 
 specimens in St. Bartholomew's Hospital Museum. 
 
 In one of the specimens in the London Hospital Museum the 
 fracture of the ulna was almost transverse, and an inch and a 
 quarter from the extremity of the styloid process. 
 
 Labadie-Lagrave records {Bull, de la Soc. Anat. 1868, Paris 1874, 
 p. 240) a case of compound separation in which the epiphysis was 
 very cleanly and completely detached, with the exception of some 
 small scales from the diaphysis adhering to the outer part of the 
 circumference of this epiphysial fragment ; the diaphysis protruded 
 through a large lacerated wound of the skin on the anterior aspect 
 of the forearm at the level of the upper articular crease. Its end 
 appeared to be covered with a thin cartilaginous layer, which at first 
 sight might have been mistaken for a compound dislocation of the 
 wrist. The carpal ends of the radius and ulna preserved their normal 
 relations with the carpus. The carpal ligaments were perfectly intact. 
 The ulna was also transversely fractured at its neck, one centimetre 
 above the articular surface. The injury occurred in a lad, aged six- 
 teen years, who died in two hours in a comatose state from injuries 
 to the head, the result of a fall from the fourth story of a house. 
 He was under the care of M. Maisonneuve at the Hotel-Dieu. 
 Attempts by powerful traction were made, during life, to reduce the 
 displaced fragments, but without success. 
 
 There was great increase in the antero-posterior diameter of the 
 hand, with the usual characteristic ' fork back ' deformity, and the 
 hand, slightly flexed, incline! to the ulnar border at the same time 
 that it appeared to be thrown (as a whole) towards the radial side, 
 so that the hand made an angle with the forearm, which was 
 open outwards. The forearm was in a position midway between 
 pronation and supination. 
 
 Fracture of both bones of the forearm. — W. Korte junior, at the 
 Berlin Medical Society {Berliner Minische Woch. Berlin 1880, 
 No. 3, May 18, S. 263), showed a specimen of separated radial 
 epiphysis and incomplete fracture of both bones of the forearm 
 from a boy, aged eighteen. The separation of the lower end of the 
 radius was perfect, but was not detected before dissection, although 
 a careful examination had been made of the part. The boy had got 
 his right arm caught between the barrel and the driving-strap of a 
 machine, so that the limb was torn off at the middle of the humerus. 
 Amputation at the shoulder was performed and terminated in 
 recovery. 
 
 On examination the forearm was seen to be semipronate and 
 bent like a bow with the concavity backwards ; the hand was also 
 bent backwards, but no fracture of the bones could be made out. 
 Subsequently there was found to be a complete solution of 
 continuity of the radius in the epiphysial line, although the 
 epiphysis was still connected with the diaphysis by means of the 
 
SEPAEATION OF LOWEK EPIPHYSIS OF EADIUS 513 
 
 periosteum. The radius was incompletely fractured fifteen centi- 
 metres higher up, and also the ulna five centimetres above the 
 wrist-joint ; in both, the dorsal fibres of the bones still held the 
 bones in position, although the anterior fibres were ruptured. 
 
 Dr. Korte thought that by the accident the hand was first of all 
 bent backwards and the epiphysis of the radius thereby separated, 
 which was analogous to a fall upon the hand bent backwards, and 
 that on further bending of the forearm the ulna yielded, and then the 
 radius, at their thinnest parts. 
 
 Dislocation of Ulna. — Professor E. M. Moore, of Rochester, U.S.A., 
 mentioned in a letter to the author (September 1893) that he had in 
 his possession an excellent specimen of epiphysial fracture of the 
 lower end of the radius, accompanied with luxation of the lower 
 end of the ulna, from a boy, aged fifteen, who was killed by 
 machinery. Unfortunately no details were given. 
 
 Dislocation of the ulna was also present in De Paoli's case 
 described above. 
 
 Wounds. — These are much more frequent complications in 
 epiphysial separations than in the corresponding fractures in adults, 
 probably owing to the greater amount of force required in the former 
 case and to the thinness of the anterior edge of the projecting 
 diaphysis. 
 
 In the Archives generales de Medecine (1867, vol. ii. p. 228; 
 Gazette medicale de Strasbourg, No. 7, 10 Juin, 1867) Dr. E. 
 Boeckel gives the following description of a case of compound 
 separation followed by sloughing of the forearm. 
 
 A boy, aged twelve years, while endeavouring to climb a tree, fell 
 to the ground a height of about eight metres upon the outstretched 
 hands, producing a serious injury to the left wrist. The surgeon 
 who saw the case stated that the lower extremity of the radius had 
 passed through the integument of the anterior aspect of the fore- 
 arm, and, finding this bone covered with a layer of cartilage, he 
 believed it to be a dislocation of the wrist. The displaced bone was 
 immediately reduced and kept in position by a suitable apparatus ; 
 sloughing of the forearm, however, soon ensued, and only stopped at 
 the elbow. Dr. Boeckel performed amputation of the arm ten days 
 after the accident, and the patient recovered. On examining the 
 limb he found the following lesions : the lower epiphysis of the 
 radius, five millimetres thick, was separated, together with the 
 epiphysial cartilage, from the shaft of the bone ; on its posterior 
 aspect it was surmounted by a fragment of the cortical layer of the 
 diaphysis, which had been torn off. A strip of the periosteum was 
 still intact on this side. The end of the diaphysis was eroded by the 
 pus, and on a fair v;ay to necrosis. The ulna was divided by a 
 transverse dentate fracture, three centimetres above its lower 
 extremity, but the wrist-joint was not opened. 
 
 Gripat records {Bidl. de la Soc. Aiiat. 1872, Paris, 1874, 
 
 L L 
 
514 EPIPHYSES OE UPPEE EXTEEMITY 
 
 p. 176) a case in which the lower epiphyses of both radii were 
 separated. 
 
 On the right side the injury was compound, the end of the 
 diaphysis protruding through the soft parts, and some fragments of 
 bone were detached from the posterior margin of the diaphysis, but 
 remained attached to the epiphysis. The diaphysial end presented 
 some small particles of cartilage, and was stripped of its periosteuna 
 in front, but more especially behind. With this exception the 
 epiphysial cartilage remained with the epiphysis. The specimen was 
 obtained from a boy, aged thirteen and a half years, who died from the 
 effects of a fall from a third story. There were other injuries present 
 
 viz. fracture of the skull and coronoid process of the ulna, with 
 
 dislocation of the elbow-joint, as well as dislocation of the hip-joint. 
 Eichet mentions {Gaz. des Hopit. 1865, pp. 145-147, and Bull, 
 de la Soc. de Chiriirg. 1865, p. 528) the case under the care of M. 
 Denonvilliers of a boy, aged fifteen years, who had fallen upon his 
 hand. The end of the diaphysis of the radius projected between the 
 flexor tendons through the skin in front of the forearm ; the projecting 
 end was removed by a chain-saw, on account of the impossibility of 
 reduction. The bone on removal was found to be covered with 
 several thin lamellse of the epiphysial cartilage, so that the separation 
 was thought to have occurred tlirough the epiphysial cartilage itself. 
 Eecovery took place. 
 
 M. Manquat records {Les decollements epiphysaires traumatiques, 
 These de Paris, 1877, p. 37) a precisely similar case observed by 
 Pean. The projection of the diaphysis through the wound and 
 the separated epiphysis bore the same characters. Eesection of 
 the diaphysis was followed by cure. 
 
 At Guy's Hospital in 1870 Mr. Cock had the case of John D., 
 aged sixteen years, under his care. While at work in a sawmill 
 his left hand became entangled in the band driving the machine, 
 and was carried upwards several times, knocking his legs and arms 
 against the beam above. A compound separation with displacement 
 of the lower radial epiphysis was found, together with simple fracture 
 of the lower third of the shaft of humerus and severe contusion of the 
 right leg. Eeduction could only be effected after the removal of half 
 an inch of the end of the radial diaphysis by means of a saw. Ee- 
 covery ensued after some suppuration and necrosis of the right tibia. 
 M. Curtillet describes {Du decollement traumatique des qjiphyses, 
 Lyon, 1891) a case of compound separation in a boy aged six years, 
 who had fallen upon his hand. There w^as the usual deformity of 
 displacement backwards of the epiphysis, and on the anterior aspect, 
 just above the wrist, a transverse wound through which the end of 
 the diaphysis, completely detached from the epiphysis and stripped of 
 its periosteum, protruded with its characteristic uniform, flat, and 
 somewhat granular surface, and mossj'-looking rounded margins. 
 There was no fracture of the ulna. 
 
SEPAEATION OF LOWEE EPIPHYSIS OF KADIUS 515 
 
 Under an anaesthetic, after the wound and bone had been carefully 
 cleansed from dirt, pebbles, and other filth, and disinfected, it was 
 found that reduction could not be effected ; the wound was therefore 
 enlarged perpendicularly by an incision three centimetres in length. 
 The end of the diaphysis was then easily and completely reduced. 
 The articulations about the wrist were found to be intact. A strip 
 of iodoform gauze was used for drainage, the wound closed by three 
 sutures, and a plaster splint applied. The wound was dressed about 
 the twentieth day, but there was no suppuration, and the patient left 
 the hospital shortly afterwards. 
 
 When examined ten months after the accident there was no 
 deformity of the wrist, with the exception of slight prominence of 
 the lower end of the ulna, and the movements of the wrist, as well 
 as those of pronation and supination of the forearm, were quite 
 natural. The patient could then use his hand freely for writing and 
 other purposes. 
 
 There was slight diminution in the length (half centimetre) of- 
 the radius, which was probably the result of slight transient dis- 
 turbance of ossification, so frequently seen in many epiphysial detach- 
 ments, and Dr. Curtillet did not think that it would be followed by 
 any more serious disturbance of growth. 
 
 In all the other compound separations observed by R. W. 
 Smith, Bennett, Hilton, Cock, Annandale, and Labadie-Lagrave, 
 already mentioned, the wound was situated on the palmar aspect 
 of the forearm in close proximity to, or just above, the wrist. In 
 Hartmann's case it was on the inner side of the anterior aspect. 
 
 The cases of Messrs. Cooper Forster and Hilton at Guy's 
 Hospital were also compound ; in the last-named primary amputation 
 was performed. 
 
 In more than one case the end of the diaphysis of the radius 
 has been mistaken for a compound dislocation of the radius — an 
 error it is difficult to imagine, considering the presence of the articular 
 cartilage covering the concave end of the bone in the latter form of 
 injury. 
 
 In Hilton's case of compound separation of the carpal epiphyses 
 of both radii, on the right side there were two wounds anteriorly, 
 laying bare the flexor tendons, but not exposing the bone ; one was 
 thought to have been caused by the protrusion of the diaphysis, 
 whilst the other was probably producecR by severe flexion of the hand 
 backwards, causing great tension of the skin in front, which then 
 gave way. On the left side the smooth diaphj'sial end of the bone 
 projected through a wound anteriorly, and was associated with an 
 oblique fracture of the shaft of the ulna one and a half inches above 
 the wrist-joint. 
 
 Bruns collected five cases of compound separation of this epiphysis. 
 
 J. Hutchinson junior found ten compound cases among fifty-four. 
 
 The author has collected fourteen cases. 
 
516 EPIPHYSES OF UPPER EXTREMITY 
 
 Pressure upon the radial nerve from the displacement of the epiphysis 
 has only been noted in one case, that of Brmmer described below ; 
 but the occurrence of this may be easily brought about in cases of 
 great displacement. 
 
 Pressure upon the median nerve by the displaced diaphysisin Hilton's 
 case was thought to have been the cause of the tetanus from which 
 the patient died on the seventh day. 
 
 Injury of radial artery. — Pressure upon the radial artery by the 
 lower end of the diaphysis projecting in front has never occurred. 
 
 Othee seveee lesions. —In most of the cases in which separa- 
 tion of the lower radial epiphysis has been found on dissection the 
 injury is an insignificant one in comparison with the injury which 
 proves fatal. 
 
 Fractured skull. — Of the twenty-one pathological specimens death 
 was caused in eleven by a more or less extensive fracture of the base 
 of the skull, after a fall from a height. It is probable that many 
 more of these specimens were taken from patients after similar 
 severe accidents, although it is not especially noted. 
 
 Among ten cases of compound separation death ensued in three, 
 and in all of these from extensive fractures of the skull ; in one after 
 a fall from a parapet sixteen feet high ; the second, after a fall from 
 the third story ; and the third after a fall from the fourth story of 
 a house. 
 
 Severe abdominal lesion. — Laceration of the kidneys and intra- and 
 extra-peritoneal haemorrhage were the cause of death in the case from 
 which one of De Paoli's specimens was taken. Complete rupture of 
 the kidney and fracture of thigh and multiple contusion complicated 
 Hartmann's case. Rupture of the small intestine occurred in Mr. 
 Shattock's case after a fall of twelve feet from a window. 
 
 Dislocation of the forearm backwards. — In three cases De Paoli 
 found the separation of the radial epiphysis accompanied by a dis- 
 location backwards of the bones of the forearm. 
 
 Compound dislocation of forearm backwards. — Galand (These de Paris, 
 1834, No. 196, p. 23) mentions the case of a youth under the care of 
 M. Roux in 1834. The patient had fallen from a tree, and was 
 thought by M. Roux to be the subject of two dislocations of the left 
 arm — one being of the elbow, compound, and another of the wrist, 
 both being backwards. M. Roux reduced the supposed dislocation 
 of the wrist with difficulty, but it tended to be reproduced. At the 
 time he had no doubt as to the correctness of his diagnosis. The 
 patient died some days later, when, to the astonishment of M. Roux, 
 a separation of the lower epiphysis of the radius was found on 
 dissection. 
 
 Kramer (Monatsschrift filr UnfaUheilkunde, 1897, No. 4) relates 
 a similar interesting but more successful example of compound 
 separation of the lower radial epiphysis complicated with compound 
 dislocation of the forearm backwards at the elbow. A boy, aged 
 
SEPAEATION OF LOWER EPIPHYSIS OF EADIUS 517 
 
 twelve years, whilst quickly running, fell, alighting first on the 
 palm of the right hand, then on the ground with the weight of his 
 whole body. The arm having lost its proper support through the 
 solution of continuity of the radius, the whole weight of the body 
 appeared to have been violently received upon the inner aspect of 
 the flexed forearm, which slid to the ground ; this, giving rise to 
 forcible abduction and perhaps also to rotation of the forearm, led 
 to laceration of the internal, lateral, and anterior ligaments, &c., of 
 the elbow-joint, and ultimate perforation of the skin by the lower 
 end of the humerus impinging against the flexure of the elbow. 
 The lower radial diaphysis appeared through a wound on the volar 
 side, while at the flexure of the right elbow there was an oblique 
 wound through which a good deal of haemorrhage occurred. The 
 ulnar artery was crushed, the vein lacerated, and the median nerve 
 torn through for a third of its distance. At the operation the 
 dislocation was reduced, the nerve sutured, and the radial epiphysis 
 replaced and secured by two silver sutures. Eecovery took place 
 without any untoward result. After six and a half weeks extension 
 of the elbow-joint was almost complete, but flexion was only 
 possible up to 100°. Pronation and supination were very restricted. 
 The wrist and finger-joints were almost free in their movements. 
 Later on functional restoration had considerably improved, yet the 
 forearm appeared to have been somewhat retarded in its growth in 
 length. 
 
 Incomplete fracture of the radius, &c. — De Paoli noted fracture of 
 the coronoid process of the ulna in one case, and in another incomplete 
 fracture of the radius in the middle, with dislocation forwards of the 
 ulna at the hand. 
 
 Later complications. Gangrene of hand and forearm. — R. W. 
 Smith mentions {Treatise on Fractures and Dislocations, Dublin, 
 1854, p. 170) the case of a boy, aged eighteen years, who had 
 a fracture of the lower extremity of the radius, through the line of 
 junction of the epiphysis with the diaphysis, caused by being thrown 
 from a horse. A surgeon applied, within an hour, a narrow roller 
 bandage tightly round the wrist. On the following day the limb 
 was intensely painful, cold, and discoloured ; still, the bandage was 
 not removed, nor even slackened. On the fourth day he was admitted 
 into the Richmond Hospital, when gangrene was found to have 
 reached the forearm. Spontaneous separation of the soft parts 
 finally occurred, and the bones were sawn through twenty-four days 
 after the accident ; afterwards ' everything proceeded favourably.' 
 
 'Rogneiid, {Gazette Medicate, Paris, 1834, p. 514) records the case 
 of a youth, aged fifteen years, who fell from a tree, dislocating his 
 forearm backwards, and injuring the wrist of the same side. He 
 was thought to have a dislocation of the wrist as well as the elbow. 
 The parts were replaced somewhat in their natural position, and a 
 retentive apparatus was applied ; intense phlegmonous inflammation 
 
518 EPIPHYSES OF UPPEE EXTEEMITY 
 
 and gangrene ensued, followed by death. At the autopsy it was 
 found that the supposed dislocation of the wrist was in reality a 
 perfect separation of the lower end of the radius. 
 
 Gangrene of the arm also followed in Barbarin's case (see above) 
 of separation of the lower epiphysis of radius and ulna, and gan- 
 genous cellulitis ensued in Dr. Boeckel's case of compound separation 
 of the radius. 
 
 Suppuration of forearm or phlegmonous inflammation of limb has been 
 noted in a few instances. In one instance of complete displacement 
 of the epiphysis recorded by Hutchinson reduction was found 
 exceedingly difficult, and suppuration subsequently occurred, but the 
 arm was saved. 
 
 Suppuration is a not uncommon result in compound separations. 
 Mr. Stonham's case of compound separation of the epiphyses of radius 
 and ulna is a notable instance. 
 
 Necrosis of the diaphysis has been a not infrequent result in com- 
 pound cases. In Boeckel's case the end of the diaphysis was infiltrated 
 with pus and about to become necrosed. 
 
 Necrosis followed resection in Mr. Cooper Forster's case of 
 compound diastasis. , 
 
 Tetanus, — In Hilton's case tetanus occurred on the sixth day, 
 after compound separation of the carpal epiphyses of both radii, and 
 terminated in death the following day. This surgeon says : ' The 
 median nerve could scarcely have escaped injury at the time of the 
 accident, lying as it does in the midst of the tendons, through which 
 the fractured bone protruded.' 
 
 The following remarkable case of traumatic tetanus is recorded 
 by Brunner {London Medical Becord, July 15, 1886, p. 298), in which 
 compression of the radial nerve was caused by a separation of the 
 lower radial epiphysis. Upon resection of the bulky callus and freeing 
 of the radial nerve the symptoms disappeared. 
 
 A boy, fourteen years old, was admitted to Conrad Brunner's 
 ward in Ziirich for a fracture of the left radius which had occurred 
 three weeks previously. The fourteenth day after the fracture the 
 child found that he could not extend the fingers of the left hand, and 
 his parents noticed that when he walked he was bent forward. The 
 symptoms became gradually more marked, so that on his admission 
 the symptoms of tetanus were evident — sardonic laugh, teeth firmly 
 set, complete emprosthotonos, the head resting against the breast. 
 There was evidence of a badly reduced fracture of the epiphysis of 
 the radius, and bulky callus just below the articulation. It seemed 
 evident that the tetanus resulted from pressure of the radial nerve 
 by new formations connected with the callus, and this was proved 
 by operation. The nerve was set free, the prominent portion of the 
 radius being resected, and the symptoms of tetanus slowly disappeared. 
 The patient was given morphine injections. Three weeks after the 
 operation he was cured. 
 
SEPAEATION OF LOWEE EPIPHYSIS OF KADIUS 519 
 
 Articular inflammation is rarely met with, notwithstanding the 
 proximity of the joint. It would ensue in fracture of the epiphysis 
 into the joint, as has been found in one of the specimens in St. 
 Bartholomew's Hospital. 
 
 Suppurative periostitis. — Suppurative periostitis was present in 
 Hilton's case of compound separation of the epiphysis, and probably 
 was associated with the death of the patient on the seventh day, 
 although this was said to have taken place from tetanus. Both 
 bones were removed after death with their epiphyses detached. The 
 specimens from the left wrist were bloodless, saturated with foetid 
 pus, and dead. This resulted from the periosteum having been 
 stripped off the bone at the time of the accident ; the bone being 
 thus deprived of its proper medium of nutrition, there resulted the 
 death of bone and the purulent condition associated with it. 
 
 This serious complication may arise even in cases of simple 
 separation. 
 
 A case of acute osteomyelitis following injury to the lower epi- 
 physis of the radius is related by Mr. Page {British Medical Journal, 
 July 20, 1889, p. 131). 
 
 On June 17, 1887, A. B., aged seventeen, a groom, was lifting a 
 horse-collar down from its peg when, because of his insecure hold 
 of it, the collar slipped back, and his right wrist was, as he thought, 
 sprained. In about three hours his wrist began to be painful, but 
 he continued at his work both on that and the next day. On the 
 21st he first noticed swelling of the wrist, and on the 23rd he came 
 to St. Mary's Hospital. His temperature was 103*4° F., and there 
 was some swelling on the flexor side of the wrist, which was also 
 hot and tender. The next day an incision was made under most 
 careful antisepsis, and a small quantity of clear serous fluid evacuated 
 from the sheath of one of the tendons, but the periosteum was not 
 opened. On the 26th examination of the wound led to the suspicion 
 that he had acute inflammation of the radial epiphysis as the result 
 of some injury sustained by it when the wrist was supposed to have 
 been merely sprained. On June 30 fluctuation, redness, and swelling 
 extended to the dorsum of the limb, and an incision was made on the 
 back of the wrist and pus was let out from beneath both skin and fascia. 
 It was then found that the whole lower end of the radial shaft was 
 quite bare. Some improvement followed, but did not last long. The 
 pus increased in amount, and soon began to burrow up the limb ; next 
 there was suppuration in the upper arm, then the elbow-joint became 
 , involved, so that amputation of the arm was performed in the 
 middle third on July 19. Then he rapidly got well. 
 
 Examination showed that the periosteum had been stripped up 
 from the shaft of the radius to a distance of five inches, but there 
 was no inflammation of this part of the bone. The epiphysis, 
 however, was quite detached, and what remained of it presented all 
 the indications of having been affected by an acute destructive septic 
 
520 EPIPHYSES OF UPPEK EXTKEMITY 
 
 inflammation. It was soft, completely broken down, and infiltrated 
 with pus. It was, indeed, abundantly clear that the beginning 
 of the mischief had been in the epiphysis itself, that in all 
 probability there had been some separation of it from the shaft, and 
 that the unhealthy character of the boy's occupation had determined 
 the virulent septicity of the inflammation which so speedily super- 
 vened. AVhether at the time of the accident there had been likewise 
 detachment of periosteum it is impossible to say w"ith certainty. 
 
 Fycemia has occurred in more than one case, and been followed 
 by death. 
 
 Displacement forwards. — Forward displacement of the epiphysis is 
 probably not so rare an occurrence as has been hitherto supposed. 
 
 In this injurj^ the epiphysis is driven towards the anterior or 
 flexor aspect of the wrist. 
 
 A case of M. Denonvilliers's is reported by Professor Pichet 
 {Anatomie cJiirurgicale, 4 ed. p. 90) of a child about eight years of 
 age, in which the upper fragment or diaphysis protruded on the 
 dorsal aspect of the forearm. The osseous projection was at first 
 taken to be the lower end of the radius, but the irregularity of the 
 surface of the fragment and the fact of its bristling with cartilaginous 
 projections clearly showed that it was a true solution of continuity 
 in the conjugal cartilage, and not a simple separation. Resection of 
 the end was rendered necessary, and the patient completely recovered, 
 without any untoward symptoms. 
 
 M. Pean observed a precisely similar case in the year 1856. 
 This patient likewise recovered in a short time without the occurrence 
 of any complications. 
 
 M. Eoux {La Presse Medicale, July 12, 1837, vol. i.) describes 
 the following case, in which there was disjunction of the lower epi- 
 physis of the radius, of the styloid epiphysis of the ulna, of the 
 upper epiphysis of the first phalanges of the thumb, and of the index 
 and middle fingers of the left hand. 
 
 On July 22, 1821, the patient (M. A., a porter), when packing 
 boxes, had his hand and forearm severely injured by an ex- 
 plosion of gunpowder. On his being taken at once to the hospital, 
 it was found that the thumb and middle finger were held to the 
 hand merely by the extensor tendons, the index finger had been 
 completely blown off (this was found some days afterwards in a 
 house near the scene of the accident), while the last two fingers 
 were uninjured. The soft parts covering the carpus and metacarpus 
 were severely contused, lacerated, and blackened by the powder. 
 The forearm was also extensively injured. The ulna was fractured at 
 its lower fourth. The lower end of the radius projected outwards 
 through the skin and muscles on the dorsal aspect ; it did not present 
 the smooth polished appearance of the articular surface, but was more 
 rough, and not so large in size. Amputation through the lower third 
 of the forearm was the only treatment to be adopted, and was per- 
 
SEPAEATION OF LOWEK EPIPHYSIS OF EADIUS 521 
 
 formed five or six hours after the accident. Kapid recovery took 
 place. M. Eoux subsequently made out the following lesions : — 
 
 (1) The pisiform bone had been carried av^^ay, as well as the index 
 finger mentioned above. (2) The ulna was fractured in its lower 
 fourth. (3) The shaft of the radius was separated from its lower 
 epiphysis, as well as the styloid epiphysis of the ulna ; and the shafts 
 of the first phalanges of the thumb, of the index and of the middle 
 fingers were separated from their upper epiphyses, which remained 
 connected with the bones of the metacarpus. Eoux states that he 
 sent the specimen to the Musee Dupuytren. 
 
 The fohowing description of a dwarfed radius, with displacement 
 forwards of its lower epiphysis (?), is given by the great surgeon 
 Dupuytren {Injuries and Diseases of the Bodies, translation, 
 Sydenham Society, 1847, p. 129), and is worthy of being quoted in 
 detail. 
 
 ' The subject of this pathological condition was an adult female, 
 respecting whom no history could be obtained. The forearm seemed 
 shorter than natural. The lower extremities of the radius and ulna 
 formed a considerable prominence beneath the skin, that of the 
 radius, however, being less marked and not descending so low as 
 that of the ulna. The upper extremity of the carpus was on a 
 plane superior and anterior to that of the lower extremity of the 
 bones of the forearm. The hand formed a right angle with the 
 forearm, and was also inclined towards its radial side ; and this 
 inclination could be extended so as to bring their outer borders into 
 contact. Extension was impracticable, but flexion could be carried 
 much beyond a right angle. On dissection, M. Cruveilhier found 
 that all the muscles of the arm were atrophied ; but this condition 
 principally affected the muscles acting on the wrist-joint and radio- 
 ulnar articulations — viz. the radial and ulnar flexors and extensors, 
 and the pronators and supinators. The tendons of the radial and 
 common extensors were lodged in a deep groove which existed at 
 the posterior surface of the lower extremity of the radius ; to this 
 osseous excavation they were firmly adherent. The extensor carpi 
 ulnaris was reflected at a right angle from the ulna, to be inserted 
 in the fifth metacarpal bone ; the flexor carpi ulnaris was shrunken, 
 and terminated as usual in the pisiform bone. The carpus pre- 
 sented a singular deformity. The upper row of bones, reduced to a 
 rudimentary condition, had lost their form and their volume, being 
 diminished to less than half of their normal size. The pisiform 
 bone alone remained unchanged. The corresponding surfaces of 
 the second row were likewise altered. There only existed trifling 
 rudiments of the os magnum and unciform bone ; and in like 
 manner the upper half of the trapezium and trapezoid, which 
 should articulate with the scaphoid, was contracted. The ulna, 
 which was very little changed in form, was prolonged five or six 
 lines below the extremity of the radius ; but a little above its 
 
522 EPIPHYSES OF UPPEK EXTKEMITY 
 
 inferior extremity, at a height corresponding to the lower end of the 
 radius, it presented a deep excavation to receive an articular apo- 
 physis of the latter bone. It was united to the cuneiform bone by 
 means of an extremely long ligament, which permitted of very 
 considerable abduction of the hand. The radius was shortened and. 
 deformed, and the latter defect was principally observable at its 
 lower extremity, which was enlarged and presented an appearance 
 as if it had been crushed. It was also deeply grooved posteriorly 
 for the united extensor tendons. 
 
 * There was a sort of transposition of the articular facet of the 
 radius, which occupied the outer side of this extremity, whilst a 
 prominent apophysis on the inner side articulated with the ulna. 
 Lastly, the shaft of the radius was more voluminous than in its 
 natural state, and the lines and elevations marking the insertion of 
 muscles were unusually prominent. Its upper extremity, instead 
 of being excavated to receive the smaller head of the humerus, 
 was convex, and its circumference appeared as if battered. 
 This case is given by M. Cruveilhier as an instance of dislocation 
 backwards of the forearm or the hand, or of the wrist forwards, but 
 it is impossible to account for many of the appearances on the 
 supposition of dislocation having existed. Thus, for example, in all 
 dislocations the displacement of a bone on one side of an articulation 
 always involves the inclination in an opposite direction of the lever 
 which it represents, whereas here the hand is in front. But why is 
 the articular surface found upon an apophysis above the joint? 
 Why is the radius so much curtailed of its length, whilst the ulna, 
 which was at least luxated with it and retained even less mobility, 
 is half an inch longer below ? On the supposition that there had 
 been fracture or separation of the epiphysis, there is no difficulty in 
 explaining and linking together all these phenomena. It is probable 
 that the accident occurred in infancy, and thence atrophy of the 
 carpal bones. It is further likely that the fracture was the conse- 
 quence of a fall on the back of the hand, in which case the violence 
 of the shock would have thrown the epiphysis of the radius forwards 
 together with the hand. In this way one may conceive that the 
 extensor muscles would have been but little stretched ; for if the 
 fragments were separated in respect of their thickness, they were 
 approximated in point of length. On the contrary, if there had 
 been dislocation, the amount of tension would have corresponded to 
 the breadth of the articular surface of the radius, which would have 
 been very great. Again, the separation of the epiphysis accounts 
 for the unusual apophysis which supports the new articulation, and 
 the dislocated ulna is, as it should be, longer than the broken radius. 
 It may be further observed that atrophy of the bones would follow 
 long disuse of the limb consequent on dislocation of the radio-carpal 
 articulation, and motion would become impracticable, whereas in 
 the present instance the joint could be flexed. AVe may therefore 
 
SEPAEATION OF LOWEE EPIPHYSIS OF EADIUS 523 
 
 conclude that the case in question is one of dislocation of the ulna 
 backwards, with fracture of the radius and displacement of the 
 inferior fragment forwards — a very remarkable case, without doubt, 
 but at the same time one which does not touch the disputed question 
 of dislocations of the wrist.' 
 
 It has already been stated that J. B. Eoberts {Fracture of the 
 Badius, Philadelphia, 1897, p. 42) experimentally produced epiphysial 
 separation with anterior displacement by extreme flexion of the wrist 
 on the amputated arm of a boy aged fourteen years. He also (p. 26) 
 gives a drawing of a specimen in the Miitter Museum of the College 
 of Physicians, Philadelphia, in which it seems probable that the 
 injury was an epiphysial fracture with moderate anterior displace- 
 ment. 
 
 Fig. 153. — pkobadle epiphysial fbactuee with moderate 
 displacement forwards 
 
 Miitter Museum, Philadelphia. (After Eoberts) 
 
 SYMPTOMS. — M. Colignon, in his thesis, 1860, has described at 
 some length the signs of this lesion, and Manquat likewise made 
 (1877) some attempt in the same direction. 
 
 Writing in 1884, Packard (International Enci/clojJt^dia of Surgery, 
 vol. iv. 1884, p. 171) dismisses this important subject as follows : 
 ' Epiphysial separations of the lower end of the radius have been 
 spoken of by some authors ; but they do not present any special 
 features as compared with ordinary fractures in this region.' 
 
 Sepaeation of the Lowee Eadial Epiphysis without Dis- 
 placement. — The lower epiphysis of the radius may be separated 
 without any displacement, and the injury is usually looked upon as a 
 sprain or severe contusion. These cases are of great importance from 
 their liability to be overlooked and their tendency to be followed by 
 arrest of growth of the shaft. Some authors believe that they are 
 more common in the first few years of life than later, but this does 
 not appear to be borne out by any clinical facts. 
 
 There will be pain about the wrist, especially on pressure over 
 the epiphysial line of the radius, but there will be none over the line 
 of the joint, provided no extravasation has taken place there. 
 
 Mobility of the epiphysis in the antero-posterior direction, but 
 not laterally, is always present at the line just mentioned ; it is more 
 limited than when displacement is present. Care must be taken 
 
524 EPIPHYSES OF UPPEE EXTEEMITY 
 
 not to confuse this with the movement at the wrist-joint, for the 
 conjugal cartilage is only five or six millimetres above the wrist. 
 
 Impaired active movement of the hand. — The hand may be more or 
 less helpless ; flexion may be performed fairly well, as well as 
 extension, but pronation and supination are impaired to some extent, 
 or even become quite impossible. 
 
 There is no deformity, but Colignon mentions that a slight depres- 
 sion at the seat of separation may be felt in certain cases during trac- 
 tion on the hand, when there is no considerable swellmg. He does 
 not appear, however, to have met with it in any case. 
 
 Muffied crepitus may be present or absent. Colignon thought it 
 was not often present in this form of injury in very young subjects. 
 
 Some swelling will rapidly occur, especially towards the dorsal 
 aspect of the forearm, from the detachment of the periosteum, and 
 from extravasation of blood into it and the soft parts. Although it 
 may extend over the lower part of the forearm, it will not, as a rule, 
 be found to extend as far as the line of the wrist-joint, the cutaneous 
 folds in this situation still remaining visible. 
 
 In other cases the swelling may be as marked on the palmar 
 aspect, or even confined to it. 
 
 Colignon believed that this form of separation took place most 
 frequently in the newly born and in early infancy, and that the pain 
 was less acute and the swelling moderate ; absence of deformity 
 and presence of soft crepitus distinguished it from separation with 
 displacement. 
 
 In seventeen cases which came under the observation of De 
 Paoli, the majority were incomplete separations occurring after 
 violence applied to the hand. They were characterised by very 
 acute pain, localised to the line of the epiphysial cartilage, absence 
 of distortion, loss of power of the forearm, especially in pronation 
 and supination — all of which he had at one time believed to be 
 merely the effect of some more simple injury, or of traumatic dis- 
 tension of the synovial sheaths, but now considered to be merely 
 more or less extensive solutions of continuity of the epiphysis from 
 the diaphysis, with slight extravasation of blood between their 
 surfaces and under the periosteum, which is more or less widely 
 separated. 
 
 Sepaeation of Lowee Epiphysis of Eadius and Ulna with- 
 out Displacement. — Ozenne {U Union Mklicale, Paris, 1887, 3rd 
 series, xliii. January 4, pp. 13-15) describes a case of simultaneous 
 traumatic separation of the lower epiphysis of the radius and ulna, 
 with inter- epiphysiary separation, in a child aged ten. 
 
 The boy, while wrestling, was thrown on to his back, and in 
 trying to disengage himself with his arms extended, his comrade 
 fell with his entire weight on to the palm of his right hand, which 
 underwent forcible extension. Great pain was experienced at the 
 lower part of the forearm, and on examination six hours after the 
 
SEPAEATION OF LOWEE EPIPHYSIS OF EADIUS 525 
 
 accident the axis of the hand was in a position midway between 
 pronation and supination, but there was no lateral deviation from the 
 axis of the forearm. The fingers were flexed to a right angle with 
 the hand. There was no wound or discoloration of the skin, but 
 slight swelling was evident on the antero-lateral aspect, scarcely 
 any, however, on the posterior aspect of the lower part of the forearm. 
 The styloid processes of the radius and ulna were in their normal 
 relations, and there was no pain or pressure over them. No trans- 
 verse prominence, abnormal projection, or prominence could be 
 detected. No displacement had been effected, and the periosteal con- 
 nections had probably not been destroyed ; on slight pressure, however, 
 by the index fingers pretty acute pain was produced, ten to twelve 
 millimetres above the tip of the styloid process of the ulna, and twelve 
 to fifteen millimetres above that of the radius. This pain existed 
 throughout the whole circumference of the epiphysiary line of 
 junction, less on the posterior aspect, not more intense at the sides, 
 but especially acute on the anterior aspect. In fixing with one 
 hand the lower part of the two bones and seizing the epiphyses with 
 the other, slight abnormal mobility was made out from before back- 
 wards and from behind forwards, but no displacement in the lateral 
 direction. Crepitus was absent. The two epiphyses could be taken 
 separately and displaced from one another with slight mobility, due, 
 no doubt, to some laceration of ligaments. The active movements 
 of the hand were preserved in part, that of flexion being the most 
 extensive, although incomplete ; that of extension was more limited 
 and painful. Pronation, but more especially supination, was very 
 limited. 
 
 Although there was no reduction of the fragments to be made, a 
 moulded splint was applied to the forearm and wrist. By the third 
 day the swelling had disappeared and complete recovery took place, 
 so that by the twentieth day there was perfect use of the limb. 
 
 Hamilton {American Medical Times, August 18, 1865, p. 116) 
 also had under his care in 1860 a case of separation of the lower 
 epiphyses of the radius and ulna in a boy aged nine, who had fallen 
 and struck the back of his right hand and wrist. On the following 
 day motion was detected in both epiphyses, accompanied with the 
 peculiar crepitus belonging to epiphysial separations. Palmar and 
 dorsal splints were employed, and after the lapse of three weeks 
 union was complete without any ankylosis. The splints were then 
 discontinued. 
 
 Separation and Displacement of the Epiphysis back- 
 wards.— As long ago as 1834, Eognetta pomted out some of the 
 symptoms which he observed in a case under his care, in which, 
 however, the displacement does not seem to have been very great 
 {Gaz. Medicale, 1834, p. 514). 
 
 A child, aged five years, while at play had been dragged about 
 the floor in a bowl by his elder brother, who held him forcibly by 
 
526 EPIPHYSES OF UPPEE EXTKEMITY 
 
 one hand. The child gave some piercing cries, and his parents, 
 finding his wrist very painful, thought it had been ' put out of 
 joint.' M. Eognetta saw the child six hours after the accident, and 
 was unable to make a diagnosis on account of the great tenderness, 
 redness, swelling, and ecchymosis of the wrist. The fingers were 
 semiflexed. But the following day, the swelling and pain having 
 much diminished, separation of the lower radial epiphysis was easily 
 recognised. While holding the forearm, there could be easily made 
 out at the wrist antero-posterior and a little lateral movement, and 
 even a certain degree of rotatory movement. During the backward 
 movement, the displacement simulated a dislocation of the wrist 
 backwards. During pronation and supination, a fragment with a 
 thin border was felt to roll under the examining fingers. There was 
 no crepitus during these movements. The styloid processes of the 
 bones of the forearm were too little developed to allow M. Eognetta 
 to make use of them for the purpose of diagnosis. Two small 
 wooden splints were applied, and remained on the limb for thirteen 
 days. The epiphysis then appeared to be consolidated, and shght 
 movements of flexion and extension were therefore commenced. 
 Eecovery took place without deformity. 
 
 Dupuytren says {On the Injuries and Diseases of Bones, Sydenham 
 Society's translation, 1846, p. 123) that in young subjects separation 
 of this epiphysis is more likely to occur than fracture, as he had 
 seen in many instances. 
 
 MalgaigTie has observed that this injury is perhaps the most 
 common of all epiphysial separations, but he has not described at 
 any length its signs, or pointed out any of its peculiar features, or 
 fio-ured a specimen of it ; however, he mentions one case of his 
 own, and alludes to the cases mentioned by Eoux, Cloquet, and 
 Johnston. 
 
 Nelaton did not consider an accurate diagnosis of this injury to 
 be possible, but it might be presumed to have occurred before the 
 twentieth year. 
 
 M. Dolbeau, during the discussion at the Societe de Chirurgie of 
 Paris in 1865, pointed out the distinguishing characteristics of this 
 lesion from fractures of the wrist, the form of the diaphysial frag- 
 ment, the mechanism of the injury, its relative frequency, and its 
 complications. 
 
 B. Anger, in his Traite iconographique des fractures et luxations, 
 notes the similarity of the deformities to fracture of the lower end 
 of the radius in a case of separation of the lower radial epiphysis 
 with displacement backwards. The accident happened to a young 
 man, a printer, whose arm had been caught in a machine. 
 
 Bruns considers it very probable that separations of the lower 
 radial epiphysis occur more often than any; for although in his 
 statistics of cases verified by an autopsy the radius only stood second 
 in point of numbers, yet he thought that from the fact of their being 
 
SEPAEATION OF LOWEE EPIPHYSIS OF EADIUS 527 
 
 very often uncomplicated and uniting well, they seldom afforded an 
 opportunity for dissection. 
 
 Mr. Hutchinson also says it is not an uncommon accident, and 
 occurs in children where Colles's fracture would occur in the adult. 
 
 In the same connection Professor E. H. Bennett, while enumerat- 
 ing the phenomena of this injury, and speaking of his case {loc. cit. 
 supra), says : ' The casts in this case contrast, as many similar 
 casts in our collection do, with the representations of the deformity 
 in Colles's fracture, in the transverse features of the dorsal and 
 palmar projections, and in the folding of the skin in the palmar 
 depression, and, again, in the absence of abduction of the hand. If 
 we add to all these the necessary reduction of the fracture and the 
 facility of obtaining crepitus, and, still more remarkable, the facility 
 of maintaining the reduced fracture in place, phenomena all long 
 since pointed out by Smith — which, I may state, I have frequently 
 observed and verified myself — there are, I think, ample grounds for 
 questioning the recent statement of Professor Macleod that " there 
 are no distinctive signs by which a separation of it (the radial 
 epiphysis) can be differentiated from an ordinary Colles's fracture." ' 
 
 Agnew dismisses this injury very hastily thus {Surgery, vol. i. 
 1878, p. 903) : ' When the line of fracture is transverse and near the 
 articulating extremity, it may follow the junction of the epiphysis 
 and shaft.' And Packard, writing in Ashhurst's Encyclopcedia, 1884, 
 vol. iv., does the same in a few words, which are quoted on p. 523. 
 The above quotations are sufficient in themselves to demonstrate the 
 great difference of opinion that exists among surgeons as to the 
 occurrence of separation of the lower epiphysis of the radius. 
 
 Deformity. — In some cases there is extreme deformity, the hand 
 together with the epiphysis or lower fragment being carried behind 
 the axis of the forearm, while the upper fragment or diaphysis is 
 projected prominently forwards. 
 
 As in Colles's fracture, the displacement is determined by the 
 direction of the force, usually from a fall upon the palm of the 
 hand. 
 
 The displacement of the epiphysis is very rarely sufficient to allow 
 it to be completely displaced off the upper fragment on to the dorsal 
 aspect, except in compound cases. 
 
 Mr. Jonathan Hutchinson believed that there was complete 
 dorsal displacement in a case figured by him {Archives of Surgery, 
 vol. i. No. 3, January 1890, p. 287), in which the amount of deformity 
 certainly appears to have been very great. 
 
 Two prominences are ordinarily seen in this injury — one on the 
 posterior or dorsal aspect and one on the anterior or palmar aspect ; 
 and two distinct depressions — a dorsal one directly above the promi- 
 nence, and a palmar one below the anterior projection. 
 
 Posterior Promine7ice. — This prominence is not so distinct as 
 the palmar ; it is formed by the upper projection of the lower 
 
528 EPIPHYSES OE UPPEE EXTEEMITY 
 
 fragment together with the carpus and base of the metacarpus. It 
 is directly continuous with the dorsal aspect of the hand. Like the 
 palmar one, it is transverse in its direction, and almost as straight and 
 regular. 
 
 The displacement appears to be more prominent on the radial 
 than the ulnar side, on account of the greater width of the styloid 
 process in this direction, and the displaced epiphysis may occasionally 
 have a backward and shghtly outward inchnation. 
 
 In some cases where the injury has been seen directly after the 
 accident, the lower fragment displaced backwards may be felt quite 
 plainly to have the form of the epiphysis, with its well-known 
 upper margin on the posterior aspect and the prominent middle 
 thecal tubercle. 
 
 The posterior sulcus, just above the projection, is also trans- 
 verse. 
 
 The abrupt angle on the dorsal aspect, formed by the separated 
 radial epiphysis and the shaft, is soon obscured by the effusion of 
 blood beneath the periosteum and into the extensor sheaths, and if 
 the child be at all fat a transverse depression only is to be seen. 
 
 Anterior Frominence. — The prominence in front commences 
 just above the anterior annular ligament and wrist-joint, extends 
 upwards for about two inches, and gradually subsides into the 
 anterior aspect of the forearm above, with which it is continuous. 
 
 It is formed by the lower end of the diaphysis, and by the skin 
 and the soft parts, with the flexor tendons, pushed forwards by its 
 anterior margin. This transverse anterior margin may sometimes be 
 felt projecting across and between the flexor tendons. The palmar 
 projection is abrupt and sharp, quite regular at its anterior margin, 
 and is transverse like the dorsal prominence, but is much more evident 
 than this. It is especially evident in cases examined before swelling 
 has taken place. The angle it forms is more acute than the corre- 
 sponding angle of Colles's fracture. A precisely opposite condition 
 is therefore presented to that met with in the latter injury, in which 
 the dorsal swelling is more marked than the palmar. The lower 
 end of the diaphysis has an appearance very similar in shape to that 
 of the lower end of the entire bone, and the projecting angle on the 
 outer side may be mistaken for the styloid process. Goyrand was 
 the first to draw attention to the straight and regular transverse 
 anterior margin of the diaphysis and the similar posterior border of 
 the epiphysis in those cases observed by him. 
 
 The sharpness and regularity of the diaphysial end is, however, 
 soon obscured, as in the dorsal sulcus, by serous and bloody effusion 
 into and between the sheaths of the flexor tendons. 
 
 In cases of more or less complete displacement backwards of the 
 epiphysis the lower fibres of the pronator quadratus will be lacerated 
 by the projecting diaphysis, and lead to still further effusion of 
 blood. 
 
SEPAEATION OF LOWEE EPIPHYSIS OF KADIUS 529 
 
 Anterior Depression. — Directly below the palmar prominence 
 there is a depression over the wrist-joint. 
 
 M. G. Goyrand, in his article ' De la Fracture, par contre-coup, 
 de I'Extremite inferieure du Radius ' {Journal Hehdomadaire des 
 Progres des Sciejices medicales, 1836, T. i. p. 170), relates the case of 
 a child, aged eleven, who had fallen from a height on to his hands. 
 The right hand was carried backwards at the wrist, close to the 
 articulation. The fingers were flexed. "The upper end of the lower 
 fragment presented, posteriorly, a horizontal angular edge, causing 
 a projection on the dorsal aspect of the forearm — unlike the rounded 
 end of the carpus — whilst the radius made an equally well marked 
 transverse projection in front above the hand. The styloid process 
 of the radius held its normal relations with the carpus. 
 
 The displacement was easily reduced, and the reduction being 
 accompanied by soft crepitus like that met with in the reduction 
 of the displaced articular surfaces, anterior and posterior splints 
 were applied for twenty days, at the end of which time the child 
 had completely recovered. 
 
 The same surgeon published in 1848, in the Bevue Medico-Chirur- 
 gicale, Paris, the following case of separation of the lower epiphysis 
 of the radius, and quotes it again in his paper on separation of this 
 epiphysis read before the Societe de Chirurgie in 1860 {Bulletin de 
 la Societe de Chirurgie, 1861, 2me Serie, t. i. p. 537 ; and Gazette 
 des Hopitaux, 1860, 124, p. 494). 
 
 A boy, aged fifteen and a half years, fell (August 20, 1846) with 
 his two hands stretched forwards. There was great" pain about the 
 left wrist, and deformity, like a Colles's fracture, with impaction. 
 The hand and wrist were carried backwards, so that the axes of the 
 forearm, wrist, and hand made a Z. The tendons of the radial 
 extensors on the outer side were prominent at the line of separation. 
 The transverse and even projection of the lower end of the upper 
 fragment in front was very marked ; its margin could be distin- 
 guished through and between the flexor tendons. Behind, at the 
 level of separation, there existed a transverse depression forming a 
 retiring angle ; the margin of the lower fragment was a little raised 
 and displaced backwards towards the dorsal aspect of the upper 
 fragment, but the projection was not so distinct as the anterior 
 margin of the upper fragment. Movements backwards and for- 
 wards, which M. Goyrand made on the hand, were followed by the 
 lower fragment ; the latter therefore being displaced still more back- 
 wards or carried forwards with it. There was no crepitus. Reduc- 
 tion was easily and perfectly carried out by extension and manipula- 
 tion of the fragment, and there was no attempt of the fragments to 
 become displaced again. Anterior and posterior splints were applied 
 to the hand and forearm, and perfect recovery ensued without any 
 trace of injury on the twentieth day, when the splints were finally 
 removed. 
 
 M M 
 
530 EPIPHYSES OF UPPEE EXTEEMITY 
 
 Buck in 1865 mentioned at the New York Pathological Society 
 (New York Medical Journal, September 1865, p. 462) a case of 
 separation of the lower epiphysis of the radius in a child twelve 
 years old, which was diagnosed by the remarkable square shape 
 of the surface presented by the end of the shaft, its transverse line, 
 and its close proximity to the articular surface. 
 
 Mr. Durham, at Guy's Hospital, in August 1884 had the 
 following case of Ed. Jas.' P., aged twelve years, under his care. 
 The boy fell out of a wagon on to some grass, and on admission 
 there was great pain in the left forearm and great deformity of the 
 wrist. Backward displacement of the hand was found on admission 
 just above the wrist, and a palmar projection a little lower down 
 than the dorsal one in the usual situation. The hand was some- 
 what dragged towards the ulnar side, and supination and pronation 
 of the hand were lost. Crepitus was absent. Anterior and short 
 posterior splints were applied, and two days later a plaster-of-Paris 
 bandage from hand to elbow. Some deformity still remained a few 
 weeks later. 
 
 Although there is no marked inclination either to the radial or 
 ulnar side like that observed in fractures with impaction, Colignon 
 has described a very apparent sloping of the hand in his case, which 
 was under the care of M. Marjolin, and Piscart thought that the 
 epiphysis was drawn somewhat outwards by the action of the radial 
 muscles on the outer side. 
 
 Projection of the loiuer end of the ulna is noticeable beneath the 
 skin on the inner side only when the displacement is great and the 
 styloid process of the ulna broken off. 
 
 The hand is also slightly supinated in cases of great displacement. 
 
 Professor E. W. Smith {Dublin Hospital Gazette, vol. vii. 1860, 
 February 15) contrasts this injury (separation of the radial epiphysis 
 alone) with others which resemble it to a greater or less extent in 
 their external characters — viz. Colles's fracture, disjunction of the 
 epiphysis of the radius with fracture of the ulna, and luxation of the 
 carpus backwards. It resembles, he says, Colles's fracture in the loss 
 of the power of rotation, the existence of a palmar and dorsal tumour, 
 and in the increase of the antero-posterior diameter of the forearm, 
 but differs from it in the absence of that singularly distorted and 
 twisted appearance which is so characteristic of Colles's fracture and 
 is owing to the lower fragment of the radius being drawn towards 
 the site of supination besides being displaced backwards. In the 
 injury we are now considering the radial epiphysis passes directly 
 backwards, without any tendency to supination ; nor is there any 
 elevation of the styloid process, so that the radial border of the 
 forearm does not present the curved outline so frequently seen in 
 Colles's fracture. In the last-named injury the dorsal prominence is 
 usually more evident than the palmar, and the sulcus or depression 
 which limits it above generally passes in an oblique direction down- 
 
SEPAEATION OF LOWEE EPIPHYSIS OF EADIUS 531 
 
 wards and inwards towards the lower end of the ulna ; but when the 
 lesion of the bone traverses the line of junction of the epiphysis 
 with the shaft, the palmar projection is by far the more striking, 
 and both tumours are placed transversely, so that there is none of 
 the appearance of obliquity which so many cases of Colles's fracture 
 present. 
 
 Professor Smith continues : ' I have, more than once, seen separa- 
 tion of the radial epiphysis mistaken for Colles's fracture, but I do 
 not think that any surgeon who has had moderate experience of 
 injuries in the vicinity of the wrist-joint is likely to commit this 
 error. It is, in my opinion, much more readily confounded with 
 fracture of both bones of the forearm close to the wrist, or, to speak 
 more correctly, disjunction of the epiphysis of the radius with 
 fracture of the ulna immediately above its lower extremity, for the 
 external characters of these two injuries present a most remarkable 
 resemblance. There is in each case, occupying the same position 
 and presenting very nearly the same form, an anterior and a 
 posterior tumour ; in both cases the hand, viewed posteriorly, 
 presents an elongated appearance ; there is the same increase in the 
 antero-posterior diameter of the forearm, and a similar impairment 
 of the functions of the limb. 
 
 ' In the case of fracture of both bones, however, the deformity is 
 greater, and at first sight might readily be confounded with that 
 observed in cases of luxation of the carpus backwards, an injury to 
 which the separation of the radial epiphysis bears but little resem- 
 blance. 
 
 ' Moreover, the projections in front and behind occupy the entire 
 breadth of the forearm, and the anterior presents none of the abrupt- 
 ness and sharpness of outline which forms so striking a feature 
 when the injury is confined to the radius. An error in diagnosis is 
 here, however, of little or no importance, as the treatment is to be 
 conducted upon precisely the same principles, no matter whether 
 one or both bones are broken.' 
 
 There is no rotation or tilting of the epiphysis on a transverse 
 axis ; therefore, there is no radial inclination or obliquity of the 
 hand and none of that abducted and twisted appearance which is so 
 striking a feature of Colles's fracture. 
 
 This is probably due to the unbroken condition of the inferior 
 radio-ulnar and radio-carpal ligaments, which has been especially 
 noted in some of the specimens mentioned above. 
 
 This rotation of the lower fragment in Colles's fracture cannot be 
 due, at any rate to any large extent, as stated by Hamilton, to the lace- 
 ration of the triangular fibro- cartilage or the internal lateral ligament, 
 for laceration of the triangular fibro-cartilage was present in the 
 specimen of separated lower epiphysis dissected by the author, and 
 fracture of the styloid process has been found in several instances 
 of epiphysial separation where such rotation does not occur, and 
 
 M M 2 
 
532 EPIPHYSES OE UPPEE EXTKEMITY 
 
 consequently we find in epiphysial separation no curving of the 
 radial border of the forearm, no tendency to supination, and no 
 elevation of the styloid process. 
 
 The styloid process of the radius is thrown out of the axis of the 
 forearm, but preserves its normal relations with the carpus, and moves 
 with the carpus, so that on moving the hand backwards and forwards 
 the displaced epiphysis moves with it ; but in many instances of 
 Colles's fracture the lower fragment does not move with the hand 
 when any motion is imparted to it, the movement taking place at 
 the wrist-joint from the impaction of one fragment in the other. 
 
 Fracture of the styloid process of the ulna. — In the more complete 
 displacement of the radial epiphysis off the diaphysial end, the 
 styloid process of the ulna will be lower than that of the radius. 
 However, in these more severe injuries there is, as we have just stated, 
 a fracture of the styloid process, and sometimes a rupture of the 
 triangular fibro-cartilage, but the process always maintains its 
 natural connection with the hand by means of the internal lateral 
 ligament of the wrist. 
 
 Eracture of this process is seen in four out of nine specimens in 
 the London Museum, fully described above, and was probably 
 present in the following case described by Malgaigne {Traite des 
 fractures, 1855, vol. ii. p. 692). 
 
 A boy, aged fourteen years, fell upon his hand, producing the 
 deformity as of a dislocation. There was a large projection backwards 
 which seemed to belong to the carpus, with a corresponding projection 
 in front. The latter was formed on the inner side by the head of the 
 ulna, and ended on the outer side by an osseous point simulating 
 the styloid process of the radius ; but this process was behind in con- 
 tact with the posterior fragment. The radius was shortened, and 
 the hand lengthened. The diagnosis made was separation of the 
 epiphysis of the radius and projection of the ulna forwards. Eeduc- 
 tion was effected with a very evident sound, and the wrist from that 
 time assumed its proper shape and movements. There was no pain 
 on pressure over the joint, but it existed over the level of the 
 fracture of the radius. Malgaigne states that the displacement was 
 similar to that of the fracture depicted in Plate XXV. figs. 2 and 
 3 of his work. 
 
 The author had recently under his care at the Miller Hospital a 
 marked example of separation of the lower radial epiphysis with 
 moderate displacement backwards and fracture of the apex of the 
 styloid process of the ulna on the one side, while on the other 
 there was separation of the radial epiphysis with little or no dis- 
 placement, the characteristic ' silver fork ' deformity of the opposite 
 side being entirely absent, thus affording a comparison of the results 
 of mild and severe forms of violence in this very common injury. 
 
 D. W., aged fourteen years, fell from off a roof about fifteen feet 
 on October 27, 1897, alighting on his face and hands. The author 
 
SEPAEATION OF LOWEK EPIPHYSIS OF EADIUS 533 
 
 saw him within half an hour of the accident, when the transverse 
 ridge or angle, so characteristic of radial separation, was so marked 
 that the forefinger of the surgeon could be placed on the front portion 
 of the end of the diaphysis. It was therefore clear that the 
 epiphysis was only about halfway displaced off the diaphysis (fig. 154). 
 
 Fig. 154. — sepaeation of lowee epiphysis of eight radius with displacement 
 backwaeds halfway off the diaphysis and feactuee of styloid peocess of ulna 
 
 From a photograph taken within half an hour of the accident, before any great 
 swelling had taken place 
 
 ,.'r^^^ 
 
 i^m'F 
 
 Fig. 155. — the same case seen feom its posteeo-inteenal aspect 
 The slight obliquity of the hand towards the ulnar side is accurately represented 
 
 There was slight obliquity of the hand towards the ulnar side, which 
 is seen in the accompanying drawings taken from photographs and 
 in the annexed skiagraphs, due to slight displacement outwards as 
 well as backwards from fracture of the apex of the styloid process. 
 The apex of this process was displaced backwards, with the radial 
 
534 EPIPHYSES OE UPPEE EXTEEMITY 
 
 epiphysis behind the lower end of the ulna. Here there was 
 some swelling and ecchymosis, but none existed in front to obscure 
 the deformity (fig. 155). On the left side there was only a slight 
 projection of the diaphysis in front on forcibly extending the wrist, 
 which was accompanied by mobility. There was no fracture of the 
 styloid process of the ulna, and only slight swelling on this side 
 from extravasation of blood. Photographs were immediately taken 
 of both hands, and skiagraphs the next day (fig. 156). Three days 
 later the patient was kindly placed under the author's care by one 
 of his colleagues, reduction of the displaced right radial epiphysis 
 in the meantime having been partially effected by the house surgeon 
 without an ansesthetic. The ansesthetic was now administered and 
 the reduction completely effected; characteristic soft crepitus was 
 
 ■■'^-■"■'''■'■'■■''"n'iv;vV;y'!'^wwtiv.\-, 
 
 Fig. 156.- sepaeation of the lower epiphysis of the left eadius without 
 
 displacement 
 
 Slight swelling is seen in the region of the diaphysial end from effusion of blood 
 into the soft tissues. From same case as the preceding 
 
 felt, and a wooden anterior and posterior splint applied, with pads 
 over the epiphysis and diaphysis on the posterior and anterior 
 aspects respectively. On the left side mobility and soft crepitus 
 were now very evident on seizing the radial epiphysis and moving 
 it in an antero-posterior direction, the end of the diaphysis becoming 
 very prominent in front ; in fact, with little more force the epiphysis 
 could have been easily displaced backwards and the characteristic 
 deformity produced. A short anterior wooden splint was applied to 
 prevent mobility and any subsequent displacement. The skiagraph 
 on the right side shows a small splinter of bone, very clearly delineated 
 from the slight displacement of the epiphysis outwards, detached 
 from the posterior aspect of the diaphysis. 
 
 The patient made a good recovery without any deformity of the 
 wrists. 
 
 A.r 
 
SEPARATION OF LOWER EPIPHYSIS OP RIGHT RADIUS. DISPLACEMENT BACKWARDS WITH A FLAKE 
 
 PROM POSTERIOR ASPECT OF DIAPHYSIS. 
 
 Author's case. Taken by Mr. Thomas Moore on day after injury. 
 
SEPARATION OP LOWER EPIPHYSIS OF LEFT RADIUS WITHOUT DISPLACEMENT. 
 Author's case. Taken by Mr. Thomas Moore on day after injury. 
 
T-P(3'"'' 
 
 SBPABATION OP LOWER EPIPHYSIS OP RADIUS WITHOUT DISPLACEMBHT. 
 Same case. Left hand, palm downwards. (Fourth week). 
 
SKIAGRAM TAKEN IN THE FOURTH WEEK AFTER SEPARATION AND DISPLACEMENT BACKWARDS 
 OP LOWER EPIPHYSIS OF RADIUS, WITH FRACTURE OP STYLOID PROCESS OP ULNA. PERFECT 
 
 REDUCTION OF DISPLACEMENT. 
 Right hand, palm downwards. Author's case. 
 
SEPAEATION OF LOWEE EPIPHYSIS OF EADIUS 535 
 
 Skiagraphs of the wrists were again taken at the commencement of 
 the fourth week. On the right side the epiphysis was in excellent posi- 
 tion, with the slightest inclination towards the ulnar side, as revealed 
 by the minute spicule of the diaphysis projecting on the outer side. 
 New periosteal bone was represented as a faint shadow along the 
 inner aspect of the radial diaphysis. The fracture of the apex of 
 the styloid process of the ulna was also clearly displaced. The 
 skiagraph showed the condition of aifairs at the left wrist to be 
 exactly normal, and although in this instance it proved most useful for 
 comparison with the more serious lesion on the right side, it con- 
 clusively demonstrated that the employment of the Eontgen process 
 in an epiphysial separation without displacement could give no 
 affirmative assistance in the matter of diagnosis of such an 
 injury. 
 
 Shortening' of radius.- — The radius appears to be shortened and 
 the hand lengthened. However, in its actual length the radius is 
 but little shortened — in displacement of the epiphysis halfway off 
 the diaphysis, not more than an eighth of an inch. 
 
 It will only be shortened to any extent in the rare case of 
 complete displacement of the epiphysis. 
 
 Although the styloid process may in these severe cases of dis- 
 placement be found to be somewhat above its normal height, it will 
 never be to the same degree as is met with in cases of fracture in older 
 persons. 
 
 Mobility of epiphysis and site of lesion.— Mobility of the epiphysis 
 with the carpus and hand takes place at its line of junction 
 with the diaphysis ; this is situated less than a quarter of an inch 
 from the articulation of the wrist-juint, and is thus nearer than the 
 line of solution of continuity in fracture, which is usually three- 
 quarters of an inch from the lower end. Manquat gives almost 
 the same measurements — a centimetre and a half for fracture, and 
 never more than six millimetres for epiphysial separation. The 
 movement can only take place in simple cases in the antero-posterior 
 direction, and very slightly or not at all laterally. It is due to the 
 absence of impaction. 
 
 The separated epiphysis can be still further displaced towards 
 the dorsal aspect by pushing the hand in this direction. Eognetta 
 considered this a very distinguishing feature of the injury {Gazette 
 medicale, 1834, p. 514), but he adds that the wrist may be displaced 
 a little laterally, and even a rotatory movement may be effected. 
 During the movements of pronation and supination a mass can be 
 felt, according to this author, rolling under the finger, but with an 
 absence of crepitus. 
 
 In certain rare cases this movement will be prevented by the 
 fixation of the lower fragment by impaction, or only a hinge-like 
 movement of the lower upon the upper fragment will be permitted ; 
 but as a rule the bones of the forearm will not be moved when the 
 
536 EPIPHYSES OF UPPEE EXTEEMITY 
 
 hand with the lower fragment or epiphysis is pushed backwards and 
 forwards, or even sHghtly supinated. 
 
 M. G. Goyrand erroneously thought that in separation the 
 abnormal mobility was much greater than in the case of fracture, 
 as in the latter the fragments were more or less impacted in one 
 another. 
 
 This surgeon related a case of separation of the lower epi- 
 physis of the radius before the Societe de Chirurgie in 1860 {Bulletin 
 de la Societe de Chirurgie, Paris 1861, 2me Serie, t. i. p. 534 ; 
 Gazette des Hopitaux, 1860, 124, p. 494), giving the principal 
 features in detail. 
 
 Albert D., aged seventeen years, while exercising on a trapeze, 
 fell and alighted on his right hand. Acute pain and great deformity 
 were found at the wrist. The lesion on a superficial examination 
 might have been mistaken for a dislocation, for the hand was carried 
 behind the axis of the forearm, and there was a transverse pro- 
 jection of the radius in front above the displaced hand which 
 elevated considerably the skin and flexor tendons. The displace- 
 ment, which was very close to the articulation, appeared to be more 
 extensive towards the radial than on the ulnar side. The ulna was 
 intact. The styloid process of the radius preserved its normal 
 relations with the hand, and although the fragment which sur- 
 mounted the carpus had very little depth, M. Goyrand could, while 
 fixing it, impart to the wrist-joint movements which were easy and 
 painless. The mass formed by the hand and the lower extremity of 
 the radius was inclined towards the dorsal aspect of the limb, but 
 without being fixed, so that on pushing the hand backwards it could 
 be displaced more forcibly in this direction without producing any 
 crepitus. The solution of continuity was exactly transverse, and 
 much nearer the articulation than ever fracture is. Separation of 
 this epiphysis was diagnosed — in spite, M. Goyrand says, of the age 
 of the patient — from fracture, by the mobility of the fragment of the 
 radius surmounting the carpus and the absence of crepitus. In 
 the case of fracture, if it were not impacted, as is mostly the case, 
 it could not move on the upper fragment without, crepitus being 
 felt. Eeduction was effected without crepitus, and without any 
 tendency for the displacement to be reproduced. Anterior and 
 posterior splints were applied, and the patient recovered perfect use 
 of the limb. There was no trace of the injury five weeks later, 
 except a little wasting of the forearm and hand and slight numb- 
 ness of the little finger. 
 
 Impaired movements. — The fingers of the hand are usually slightly 
 flexed, and the movements of pronation and supination impaired, 
 or even completely lost, the patient being unable to rotate the hand 
 in the least degree. 
 
 Ease of reduction. — Eeduction is generally effected with great ease, 
 but in some cases only after the administration of an anaesthetic ; for 
 
SEPAKATION OF LOWEE EPIPHYSIS OF EADIUS 537 
 
 not until the extensor muscles have been relaxed, which permits only 
 of a hinge-like movement of the lower upon the upper fragment or 
 posterior edge of the diaphysis, is it possible for the lower epiphysial 
 fragment to pass across the face of the end of the diaphysis. 
 
 Hutchinson says that not unfrequently great difficulty is ex- 
 perienced in effecting complete reduction, and in afterwards retaining 
 the two portions in accurate apposition. 
 
 Eeduction will be difficult in the rare cases of impaction of the 
 fragment, or only permitted to a certain degree. 
 
 On the other hand, Goyrand says that the natural shape of the 
 parts is perfect after the reduction of a separation, whilst in the case 
 of fracture if the extension (before the splint is applied) is relaxed 
 the displacement is more or less reproduced. This cannot, however, 
 be considered a distinguishing feature, when it is remembered that 
 many cases of fracture unite rapidly without leaving any deformity. 
 
 M. Leroux, of Versailles, in 1866, observed a case of separation 
 of the lower epiphysis of the radius of both forearms (Nelaton, 
 Pathologie chirurgicale, 2nd edit. t. ii. p. 237). The prominent 
 border of the diaphysial fragment stretched and threatened to lacerate 
 the skin. The condition presented an absolute irreducibility. 
 
 Rigidity of supinator longus and other extensors on the posterior 
 aspect, which are raised up over the separated epiphysis. 
 
 Doubtless impaction of the fragments has occurred in a few cases 
 and has prevented reduction, but is it muscular action alone that 
 can maintain the deformity ? This may be possible, as shown by 
 the tense condition of the extensors on the dorsum and towards the 
 radial side, which has been noted by several authors and was a 
 marked feature in the specimen dissected by the author. 
 
 Through the attachment of the posterior annular ligament — which 
 is only a transverse thickened portion of the fascia of the forearm — 
 to the thecal ridges on the lower epiphysis of the radius, and, on the 
 inner side, to the styloid process of the ulna and cuneiform and 
 pisiform bones, the tendons of the extensor carpi radialis longior, 
 the extensor carpi radialis brevior, the extensor communis digitorum, 
 the extensor indicis, and the extensors of the thumb, are all held down 
 in their grooves close to the epiphysis. All these muscles, aided 
 by the supinator longus attached to the epiphysis, by their action 
 tend to displace the separated epiphysis backwards. The flexor 
 muscles, on the other hand, have no such influence on the epiphysis 
 in front, for the anterior annular ligament (deep portion) is not 
 attached to the radius, but to two of the carpal bones— the unciform 
 and trapezium. 
 
 Muffled crepitus. — The characteristic mufiied crepitus is sometimes 
 detected during the reduction of the fragments, but more often it is 
 entirely absent, whereas in fracture crepitus can frequently be 
 detected when true impaction does not exist between the fragments, 
 or when hinge-like movement of the lower upon the upper fragment 
 
538 EPIPHYSES OF UPPEE EXTEEMITY 
 
 is absent ; at any rate, when the lower fragment can he moved to the 
 extent that is possible in epiphysial separations. 
 
 Goyrand goes so far as to say that crepitus is not produced 
 during the reduction of the separated epiphysis, and gives this as a 
 distinguishing sign from fracture. 
 
 Manquat thought that as the separation is seldom pure, this sign 
 is of little importance. 
 
 No tendency to reproduction of deformity after the epiphysial 
 fragment has been reduced. 
 
 Subsequent malposition of the fragment is unlikely to occur from 
 the more or less square condition of the separated surfaces in 
 pure separations. In fracture, on the other hand, the displacement 
 is often reproduced — at least, in part. 
 
 But M. Eobert, in certain cases of fracture of the lower end of 
 the radius, has not applied any apparatus after reduction, and with 
 satisfactory results — results which he could not have obtained if 
 there had remained any great tendency to displacement after the 
 fracture had once been reduced. Such fractures are certainly met 
 with in the case of children, without any tendency to reproduction 
 of displacement, but they rarely occur. 
 
 Colignon thought that the epiphysis often returned to its dis- 
 placed position after it had been reproduced. 
 
 Pain. — Pain is intense over the situation of the epiphysial lines, 
 but not usually at the joint. 
 
 Swelling, although greater than in separation without displace- 
 ment, is usually not very extensive. 
 
 Complications. — Out of seventeen cases alluded to by De 
 Paoli, in one case the lesion was bilateral, in another there was, in 
 addition, separation of the epiphysis of the ulna, and in a third a 
 fracture of the diaphysis of this bone. 
 In Eoux's case the lesion was double. 
 
 Separation of the lower epiphysis of the ulna. — Bertrandi is said to 
 have reported that be had seen the epiphyses of the radius and ulna 
 separated in a child who had been violently lifted by the hand from 
 the ground. 
 
 The following case, which the author had the opportunity of 
 observing, is a good example of separation of the lower epiphyses of 
 the radius and ulna. On July 7, 1894, Hilda J., aged eleven, 
 fell (whilst playing) off a wall seven feet high on to both her out- 
 stretched hands, but the right touched the ground first. The 
 forearm was painful, and she was unable to move it ; she kept it 
 in the flexed position, supported by the other hand. Twenty 
 minutes after the accident she came to the Miller Hospital hold- 
 ing the arm in this position. The forearm was also in a position 
 midway between pronation and supination, and there was great 
 pain on the slightest attempt at movement of the hand. On the 
 dorsal aspect, just above the wrist, there was a very prominent 
 
SEPAEATION OF LOWEE EPIPHYSIS OF KADIUS 539 
 
 and characteristic swelling projecting three-quarters of an inch 
 beyond the posterior aspect of the forearm, with a depression above. 
 Corresponding to the latter on the anterior surface was another 
 prominence, which, on account of the small amount of swelling and 
 bruising present, it was not difficult to make out as the lower ends 
 of the radial and ulnar diaphyses. Soft crepitus was .easily felt. 
 The hand was not deflected either towards the inner or outer border 
 of the forearm. Reduction was easily effected by extension and 
 manipulation of the dorsal swelling (caused by the displaced epiphyses) 
 into position. This was accompanied by soft crepitus, and there was no 
 tendency for the displacement to recur. The forearm was then put 
 up in splints. Through the courtesy of Dr. H. D. Coles the author 
 saw the case eight days after the injury. There was then absolutely 
 no deformity whatever, the fragments were in accurate position, 
 and there was only the smallest amount of thickening about the 
 lower ends of each bone ; in fact, examining it at this early period, 
 it would have been difficult to say that there had been any solution 
 of continuity of the bones. As gentle movements of the wrist did 
 not cause pain, passive motion was commenced. On the fourteenth 
 day the splints were taken off, and the arm was carried in a sling. 
 The patient now used her wrist for flexion and extension. Three days 
 later there were no signs of any injury. Flexion and extension, 
 and all movements of the wrist, were perfect. Eight months 
 after the injury there was no appearance of shortening. There was 
 the nearest approach in this instance to immediate union of 
 separated epiphyses — if the author may so call it — that he has ever 
 seen. But in other cases he has seen the union has not been so rapid 
 or so good, doubtless on account of the incomplete reduction of the 
 displaced epiphysis. 
 
 The following case (of H. H.), aged ten years, the author saw at the 
 Miller Hospital, July 5, 1895, three weeks after the accident. The boy 
 had fallen from a bar, eight to ten feet high, on to the palmar surface 
 of his left outstretched hand ; he was attended to at once, and the dis- 
 placement, which was not very great, was reduced; this reduction was, 
 however, imperfect, for at the time there was still some displacement 
 of the diaphysis forwards, pressing the radial artery forwards. The 
 epiphysis was somewhat mobile, showing that the new bone, which was 
 pretty abundant, had not consolidated so firmly as in the instance just 
 recorded. There was some thickening about the lower end of the ulna, 
 but no displacement ; this, together with the absence of any deflection 
 of the hand, pointed to the probability of the lower epiphysis of the 
 ulna having been separated, at any rate partially, without being 
 displaced. The movements of the wrist were already good passively, 
 but not actively. 
 
 Dr. C. A. Sturrock reports {Edinhnrgh Hospital Reports, 
 vol. ii. 1894, p. 602) that Mr. Annandale has treated successfully 
 several cases of separation of both epiphyses, in one of which, 
 
540 EPIPHYSES OF UPPEE EXTEEMITY 
 
 however, excision of the lower fragments was necessary. He also 
 relates a good example of this injury. 
 
 N. E., a boy aged twelve, sought advice in Mr. Annandale's out- 
 patient department at the Eoyal Infirmary, Edinburgh, for an injury 
 which he had sustained by falling from a swing on to the dorsum of 
 his hand. When seen within half an hour of the accident, the lower 
 ends of the shafts of the radius and ulna were felt to be displaced 
 forwards, while there was a prominence on the back of the wrist 
 caused by the separated epiphyses ; there was epiphysial crepitus, 
 and only when traction was made on the hand, under an anaesthetic, 
 could the bones be brought into position, the displacement recurring 
 the moment extension was withdrawn. The arm, with the hand 
 flexed, was put up in a temporary apparatus until next day, when 
 anterior and posterior splints were applied and retained for a fortnight. 
 Passive movements of the wrist and fingers were then commenced, 
 and continued for fourteen days, when the boy ceased attending the 
 Infirmary. Eour months after the accident the movements at the 
 wrist were slightly restricted, there was some thickening at the 
 epiphysial line, and a fluctuating swelling extending one inch below 
 and two inches above the anterior annular ligament, apparently in 
 the flexor sheaths, which closely resembled a compound ganglion. 
 A wristlet was worn for five months more, at the end of which time 
 the swelling had gradually disappeared, movements at the wrist had 
 become more extensive, no shortening could be detected, and there 
 was only slight thickening at the epiphysial line. 
 
 Dr. J. E. Erdmann, of New York, quotes {New York Medical Eecord, 
 October 26, 1895, p. 588) a case of epiphysial separation occurring 
 in both bones of the wrist, and a separation of the lower epiphysis 
 of the humerus. A girl (M. D.), four years of age, fell down a flight 
 of fourteen steps. She complained of pain in the right wrist and 
 elbow. Upon examination, a peculiar transverse deformity, sharply 
 outlined, upon the posterior aspect of the forearm, about half an inch 
 above the wrist-joint, was observed, while anteriorly there was a 
 deformity continuous with the shafts of the bones. At the site of 
 the deformity during manipulation a soft crepitation was apparent. 
 At the elbow there were the characteristic evidences of an epiphysial 
 separation of the lower end of the humerus. The separations were 
 reduced, and the limb was placed on a long posterior splint extend- 
 ing down to the metacarpo-phalangeal joints. The patient was 
 discharged in four weeks with a good result. 
 
 As stated above, these separations are often but insignificant 
 lesions compared with those received at the time of the accident. 
 Fracture of the base of the skull is a frequent concomitant lesion. 
 In 1885 Mr. Davies-Colley had a case under his care at Guy's 
 Hospital with the following lesions. James C, aged eight, fell about 
 forty feet from a bridge on to a railway, and was picked up insen- 
 sible. There were found, on his admission, separation of the lower 
 
SEPAEATION OF LOWEE EPIPHYSIS OF EADIUS 541 
 
 epiphysis of each radius (with deformity similar to that of Colles's 
 fracture) and of the right olecranon epiphysis, which was also 
 vertically fractured, fracture of the shaft of the right femur, and 
 fracture of the anterior fossa of the skull. The patient recovered, 
 and left the hospital in about four weeks' time with half an inch 
 shortening of the right leg, some impairment of flexion and exten- 
 sion of the forearm, and deformity of the limbs. 
 
 The following two cases at Guy's Hospital were also accom- 
 panied by fracture of the base of the skull. 
 
 In the first case, under the care of Mr. Cooper Forster in 1871, 
 a youth (Daniel C.) fell out of a warehouse a distance of eight feet 
 on to his chin and right arm. There was separation of the lower 
 epiphysis of the radius and hsemorrhage from the right ear. The 
 patient recovered, and was able to use his arm well. His age is not 
 given. 
 
 In the second, under the care of Mr. Howse in 1887, the boy 
 (Thos. W.), thirteen years old, fell from a balcony a distance of ten 
 feet, and alighted upon his head. There was a separation of the 
 lower epiphysis of the radius with backward displacement and 
 fractured base of skull. Death ensued oh the seventh day from 
 meningitis due to extensive fracture of the anterior and middle 
 fossse of the skull. 
 
 Both the following cases of epiphysial separation of the lower 
 end of the radius with other severe injuries were under the care of 
 Mr. Howse at Guy's Hospital in 1883. 
 
 In the first instance the boy (William N.), aged seventeen, fell a 
 distance of twenty feet from a second floor to the basement. There 
 was the usual displacement of the lower fragment on to the dorsum, 
 causing the projection with the hollow above and also the convexity 
 on the palmar aspect. The forearm and wrist were much swollen, 
 and there was a fracture of the internal condyle of the femur with 
 much effusion into the joint. The injury to the radius was treated 
 with a Carr's splint, and the patient recovered perfectly. 
 
 In the second instance the child (Herbert A.), three years old, fell 
 down an area a distance of ten to twelve feet. The separated epiphysis 
 of the radius was displaced backwards and the upper fragment forwards, 
 the hand being in the extended position and extremely pronated. 
 There was a comminuted fracture of the lower end of the humerus. 
 An internal angular splint was applied after reduction, and subse- 
 quently an anterior rectangular one, with a posterior straight splint 
 to forearm. Four weeks later he left the hospital, with both the elbow 
 and wrist in good position. Movements of the elbow were excellent, 
 only extreme flexion being a little painful, with some thickening about 
 the lower end of the humerus. Pronation and supination and use 
 of the wrist were perfect. 
 
 Injury to radial artery. — Mr. Hutchinson alludes to a case under 
 his care in the London Hospital of separation of the radial epiphysis 
 
542 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 in which the displacement forwards of the diaphysis was so great 
 that the lower end of the shaft was in front of the radial artery. 
 
 Latee Complications. — Suppuration, necrosis, and osteomyelitis 
 are very uncommon complications in simple cases, although the 
 periosteum is so often extensively stripped up. 
 
 Mr. Jonathan Hutchinson, however, records {Illustrations of 
 Clinical Surgery, fascic. xix. pi. Ixxi. fig. x.) and figures a case 
 of simple separation of the carpal epiphysis of the radius in a boy, 
 aged thirteen years, in which the first of these complications 
 occurred. There was complete dislocation of the epiphysis on to 
 the back of the end of the shaft, giving rise to extreme deformity. 
 The styloid process of the radius was still in relation with the carpal 
 bones. Eeduction was found to be impracticable, and an abscess 
 subsequently formed, probably in connection with great stripping 
 of the periosteum from the shaft. Eecovery took place with a much 
 injured arm. 
 
 ^^■Wi'tiH 
 
 Fig. 157. — complete doksai displacement of caepal epiphysis of eadius 
 
 From a lad aged fourteen. Eeduction could not be effected, although anaesthetics 
 were given and much force used. Sup^Duration followed, and the arm was in the 
 end much crippled. (Hutchinson) 
 
 The same surgeon gives {Path. Soc. Transactions, vol. xiii. 1862, 
 p. 265) the following description of a case of detachment of the 
 radial and ulnar (?) epiphysis, at the age of eight, in which suppu- 
 ration occurred at the seat of injury, and was fpllowed by ankylosis 
 of the wrist and arrest of growth of the bones. 
 
 ' J. P., aged twenty-three, came under my care, on account of 
 a skin eruption, on November 19, 1860. I noticed that one of his 
 wrists was deformed. The right hand was bent over to the radial 
 border and firmly fixed by bony ankjdosis at the wrist. There was 
 not the slightest motion of the carpus on the radius. The wrist 
 was thin and small, looking too small in proportion to the hand. 
 It was considerably less in width than that of the other hand, but 
 fully as thick, if not a little thicker. On his directing my attention 
 to it, I noticed a small scar in front of the wrist. Being struck by 
 the smallness of his wrist, I compared his arms, and found that 
 both bones of the right forearm were an inch and a third shorter 
 than those of the other side. The upper arms and the hands were 
 
SEPAEATION OF LOWEE EPIPHYSIS OF RADIUS 543 
 
 of similar size. The diminution was in the lower parts of the 
 bones of the forearm. The history of the case was that at the age 
 of nine, in playing at leap-frog and " taking a seven-foot fly," he 
 fell, and came with his hand violently on the gromid. The wrist 
 was supposed to be dislocated. It inflamed, an abscess formed, 
 which a surgeon opened, and a piece of bone came out " about as 
 large as his finger-nail." In two or three months it had soundly 
 healed, and has remained quite well ever since. The hand is so 
 useful to him that he is scarcely aware of any defect. It is his right 
 hand, but he employs it as usual, and can write easily. Putting 
 together the history of the accident, the supposed dislocation, the 
 suppuration afterwards, the age of the boy at the time, and the 
 subsequent arrest of growth of the bones, there can, I think, be 
 little doubt but that the injury was a separation of the epiphysis. 
 Very probably the radial epiphysis was fissured longitudinally, and 
 the joint became involved in the inflammation which followed. In 
 consequence of the abscess the nutrition of the epiphysis was, no 
 doubt, greatly interfered with, and hence the arrest of growth of the 
 bone.' 
 
 Gangrene of hand and forearm. — One instance is recorded by 
 R. W. Smith {loc. cit. supra) in which gangrene of the forearm and 
 hand was the result of tight bandaging. 
 
 InEognetta'scase {loc. cit. supra) death resulted from phlegmonous 
 inflammation and gangrene of the arm, and a like result ensued in 
 Barbarin's case. 
 
 Tetanus has been met with in two compound separations in both 
 of which death ensued, and in a third in a simple separation, all 
 described above. This fatal result occurred, it was thought, from 
 pressure upon the median nerve in one of the first, and upon the 
 radial nerve in the second case. 
 
 Pyaemia occurred in another compound case and death ensued. 
 
 DIFFERENTIAL DIAGNOSIS.— In former years a diagnosis of this 
 injury was rarely made ; indeed, in many of the earlier recorded 
 cases, and in many in which the specimens were obtained and put 
 up in museums, the nature of the injury was only discovered after 
 death or amputation. 
 
 Dislocation of carpus backwards. — The error of mistaking separa- 
 tion for a dislocation of the wrist has been committed in former years 
 by eminent surgeons. 
 
 Separation of the radial epiphysis alone does not bear so great a 
 resemblance to dislocation as separation associated with fracture or 
 separated epiphysis of the ulna. 
 
 In Boeckel's case the injury was mistaken for a dislocation, 
 although the injury was compound. The diaphysial end, being 
 covered with a layer of cartilage, was thought by the doctor who 
 first saw the case to be the articular extremity, and reduction 
 was effected. 
 
544 EPIPHYSES OF UPPEE EXTEEMITY 
 
 M. Eoux (1834) had no doubt as to the correctness of his diagnosis 
 during hfe in the case above recorded (p. 516). On death ensuing 
 some days later he was astonished to find a fracture of the lower 
 end of the radius with separation of its epiphysis. 
 
 In a child, a fall upon the palm of the hand, followed by 
 deformity at the wrist, must nearly always suggest the occurrence 
 of traumatic separation of the radial epiphysis. 
 
 Epiphysial separation is of frequent occurrence in youth, whilst 
 dislocation of the wrist is almost unknown or extremely rare, 
 though examples have been recorded by Guyon, Desormaux, Paret, 
 and others. 
 
 Colignon, writing in 1868, says that since the death of Dupuy- 
 tren, twenty years previously, dislocation of the wrist had only been 
 noted three or four times (Marjolin, These inaugurale ; Voillemier, 
 A7'chwes de medecine, Dec. 1839). 
 
 The specimen of displacement forwards of the radial epiphysis 
 described by Dupuytren was taken from a patient who during life 
 was considered by Cruveilhier to have had a dislocation of the wrist 
 forwards. 
 
 Sir Astley Cooper has also recorded {Fractures and Dislocations, 
 edited by Bransby Cooper, 1842, p. 485) an unusual case in a boy, 
 aged thirteen years, in which both wrists were dislocated, one 
 forwards and the other backwards. 
 
 Dr. H. Hollis records {Lancet, December 8, 1894, p. 1345) a rare 
 case of backward dislocation of the wrist in a boy fourteen years of 
 age. Half an hour previously he had fallen backwards from a 
 ladder about twenty feet on to some sand. His hand was partly 
 flexed at the wrist, and displaced slightly to the radial side ; the 
 fingers were also flexed, and, including the thumb, could not be 
 perfectly extended. There was no pain. On the posterior surface 
 the upper end of the carpus with its convexity upwards and to the 
 right was easily felt, the scaphoid lying higher than the other 
 bones. Anteriorly there was a decided depression below the end of 
 the radius, becoming less marked towards the ulnar side. The 
 styloid processes were very easily felt below the skin. The dis- 
 location was reduced by traction on the hand, but needed consider- 
 able force. Afterwards the boy could move the fingers and hand 
 perfectly. There was some swelling of the wrist for a few days, but 
 in a week the splint was removed and he resumed his occupation. 
 
 A similar case of dislocation of the carpus backwards was seen 
 by Dr. T. H. Morton, of Sheffield {British Medical Journal, July 20, 
 1895, p. 131), and occurred in a boy, aged sixteen, who had fallen 
 on his thumb with the arm backwards, the hand being probably 
 pronated slightly and under him. On examination the radial and 
 ulnar processes were in the normal plane. The carpus projected 
 upwards and backwards, but not to any great extent. Eeduction 
 was effected easily by fixing the forearm, grasping the hand, and 
 
SEPAKATION OF LOWEE EPIPHYSIS OF EADIUS 545 
 
 making forcible extension. A slight grating was felt. That no 
 radial fracture existed was proved by the natural position being 
 sustained when the patient moved the joint, and also by the 
 satisfactory rotation of the radius without crepitus or displacement. 
 Mr. Jas. Hossack gives {British Medical Journal, December 7, 
 1895, p. 1424) another instance. J. B., aged sixteen, came to the 
 Eoyal Infirmary, Edinburgh, on September 10, 1895. Twenty 
 minutes previously he was riding on a lorry, and, in attempting to 
 jump off when it was in motion, caught his foot against the edge 
 and fell to the ground, landing on the flat of his hands. At first 
 sight, to all appearances, it was a case of Colles's fracture, and, seen 
 from the radial side, was a beautiful specimen of the ' silver fork ' 
 deformity seen in that fracture. The illustration shows the condi- 
 tion fairly well. On examination, however, the styloid processes of 
 both the radius and ulna were in their usual positions, while the 
 prominence on the back of the wrist was not limited to the radial 
 side of the forearm, but was equally marked over the ulnar. On the 
 palmar aspect the ends of both radius and ulna made an abrupt 
 
 ■Ml ■.,■■!■" a .^. 
 
 1 ' 1, i[ 1; 
 
 f 11! ' " ',',ii''j!!y!j'" 
 
 ',1 i" _JLi.!i!,!^*=^ 
 
 Fig. 158. — james hossack's case of backward dislocation of the carpus 
 
 prominence, while the flexion lines there were especially well 
 marked. Eeduction was simple. The forearm was steadied and 
 slight extension made on the hand. Suddenly the carpus slipped 
 back with a distinct ' click.' There was no fracture present ; this 
 was definitely ascertained after reduction. No crepitus could be felt 
 when rotating the radius. The whole bone rotated in one piece, 
 and no prominence or deformity was to be made out along the 
 course of either bone. There was no suspicion of return of the 
 condition. It was put up in anterior and posterior splints, and 
 resort was early had to passive movement. The wrist, three weeks 
 after, was perfectly well ; the boy, however, complained of its being 
 weak and stiff. 
 
 E. W. Smith says : ' Nothing bat extreme ignorance or extreme 
 carelessness can lead to the injury under consideration being con- 
 founded with dislocation of the carpus backwards, for the means of 
 diagnosis are simple and sufficient. In fracture or separation of the 
 epiphysis the styloid processes of the radius and ulna hold their 
 natural relations to the carpus, and follow any motion imparted to 
 
 N N 
 
546 EPIPHYSES OF UPPEE EXTEEMITY 
 
 the hand ; the reverse obtains in the case of hixation. Again, the 
 distance from the upper edge of the dorsal tumour to the end of the 
 middle finger is, in the case of fracture, greater than that between 
 the corresponding point of the hand and the upper edge of the 
 carpus of the sound limb ; but in the case of luxation of the wrist 
 backwards this measurement will give the same results upon each 
 side.' 
 
 To this norinal relationship of the styloid processes, and the fact 
 that they move with the carpus when any motion is imparted to 
 the hand, may be added movement at the wrist-joint when the 
 lower fragment is fixed. Although this epiphysis which surmounts 
 the carpus is of small size, it can be seized with the fingers and 
 thumb and fixed, and movement made at the wrist-joint without pain. 
 Again, in this injury the styloid process deviates from the axis of the 
 radius, whereas in dislocation it still remains in a line with it. In 
 dislocation the displaced hand remains almost fixed, whilst in 
 epiphysial separation antero-posterior movement of the hand with 
 the epiphysis upon the forearm can, as a rule, be effected. The 
 radius in separation of the epiphysis will be found to be shortened 
 to a greater or less extent when measured on the outer side from 
 the styloid process ; in dislocation this shortening does not take 
 place. 
 
 Finally, a dislocation, when reduced, does not tend to be" repro- 
 duced like some cases of separation of this epiphysis. 
 
 Colles's fracture. — Separation of the radial epiphysis resembles 
 to a great extent Colles's fracture in the existence of a palmar and 
 dorsal swelling, and loss of power of rotation. The deformity is, 
 however, very different, for in disjunction of the epiphysis the dis- 
 placement is directly backwards, and there is none of the rotation, 
 obliquity, or curved outline of the radial border, characteristic of 
 Colles's fracture. Moreover, in the latter injury the dorsal projection 
 is usually more distinct than the palmar, the anterior projection being 
 therefore not so abrupt. It forms a much more obtuse angle than in 
 epiphysial separation. The dorsal groove is oblique, but in separa- 
 tion of the epiphysis it is transverse. The palmar swelling is 
 therefore, in epiphysial separation, more evident than the dorsal, 
 and there is no third prominence, as in Colles's fracture, from the 
 projection of the styloid process. 
 
 The margins of the anterior and posterior projections, if they can 
 be felt, are irregular in -Colles's fracture. 
 
 The age and crepitus assist but little ; for as to the former point, 
 fracture of the lower end of the radius occurs in children, although 
 but rarely, and as to the latter, the characteristic muffled crepitus is 
 often absent in separation of this epiphysis as well as in fracture. 
 If characteristic dry crepitus is present, a true fracture suggests 
 itself, but even here the presence of a fracture of the diaphysis 
 complicating the separation must not be lost sight of. 
 
SEPAEATION OF LOWEE EPIPHYSIS OF EADIUS 547 
 
 The mobility is greater, as a rule, in epiphysial separation, due 
 to the gliding of one fragment upon the other ; in fracture it is often 
 of a see-saw movement only. Mr. D'Arcy Power says : ' It may be 
 distinguished by observing that the outline of the wrist is angular, 
 whilst in fractures it is curved. The projection, too, upon the pal- 
 mar surface is more obvious after epiphysial separation than after 
 fracture.' 
 
 Goyrand believed that crepitus was always absent in separation 
 of the epiphysis, and therefore considered this a distinguishing sign 
 from fracture, when mobility could be obtained. 
 
 In Johnston's case, related above, the injury was mistaken for a 
 fracture during life. 
 
 In one of the interesting specimens in St. Bartholomew's Hospital, 
 Nos. 931 and 932, on the left side there was a separation of the 
 epiphysis, and on the right a fracture of the diaphysis one inch and 
 a quarter from the articular surface, with impaction of the shaft 
 into the lower end ; in the latter instance, with an absence of crepitus 
 during life. The boy, aged fourteen, had fallen from a window, and 
 he died from injuries of the head. 
 
 A comparison of the two injuries in this case during life would 
 have afforded an important clinical study. 
 
 The following case of fracture of the lower end of the radius just 
 above the conjugal line, closely resembling separation of the epiphysis, 
 is one of many which have come under the author's care at the 
 Miller Hospital. 
 
 H. S., aged eight years, fell, September 29, 1894, from a dustbin 
 a distance of three feet, on to his hand. He came to the hospital 
 within an hour, his mother having seen that his forearm was not of 
 the right shape. He complained of great pain from the time of the 
 accident. On examination the forearm was midway between prona- 
 tion and supination, with loss of power, so that he was obliged to 
 support it with the other hand. The dorsal aspect of the wrist 
 presented a marked prominence with a concavity above, while the 
 palmar aspect showed a corresponding depression and elevation. 
 Pronation and supination of the hand produced no movement of the 
 head of the radius. There was mobility in an antero-posterior 
 direction just above the level of the lower epiphysis of the radius. 
 The ulna was uninjured. The dry crepitus of fracture was very 
 noticeable during reduction. An immovable apparatus was applied 
 for a week, when union was found to have taken place ; the slightest 
 thickening of the radius above the epiphysial line was the only 
 discernible feature. Passive movement was commenced on the 
 tenth day ; no pain then on moving the wrist. At the end of 
 three weeks the movements of the wrist and forearm were perfect, 
 and there was no deformity. A photograph of this case was 
 taken directly on admission to the hospital, but was not very 
 successful. 
 
 N N 2 
 
548 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 jp.i 
 
 F.S.^. 
 
 m 
 
 De Paoli draws attention to this form of fracture, and illustrates 
 it with the accompanying drawing (fig. 159). 
 
 Professor J. B. Pv^oberts, in his excellent monograph {A Clinical, 
 Pathological, and Experimental Study of Fracture of the Loiver End 
 of the Badius with Dis'placement of the Carpal Fragment toioards 
 the Flexor or Anterior Surface of the Wrist, Philadephia, 1897, p. 11), 
 
 gives six instances observed clini- 
 cally of fracture of the lower end 
 of the radius, with displacement 
 forwards of the carpal fragment, in 
 
 W- ""' .^Jaid^ children from ten to fourteen years 
 
 of age. For a detailed description 
 of the symptoms of this injury the 
 reader must be referred to that 
 work. It corresponds to ' Smith's 
 fracture ' — that is, fracture in 
 adults with displacement forwards 
 of the lower fragment, first de- 
 scribed by B. W. Smith. 
 
 Separation of the lower radial 
 epiphysis, with fracture of the ulna 
 above the epiphysial line, will be 
 discussed in the following section. 
 Fracture of both bones of the 
 forearm near to the wrist will 
 simulate radial separation, with 
 fracture of the ulna, very closely, 
 by the presence of the same pal- 
 mar and dorsal swelling, giving 
 rise to increase in the antero- 
 posterior thickness of the forearm 
 and loss of power over the forearm. 
 This is a rare form of injury in the child, the shafts of both bones 
 usually giving way higher up. 
 
 In both these varieties of fracture of the shaft, however, the 
 deformity is, as a rule, greater than in separation of the radial 
 epiphysis alone, and in fracture of both bones the crepitus is of a 
 drier character, 
 
 The following case of fracture of the ulna and radius just above 
 the epiphysial line came under the author's care. 
 
 H. W., aged fourteen, on November 6, 1894, while playing foot- 
 ball, slipped and fell on his hand, which he put out to save himself. 
 On getting up he experienced great pain, and noticed that his wrist 
 was bent. When he was seen at the Miller Hospital soon afterwards 
 there was a dorsal projection of the whole wrist, the whole hand 
 and width of the wrist being displaced backwards. The fingers of 
 the hand were slightly flexed. There was a solution of continuity 
 
 fe 
 
 Fig. 159. — feactdre of the lower end 
 of the radius in the vicinity op the 
 conjugal cartilage, which has already 
 disappeared 
 
 F. I. lower fragment ; F. S. upper frag- 
 ment ; 0, fragments of compact tissue 
 of upper fragment adhering to the lower. 
 (De Paoli) 
 
EARLY RONTGEN PIOTUEE OF DISPLACEMENT OE LOWER EPIPHYSIS OE RADIUS. 
 
 The image of the bones is magnified on account of the close proximity of the tube to the patient's wrist. 
 
 ihe restlessness of the patient has produced double shadows. The apex of the styloid process of ulna appears 
 
 to be bent outwards or incompletely fractured. 
 
 Mr. Charles Coppingee's case. Short exposure. Taken May 21, 1 89G, by Mr. Charles Copplxger. 
 
SEPAEATION OF LOWEE EPIPHYSIS OF EADIUS 549 
 
 of the shafts of radius and ulna above the level of the epiphyses, 
 with mobility. On moving the hand with the lower fragments, 
 hard crepitus, as of ordinary fracture, was felt. 
 
 Eeduction was easy, and the forearm and wrist were put up in 
 straight anterior and posterior splints. By the eleventh day the bones 
 had united and there was no pain, only some thickening of the lower 
 end of the ulna, and three days later the splints were removed. On the 
 eighteenth day passive movement, which had been carried out daily, 
 resulted in perfect movement of the hand and forearm. At the end 
 of three weeks there was perfect consolidation, without any deformity, 
 and all movements were restored. 
 
 The method of photographing by means of Eontgen's rays will 
 prove of the greatest assistance in the diagnosis of all these injuries 
 to the bones of the forearm at the wrist, as in diagnosis of other 
 forms of epiphysial separation in other parts of the body. 
 
 Mr. Charles Coppinger gives {British Medical Journal, June 6, 
 1896, p. 1411) a brief record of a case in which he found this process 
 of use in the diagnosis of an epiphysial separation of the radius. 
 
 J. E., aged twelve, was admitted to the Mater Misericordise 
 Hospital on May 21 with an injury to his right wrist, caused about 
 an hour before by a fall from the horizontal bar at a gymnasium. 
 The boy had fallen to the ground palm downward, and the existence 
 of a fracture was at once apparent. The deformity was great and 
 unmistakable, the dorsal and palmar elevations producing the usual 
 appearance of undulation at the wrist. There was, however, no 
 appearance of rotation, the displacement of the carpus being directly 
 backwards, so that the deformity resembled that caused by a dis- 
 location of the wrist in that direction. The absence, moreover, of 
 the curved outline of the radial border of the arm characteristic of 
 CoUes's fracture was noticed. 
 
 A Eontgen photograph of the wrist was taken without delay, 
 but with some difficulty on account of the patient's restlessness. 
 
 The negative, though not fully exposed, showed, when compared 
 with a radiograph of the normal wrist, that the injury was really a 
 displacement at the epiphysial line, and not the well-known fracture 
 of Colles, or the far more rare dislocation of the wrist backwards. 
 The facility with which the deformity was subsequently reduced by 
 simple traction, and the absence of bony crepitus during its reduction, 
 confirmed the diagnosis. 
 
 Mr. Coppinger purposed taking another skiagraph of the boy's 
 wrist at an early date for comparison. 
 
 Separation of the Eadial Epiphysis with Fracture of the 
 Ulna. — Separation of the radial epiphysis with fracture of the lower 
 end of the shaft of the ulna will present the same symptoms as separa- 
 tion of the epiphyses of both bones. 
 
 Although simultaneous separation of both lower epiphyses of the 
 forearm is not a rare event, yet the more common accident is for the 
 
550 EPIPHYSES OF UPPEE EXTEEMITY 
 
 shaft of the uhia to give way at its weakest point just above the 
 epiphysial hne. 
 
 R. W. Smith beHeves that both of these resemble more a disloca- 
 tion of the carpus backwards "than does a simple separation of the 
 radial epiphysis. ' Moreover, in the latter injury,' he says, ' the anterior 
 tumour does not extend completely across the entire breadth of 
 the forearm, being limited to the transverse extent of the radius ; 
 but the opposite is the case when the lesion implicates both 
 bones.' 
 
 Deformity. — Professor R. W. Smith, as long ago as 1847 {Fractures 
 and Dislocations, Dublin, 1847, p. 164), described the deformity in 
 separation of the inferior epiphysis of the radius with fracture of 
 the lower extremity of the ulna. 
 
 ' When the limb is viewed posteriorly it is found to present two 
 planes, one extending from the elbow to the seat of fracture, i.e. 
 from half to three-quarters of an inch above the wrist-joint ; the 
 other, which is placed more inferiorly, begins at the situation of the 
 fracture and reaches to the fingers ; where these two planes join 
 there is a deep and abrupt depression, succeeded by a solid tumour 
 placed above the carpus, but on a level with the dorsum of the 
 hand ; the latter presents an elongated appearance. Viewed 
 anteriorly, the forearm presents an unnatural convexity, commencing 
 immediately above the annular ligament of the carpus, and fading 
 gradually as it ascends ; the tendons of the extensors of the thumb, 
 where they cross the hollow above the posterior tumour, are elevated 
 and thrown into relief, and the antero- posterior diameter of the 
 forearm is considerably increased at the seat of the injury. The 
 injury consists in a fracture, usually transverse, of the lower ex- 
 tremities of both radius and ulna, close to the wrist-joint, or through 
 the line of their epiphyses ; the lower fragments are displaced 
 directly backwards, and the superior consequently project in front.' 
 
 The deformity is greater than in separation of the radial epi- 
 physis alone, and is more like that of dislocation of the wrist 
 backwards. 
 
 The dorsal swelling is transverse, and also broader than in 
 separation of the radial epiphysis alone, so that the anterior and 
 posterior projections occupy the entire breadth of the forearm. 
 
 As in the case of separation of the radial epiphysis, the projection 
 on the palmar surface is more pronounced than those on the dorsal 
 aspect, the opposite condition to that found in Colles's fracture. The 
 twisted appearance of this fracture also is absent ; and the anterior 
 margin of the diaphysis may be distinctly felt. 
 
 There is no abduction of the forearm, and both the ulnar and 
 radial borders of the forearm are somewhat shortened. 
 
 Besides the pahnar and dorsal prominences, a third is visible on 
 the inner side due to the projection of the lower end of the ulna. 
 
 Muffled crepitus is more easy of production than in separation of 
 
SEPAEATION OF LOWEE EPIPHYSIS OF EADIUS 551 
 
 the radial epiphysis alone, but is likely to be obscured by the crepitus 
 associated with the fracture of the ulna. 
 
 Eeduction is easy, but there is more difficulty in keeping the frag- 
 ments in position than in the case of separation of the radial epiphysis 
 alon e. 
 
 Numbness of the little finger may be present, and is due to injury to 
 the dorsal branch of the ulnar nerve, caused by the stretching or 
 displacement of the nerve in fracture of the ulna, or in separation of 
 its lower epiphysis. 
 
 The symptoms in a case of compound separation with fracture 
 of the ulna are described by E. W. Smith ijoc. cit. supra). 
 
 Loss of power over the forearm, especially rotation, will be present 
 in this as in other forms of fracture of the lower ends of the bones 
 of the forearm. 
 
 The following case came under the author's observation at the 
 Miller Hospital in 1890. 
 
 John M., aged eleven years, fell and pitched on the palm of his 
 outstretched hand. The arm was quite useless, and the patient 
 unable to support it in the slightest degree. The hand, with the 
 lower part of the forearm, was freely movable on the rest of the 
 limb. There were the usual prominences above the carpus on the 
 dorsal and palmar aspects, as well as the hollow characteristic of a 
 CoUes's fracture on the palmar aspect of the wrist. The hand was 
 slightly abducted, and crepitus was easily felt along the line of 
 fracture, which involved both bones. The deformity was easily 
 reduced by extension, and the limb put up in anterior and posterior 
 splints. It quickly and firmly united, with some thickening both on 
 the dorsal and palmar surfaces. 
 
 Diagnosis. — Professor E. W. Smith says : ' This accident is 
 very liable to be mistaken for dislocation of the wrist backwards, 
 but cannot be confounded with the ordinary fracture of the radius ; 
 the dorsal tumour is transverse, and the limb presents none of the 
 peculiar deformity arising from the displacement of the lower 
 fragment of the radius towards the side of supination which dis- 
 tinguishes CoUes's fracture-. Although this injury assumes very 
 much the appearance of dislocation of the" carpus backwards, it may 
 yet be distinguished from it without any considerable difficulty, 
 more especially should we be fortunate enough to see it before the 
 occurrence of tumefaction has obscured the diagnostic signs. The 
 styloid processes of the radius and ulna can be felt still holding 
 their normal relations to the carpus, and, as has been remarked by 
 Boyer, these processes move with the hand when any motion is 
 imparted to the latter. If the distance between the superior margin 
 of the dorsal tumour and the extremity of the middle finger of the 
 injured limb be measured and compared with that between the 
 corresponding point of the hand and the upper edge of the carpus 
 of the sound limb, the former measurement will be found to exceed 
 
552 EPIPHYSES OF UPPEE EXTEEMITY 
 
 the latter by at least half an inch ; sometimes the difference is 
 greater, but . if the case should be one of dislocation of the wrist 
 backwards this measurement will give the same results upon each 
 side, and the styloid processes will be found to remain at rest when 
 the hand is moved ; if we add crepitation, the easy reduction of the 
 deformity by extension, and its liability to recur when the extending 
 power is removed, we are at once furnished with a group of symptoms 
 quite sufficient to enable us to distinguish this injury from that very 
 rare accident, luxation of the wrist.' 
 
 Displacement foewaeds of the Epiphysis.— Displacement of 
 the lower radial fragment or epiphysis, anterior to the upper, is rare 
 compared with the dorsal displacement. Several instances have 
 already been quoted in which this position of the fragments was 
 found by direct examination. It does not appear absolutely essential 
 that forward displacement must be caused by a fall upon the back 
 of the hand, although this is the usual manner in which the force is 
 applied. In the case related below — Mr. E. Le Gros Clark's — it was 
 produced in exactly the same manner as in the dorsal displacement 
 by a fall on the outstretched hand. 
 
 Experimentally it has been produced by forcible flexion, placing 
 the dorsal aspect of the hand on the ground and letting a weight 
 fall on the upper part of the forearm placed in a vertical position. 
 M. Curtillet found that separation thus produced occurred at the 
 posterior half of cartilage, and was associated with a fracture in the 
 rest of the thickness of the bone. 
 
 Mr. E. Le Gros Clark describes (Medical Times and Gazette, 
 vol. ii. 1860, p. 27 ; St. Thomas's Hospital Beports, new series, 
 vol. xvii. 1887, p. 2) a case in which the separated radial epiphysis 
 was displaced forwards, and mistaken at first for a dislocation of 
 the carpus. 
 
 The patient, a lad aged fifteen years, had fallen with violence 
 upon his outstretched hand. The supposed dislocation had been 
 reduced, but immediately the support was removed from the wrist 
 the hand fell, and the radius projected on the back of the carpus. 
 A brief examination showed that the case was one of separation of 
 the epiphysis of the radius, which was thus carried forwards in 
 company with the hand, the base of the bone being felt, deprived of 
 its articular extremity, projecting on the back of the wrist. The 
 source of the error in diagnosis was the similarity in the form of the 
 base of the radius, minus the epiphysis, to that of the perfect bone. 
 Le Gros Clark says : ' The diagnostic difference is in the interval 
 between the base of the middle metacarpal bone and the projecting 
 extremity of the radius, which is of course greater when the epiphysis 
 accompanies the carpus ; but more especiahy in the noticeable fact 
 that the styloid process of the radius is identified with the carpus in 
 its movements, and distinctly isolated from the radius. Moreover, 
 if this joint can be, or ever is, dislocated, it would surely not be so 
 
SEPAEATION OF LOWEE EPIPHYSIS OF EADIUS 553 
 
 readily reducible as in the form of injury I am speaking of. I have 
 had an opportunity of dissecting a precisely parallel case to this, 
 and I believe the preparation is in our museum of St. Thomas's 
 Hospital.' 
 
 The treatment in this case consisted in confining the hand and 
 wrist in gutta-percha splints, moulded to the entire palm and the 
 lower part of the forearm, both before and behind. Passive motion 
 was commenced at the end of three weeks, and the boy recovered 
 a useful limb, there being free motion in every direction, and 
 scarcely perceptible deformity. 
 
 PROGNOSIS AND RESULTS.— There are no cases on record of 
 non-union. 
 
 Union without deformity. — ^In simple cases without complications, 
 without much displacement, without laceration of the periosteum 
 or fracture of the diaphysis, or in which the deformity has been 
 reduced, the union is very rapid and good from the thirteenth to 
 the twentieth day. The use of the limb under these circumstances 
 is perfectly unimpaired (see author's case from the Miller Hospital 
 already described). 
 
 All complications — such as wounds, fracture of the epiphysis or 
 of the diaphysis of the radius or ulna, and other rare lesions — affect 
 the progress, union, and ultimate result very considerably. The author 
 has, however, recorded a case of separation of the lower epiphyses 
 of the radius and ulna in which the most perfect union without 
 deformity took place within a fortnight of the injury. 
 
 Malgaigne treated separation of the lower epiphyses of both 
 radii in a child six years old, and consolidation ensued in the usual 
 time and without deformity. 
 
 M. Eoux has recorded {La Presse Medicale, No. 55, July 15, 
 1837, vol. i.) a similar case of disjunction of the carpal end of both 
 radii which he had seen in consultation. B., a labourer, aged 
 seventeen years, fell from a building a distance of fifteen feet on 
 his face and on the palms of his hands, which were carried 
 forwards. The double lesion of the forearms was easily made out by 
 the peculiar character of the crepitus produced by rubbing together 
 the cartilaginous surfaces, by the uniformity of the solution of 
 continuity, and by the height at which it had taken place on the 
 two sides. The displacement was slight, although the pain was 
 acute. The apparatus applied to each forearm consisted of two 
 splints and a bandage. The treatment only lasted about twenty 
 days, when remarkably firm union had taken place. Such firm 
 union, M. Eoux says, could not have been expected in the same 
 space of time in the case of a fracture, even if the fractm-e had 
 occurred in a subject of the same age. 
 
 Deformity. — Deformity from non-reduction of the displaced 
 epiphysis. 
 
 Consolidation in a vicious position should never be allowed to 
 
554 EPIPHYSES OE UPPEE EXTEEMITY 
 
 take place, yet even where the reduction of the displacement has 
 not been effected the resulting deformity is slight, and in the course 
 of a few years this will be completely effaced. There need not, 
 therefore, be any fear that permanent deformity will result. 
 
 There is usually none of that persistent distortion on the dorsal 
 and palmar aspect so characteristic of Colles's fracture. 
 
 Mr. Hutchinson describes {Lancet, August 24, 1861, p. 184 ; 
 New Sydenham Society's Betrospect, 1862, p. 270) the case of a 
 boy, aged eight, who was admitted into the London Hospital, 
 having fallen from a tree upon his outstretched hands and after- 
 wards struck his head. He sustained concussion of the brain and 
 detachment of the epiphysis of the radius in both forearms. The 
 deformity of the right wrist was more marked than that of the left, 
 but exactly similar. It was so great in the right that the case looked 
 like a dislocated wrist. No cre^^itus was felt. All deformity was 
 removed by extension, and both forearms were put up in splints in 
 the usual manner. Three weeks after the accident the epiphyses 
 were firmly united to the shafts, with, however, a large amount of 
 thickening and some displacement backwards. 
 
 Mr. Hutchinson says : ' Even in cases in which perfect reduc- 
 tion was not effected, the patients usually recovered vdth very 
 useful arms, and in course of years all trace of deformity might be 
 expected to be removed.' 
 
 When the reduction is effected early and completely, and the 
 fragments are maintained in position carefully, the separation is 
 very rapidly repaired. 
 
 In 1888 the author saw a young man, who was about to enter the 
 army as an officer, aged eighteen and a half years, who had fallen on 
 some grass with his right hand outstretched. When seen in the 
 first instance by Dr. Creed, of Greenwich, there was dorsal dis- 
 placement of the hand and lower end of radius, which he easily 
 reduced and retained in position by anterior and posterior splints. 
 Recovery took place mthout any deformity. 
 
 In the following case of probable injury to the lower epiphysis 
 of the radius the state of the parts twenty months afterwards is 
 given by E. H. Bennett {British Medical Journal, vol. i. 1880, 
 p. 759). A little girl, aged four years, fell on her hand, and 
 was brought to him twenty months afterwards. A separation 
 of the carpal epiphysis of the radius had been diagnosed, and 
 treated with plaster of Paris and a hinged splint. Pronation and 
 supination were quite free, and the patient could use the arm for 
 almost all purposes, except that the elbow-joint could not be flexed 
 beyond 45". 
 
 Roux records {La Bresse Medicale, July 12, 1837) a case of 
 separation of the carpal epiphysis on both sides, in which the 
 deformity partially destroyed the symmetrical shape and the power 
 of both upper extremities. He gives no description of the 
 
SEPAEATION OF LOWEE EPIPHYSIS OF EADIUS 555 
 
 appearance of the limbs, but merely remarks that there was a 
 ' shocking ' deformity above the wrists. The patient, a girl, 
 aged twenty-two years, had been under his care for a short time 
 with some strumous affection. During infancy she had met with a 
 double disjunction of the lower epiphysis of the radius, the cause of 
 which she did not remember. This disjunction had doubtless been 
 overlooked, and had not been treated. 
 
 MM. Bauby and Bardier {Le Midi Medical, Toulouse, 8 Octobre 
 1893), in their article, ' Considerations surle Traitement des Fractures 
 epiphysaires,' upon the immediate treatment by massage, quote the 
 following two cases as examples of the evil result of fixation of 
 epiphysial fractures of the lower end of the radius. 
 
 Case I. — A healthy youth (P. B.), aged twenty, slipped on a 
 waxed floor and fell backwards on to the palm of his outstretched 
 hand. There was pain at the wrist, loss of power in the hand, and 
 the characteristic ' fork back ' deformity. The hand was inclined 
 towards the radial border as well as strongly extended on the 
 forearm. A doctor who saw the case immediately after the acci- 
 dent, before swelling occurred, attempted reduction by means of 
 traction, and placed graduated compresses with wooden splints in 
 front and behind in the interosseous space. Ten days later this 
 apparatus was re-applied in a tighter manner. At the end of 
 twenty-five days the fracture was united, with the hand bent 
 towards the radial border, so that at its lower third the forearm 
 presented a concavity postero-externally and a bony projection in 
 front. Movements were very restricted and muscular atrophy very 
 marked. Four years after the accident the bony deformity, from 
 union in the bad position, was very marked, and although the joint 
 had almost completely regained its power of action there still 
 remained a certain hindrance to free movements together with 
 muscular atrophy. 
 
 Case II. — A youth (J. E.), aged sixteen years, came under care 
 for operative treatment to free his right hand, which could scarcely 
 be moved. At the lower extremity of the radius there was a 
 cicatrix corresponding to an old injury, and the tendons on the 
 dorsal aspect appeared to be bound together with cicatrised tissue. 
 The fingers were almost completely fixed in the extended position, 
 and there was scarcely any movement at the wrist. He said that 
 ten years previously he fractured his wrist, and was treated by a 
 bone-setter at Toulouse, who applied an immovable apparatus for 
 twenty-three days. When this came to be taken off the fracture 
 was found to be united, but in the bad position with which he 
 presented hiixiself. The forearm and hand were much atrophied. 
 
 The operation had not been carried out at the time of the 
 report, but the fingers could be used more freely after the use of 
 massage. 
 
 De Paoli relates a case of double separation of the lower 
 
556 EPIPHYSES OF UPPEE EXTEEMITY 
 
 epiphysis of the radius of a month's duration, in which con- 
 sohdation had taken place in a false position. The subject was a 
 youth, aged nineteen, who had fallen from a tree on to the palms 
 of his hands, and the deformity was practically identical on the two 
 sides and had not been corrected at the time of the accident. The 
 transverse form of the upper fragment in front and the lower frag- 
 ment behind were easily recognised now that the swelling had 
 subsided. The forearms were semi-pronated and semi-supinated, 
 and the end of the radius and hand were forcibly supinated. 
 
 Pronation and supination were almost impossible, flexion being 
 also very limited, and the patient was almost powerless to make any 
 use of his hands. Dr. Margary, under whose care he was (Sep- 
 tember 1879) at the Hospital of S. Giovanni, broke down the 
 osseous union between the fragments by forcible hyperflexion and 
 pronation while the patient was under chloroform, and completely 
 corrected the deformity. A short palmar and long dorsal splint were 
 then applied and twenty-six days later removed, when it was found 
 that pronation and supination had been in great measure restored. 
 Nine days later the patient returned home, making careful use of 
 his hands. When seen three years afterM^ards he could work 
 perfectly, using his arms in fatiguing occupations. 
 
 The following case, under the care of Mr. T. Bryant at Guy's 
 Hospital in January 1885, was probably one of separation of this 
 epiphysis with dorsal displacement. Florence D., aged ten years, 
 three weeks previously, while walking slipped and fell forwards on to 
 her hands, especially the left ; the latter became very painful and 
 swollen, and she was unable to use it. The wrist was bandaged up, and 
 arnica applied. Lately she had regained some use in the left hand. 
 
 On admission there was considerable deformity, some swelling 
 over the dorsum of the carpus, and immediately above it a hollow 
 about one inch above the lower end of the radius ; on the anterior 
 aspect, just above the wrist, another considerable swelling; the 
 styloid process of the ulna was lower than that of the radius. The 
 articulation was free from pain, and movable. Although the frag- 
 ments had to a large extent united, Mr. Bryant attempted reduction 
 under the influence of chloroform, and succeeded in diminishing the 
 amount of deformity by bringing the styloid process of the radius 
 on to a level with that of the ulna. 
 
 De Paoli figures a specimen preserved in the Biberi Pathological 
 Museum which illustrates a separation of the epiphysis consolidated 
 in an abnormal position. 
 
 The diaphysis is much enlarged, especially at the posterior and 
 inner part, where it presents a somewhat rough surface, terminated 
 by a clean edge, which, commencing below at the outer margin, 
 ascends obliquely upwards, reaching to a height of three centimetres 
 on the diaphysis, and terminates on the inner margin at the line of 
 insertion of the interosseous ligament. The anterior surface of the 
 
SEPAKATION OF LOWEE EPIPHYSIS OF EADIUS 557 
 
 diaphysis is tnrned outwards. Its lower extremity has left the 
 upper surface of the epiphysis almost completely on the inner 
 side, less so towards the outer side, and is flat and smooth 
 owing to a thin strip of compact tissue which covers it. The epi- 
 physis, the upper edge of which is throughout very distinct and 
 does not show any considerable alteration from its normal shape, 
 has been displaced backwards, and its articular surface looks 
 downwards and backwards in such a way that the direction of its 
 
 outer lateral edge, instead of 
 following that of the lateral 
 edge of the diaphysis, makes an 
 angle of about 45° with its 
 prolongation below. 
 
 
 
 -u 
 
 I 
 
 Fig. 160. — TEAUiiAxic separation of the 
 
 LOWER EPIPHYSIS OF THE RADIUS UNITED IN 
 BAD POSITION. SAGITTAL SECTION. (dE PAOLi) 
 
 Specimen in the Eiberi Pathological Museum. 
 -D, diaphysis ; E, epiphysis ; P, newly 
 formed osseous tissue from the periosteum ; 
 C, compact tissue of diaphysis. 
 
 Fig. 161. — the same viewed laterally 
 
 An antero-posterior section 
 of the specimen gives a clearer 
 idea of what has taken place. 
 It can be seen that the epi- 
 physis is only in contact with 
 the posterior part of the dia- 
 physis for a distance of two 
 millimetres ; elsewhere it is completely separated from it, so 
 that its upper margin makes an angle of 45° with the posterior 
 surface of the diaphysis. About forty-five millimetres from the 
 lower end of the diaphysis a thin compact layer covers the diaphysis 
 for a short distance, gradually thinning upwards, and passes abruptly 
 downwards and backwards to join the posterior margin of the 
 epiphysis. The normal compact tissue of the posterior aspect of 
 the diaphysis may be traced as far as its lower end. The irregular 
 
558 EPIPHYSES OF UPPEE EXTREMITY 
 
 triangular interval thus left is filled up with new osseous tissue, 
 which has its cellular spaces much smaller than those of the 
 lower end of the diaphysis, and constitutes the posterior enlarge- 
 ment of the diaphj'sial end, and is the principal bond of union 
 of the separated bones. The epiphysis was fifteen millimetres 
 in ^ddth (height) at its styloid process, four at its middle, and five at 
 its inner margin. The radio-carpal articulation was in a permanent 
 condition of h5^er-extension. The epiphj^sis of the ulna had united 
 to the shaft, and the preparation was believed to have been taken 
 from a woman, aged twenty, who had the lower epiphysis separated 
 some 5'ears prior to her death. The displacement had not been 
 corrected, and the epiphysis had consolidated in this vicious position. 
 
 A case of marked deformity after separation of the epiphyses of 
 the lower ends of the radius and ulna came under the author's care 
 at the City Orthox^^edic Hospital on October 12, 1894. 
 
 The accident had taken place between five and six weeks 
 previously, and the author was asked to give an opinion as to the 
 damaged condition of the limb. 
 
 Fig. 162. — defoemitt followixg sepaeation of lo\^-ee eadial epiphysis 
 (From a cast taken six weeks after the injury) 
 
 Ered P., aged ten years, on September 5, feh at school, whilst 
 jumping, a height of iive feet, and put out his left hand to save 
 himself. He immediately experienced great pain in the wrist, which 
 was much displaced, the deformity being of the same character as 
 when he came under observation, only it was much more marked. 
 He was taken immediately to one of the large hospitals in the 
 north of London. The bones were there replaced in position, and 
 anterior and posterior spUnts appfied and retained for a month. At 
 the end of this time the splints were removed, and the bones found 
 to be displaced again in the same position as when he came for treat- 
 ment. When the author saw him there was the typical ' silver fork 
 deformity ' indicating displacement backwards of the lower epiphyses 
 of the radius and ulna, with the wrist and hand, although the epi- 
 physis of the ulna did not appear to be so much displaced m this 
 direction as the radius ; the hand was not deflected to one side or 
 the other. The styloid processes of the bones were in normal relation 
 with the wrist and hand. The fragments were very firmly con- 
 
SEPAEATION OF LOWEE EPIPHYSIS OF EADIUS 559 
 
 solidated, and there was some thickening of the shafts of the bones 
 to be felt on the dorsal aspect, extending upwards from the diaphysio- 
 epiphysial line. The radial artery was pushed very prominently 
 forwards by the displaced lower end of the diaphysis in front. The 
 flexor tendons also were very prominent, and around them a 
 ganglionic swelling had developed. The fingers were kept slightly 
 flexed, and complete active extension was not possible ; with this 
 exception, all movements of the wrist and hand were good. 
 
 A leather moulded wristlet was worn for five months, and massage 
 employed. At the end of this time the ganglionic swelling was much 
 reduced, the flexor tendons were less prominent, and the diaphysial 
 end of the radius rounding off and less distinct. The movements 
 of the fingers were perfect. 
 
 When seen at the end of June 1895 there was little deformity 
 left and no swelling about the flexor tendons, and in October 1896 
 there was no distinguishable deviation from the natural condition. 
 
 Fig. 163. — the same case, showing nearly complete absence op deformity, 
 TWO years after the accident 
 
 Professor L. Freeman, of Denver, U.S.A. (' Some Fractures of 
 the Lower End of the Eadius as seen by the Eontgen Eays,' Annals 
 of Surgery, April 1897, No. 52, p. 471), describes the following case 
 of deformity after epiphysial separation, which he attributed to 
 stimulated growth of part of the epiphysial cartilage. The evidence 
 he adduces is not by any means conclusive that the abnormal position 
 was caused in this way. However, the case is quoted on his 
 authority : 
 
 ' A boy, about ten j'ears of age, fell from a height on to his hands and fractnred 
 the lower extremity of each radius. There was marked "silver fork" deformitj^ 
 with flexion of the fingers and inclination of the hands to the radial side. A 
 diagnosis of probable epiphysial separation was made. Complete reduction was 
 easily accomplished by dorsal flexion of the hands upon the wrists and pressure 
 applied to the distal fragments. The forearms could then be shaken until the 
 hands jerked to and fro with considerable violence without reproducing displace- 
 ment of the fragments. A dorsal splint was employed, reaching to the tips of the 
 fingers and padded at its extremity so as to maintain volar flexion at the wrist. 
 The apparatus was purposely made large and clumsy, in order, as far as possible, 
 to prevent the boy from using his hands. Following reduction there was no pain 
 and little tenderness. 
 
 ' The wrists were examined every day or two in order to note any tendency 
 towards displacement. In about a week a slight deformity was seen upon the 
 
560 EPIPHYSES OE UPPEK EXTEEMITY 
 
 right side, which was attributed to swelling of the soft parts. In a few days this 
 had increased to a considerable extent. Chloroforni was administered and reduction 
 of the deformity attemj)ted without success, although much force was employed in 
 combination with extension, dorsal flexion, and direct pressure. After several 
 days, the deformity in the meantime having increased, a second attempt at its 
 correction was made, likewise without result. It was found impossible to even 
 rebreak the bone with the amount of force which could be applied by the hands 
 alone. 
 
 ' The little patient ultimately recovered, however, with a functionally perfect 
 right wrist, although with moderate deformity. It is impossible to detect that the 
 left wrist has been broken. 
 
 ' During treatment, the boy, in spite of repeated warnings, insisted on using 
 his hands when he imagined himself free from observation. On several occasions 
 he reached backward from his bed and pulled open a drawer with his right hand. 
 At the time this was thought to account for the redislocation of the fragments. It 
 was difficult to understand, however, why the bones could not be replaced, or, in 
 fact, moved at all ; and besides this, when closely questioned the patient said that 
 at no time had he felt any pain or been conscious of anything sHpping. 
 
 ' About fourteen weeks after the injury two skiagraphs of the wrists were taken, 
 one in the prone and one in the semiprone position. Cartilage being easily 
 penetrated by the Rontgen rays, the epiphj^sial lines of the bones of the forearm 
 were clearly shown, as were also those of the metacarpal bones and the phalanges. 
 The incomplete ossification of the bones of the carpus was also indicated. 
 
 ' In the prone position of the forearms the epiphysial line of each radius was of 
 the same width throughout, one bone being apparently as perfect as the other. In 
 the semiprone position, however, the anterior half of the right epiphysial line was 
 obscm-ed by a dark shadow, representing, undoubtedly, a growth of new bone, and 
 the anterior border of the epiphysis was tilted downward from the shaft. 
 
 ' It may be that the injury alone was responsible for this excessive growth and 
 premature ossification of the epiphysial cartilage ; or it is possible that the extent 
 to which the boy insisted upon using his hand may have had somethmg to do 
 with it. 
 
 ' The skiagraphs made it at once clear why no amount of force or method of 
 manipulation would cause the disappearance of the deformity ; and why the boy, 
 in spite of an apparent redislocation of the fragments, had been free fi.'om pain and 
 tenderness.' 
 
 Professor Ereeman adds : ' In several treatises upon surgery, 
 brief mention is made of the fact that subsequent deformity may 
 appear after separation of the epiphysis of the lower end of the 
 radius; but in most text-books the question is entirely ignored, 
 although its importance in prognosis is certainly considerable. The 
 only deformity mentioned, however, is that produced by cessation of 
 growth on the part of the radius, due to premature ossification of 
 the epiphysial line, while the ulna continues to elongate, thus 
 twisting the hand to the radial side. This is entirely different from 
 the case reported above, in which the abnormal position of the bones 
 is due to stimulated growth and not to inhibited growth, although 
 the latter may take place later. 
 
 ' I know of no way in which this misfortune can be prevented 
 unless something may be accomplished by keeping the broken bone 
 absolutely at rest. It is perhaps possible that a marked deformity 
 could be lessened by stimulating the bone-producing power of the 
 remainder of the epiphysial line through injection of Lannelongue's 
 
SEPAKATION OF LOWEE EPIPHYSIS OF EADIUS 561 
 
 ten-per-cent. solution of chloride of zinc ; but this is theoretical 
 only, and more harm than good might be done. Seeing that the 
 epiphysial line seems to be at least partially ossified upon its anterior 
 surface, it may be that the remainder which is unaltered will cause 
 a more rapid growth of the posterior half of the bone, thus tilting 
 the epiphysis back into its normal position. The efficacy of re- 
 breaking the bone would be, to say the least, doubtful, while operative 
 interference might so damage the cartilage as to stop all growth. 
 In case of great deformity an osteotomy might be made higher up.' 
 
 Impaired movements. — There is never seen in young subjects any of 
 that almost permanent stiffness of the wrist, fingers, or hand which 
 occurs in adults — lasting, e.g., for months or even years in the case 
 of Colles's fracture ; although some little embarrassment in the 
 more severe cases is noticeable for some time. The effusion into the 
 synovial sheaths of the numerous tendons passing over the wrist is 
 rapidly absorbed, and but little fear need be apprehended of 
 adhesions forming, provided passive motion has been properly carried 
 out and commenced early. 
 
 In the case related by Dr. Sturrock, four months after the 
 accident the movements of the wrist were slightly restricted, and 
 a ganglion-like swelling extended one inch below and two inches 
 above the anterior annular ligament, apparently in the flexor sheaths. 
 But at the end of nine months this had disappeared, movements 
 were more extensive, there was no shortening, and only slight 
 thickening at the epiphysial line. 
 
 A similar swelling existed in the author's own case just men- 
 tioned. 
 
 InProfessorAnnandale's case, recorded by Dr. Sturrock, the patient 
 when seen some fifteen months after the injury (compound separation 
 of radial and ulnar epiphyses) had almost completely regained the 
 movements of the wrist, and little or no shortening had occurred, 
 although three-quarters of an inch of the shafts of the radius and 
 ulna had been removed by operation. 
 
 Ankylosis of the wrist is not produced by extension of the inflamma- 
 tion to the joint, but may ensue in those rare instances where the 
 separation is associated with a splitting or fracture of the epiphysis 
 into the joint, or in compound separation. 
 
 Wasting of forearm and hand is never severe ; if movements and 
 massage^have been properly carried, out it is slight and of a transient 
 nature. 
 
 Non-union. — Although non-union and the formation of a false 
 joint, from the separation being overlooked or badly reduced and 
 the fragments allowed to move one upon another, have been alluded 
 to by some writers as very uncommon, their occurrence is open to 
 great doubt. No authentic case has ever been recorded. 
 
 Union may be retarded by these movements, but they appear 
 never to produce non-union. 
 
 o o 
 
562 EPIPHYSES OF UPPEK EXTEEMITY 
 
 Arrest of growth and subsequent deformity. — In the forearm, as in 
 the case of other bones which He x^arallel, shortening of one bone 
 from arrest of growth is usually accompanied with marked deformity. 
 
 Although the radius lengthens principally by its lower extremity, 
 it is less dependent for its growth on the lower epiphysis than 
 is the ulna, and hence the deformity after epiphysial separation 
 is not usually so great in the former as in the latter. The hand 
 is in a valgus position. The transverse diameter of the wrist is 
 increased, the hand often a little atrophied and inclined to the 
 radial side, making with that of the forearm a greater or less 
 angle. The ulna appears to be displaced downwards and outwards, 
 the end of the bone being very prominent. But the free mobility 
 of the articulation is unaltered. 
 
 Ozenne thinks that arrest of growth is slight in separation 
 without displacement on account of the union being rapid and conse- 
 quently ossification of the cartilage less interfered with. But from 
 some of the pubhshed examples of arrest of growth it is quite clear 
 that there has been little or no displacement at the time of injury, 
 which has been looked upon as a sprain. 
 
 De Paoli did not find any arrest of growth in seventeen cases, 
 principally incomplete separations, observed by him, even after the 
 lapse of two years. However, he agrees with some authors in 
 thinking that arrest of growth usually occurs in cases of great or 
 complete displacement of the epiphysis, for he says not only is 
 there no longer any connection between the diaphysis and the 
 epiphysis, but the latter is, in addition, united to some higher part 
 of the former by means of an exceedingly dense osseous tissue, while 
 it is only connected in a very remote degree with the nutritive artery 
 of the diaphysis, and is therefore henceforth practically incapable of 
 performing its function in promoting the increase in length of the 
 lower end of the radius. 
 
 M. Goyrand, in referring to his two cases described above, states 
 that there was no arrest of growth of the injured radius in either 
 when he examined the upper extremities some years after the 
 accident. There did not exist any difference in the corresponding 
 arms, but both had grown well. He moreover says (1861) : ' I can 
 now, therefore, confidently say that separation of the radial epiphysis 
 is an accident without serious consequences when it is simple, that 
 union is accomplished in a very short time, and that no trace is left 
 of the injury. Fracture, on the contrary, leaves some stiffness at 
 the wrist for some time, even in infants, and after recovery it is 
 possible to distinguish, even throughout the whole of life, the 
 fractured limb. I will go still further : from many cases I have 
 observed, two of which were published in my paper in 1848, it 
 appears that in cases where the radius has been fractured before 
 osseous union has taken place between the epiphysis and the 
 diaphysis, the end of the bone has ceased to grow regularly, and 
 
SEPAEATION OF LOWEE EPIPHYSIS OF KADIUS 563 
 
 when the patient has attained his full height the radius has been 
 found to be perceptibly shorter and its carpal extremity atrophied. 
 This condition apparently results from the ossification of the 
 cartilage, and is produced during the formation of the reparative 
 callus. This ossification will be found to occur more especially 
 in comminuted fractures of the lower end, which involve the 
 extremity of the diaphysis as well as the epiphysis. Separation of 
 the epiphysis is therefore a much simpler and milder injury than 
 fracture of the extremity of the bone.' 
 
 Goyrand mentions also the case of a girl (a member of his family) , 
 aged seven or eight years, who had separated her lower radial epi- 
 physis, the result of a fall at the age of three years. The injured 
 arm developed like the other in every respect. 
 
 In the author's own five cases of separated lower radial epiphysis 
 there was no arrest of growth in any, nor did any arrest of growth 
 occur in the several cases under his care of fracture of the radius 
 immediately above the epiphysial line, which closely resembled 
 epiphysial disjunction. This might have been expected, as frac- 
 tures have in some instances, in the case of other bones, led to 
 this result. 
 
 J. Hutchinson junior' has followed up six cases of undoubted 
 separation of the lower epiphysis of the radius for a considerable 
 • time after the accident ; in only one (in which some backward 
 tilting persisted) was there decided shortening. 
 
 The deformity and attendant inconveniences fj'om arrest of 
 growth increase in proportio7i to the age of the patient and the 
 time which has elapsed from the date of the accident. 
 
 The three following cases quoted by Curtillet as mentioned by 
 Wilhelm Stehr (Th. inaug. Tiibingen, 1889 ; Curtillet, Du decollement 
 traumatique des epiphyses, Lyon, 1891) are good examples of the 
 truth of this. 
 
 Case I. — A boy (K. E.), aged sixteen years, fell from the second 
 story of a house at the age of twelve. It was noticed that there 
 was a lesion of the right wrist, but it was unimportant compared with 
 the other lesions, which attracted more attention. He remained 
 insensible for a long time after the accident. It was not until two 
 years later that the patient perceived that he could not use his hand 
 so well at his employment of hairdresser, and that it inclined to the 
 outer side, whilst there was some projection of the styloid process of 
 the ulna. When examined the hand was found to be in the position 
 of extreme abduction, the axis of the hand making with that of the 
 forearm an angle of 150 degrees. The right radius measured 18 
 centimetres, the left 22 centimetres ; the right ulna 23-3 centimetres, 
 the left ulna 24 centimetres. Freedom of movement of the wrist- 
 joint appeared to be normal. It was subsequently ascertained 
 that the patient had been obhged to give up his work as hairdresser 
 and had taken to work with a corn merchant, which did not appear 
 
564 EPIPHYSES OF UPPEE EXTEEMITY 
 
 to aggravate his condition, although there was no improvement 
 in it. 
 
 Case II. — A lad (Bernard S.), at the age of fourteen years, in 
 1876 fell from a tree and produced an injury to the wrist, which was 
 diagnosed at the time as a fracture. In 1885, when twenty-three 
 years old, he complained of pain in the arm on military service, and 
 in the following year the left hand was found to be in a position of 
 extreme adduction, with great prominence of the head of the ulna. 
 The left radius measured 19 centimetres, the right 24-5 centimetres ; 
 the left ulna 26-4 centimetres, the right 27'4 centimetres. The 
 radius presented an osseous outgrowth at its articular margin, and a 
 kind of depression about its epiphysial line. 
 
 Case III. — A lad (G. W.), aged eighteen years, was seen on 
 February 14, 1889. In March 1884 he had fallen from a height of 
 five metres upon a cemented surface. The left hip was contused, 
 and he experienced very acute pain above the left wrist ; he also 
 asserted that he had noticed a very marked depression on the dorsal 
 aspect of the forearm, whilst on the palmar aspect there was a bony 
 prominence. The doctor, however, treated the injury by cold appli- 
 cations, &c., and made the patient carry the arm in a sling without 
 attempting any reduction. At the end of four to five weeks he said 
 he could very freely use his hand, and rotation was but little di- 
 minished. Since 1885 the patient had worked in a spinning factory, 
 then as a locksmith, and could easily perform his work till the 
 autumn of 1888, when he found that after he had been at work 
 ' screwing ' for some time and was obliged to use his left hand, it 
 gave him slight pain ; he also noticed that the hand inclined more 
 to the radial side than before. On examination the left forearm 
 was a little thinner than the right (the former being 23-2 centimetres 
 in circumference, the latter 24-5 centimetres), while the left arm 
 was normal. During the state of rest the left hand was bent to 
 the radial side to an angle of 170 degrees, and the styloid process 
 of the ulna projected very prominently. About the epiphysial line 
 the left radius was somewhat thickened ; it was also 4*7 centimetres 
 shorter than the right. The left ulna was 1"7 centimetres shorter 
 than the right. 
 
 Mr. Augustus Clay exhibited a boy, aged fourteen, at the Midland 
 Medical Society in 1888 {Laiicet, April 7, 1888) who had injured his 
 forearm six years previously by falling ofi^ a cart. The injury had 
 been treated then as a sprain, and after three weeks was apparently 
 well. Three weeks previous to his appearance before the society 
 he again hurt his arm, and the shortening was discovered. The 
 wrist was much wider than the other, and the hand was pushed 
 over to the radial side by the increased length of the ulna, which 
 bone was exceptionally prominent and slightly bowed. 
 
 Museum specimens. — Several specimens in the museums of 
 the London hospitals show great dwarfing of the radius and 
 
SEPAEATION OF LOWEK EPIPHYSIS OF EADIUS 565 
 
 deformity of the forearm after what was probably an epiphysial 
 separation. 
 
 The specimen, No. 956a, in the musemn of the Eoyal College 
 of Surgeons {Catalogue of the Museum of the Boyal College of 
 Surgeons, vol. ii. p. 129 ; Trans. Patholog. Soc. vol. xvii. 1866, 
 p. 223, with fig. ; and London Hospital Reports, vol. ii. 1865, p. 351, 
 with fig.) shows arrested development of the radius, forearm, and 
 hand after an injury in childhood. The following account is mostly 
 taken from Mr. Hutchinson's description — both the long bones are 
 unusually slender ; the radius is relatively much shorter than the 
 ulna. The radius measures five inches from the middle of its articular 
 surface at the wrist to the articular surface of its head, and the 
 ulna is eight and a quarter inches from the styloid process to the 
 tip of the olecranon. Measured from the tip of the styloid process 
 of the ulna to the inner side of the articular surface of the 
 radius the latter is one and one-eighth inches higher than the 
 former. 
 
 The carpal bones are drawn upwards with the radius, and the 
 side of the ulna is consequently in apposition with the inner side of 
 the cuneiform. The cartilage covering the articular surfaces of the 
 bones at the wrist-joint is irregularly thinned at various places, 
 especially that covering the extremity of the radius, and two or 
 three bands of adhesions pass between them. 
 
 The lower articular extremity of the radius is widened, the 
 articular surface is directed somewhat forwards, and upon the 
 palmar surface is a prominent ' lip,' caused by the abrupt inclina- 
 tion forwards of the lower extremity of the bone. Near the 
 posterior margin of the articular surface is a ridge with a prominent 
 central spine, nearly corresponding to the concavity on the palmar 
 aspect of the shaft. The grooves for the tendons on the dorsal 
 aspect are well marked. 
 
 The articular facet for the lower end of the ulna is only faintly 
 indicated ; that of the head of the radius is very limited. It is 
 placed obliquely, starting from within outwards and downwards, 
 and at its outer side the cartilage is deficient over a patch, as if 
 from attrition. From its appearance it would seem that pronation 
 and supination must have been confined within narrow limits. 
 
 The bicipital tubercle of the radius is so far rotated outwards 
 that it is directed upwards. 
 
 • About the middle of the shaft the outer margin bulges con- 
 siderably, but there is not the slightest indication of fracture of the 
 shaft at any part. A longitudinal section of the radius shows no 
 interruption of the continuity of the medullary canal or of the 
 compact wall, even at the lower extremity. The ulna, except in the 
 adaptation of its articular facets to the shortened radius, presents 
 no unusual feature ; its styloid process projected considerably. The 
 carpal bones were displaced slightly forwards, being in apposition 
 
566 
 
 EPIPHYSES OF UPPEE EXTKEMITY 
 
 with the anterior portion of tiie articular surface of the radius. 
 The remodeUing of the parts has been perfect. 
 
 The specimen was removed by Mr. Hutchinson from a woman, 
 aged twenty-five years, who died in the London Hospital of tetanus 
 
 consequent on a burn. The 
 patient stated that when five 
 years old she had ' her wrist put 
 out by a fall on the hand.' Her 
 right forearm was less developed 
 in all respects than the left, and 
 the bones were much shorter ; 
 the right wrist-Joint was con- 
 siderably deformed, and the hand 
 was inclined to the radial side. 
 The hand itself was slightly 
 smaller than the other one. From 
 the condition of the bones it was 
 conjectured that the lower epi- 
 physis of the radius had been 
 injured in early life. Although 
 both the ulna and the radius were 
 less developed than those of the 
 opposite limb, and even the hand 
 was somewhat smaller, yet the 
 dwarfing of the radius was out 
 of all proportion to that of the 
 other bones. It seemed even 
 probable that the retarded de- 
 velopment of the rest of the 
 forearm was secondary to that 
 of the radius. 
 
 The specimen in the Lon- 
 don Hospital Museum, No. 400 
 {Catalogue of the London Hospital 
 Museum, 1890, p. 95), is described 
 and figured by Mr. Hutchinson 
 in the Path. Soc. Trans, vol. xvii. 
 1866, p. 237, and is almost a 
 counterpart of the one just related. 
 Mr. Hutchinson obtained it from 
 the forearm of a man between 
 forty and fifty years of age at the time of his death. 
 
 The injury to the epiphysis had occurred in boyhood. The 
 injured hand had been very useful ; there was free motion at the 
 wrist, and no defect whatever at the elbow. The ulna projected 
 considerably, and the hand was pushed over to the radial side. A 
 vertical section has been made through the carpal bones and the 
 
 Fig. 164. — akeest of growth of radius 
 (Eoyal College of Surgeons Museum) 
 
SEPAKATION OF LOWEE EPIPHYSIS OF EADIUS 567 
 
 lower third of the ulna and the radius. The ulna is about three- 
 quarters of an inch longer than the radius, and articulates with the 
 side of the cuneiform bone, the triangular fibro-cartilage intervening. 
 This cartilage is very much elongated. The styloid process of 
 the ulna is short and ill-marked. Part of the articular surface of 
 the ulna is devoid of cartilage, but there are no adhesions ; at the 
 other parts the cartilage is of normal thickness, and the edge is 
 quite smooth and bevelled off where it has been removed. The 
 carpal end of the radius is shaped exactly like that of the specimen 
 described above. It has a strong lip anteriorly, projecting towards 
 the palmar aspect, and occasioning a deep hollow on the front of 
 the bone just above it. Against this lip the carpal bones chiefly 
 rest ; the cartilage of the radius is deficient or much thinned on 
 that part of the bone nearest the ulna, and there are some strong 
 bands of adhesion between it and the scaphoid and semilunar bones. 
 There is free motion at the joint. There is nothing in the section 
 of the bone to indicate the line of fracture, reparation having been 
 complete and the alteration in form being the chief remaining 
 peculiarity. The increased thickness of the compact tissue on the 
 ulnar border of the radius is deceptive, and results from the section 
 having passed close to its surface. 
 
 Mr. Hutchinson's belief respecting this and the preceding 
 specimen is that they illustrate the results of displacement of the 
 carpal epiphysis of the radius at a very early period of life, when 
 the remodelling power was great. Probably the epiphysis was, he 
 says, as is usual, displaced backwards, carrying with it, of course, the 
 carpus. The bones of the carpus thus placed would probably tend 
 to glide forwards, and hence the formation of a strong lip of bone 
 in front to support them. 
 
 By the displacement backwards, the great depth of all the grooves 
 for the tendons on the dorsum may also be explained, as these would 
 have to play over a ridge, and would gradually deepen their channels. 
 The evidence of absorption of cartilage in both specimens, and of 
 strong bands crossing the articulation, is difficult to deal with, but 
 it does not materially militate against the hypothesis of epiphysial 
 detachment. In both cases, and in several other examples of similar 
 deformity which Mr. Hutchinson had seen in living patients, there 
 was the clear history of an accident in childhood — a supposed 
 ' dislocation of the wrist.' 
 
 A specimen, No. 95, in St. Mary's Hospital Museum is figured 
 and described by Mr. Hutchinson in the Path. Soc. Trans, vol. xiii. 
 1862, p. 264, plate xi. fig. 2 ; London Hospital Bej^orts, vol. i. 1864, 
 p. 95 ; Catalogue of the Pathological Musemn of St. Mary's Hospital, 
 1891, p. 10, as an arrest of growth of the radius probably consequent 
 on separation of its epiphysis. The specimen was obtained in the dis- 
 secting room of St. Mary's Hospital from the body of an adult man. 
 of whom no history could be procured. The radius is about one 
 
568 EPIPHYSES OF UPPEE EXTKEMITY 
 
 inch shorter than the ulna, and articulates with a facet, on the side of 
 the shaft of the latter bone, considerably below its head. The relative 
 position, &c., of the bones, and the shape of the extremity of the 
 radius, are well shown. On the outer aspect of the extremity of 
 the ulna is seen a new facet, smooth and polished, but not covered 
 with cartilage. With this facet the cuneiform bone was in apposition 
 during life. The supposition as to the cause of the arrest of growth 
 on the part of the radius is that the epiphysis of the latter was 
 detached at an early period of life, and that the reunion was interfered 
 with, either by inflammation or otherwise. 
 
 Dupuytren's specimen of dwarfed radius has already been fully 
 described (see page 521). 
 
 Professor Nicoladoni figures (Wiener medizin. JaJirbilcJier, 1886, 
 S. 264) a specimen of displacement of the hand into the valgus 
 position from a male subject in the dissecting room of Innsbruck 
 (see page 115). 
 
 This deformity had been brought about by the abnormal short- 
 ness of the radius, whose carpal surface was placed oMiquely to its 
 long axis (at an angle of 135°, open towards the ulnar side). 
 
 Above the obliquely placed radial epiphysis there was a rough 
 edge on the volar and dorsal aspect. The head of the ulna projected 
 three centimetres beyond the styloid process of the radius, while on 
 the radial side of the lower end of the ulna there was a longish 
 facet articulating in part with the radius, and in part with the 
 inner border of the carpus. The articular surface of the head of 
 the radius was placed obliquely, and sloped off towards the outer 
 side; the lesser sigmoid cavity of the ulna had also an oblique 
 direction, so that the elbow-joint must have assumed a considerable 
 valgus position. 
 
 Clinical cases. — Mr. W. H. Brown figures and describes (Lancet, 
 March 17, 1888) a case of arrest of development of the radius 
 following injury, with resulting luxation of the head of the ulna. 
 
 A. W., a boy aged ten years, was admitted in June 1880 into 
 the Leeds General Infirmary, having fallen from a two-storied 
 house upon his face and right arm. He was unconscious. There 
 were several severe wounds upon the face ; the right wrist was 
 swollen, but there was no displacement of bones and no fracture. 
 He was discharged well after two weeks, being able to move his 
 wrist freely and without pain. There was no alteration in the 
 shape of the wrist at that time. Two years later his mother first 
 noticed a ' lump ' on the wrist, but as the boy had no pain she 
 did not consult any one. The deformity gradually increased, and on 
 February 6, 1888, she brought him to the infirmary. On examination 
 the head of the ulna of the right side was found to be dislocated 
 inwards and somewhat backwards ; the movements of the joint 
 were but little interfered with ; the radius was in its normal position, 
 and practically unchanged in contour. On measurement, the radius 
 
SEPAKATION OF LOWEE EPIPHYSIS OF KADIUS 569 
 
 of the affected side was found to be one inch shorter than its fellow, 
 whilst the length of the ulna on the two sides corresponded. Mr. 
 Brown remarked that he had met with but one other instance 
 where the radius almost entirely disappeared after a blow, leaving 
 but the upper and lower epiphyses. 
 
 The injury in the present case was a very severe one, and it 
 would seem probable that the lower epiphysis of the radius was 
 impacted, and that as a result ossification followed, whilst the ulna 
 continued to grow in the ordinary way. 
 
 Goyrand {Bevue Med. chir. de Paris, 1848, p. 25) observed an 
 arrest of growth of the radius in two cases after separation of its 
 lower epiphysis. One of the cases was that of a lady, aged twenty- 
 seven years, who had received a lesion at the wrist which was treated 
 as a fracture of the lower end of the radius when she was ten years old, 
 and which had united without any deformity. It was only during the 
 subsequent growth of the body that a corresponding and increasing 
 
 
 .piie 
 
 ,, J^'if^:.' 
 
 Fig. 165. 
 
 -DEFORMITY OF HAND AND FOREARM FROM ARREST OF GROWTH OF RADIUS 
 DUE TO EPIPHYSIAL INJURY. MR. \V. H. BROWN'S CASE 
 
 deformity began to appear in the neighbourhood of the wrist. 
 Examination disclosed a very striking shortening of the radius and 
 abnormal projection of the lower end of the ulna. The outline of 
 the radius, which was smaller than that of the opposite side, was 
 quite regular, showing that there had been no overlapping of the 
 fragments. 
 
 The other case was precisely similar in a man aged twenty-seven, 
 who had met with the injury in very early childhood ; the radius was 
 slender and shortened by two centimetres, and its lower end dis- 
 placed towards the dorsal aspect. In both cases there was abnormal 
 projection of the styloid process of the ulna on the inner side. 
 
 Goyrand some years afterwards modified his opinions as to the 
 frequent occurrence of arrest of growth after this injury, when 
 reporting a few new cases which have already been described. 
 
 A. Poncet describes (Barbarin, Des fractures chez les enfants, 
 These de Paris, 1873, No. 206, pp. 57, 58 ; Lijo)i Medical, 1872) 
 
570 EPIPHYSES OF UPPEE EXTEEMITY 
 
 two cases of adults in which there existed marked deformity in the 
 neighbourhood of the wrist, from the pushing of the hand towards 
 the radial side and displacement of the lower end of the ulna down- 
 wards and outwards. In both there was an arrest of growth of the 
 radius following a separation of the lower epiphysis in childhood, 
 which was diagnosed and afterwards verified by dissection. The 
 transverse diameter of the wrist was notably increased. In the one 
 case the shortening of the radius followed a fracture at the age of 
 ten to twelve years, and amounted to five centimetres, and in the 
 other, in which the injury occurred at the age of sixteen, it was only 
 three centimetres. In the former at the time of the accident no 
 marked deformity was noticed. 
 
 Both had been carefully treated in the first instance with 
 splints ; the latter was, moreover, treated as an in-patient at the 
 Hotel-Dieu de Paris. 
 
 In the former, although the limb was a very useful one, it was 
 weaker than its fellow, and in the latter pronation, flexion, and 
 extension were easily effected ; the lateral movement inwards of the 
 hand, in addition, was limited by the ulnar projection. 
 
 At the Bradford Medico- Chirurgical Society in 1889 {British 
 Medical Journal, January 19, 1889) Mr. J. Appleyard showed a child 
 in whom an arrest of growth of the radius at its lower epiphysis 
 occurred after a fall eleven months before. The lower epiphyses of 
 the ulna and radius were connected with the bone above by fibroid 
 tissue. 
 
 Before the Midland Medical Society, November 28, 1888 {British 
 MedicalJournal, December 22, 1888, p. 1397) Mr. Haslam exhibited 
 a girl, aged seventeen, who three years before had sustained a frac- 
 ture at the lower end of the radius. This had arrested the growth 
 of the bone, and the hand was being gradually fixed to the radial 
 side by the increase in length of the ulna. 
 
 Holmes {Surgical Treatment of Diseases of Children, 1869, p. 239) 
 also mentions that he had observed several instances of loss of 
 growth after fracture in the neighbourhood of the wrist. 
 
 G. A. Wright, of Manchester, figures (Ashby and "Wright, 
 Diseases of Children, 3rd edition, 1896, p. 754) another instance of 
 an arrest of growth of the radius from separation of the lower 
 epiphysis many years before. 
 
 A very interesting example of dwarfing of the radius after injury 
 to its carpal epiphysis came under Mr. Hutchinson's notice 
 {Archives of Surgery, October 1892, vol. iv. No. 14, p. 171) 
 in the wrist of a medical friend. During a consultation he 
 noticed that the ulna of his right wrist projected greatly, and, 
 having asked permission to examine it, Mr. Hutchinson found the 
 ulna at least three-quarters of an inch longer than the radius. 
 There was not so much obliquity as is usual in these cases. The 
 wrist was simply placed at the distance named above the end of the 
 
SKIAGRAM OP WRIST OF A GIRL AGED TWELVE YEARS, showing considerable deformity 
 
 AND ARREST OP GROWTH OP LEFT RADIUS. 
 
 Twelve months after a fall on hand, which was treated as a sprain. The ulna projects about half an inch 
 
 lower than its proper relation to radius ; the epiphysial cartilage of the radius is obliterated, 
 
 but that of the ulna is quite normal. 
 
 Mr. Wm. Thomas's case. 
 
SEPAEATION OF LOWEE EPIPHYSIS OF EADIUS 571 
 
 
 
 
 
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572 EPIPHYSES OF UPPEK EXTEEMITY 
 
 ulna, the lower part of the forearm and hand being nearly straight. 
 Mr. Hutchinson was told that the condition had resulted from an 
 accident which occurred at the age of four. 
 
 Arrest of growth was attributed by Colignon to premature 
 ossification of the conjugal cartilage leading to union of the 
 epiphysis with the diaphysis, produced during the formation of callus 
 in separations which were not simple but accompanied by pre- 
 epiphysial or juxta-epiphysial fracture, or by a splintered fracture of 
 the diaphysis. For the several views on this subject the author 
 must refer the reader to the commencing chapters on epiphysial 
 injuries in general (Part I., Chapters II. and VIII.) . 
 
 Arrest of growth after suppuration and necrosis in epiphysial 
 separation of the radius and ulna is noted in a case described by 
 Mr. Hutchinson. 
 
 Gangrene, as a result of the improper use of splints, has already 
 been alluded to. 
 
 It is usually due to the tight application of the splint 
 impinging upon the two principal arteries of the forearm, which 
 occupy a superficial position in the lower part of their course. 
 "Where the violence has been great and is followed by great 
 inflammatory swelling, should the apparatus not allow of its 
 being loosened as the swelling increases, this disastrous occurrence 
 may result. However, we must not be too ready to attribute it 
 entirely to the negligence of the surgeon. In cases of severe 
 violence the hand and forearm should be carefully examined day by 
 day, and in this respect the patient or his parents are often too 
 ignorant or careless. 
 
 Again, the severe nature of the original violence, the extensive 
 extravasation of blood, and the pressure of the diaphysial end upon 
 one of the main vessels, are sometimes sufficient, especially in a 
 feeble constitution, to produce such a result. 
 
 TREATMENT. — There is a very marked contrast in the rapid 
 union of separations in comparison with that of fractures in older 
 patients. In epiphysial sepaeations without displacement, 
 and in the simpler forms of displacement when reduction has 
 been effected, the most simple retentive apparatus is sufficient to 
 keep the fragments in position — a moulded plastic splint to the 
 forearm, wrist, or palm, or Gamgee tissue soaked in silicate of 
 potash, or cardboard splints. Absolute rest for a few days in 
 these instances is sufficient to remove all traces of the lesion. 
 
 The splint should, however, in most cases be applied for eighteen 
 to twenty days, and the hand supported in a sling on account of 
 the tendency to inflammation of the periosteum and bone. In a 
 few instances the splint may be removed as early as the fifteenth 
 day. 
 
 , In these cases there is no tendency for the deformity to be 
 r_eproduced on account of the broad and transverse surfaces of the 
 
BEPAEATION OF LOWBK EPIPHYSIS OF RADIUS 573 
 
 Fig. 166. — method of applying an- 
 terior WOODEN SPLINT TO FOREARM 
 AND HAND 
 
 epiphysis and diaphysis. A very different condition is present in 
 fracture, where the greatest care is necessary to prevent a recurrence 
 of the deformity. The majority of such cases do not unite without 
 some deformity. Satisfactory results such as this can only occur, 
 as a rule, in epiphysial separations. . ■ 
 
 In more or less complete displacements reduction should in 
 the first place be effected by means of extension and manipulation, 
 and approximation of the displaced 
 parts. It can always be accomplished 
 easily and completely. In more 
 complicated cases some periosteal 
 tags may intervene between the dia- 
 physis and displaced epiphysis and 
 prevent complete reduction. The 
 extension should be carried out with 
 the hand in the supinated position. 
 The thumb or fingers of the surgeon's 
 hand will also help to press the 
 epiphysis directly into its normal 
 position. As a rule there is but 
 little tendency to reproduction of the 
 displacement. 
 
 The second point is to retain the 
 epiphysis in position by means of 
 
 Gordon's, or two straight wooden, splints, one on the anterior and 
 the other on the posterior aspect of the forearm. The dorsal splint 
 may be longer than the palmar (Nelaton's plan). 
 
 Nelaton's splint, or any other form of pistol-shaped splint, is un- 
 necessary, and, as a rule, in simple cases of separation of the radial 
 epiphysis alone, no inclination of the hand towards the ulnar side is 
 necessary, as the fracture is transverse and not oblique. Indeed, a 
 pistol-shaped splint is actually harmful, as it tends to separate the 
 epiphysis from its diaphysis. 
 
 Dr. E. W. Smith says (Dublin Hospital Gazette, 1860, p. 49) : 
 ' Compared with Colles's fracture there is but little difficulty in the 
 treatment of this accident, nor need any apprehension be enter- 
 tained of permanent deformity resulting, or of any lasting impair- 
 ment of the functions of the limb. The pistol-shaped splint, 
 usually employed in the common fracture of the lower end of the 
 radius, is not required ; when the fragments have been brought into 
 opposition by extension, a cushion, thickest opposite the disjointed 
 epiphysis, is to be placed along the posterior surface of the limb, 
 and a second along the front of the forearm, its thickest part corre- 
 sponding to the lower end of the upper fragment ; two straight 
 splints are then applied, reaching from the elbow to the metacarpo- 
 phalangeal articulations at least, and secured either by a continued 
 roller or by tapes ; the latter mode of securing them facilitates the 
 
574 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 use of evaporating lotions, and favours the early detection of any 
 
 amount of swelling.' 
 
 Levis's metallic splint for the palmar aspect of the forearm and 
 
 hand is a good one, provided an accurately fitting one can be obtained, 
 
 Usually a special one has to be made for the particular case. 
 
 A moulded splint of gutta percha, plaster of Paris, or other 
 
 material may be accurately moulded to the palmar aspect in a few 
 
 minutes. 
 
 The forearm and hand should be enveloped as far as the meta- 
 
 carpo-phalangeal articulation in the plaster dressing ; in separation 
 
 of both lower epiphyses of the forearm 
 the hand should be slightly inclined 
 to the ulnar side after the fragments 
 have been replaced in position. The 
 dressing, if made of plaster of Paris 
 in the form of palmar and dorsal 
 splints, may easily be cut up along the 
 inner or outer borders to examine the 
 condition of the bones, and as readily 
 re-applied. Great caution should be 
 exercised in avoiding any tightness of 
 the bandage applied to the retentive 
 apparatus, especially in the more severe 
 cases, on account of the great amount 
 of extravasation of blood present. 
 
 No graduated compress between 
 the bones of the forearm is necessary, 
 inasmuch as the lower end of the 
 diaphysis of the radius is almost the 
 same shape as the articular end, and 
 hence the interosseous space has no 
 tendency to become obliterated. 
 
 Great care must be exercised in 
 applying the splints, on account of the 
 not infrequent accident of gangrene 
 from tight bandaging. A bandage 
 should never be applied to the limb 
 before the sphnts are fixed. 
 Professor Eoux was the first to lay stress upon the frequency 
 
 with which gangrene occurred in fracture of the forearm from 
 
 retardation of the circulation, in severe injuries from pressure of 
 
 effused blood upon the vessels. 
 
 The arm and hand should be examined frequently. Once a day 
 
 at least the surgeon should carefully examine the condition of 
 
 the limb. It would be far better to apply no splints at all than 
 
 to allow them to be on the limb with the danger of increasing the 
 
 inflammatory swelling. 
 
 Fig. 167. — pattern foe anterior 
 and posterior pieces of antero- 
 POSTERIOR SPLINTS (croft's), FOR 
 THE HAND AND WRIST AND FOREARM 
 OF A BOY OF FIFTEEN TEAKS 
 
 Eeduced to one-quarter size on scale 
 of inches 
 
SEPAEATION OF LOWEK EPIPHYSIS OF EADIUS 575 
 
 J. Hutchinson junior says that out of fourteen cases, nine of 
 which were under his own observation, of simple detachment of this 
 epiphysis, most of them with very marked displacement, reduction 
 was in every case effected, and a very good result obtained by 
 treatment. 
 
 Passive motion must be commenced early; after the tenth day 
 the fingers, at any rate, should be freely moved. 
 
 The sphnts should be finally removed on the fifteenth to the 
 twentieth day in cases of separation without displacement; but 
 
 Pig. 168. — croft's antero-posterior splints of plaster of paris applied to 
 the right forearm and hand 
 
 Fig. 169. — the same, with dorsal portion laid aside after cutting through 
 the muslin along gap on outer side 
 
 where displacement has been present they should be removed on 
 the eighteenth to twenty -fifth day, or even a few days later if 
 thought to be necessary. 
 
 After removal of the splint when union has taken place, the 
 movements of the wrist-joint are soon regained, the swelling of 
 the forearm rapidly disappears, and supination and pronation soon 
 become normal ; whereas in the corresponding fractures in older 
 persons great stiffness of the wrist-joint and tendon-sheaths and 
 wasting of the muscles of the forearm are a frequent result from the 
 penetrating fracture of the joint, the feebler circulation, &c. 
 
 An injury at the lower end of the radius in a boy, described by 
 John Ashhurst junior {International Clinics, '2nd series, 1892, vol. i. 
 
576 EPIPHYSES OF UPPEE EXTEEMITY 
 
 p. 200) as an ordinary fracture a short distance above the joint, was 
 probably a separation of the epiphysis produced by a fall upon the 
 hand, which sustained the weight of the body. The deformity was 
 well marked, being the ordinary ' silver-fork ' deformity, and mobility, 
 though not crepitus, existed at the seat of fracture. 
 
 He recommends two compresses, which should be large enough 
 to effect the desired purpose. The upper compress is appHed over 
 the lower end of the upper fragment, on the palmar surface, and 
 the other is appHed on the dorsal surface over the lower fragment. 
 "When the compresses are brought together, the bones are neces- 
 sarily pushed into position. Even if this cannot be accomplished 
 at once, it will be found, he says, that by careful dressing the deformity 
 will in a few days disappear. The hand should be put in the supine 
 position and a Bond's splint apx)lied. 
 
 Dr. Thomas S. K. Morton recently advocated {New York Medical 
 Journal, July 7, 1894, p. 26) a new method for reduction of fractures 
 of the lower end of the radius, which had proved satisfactory in his 
 hands dming the previous few years. By this manipulation a 
 separated epiphysis of the lower end of the radius was easily re- 
 ducible. The method was as follows : 
 
 ' The surgeon stood in front of the patient and interlaced- his 
 fingers beneath the supinated wrist and palm of the injured member, 
 so that his two index fingers lay parallel crossv\dse beneath the 
 lower end of the upper fragment of the radius. The palms of the 
 surgeon's hands were then closed in upon the thenar and hypothenar 
 portions of the patient's hand respectively, while the surgeon's 
 thumbs rested parallel lengthwise upon the upwardly displaced lower 
 fragment of the radius. The x^arts were thus firmly grasped by the 
 surgeon while the following movements were made : The patient's 
 wrist was excessively extended by carrying his hand upward. When 
 superextension had thus been secured, the surgeon made powerful 
 traction upon the wrist in the line of superextension. WTiile this 
 traction was maintained the hand w^as suddenly carried into full 
 flexion, and at the same time powerful dov^nward pressure upon the 
 upwardly displaced lower fragment of the radius was made by the 
 surgeon's thumbs opposed by the interlaced index fingers beneath 
 the lower end of the upper fragment. The excessive extension 
 of the first portion of the movement had always, so far in my 
 experience, loosened or disentangled the displaced lower fragment, 
 while the subsequent traction, flexion, and direct thumb pressure 
 had not yet failed to accurately force the lower fragment into its 
 proper position. Anesthesia was unnecessary for making a single 
 effort at reduction by this method, but was necessary for a second 
 attempt.' 
 
 The immediate treatment by massage without the use of retentive 
 splints, lately recommended by French surgeons, has been adopted 
 by M. Bauby and M. Bardier (Le Midi Medical, Toulouse, 8 Octobre,, 
 
SEPAEATION OF LOWEE EPIPHYSIS OF EADIUS 577 
 
 1893, p. 473, ' Considerations sur le traitement des fractures epi- 
 physaires ') in this as in other forms of epiphysial fracture. 
 
 The reduction of the fragments is said to be slower and surer by 
 this method. 
 
 The author quotes the following case mentioned by them in 
 order to strongly deprecate their procedure — at any rate, if it be 
 carried out to its fullest extent in children, as it is in adults. 
 
 A patient (M. B.), aged twelve, fell from a trestle upon his hands. 
 A fracture occurred at the level of the lower epiphysis of the right 
 radius, and was easily diagnosed by the characteristic deformity. A 
 compression-bandage was applied for twelve hours and then taken 
 off, and massage commenced at the seat of the fracture. There was 
 discoloration and swelling of the wrist, with great pain on pressure, 
 and all movement was impossible. 
 
 Massage was carried out daily for five minutes, the pressure being 
 progressively increased. At the end of fifteen days consolidation 
 took place, and there was neither pain, swehing, nor deformity. 
 During the intervals of the massage a very light dressing was applied, 
 but not sufficient to fix the part, the arm being in a sling. 
 
 At the time of the report (four months later) recovery was said to 
 be perfect, without any articular stiffness and without the slightest 
 untoward sign. 
 
 Compound Sepaeation. — An attempt should always be made 
 to save the limb, even though it be so severely damaged as to 
 apparently preclude recovery. 
 
 The wound must, of course, be carefully and thoroughly cleansed 
 from all dirt and grime ; for this purpose it may be found necessary 
 to remove the superficial parts of the soiled soft tissue of muscle, 
 cellular tissue, &c. If the subject be very young, soiled portions 
 
 Fig. 170.— stout knife employed by authok (may also be used as a chisel 
 
 WITH A mallet) for EEMOVING ROILED PORTIONS OF THE DIAPHYSIS IN COM- 
 POUND EPIPHYi-IAL SEPARATIONS 
 
 of the diaphysial end may be cut away with a stout knife ; and in 
 older subjects the careful use of a saw may be found advantageous 
 for the same purpose. The wound and bone should then be dis- 
 infected by means of a suitable antiseptic solution, such as ca.rbolic 
 acid (1 in 30), hyd. perchlor. (1 in 1,000). 
 
 The wound may require to be enlarged before the diaphysis can 
 be replaced in its normal position through the rent in the periosteum. 
 In some of the recorded cases this reduction appears to have been 
 very incompletely carried out. 
 
 Resection of the diaphysial end may be necessary to effect the 
 reduction of the fragments. This irreducibility of the diaphysis is 
 
 p P 
 
578 EPIPHYSES OE UPPEE EXTREMITY 
 
 mainly due to its particular shape — viz. its marked enlargement in 
 its lower fifth from above downwards — and to the shrinking of the 
 skin, which has lost its proper circumference, and the buttonhole 
 condition of the aponeurosis and flexor muscles. 
 
 Resection was performed in the cases of Denonvilliers, Pean, 
 Richet, Annandale, and others with a successful result. 
 
 Antiseptic dressings and great care are required to prevent 
 subsequent inflammatory comx^lications. 
 
 In two cases of compound separation in children, both aged 
 thirteen years, one recorded by M. Pean in 1856 and the other by 
 M. Richet in 1859, M. Denonvilliers, under whose care they were 
 placed, resected the protruding end of the diaphysis, rather than 
 incise the skin, to effect reduction. Both patients recovered in a 
 short time, and without any unfavourable occurrence. 
 
 J. Hutchinson junior found ten compound cases among fifty- 
 four otherwise uncomplicated cases ; in four it was found necessary 
 to resect the end of the protruding diaphysis before it could be 
 reduced. In all these good recovery ensued ; in the other six this 
 course was not followed, but more or less imperfect reduction was 
 obtained. Two patients died, both with suppuration, tetanus being 
 responsible in the one case, pyaemia in the other ; one case recovered 
 with a crippled wrist-joint after tedious suj)puration ; three underwent 
 amputation on account of gangrene. Two deaths and three cases 
 of loss of limb occurred out of six, nearly all being comparatively 
 recent cases. 
 
 Secondary amputation may be required, from sloughing or gangrene 
 of the forearm. 
 
 Dr. Bceckel performed amputation on the tenth day after 
 compound separation for sloughing of the forearm, and the patient 
 recovered. 
 
 Resection of whole or part of the epiphysis may be expedient in 
 some few exceptional cases of comminnted fracture of the epiphysis 
 (see Professor Annandale's case, described above), and in cases 
 where ankylosis of the wrist appears to be inevitable. 
 
 Replacement by operation in old cases. — L. von Lesser, of Leipzig, 
 has drawn attention {Centralhlatt fur Cliirurgie, No. 15, April 9, 
 1887, S. 265) to the operative treatment of badly united fractures 
 of the radio-carpal epiphysis, and mentions the case of a boy, aged 
 thirteen years, in which the lower end of the radius, which had 
 been displaced towards the dorsum, was detached by means of a 
 chisel. Other complications in this case — ankylosis of the meta- 
 carpo-phalangeal joint of the thumb, matting together of the flexor 
 tendons, and marked atrophy of the muscles of the hand — had 
 rendered operative interference necessary. 
 
 Conjugal chondi'ectomy, or excision of the conjugal cartilage of the 
 ulna, may be performed to produce its arrest of growth in deformity 
 arising from cessation of growth of the radius after epiphysial 
 
SEPAEATION OF LOWEE EPIPHYSIS OF EADIUS 579 
 
 separation. This may be especially desirable when there is a 
 considerable period of time to elapse before the bone reaches its 
 limit of increase in length. 
 
 The distances given by Oilier (through the skin) from the con- 
 jugal cartilages to the top of the styloid processes are as follows : 
 
 Eadius : at four years of age, eleven to twelve millimetres ; at 
 fifteen years of age, fifteen to sixteen millimetres. 
 
 Ulna : At four years of age, eight to nine millimetres ; at fifteen 
 years of age, eleven to thirteen millimetres. 
 
 The deformity of the wrist caused by shortening of the radius 
 after fracture in an adult has been successfully treated by Dr. Gill 
 (U.S.A.) by the removal of a portion of the shaft of the ulna {Neiv 
 YorJc Medical Becord, January 6, 1894, p. 9). The portion of the 
 ulna removed was five-eighths of an inch in length, and was taken 
 from just above the attachment of the pronator quadratus. 
 
 Correction of deformity by osteotomy. — Dr. McBurney operated on 
 a boy of about sixteen years for the relief of deformity and impaired 
 function caused by a CoUes's fracture of the radius, one and a half 
 inches from the lower extremity. Perfect union had resulted after 
 the fracture, vdth well-marked silver-fork deformity, loss of power of 
 flexion at the wrist, partial loss of flexion of the fingers, and a good 
 deal of pain on motion. He did not think he could with propriety 
 attempt refracture without cutting down upon the bone. He therefore 
 divided this as nearly as he could in the line of the fracture, which 
 ran somewhat obliquely. He was then able to put the parts up in 
 proper position and retain them with a plaster-of-Paris splint. 
 Subsequently there was very little deformity left, and the restora- 
 tion of function was extremely satisfactory {Neio York Medical 
 Becord, April 3, 1897, p. 495). 
 
 However, the author cannot consider this an example of Colles's 
 fracture, inasmuch as the fracture occurred one and a half inches 
 above the wrist. , 
 
 p p 2 
 
580 EPIPHYSES OF UPPEE EXTEEMITY 
 
 CHAPTEE XIII 
 SEPARATION OP THE LOWER EPIPHYSIS OP THE ULNA 
 
 ANATOMY. — Up to three years the lower end of the shaft of the 
 uhia keeps its cyHndrical form, and it is the lower epiphysis which 
 chiefly gives the shape to this end of the bone. 
 
 About the fourth, fifth, or sixth year the chief nuclei of the 
 carpal extremity appear towards the centre of the head and base 
 of the styloid process. These lie close together, and soon blend, 
 forming an osseous plate which extends downwards en the inner 
 side into the styloid process. This process is formed principally 
 from this centre, but an additional centre is sometimes seen at 
 the summit, appearing about the twelfth year, and joining the rest 
 of the osseous epiphysis three or four years later. 
 
 Beclard described two centres, one for the articular end and 
 the other for the styloid process, appearing soon after birth. 
 
 This epiphysis joins the shaft at twenty years of age, often a 
 little later. 
 
 The fully formed epiphysis comprises the whole of the articular 
 surface of the head on the outer aspect, for the radius, as well as 
 on the inferior aspect towards the inarticular fibro-cartilage ; it also 
 includes the styloid process projecting downwards on the inner 
 side, which is grooved behind for the tendon of the extensor carpi 
 ulnaris. Its upper aspect is concave and mammillated, and fits the 
 corresponding convexity of the diaphysis. 
 
 The level of the epiphysial line of the lower end of the ulna is very 
 shghtly above the level of that of the radius, about ^V^l^ of an inch. 
 The cartilaginous disc is twelve millimetres vertically above the 
 apex of the styloid process in the fully formed epiphysis, and seven 
 millimetres at fourteen years of age. On the inner side or head it is 
 eight millimetres vertically above the lower articular surface, and 
 at fourteen years of age five millimetres. "Where the head joins the 
 styloid process on the outer side the thickness (vertically) of the 
 mature epiphysis is only five millimetres, at fourteen years three 
 millimetres. 
 
 The head of the ulna is covered by the synovial membrane of 
 the inferior radio-ulnar articulation, and rotates within the sigmoid 
 cavity of the radius and on the surface of the triangular fibro- 
 cartilage. 
 
SEPARATION OF LOWER EPIPHYSIS OF ULNA 581 
 
 This epiphysis is held to the lower epiphysis of the radius in 
 front and behind by the anterior and posterior inferior radio-ulnar 
 ligaments, and also by means of the triangular fibro-cartilage, 
 which is attached by its apex to the root of the styloid process, and 
 by its thin base to the lunar margin of the radius. To the carpus it 
 is held by the numerous anterior and posterior fibres of the capsular 
 ligament of the wrist. 
 
 The apex of the styloid process affords attachment to the 
 internal lateral ligament of the wrist. 
 
 The synovial membrane of the inferior radio-ulnar articulation 
 is especially loose in front, where it slightly overlaps the epiphysial 
 margin of the ulna ; on the outer side it extends upwards between 
 the radius and ulna, and overlaps the epiphysial line at this 
 point. This cul-de-sac is not necessarily opened in epiphysial 
 detachment, on account of its being firmly attached to the epiphysis 
 and but loosely to the diaphysis, from which it is readily separated. 
 
 PATHOLOGICAL ANATOMY. Simple sepaeation. — This is an 
 exceedingly rare injury. The author knows of no specimen where 
 simple detachment of this epiphysis has taken place without some 
 accompanying serious injury to the neighbouring bones or soft 
 parts. 
 
 Separation with othee lesions. — In separation of the lower 
 epiphysis of the radius it is surprising to see how very infrequent 
 is an accompanying separation of the lower end of the ulna. In 
 radial separation the styloid _^,^_ 
 process of the ulna is mostly W^^\ 
 broken off, or, as we have seen ; ' 
 
 above in E. W. Smith's and }\,:' '. \ 
 several other instances, the 
 diaphysis of the ulna is broken 
 at its smallest jjart — namely, 
 three-quarters of an inch above 
 the lower extremity (con- 
 sidered at fifteen years of age). 
 
 In Bruns's 100 cases of 
 epiphysial separation, of which 
 the anatomical details were 
 given, only two were of the 
 lower end of the ulna. 
 
 Mr. Jonathan Hutchinson junior's specimen in the Royal College 
 of Surgeons Museum shows this lesion, amongst others, caused by 
 direct crushing violence. It consists of the lower ends of the right 
 radius and ulna taken from a lad, aged fourteen, whose forearm had 
 been caught in a jute-tearing machine, rendering primary ampu- 
 tation necessary. The lower epiphysis of the ulna (the head 
 and styloid process), cleanly detached, is displaced outwards, so 
 as to be firmly wedged between the shaft and the lower end of 
 
 Fig. 171. — sepaeatic:n or lowke epiphyfts ni' 
 
 ULNA, AND FRACTUEE OF R.'.DIUS 
 
 Specimen, Eoyal College of Surgeons Museum, 
 No. 956d. 
 
582 EPIPHYSES OF UPPEK EXTEEMITY 
 
 the radius, which is extensively fractured. The membrana sacci- 
 formis and wrist are uninjured ; the former has been cut open in 
 order to expose the epiphysis. 
 
 The fracture of the radius occurs on the inner side, rather more 
 than a quarter of the width of the diaphysis being broken away ; 
 the rest of the conjugal line is uninjured (see fig. 171). 
 
 Incomplete detachment, with greenstick fracture of the shaft. — In 
 the Charing Cross Hospital Museum there is a specimen, No. 355 
 {Catalogue of Museum of Charing Cross Hospital, 1888, p. 33 ; 
 Lancet, January 8, 1859), showing incomplete separation of this 
 carpal epiphysis, associated with a greenstick fracture of the shaft. 
 The detachment of the epiphysis has been effected only on the 
 outer and anterior aspects ; the posterior and inner are still con- 
 nected with the diaphysis by means of the periosteum, so that there 
 is no displacement, and only a slight gap between the epiphysis and 
 the shaft on the outer side. The latter presents a greenstick 
 fracture one and a half inches above the lower end for three-quarters 
 of an inch of its thickness, with bowing (convexity) outwards of the 
 remaining portion of the bone. The lower epiphysis of the radius 
 is completely separated. 
 
 The patient was a boy, aged fourteen, who received a lacerated 
 wound of the outer side of the arm in a printing machine. The 
 forearm was amputated by Mr. Canton. 
 
 Comminution of epiphysis with fracture of shaft of radius. — In a 
 specimen. No. 932, in the Museum of St. Bartholomew's Hospital 
 {Catalogue of Museum of St. Bartholomeio's Hospital, vol. i. p. 134) 
 the lower epiphysis of the ulna is separated from the diaphysis 
 and broken into several pieces. The largest piece of the epiphysis 
 with the triangular fibro-cartilage is displaced outwards off the 
 diaphysis towards the radius, and the periosteum still attached to it 
 is stripped upwards from the shaft for nearly half an inch. The 
 diaphysis is displaced somewhat inwards off the comminuted 
 epiphysis. The radius is fractured transversely one and a quarter 
 inches from its articular surface and above the epiphysial line. The 
 shaft is firmly impacted in the cancellous tissue of the lower end, 
 which is displaced backwards. No history is appended to the case. 
 
 Separation of the epiphysis with that of the radius. — Instances 
 have been recorded in which separation of this epiphysis was 
 associated with that of the radius, and have already been alluded to 
 in the previous chapter. 
 
 It occurred in Voillemier's, Geoghegan's and other cases already 
 described. 
 
 Dolbeau {Bullet, de la Soc. de Chirur. 1865 ; Gazette des 
 Hopitaux, 1865) mentions a separation of the carpal epiphyses of 
 both bones of the forearm and of the opposite radius in a child, 
 aged thirteen years, who fell from a second story and died nineteen 
 days later from fracture of the skull. 
 
SEPAEATION OF LOWEE EPIPHYSIS OF ULNA 583 
 
 Barbarin relates {Les fract. chez les enfants, These de Paris, 
 1873, p. 34) a similar case of separation of the carpal epiphyses of 
 the radius and ulna on the same side in a boy, aged eighteen years, 
 who fell from a height. Amputation was performed at the shoulder- 
 joint for gangrene. 
 
 In Koux's specimen of separation of the radial epiphysis the 
 styloid epiphysis of the ulna, as well as the epiphyses of the first 
 phalanges of the thumb, index, and middle fingers, were detached 
 by an explosion of gunpowder. 
 
 ETIOLOGY. — Severe direct violence appears to be the usual cause 
 in the published examples. 
 
 Bertrandi said he had seen in a child 'the epiphyses of the 
 radius and ulna separated by its being violently raised by its hand 
 from the ground.' 
 
 AGE. — Of the eleven cases recorded six are pathological sjjecimens 
 and five simple cases of arrest of growth. Of the former the age 
 is stated in four: one at eighteen, two at fourteen, and one at 
 thirteen years. Of the latter the injury is said to have occurred : 
 two at five, one at two, one at eleven, and one in a little boy. 
 
 SYMPTOMS. — No instance has been pubHshed, apart from those 
 accompanied by other severe injuries to the wrist, in which the 
 injured lower ulnar epiphysis formed an insignificant part, while 
 more than one was caused by direct crushing violence as just stated. 
 
 It is possible that a less degree of violence does not unfrequently 
 cause a partial separation, which is then overlooked; the signs of 
 these partial separations cannot differ materially from those of 
 other bones. (See Part I. Chapter VII.) 
 
 PROGNOSIS. Suppurative periostitis.— Mr. Cock had a case under 
 his care at Guy's Hospital {Lancet, 1850, vol. ii. p. 652) of a child, 
 aged three and a half years, with acute periostitis and necrosis of 
 the entire ulna from suppuration extending upwards beneath the 
 periosteum. Three months previously the child had received a 
 severe blow with a stick on the inner side of the arm just above the 
 wrist. Mr. Cock considered the acute periostitis to be the result of 
 the original injury — viz. a fracture or separation of the epiphysis 
 just above the styloid process. The end of the ulna, which pro- 
 jected through a large ulcerated opening immediately above the 
 wrist, was seized, and the entire ulna, with olecranon and coronoid 
 processes complete, was drawn out through the opening. Thickened 
 soft tissues only remained, as no new shell of bone had been formed 
 round it. Four months later the use of the arm was completely 
 restored, but with entire deficiency of the ulna and the absence of 
 any attempt at restoration by the deposition of new bone. 
 
 Arrest of growth. — The ulna depends almost entirely upon the 
 integrity of the lower epiph}'sis for growth in length ; the upper 
 epiphysis being of comparatively little importance in this respect. 
 From the examples of arrest of growth now recorded it would 
 
584 EPIPHYSES OF UPPEE EXTEEMITY 
 
 appear probable that injury to the lower epiphysis of the ulna is not 
 so rare as has been supposed. At any rate a partial separation 
 without displacement or juxta-epiphysial sprain appears to be not 
 uncommon. 
 
 Arrest of growth from injury to the lower end of the ulna, as in 
 the case of the other parallel bones (the radius, tibia, and fibula), is 
 usually seen to give rise to much lateral displacement or adduction 
 of the hand, from the continued growth of the second bone (radius) . 
 The hand is thereby thrust over into the varus position. 
 
 Mr. Jonathan Hutchinson figures {Illustrated Medical Neios, 
 November 17, 1888) the peculiar deformity of the forearm which 
 followed an injury to (detachment of) the carpal epiphysis of the 
 ulna in early life. The hand seemed to be pushed over to one side. 
 It was the radius which had grown in excess of the ulna. 
 
 The patient was a young man of about eighteen, who had re- 
 ceived an injury to his wrist when a little boy. No history of the 
 precise diagnosis at the time of the accident was forthcoming, and 
 although separation of the carpal epiphysis of the ulna is very rare, 
 yet it had in all probability occurred in this instance and occasioned 
 the arrest of growth. Mr. Hutchinson continues : ' I do not know 
 that I have ever seen a recent example of detachment of this 
 epiphysis, and the present is, I think, the only case in which I 
 have seen dwarfing of the ulna of the kind which suggested its 
 occurrence.' 
 
 The following notes by the same author {Pathological Society's 
 Transactions, vol. xvii. 1866, p. 251) appear to be of the same case, 
 shown by this surgeon at the Pathological Society in 1866. 
 
 Mr. Hutchinson says : ' The young gentleman, aged seventeen, 
 was sent to me on account of an unusual condition of his right arm. 
 The hand was bent over to the ulnar border. The extremity of the 
 ulna was hidden. The styloid process of the radius projected, and 
 the lower fourth was bowed outwards. It was clear, from the 
 thickening and bend, that the radius had been fractured between 
 two and three inches above the wrist. I could not find any evidence 
 of former fracture of the ulna, but the whole of the lower half of 
 this bone was very thin, and so buried amongst other muscles that 
 it was not easy to examine it. The ulna of the left arm measured 
 from the olecranon to the styloid process nine and three-quarter 
 inches ; the ulna of the right arm, eight inches ; the radius of left 
 arm, nine and a half ; the right, nine inches ; the girth of the left 
 forearm at thickest part, nine and three-quarters ; and the right, nine 
 inches. The accident occurred at the age of five, from a kick from 
 a horse ; it was said to be a fracture at the time, and the skin was 
 not lacerated. The deformity has gradually increased as the lad 
 grew. He complains that the right arm is much weaker than the 
 other, but still he can use it for most things. The right hand is 
 not smaller than the left to any perceptible degree. There is no 
 
SEPAKATION OF LOAVEE EPIPHYSIS OF ULNA 585 
 
 deformity at the elbow. My diagnosis was that there had been a 
 fracture of the radius in its lower third, and probably at the same 
 time detachment of the epiphysis of the ulna, and that thus the 
 growth of the ulna had been arrested.' 
 
 Mr. Edmund Owen shovv^ed before the Medical Society of London, 
 March 26, 1888 {British Medical Journal, vol. i. 1888; Medical 
 Societifs Proceedings, vol. xi. 1888, p. 353 ; Lancet, October 3, 1891, 
 p. 767), the following case of arrested growth after injury to the 
 lower epiphysis of the ulna. The girl, aged eighteen, had been 
 under his care sixteen years previously at St. Mary's Hospital for an 
 incised wound of the left wrist. The blade of a chaff machine 
 had passed through the ulna, just above its articulation with the 
 lesser sigmoid cavity ; that joint was not opened, but the lesser 
 sigmoid cavity was sliced from the radius, and the wrist-joint was 
 laid widely open. The tendon of the flexor carpi ulnaris, the ulnar 
 nerve and artery, ■ and some of the adjacent flexor tendons were 
 cleanly severed. Circulation and cutaneous sensibility were ulti- 
 mately restored along the inner side of the hand, and though 
 inflammation attacked the surrounding tissues and an abscess formed 
 on the back of the hand, the power of movement became in due 
 course as free as ever. Indeed, the child was left-handed ; as she 
 grew up she easily used her knife in that hand. Ultimately she 
 became a useful domestic servant. But when the ulna had ceased 
 to be developed, it pla3'ed the part of a bowstring, bending the 
 radius over to that side, so that the hand was greatly adducted. In 
 September 1887 the girl fell upon the inner side of the damaged 
 wrist, and immediately afterwards (according to her account) sensa- 
 tion became diminished along the inner side of the hand, and the 
 member became useless. How far the case might be influenced 
 by hysteria Mr. Owen could not say, but it was evident that the 
 ball of the little finger and the web of the thumb were wasted ; 
 probably the nerve was injured. The chief interest consisted in 
 the apparent overgrowth of the radius ; actually, however, that 
 bone was half an inch shorter than the opposite one, whilst it 
 was bowed in its lower two-thirds towards the ulna, which latter 
 bone was three inches and a half shorter than its fellow on the right 
 side. Mr. Owen excised one inch of the lower third of the shaft 
 of the radius, with the result that the hand and forearm became much 
 straighter, and their usefulness w.as increased. See cast specimen 
 No. 96 in St. Mary's Hospital Museum {Catalogue of the Fatho- 
 logical Museum, St. Mary's Hospital, 1891, p. 10). 
 
 The figure in Part I. Chapter VIII. p. 118 is of a case described 
 by Curtillet (Du Decollement traumatigue des epiphyses, Lyon, 1891) 
 from the clinique of M. Poncet, in which a compound traumatic 
 separation of the lower epiphysis of the ulna was followed by 
 suppuration and necrosis of the epiphysis, and subsequently by 
 arrest of growth and considerable deviation of the hand. 
 
686 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 The youth (V. P.), aged 22, was admitted into the Hotel-Dieu in 
 November 1890. At the age of eleven he had fallen from a trapeze 
 about two metres in height, causing a wound at the lower part of the 
 left forearm through which the ulna projected for about six centi- 
 metres. The patient stated that the end of the bone was smooth and 
 regular. It was reduced by a bone-setter. Profuse suppuration oc- 
 curred through several openings which were found on the inner side of 
 the forearm, and extended over four months. Three or four months 
 after the accident the patient perceived a movable piece of bone in 
 the wound, which he removed with his fingers. The fragment was 
 
 cylindrical, about two centimetres 
 in length, with a flat surface at 
 each end. The wound completely 
 healed shortly afterwards. The 
 deformity seen was considerable. 
 The radius, although normal at its 
 upper end, was bent like a bow at 
 its lower end, being thrust over to 
 the ulnar side. The axis of the 
 hand made vnth that of the fore- 
 arm an angle of 130 degrees. The 
 ulna was likewise normal at its 
 upper end, as well as at the 
 superior radio-ulnar and humero- 
 ulnar joints ; its lower end, how- 
 ever, terminated abruptly, thereby 
 leaving a hollow one and a half 
 centimetres in length, which cor- 
 responded precisely with the frag- 
 ment which had been removed. 
 The forearm was somewhat atro- 
 phied, but pronation, supination, 
 and flexion were effected naturally, 
 whereas extension was slightly 
 less than normal. 
 The right radius measured from the epicondyle to the styloid pro- 
 cess 24-5 centimetres ; the left, 22-5 centimetres ; the right ulna from 
 the olecranon to the styloid process, 24-5 centimetres; the left, 17-5. 
 The length of the humerus was the same on the two sides, and 
 there was no difference between the two clavicles. 
 
 Professor Nicoladoni, of Innsbruck, noticed (Wiener medizin, 
 JahiMcher, 1886, S. 264) a striking example of this varus position 
 of the hand compHcated with deformity at the elbow-joint, following 
 arrest of growth of the ulna in a boy aged eleven years. 
 
 The left hand (fig. 172) in complete supination of the forearm 
 was placed in a very marked varus position— that is, inclined to the 
 ulnar side. The line of the wrist passed obliquely from the styloid 
 
 Fig. 172 vaeus position of hand axu 
 
 elbow the kestjlt of aeeest of 
 growth of ulna following injuey 
 (nicoladoni) 
 
CURVATURE OP RADIUS, DUE TO ARRESTED DEVELOPMENT OP THE ULNA 
 AT ITS DISTAL EPIPHYSIS. «. 
 
 Prof. J. W. White's case. 
 
SEPAEATION OF LOWEE EPIPHYSIS OF ULNA 587 
 
 process of the radius upwards and inwards towards the head of the 
 ulna, which was represented by a spindle-shaped projection. The 
 elbow-joint, when extended, was likewise in a varus position, the 
 axis of the humerus forming with that of the forearm an angle 
 inwards of 165 degrees. The head of the radius projected on the 
 outer side of the elbow-joint, and the epitrochlea stood more 
 than a centimetre higher than the (outer) epicondyle. The right 
 ulna measured twenty-two centimetres and the left sixteen, while 
 the right and left radius were of equal length. The extremity was 
 otherwise well developed, and the movements of the wrist and 
 elbow-joints were free. The boy was said to have had a fall when 
 five years old, and to have injured his left hand. The injury, how- 
 ever, appeared to his relatives to be so slight that no medical 
 assistance was called in. Dr. Nicoladoni thought that the 
 thickening of the lower end of the ulna indicated a disjunction of 
 the lower epiphysis at the time of the injury, and that this had led 
 to arrest of growth and consequent deformity. The deformity had 
 perceptibly increased (1886) since the time it had been first observed 
 (1884). 
 
 J. Hutchinson junior records {British Medical Journal, March 31, 
 1894, p. 669) another case, of a student aged twenty-four, which 
 'came under his own observation. When five years old he had been 
 kicked by a horse on the right wrist. There was no wound and no 
 subsequent suppuration. The radius gradually became curved, and 
 the ulna was ultimately nearly two inches shorter than that on the 
 other side. The forearm muscles were not so well developed as on 
 the left side, but the patient had very good use of the hand. 
 
 A skiagraph produced by Professor A. W. Goodspeed {The 
 American Journal of the Medical Sciences, August 1896) shows very 
 well the condition and appearance of the forearm produced by curva- 
 ture of the radius due to arrested development of the ulna at its distal 
 epiphysis. E. A., aged fifteen years, came to the University Hospital 
 of Pennsylvania, under Professor J. W. White, in January 1896. 
 The affection began in the seventh or eighth year, when a little lump 
 was noticed on the arm and the patient complained of pain located 
 at that point. There was no sign of curvature at that time ; it had 
 come on gradually since, while the pain had been inconstant and 
 rheumatic in character, seemingly after a slight cold at each attack. 
 As the patient had fair use of the hand, and could write with it and 
 do almost everything useful, no operation was advised. 
 
 TREATMENT. — The general rules of treatment are the same as 
 in other epiphysial separations. 
 
EPIPHYSES OF UPPEE EXTEEMITY 
 
 CHAPTER XIV 
 
 Separation of the Epiphysis or the Metacarpal Bone of the TnuiviB — 
 Separation of the Epiphyses of the True Metacarpal Bones — Separa- 
 tion OF THE Epiphyses of the Phalanges of the Digits 
 
 SEPARATION OP THE EPIPHYSIS OF THE METACARPAL 
 BONE OF THE THUMB 
 
 ANATOMY. — The first metacarpal bone, or metacarpal bone of the 
 thmnb, is developed like one of the phalanges, the epiphysis being 
 situated at its proximal end. In the four inner or true metacarpals 
 the epiphysis is placed at the lower extremity. Both morpho- 
 logically and developmentally this bone should be regarded as a 
 phalanx. 
 
 The epiphysis begins to ossify about the third year, and unites 
 with the shaft about the twentieth year. 
 
 The epiphysis is at fourteen years of age five millimetres thick 
 vertically at the posterior border, and four millimetres anteriorly ; 
 in width, laterally, eleven millimetres. The epiphysis is at eighteen 
 years of age six and a half millimetres thick vertically at the 
 posterior border, and seven millimetres anteriorly ; in width, eighteen 
 millimetres. 
 
 To the margin of this epiphysis is attached the capsular 
 ligament of the carpo-metacarpal joint, which is stronger behind 
 and on the outer side than in front. 
 
 The synovial membrane of the carpo-metacarpal joint of the 
 thumb, although loose, does not extend downwards so far as to 
 overlap the epiphysial cartilage. 
 
 Traces of a distal epiphysis in this metacarpal bone are usually 
 to be seen, and in some instances a distinct epiphysis (as in the 
 seal and some other animals) is visible at the age of seven or eight 
 years. 
 
 The nutrient artery of this bone is situated on the ulnar aspect 
 and runs downwards. 
 
 ETIOLOGY. — Indirect as frequently as direct violence is the cause 
 of separation of this epiphysis. 
 
 Indirect injury, such as a fall upon the thumb, or a blow with the 
 fist in pugilistic encounters. 
 
 Direct violence, such as a blow from a stick or cricket-ball. 
 
EPIPHYSIS OF METACAEPAL BONE OF THUMB 589 
 
 AGE. — There are onlj^ two simple cases recorded ; one at 
 eighteen, one at sixteen years of age. 
 
 PATHOLOGICAL ANATOMY. — There is no specimen of this lesion 
 in the London hospitals or elsewhere, and no case has been verified 
 by immediate dissection. 
 
 SYMPTOMS.— Pain is expe- 
 rienced on pressing the thmnb 
 towards the carpo-metacarpal 
 articulation. 
 
 Deformity arises from the 
 displacement of the base of the 
 diaphysis more or less com- 
 pletely off the epiphysis, giving 
 rise to a projection on the dorsal 
 or palmar aspect, together with 
 shortening of the thumb. 
 
 Displacement backwards. — 
 The only case which has been 
 diagnosed dm'ing life is one 
 recorded by Mr. R. Clement 
 Lucas {Lancet, October 31, 
 1885, p. 801), in which he was 
 able to determine the exact 
 character of the lesion by ex- 
 amination under chloroform. 
 
 C. W., aged sixteen, came 
 to Guy's Hospital on March 6, 
 1885. He had fallen with his 
 hand bent under him, the 
 weight of the body being re- 
 ceived upon the outer side of the 
 left thumb ; this was bruised 
 and painful, and he was unable 
 to move it without great pain. 
 There was a projection out- 
 wards and backwards, at the ^m. its.-epiphyses of the jietacakpus and 
 
 ^ r, ■. . PH-U:.AXGES AT THE AGE OF FIFTEEN AND A 
 
 base 01 the metacarpal bone half yeaks. \ natural size 
 which at first sight appeared to 
 
 be caused by a dislocation of the carpo-metacarpal joint. The 
 dresser attempted a reduction and failed. Under chloroform Mr. 
 Lucas traced the metacarpal bone down towards its base, where it 
 terminated in a projection situated on the outer and posterior aspect 
 of the thenar eminence. It could be easily pressed into its place, 
 but showed a tendency to recur to its miusual position. There was 
 no true bony crepitus. The seat of abnormal movement was too inferior 
 to be in the joint between the metacarpal bone and the trapezium, 
 and the symptoms present were considered sufficient to distinguish it 
 
590 EPIPHYSES OF UPPEE EXTEEMITY 
 
 from dislocation of the metacarpal bone. Peduction was effected by 
 pressure and extension, and a well-padded splint w^as applied from 
 the wrist to the end of the thumb on its dorsal aspect. Complete 
 recovery without deformity took place in three weeks. 
 
 Abnormal mobility between the fragments is difficult of detection 
 by reason of the smallness of the epiphysis and the difficulty 
 experienced in grasping it. If this can be accomplished by the 
 jfinger and thumb, mobility may be felt during attempt at flexion of 
 the metacarpus. 
 
 Crepitus of the characteristic soft kind may be found during 
 reduction ; it will be slight on account of the small size of the 
 separated surfaces. 
 
 Dr. C. A. Sturrock {Edinburgh Hospital Beports, vol. ii. 1894, 
 p. 603) has seen ' one case in which separation of the head of the 
 first metacarpal as an epiphysis was diagnosed by an eminent 
 surgeon, though the epiphysis for the extremity of this bone is 
 usually at the base ; in many instances there is also one for the 
 head (Quain). The accident referred to occurred in a patient aged 
 eighteen, and now, fourteen years after the accident, there is 
 very slight stiffness of the joint, with some thickening, but no 
 shortening.' 
 
 J. Hutchinson junior alludes to a case in which the proximal 
 epiphysis of the first metacarpal bone was separated during an 
 attempt (fortunatelj^ successful) to reduce a dislocation of that bone. 
 
 COMPLICATIONS. — Inflammation of the carpo-metacarpal joint 
 may follow epiphysial separation. 
 
 DIAGNOSIS. — Separation of the epiphysis of the metacarpal bone 
 of the thumb might be mistaken for a dislocation, which it closely 
 resembles either in its forward or backward displacement. 
 
 Shortening of the thumb and mohility may be present in both 
 injuries, although in separation of the epiphysis the latter may be 
 detected somewhat lower down than the joint. 
 
 Tendency to re-displacement after reduction may exist in dis- 
 location, as well as in separation of the epiphysis. 
 
 Muffled crepitus is the only trustworthy sign ; it may be absent 
 from the small size of the separated surfaces. 
 
 TREATMENT. — The treatment of separated epiphysis is much 
 the same as that for dislocation of the metacarpal bone backwards or 
 forwards. The reduction will readily be accompHshed by employing 
 extension and making direct pressure upon the disx^laced end of the 
 diaphysis. 
 
 A moulded splint of gutta-percha, or other material well padded, 
 should then be api^Ued, and the hand kept in a shng. 
 
 Operative treatment by open incision may be necessary if the 
 displacement of the base of the diaphysis be completely off the 
 epiphysial plate, and reduction cannot be accompHshed by more 
 simple means. 
 
EPIPHYSIS OF METACAEPAL BONE OF THUMB 591 
 
 Compound separations should be carefully dissected down 
 upon, freely exposed, and the fragments placed in their normal 
 position and fixed together by sutures. 
 
 Amputation should perhaps never be performed, although the 
 diaphysis may be comminuted and apparently crushed in an almost 
 hopeless manner. 
 
 SEPARATION OP THE EPIPHYSIS OP EITHER OP THE 
 TRUE (POUR INNER) METACARPAL BONES 
 
 ANATOMY. — In the fom^ inner or true metacarpal bones the epi- 
 physis is developed at the distal extremity. The osseous nucleus 
 appears about the centre of the cartilaginous end from two and a 
 half to five years of age, commencing in that of the index finger. 
 
 The epiphysis unites with the shaft about the twentieth year. 
 The proximal end in each metacarpal bone is formed by the shaft. 
 
 In the second metacarpal bone the nutrient artery runs upwards 
 on the ulnar side ; in the other three it runs upwards on the radial 
 side. 
 
 Fig. 174. — epiphyses of the phalanges and metacarpal bone at sixteenth yeak 
 (aptee eambaud and Renault) 
 
 Mr. Allan Thompson states that there are traces of a proximal 
 epiphysis to be seen in the second metacarpal bone. 
 
 The fully formed epiphysis constitutes the whole of the condyloid 
 head, and has the lateral ligaments attached to the tubercles and 
 hollows on each lateral aspect. 
 
 The length of the epiphysis (of the index finger) vertically from the 
 epiphysial line is nine millimetres posteriorly and seven millimetres 
 anteriorly. The width from side to side is at fourteen years, ten milli- 
 metres ; at eighteen years, twelve millimetres ; the width antero- 
 posteriorly at fourteen years, twelve millimetres ; at eighteen years, 
 fifteen millimetres. 
 
 The synovial membrane is firmly fixed to the epiphysis laterally 
 below the attachment of the lateral ligaments, but in front and 
 behind it overlaps the epiphysial cartilage. Even here the membrane 
 springs from the epiphysis, and is but loosely attached to the 
 diaphysis. 
 
 ETIOLOGY. — Indirect violence. — Falls upon the hand with the fist 
 closed, in such a manner that the lower end of the metacarpal bone 
 
692 EPIPHYSES OF UPPEE EXTEEMITY 
 
 strikes against the ground, whilst the upper end receives more or 
 less the weight of the body. The natural curve of the bone is 
 thereby increased, and the epiphysis thrown forwards. 
 
 By reason of their greater length, on receiving the violence in a 
 fall upon the closed fist, the epiphyses of the first and second meta- 
 carpal bones are more likely to be separated than those of the other 
 metacarpal bones of the fingers. 
 
 Striking with the fist closed or a fall on the palm or heads of 
 the metatarsal bones when the fingers are in the over-extended 
 position may produce displacement of the epiphysis backwards. 
 
 Direct violence. — Direct blows upon the knuckles are more likely 
 to separate one or more epiphyses, while indirect violence is more 
 likely to separate single bones. 
 
 _A.(jE. — There are seven clinical cases recorded : two at ten, one 
 each at fourteen and a half, twelve, nine, eight, and six years 
 respectively. 
 
 U Ab 
 
 E e mV. I IV. 
 
 Fig. 175.— feontal section of the little .finger of the left h^nd of a eoy 
 
 AGED EIGHT YEAES, SHOWING EELATION OF SYNOVIAL MEMBEANES TO THE EPI- 
 PHYSIAL LINES 
 
 Posterior sectional surface : U, ulnar, and E, radial side ; mV, fifth metacarpus ; 
 e, its epiphysis ; Ab, abductor of little finger ; I IV, fourth interosseous muscle. 
 The section has been made a httle obliquely, so that the synovial mem- 
 brane of the metacarpo-phalangeal joint appears to be higher on the outer 
 than on the inner side. (V. Brunn) 
 
 PATHOLOGICAL ANATOMY.— No example has been verified 
 anatomically. 
 
 SYMPTOMS.— It is exceedingly probable that many examples 
 diagnosed as fracture of the head of these bones were really cases 
 of separation of the epiphysis. 
 
 From its more exposed position the epiphysis of the metacarpal 
 bone of the index finger is more likely to be separated than that of 
 the other metacarpal bones. 
 
 Displacement of the epiphysis foewaeds. — From the 
 direction of the violence and the anatomical connections of these 
 bones, it wih be found that displacement forwards of the epiphysis 
 is the most frequent, the epiphysis being driven forwards mto the 
 palm. 
 
 Deformity.— Besides the projection of the epiphysis in the palm 
 of the hand beyond the level of the neighbouring bones, there is an 
 angular projection of the diaphysial end on the dorsum. It is quite 
 
DISPLACEMENT FORWARDS OF EPIPHYSIS OF METACARPAL BONE OF IXDEX FINGER. 
 Author's case. Taken by ilr. Stdney Rowlaxd in March 1896. 
 
EPIPHYSES OF TKUE METACAEPAL BONES 593 
 
 possible that tlie concavity on the upper aspect of the epiphysis 
 may be felt in the pahn. 
 
 After the deformity has been reduced there is a great tendency 
 for it to recur, due in part to the smallness of the separated surfaces, 
 in part to the action of the powerful flexors, aided by the inter- 
 ossei. 
 
 The finger is shortened from the overlapping of the diaphysis 
 by the epiphysis. 
 
 Hamilton {Fractures and Dislocations, London, 1884, 7th 
 edit., p. 393) relates the following case, in which the metacarpal 
 bone was probably separated at the epiphysis. 
 
 Thomas E., aged eight, fell down a flight of steps, September 11, 
 1855, breaking the metacarpal bone of the index finger of the right 
 hand near its lower extremity, and apparently at the junction of the 
 epiphysis with the diaphysis. The lad was seen sixteen hours 
 after the accident. The lower fragment, projecting abruptly into 
 the palm of the hand, could be easily replaced, or with only moderate 
 effort, yet immediately when the support was removed it would 
 become displaced. There was no crepitus. It was dressed very 
 carefully with a splint and compress ; but, notwithstanding con- 
 tinued efforts to keep the fragments in place, the epiphysis united 
 considerably depressed towards the palm. 
 
 M. Polaillon quotes another case from a thesis by Pichon in a 
 child aged twelve years. 
 
 The following interesting case was sent to the author by Dr. 
 Atkins of Sutton. The patient (W. F. C), aged fourteen and a 
 half, the son of a well-known medical man, injured his right hand 
 on April 17, 1893, by falling with a stick twisted in between his 
 fingers. Separation of the epiphysial head of the metacarpal bone 
 of the first finger, with displacement forwards, was diagnosed at tbe 
 time. Under chloroform the epiphysis was readily replaced back- 
 wards into its normal position, but on account of some deformity 
 recurring the author was asked to see the case. There was still some 
 tendency for the epiphysis to ride forwards towards the palm, and 
 also some displacement outwards. Beyond this there was sub- 
 luxation of the first phalanx. Chloroform was again administered, 
 and the finger placed in a good position. In spite, however, of 
 repeated and careful application of plaster-of-Paris and other splints, 
 the epiphysis again became a little displaced forwards, but all 
 lateral displacement was entirely corrected. In this position it 
 finally united to the diaphysis. As a result, at the present time 
 (March 1896) the head of the metacarpal bone is still prominent in the 
 palm, as seen by the photograph (see fig. 176). The power of flexion 
 at the metacarpo-phalangeal joint is a good deal restricted and the 
 finger shorter than its fellow, but its usefulness is scarcely impaired. 
 
 In March 1896 Mr. Sydney Eowland kindly took a skiagraph (British 
 Medical Journal of March 1896, p. 620) of the hand, which confirmed 
 
 Q Q 
 
594 EPIPHYSES OE UPPEK EXTEEMITY 
 
 absolutely the diagnosis of separation of this epiphysis. The space 
 noticeable between the first phalanx and the displaced posterior 
 margin of the epiphysis and the diaphysial end is probabty occupied 
 by fibroid tissue, forming some portion of the new articular surface 
 
 between the bones. The 
 epiphysial discs of the 
 other metacarpals, as 
 well as of the phalanges, 
 are clearly seen. 
 
 Crepitus of the usual 
 muffled character is often 
 absent. M. Mirault de- 
 tected it in his case. 
 
 Fig. 176. — Separation op the head of the meta- There will be acute 
 
 CARPAL BONE OF THE INDEX FINGER, WITH DISPLACEMENT • ' +V, l, /^l A 
 
 FORWARDS. A SOMEWHAT PROMINENT KNOB IS SEEN IN P^'Ul lU tlie liana, aUCl a 
 
 THE PALM. THE FINGER IS SLIGHTLY SHORTER THAN Cracklluff SCUSation at 
 
 ITS FELLOW , , . . n 1 • t 
 
 the tnne oi the accident ; 
 also pain at a point opposite to the epiphysial junction, more marked 
 than in dislocation. 
 
 Swelling or ecchymosis will be chiefly noticeable on the dorsal 
 aspect, and but seldom on the palmar. 
 
 There will be some loss of power of moving the finger, it is 
 somewhat bent up towards the palm, and the patient is unable to 
 extend it. 
 
 In cases of great displacement, the extensor tendon may be 
 pushed to one or other side of the dorsal projection. 
 
 Mobility may be obtained in forcibly flexing the finger and 
 pressing with the finger or thumb in the palm opposite to the level 
 of the epiphysial junction. In the metacarpal bone of the index 
 finger about the fifteenth year the line is about a quarter of an inch 
 above the articulation, but great care must be exercised on account 
 of the natural mobility of the lower ends of the metacarpal bones 
 and the smallness of their epiphyses. 
 
 Displacement backwaeds. — Gueretin describes {La Presse 
 Medicale, 1837) a case of separated epiphysis of the metacarpal bone 
 of the index finger observed by M. Mirault, surgeon to the Hotel- 
 Dieu d'Aiigers, in a child aged ten years. The child, whilst lying on 
 his back at play, June 2, 1836, was said to have received his brother 
 (who rushed at him from a distance) on his hands and feet, so that 
 the fingers of his left hand were turned forcibly backwards. Acute 
 pain and deformity of the index finger immediately took place. A 
 dislocation of the first phalanx of the index finger from the meta- 
 carpal bone was supposed to have occurred, and numerous ineffectual 
 attempts were made by the doctor who first saw the case to reduce it. 
 The finger was fixed, the second phalanx flexed almost at a right 
 angle upon the first, whilst the latter was in extreme extension 
 upon the metacarpus, so as to form with it an obtuse angle. The 
 
DISPLA-OEMENT OUTWARDS OF EPIPHYSIS OF METACARPAL BONE OP 
 
 IXDBX PINaEE. 
 
 Dr. E. Kex. HERRiN(i's case 
 
EPIPHYSES OF TKUE METACAEPAL BONES 595 
 
 whole finger was placed on a plane posterior to the direction of the 
 metacarpal bone, and the metacarpal phalangeal joint appeared to 
 be much thicker than normal. But neither towards the dorsal nor 
 palmar aspect of the hand was there an abrupt projection such as 
 is usually met with in dislocation. Flexion and extension of the 
 first phalanx could be effected ; these movements, however, did 
 not take place at the metacarpo-phalangeal joint, but about four 
 lines higher up. It was at this spot that an abrupt solution of 
 continuity perpendicular to the long axis of the metacarpal 
 bone was recognised. M. Mirault thought he could distinctly 
 detect a rough friction sensation, which was somewhat less harsh 
 than that of two irregular osseous surfaces. The solution of 
 continuity of the metacarpus was therefore clearly made out, and 
 the lower end of the upper fragment of the bone distinctly felt 
 towards the palm of the hand. The lower fragment was displaced 
 obliquely upwards and backwards between the metacarpus and 
 phalanx. It was the latter which gave the thickened appearance to 
 the joint, and the finger was no longer in the same plane as the 
 metacarpus. 
 
 This oblique position of the fragment had also produced a 
 shortening of about two lines in the length of the index finger, 
 whilst the measurement of the index finger itself from the seat of 
 separation appeared to be longer than that of the opposite side. 
 The epiphysis, intimately attached to the end of the phalanx, 
 followed it in all its movements. Unfortunately, the mode of re- 
 duction, the retentive apparatus used, and the length of time to 
 effect union are not mentioned. 
 
 ■ M. Gueretin adds that, from the symptoms enumerated by 
 Mirault, the case had probably been seen a short time after the 
 accident, and that there did not appear to have been any swelling 
 to obscure the diagnosis. 
 
 Displacement outwards. — Dr. E. K. Plerring of Ballarat 
 {Intercolonial Medical Journal of Australasia, March 20, 1897, 
 vol. ii. No. 3, p. 144) publishes the notes of a case of dislocation 
 outwards of the epiphysis of the metacarpal bone of the index finger, 
 and gives a skiagraph of the hand. 
 
 O. W., aged ten, was brought by his mother on account of a lump 
 in his hand. He had fallen from a tree six or seven weeks 
 previously, and says he fell on his outstretched hand. He com- 
 plained of pain in the hand next morning, and the mother says the 
 lump was there then. On examination of the palmar surface of 
 the right hand, just over the neck of the second metacarpal bone, 
 there was found a small, rounded, hard, and firm nodule, about the 
 size of a pea, not movable from the metacarpal bone, which other- 
 wise appeared normal. Flexion and extension were free, and there 
 was no pain on pressure. On closing the fist, the knuckle was not 
 quite so prominent as the others. The injury was diagnosed by 
 
 Q Q 2 
 
596 
 
 EPIPHYSES OF UPPEE EXTEEMITY 
 
 several medical men as an exostosis, but the skiagraph revealed a 
 detachment of the epiphysis. By a tenotome, separation and re- 
 placement were effected, but the nodule could not be kept in 
 position, and had finally to be removed. 
 
 DIAGNOSIS. Dislocation of first phalanx of finger forwards. — Dis- 
 location is rare, and is not accompanied by cartilaginous crepitus 
 during reduction. The finger is more fixed than in separated epi- 
 physis except in the case of the index finger, while the dorsal pro- 
 jection has a less sharp edge, is less painful to the touch, and is on 
 a level with the heads of the other metacarpal bones. 
 
 In dislocation there is less tendency for the deformity to be re- 
 produced after reduction. 
 
 Fig. 177. — dislocation at metacaepo-phaiangeal joint with slight feactuee of 
 the head of metacaepal bone. the palmae peojection is seen to be lower 
 
 DOWN THAN IN THE CASE OF SEPAEATION OF THE EPIPHYSIS. ME. THOMAS MOOEE's 
 CASE 
 
 Fig. 178. — the same, lateral view 
 
 Dislocation at metacarpo-plialangeal joint backwards.— Gueretm 
 
 notes the similarity of the symptoms met with in Mirault's case to 
 dislocation backwards, but the signs given in this case were too pre- 
 cise to admit any doubts as to epiphysial separation. 
 
 Fracture.— Polaillon only found (loc. cit. infra) two examples of 
 fracture of the metacarpus in children. One of them is the case 
 alluded to below. 
 
 In fracture the dorsal prominence is pointed, and in separation 
 
DISLOCATION OF METACARPO-PHALANGEAL JOINT, WITH FRAOTUEB OF EPIPHYSIS 
 
 OF METACABPAL BONE OP INDEX FINGER. 
 
 Mr. Thomas Moore's case. Taken by Mr. Thomas Moork. 
 
EPIPHYSES OF TKUE METACAEPAL BONES 597 
 
 of the epiphysis angular, while in both the distance from the tip 
 of the finger is greater than in dislocation, and in them it may be 
 possible to detect some movement of the metacarpo-phalangeal joint. 
 
 Simple contusion. — It is doubtless true that many cases of 
 epiphysial separation are masked by the pain and swelling, espe- 
 cially cases of but Httle displacement. In the progress of these, 
 when the swelling and pain have subsided, the diagnosis will be 
 made clear. A separation, in these difficult cases, may be pre- 
 sumed to have occurred if the patient has experienced a craclding 
 sensation at the time of the accident, and pain persists at a certain 
 point with some loss of power in the finger. 
 
 PROGNOSIS AND RESULTS.— Non-union is not Hkely to occur ; 
 the epiphysis quickly rejoins the diaphysis without any deformity in 
 two to three weeks. 
 
 There was failure of union, however, in the following case, 
 although there was no loss of function thirteen years after the injury. 
 
 M. Polaillon describes (art. ' Main,' Diet. Encycl. des Sciences 
 Medicales, 2^ Section, vol. iv. 1870-71, p. 51) this case, which 
 Malgaigne considered to be one of epiphysial disjunction resulting 
 in non-union. The patient (E. H.), aged twenty-two years, 
 had had a fall at the age of nine years which gave rise to a 
 fracture of the fourth left metacarpal bone, and resulted in a false 
 articulation. The head of the bone was deformed and movable, and 
 appeared to have a concave surface. When the patient flexed her 
 fingers the head sank down towards the palm of the hand, and the 
 upper fragment made a marked projection backwards. This pro- 
 jection became so marked that at the same time the extensor tendon 
 slipped to the outer side of the bone by the side of the middle 
 finger. During extension this projection diminished, but did not 
 entirely disappear, and then on the palmar aspect, opposite to the 
 head of the bone, the flexor tendon could be felt thickened and 
 enlarged, and appeared to contain a cartilaginous or osseous 
 nodule. All movements could be carried out freely and to their 
 natural extent. As Polaillon states, it is very diflicult to form a 
 precise opinion on the nature of a lesion observed thirteen years 
 after the accident, but he gives his opinion that epiphysial separation 
 was more probable than a fracture in this case. 
 
 M. Eenault, however, thought that if there had been a separa- 
 tion this was probably owing to its having been predisposed to it 
 by rachitic enlargement of the epiphysial cartilage. 
 
 Even in those instances where great difficulty has been ex- 
 perienced in retaining the epiphysis in position, and some deformittj 
 has been the inevitable result, the utility of the hand will not be 
 seriously affected. 
 
 Some synovitis of the metacarpo-phalangeal joint may prolong 
 the diminished power of moving the finger, and even delay the 
 union. 
 
598 EPIPHYSES OF UPPEK EXTREMITY 
 
 An instance of deformity of the hand from epiphysial injury to 
 the metacarpal bone of the third finger is reported by Dr. J. H, 
 Sequeira {Hunterian Society Trans. 1897, p. 109). The patient, a 
 healthy girl aged nine years, presented a remarkable shortening of 
 the ring finger of the left hand — in fact, it was bnt slightly longer 
 than the little finger. The shortening was in the metacarpal bone, 
 and amounted to three-eighths of an inch. It was well seen when 
 the finger was strongly flexed into the palm, the absence of the 
 prominent head, the fourth metacarpal, being marked by a hollow 
 in the line of the knuckles. Three years previously the patient 
 injured that hand, and there seemed little doubt that the metacarpal 
 epiphysis had been injured, and in consequence there had been 
 failure of growth ; but it was probable also that part of the shorten- 
 ing arose from the displacement forwards of the metacarpal head 
 into the palm of the hand. 
 
 TREATMENT. — If the separation is \vithout displacement, the 
 simpler the form of apparatus the better, and the hand and forearm 
 should be kept at rest for fourteen days in the elevated position. 
 Evaporating lotions should be applied to the dorsal aspect to allay 
 any inflammation. 
 
 Displacements. — Eeduction should be effected by means of moderate 
 extension on the finger, and pressure on the epiphysis, either on 
 the palmar or dorsal surface, towards the eiid of the metarcarpal 
 bone, and counter-extension made on the forearm by an assistant. 
 
 A moulded gutta-percha or poroplastic splint should then be 
 applied to the whole of the palmar and dorsal surfaces of the hand 
 and fingers. In some cases of displacement /or^fa^-cZs it may be found 
 advisable to insert a thick pad of lint or tow in the palm before 
 applying the splint. Notwithstanding all efforts, in others the 
 fragments are not easily retained in position. The hand should 
 be worn in a sling and carefully examined each day. 
 
 Passive motion should be commenced on the tenth day. 
 
 In displacement hackivarcls the fingers of the hand should be 
 kept in the extended position with a flat dorsal splint or moulded 
 gutta-percha splint, including the fingers. 
 
 Malgaigne's method of treatment of fractures in the adult will be 
 found of service in certain instances. A thick compress is placed on 
 the dorsal projection and another on the palmar surface over the head 
 of the bone, which is pushed backwards. Two large splints are 
 then placed across — one on the palm, the other on the dorsum, of the 
 hand, and their ends brought near to one another and fixed by 
 bandages or plaster. By this means the fingers are left quite free. 
 
EPIPHYSES OF PHALANGES OF DIGITS 599 
 
 SEPARATION OP THE EPIPHYSES OF THE PHALANGES 
 OF THE DIGITS 
 
 ANATOMY. — In all the three rows of phalanges of the fingers, and 
 in the two rows of the thumb, the epiphysis is placed at the proximal 
 end. The lower ends are developed from the shafts. 
 
 There is commonly one osseous centre, but M. Serres describes 
 two centres appearing in the middle of the cartilaginous epiphysis 
 side by side, which rapidly unite and form one osseous plate. 
 
 The same writer states that three centres are sometimes seen in 
 the epiphysis of the first phalanx of the thumb. 
 
 Ossification takes place successively from the first phalanges to 
 the second, and lastly in the third ; in the first row from the third 
 to the fourth year, and in the second and third row from the fourth 
 to the fifth year. 
 
 The epiphyses unite to their respective shafts about the nine- 
 teenth year. 
 
 The nutrient canal runs upwards in each phalanx. 
 
 Fig. 179. — epiphyses of the phalanges at the sixteenth year 
 (after rambaud and Renault) 
 
 It should be noted that the ungual phalanges of the fingers com- 
 mence the ossification of their shafts at the distal end instead of in 
 the middle like all the other long bones. 
 
 The proximity of the sheath of the flexor tendons on the palmar 
 aspect of the epiphyses should be remembered. 
 
 The flat disc-like epiphyses (of the first row) are in depth, ver- 
 tically, at fourteen years, at the sides four millimetres, posteriorly 
 two millimetres, anteriorly three millimetres at eighteen years, at 
 the sides six millimetres, posteriorly two and a half millimetres, 
 anteriorly four and a half millimetres. 
 
 In width across, laterally, they are at fourteen years thirteen 
 millimetres, at eighteen years seventeen millimetres. 
 
 ETIOLOGY. — Direct violence, as a blow from a bat or cricket-ball, 
 and indirect violence, as from a fall upon the fingers, or by the fingers 
 being caught in a hole or between two rigid bodies and wrenched, 
 have been described as the cause in the published examples. 
 
 AGE. — In M. Eoux's specimen of separation of the epiphyses 
 of the index and middle fingers by direct violence the age is not 
 stated, but in Hamilton's clinical example the lad was aged four 
 years ; Macdonnell's was also in a lad. 
 
600 
 
 EPIPHYSES OF UPPEK EXTREMITY 
 
 PATHOLOGICAL ANATOMY.— The only specimen recorded is 
 that by M. Roux in 1822, in which an explosion of gunpowder 
 produced separation of the lower radial epiphysis, as well as of the 
 shafts of the first phalanges of the thumb and of the index and 
 middle fingers from their upper epiphyses. 
 
 The upper epiphyses of these three phalanges remained con- 
 nected with the corresponding metacarpal bones (see Part II. 
 chap. xii.). 
 
 SYMPTOMS, — Epiphysial separation of the phalanges is extremely 
 
 rare. 
 
 Fig. 180. — sagittal section theough middle finger — ulnae sueface of section, 
 showing relation of synovial membranes to the various epiphyses 
 
 r, radius ; er, epiphysis of radius ; 1, semilunar bone ; Ei, extensor indicis tendon ; 
 EcII and Ec III, tendons of extensor communis digitorum ; om, os magnum; 
 mill, third metacarpal bone ; em, its epiphysis ; 1, 2, 3, phalanges ; Fpd II, 
 flexor profundus digitorum tendon to index finger ; Fpd III, the tendon of same 
 muscle to second phalanx of middle finger ; Fsd, flexor sublimis digitorum ; 
 Fsd II and III, the same tendons of flexor sublimis digitorum ; Adp, adductor 
 pollicis cut obliquely ; In, second dorsal interosseous muscle ; Lii, second 
 lumbricalis muscle ; Pq, pronator quadratus ; Elp, extensor longus pollicis. In 
 none of the joints in this section does the synovial membrane come in imme- 
 diate relation with the epiphysial discs. (After Brunu) 
 
EPIPHYSES OF PHALANGES OF DIGITS 601 
 
 Mobility at the epiphysial Hne, which is ahnost immediately below 
 the upper end of the bone, will be the most constant sign. 
 
 Deformity. — Displacement may occur in any direction, viz. for- 
 wa?'ds, most frequently from the powerful flexor tendons, laterally 
 to one side or the other, or the epiphysis may be rotated on its 
 vertical axis. 
 
 Muffled crepitus may be readily detected, but sioelling is not very 
 great, the thin covering of skin over the phalanges usually permitting 
 a close examination. 
 
 J. Macdonnell says {Cyclopcedia of Practical Surgery, vol. ii. 
 p. 331, art. ' Fracture ') that he had once seen, in a lad, the epiphysis 
 of the upper end of the first phalanx of the forefinger detached 
 from the shaft. 
 
 In the following case recorded by Hamilton {Fractures and 
 Dislocations, 1884, 7th edit. p. 395) there was probably an epiphysial 
 disjunction. 
 
 A lad, four years old, was admitted to the Buffalo Hospital of 
 the Sisters of Charity, December 24, 1849, with a simple fracture 
 of the first phalanx of the ring finger of the left hand ; the fracture 
 being at the proximal end of the bone, and at the junction of the 
 epiphysis with the shaft. The finger was so much swollen at first 
 that no dressings were ajpplied until the fifth day, at which time a 
 gutta-percha splint was moulded to it carefully. It resulted in a 
 perfect cure. 
 
 DIAGrNOSIS. Dislocation. — The first phalanx is usually dislocated 
 backwards. It may be distinguished by the fixation before reduction, 
 and by the less tendency to displacement after reduction. 
 
 PROGNOSIS. — Deformity should be guarded against, especially in 
 the case of girls, where any deformity is an unsightly disfigure- 
 ment. 
 
 Non-union must be of rare occurrence. 
 
 Suppuration of the flexor sheath is not likely to occur unless the injury 
 be a compound one, yet osteomyelitis, terminating in necrosis of 
 the epiphysis or shaft, may result from contusion at the time of the 
 injury. 
 
 Probably many of the examples of acute inflammation of the 
 finger and whitlow, accompanied by necrosis of the epiphysis, 
 which is situated at the proximal end of the phalanges, are the 
 result of epiphysial sprain or separation. In one case, of a girl aged 
 seven years, in which the author removed the necrosed epiphysis of 
 the first phalanx, the finger had been injured by being caught between 
 two pieces of wood whilst the girl was at play. 
 
 The author has seen a similar portion of bone removed on two 
 occasions, on opening acute suppuration of the finger. 
 
 TREATMENT. — Eeduction of displacement should be effected by 
 gentle extension and manipulation of the epiphysis. 
 
 A moulded splint of gutta-percha (or small straight wooden 
 
602 EPIPHYSES OF UPPEE EXTEEMITY 
 
 splint) should be carefully applied to the dorsal or palmar aspect of 
 the finger. 
 
 In some cases it will be found convenient to apply the splint to 
 two or more fino-ers. 
 
 Fig. 181. — tin fixgee splint, one half size. 
 
 The finger should be examined daily. 
 
 Passive motion should be commenced early during the second 
 week, as union occurs rapidly. 
 
PART III 
 
 SEPARATION OF THE EPIPHYSES OF THE 
 LOWER EXTREMITY 
 
 CHAPTEE I 
 
 SEPARATION OP THE EPIPHYSES OP THE 
 OS INNOMINATUM 
 
 Separation of th.e Epiphysial Parts of the Acetabulum 
 
 Anatomy. — Seen at the second year of life, the three, already 
 well developed, primary pieces of the os innominatum — viz. the 
 ilium, ischium, and pubes — are received into the hollows of the 
 intervening cartilage, usually designated the Y-shaped cartilage ; at 
 this period this cartilage comprises the ilio-pectineal eminence, the 
 anterior inferior spine of the ilium, the spine of the ischium, and 
 the bottom of the acetabulum. The pubes and ischium are also 
 separated by a wide cartilaginous interval. 
 
 In the acetabulum at the ninth year the ilium, pubes, and 
 ischium are still separated by the Y-shaped cartilaginous interval, 
 which is intimately connected with the cartilage covering the 
 articular surface. 
 
 About this period — ninth to tenth year, some anatomists say as 
 early as the sixth year — this cartilage begins to ossify in two or 
 more pieces, usually commencing at the ilio-pectineal eminence. 
 When ossification has advanced, it is seen that the largest and most 
 constant piece of bone is of a triangular shape, and placed towards 
 the fore and upper part of the acetabulum, of which it forms the 
 whole of the pubic portion. It is called the cotyloid or acetabular 
 bone. Its upper surface is placed between the ilium and pubes, and 
 assists in forming the ilio-pectineal eminence ; its external surface, 
 also triangular, corresponds to the articular head of the femur, is 
 slightly concave, and forms a part of the cavity as well as the inner 
 lip of the same. 
 
 Between the ilium and ischium there are some irregular nodules 
 
604 
 
 EPIPHYSES OF LOWEE EXTEEMITY 
 
 of bone, which appear about the thirteenth year and form a 
 somewhat thick mass. Occasionahj^ some thin osseous plates are 
 developed in addition over the iliac and ischial portions of the 
 articular surface. 
 
 The ossific centre at the bottom of the acetabulum may be 
 Y-shaped like the cartilage in which it arises, but the limb between 
 
 the ilium and ischium is 
 said to be usually the 
 thickest in the male sub- 
 ject, and that between the 
 pubes and the ihum in the 
 female. The part between 
 the ischium and pubes is 
 generally absent or very 
 thin. This unites at four- 
 teen years of age with the 
 ilium and ischium, and at 
 about fifteen with the 
 pubes. 
 
 The several portions of 
 the acetabulum are com- 
 pletely united at the seven- 
 teenth to nineteenth year. 
 From the twelfth to 
 the thirteenth year, or 
 even a little later, the 
 ischium has reached the 
 ilium and joins with it, at 
 first on the inner surface, 
 and later externally ; the 
 convex line of junction 
 persists here throughout 
 life, but on the acetabular 
 aspect these two portions 
 of the bone are still sepa- 
 rated by a thin layer of 
 cartilage. The union of 
 the pubes and ilium is a 
 little later, but up to this 
 time they are still separated 
 in the acetabulum by a 
 narrow cartilaginous line containing osseous deposit. 
 
 The ischial and pubic rami unite at eight years of age— accord- 
 ing to Beclard at the sixth year ; but in some instances this union 
 may be delayed up to twelve or fourteen years of age. 
 
 The synovial membrane covers all the epiphysial lines in the 
 acetabulum, and no separation of one of the three primary pieces of 
 
 Fig. 182. — os ixxoiiiXATrM at the twelfth year 
 (Eambaud and Eenault.) J-size. 
 
 h, line of cartilage between the ilium and ischium 
 (which are blended about the thirteenth year) 
 extending to the interior of the acetabular cavity ; 
 i, narrow line of junction of the pabes and ilium 
 (which unite a little later than the last two primary 
 pieces) ; g, the junction between the ischium and 
 pubes is indicated by a small line : it is often 
 consohdated a few years earlier (eighth year) ; 
 b, osseous centre of tuberosity of ischium has 
 just commenced to apirear as a small nucleus in 
 the thick cartilaginous mass which forms this 
 poi-tiou of the bone ; d, cotyloid or acetabular 
 bone placed between ilium and pubes towards the 
 upper border of the acetabular cavity, and forming 
 nearly the whole of the pubic portion of this 
 cavity. 
 
EPIPHYSES OF OS INNOMINATUM 
 
 605 
 
 the OS innominatum from the other two can be effected in the aceta- 
 bulum fossa without the articular cavity being involved. It is 
 possible, however, for a separation to occur between the pubic and 
 ischial portions without the joint being directly involved, on account of 
 the synovial membrane being protected by the fat and soft structures 
 filling in the acetabular fossa, provided, of course, in this case that no 
 displacement of either the ischial or pubic portions has occurred. 
 
 Pathological anatomy. — -A few specimens exist in museums which 
 show the possibility of partial or complete separation of the epiphysial 
 ends of the pubes, ischium, and ilium at the hip-joint. 
 
 These lesions will necessarily be accompanied by a more or less 
 complete detachment of the acetabular bone developed in the 
 Y-shaped cartilage. 
 
 Dupuytren speaks of a case in which the bones forming the 
 cotyloid cavity had been forced in, and the head of the femur had 
 passed completely into the cavity of the pelvis. 
 
 In St. George's Hospital Museum {Catalogue oj St. George's 
 Hospital Museum, 1866, p. 40, No. 121) there is a specimen of 
 separation of the epiphysial ends of the pubes and ischium in the 
 hip- joint accompanied by fracture of the pelvis ; it is also recorded 
 by Holmes in the Pathological 
 Society's Transactions, vol. xiii. 
 p. 187. It occurred in a girl 
 aged ten, who was run over by a 
 carriage and lived three months 
 after the injury. In the specimen 
 a fracture traverses the hip-joint 
 at the junction of the ischium and 
 pubes, another passes through the 
 horizontal ramus of the pubes 
 near the former, and a third 
 through the ascending ramus of 
 the ischium. 
 
 Mr. T. Wilkinson King men- 
 tions {GyclopcBdia of Practical 
 Surgery, vol. ii. art. on ' Fracture, 
 Special,' p. 356) the fact that 
 fracture of the acetabulum may 
 occur as a kind of diastasis, but 
 that other attendant injuries are 
 to be expected. He gives an illustration of separation of the os 
 innominatum into its original parts in a young person. 
 
 Sir William Stokes, of Dublin, showed at the Iniernational 
 Medical Congress, London, 1881 {Catalogue of Museum, Inter- 
 national Medical Congress, London 1891, p. 83, No. 775, Series A, 
 No. 6), a specimen of epiphysial fracture of the acetabulum from 
 the Museum of the Eichmond Hospital, Dublin. 
 
 Fig. 183. — separation of the os innomi- 
 natum INTO ITS OUIGINAL PARTS 
 
 (Drawing from Guy's Hospital Museum, 
 Mr. King's case) 
 
606 EPIPHYSES OF LOWEE EXTEEMITY 
 
 The author has been unable to obtain any history or details of 
 this case of epiphysial separation, but in a letter to him in 1884 Sir 
 William Stokes spoke of the specimen as being* a most beautiful and 
 rare one. 
 
 Separations in the acetabular cavity, with the exception of that 
 of the cotyloid bone, should properly be classified under fractures of 
 the pelvis. 
 
 Separation of the Epiphysis of the Iliac Crest and Anterior and 
 Posterior Superior Iliac Spines 
 
 Ajiatomy. — Beclard fixes the commencement of osseous develop- 
 ment of the iliac crest at the sixteenth year. 
 
 Some osseous granules, which show themselves in the cartilagi- 
 nous margin of the iliac crest, congregating especially at two points 
 — in the front and back parts to form the anterior and posterior 
 spinous processes — are often seen at the fifteenth year. 
 
 At the nineteenth to twentieth year two thick and broad 
 epiphyses are seen, the anterior one forming the anterior superior 
 iliac spine and the antrrior three-quarters of the iliac crest, the 
 posterior one the posterior superior iliac spine and contiguous part 
 of the crest. The point of interruption between the two is at the 
 posterior flexion of the letter S, which represents the outhne of the 
 iliac crest. 
 
 More often these two parts are united into one long epiphysis 
 capping the iliac crest. 
 
 This epiphysis does not join the body of the iHum till the 
 twentieth to twenty-fifth year, usually at the twenty-first year. 
 
 The anterior superior spine has attached to it numerous 
 muscles— the sartorius, tensor vaginEe femoris, external obfique, 
 internal obHque, and transversaHs and ihacus on the inner aspect, 
 besides the fascia lata and Poupart's ligament. 
 
 To the posterior superior spine are attached a few fibres of the 
 gluteus maximus (externally), the obHque portion of the posterior 
 sacro-sciatic ligaments, and a few fibres of the multifidus spinse 
 (internally), while the intermediate portion of the iliac crest, which 
 is thinnest about the middle, affords attachment to the fascia lata, 
 tensor vaginae femoris, obhquus externus, latissimus dorsi, internal 
 oblique, transversaHs, quadratus lumborum, and erector spinse 
 muscles, and iliac fascia. 
 
 Etiology. — The anterior superior iliac spine being developed as 
 part of the iHac crest, a much greater amount of muscular violence 
 will be necessary to effect its separation than in the case of 
 the anterior inferior iHac spine, which develops from an isolated 
 centre, while direct violence, such as in a fall against some hard 
 
EPIPHYSES OF OS INNOMINATUM 607 
 
 surface, or by a severe blow, or by the patient being run over by the 
 wheel of a vehicle, may not be an uncommon mode of separation. 
 
 Fracture of the anterior superior iliac spine, as a consequence of 
 direct injury, is not uncommon in the adult. 
 
 A case of fracture of the anterior superior spine of the ilium by 
 muscular action is recorded by Nickerson {Deutsche medicinische 
 Wochenschrift, Leipzig, March 6, 1890). It was the case of a lad, 
 aged seventeen years, who felt something give way while running, 
 and was unable to walk ; the symptoms were tenderness, crepitus, 
 and mobility on pressure. 
 
 Nickerson adds abstracts of four other reported cases. 
 
 Dr. C. Haig Brown relates [British Medical Journal, August 16, 
 1884, p. 320) the case of a lad, aged seventeen, who separated the 
 anterior superior iliac spine by muscular action. At some sports he 
 was commencing to jump, after having finished his run (or, in 
 technical language, ' taking off'), when he felt a sudden snap on the 
 right side of the pelvis, and fell, being in considerable pain. In 
 jumping from his right leg the boy had called into sudden and 
 violent action the external oblique, internal oblique, and trans- 
 versalis muscles (all of which are, in front, attached to the anterior 
 superior iliac spine), and had separated the spine from the body of 
 the bone. On examination, fifteen minutes after the accident, it 
 was found that he could not stand, and though each hip-joint 
 moved naturally, movements at the right hip-joint caused pain in 
 the lower part of the abdomen on that side. Coughing and passing 
 water also caused pain in the same place. The right anterior 
 superior spine was not to be felt in its place, but was represented by 
 a rough piece of bone. All round this was a considerable haema- 
 toma, while the spine itself was distinctly felt displaced upwards 
 and a little inwards. With the abdominal muscles relaxed it could 
 be brought back to its proper position, and the characteristic soft 
 but marked crepitus was elicited. The boy was kept in bed on his 
 back for ten days with a stout spica bandage round the right hip- 
 joint and a pad to keep the displaced fragment in position. Move- 
 ment was allowed at the end of a fortnight, and at the end of ei^ht 
 weeks he was able to walk about as well as ever, although crepitus 
 was still present over the seat of injury. The whole epiphysis was 
 not separated — i.e. the whole iliac crest — but only a small portion of 
 it, which has no separate centre of ossification from the rest of the 
 iliac crest. The iliac crest in this case — the age being seventeen — 
 was in an unossified condition. 
 
 A case of fracture of the anterior superior iliac spine by the 
 action of the sartorius muscle is recorded by C. E. Corlette 
 {Australasian Med. Gazette, March 15, 1895, p. 99). S. D., aged 
 seventeen years and eight months, was admitted into Sydney 
 Hospital, August 24, 1894. As he was getting down behind from the 
 top of an omnibus the omnibus suddenly went forward, causing him 
 
608 EPIPHYSES OF LOWEE EXTEEMITY 
 
 to slip and lose his footing. He came down with his whole weight on 
 the right foot, and immediately felt a pain in the region of the 
 anterior superior iliac spine. He fell forward and could not rise. 
 On being assisted up he could not stand on the left leg, and could 
 bear very little weight on the right, the attempt causing pain. On 
 examination when standing, he stood bent forward, w4th the right 
 hix3 and knee partly flexed, the toes touching the ground and turned 
 slightly inwards. When he lay down passive movement of the 
 hip and knee could be done freely without causing pain, so long as 
 the hip was not extended beyond a certain point. There was an 
 evident loss of prominence over the right anterior spine as compared 
 with the opposite side, with pain at this site, but absent elsewhere. 
 Manipulation caused great pain ; closely localised and distinct 
 crepitus was obtained. The treatment adopted was flexion of the 
 hip by a high pillow beneath the knee. A considerable amount of 
 callus subsequently formed. He was discharged September 24, 
 1894. 
 
 Age. — A separation of the true osseous epiphysis can only occur 
 from the fifteenth year, the time of its formation, to the twenty-fifth 
 year, its union with the body of the bone. 
 
 Pathological anatomy. — Separation of the anterior and inferior 
 iliac spines was found {Bull, de la Soc. Anatomique, 1867, p. 283) 
 in Bousseau's case of separation of the head of the femur quoted 
 in the next chapter. The anterior superior spine was still held to 
 the ilium by a small portion of cartilage and periosteum ; the inferior 
 spine was completely detached. There were other severe lesions of 
 the soft parts in this case produced by the passage of a wagon- 
 wheel over the left hip. 
 
 M. Gosselin has reported {Gazette Medicale de Paris, 1879, 6, 
 s. I. p. 129) a case in which the whole marginal cartilaginous crest of 
 the ilium and the cartilaginous apex of the inferior iliac spine were 
 both detached in a boy aged fourteen. 
 
 Gosselin thought that this was due to the suppurative inflamma- 
 tion extending from the fractured pelvis and fractured thigh (com- 
 plicated wdth an extensive wound) rather than to the primary injury 
 at the time of the accident. The child had been knocked down in 
 the street and run over by the wheel of an omnibus. 
 
 Symptoms. — Although a rare accident, a separation of the iliac 
 crest should always suggest itself to the surgeon's mind when a 
 child has been knocked down in the street and its pelvis run over, 
 although there may be no external evidence of contusion. Local 
 pain, soft crepitus, and mobility are the chief signs. 
 
 The following case related by Bransby B. Cooper {Lectures on 
 the Principles and Practice of Surgery, 1851, p. 251) was probably 
 one of epiphysial separation. A sailor boy, aged fourteen, was admitted 
 into Guy's Hospital. He had fallen from the rigging of a ship and 
 alighted on his hip. When brought to the hospital he appeared to 
 
EPIPHYSES OF OS INNOMINATUM 609 
 
 suffer severe pain, particularly when the abdominal muscles were 
 called into action. A fracture was discovered separating the 
 superior spinous process and about a fourth of the crista ilii from 
 the rest of the bone. A bandage was placed round the pelvis and 
 upper part of the right thigh. The lad was soon able to get out of 
 bed, and could stand very well, although he walked rather lame. 
 Shortly afterwards he w^as discharged as perfectly cured, the pain 
 having entirely, and the lameness almost, disappeared. 
 
 Mr. Davies-Colley had under his care at Guy's Hospital in July 
 1885 a girl (Ellen D.), aged eight years, who was run over by an 
 omnibus, which separated a portion of the cartilaginous iliac crest. 
 Dull crepitus was detected over the right iliac crest, and a long 
 ridge of bone was felt at the anterior part of the crest. This was 
 accompanied by an obscure abdominal injury, from which she 
 slowly recovered. 
 
 Treatment. — Rest in bed, with the legs flexed and kneeg tied 
 together, and a stout broad bandage round the pelvis and hips, com- 
 bined with a pad above and in front of the epiphysis to keep it in 
 position, are the best indications for treatment. Or a firm spica 
 bandage may be applied round the pelvis and hip of the injured side. 
 Some unimportant deformity about the region of the iliac spine 
 and crest may result. 
 
 Separation of the Epiphysis of the Anterior Inferior Spine of the Ilium 
 
 Anatomij. — The epiphysis for the anterior inferior spine of the 
 ilium is not always present, but is more frequent in the male than 
 in the female subject. 
 
 It appears from the eighteenth to the twentieth year, often as 
 early as the sixteenth year, and joins the body of the bone from the 
 nineteenth to the twenty-first year, or as late as the twenty-fifth 
 year. 
 
 It is of a largish size, prominent, and rounded in outline, having 
 attached to it the straight head of the rectus femoris muscle, and a 
 few fibres of the ilio-femoral ligament at its lower part. On the 
 inner side a few fibres of the iliacus muscle are attached. 
 
 According to Sir George Humphry {The Human Skeleton, 1858, 
 p. 458), the anterior inferior spine is peculiar to the human pelvis. 
 It serves to give a slight leverage to the rectus femoris, making some 
 amends to that muscle for the unfavourable position in which it is 
 placed by the erect position. 
 
 Etiology. — The iliac or straight head of the rectus is ex- 
 ceedingly strong in muscular subjects. 
 
 Of the two heads the acetabular is the primary, the other (the 
 
 1{ E 
 
610 
 
 EPIPHYSES OF LOWEE EXTKEMITY 
 
 straight) develops early in the third month of foetal life as a 
 secondary thickening of the sheath, owing to the change of axis of 
 the limb consequent on the assumption of the capacity of full 
 extension of the hip and knee. The muscle acts chiefly from its 
 
 straight head when the hip is ex- 
 tended, but from its curved head 
 when it extends the knee during 
 flexion of the hip (Macalister). 
 Thus in the position which was 
 described in the case of Dr. 
 Whitelocke's two patients as 
 obtaining prior to starting in 
 running — viz. that of flexion of 
 the hip and semiflexion of the 
 knee — the posterior head would 
 fix the rectus above ; but in the 
 first bound of the start, when the 
 knee- and hip-joints were sud- 
 denly, rapidly, and forcibly ex- 
 tended, the direct or straight 
 head would come into action. 
 
 The flexed position of the 
 foetal extremities necessitates 
 only the acetabular head, which 
 in this position of the hip-joint 
 is in a direct line of action. 
 
 Mr. Eoger Williams states 
 {Journal of Anatomy and Physio- 
 logy, vol. xiii. 1879, p. 204) that 
 only at about the sixth month of foetal hfe can this head be distin- 
 guished. The iliac head cannot be discriminated from the fascia 
 of the part. At full term the acetabular head is as large as the 
 main tendon, of which it is obviously the direct continuation, whilst 
 the ihac head, though plainly visible, is relatively insignificant. The 
 size of the straight head is proportional to the muscularity of the 
 subject, but the reflected head does not undergo a corresponding 
 variation. Hence the difference between the heads is most marked 
 in women. The histological structure of the two heads is different, 
 the straight head containing many elastic fibres, and partaking more 
 of the nature of a ligament than a tendon. 
 
 Mr. Maunder observed (Lancet, May 6, 1876, p. 668) at the 
 London Hospital a case of separation of the epiphysis of the 
 anterior inferior spinous process of the ihum by muscular action in 
 a boy (W. G.) aged eighteen years. The patient stated that while 
 running in a flat race he thought it necessary to 'put on a spurt,' 
 and whilst doing so suddenly felt a sharp snap, followed by acute 
 pain in the right groin, and accompanied by a sensation of ' some- 
 
 FlG. 184. — OS INNOMINATUII AT THE END OF 
 THE EIGHTEENTH YEAR. THE EPIPHYSIS 
 OF THE ANTERIOR INFERIOR SPINE HAS 
 COMMENCED TO JOIN TO THE ILIUM 
 
EPIPHYSES OF OS INNOMINATUM 611 
 
 thing being out of its place.' He found it impossible to stand 
 upright without great pain in the right groin, which was somewhat 
 relieved by resuming the stooping posture. On examination he lay 
 flat on his back with the thighs extended and the right foot slightly 
 everted. He could rotate the right thigh inwards or outwards, but 
 with slight pain. There was total inability to flex the thigh upon 
 the pelvis, and the attempt caused great pain in the groin. A little 
 fulness was evident in the position of the spinous processes, and the 
 inferior spinous process (the attachment of the straight tendon of 
 the rectus femoris muscle) was found to be detached and freely 
 movable. Cartilaginous crepitus was very distinctly felt, both by 
 the patient and the surgeon. This, together with the age of the 
 patient, led to the diagnosis of separation of the epiphysis. The 
 treatment adopted was rest in bed with the thigh flexed by a pillow 
 beneath the knees to relax the rectus femoris muscle. At the end 
 of three weeks firm union had taken place, and the patient could 
 walk with ease and flex the thigh without discomfort. 
 
 In Dr. Whitelocke's two cases, and in that of Mr. Symonds, of 
 Oxford, the injury was the result of running in a race. It appears 
 from these examples to occur not uncommonly from sudden strain in 
 young athletic men of good muscular development with powerful 
 recti muscles. 
 
 Treves, in his Surgical Applied Anatomy, p. 370, says : ' In one 
 case the anterior inferior spinous process was torn off by the rectus 
 muscle during the act of running a race.' 
 
 The anterior inferior spine is so well protected from direct 
 violence on all sides by muscles that separation from this cause is 
 extremely improbable. 
 
 Symptoms. — Loss of power or difficulty of flexing thigh, 
 accompanied by pain, flexion of hip, and crepitus, are the chief 
 signs. The latter may not easily be detected on account of the 
 deep position of the parts, especially in a muscular limb, although 
 the posterior head of the muscle will not allow very great displace- 
 ment of the epiphysis. 
 
 Ecchymosis, swelling, and pain will not be very great. 
 
 From the close association of the ilio-femoral ligament with the 
 anterior inferior spinous epiphysis it is not unlikely that the hip- 
 joint may be affected when this process is separated. 
 
 Dr. R. H. A. Whitelocke describes {Lancet, November 25, 1893, 
 p. 1302) two instances of detachment of the epiphysis of the anterior 
 inferior spinous process of the ilium through enforced muscular 
 action. The respective ages of the patients were eighteen and 
 nineteen years. The clinical histories, causation, and symptoms 
 of the two cases were nearly identical. In February 1891 an under- 
 graduate, in starting to run in a race of a hundred yards length, 
 while practising for his college sports, ' seemed to have scarcely 
 travelled ten yards when he had sudden! 5' to stop, as he felt 
 
 1! R 2 
 
612 EPIPHYSES OE LOAVER EXTREMITY ' 
 
 something snap, and at the same time his Hmb became powerless.' 
 There was then some pain, but it was ' by no means severe,' 
 although he ' became faint and felt sick.' There was little to be 
 seen excepting that the injured limb assumed the position of semi- 
 flexion and was in advance of its fellow, which, being fully extended, 
 was sustaining the whole weight of the patient. On attempting to 
 straighten the injured limb by extending the hip- and knee-joints, 
 he felt increased pain, and he had extreme difficulty in extending 
 the knee-joint. The chief complaint was an unpleasant feeling of 
 numbness and tingling perceived all down the extensor surface of 
 the thigh. There was very little discoloration, accompanied by an 
 inconsiderable swelling situated for the most part beneath and to 
 the outer side of the middle of Poupart's ligament. After carefully 
 comparing the two sides and palpating, a distinct crepitation could 
 be elicited on deep pressure at that point, and this could be 
 even more distinctly made out when, while the pressure was made, 
 the patient made an effort to bring the rectus muscle into action. 
 The movable piece of bone gave a feeling on palpation not unlike 
 that of a loose cartilage in a joint. A pad with a temporary spica 
 bandage was applied. Another undergraduate gave an almost 
 similar history. He had been starting to run ' a quarter mile.' In 
 the very act of starting — in the first bound, as it were — he 'felt 
 something give, and became powerless to proceed.' With Dr. 
 Whitelocke's experience of the former case it was not difficult to 
 discover what was the matter. In this case a mere scale of bone, as 
 far as could be elicited, came, away with the straight head of the 
 rectus, and crepitus was with difficulty made out at first. The 
 tingling sensation and other sjmiptoms described in the former 
 case were also evident. 
 
 Each patient had started with his left limb somewhat flexed 
 both at the hip- and knee-joints, and in advance of the right, the 
 body being bent forwards and, as it were, poised upon and sup- 
 ported by it. In the sudden act of starting, the limb behind was 
 used to give the spring, and in the first bound the body and the 
 advanced and flexed limb were suddenly and quickly straightened 
 together, and the rectus muscle, already contracting and fixed at its 
 lower a,ttachment to support the weight of the body on the semi- 
 flexed knee, being forcibly put upon the stretch during the sudden 
 extension of the hip-joint, tore away the unossified epiphysis of the 
 anterior inferior spinous process of the ilium. 
 
 The treatment in both cases was immobilisation of the flexed hip 
 in a plaster spica bandage for four weeks, and then a simple spica 
 was substituted. Recovery was complete in both. The ' tingling and 
 feeling of cold water ' were the most persistent symptoms in one 
 case, and in this one a considerable amount of callus was thrown 
 out. 
 
 Dr. AVliitelocke mentions a similar case with a satisfactory 
 
EPIPHYSES OF OS INNOMINATUM 613 
 
 rf^sult under the treatment of Mr. Symonds of Oxford, and believes 
 that this accident is probably not so rare as at first would seem to 
 be the case. 
 
 Separation of the Epiphysis of the Symphysis Pubis 
 
 Anatoviy. — The angle of the pubes has an epiph}sial plate 
 appearing towards the end of puberty — i.e. about the sixteenth or 
 seventeenth year — and consisting of two parts or branches, one 
 extending on the horizontal ramus of the pubes, the other on the 
 inner side of the symphysis to the descending ramus, downwards, in 
 some cases, as far as the anterior end of the epiphysis for the 
 tuberosity of the ischium. To the epiphysis the fibro-cartilage of 
 the symphysis is firmly attached. 
 
 This epiphysis joins about the twentieth or twenty-first year to 
 the body of the bone. 
 
 Although it is said that the crest of the pubes may be torn off by 
 the action of the abdominal muscles (rectus abdominis, pyramidalis, 
 conjoined tendon, &c.) in the adult, yet this epiphysis in its entirety 
 in children can only be detached by severe crushing" violence. 
 
 Many examples that have been recorded as separations of the 
 symphysis pubis, especially those in patients of two years of age 
 and thereabouts, were separations of the pubic articulation associated 
 with fracture of one or other ramus. Holmes's case of separation 
 of the symphysis pubis occurred, as is common enough in severe 
 pelvic injuries, between the cartilaginous articular surfaces. 
 
 Traumatic separation of the osseous epiphysis is only possible 
 from the sixteenth to the twentieth or twenty-first year ; before this 
 it is a question of detachment of the cartilaginous margin. 
 
 The proximity of the bladder to the epiphysis must always be a 
 source of danger after severe direct violence — e.g. being run over by a 
 cart, or crushing between two opposing forces. 
 
 Hsematuria associated with dull crepitus, mobility at the sym- 
 physis, or with a depression at this spot, will suggest to the 
 surgeon's mind a separation of the epiphysis. 
 
 Separation of the Epiphysis of the Spine of the Pubes 
 
 At times a distinct epiphysis forms at this point about the 
 sixteenth year or a little later. It is usually of a lenticular or 
 irregular shape, and more often present in females than males. It 
 is analogous to the marsupial bone of the didelphidte (Beclard). 
 
 This epiphysis, when present, unites with the epiphysis of the 
 symphysis pubis first, and later with the body of the bone itself 
 about the twentieth year. 
 
614 EPIPHYSES OF LOWEE EXTEEMITY 
 
 The abdominal muscles acting upon the pubic spine by means 
 of Poupart's ligament may tear it off, but no instance of separation 
 has as yet been recorded. 
 
 Separation of the Epiphysis of the Sciatic Spine 
 
 Sometimes the sciatic or ischial spine has a distinct epiphysis of 
 small size which appears about the sixteenth to seventeenth year, and 
 joins the body of the bone at the eighteenth year. 
 
 To the apex of the ischial spine is attached the lesser sacro- 
 sciatic ligament — the gemellus superior to its outer aspect, and the 
 coccygeus and posterior fibres of the levator ani to its inner 
 aspect. No case of separation has been recorded.' 
 
 Separation of the Epiphysis of the Tuber Ischii 
 
 This epiphysis is a wide and thick plate, wider and thicker than 
 any of the other epiphyses of the hip bone. It extends from the 
 lesser sacro-sciatic notch to the upper end of the ascending ramus 
 of the ischium, reaching occasionally on to the descending ramus of 
 the pubes. 
 
 The centre of ossification appears about the fourteenth year. 
 
 This epiphysis consolidates with the body of the ischium at the 
 twentieth year. 
 
 Considering the powerful hamstring and other muscles, ad- 
 ductor magnus, &c., and the great sacro-sciatic ligament attached to 
 this epiphysis, it would appear that detachment of this epiphysis 
 might readily occur from muscular action. 
 
 Mr. E. W. Parker has observed a separation of the epiphysis of 
 the tuber ischii with suppuration following a kick, and the author has 
 seen a similar example, the result also of direct violence. 
 
615 
 
 CHAPTEE II 
 
 SEPARATION OP THE EPIPHYSIAL HEAD OP 
 THE FEMUR 
 
 ANATOMY. — The epiphysis of the head of the femur is developed 
 from a single ossific centre appearing just about its centre — that is, 
 above and somewhat behind the attachment of the round ligament — 
 from the tenth to tv^elfth month after birth. This centre is often 
 
 Fig. 187. — coronal sec- 
 tion THROUGH UPPER 
 END OF FEMUR BEFORE 
 BIRTH, CARRIED THROUGH 
 THE LIG. TERES AND TRO- 
 CHANTER MAJOR 
 
 .4, the head ; B, neck of 
 thigh bone ; C, trochan- 
 ter major. (Kiistner) 
 
 Fig. 185. — upper and lower 
 ends of the femur a 
 few weeks before birth. 
 natural size. (anterior 
 VIEW.) (after KAMBAUD 
 AND Renault) 
 
 Fig. 186. — the sabie (pos- 
 terior view). NATURAL 
 SIZE, (after rambaud 
 AND Renault) 
 
 surrounded by a number of small osseous granules, especially at its 
 upper part. The cartilaginous head is still connected at this period 
 v^ith the great trochanter by a thick layer or mass of cartilage. 
 This layer or strip at the end of the second year is thin and 
 hollowed out, and presents many small depressions caused by the 
 upward extension and increase in size of the osseous shaft to form 
 
616 
 
 EPIPHYSES OE LOWEE EXTEEMITY 
 
 the neck of the bone. It is all that remains now of the original 
 cartilaginous upper end of the femur, from which the head and 
 great and lesser trochanters are developed. These are gradually 
 separated away from each other by the growing neck, and subse- 
 quently increase in size quite independently of each other. The 
 head passes upwards and inwards from the growth of the neck 
 
 in that direction, whilst the greafc 
 trochanter continues in the direc- 
 tion of the shaft. At this time, 
 the end of the second year, the 
 cartilaginous lesser trochanter is 
 already widely separated from the 
 other two cartilaginous epiphyses. 
 By the end of the fourth year 
 nearly the whole of the epiphysis 
 of the head is osseous, and sepa- 
 rated from the great trochanter. 
 At this time the thin dentate car- 
 tilaginous epiphysial line between 
 it and the shaft is visible, and' by 
 the sixth year is seen to almost 
 exactly correspond to the articular 
 surface. The epiphysial head is of 
 a hollow hemispherical shape, and 
 caps the mammillated end of the 
 projecting neck. In many cases 
 the upper surface of the neck is 
 encroached upon by a thin irregu- 
 lar rim extending outwards from 
 the upper part of the head, and 
 assists in transmitting the weight 
 from the head above to the calcar 
 femorale or vertical plane of com- 
 pact bony tissue projecting upwards 
 into the cancellous tissue of the neck 
 and the great trochanter from the 
 lower part of the neck (Macalister). 
 On the other hand, the lower 
 aspect of the epiphysial rim is 
 exceedingly thin, and the last 
 portion of the epiphysis which becomes entirely osseous. The 
 epiphysial line is now still better marked. At the seventeenth year 
 the epiphysis is entirely ossified, and appears about to join to the 
 neck, but this is not finally accomplished until the nineteenth to 
 twentieth year. A line of separation at its circumference, especially 
 at its lower part, often persists, although it may be firmly joined in 
 the centre. 
 
 Fig. 188. — femub at the end of the 
 second teab 
 
 The head is coanected with the great tro- 
 chanter by means of a thin cartila- 
 ginous strip which appears as if riddled 
 with holes. At the bottom of these 
 the osseous tissue is seen, indicating 
 that the connecting strip has already 
 been invaded by osseous material. The 
 lesser trochanter is now separated from 
 the great trochanter by the elongation 
 of the neck, so that the upper end is 
 divided into two parts, one of which 
 comprises the head and great trochanter 
 and the other the lesser troclianter. 
 (After Eambaud and Eenault, |-size.) 
 
SEPAEATION OF EPIPHYSIAL HEAD OF FEMUE 617 
 
 On section, a line of dense bony tissue may be seen remaining 
 for some years, traversing the cancellous tissue of the head and 
 neck, and indicating the cartilaginous line of union. 
 
 With the exception of the first few years of infancy, the neck of 
 the femur is therefore a prolongation of the shaft, not a part of the 
 superior epiphysis. 
 
 Fig. 189. — anterior view of upper end of femur, showing the epiphyses 
 of head and great trochanter at seventeen and a half years 
 
 Fig. 190. — posterior view of the upper end op femur, the epiphyses of 
 the head, great and lessee trochanters, between the seventeenth and 
 eighteenth years 
 
 (h-size) 
 
 The femoral neck beyond the epiphysial line is covered in the 
 w^hole of its circumference by the synovial membrane of the hip- 
 joint. At thirteen years of age, on its inferior aspect it is covered 
 by the membrane for nearly two centimetres, and above for nearly 
 one centimetre (Sesary). 
 
 Although this epiphysis is situated entirely within the capsule 
 and is completely surrounded by the synovial membrane, yet it might 
 
618 
 
 EPIPHYSES OF LOWEK EXTEEMITY 
 
 in some instances be detached without opening the joint, by reason 
 of the easy detachment and stripping up of the synovial membrane 
 and capsule from the neck of the bone right up to the head, thereby 
 leaving the joint intact. The extent to which the synovial membrane 
 covers the head and neck of the bone maybe seen from the diagram. 
 
 Of course the joint would be unopened if separation of the upper 
 end of the bone occurred before the fourth year. Not only is the 
 cartilaginous head at this early age still connected with the great 
 trochanter by the thick cartilaginous layer along the upper surface 
 of the neck, but the synovial membrane on the under surface of the 
 neck is more readily detached than later on. 
 
 JDe Paoli gives the following table of measurements of the height 
 of the upper epiphysis of the femur in a frontal section. 
 
 Age 
 Aud periods of development 
 
 • 
 
 He: 
 
 tht : 
 
 1 
 Breadth 
 
 From the 
 lower surface 
 
 At the middle of 
 
 tbe articular 
 
 lieiid 
 
 From tbe apex 
 of the great tro- 
 chanter to the 
 lower edge 
 
 As shown from the osseous 
 nucleus to the summit 
 
 Before birtli 
 
 ■' 1 
 1 
 
 4 
 
 13 mm. 
 12 „ 
 
 14 ,. 
 
 15 mm. 
 
 19 „ 1 
 23 „ 
 
 20 mm. 
 29 „ 
 42 „ 
 
 As shown from the os- 
 seous nucleus to the 
 trochanter 
 
 1 
 
 5 
 
 6 
 
 7 
 
 13 „ 
 
 14 „ 
 16 „ 
 
 24 „ 
 
 22 „ 
 22 „ 
 
 45 „ 
 
 49 „ 
 51 „ 
 
 Separation of tlie epi- 
 physis 
 
 1 
 ) 
 
 8 
 
 (16 „ 
 (19 „ 
 
 01 to 
 to to 
 
 152 „ 
 (52 „ 
 
 — 
 
 
 9 
 
 17 „ 
 
 30 „ 
 
 51 „ 
 
 — 
 
 
 13 
 
 19 „ 
 
 31 „ 
 
 — 
 
 — 
 
 
 14 
 
 17 „ 
 
 35 „ 
 
 — 
 
 — 
 
 
 15 
 
 20 „ 
 
 36 „ 
 
 — 
 
 As shown fi'om the os- 
 seous nucleus to the 
 small trochanter 
 
 I 
 
 16 
 
 17 „ 
 
 35 „ 
 
 — 
 
 Line dividing the epi- 
 physis fi'om the dia- 
 
 physis 
 
 I 
 1 
 
 17 
 
 IS „ 
 
 36 „ 
 
 — 
 
 To the end of develop- 
 ment 
 
 
 — 
 
 ( 18 „ 
 117 „ 
 
 (44 „ 
 (40 „ 
 
 
 AGE. — From the condition of the upper end of the femur it is 
 evident that a pure detachinent of the head cannot take place — until 
 the fourth year, at least— the head not being a separate epiphysis from 
 the upper part of the neck and great trochanter, although a fracture 
 may take place through the cartilage of the neck anywhere between 
 the head and the great trochanter. After this period the possibility of 
 its occurrence is rendered more certain by the growth of the neck of 
 the bone, which by this time will have attained suthcient length and 
 
SEPAKATION OF EPIPHYSIAL HEAD OF FEMUE 619 
 
 strength to afford a very powerful arm of a lever. At the age of 
 two it is only three-quarters of an inch long. The whole epiphysis 
 of the head at the fourth year is almost entirely osseous. Therefore 
 epiphysial separations described as occurring under the age of four 
 cannot be regarded as simple detachments of the head, and would 
 more correctly be placed under separations of the upper end of the 
 femur, and their symptoms must differ very considerably. Salmon 
 readily separated the upper end of the bone in experiments on 
 the bodies of infants, but this author could not record any case 
 in which this lesion was diagnosed during life. Out of thirty-three 
 
 Fig. 191. 
 
 -FRONTAL SECTION OF LEFT HIP-JOINT OF A LAD AGED SEVENTEEN AND A HALF 
 YEAKS. RELATION OF SYNOVIAL MEMBRANE TO EPIPHYFIAL LINES 
 
 cases described in this chapter (two of these being simple cases, two 
 operative cases, and three pathological specimens) recorded as separa- 
 tions of this epiphysis— excluding the five below two j^ears of age 
 (three at 2, one at 1 year, and one in infancy), and two in which the 
 age is not stated — fourteen were between the ages of 14 and 18 years 
 (thus two at 18, three at 17, two at 16, three at 15, four at 14) and 
 five between 6 and 11. Of the rest, two were at 19 years, one each 
 at 10, 5, 4^, 4, and 3 years. 
 
 Hutchinson says that it is probably the length and inclination 
 of the neck which save the epiphysial line by throwing the force upon 
 other parts ; and that as both of them are less pronounced in early 
 
620 EPIPHYSES OF LOWEK EXTEEMITY 
 
 life, we may reasonably suppose the risk of detachment to be greater 
 then than later. This is not borne out by other recorded cases, nor 
 by experiments upon the dead subject. 
 
 Below the fourth year and during the earliest periods of infancy 
 it is only a question of separation of the upper cartilaginous end of 
 the femur, whilst later on it is a matter of separation of the 
 different epiphybes formed from this — viz. the head, the greater and 
 the lesser trochanters. 
 
 Separation of the whole upper end of the femur has only been 
 proved by anatomical observation, and it is probable that ' separations 
 of the upper epiphysis ' of the femur produced during the first few 
 years of life, or during delivery of infants, were of this nature. The 
 author has produced it on many occasions in experiments on the 
 bodies of recently born infants. In Sayre's case the accident occurred 
 at the age of two years, and was probably due to separation of the 
 epiphysis of the head, accompanied by fracture of the upper carti- 
 laginous end uniting the head to the great trochanter. 
 
 Of the two other cases verified by direct examination, one occurred 
 at the age of six years and one at fifteen years. 
 
 In two instances in which the lesion was discovered at the time 
 of operation, the age of the patient was fourteen years in one, and 
 in the other the age is not stated. 
 
 ETIOLOG-Y. — In the recorded cases many were caused by direct 
 violence applied to the front or outer side of the hip, such as the 
 passage of a cart-wheel, or the heavy blow from a falling boiler, or 
 in jumping and alighting on the feet, &c., and some few were said to 
 have been caused principally by sudden muscular action, as in slipping, 
 or in the patient trying to save himself from falling. 
 
 Indirect violence. — ^^Dr. Post {Neio York Medical Journal, vol. iii. 
 p. 190, July 1840) related a case in a girl, aged sixteen, who, when 
 carrying a child in her arms, made a false movement in stepping, 
 and, feeling something give way, was obliged to lean against a 
 wall. The next day the limb was found to be shortened one inch, 
 but movable with the foot erected. There was no swelling, but 
 slight pain at the upper part of the thigh. The great trochanter 
 moved with the shaft, and crepitus was felt. From the age of the 
 patient and the slight amount of violence producing the injury a 
 separation of the epiphysis of the head was diagnosed. Extension 
 was applied, and recovery took place with a quarter to half an inch 
 shortening of the limb. 
 
 Dr. G. Stetter, in a paper on the etiology of fractures of the neck 
 of the femur {Gentralhlatt fur CJiirurg. Sept. 8, 1877, No. 36), related 
 a case in a boy, aged fourteen, who slipped on a smooth floor, and 
 in trying to keep on his legs threw himself violently backwards and 
 fell on his left side. Great pain was felt in the right hip, and he 
 was unable to stand. The right limb was shortened three centi- 
 metres and very strongly everted, with slight flexion of the knee. 
 
SEPARATION OF EPIPHYSIAL HEAD OF FEMUE 6'21 
 
 There was inability to move the hmb, and passive movement 
 caused intense pain in the neighbourhood of the hip-joint. There 
 was shght swehing about the great trochanter, which was painful 
 on pressure. The left hip-joint was normal. 
 
 Dr. Stetter believes that the separation in his case was brought 
 about by the powerful ilio-femoral ligament, which plays much the 
 same role in this injury as in dislocations of the hip-joint. 
 
 In Dr. C. A. Sturrock's case the boy fell and twisted his hip. 
 
 In experiments the author has made in the post-mortem room, 
 it was found that separation of the femoral head was most easily 
 accomplished by means of extreme extension of the thigh, especially 
 if accompanied by slight abduction. 
 
 Longaker, in relating a case of this injury {loc. cit. infra), draws 
 attention to the mode of action of extreme extension of the limb. 
 He says : ' The explanation of the accident was that as the patient 
 fell prone the left leg was carried to a point of extreme extension, 
 and possibly at the same time it was abducted. Great force was 
 thus brought to bear upon the epiphysial junction, which, being 
 the weakest part, yielded. We can easily appreciate the action of 
 the powerful lever : the force is applied at the knee ; extension can 
 be carried only to a certain point, when it is resisted by the tension 
 of the strong ilio-femoral ligament ; this becomes the fulcrum, the 
 weight is the point upon which the short arm of the lever is 
 brought to bear, viz. the anterior margin of the acetabulum and the 
 ligamentum teres and cotyloideum.' 
 
 This is probably the explanation of Dr. Stetter' s case, in which 
 the lesion is said to have been caused by muscular action, for it is 
 exceedingly doubtful whether in a healthy subject, the action alone of 
 the muscles can be powerful enough to cause complete separation with 
 displacement. That it is sufficient to cause a partial or incomplete 
 separation without displacement we have abundant evidence to 
 prove in cases of acute disease of the hip, accompanied by necrosis 
 of either the whole of the head or some part of the neck of the bone, 
 the result of slight injur}^ 
 
 Boerhaave's celebrated commentator. Van Swieten, was, the 
 author believes, the first to observe that this was the most frequent 
 cause of certain of these detachments. 
 
 Charles Bell believed that separation of this epiphysis was 
 produced by children, while being carried in the arms of a nurse, 
 violently throwing themselves backwards in a passion, whereby the 
 full weight of the trunk is thrown on to the upper end or neck of 
 the femur. 
 
 Bruns merely quotes as the etiology of this lesion the experiments 
 of Colignon— viz. in using forcible abduction and rotation. 
 
 In proof of the statement as to the ligamentous character of the 
 periosteum being often its strongest bond of union between the 
 diaphysis and the epiphysis, it has been shown, according to 
 
622 EPIPHYSES OF LOWEE EXTEEMITY 
 
 Dr. Ei. H. Harte {Trans. Avier. Surg. Association, 1897, vol. xv. 
 p. 216) in the small epiphysis of the head of the femur, where the 
 periosteum was divided circularly, that one-fifth of the amount of 
 force will suffice to detach the epiphysis which would be required 
 under other circumstances. 
 
 From the history of some cases it would appear that the violence 
 was applied to the knee or outer side of the thigh while in the 
 slightly adducted position, or to the foot or knee while the limb was 
 in the extended and slightly adducted position. 
 
 In both these conditions the force acts from below upwards, 
 backwards, and outwards, in a direction almost perpendicular to the 
 axis of the neck. 
 
 Speaking of separations produced in the foetus, Kiistner (Die 
 typischen Verletzwngen der Extremitdtknochen des Kindes durch 
 den G eh'urt shelf er, Halle, 1877, S. 45) is quoted by Simpson {Edin- 
 hurgh Medical Journal, June 1880) as follows : ' As regards the 
 recorded cases of epiphysis separation, Henke, indeed, notes the 
 possibility that " the upper cartilaginous epiphysis may be detached 
 from the femur by strong traction on the foot," but he records 
 no case. Thudichum {Illustr. med. Zeitung, 1855) knows a case 
 of separation of the upper epiphysis (Bertrandi) ; Euge has none ; 
 to myself also no case is known. Yet my experiments shov/ that 
 hyperabduction of the leg is very likely to produce this kind of 
 injury ; the leg may get into this situation during version, perhaps 
 also during extraction.' 
 
 Incomplete separation of the whole cartilaginous upper end of 
 the bone — or, as Oilier terms it, juxta-epiphysial separation— is often 
 brought about in young children by violent abduction or adduction 
 of the Hmb, more especially the former, as when a child falls, 
 slipping with its legs apart. 
 
 Oilier {Traits des resections, torn. iii. 1891, p. 70) gives a re- 
 presentation of the lesions produced at the upper end of the femur 
 by violent abduction — viz. commencing separation of the diaphysis 
 on the inner side — so that there is a gap left of about a centimetre 
 and a half between the diaphysis and epiphysis, wdiile on the outer 
 side below the trochanter the spongy tissue of the diaphysis is some- 
 what crushed up. (See Part I. Chapter VI. fig. 5.) 
 
 Such an injury is often the starting-point of tuberculous disease 
 of the hip-joint. 
 
 Dr. J. D. Eushmore relates {Trans. Amer. Surg. Association, 
 1895, vol. xiii. p. 502) a remarkable instance of separation of the 
 femoral head, probably the result of unsuccessful attempts to 
 reduce a supposed recurrent dislocation of the hip. Male, aged 
 sixteen years, admitted to Brooklyn Hospital May 12, 1890, with a 
 pubic dislocation of the right femur. The inability to use the limb 
 was developed suddenly while walking, but the patient had been in 
 the habit of separating his legs as wide apart as possible for several 
 
SEPAEATION OF EPIPHYSIAL HEAD OF FEMUE G23 
 
 months, and had gradually acquired the ability to bring the buttocks 
 into contact with the floor with the knee-joints extended. The hip- 
 joint was opened and the dislocation reduced with some difficulty, and 
 healing was complete by June 15. Subsequently, under the care of 
 one of Dr.Eushmore's colleagues, the limb was thought to be shortened 
 and the head of the bone displaced. Efforts were made unsuccess- 
 fully to reduce the dislocation ; the joint was then opened and the 
 head of the bone found in place, but separated from the neck. The 
 loose bone was removed, the neck sawn off, and the limb placed in 
 a plaster-of-Paris splint. Suppuration with marked loss of flesh 
 and strength followed, but when seen on December 1 the wound had 
 been healed for several weeks and the patient's general condition was 
 much improved. The knee, however, without having been originally 
 injured and without having subsequently shown any evidence of 
 inflammatory trouble, was found, on removal of the plaster splint, 
 to be stiff from extra-articular adhesions. On commencing to break 
 up the adhesions the tibia was fractured just below the tubercle. 
 The leg was put up in a plaster splint, and united at the end of a 
 month. In February 1891 the patient left the hospital with the limb 
 one and a half inches shorter than the opposite limb, the hip- and knee- 
 joint becoming more and more useful under gentle passive motion. 
 At the time of the report, more than four years afterwards, he had 
 all the movements of the hip and complete use of the knee-joint. 
 Except for the one and a half inch shortening, the limb was as good, 
 but not so well developed, as its fellow. 
 
 Direct violence. — As the age of the child advances, the epiphysial 
 junction of the head of the femur gains in width and strength, 
 while the neck of the bone becomes the weaker point. Epiphysial 
 separation is at this period commonly the result of great violence 
 applied directly to the upper end of the bone, but nevertheless the 
 neck of the bone is more likely to be fractured under these circum- 
 stances. 
 
 The author found that separation was most easily produced by a 
 direct blow on the outer side of the thigh below the great tro- 
 chanter while the limb was adducted and semiflexed, and in this 
 case it was found that it was sometimes accompanied by some 
 splintering of the neck of the bone. 
 
 Separations brought about by direct violence during life are 
 recorded by several writers. Mr. J. F. South mentions {CJieliiis's 
 System of Surgery, vol. i. 1847, p. 565, note to German translation), 
 a case in a boy, aged ten years, who had fallen out of a first-floor 
 window upon his left hip. The foot was slightly turned out, and 
 scarcely any difference in the length of the limbs could be observed. 
 The thigh could be readily moved in any direction and without 
 much pain, but on bending the knee and rotating the limb outwards 
 a very distinct dummy sensation was very frequently felt, as it 
 seemed, within the hip-joint, as if one articular surface had slipped 
 
624 EPIPHYSES OF LOWEE EXTEEMITY 
 
 o£f another. Mr. South and Mr. Green came to the conchision that 
 it was a case of separation of the head within the capsule. The 
 boy suffered such little inconvenience that he had two or three times 
 got out of bed and walked about for a short distance. He was put 
 upon a double inclined plane. 
 
 A fall on the side has been noted in a few instances, e.g. in the 
 cases of Sabatier and Fabrice de Hilden quoted by Eognetta, both 
 of which were mistaken for fracture of the neck of the femur by 
 these surgeons, while in both those recently recorded by Professor 
 Kocher it is important to note that the cause of the epiphysial 
 separation is expressly stated as a fall on the great trochanter. 
 Both were instances of removal of the head by operation. 
 
 Mr. Mayo Eobson {Lancet, vol. ii. August 21, 1886) has reported 
 and given a drawing of the case of a child, aged five, who was 
 brought to the Leeds General Infirmary on account of lameness, due 
 to shortening of the left lower extremity, with the history of having, 
 four years previously, been thrown up by her uncle, who, failing to 
 catch her, let her fall heavily on the left side. Beyond rest no 
 treatment had been followed out, and the mother was unaware of 
 any other accident having happened to the child, but she had noticed 
 the limp to become more marked during the previous few months. 
 
 On examination the signs were as follows : marked limping on 
 walking, the patient leaning to the left ; well-marked eversion of 
 the foot, which could, however, be brought parallel with the right 
 wuthout giving pain ; ability to completely flex and extend the 
 thigh. Shortening of limb three-quarters of an inch. Left great 
 trochanter raised three-quarters of an inch, as shown by Nelaton's 
 line. Folds of the buttocks well marked. On flexing and rotating 
 the left femur inwards the fingers could clearly feel the neck of the 
 femur as far as the head, but the prominent part of the caput femoris 
 was apparently in the acetabulum, and was not attached to the cervix. 
 
 The muscles of the limb were well developed, and a thickened 
 sole on the left boot almost abolished the limp. 
 
 From the anatomical condition of the upper end of the femur at 
 the early age at which the accident occurred — viz. one year — it 
 appears to the author that a true separation of the head alone in this 
 case was impossible, but the history and symptoms would rather 
 lead to the supposition that it was a fracture through the neck and 
 cartilaginous band uniting the head to the great trochanter. 
 
 Packard thinks that there is ' an important difference between 
 this injury and fracture of the neck of the bone close to the head, 
 as appears from the recorded cases— viz. the much greater violence 
 generall}^ assigned as the cause of the epiphysial disjunction.' 
 
 PATHOLOGICAL ANATOMY. — Fabrice de Hilden, about the 
 middle of the seventeenth century, and Verduc, at the end of the 
 same century, J. L. Petit {Maladies des os ; Bescrijption exacte 
 des OS, Leyden, 1709), and G. J. Duverney {Maladies des os, 1751, 
 
SEPAEATION OF EPIPHYSIAL HEAD OF FEMUE 625 
 
 translated by G. S. Ingham, 1762) all allude to epiphysial separation 
 in speaking of fracture of the neck of the femur. Writing in 1837 
 Gueretin considered this injury as a very rare one, and mentions 
 the cases of Bertrandi and Reichel as having been confirmed by an 
 autopsy. 
 
 Dupuytren alluded to the possibility of its occurrence, but has 
 not recorded any example of it. 
 
 Liston supposed, and many others since his day have asserted, 
 that epiphysial separations of the head of the femur may occasion- 
 ally take place. 
 
 Gurlt also, in 1862, although admitting the possibility of this 
 lesion, had no knowledge of any case. 
 
 Holmes says {Surgical Diseases of Children, 1869, p. 258) ' that 
 fractures of the neck of the femur are hardly known in childhood, 
 and the upper epiphysis is so small, and lies so completely within 
 the hip-joint, that its disjunction is unknown, except perhaps in the 
 foetus.' 
 
 Hamilton was very doubtful as to its occurrence. 
 
 Henry Morris, in his article ' On Injuries of the Lower Extremity,' 
 in the last edition (1883) of Holmes's Sy stein of Surgery, states that 
 ' several supposed examples of this accident have been recorded, but 
 I agree with Mr. Holmes in thinking that they are not conclusive 
 as to the real existence of the lesion.' 
 
 It is true that this epiphysis, including only, as a rule, the 
 cartilaginous articular surface, accurately fits into the acetabulum, 
 and rather more than fills it in youthful subjects. This fact, 
 together with the deep situation of the part, renders the detection of 
 its separation difficult, yet such a disposition of the head of the bone 
 and the mechanical disadvantage arising from the length of the neck 
 must favour separation to a considerable extent. 
 
 The real existence of this separation has been established by 
 direct examination in eight instances. The first case is described 
 and figured by Bousseau {Bull, de la Soc. anatomique, 1867, p. 283, 
 Plate) in a boy, aged fifteen, who was severely injured by the 
 passage of a wagon-wheel over his left hip and arm. The left 
 lumbar and hypogastric regions and upper part of the thigh were 
 considerably swollen and contused. There was inability to move 
 the limb, which was shortened, slightly flexed, and completely 
 rotated outwards, the left heel being in contact with the right 
 internal malleolus, and the limb lying upon its outer side. The thigh 
 was also slightly abducted. Death ensued in a few hours. Severe 
 laceration of the muscles and soft parts of the thigh was found, to- 
 gether with extensive hsemorrhage in the thigh, the iliac fossa, and 
 around the pelvic viscera (sub-peritoneal), although all the large vessels 
 of the thigh were intact. A complete separation of the femoral head at 
 the epiphysial line appeared, as though a section had been made of 
 the femoral head perpendicular to the neck at the level of the brim 
 
 s s 
 
626 
 
 EPIPHYSES OF LOWEE EXTEEMITY 
 
 of the cotyloid cavity. A small strip of cartilaginous and periosteal 
 tissue still clung to the upper third of the neck on the outside. The 
 periosteum was extensively detached from the neck all round, 
 excepting on its outer side and above, as just mentioned, but it still 
 remained attached to the epiphysis. The strip, which alone bound 
 the two fragments together, was two millimetres wide. A vertical 
 laceration existed on its inner side and extended downwards to the 
 lesser trochanter. The capsule of the joint was also lacerated exten- 
 sively at its inner part, through which the margin of the femoral 
 head could be seen. Separations of the anterior superior, and inferior 
 iliac spines were also found, the former still holding to the ilium by 
 a small portion of cartilage and periosteum, the latter completely 
 
 detached, T^^th the exception of a 
 small tag of periosteum uniting it 
 to the superior spine. The rectus 
 tendon remained attached to it. 
 The iliac fossa was full of blood 
 (sub-peritoneal). Each spinous 
 process presented a thin osseous 
 layer in the centre of the cartila- 
 ginous separated surface. There 
 was also a transverse fracture of 
 the lower end of the humerus. 
 
 The convex end of the femoral 
 diaphysis was wavy in outline, and 
 had scattered over its greyish- 
 looking surface small projections 
 and excavations, two or three of 
 the latter really forming holes. 
 Under the microscope the surface 
 of bone was seen to present osteo- 
 blasts, which were incompletely 
 formed, and a considerable num- 
 ber of cartilage cells in various 
 stages of transformation. 
 The surface of the epiphysis was deeply excavated, especially on 
 the inner side, and also presented some less marked elevations and 
 depressions scattered over it. Under the microscope little else than 
 cartilage was seen, although some calcareous groups and unformed 
 osteoblasts could be detected. 
 
 The separation had taken place between the chondroid and 
 spongy layers. 
 
 The second remarkable case is recorded b}' Lewis Sayre (' On 
 Diastasis of the Head of the Femur,' American Practitioner and 
 London Medical Becord, 1873, p. .393) of a child, aged ten, who died 
 of cholera eight years after the occurrence of the accident. The 
 acetabulum was found to be of small size and irregular shape, and 
 
 Tig. 192. — teaumatic SEPAKATIO^' of the 
 
 EPIPHYSIAL HEAD OF THE FEMCK. (.AFTER 
 BOUSSEAU) 
 
 H, head of the femnr ; D, end of diaphy- 
 sis; C, detached periosteum and capsule 
 
SEPAEATION OF EPIPHYSIAL HEAD OF FEMUE G27 
 
 was filled by the remnants of the head of the femur ; a new 
 acetabulmTi had been formed on the dorsum of the ilium, the upper 
 part of which was attached to the great trochanter by a firm dense 
 ligament, the lower portion being polished and eburnated, and 
 corresponding to a similar eburnation of the part of the neck of the 
 femur fitting against it. 
 
 This case cannot be regarded as a true separation of the head 
 alone at the time of the accident, when the child was only two years 
 old. The fibrous band alluded to by Professor Sayre was probably 
 the remains of the upper part of the epiphysis uniting the head to 
 the great trochanter. A section through the upper end of the shaft 
 and trochanter would have thrown much light upon this interesting 
 specimen. 
 
 Longaker {Medical and Surgical Beporter, Philadelphia, 1883, 
 xlix. pp. 228-231) relates the case of a male child, aged six years, 
 who had up to that time good health and no tendency to inherited 
 disease. Nine weeks previously a heavy boiler fell against him, 
 causing a large wound at the back of the upper part of the right leg. 
 One week after the accident there was high fever with chills. Rapid 
 emaciation and swelling of the upper part of the front of the left 
 thigh increased steadily and rapidly to the time when he was seen. 
 There was a cicatrix three-quarters of an inch in width and two 
 inches long running obliquely across the right leg. The patient lay 
 on his right side with thigh flexed upon pelvis and leg on thigh. 
 Pain on movement of left leg. Enormous fluctuating swelling 
 of thigh extending upwards as far as the crest of the ilium. Any 
 attempt at extension caused great pain. There was aching of the 
 lumbar vertebrse, and the pelvis moved with the femur. Occasional 
 diarrhoea. An incision was made behind the trochanter and a 
 quantity of pus evacuated. The hip-joint was found to be opened 
 and the head of the femur detached, and only adherent by the 
 ligamentum teres. The upper end of the shaft presented a distinct 
 sharp edge, from which the periosteum was not separated, but 
 normal. The part of the line which was separated was grasped by 
 an ordinary dressing forceps, and with little difficulty removed from 
 its attachment. There was no erosion of the articular cartilage of 
 the removed fragment ; it was normal in appearance. Carbolic acid 
 was injected and a drainage tube inserted. On the sixth day the 
 thigh was extended with considerable force, and some adhesions 
 were felt to give way. A moulded splint was then applied to the 
 anterior and outer aspect of the left side. Death occurred three 
 days later from exhaustion. 
 
 At the post-mortem examination of the thigh the body was found 
 in a state of great emaciation. Bands of adhesions had formed between 
 the neck of the femur and the innominate bone, some of them being 
 ruptured, and the others effectually preventing complete extension. 
 The upper extremity of the bone presented an almost even surface 
 
628 
 
 EPIPHYSES OE LOWEK EXTEEMITY 
 
 with no necrosis. There was no periostitis or ostitis. Tissues about 
 the joint had evidently suffered from violence. 
 
 Mr. Davies-Colley refers {loc. cit. infra) to a case he had seen 
 under one of his colleagues at Guy's Hospital. Excision of the 
 head and neck of the femur was performed, and it was found that 
 there was a separation of the epiphysis which had united by bone 
 after the gliding upwards of the shaft. He inferred that separation 
 of the upper epiphysis had occurred from the shortening of the limb 
 accompanied by great projection of the trochanter. 
 
 Professor Theo. Kocher {Beitrdge zur Kenntniss einiger praJctisch 
 wiclitiger Fracturformen, Leipzig, 1896, S. 238) describes in every 
 clinical detail, and gives semi-diagrammatic drawings of, two interest- 
 ing cases of traumatic separation of the epiphysial head of the femur, 
 
 both caused by a fall upon the trochanter 
 major, and both subjected to an exact dia- 
 gnosis before operation. 
 
 In the first case, of a girl aged sixteen 
 years, the head of the femur was removed 
 by a posterior incision in Eebruary 1889, 
 about three weeks after the accident. 
 
 In the second the operation was under- 
 taken in a girl, aged fourteen, four years 
 after the accident, when the diagnosis was 
 made. 
 
 In the latter the neck of the bone 
 appeared to have a very oblique downward 
 direction, was tuberculated, and seemed as 
 if it had formed a new head, while the 
 epiphysial head itself was attenuated. 
 
 Konig has also performed resection in 
 two cases of epiphysial separation of the 
 head of the femur. 
 
 Amongst the photographs of specimens 
 which Professor J. G. Adami, of McGill University, Montreal, gene- 
 rously handed to the author, was one of separation of the epiphysial 
 head of the femur. The specimen is so valuable that it is repro- 
 duced here, though the drawing shows but little of the part involved 
 in the injury. Dr. Adami supplied the author with the following 
 note — viz. ' that it was taken from a child and was a fracture of the 
 epiphysis of the head ; it was photographed to show the trochan- 
 teric imperfect union. In this specimen the head has been broken 
 off sharply along the epiphysial line. Unfortunately the head is 
 missing' (see fig. 193). 
 
 The following case of epiphysial separation in a lad, aged twelve 
 years, came under the author's observation at the City Orthopaedic 
 Hospital on July 20, 1894, two years after the accident. S. S., aged 
 twelve years, was admitted under the author's care for deformity of the 
 
 Fig. 193. — puee separation of 
 head of femur. a portion 
 only op the epiphysial end 
 of the neck appears in the 
 
 DRAWING 
 
 (McGill College Museum, Mont- 
 real) 
 
SEPAEATION OF EPIPHYSIAL HEAD OF FEMUK 629 
 
 left hip, with the history that on August 30, 1892, he had been knocked 
 down in Eosebery Avenue and run over by a hansom cab. He 
 was taken to a hospital, where ' traumatic dislocation of the hip 
 was diagnosed and easily reduced ' — so the author was informed by 
 a letter from the registrar of the hospital. After seventeen days he 
 left the hospital with a plaster-of-Paris dressing and crutches. 
 The plaster casing was removed after a month, but at the end of 
 three months he was only able to walk with a ' limp.' This got 
 worse, and in April 1894 he again slightly injured the hip whilst at 
 play, and at the end of May, six weeks later, he was taken into the 
 same hospital for a week 
 on account of the stiffness. 
 Under an auEBsthetic some 
 adhesions were found and 
 broken down. The stiff- 
 ness recurring, the patient 
 was brought to the City 
 OrthopEedic Hospital. He 
 was a muscular boy for 
 his age. The left leg was 
 everted, so that the inner 
 side of the foot looked for- 
 wards and inwards and the 
 patella outwards. The 
 muscles of the thigh were 
 wasted, and there was 
 rather more than a quar- 
 ter of an inch shortening. 
 The great trochanter was 
 very prominent, with great 
 thickening both in front 
 and behind, especially in 
 front towards the neck of 
 the bone, so that this pro- 
 cess felt almost twice as 
 thick as on the opposite 
 side ; it was half an inch 
 
 nearer the iliac crest than that on the right side 
 was lost on this side. The leg was neither adducted nor abducted, 
 and the patient was quite unable to raise it from the bed. Passive 
 flexion of the thigh was only permitted through an angle of forty 
 degrees from the extended position, whilst rotation was almost lost ; 
 the shght amount of rotation inwards that was possible produced 
 some pain. 
 
 On October 30 forcible flexion of the hip-joint was carried out 
 up to an angle of seventy degrees with the trunk, and was accom- 
 panied by some ' crackling.' Forcible rotatory movements were also 
 
 Fig. 194. — traumatic sepakation op the epiphysial 
 head of the femur. appearance of the limb 
 
 TWO YEARS AFTER THE ACCIDENT (aUTHOR's CASE) 
 
 The gluteal fold 
 
630 
 
 EPIPHYSES OF LOWEK EXTKEMITY 
 
 effected. For six weeks the patient was kept in bed, gentle movements 
 of the hip-joint being carried out from time to time, and a month later 
 he was discharged from the hospital, able to walk well without any- 
 limping. Flexion could be effected up to an angle of sixty degrees 
 without causing any pain. The trochanter appeared less prominent, 
 but this w^as no doubt partly due to the improved condition of the 
 muscles, although the thigh was still considerably smaller than the 
 opposite one. There still remained a good deal of thickening of the 
 front of the neck of the bone. Two years later the patient was again 
 under the author's treatment at the Miller Hospital, the deformity 
 having greatly increased. 
 
 The eversion of the limb was so great that the outer malleolus 
 rested on the bed ; its shortening amounted to nearly half an inch. 
 The bony prominence in front of the hip was now very marked, 
 owing probably to the wasting of the muscles, the continued 
 displacement forwards of the end of the neck, and the rotation of 
 the epiphysial head in the acetabulum." The position was very like 
 that of a dislocation forwards of the head of the femur. 
 
 Active and passive movements of flexion of the hip-joint were 
 almost absent. From the extended position the thigh could only be 
 flexed about ten degrees. The great trochanter was in its normal 
 position as regards Nelaton's line. 
 
 On November 19, 1896, by an anterior incision along the border 
 of the tensor vaginae femoris, the author excised, by means of a 
 chisel, the end of the neck of the femur which was rotated forwards, 
 so that its epiphysial surface presented in front and formed the 
 
 mass noticed previously. A 
 small portion of the front 
 margin of the head of the 
 bone appeared to have been 
 broken off and displaced for- 
 wards and outwards with the 
 neck ; the rest of the head 
 of the bone had undergone 
 some rotation in the aceta- 
 bulum. The articular carti- 
 lage was undergoing fibroid 
 degeneration, and slight ad- 
 hesions existed in the joint. 
 No traces of the ligamentum 
 teres could be found ; it had 
 evidently been ruptured. The neck of the bone was firmly united 
 to the epiphysis. The parts were removed in several pieces, since 
 it was desirable to leave as much of 'the posterior part of the neck 
 as possible in contact with the back of the acetabulum to form a 
 new joint with it. The great trochanter was uninjured, and there- 
 fore left intact. 
 
 Fig. 19-5. — portion of head and neck of femur 
 ex0ise3j for displacement forwards of the 
 latter following epiphysial separation, 
 posterior view of divided surfaces. 
 (author's casf) 
 
SEPAEATION OF EPIPHYSIAL HEAD OF FEMUE 631 
 
 After the operation the eversion was entirely corrected, and the 
 limb could be freely flexed. No drainage. The patient made a 
 good recovery, but the precise condition of the limb could not 
 be ascertained at the time of this report, after he had left the 
 hospital. 
 
 There is no specimen of this injury in any of the London 
 hospital museums. 
 
 Although specimens are so rare, the author believes the accident 
 to be by no means an uncommon one. 
 
 Several specimens from the lower animals have been obtained 
 by Mr. Hutchinson, all resulting from violence in attempts at sexual 
 connection. He believes that ' in almost all instances the injury is 
 partly a fracture as well.' 
 
 Separation with fracture of a portion of the diaphysial neck. — It is 
 probable in some cases that the separation does not follow exactly 
 the line of conjugal cartilage, but that some small splinters of the 
 neck may be detached, as in other epiphysial separations. 
 
 At the same time it must be remembered that the epiphysis of 
 the head extends somewhat over the neck, especially on the upper 
 and anterior aspects. 
 
 Incomplete separation. — Incomplete separation of the diaphysis is 
 a very common origin of acute suppurative hip disease, the primary 
 lesion being often overlooked. 
 
 It has been stated above that Oilier has recently drawn attention 
 to these injuries under the name of juxta-epiphysial sprain. 
 
 Professor De Paoli, of Perugia, describes and figures {Comunica- 
 zioni della clinica chirurgica propedeictica, Perugia, 1891) a typical 
 case of this kind in which he performed excision of the hip in a boy 
 aged seventeen years. The injury (caused by jumping a ditch) had 
 produced a partial separation or fracture of the epiphysis at its upper 
 and anterior margin, and led to inflammatory softening of the con- 
 jugal cartilage. 
 
 This produced separation of the upper epiphysis with backward 
 displacement of the diaphysis and acute suppurative inflammation 
 of the hip-joint. 
 
 De Paoli believed that in this case there v/as added some pysemic 
 infection from a ' boil ' w^hich had been in existence on the back 
 of the hand for some days previous to the injury. The ordinary 
 micro-organisms of suppuration, and especially streptococci, were 
 found in the pus on cultivation. 
 
 Most surgeons have seen various conditions of acute hip disease, 
 succeeded by similar detachments, many of which have not been 
 detected before the operation of excision of this joint. 
 
 SYMPTOMS.— In his memoir in 1834 M. Eognetta states that 
 after a careful investigation he was persuaded that separation of 
 the ep'physial head of the femur happens more frequently than was 
 thought, and that it was often not detected. 
 
632 EPIPHYSES OF LOWEE EXTREMITY 
 
 Diiverney thought that this lesion conld only occur as the result 
 of disease {Maladies des os, 1751, t. i. p. 351). 
 
 J. L. Petit, writing in 1837, at the end of a chapter on fracture 
 of the neck of the femur, makes the following remarks, but it does 
 not appear that he had ever met with a case : 
 
 ' II s'agit, pour finir cette matiere, de dire un mot du decollement 
 ou de la separation du col d'avec I'epiphyse qui forme la tete. Cette 
 epiphyse ou cette tete est unie, comme on sait, au corps de I'os par 
 un cartilage qui se trouve entre eux et qui, comme une colle, fait la 
 jonction de ces parties. On congoit par la que le decollement ne 
 pent arriver que dans les jeunes sujets en qui le cartilage qui joint 
 I'epiphyse n'est point ossifie : car dcins ceux en qui I'ossification est 
 parfaite, le cou et I'epiphyse ne faisant qu'un, s'il arrive que la tete 
 se separe, ce sera par fracture et non par simple decollement. . . - 
 Pour determiner si ce decollement est simple ou s'il est cause par 
 une fracture, il faut done avoir egard a I'age. . . . Apres tout, il ne 
 sert pas beaucoup, pour la guerison, de distinguer le decollement de 
 I'epiphyse d'avec la fracture du col, puisque I'operation est la meme 
 et que les moyens de maintenir les os, quand ils sont reduits, ne 
 different point.' 
 
 Although M. Colignon was able to collect ten cases of this injury, 
 many of them cannot be accepted as trustworthj^ on account of the 
 insufficient data given by their authors at a very remote period. 
 
 MM. Cruveilhier, Becamier, and Marjolin diagnosed a probable 
 separation of this epiphysis in a child aged three j^ears, who pre- 
 sented all the characters of a fracture of the neck of the femur. 
 
 Boyer, in his Traite des maladies chirurgicales, says that separa- 
 tion of the head does not differ at all from fracture of the neck, that 
 the symptoms are the same for both, and that consolidation takes 
 place as readily as after fracture. He quotes Pare as having 
 described the symptoms of this lesion and alluded to the possibility 
 of mistaking it for a dislocation. 
 
 Chelius says that the symptoms of this injury can in no respect 
 bs distinguished from those of fracture within the capsule. 
 
 One of the earliest cases recorded is related by E. Spillmann 
 {Diet. Encycl. des Sci. Med. vol. xxiv. p. 238), as observed by Sabatier 
 in a boy aged eleven, but he gives no account of the case. Spillmann 
 also refers to another seen by Verduc. 
 
 The late Mr. John Hilton of Guy's Hospital made a diagnosis 
 of this injury in two cases, and Mr. G. A. Wright, of the General 
 Hospital for Sick Children, Manchester {HijJ Disease in Childhood), 
 has once met with diastasis of the upper femoral epiphysis. Mr. 
 Hutchinson {Medical Times and Gazette, vol. i. 18C6, p. 195), in 
 speaking of separations of this epiphysis, maintained that ' at best a 
 plausible guess is all that is possible.' However, the same surgeon 
 in a recent article {Archives of Surgery, April 1892) upon detach- 
 ment of the epiphysial head of the femur, speaks of the diagnosis 
 
SEPARATION OF EPIPHYSIAL HEAD OF FEMUE 633 
 
 of this injury in more certain terms. Also, Hamilton states that 
 ' we have as yet no means of determining absolutely the symptoms 
 of epiphysial separations.' 
 
 The numerous cases which have now been published should 
 enable us to make an accurate diagnosis. 
 
 Sepaeatiox with Displacement. — The symptoms of complete 
 separation with displacement resemble mostly those of fracture of 
 the neck of the femur within the capsule in adults, to which some 
 of the signs of dislocation are often added. 
 
 Many examples of fracture of the neck of the femur in children 
 have been verified by anatomical examination ; a few only of these 
 need be quoted here to show their existence. 
 
 Mr. Henry Morris (Holmes and Hulke's System of Surgery, 3rd 
 edit. vol. i. p. 998) points out that occasionally undoubted intra- 
 capsular fractures occur in the young, and quotes cases recorded by 
 Morgagni, Stanley, and others, while he gives a drawing from a speci- 
 men in the Middlesex Hospital taken from a person under seven- 
 teen years of age. In Guy's Hospital Museum there is a specimen 
 of a similar fracture united by so large an amount of callus, obscuring 
 the upper end of the bone, that it is probable that a more extensive 
 fracture of this portion of the bone had existed. 
 
 Hamilton reported another case (F. H. Hamilton and Stephen 
 Smith, Fracticres and Dislocations, 1891, p. 369). A girl, aged 
 sixteen, was caught between the wheels of two carriages, the blow 
 being received directly upon the trochanter major of the right side. 
 The symptoms which presented themselves showed conclusively 
 that there was a fracture — viz. shortening, loss of voluntary motion, 
 eversion, and well-marked crepitus. At the end of three years she 
 died of acute disease, and it was found that there had been a 
 transverse fracture of the bone just at the junction of the head and 
 neck, and not an epiphysial separation. The head of the bone was 
 still attached to the acetabulum by the ligamentum teres. 
 
 Schultz records another case of fracture of the neck of the femur 
 under the care of Dr. Hoffa {Zeitschriftfilr ortliop delis die Cliirurgie, 
 i. S. 49), who removed the head of the femur in a girl of fourteen 
 for ununited fracture six weeks after the injury from a fall. 
 
 Epiphysial separations cannot, therefore, be judged simply from 
 the age ; the narrowest portion of the neck of the femur is below 
 the epiphysial line of junction of the head, and would therefore 
 appear to be more liable to fracture than the broader epiphysial 
 head to be separated above ; but the subject will be alluded to again 
 more fully under the head of diagnosis. 
 
 Shortening is the most marked sign ; it is noted in eighteen out 
 of twenty cases, and may be considerable, ranging from three- 
 quarters to one and a half or two inches ; in others it may be slight, 
 and unrecognisable unless careful measurements be taken. On the 
 other hand, it may be absent at the time of the accident, only 
 
634 EPIPHYSES OF LOWEE EXTEEMITY 
 
 being evident subsequently when the femur has become displaced 
 in walking or by muscular action. 
 
 It may therefore be said to be dependent upon the extent of 
 the displacement of the neck of the bone. Extension of the lower 
 extremity readily reduces slight displacement, consequently short- 
 ening may be overlooked. 
 
 In Hamilton's case there was three-quarters of an inch shorten- 
 ing, in Post's one inch, Hutchinson's one inch, and in Maunder's 
 half to three-quarters of an inch. 
 
 De Morgan has recorded {Med. Times and Gazette, 1859, vol. i. 
 p. 137) the case of a young man, -aged nineteen years, as a 
 fracture of the neck of the femur ; whilst standing on some movable 
 steps, they slipped from under him, and he was thrown four feet on 
 to the flags below, striking the back of his hip with great violence 
 against the edge of some railings. The symptoms were eversion of 
 the foot ; the outer surface of the trochanter looked backwards ; there 
 was one and a half inch real shortening (which was readily reduced 
 and as easily recurred) . The trochanter, less prominent than on the 
 opposite side, rotated with the shaft ; there was obscure crepitus. 
 He recovered with bony union. 
 
 A separation of the epiphysis probably occurred in this case. 
 
 Mr. Noble Smith {Lancet, March 20, 1886, vol. i.) records and 
 figures an instance in a young lady, aged seventeen, who nearly fell 
 while walking on wet boards, the right leg slipping outwards and 
 forwards. She recovered herself, but felt pain, chiefly in the knee, 
 but also in the region of the hip-joint. No shortening of the limb 
 could be detected, but the toes inclined outwards at about 30° 
 from the vertical. 
 
 The case was diagnosed as ' severe strain ' of the femoral muscles 
 from violent external rotation of the limb, with probably some 
 rupture of the capsular ligament. She rested in bed for three weeks, 
 and then endeavoured to get up, but found the leg useless. Five 
 weeks before the accident the patient strained the right knee in 
 walking, and this, although apparently recovered from, had probably 
 contributed to the second severe accident. When seen by Mr. 
 Smith eleven weeks after the accident, there was one and a quarter 
 inch shortening of the limb. The trochanter was somewhat 
 prominent laterally. The foot was rotated outwards to the extent of 
 50° ; whilst in the recumbent position she could flex the thigh to an 
 angle of 45° with the straight line of the body, without moving the 
 pelvis. Limb utterly useless for standing. When placed on her side 
 the patient could extend the thigh almost completely. The toes could 
 be rotated inwards one inch towards the vertical without causing 
 the slightest pain in the hip. Mr. Smith further states : ' The first 
 slight accident caused a sprain of the muscles surrounding the hip- 
 joint, leaving them somewhat weak, and favouring injury to the 
 joint. At the time of the second accident, when the patient stumbled, 
 
SEPAKATION OF EPIPHYSIAL HEAD OF FEMUE 635 
 
 the leg slipped outwards and forwards. Upon this latter occasion 
 I believe the epiphysis was separated from the shaft, but was kept 
 in position by the capsule, as occurs in intracapsular fracture, and 
 subsequently the bone became displaced by muscular action. It 
 will not, I think, be doubted that the head of the bone was separated 
 from the shaft. The trochanter being an inch and a quarter higher 
 than that of the opposite limb, and the two trochanters on the same 
 level wdth the front of the body, although the right one was rotated 
 out while the left was held with the foot vertical, indicated one of 
 two conditions : either the head of the femur must have been dis- 
 located from the acetabulum, or, if it remained in its place, it must 
 have been separated from the shaft. If it had been dislocated, the 
 head must have been discovered in the displaced position. In 
 rotation outwards of a thigh the trochanter is naturally carried 
 backwards ; but here the trochanter was level with the other, and 
 therefore the head of the bone would have been very prominent had 
 there been dislocation. There was no sign of it. Assuming that 
 the head of the bone was separated from the shaft, its production by 
 disease of the joint was contraindicated by the history, the symptoms, 
 and the result of treatment. Under ether, the thigh could be flexed 
 upon the body nearly to a right angle. The movement of the joint 
 in all directions was more free than before. While in a flexed 
 position traction was applied to the thigh, rotation inwards, and 
 the limb brought down to a straight line with the body by very 
 moderate force. A cartilaginous grating was felt in the joint. 
 The deformity was completely reduced with the exception of less 
 than a quarter of an inch. Liston's long sphnt was applied for six 
 weeks ; the patient then moved about on crutches for twenty-five 
 days. Since then she has walked about comfortably with the 
 assistance of a mechanical support. Firm union took place, but the 
 movements of the joint were very restricted.' 
 
 Dr. Harvey {Brit. Med. Journal, February 19, 1887, p. 396) 
 mentions the case of a child in whom there was lengthening of the 
 limb by three-quarters of an inch after injury, reduced when in the 
 recumbent position, but returning on standing, the result of separa- 
 tion of the upper epiphysis of the femur. A long splint was applied, 
 and recovery took place. 
 
 The facts given in this case are unfortunately insufficient to 
 explain this unusual symptom of lengthening. 
 
 Eversion of the limb is a most frequent symptom ; it appears to 
 have been a more or less marked feature in eighteen out of twenty 
 cases. As in intracapsular fracture, it is chiefly owing to the weight 
 of the limb, and may be accompanied by slight flexion, abduction, 
 or adduction of the limb. 
 
 In Bousseau's case the limb was completely everted, lying upon 
 its outer side, the heel touching the internal malleolus of the opposite 
 limb. 
 
636 EPIPHYSES OF LOWEK EXTEEMITY 
 
 It is less marked in younger children, where muscular action 
 comes less into play. 
 
 Inversion of the limb. — Inversion of the limb was present in one 
 case mentioned by Mr. Hutchinson {Archives of Surgery, April 1892) 
 under his care at the London Hospital in 1873. It was that of a 
 boy (Herbert B.), aged four and a half years, who had fallen out of 
 a high bed. There was at least an inch of shortening with inversion, 
 and a distinct cartilaginous crepitus was detected w^hen the limb 
 was di'awn into position. The deformity M'as reproduced imme- 
 diately that extension w^as remitted. Mr. Hutchinson says : ' We 
 did our best to keep the bone in position, but I am not sure that we 
 obtained union.' 
 
 Like the rare cases of intracapsular fracture of the neck in the 
 adult with inversion, the internal rotation must be due, as R. W. 
 Smith thinks, to the relative position of the fragments — the lower 
 being placed in front of the upper — rather than to the influence of 
 muscular action, w^hich must only act secondarily. The limb at the 
 time of the accident is probably in the inverted position. In this 
 relation of the fragments he is of opinion that the pectineus and the 
 upper portion of the adductor magnus would then act as internal 
 rotators, and the position of the fragments would mechanically 
 hinder eversion. 
 
 One or two of those rare cases in the adult, described by Stanley, 
 Spence, Dupuytren, Hamilton, Cruveilhier, Guthrie, Smith, &c., 
 have been mistaken for dislocation on to the dorsum of the ilium, or 
 into the ischiatic notch. 
 
 Crepitus is of the usual muffled or dull character. Mention is 
 made of it in nearly one half of the recorded cases. 
 
 The following are the particulars of the only instance of epiphysial 
 detachment of the head of the femur which up to 1866 had been under 
 Mr. Hutchinson's care (' On Separation of the Upper Epiphysis of 
 the Femur,' Med. Times and Gazette, vol. i. February 24, 1866, 
 p. 195). He was sent for one night to the London Hospital to see 
 a patient with a supposed dislocation of the femur. The house 
 surgeon believed that he had reduced it more than once, but it had 
 slipped again. The patient was a lad of eighteen, who had been 
 violently knocked backwards by an explosion of gunpowder. His 
 left limb was slightly everted, and shortened to the extent of about 
 an inch. The great trochanter moved with the shaft. The limb 
 could be drawn down, but it slipped up again as soon as the traction 
 was remitted. No distinct bony crepitus could be elicited, but a 
 somewhat rough grating could be easily produced. Chloroform was 
 given to facilitate accurate coaptation. When the muscles were 
 fully relaxed the limb was very forcibly extended, and then carefully 
 secured at full length on a straight spHnt with perineal band. The 
 splint was re-adjusted at the end of a fortnight, and taken off at the 
 end of six weeks, when the union was found to be tolerably firm ; but 
 
SEPAKATION OF EPIPHYSIAL HEAD OF FEMUE 637 
 
 as a precaution it was retained for three weeks longer. The result 
 was perfect, the limb being of the same length as the other, and 
 the union quite firm.' 
 
 Hamilton (op. cit. p. 424) describes a case reported by Dr. H. 
 Wardner, of Cairo, Illinois, as one ' of intracapsular fracture of 
 the neck of the femur,' which he regarded, from the ' dull crepitation ' 
 and other symptoms, as really epiphysial. 
 
 A boy, aged fourteen, hurt himself by jumping and alighting 
 upon his feet, this being followed by a lameness in the hip-joint and 
 some difficulty in walking. Twenty-four hours later, on attempting 
 to get out of bed, one foot became entangled in the bedclothing, and 
 this led him to exert forcibly the adductor muscles, when he suddenly 
 cried out with pain, saying his hip had gone out of place and he 
 found himself unable to rise. Under chloroform, reduction was 
 attempted unsuccessfully. The following day the limb was found to 
 be shortened one or two inches, and was lying nearly parallel with 
 the other limb, with the toes rotated. Dull crepitus w^as detected. 
 Extension was applied for several weeks, and at the end of thirteen 
 months there was one inch shortening, and the motions of the hip- 
 joint were limited to about one half the normal extent, the muscles, 
 leg, &c., of that side of the pelvis being considerably shrunken. The 
 patient walked a little lame, and complained of weakness of the 
 limb. 
 
 The same author quotes a more decided case under his own care 
 at Bellevue Hospital. Andrew L., aged fifteen, fell from the fourth 
 story of a house ; the following morning he was admitted into Pro- 
 fessor Hamilton's w^ards at Bellevue Hospital. The right thigh was 
 found to be shortened three-quarters of an inch, and slightly ab- 
 ducted ; toes everted. Under chloroform feeble crepitus was felt in 
 the vicinity of the joint, unlike the crepitus of broken bone. The 
 shortening was entirely overcome with fifteen pounds of extension, 
 the limb put in position, and maintained with Buck's apparatus. 
 At the end of two weeks there was still half an inch shortening. 
 The ultimate condition of the limb could not be ascertained. 
 
 Cartilaginous crepitus was determined in one case by Dr. Elder 
 between the head of the femur and trochanter. 
 
 Dr. E. H. Bradford, of Boston, U.S.A. {Boston Medical and 
 Surgical Journal, 1892, vol. cxxvi. No. 9, p. 212), records a case of 
 the separation of the epiphysis at the head of the femur, in which 
 the diagnosis was clear. 
 
 A boy, seventeen years old, fell from a window, striking upon a 
 shed of the story below. He was brought to the hospital with 
 symptoms suggesting a fracture of the right limb. On examination, 
 however, no fracture was found of the leg or the thigh. The 
 limb was held in a position of eversion and was slightly shortened, 
 but no injury was discovered below the trochanter, which rotated 
 on twisting the leg. On examination under an ana3sthetic, abnormal 
 
638 EPIPHYSES OF LOWEE EXTKEMITY 
 
 mobility and a cartilaginous crepitus were determined between the 
 bead of the femur and the trochanter. The trochanter was higher 
 on the affected than on the other side. 
 
 Mr. W. H. Battle, in a short paper on ' Traumatic Separation of 
 the Upper End of the Femur in Early Life,' gives {St. Thomas's 
 Hospital Beports, n.s. vol. xxii. 1894, p. 22) an account of two cases 
 in which soft crepitus and some of tlxe other usual signs were present, 
 and the diagnosis established. 
 
 Case I. J. P., aged eight years, was admitted under the care of 
 Mr. A. 0. MacKellar into St. Thomas's Hospital on July 7 and dis- 
 charged August 19, 1887, Whilst climbing a stack of timber (twenty 
 feet high) he fell on his right side, and a plank struck him on his left 
 hip and forehead. He was unable afterwards to stand, or to put the left 
 leg to the ground. On admission he complained of slight pain over 
 the left hip and down the front of the thigh. There was no eversion 
 of the limb, no apparent shortening, and he could flex the thigh on 
 the abdomen. On firmly grasping the thigh with one hand, and 
 placing the other over the hip-joint, the movements of rotation were 
 not diminished ; crepitus was not obtainable, neither was it on press- 
 ing the bone firmly upwards towards the acetabulum, and the pain 
 during these manipulations was slight, being felt in the upper part of 
 the thigh. On firmly grasping the great trochanter, pressing in- 
 wards whilst extension was made on the thigh, and then gently 
 moving it backwards and forwards, fine crepitus could be felt. Under 
 an anaesthetic, the great trochanter was found to be half an inch 
 above Nelaton's line ; the femur could be rotated to a greater extent 
 than normal, and grating was distinct. After this examination the 
 shortening was three-quarters of an inch, and eversion became 
 evident. There was no marked crepitus, but the sensation was un- 
 doubtedly that conveyed in cases of separation of epiphysis in other 
 parts of the body. 
 
 The shortening could be done away with on extension of the 
 limb. Extension and weight of four pounds, with plaster and long 
 outside splint, were applied. On July 16 the splint was taken off and 
 a quarter of an inch shortening found. The splint was then re- 
 applied. 
 
 Case II. was that of a boy, aged seven, who was admitted under 
 the care of Sir W. MacCormac on May 15, and left on June 26, 
 1882. He was running along when he caught his left foot against the 
 pavement, felt a crick in his hip, and fell down on the opposite 
 limb ; he did not strike the injured side at all. On admission there 
 was well-marked eversion and one inch shortening, but crepitus 
 could not be felt until the boy had been placed under ether. He 
 made a good recovery, but no note was made as to the ultimate 
 result as regards shortening. No doubt was entertained of the 
 nature of the injury in this case, but in a third case described by Mr. 
 Battle the epiphysial separation rather pointed to disease. 
 
SEPARATION OF EPIPHYSIAL HEAD OF FEMUE 089 
 
 The absence of crepitus in Sturrock's case formed (it is said) one 
 of the signs in making a diagnosis. 
 
 Deformity. — The chief noticeable alteration of the natural shape 
 of the hip is the result of the displaced position of the great 
 trochanter. 
 
 This displacement is usually detected in fractures of the neck of 
 the femur by Nelaton's line, by Morris's bi-trochanteric or transverse 
 measurement {System of Surgery, 3rd edit. vol. i. p. 1003), or by 
 Bryant's test line {Lancet, vol. i. p. 119, 1876). 
 
 Mayo Eobson's method of measuring the shortening at the neck 
 of the femur is a very exact one with the patient in the dorsal 
 decubitus. The method consists {Lancet, December 14, 1895, 
 p. 1506) in drawing a transverse line from the tip of the great 
 trochanter forwards and inwards across the front of the thigh on 
 each side, and dropping a vertical line to meet this from the tips of 
 the anterior superior spines ; the latter constitute the measuring 
 lines. 
 
 The trochanter generally will be seen to be unaltered in shape, 
 but more prominent and placed higher, and to be nearer the anterior 
 superior spine of the ilium than that of the sound side. 
 
 There is a great tendency for the deformity to recur when the 
 reducing force is relaxed, while there may be an absence of tender- 
 ness about this process. 
 
 In others some fulness or swellmg may be noticed at the upper 
 part of Scarpa's triangle. 
 
 J. M. Barton, in a paper {Medical Neios, Philadelphia, 1883, xliii. 
 p. 43) on separation of the epiphysis of the head of the femur, 
 relates a case in which he had taken careful measurements of this 
 displacement. John L., aged fifteen years, while crossing a yard a 
 few days previously, carrying a bundle, was pushed ; the bundle fell, 
 but he saved himself from falling by resting his hands on it. AVhile 
 thus leaning forwards a second push was received, and he came to 
 the ground seated, supporting his weight by his hands. His hip 
 came but lightly, if at all, in contact with the ground. 
 
 On examination there was one inch shortening and eversion of 
 the foot, so that its outer margin was at an angle of twenty degrees 
 with the bed. Knee and back in contact with bed. Fascia lata 
 relaxed. Great trochanter higher, more prominent, and nearer 
 anterior superior spine than on the opposite side. No spasm of 
 muscles of hip. Buttock flattened, gluteo-femoral fold not well 
 marked. 
 
 Under chloroform the limb could be as readily and fully rotated as 
 its fellow, the trochanter describing a large arc of a small circle, or, in 
 other words, rotating on its own centre, and not increasing its 
 distance from the median line of the body. On extension the limb 
 readily acquired its full length, and all deformity disappeared ; both 
 shortening and prominence of the trochanter immediately re-appeared 
 
640 EPIPHYSES OF LOAVEK EXTEEMITY 
 
 on relaxing extension. Crepitation as of large surfaces of denuded bone 
 was felt. By placing the patient on his side the knee of the injured 
 side could be made to pass three inches further posteriorly than its 
 fellow. The boy had slightly limped for some weeks before the 
 accident, and had had pain on the inner side of the knee, but was 
 able to work and play football, even kick the ball with his leg. 
 
 Sandbags with extension were applied for five weeks, when 
 there was less than half an inch shortening. 
 
 In taking the distance of the great trochanter from the middle 
 line, Barton recommends the patient to be placed on the back with 
 a book against each trochanter ; the legs to be then rotated, and 
 the distance measured of the book from the middle line. 
 
 An interesting case of unusual displacement has been recorded 
 by Mr. Maunder {Lancet, 1870, vol. i. p. 19-2). A lad, aged 
 fourteen, received a blow upon the front of his thigh, and fell upon 
 his hip. He walked home, some hundred yards, leaning on the 
 shoulder of a comrade. On examination the limb was much 
 rotated outwards and shortened to the extent of from half to three- 
 quarters of an inch, but it had not the thoroughly helpless appearance 
 of fractured neck of femur. Manipulation of the upper part of the 
 limb caused great pain. There was a firm resisting bony swelling 
 in the groin, under the line of the rectus muscle, which moved with 
 the thigh and seemed to increase the antero-posterior width of the 
 upper end of this bone. The patient could rotate the limb very slightly 
 inwards. The following day, neither swelling nor ecchymosis exist- 
 ing, chloroform was administered, and the limb drawn down to its 
 normal length. A soft crepitus was felt about the head of the bone. 
 Mr. Hutchinson, who saw the case, also regarded it as one of 
 epiphysial separation, notwithstanding the boy could flex the thigh 
 slightly on the pelvis. 
 
 At the Clinical Society, on February 26, 1892 {Clinical Society's 
 Transactions, vol. xxv. 1892, p. 288), Mr. Davies-Colley showed the 
 following interesting case, which will be given in his own words : 
 ' E. C, set. fifteen, while playing at football about the end of November 
 1891, fell with another boy on the top of him, and hurt his left hip. 
 He was able to walk home, and there he remained almost entirely 
 in bed for a fortnight, but occasionally he got up and hobbled about 
 in much pain. At the end of that time he was admitted under my 
 care into Guy's Hospital. There was pain and tenderness about 
 the hip, and some fulness of Scarpa's triangle with slight eversion 
 of the foot. The most remarkable symptom was great prominence 
 of the trochanter major, which was of natural shape and hardly at 
 all tender. This prominence at once suggested dislocation of the 
 hip, but the head of the femur could not be felt in any abnormal 
 position. At first no shortening was detected. There was no 
 active movement of the hip, but passive movement, though painful, 
 was almost complete. The next day, December 10, I examined 
 
SEPAEATION OF EPIPHYSIAL HEAD OF FEMUE G41 
 
 him under ether. A rubbing sensation, or very slight crepitus, 
 could be felt when the thigh was rotated outwards. There was 
 some limitation to the movement of abduction, while adduction 
 and the other movements of the hip were free. I made a careful 
 measurement, and found that the injured limb was a quarter of an 
 inch shorter than the other. The injury was unlike a fracture of 
 the cervix on account of the prominence of the great trochanter. 
 Moreover, if, as is usual in so young a patient, the fracture had 
 been extracapsular, I should have expected to find the great tro- 
 chanter altered in shape and very tender. 
 
 ' The diagnosis of dislocation was excluded by the fact that the 
 head seemed to be in the acetabulum. I could find no other 
 explanation of the symptoms than that a separation of the epiphysis 
 of the head had occurred, and that the upper surface of the shaft 
 had ghded upwards and outwards upon the obliquely placed plane of 
 the epiphysial line, so as to produce a slight shortening, together 
 with the marked projection of the great trochanter. Probably some 
 fibres of the periosteum had remained untorn, so as to prevent the 
 two surfaces from becoming completely free of one another. This 
 would also account for the fact that the boy had been able to walk 
 about a little. The rubbing sensation felt when the limb was 
 moved about under ether was also confirmatory of the diagnosis of 
 separated epiphysis. 
 
 ' The subsequent progress of the patient was satisfactory. He 
 was kept in bed about four weeks with a long outside splint and 
 perineal bandage on, and two weeks afterwards he went out nearly 
 well. The shortening had increased to half an inch. When shown 
 at the meeting he could move his leg about as freely as the other. 
 There was no pain, but the great trochanter was as prominent as 
 ever, and distinctly nearer to the crest of the ilium than upon the 
 uninjured side.' 
 
 The amount of displacement at first present in separation of the 
 femoral head, as in other epiphysial separations, will be found in 
 great measure to vary with the violence which has been applied to the 
 hip. Yet the diaphysis is very prone to even great displacement if 
 the lesion be undetected and the patient be allowed the use of 
 the limb. 
 
 The relaxed condition of the fascia lata between the crest of the 
 ilium and the great trochanter, and of the ilio-tibial band on the 
 injured side, to which Dr. Allis has drawn particular attention in 
 the case of adults, may assist in young muscular subjects in forming 
 a diagnosis. 
 
 Active movement of the lower extremity is almost entirely absent 
 where the fragments are separated to any extent. 
 
 In others, where the head is still held to the neck by the tough 
 fibrous periosteum and but little displacement has taken place, a con- 
 siderable amount of active movement may still be retained, and 
 
 T T 
 
G4'2 EPIPHYSES OF I^OWEK EXTEEMITY 
 
 mislead the surgeon into the supposition that no serious lesion has 
 occurred. 
 
 Inahility to move the limh or hear the least iveight on it may bo 
 present, but on the other hand it has been found that the limb can 
 sometimes be slightly moved, for the patient can raise the limb 
 somewhat, flex the thigh, or even rotate it inwards to some extent, 
 though with a little pain. 
 
 Pain more or less severe in character is experienced at the time 
 of the accident. The subsequent pain is often no more than in 
 cases of a severe sprain to the hip-joint. 
 
 When the patient is resting in bed but little pain or tenderness 
 is felt at the hip, and it is only when pressure is made and the limb 
 is rotated or moved during manipulation that it becomes noticeable, 
 but even then it may be almost entirely absent. Dr. R. H. Harte is 
 of opinion that, as a rule, the pain is distinctly less than in fracture, 
 when two bony surfaces are drawn past each other, as in the attempt 
 to elicit crepitus. 
 
 Abnormal mobility of the great trochanter, in describing a smaller 
 circle, although a larger segment than on the sound side, is not such 
 a trustworthy sign as in fracture of the neck, and has only been 
 noticed in a few instances. This may be accounted for by the fact 
 of the neck still being attached to the shaft of the femur. Dr. Harte 
 Gays that the movements of the hip-joint in which the ligamentum 
 teres is made tense — e.g. external rotation and adduction: — are exag- 
 gerated. 
 
 In all cases of recent injury the use of an anesthetic is necessary 
 to establish the diagnosis accurately. 
 
 DIFFEEENTIAL DIAGNOSIS.— As Hutchinson says : ' We may 
 probably venture to assume that of the three accidents, fracture of 
 the neck, dislocation, and separation of the neck from the head at 
 the acetabular edge, the latter is by far the most likely injury to 
 occur in young persons.' 
 
 But it is quite impracticable to agree with him that it would be 
 next to impossible to establish a diagnosis during the patient's life, 
 and that fractures of the neck as distinct from detachments of the 
 head are perhaps unknown, or that not improbably all cases in which 
 they have been suspected were really examples of the latter. 
 
 Dislocation. — Bognetta states that Ambrose Pare and J. L. Petit 
 both mistook a separation of this epiphysis for dislocation, and E. de 
 Hilden one for a fracture of the neck. 
 
 E. Spillmann also mentions that Verduc was once called in 
 consultation by J. L. Petit for an injury to the hip which was 
 mistaken for a dislocation, but which was afterwards recognised as 
 a separation of the femoral epiphysis {Dictionnaire Encydopediqiie, 
 art. ' Cuisse,' p. 238). 
 
 Although infrequent in an extreme degree, many cases of dislo- 
 cation in 5^oung children from a few months to seven or eight 3'ears 
 
SEPAEATION OF EPIPHYSIAL HEAD OF FEMUE G48 
 
 of age have now been recorded — the majority on to the dorsum ihi — 
 the almost constant and well-marked inversion and fixation of the 
 limb being sufficient to distinguish thein — and a few into the thyroid 
 foramen, giving rise to apparent lengthening of the limb. It must. 
 be remembered, however, that in a few rare examples of separation 
 inversion of the limb occurs, and the injury will then simulate dis- 
 location more closely. 
 
 In all dislocations the head of the femur may be felt in its 
 abnormal position, whereas in separation it appears still to occupy 
 the acetabular cavitj' ; in the latter case, also, the end of the bone is 
 found very difficult to retain in position after reduction. It usually 
 slips out again immediately. 
 
 Sir Astley Cooper has recorded a case of dislocation of the femur 
 upwards on to the dorsum ilii in a girl aged seven years, and Mr. 
 Arnallt Jones, of Aberavon, mentions {British Medical Journal, 
 May 31, 1890) a typical case of this dislocation on to the dorsum 
 ilii ; the thigh was flexed and the limb adducted^ and rotated 
 inwards, and there was shortening to the extent of an inch and a 
 half. See also recent examples in British Medical Journal, March 28, 
 1896 (in a boy aged four years). Lancet, October 12, November 2 
 (in a child of six), November 9, 1889 (in a child of seven and a half), 
 and others. 
 
 Fracture of the neck. — The signs that will assist in distinguishing 
 complete separations with displacement from fracture of the neck 
 are the age of the patient and the absence of bony crepitus. How- 
 ever, it must be remembered that, as Mr. Morris has pointed out 
 {loc. cit. sujrra), true fracture may occur before the epiphysis has 
 united. Still, it becomes extremely improbable in the younger 
 periods of age, when separation is frequently met with, no doubt 
 from the short and undeveloped condition of the neck of the bone. 
 From the reported cases it would seem that the violence causing 
 the separation is much greater, as a rule, than that producing frac- 
 ture of the neck of the bone. 
 
 The signs are similar in both — viz. cversion, usually slight 
 shortening, pain, and inability to raise the limb, and swelling about 
 the trochanter — except that in fracture the crepitus is more distinct 
 and rough, while in epiphysial separation it is more indistinct, 
 iTLuffied, and soft. 
 
 Besides the cases of fracture of the neck of the femur in children 
 mentioned above as verified by direct examination, Stanley describes 
 {Med. Chir. Trans, vol. xvih. 18B3, p. 256) the case of a lad, aged 
 eighteen years, who fell from the top of a loaded cart upon his right 
 hip. He was unable to move the limb ; it was bent to a right angle 
 with the pelvis, could not be extended, and abduction was difficult ; 
 an attempt at passive motion caused pain. There was eversion, but 
 no shortening or crepitus. He died three moiiths afterwards of 
 sinall pox. The capsule was a little thickened, the ligamentum teres 
 
G44 EPIPHYSES OF LOAYEE EXTREMITY 
 
 uninjured ; a line of fracture extended obliquely through the neck 
 entirely within the capsule ; the neck was shortened, and its head 
 approximated to the trochanter. The fractured surfaces w^ere in the 
 closest apposition, and united nearly in their whole extent by bone. 
 There was an irregular deposit of bone beneath the periosteum and the 
 synovial membrane along the line of the fracture. Stanley believed 
 that this was the only recorded case of this injury. 
 
 John Johnson relates {Neiv York Journal of Medicine, 1857, 
 p. 303) an instance of an intracapsular fracture. The patient was a 
 young lady, aged sixteen years, who had been caught between the 
 wheels of two carriages. Her symptoms showed conclusively that 
 there was a fracture ; crepitus was well marked. The fracture failed 
 to unite, and at her death, three years later, of an acute disease, the 
 head and neck w^ere found very soft and partly absorbed. The head 
 was soft and spongy. The fracture was transverse at the junction 
 of the head and neck. 
 
 The following remarkable instance of fracture of the neck of the 
 thigh bone was placed under the author's care at the Miller Hospital, 
 through the courtesy of Dr. John Mackern, of Blackheath, in 
 December 1897. The lad (A. J. B.), aged twenty-one, had, ten months 
 previously, fallen off a ladder to the ground, a distance of eight or nine 
 feet, on to his right side. Ki the time of the accident the pain in the 
 hip was rather severe and he felt ' shaken,' but after a few minutes 
 both these symptoms passed off and he could walk without lameness. 
 Xo treatment was employed. Four months later the patient noticed 
 that ' the side of his hip was growing out,' and he began to limp. 
 The limb appeared to be getting short and continued so up to the 
 time of admission, while pain was only experienced on a sudden jerk 
 to the limb or after walking five or six miles. On examination there 
 was lameness in walking, and the right limb was greatly everted, 
 and adducted so that the knee was placed in front of the opposite 
 limb when the pelvis was straightened. There consequently existed 
 very considerable apparent shortening and tilting of the pelvis, and 
 compensatory bending of the vertebral column (see fig. 196) when the 
 lad placed both feet on the ground. Eeal shortening of the limb 
 scarcely amounted to one-eighth of an inch. The great trochanter 
 was very prominent, and projected further backwards than on the left 
 side, but was not placed above Nelaton's line. The hip joint was 
 almost completely fixed, the slightest flexion being the only move- 
 ment permitted. The adductors of the thigh were tense and con- 
 tracted. In front of the hip-joint an irregular mass of osteophj^tic 
 growth could be felt ; this fact, taken in connection with the signs 
 just enumerated, determined the diagnosis of detachment of the head 
 of the femur from gradual displacement at the neck of the bone the 
 result of the injury. Several skiagraphs were now taken, which con- 
 firmed absolutely the diagnosis, and an operation upon the neck of 
 the femur was undertaken to remedy the crippling condition. Under 
 

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SEPAKATION OF EPIPHYSIAL HEAD OF FEMUK 645 
 
 chloroform the adductor tendons were first divided, and the joint 
 forcibly moved in all directions ; but although flexion and extension 
 were carried out almost to their furthest limit the eversion was in no 
 way lessened. An anterior incision was therefore made, the distended 
 joint incised, letting out about two ounces of dark bloody fluid. The 
 neck of the bone was divided, and the head of the femur removed 
 from the cotyloid cavity. The end of the neck was replaced in 
 position. The ligamentum teres was found to be ruptured, the head 
 
 Fig. 196.— fracture of neck of femur close to epiphysial junction of head, 
 great eversion and adduction of lijib 
 
 becoming atrophied with its articular cartilage in a shrunken and 
 crumpled condition. The fracture had been firmly united, though 
 the end of the diaphysial fragment projected forwards into the 
 osteophytic mass, probably the result of the atrophied and rotated 
 condition of the epiphysis. On section of the portion removed the 
 neck of the femur was found to have been divided nearly three- 
 quarters of an inch from the remains of the conjugal line of cartilage, 
 traces of which were still visible, the cancellous tissue of the 
 ■epiphysis becoming rarefied. The patient was making an unmter- 
 
646 EPIPHYSES OF LOWEK EXTKEMITY 
 
 rupted recovery with the hiiib in good position at the time of this 
 report. 
 
 Prof. Jeannel {Archives Medicales cle Toulouse, 1"' Juin 1897, 
 p. 236) relates the case of a young soldier, aged 2'2, who had fallen 
 from a height of about eight metres. The patient did not know 
 upon what part of his body he had fallen, but the injury was regarded 
 at first as a contusion of the left hip. Ten months later he came 
 under Dr. Jeannel's care, who found the limb wasted, the thigh 
 slightly flexed and rotated outwards, but without abduction or adduc- 
 tion. The limb was also shortened three and a half centimetres, 
 and the great trochanter above Nelaton's Ime. In spite of the 
 external rotation, a diagnosis of irreducible iliac dislocation of an 
 excspfcional character was determined upon, and reduction attempted 
 under chloroform. This having failed, a posterior incision was made, 
 the detached head of the femur removed from the acetabulum, and 
 the neck placed in the cavity. The result was perfect, the patient 
 walking with scarcely a limp. 
 
 A case, probably of the same nature, is reported by Mr. Adams 
 (Med. Times and Gazette, vol. i. 1859, p. 137) of a sailor aged seven- 
 teen. He had just before fallen into the hold of a ship, a distance 
 of about sixteen feet. He did not know on what precise part he 
 had been struck. He was unable to raise the right leg, and had pain 
 in the hip. There was one inch shortening, eversion of the foot, 
 and crepitus was distinctly felt on the great trochanter. An ordinary 
 straight thigh splint was applied, but owing to the restless condition 
 of the patient it had to be frequently re-applied. At the end of six 
 weeks the fracture was found to be ununited, the splint was re- 
 applied, and firm union eventually took place after some months. 
 It was thought at the time that separation had occurred at the epi- 
 physis, where it was not wholly cartilaginous, but contained some 
 bony spiculge. 
 
 Dr. Eoyal "Whitman records {New York Medical Becord, 
 February 7, 1891, p. 165) a case of fracture of the neck of the 
 femur, probably impacted, in a boy, aged eight, who had fallen 
 eighteen feet. The symptoms upon which the diagnosis was made, 
 six months after the injury, were half an inch shortening, elevation 
 of the trochanter and its approximation to the middle line, while the 
 movements of the joint were free, painless, and practically unimpaired. 
 
 Whitman thinks that under normal conditions the epiphysial 
 junction of the head of the femur is not a weak point in the con- 
 tinuity of the bone ; that, as a result of violence, fracture may occur 
 above, below, and through the line of cartilage, and says {Netv York 
 Medical Becord, February 25, 1893, p. 230) : ' Such fractures or 
 displacements are of especial importance, because of the vicinity of 
 the joint, because of the difficulty in keeping the fragments in 
 apposition, and because cessation or diminution of growth or non- 
 union may result.' 
 
S-EPAEATION OF EPirilYSIAL HEAD OF FEMUE 647 
 
 The same surgeon read a paper before the New ITork Academy of 
 Medicine in December 1892 {Neiu York Medical Record, January 14, 
 1893, p. 59) on ' Observations on Fractures of the Neck of the 
 Femur in Childhood, with especial reference to Treatment and 
 Differential Diagnosis from Separation of the Epiphysis.' The 
 number of patients shown in illustration of fracture of the neck of 
 the femur in childhood was five, all of whom had been brought to 
 the Hospital for the Euptured and Crippled with a different diagnosis, 
 usually that of hip-joint disease. He had seen none of the cases 
 during the earlier stage, or not until the fourth week to the sixth 
 month. Most of the children had fallen a distance of fourteen feet 
 or more. In all the cases there was perfect or nearly perfect 
 motion of the limb. The degree of shortening was usually from 
 
 II 
 
 III 
 
 IV 
 
 Fig. 197 diagrams of injuries to the neck of the femur (royal whitman) 
 
 I. The upper extremity of the femur, at the age of five years, drawn from a specimen 
 
 in the Museum of the Hospital for Ruptured and Crippled, showing the epiphysis 
 of the head and trochanter and the relation of the trochanter to Nelaton's line, N. 
 The shaded area in the head and trochanter represents the cartilages. 
 
 II. A diagram to illustrate epiphysial disjunction, showing the separation of fragments 
 
 necessary to account for upward displacement of the trochanter to the extent of 
 three-fourths of an inch. 
 
 III. A diagram to illustrate fracture and depression of the neck of the femur and con- 
 sequent elevation of the trochanter, also the limitation of the range of abduction 
 of the limb that must result. 
 
 IV. A diagram to illustrate further depression of the neck and its effect in causing 
 permanent abduction of the thigh. 
 
 three-fourths of an inch to one inch. There was in all an elevation 
 of the trochanter which constituted a projection ; in walking there 
 was a dragging of the foot and eversion. The pain in most of the 
 cases had disappeared. From the return of mobility in all direc- 
 tions, there could be no doubt but that the head of the femur rested 
 in the acetabulum ; there must have been a fracture between the 
 head and the neck which changed the angle from an obtuse to 
 almost a right angle. It was this alteration which caused the 
 projection of the trochanter and the immediate shortening of the 
 limb. The shortening had increased subsequently. 
 
 Dr. Whitman said that this accident in childhood had not been 
 admitted as true heretofore. He did not deny that separation of 
 the epiphysis m.ight take place, but insisted that such was not the case 
 
648 EPIPHYSES OE LOWEK EXTKEMITY 
 
 in the patients presented, and expressed the behef that fracture was 
 by far the more common accident in early life. The treatment 
 employed by him consisted in obtaining immobility by the modified 
 double Thomas splint. 
 
 Dr. Whitman {Annals of Surgery, June 1897, p. 673) has 
 recently made some further observations on this fracture in child- 
 hood, and added five more cases. He also presents two skiagraphs 
 showing the consequent deformity of the bone at the seat of injury, 
 and he draws especial attention to this peculiarity — viz. that 
 although the immediate results are extremely favourable even 
 without treatment, yet the final outcome is likely to be a disability 
 even more noticeable than after fracture in adult life. He also 
 holds that it would be rather extreme violence followed by non- 
 union of the fragments and subsequent disability that would favour 
 th3 diagnosis of separation of the epiphysis. The less the violence 
 and the less the immediate disability, the greater would be the 
 probability of fracture when signs of fracture are present. 
 
 Mr. W. H. Battle, in a short paper on ' Traumatic Separation of 
 the Upper End of the Eemur in Early Life ' {St. Thomas's Hospital 
 Beports, N.s. vol. xxii. 1894, p. 19), has found four cases of intra- 
 capsular fracture of the neck of the bone, below twenty years of age, 
 from an analysis of the statistical reports of this hospital for ten 
 years — viz. 1881 to 1890 inclusive — three males, aged seven, eight, 
 and fifteen, and one female aged thirteen years, out of a total of 
 106 fractures of the neck. One, in the girl aged thirteen, was 
 probably an intracapsular fracture, for the crepitus was rather more 
 distinct than would be expected after epiphysial separation. Another, 
 in the boy aged fifteen, was an example of separation the result of 
 disease of the hip. The other two, aged eight and seven respectively, 
 were epiphysial detachments. 
 
 Hip disease. — If a diagnosis has not been made at the time of the 
 accident, it is easy to understand how, at a later period during the 
 stage of recovery, it may be mistaken for hip disease. The subse- 
 quent halting walk of the patient, the pain and restricted move- 
 ments of the hip-joint, the shortening and deformity of the limb, 
 the pain in the knee (occasionally present) may be erroneously 
 interpreted as symptoms of disease. The differences between the 
 two are, however, well marked. The history of more or less severe 
 injury, innnediately followed by severe signs, is unlike the insidious 
 nature of tuberculous disease following slight injury. The amount 
 of deformity, also, caused by the former injury would, if it were the 
 result of disease, be due to great disorganisation of the joint, and 
 would be necessarily accompanied by other local phenomena of 
 disease. 
 
 Pv.. W. Parker (Heath's Diet, of Practical Surgery, vol. ii. 1887, 
 p. 414) says that he has seen a case which simulated hip-joint 
 disease. 
 
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SEPAKATION OF EPIPHYSIAL HEAD OF FEMUE G49 
 
 In the International Clinics (4tli series, vol. ii. p. 187) Dr. K. H. 
 Sayre alludes to a case of diastasis of the left femur in a girl, and 
 contrasts the manner of walking after union with that met with in 
 hip disease, with which it might be confounded. 
 
 Congenital dislocation of the hip may be at once excluded by the 
 absence of history of injury, its chronic and painless condition, and 
 by the fact of the femoral head being felt in the gluteal region. 
 
 Simple contusion of the hip. — In contusion the normal relations 
 between the anterior superior spine and great trochanter are 
 preserved. 
 
 The shortening of the neck or of the limb, though often small 
 in amount in epiphysial separation with displacement, apart from 
 other signs, should at once remove all doubt as to its correct nature. 
 
 Incomplete separations without displacement the author believes to 
 be far from uncommon. Unfortunately, a conjecture is all that can 
 be made from the age, pain in the region of the head of the bone, 
 and the history of injury, which may be slight. A much smaller 
 amount of violence is required in these than in complete separations — 
 e.g. a slight over-extension of the joint. 
 
 PROGNOSIS. — It is probable that good bony union will usually 
 result, provided the limb be brought down and maintained in good 
 position. 
 
 The ultimate result is also often good, although the union may 
 only be a fibrous one. 
 
 In Mr. Davies-Colley's case of traumatic separation of this epi- 
 physis repair had taken place, leaving considerable range of move- 
 ment, but with marked projection of the great trochanter. 
 
 A similar good result, both as regards union and function of the 
 limb, is recorded by Mr. A. E. Maylard {British Medical Journal, 
 April 2, 1892, p. 709) in the following case under his care at the 
 Victoria Infirmary at Glasgow. 
 
 'A boy, aged seventeen, was admitted on November 15, 1891. 
 He had stumbled over a plank and fallen into a pit about eighteen 
 feet deep. He had no power to raise the left leg from the bed ; the 
 foot was everted and there was slight shortening. On measuring 
 from the anterior superior spine of the ilium to the great trochanter, 
 the distance on the left side was increased by one inch. The left 
 trochanter was, in appearance, more prominent than the right, and 
 was on a higher level. Passive movement of the limb caused a 
 corresponding movement of the trochanter, accompanied with the 
 sensation of "cartilaginous" crepitus at the seat of fracture. He 
 suffered very little pain. After about two months' residence in the 
 infirmary he left, with neither appreciable shortening of the limb, 
 nor impairment of its function.' 
 
 In the two cases mentioned by Mr. Hutchinson {Med. Times 
 and Gazette, vol. i. 1859, p. 162) undoubted true bony union occurred, 
 although in one there was some doubt as to its being a real fracture 
 
650 EPIPHYSES OF LOAVEE EXTEEMITY 
 
 of the neck of the femur ; he also thmks that this tends to support 
 the opinion that among the most eihcient factors in non-union after 
 fracture of the neck of the thigh bone in elderly persons is the age of 
 the patient. Writing in 1866 {Med. Times and Gazette, February 24, 
 1866, page 195) he said he had seen two cases under the care of other 
 surgeons in which this accident was diagnosed. In each the patient 
 was between seventeen and twenty. In one union was delayed for 
 several months, but in both it was event aally completed. 
 
 Dr. E. H. Bradford, of Boston, U.S.A., records {loc. cit. supra) the 
 result in two cases which had been diagnosed as epiphysial separation. 
 
 Case I. A healthy boy, sixteen j^ears of age, reported himself 
 for examination with the follo^-ing history : He had been perfectly 
 well, and had not been lame. On attempting to milk a cow, seated 
 on an ordinary milking-stool, he was kicked at by the cow and 
 turned quickly to avoid a blow, suffering a sensation of sudden pain. 
 Immediately after this he was unable to step and was taken to the 
 house, being obliged to remain in bed several weeks. 
 
 He was etherised, and the limb, which was flexed, painful, and 
 useless, was put into position, and made a recovery, but he was 
 able to walk about only with crutches for some time. At the time 
 of examination, three months later, he walked with crutches and 
 could do so without them, but with marked lameness. He suffered 
 no pain. An examination showed that the affected limb was shorter 
 by an inch than the fellow. The trochanter was above the Xelaton 
 line to that extent. The motions at the hip-joint were perfectly 
 free, with the exception of inversion, which was not possible beyond 
 the rififht an^le. It was entirelv free on the other side. 
 
 Case II. A child, seven years old, of fairly good health, sustained 
 a fall from the window in the first story. The patient was taken 
 up, placed in bed, and complained of great pain ; but no injury of 
 the limb was determined at the time. The child was of a nervous 
 type, and it was thought that her sA'inptonis were due to fright 
 rather than to any injury to the bone. She remained in bed for 
 several weeks, finally was able to get up, and after a while to walk, 
 though she still limped. Upon examination, four months after the 
 accident, it was found that the head of the trochanter was half an 
 inch higher on the right, the affected side, than normal. The head 
 of the trochanter v\'as also placed more posteriorly than is normal, 
 and the foot was everted. The motions at the hip-joint were free, 
 with the exception of the inversion, which was not possible beyond 
 the vertical. The patient was free from pain and able to walk. A 
 rotation of the thorax had taken place in the four months, and the 
 ribs on the right side projected. 
 
 Where no treatment has been adopted, the limb has been found 
 permanently shortened and everted, but the patient had more or less 
 complete use of it ; this was the condition in Mr. Eobson's case Ooc. 
 cit. su2V'a). In this connection Dr. E. H. Bradford mentions two 
 
SEPAEATION OF EPIPHYSIAL HEAD OF FEMUE 651 
 
 cases of deformity after separation of the epiphysis of the head of 
 the femur which were brought to the Children's Hospital, Boston, 
 U.S.A. {Medical and Surgical Beport of the Children's Hospital, 
 1869-94, Boston, U.S.A., 1895, p. 292), with a history of a fall| 
 followed by severe pain for three or four weeks, and lameness sub- 
 sequent to this. In neither of the cases had the lesion been 
 recognised. In one there was shortening of an inch, in the other 
 of half an inch. In one there was marked inversion (? eversion) ; 
 in the other there was but little. In the first, a girl of twelve, 
 osteotomy of the neck of the femur was performed, and the limb 
 brought into a normal position and treated by traction for several 
 weeks. The result was satisfactory, but the shortening of an inch 
 was not entirely overcome. Perfect motion at the joint was re- 
 established six months after the o])eration. The eversion of the foot, 
 which constituted a disfiguring deformity, was entirely corrected. 
 
 In the second case, a boy of four, there was no noticeable eversion, 
 and no operation was attempted. 
 
 Dr. R. H. Harte (Trans. Amer. Surg. Association, vol. xv. 1897, 
 p. 222) reports the following example of epiphysial separation of the 
 head of the femur, in which the recent condition after injury is 
 described as well as the appearance of the limb four months later. 
 There was about one inch of shortening. 
 
 R. C, aged fifteen j'ears, of fair physical development but of 
 impaired mental condition, was admitted to the Episcopal Hospital 
 on December 28, 1896, several days after the injury. He had 
 slipped on the ice when walking, striking his hip, and was carried 
 home, being unable to walk. On admission there was inability to 
 stand or bear weight on the injured limb, and some tenderness over 
 the hip. In the dorsal position with the legs together and moderate 
 extension, the shortening disappeared so completely that at first Dr. 
 Harte was disposed to consider it simply as a contusion of the hip ; 
 moreover, all movements could be perfonned almost vrithout pain, 
 and with little restriction of motion. On the following day there 
 was again marked deformity, with about one inch shortening, and 
 some prominence of the trochanter ; there was no eversion of the 
 foot, although this could be effected with pressure on the inner side 
 of the foot. Inversion of the foot was equally carried out ; in fact, 
 under ether all the normal movements of the joint could be exagge- 
 rated. The trochanter could be rotated more than on the uninjured 
 side, but without any apparent diminution in its arc. No distinct 
 crepitus could be elicited, although seme slight rubbing sensation 
 was detected, as though two rough cartilaginous surfaces were brought 
 in contact. A skiagraph was taken with an indifferent result. The 
 patient was treated in bed with extension by means of weight and 
 sandbags for lateral support. The extension was removed on 
 February 9 with apparently good union, and measurements showed 
 no difference in the length of the limbs. The patient was soon 
 
652 EPIPHYSES OF LOWEE EXTEEMITY 
 
 permitted to leave his bed, but owing to his mental condition he 
 acquired the art of walking slowly, and left the hospital soon at the 
 request of his parents. On examination, four months after the 
 injury, there was a shght limp on walking and a shortening of about 
 one inch. The movements of the injured Hmb were sHghtly em- 
 barrassed, apparently unaccompanied with pain ; no eversion of 
 foot, although it could be everted beyond normal ; it could be equally 
 inverted ; the thigh could be flexed, without tilting the pelvis, to 
 about forty-five degrees, no roughening on moving the joint, the 
 articular functions being performed without friction ; fair abduction 
 without tilting of the pelvis, of about two and a half feet from the 
 median line ; the upper margin of the trochanter being slightly above 
 Nelaton's line, and the prominence of the trochanter being increased 
 aboiit three-quarters of an inch, with distinct depression behind it. 
 There w^as some flattening of the gluteal muscles and disappearance 
 of the rima-natium. The muscles of the injured limb were equally 
 nourished with the opposite side. Another attempt to skiagraph the 
 joint proved unsatisfactory. Dr. Harte also saw another example 
 under Dr. Barton at the Philadelphia Hospital in wiiich the most 
 pronounced remaining symptoms were the undue prominence of the 
 trochanter, with one and a half inches shortening, impairment of 
 motion, which appeared to be intensified by a number of osteophytes 
 or periosteal new growths round the joint, and a distinct limp on 
 walking. 
 
 Non-union. — The grave prognosis — the lameness and atrophy of 
 the hmb — which are said by so many of the older writers to be the 
 inevitable consequences of separation of this epiphysis, may be traced 
 to Van Swieten, who quotes Boerhaave as giving a grave prognosis 
 in this as in epiphysial separation in general. 
 
 Eeichel relates {loc. cit. supra) a case seen by Ludwig of a young 
 man, aged twenty, who had had from infancy a separation of the 
 femoral head. There was no union, and a false joint developed, 
 which allowed the man to turn the limb in all directions and to 
 carry his foot easily up to his head. The limb was twelve inches 
 shorter than the other. 
 
 Mayo Eobson's case also appears to be one of non-union. 
 Mr. Jonathan Hutchinson says : ' In the later stage of confirmed 
 non-union, which according to my experience is that which most 
 frequently comes under notice, the symptoms are those of un- 
 reduced dislocation upon the dorsum, but with very free mobility 
 and with inability to find the rounded head of the bone. The femur 
 can generally be rotated with unusual ease, and in some instances 
 pushed upwards and pulled downwards with considerable freedom.' 
 He then gives the following three cases (' On Detachment of the 
 Epiphysial Head of the Femur,' Archives of Surgery, vol. iii. No. 12, 
 April 1892) as examples of this condition of things, in conjunction 
 with a history entirely negative as regards disease. 
 
SEPAEATION OF EPIPHYSIAL HEAD OF FEMUE 653 
 
 The following note, he states, is only an unverified fragment, 
 but all that bears upon detachment of the upper epiphysis of the 
 femur is so valuable that he did not like to wholly neglect it. A 
 very intelligent man told him that one of his brothers had been 
 obliged all his life to wear a high-heeled boot because ' one hip had 
 been dislocated ' in a fall from his rocking-horse when a child. The 
 ' dislocation ' had not been recognised or reduced, and hence per- 
 manent shortening of the limb. The diagnosis of dislocation was 
 based upon opinions given by consultants long after the accident. 
 Looking at the age of the patient, and also at the fact that the early 
 diagnosis was missed, it is far more likely to have been a detached 
 epiphysis than a real dislocation. Mr. Hutchinson never saw the 
 patient. 
 
 His next case is a more detailed one. A little girl presented 
 conditions which were very suggestive of an ununited separation 
 of the epiphysis. She was four years of age, very active, said 
 to be always in motion, and never complaining of pain. She had 
 never been laid up by any illness. There was a history of two 
 accidents in infancy, one at the age of one month, and the other 
 at the age of six months ; but after neither of them had there been 
 any special treatment. Her condition when brought to Mr. Hutchin- 
 son was that the right limb was one inch shorter than the other, 
 the shortening being apparently at the hip. There was neither 
 inversion nor eversion, but the limb was simply shorter and too 
 movable at the hip. The great trochanter was much nearer the 
 crest ,of the ilium on that side than on the other ; and the distance 
 between these points could be considerably altered by pulling the 
 limb up and. down. Eversion and inversion were also much too 
 free. The examination did not cause the child the slightest pain. 
 A diagnosis of infantile paralysis had formerly been given by a 
 distinguished physician. Any indications in support of this opinion 
 could not, however, be found. The limb was well nourished, just 
 as useful as the other, and not liable to become cold. The two 
 calves were of the same girth ; nor was there any wasting to be 
 observed about the thigh or buttock. The diagnosis seemed to rest 
 between an ununited separation of the head and disease of the hip- 
 joint with absorption of the head of the bone ; or possibly a patho- 
 logical detachment of the epiphysis. With the exception of a rumour 
 that the child used at one time to complain of pain in the knee, 
 there was no history of any symptoms pointing to inflammation of 
 the joint. The child had never been laid up, nor had she ever worn 
 an apparatus. 
 
 The preceding case came under notice seven or eight years pre- 
 viously, and Mr. Hutchinson had recently seen its exact counter- 
 part. Indeed, he found it hard to believe that it was not the 
 same patient who was again brought to him, for it was the same 
 limb, and the advance in age fitted exactly. Miss G., a little slim 
 
654 epiphysp:s of lowee exteemity 
 
 active girl, aged twelve, was w^earing a boot with two inches of 
 additional heel, and her right limb measured exactly two inches 
 shorter than the other. Yet she could scarcely be considered la.me, 
 and he was told that she would run and play as freely as other girls. 
 There w^as no history of any disease. She had never had any 
 illness, and had never at any time complained of pain in the hip. 
 The monthly nurse, who was a careful person, observed nothing 
 peculiar in her limbs at birth. It was not until she was several 
 months old that it was discovered that there was something amiss 
 with her right hip, and in the interval (her mother having died) she 
 had been in the sole charge of a nurse girl, who had on one occasion, 
 it was rumoured, in a passion thrown the crying baby from one end 
 of the bed to the other. This was the only history of injmy which 
 could be obtained. From the time of the first discovery of defor- 
 mity to the present date, the shortening of the affected limb had 
 been steadily increasing, and it has been needful to make the heel 
 thicker and thicker. With the exception of this, there has been no in- 
 convenience. On examining the limb, its nutrition was perfect. There 
 was, as above stated, two inches of real shortening. The hip was very 
 obviously prominent, and the great trochanter was not more than 
 an inch and a half below the middle of the crest of the ilium. The 
 foot was usually pointed straight, but it could be inverted or everted 
 very easily. It was not easy to push the great trochanter upwards 
 or downwards, but its freedom of rotation was remarkable. The 
 buttock being very thin, it was quite easy to feel a prominence of 
 bone slanting obliquely upwards from the trochanter. This might 
 be the head or onl}' the decapitated neck of the bone. Mr. 
 Hutchinson was inclined to believe that it was the latter, for the 
 following reasons. Firstly, the rounded head could not be felt ; 
 secondly, it was shorter than usual in dislocations ; thirdly, it was 
 very freely movable ; and fourthly, it might be rotated to such an 
 extent that it could be felt now behind and now in front of the 
 shaft. It cannot be possible that this last-named alteration of 
 position could be effected in a case of dislocation of the entire bone. 
 These conditions made it, he thought, quite certain that in this case 
 the femur had lost its articular head. The diagnosis lay between a 
 detachment of the epiphysis by violence, a congenital dislocation of 
 a deformed bone, and absorption or detachment of the head by 
 disease. He inclined to the first-named. There was not a tittle of 
 evidence in f a,vour of disease ; nor, if the conditions were pathological, 
 could it be believed that the freedom of motion would be what it was. 
 The cases which he recorded in this paper clearly proved that 
 there are conditions occasionally met with which are most easily 
 explained on the supposition that the cartilaginous head of the bone 
 has been left in the acetabulum, wholly detached from the neck, as 
 the result of violence in very early infancy. They must not, he 
 says, l)e held to do more, liowever, than to establish a certain amount 
 
SEPARATION OF EPIPHYSIAL PIEAD OF FEMUE 655 
 
 of probability. That they constitute a very interesting group of 
 cases which has as yet received very httle attention wih be readily 
 admitted. 
 
 The views of the author on this subject of epiphysial separa- 
 tions of the upper femoral epiphysis in infants have already been 
 given. 
 
 Mr. D. Wallace, of Edinburgh (Lancet, August 20, 1892, p. 421), 
 gives the follov.'ing account of a case he saw in April 1892 which 
 was supposed to have been an old-standing dislocation of the hip- 
 joint. On examination he concluded that it was probably a diastasis 
 through the neck of the femur, not a dislocation. 
 
 M. B., aged eleven years, a girl of good build, tall and strong 
 for her age, was said by her mother to have been a well-nourished 
 child, who walked before she was nine months old. AVhen arrived 
 at this age she fell out of her cot, and the mother believes that 
 when falling the right foot caught between the bars, so that the leg 
 was severely twisted. The child cried, and refused to stand up or 
 allow the leg to be moved. There were pain and swelling in the 
 neighbourhood of the hip. Hot fomentations were applied during 
 the first few days, but in the course of two or three weeks (?) a 
 doctor was called in, who said the hip-joint was dislocated, and 
 attempted to reduce it, but failed to do so. Two or three years 
 later the child walked with a distinct halt, and the hip was prominent. 
 At this time the mother showed the girl to a 'bone-setter,' who 
 tried ' to put the bone in,' but also failed. The swelling and lame- 
 ness persisted until the time of examination, but the girl walked, 
 ran, and jumped usually without any pain, although after much 
 romping she now and then complained of pain at the hip. Xo other 
 injury had been sustained, and there was no historj^ of joint or chest 
 disease in the patient or in other members of the family. The 
 patient complained of no pain or discomfort, but said she was 
 lame and that the 'leg comes- out at the haunch.' She walked 
 with a distinct limp, and when she stood the right foot was observed 
 to be a little more everted than the left, while there were marked 
 drooping and rotation forwards of the right anterior superior iliac 
 spine. The right limb was evidently shorter than the left. 
 
 The measurements were : From anterior superior iliac spine to 
 internal malleolus : right, 27 inches ; left, 29| inches. From 
 anterior superior iliac spine to tip of patella : right, 14 inches ; left, 
 16 inches. From tip of trochanter major to external condyle : 
 right, 13f inches ; left, 14;^ inches. Xelaton's line on the right side 
 passed 1^ inches below the tip of the trochanter ; on the left side it 
 was normal. The right thigh could be flexed on the abdomen, but not 
 quite so fully as the left. Rotation of the right was gi'eater than the 
 left. Abduction was equal on the two sides. AVhen the right leg 
 was flexed on the thigh and the thigh on the abdomen the trochanter 
 major was felt as a distinct prominence midway between tlie anterior 
 
656 EPIPHYSES OE LOAVER EXTEEMITY 
 
 superior spine of the ilium and the ischial tuberosit}^ and moved 
 through a much wider radius than the left. No rounded prominence 
 corresponding to the head of the femur could be felt, but there was 
 a distinct mass of bone projecting internally to the trochanter, which 
 moved with the trochanter. When rotary movements were carried 
 out, a rough grating was felt deeply seated. The right leg was 
 thinner than the left, but was muscular and showed no sign of mal- 
 nutrition. 
 
 Erom a consideration of the above points in this case Mr. Wallace 
 concluded that it was a diastasis of the neck of the femur, because 
 of (1) a history of injury at an early age, but subsequent to the 
 child walking ; (2) no history or appearance of tuberculous disease ; 
 (3) marked displacement of the trochanter major upwards, associated 
 with very free movement and eversion of the foot ; and (4) a slight 
 degree of shortening of the femur. 
 
 The author cannot think that non-union is the rule after epi- 
 physial separation of the head of the bone, provided the lesion has 
 been diagnosed ; an examination of the result of cases in which a 
 diagnosis was made soon after the accident points in quite an 
 opposite direction — a firm and good union. 
 
 Xon-union occurs in exceptional cases where the displace- 
 ment of the neck is very great, and the periosteum of the neck 
 extensively lacerated ; such a condition must be quite excep- 
 tional, and associated with great violence and severe injury to 
 the soft parts. We must remember the great strength and tough- 
 ness of the periosteal covering of the femoral neck. 
 
 The cases which the author has quoted as described b}' Hutchinson, 
 Wallace, and others were, as these surgeons suggest, in all probabilit}' 
 separations of the head or of the cartilaginous upper end of the bone 
 in infancy, but it is most likely that there was but little displacement 
 at the time. Erom the fact of no immediate diagnosis being made 
 and from the fact that no treatment was adopted, the child being 
 allowed to move or walk about, it is more than probable that 
 displacement took place gradually, thereby effectually preventing any 
 union taking place between the diaphysis and the head of the bone. 
 In many of these instances the violence causing the injmy was 
 by no means severe. 
 
 Sayre, in addition to the case quoted above (loc. cif. sujjra) as 
 having a new acetabulum forimed, mentions another which was still 
 under his treatment. Both cases presented marked similarity in 
 history and symptoms. The injury occurred to each patient at the 
 age of two years, and when seen two years later the symptoms in 
 both instances were : flexion of the thigh to a right angle ; slight 
 adduction ; extreme rotation outwards ; almost complete fixation of 
 the limb in this position ; and, with these, the total absence of pain, 
 tenderness, suppuration, or interference with health, such as are 
 the usual evidences of carious disease of the articulation. The 
 
SEPAEATIOX OF EPIPHYSIAL HEAD OF FEMUK 657 
 
 treatment in both cases consisted in subcutaneous section of the 
 adductor longus, graciHs, and tensor vaginas femoris muscles ; re- 
 position of the Hmb in the extended state ; breaking up the 
 existing adhesions; and the subsequent employment of this author's 
 wire breeches and extension splint. 
 
 Higidity of joint and limb. — Subsequent mobility of the joint is 
 usually good. However, in some instances new periosteal deposit 
 or osteophytic processes round the neck of 
 the bone, especially in front, may greatly 
 hamper or even annihilate the function of 
 the hip-joint. 
 
 Suppuration may ens'ue from periostitis or 
 ostitis, or may be due simply to the injury 
 to the epiphysial cartilage line. 
 
 Hamilton quotes a case recorded by Dr. 
 Parker of New York {Amer. Med. Gazette, 
 November 30, 1850, vol. i. p. 342). A girl, 
 aged eighteen, had been injured by a fall 
 upon a curb-stone when eleven years old. 
 The accident was followed by suppuration and 
 a fistulous discharge, from which, however, 
 she finally recovered, but with the foot everted 
 and a shortening of one inch and a half. 
 ' Flexion and rotation of the joint occasioned 
 no inconvenience.' This latter circumstance 
 alone was thought sufficient to distinguish 
 it from hip disease, in which ankylosis is the 
 termination. 
 
 Suppuration and necrosis of any extensive 
 portion of the diaphysis are not, however, 
 common results of separation of this epi- 
 physis, judging by the recorded cases. 
 
 Acute hip disease, with rapid necrosis of 
 the head or some small part of the neck, is 
 more commonly the effect of epiphysial de- 
 tachment, mostly of the incomplete form, rather than the cause of 
 displacement at this epiphysis. 
 
 Death from pysemia may even result under certain circumstances. 
 
 Arrest of growth of the femur does not occur to any appreciable 
 extent after injury to this epiphysis, for very little of the growth of 
 the femur takes place at this end of the bone. 
 
 TREATMENT. Sepaeation without Displacement. — Any of 
 the forms of plastic splint about to be mentioned below should bo 
 carefully and firmly applied wherever a partial separation is 
 supposed to have occurred. Careful padding with cotton wool 
 should be used wherever necessary. In the milder forms of 
 separation without displacement a Thomas's hip splint may be 
 
 u u 
 
 Fig. 198. — thoiias's hip 
 splint, with beoad 
 pelvic band 
 
658 
 
 EPIPHYSES OF LOWER EXTREMITY 
 
 preferred with or without extension. A very guarded prognosis 
 should be given, on account of the possible subsequent affection of 
 the hip-joint. 
 
 Separation m^th Displacement. — In all cases of displacement 
 the end of the femur should be brought dow^n by gentle steady 
 traction into as accurate apposition with the head as possible. No 
 circumduction or severe manipulation is jDennissible, on account 
 of the risk of further stripping the periosteum from the neck 
 of the bone. The limb should be maintained in position by 
 
 means of an immovable ap- 
 paratus, with extension, for 
 three to four weeks. Bryant's 
 double outside splint with 
 interruptions and the long 
 thigh splint with perineal 
 band and extension are suit- 
 able, or a plaster- of-Paris 
 splint round the pelvis and 
 whole of thigh may be im- 
 mediately applied during 
 extension, under an anes- 
 thetic. At the end of the 
 month the pelvis and thigh 
 should be surrounded hj a 
 plaster-of-Paris, poroplastic, 
 starch, laminated plaster, or 
 Hide's splinting, and the 
 patient allowed to move 
 about . on crutches, or the 
 plaster-of-Paris splint may 
 be applied from the com- 
 mencement. Good union 
 may be anticipated in these 
 cases, but it is not so rapid 
 as in other separations on 
 account of the probable con- 
 tact of synovial secretion with the fractured surfaces. 
 
 ' Far more,' says Packard, ' may be expected from treatment, 
 in a lesion of this kind, than in the fractures which affect the 
 same region in advanced life. Such shortening as exists may be 
 corrected by extension with the weight and pulley, and the joint 
 may be immobilised by means of a well-applied plaster-of-Paris 
 bandage round the pelvis and thigh. This confinement may be con- 
 tinued, with sandbags on either side of the limb, and the extension 
 kept up, for two or three weeks in the case of a child ; a longer 
 confinement would be advantageous in patients beyond the age of 
 puberty. Cautious experiments should be made at first in allowing 
 
 inches. 
 
 Fig. 199. — pattern in house-flannel of 
 plaster-of-pakis splint foe hip, encircling 
 
 PELVIS AND LOWER EXTREMITY. 
 OF EIGHT TEARS 
 
 FOR A CHILD 
 
 Eeduced to one-eighth size on scale of inches 
 
SEPAEATION OF EPIPHYSIAL HEAD OF FEMUE 659 
 
 flexion of the hip-joint, but if they are productive of no pain or 
 irritation more and more freedom may be accorded to the patient 
 until he can move the Hmb without hindrance, after which, with 
 equal caution, he may be encouraged to put the foot to the ground 
 and bear his weight upon it.' 
 
 A number of years ago Packard had (Ashhurst, EncyclopcBdia of 
 Surgery, vol. iv. 1884, p. 198) a case which he believed was really a 
 separation of the epiphysis. A boy, nineteen years of age, by 
 a fall from a very high wagon-seat, had sustained a fracture of the 
 cervix femoris, the existence of which was verified under ether. He 
 was treated in the manner above mentioned, and in six weeks was 
 
 Fig. 200. — plastee-of-paris splint applied to eight hip, pelvis, 
 and lower extremity 
 
 3''*t'(l.n,|-^jj_: 
 
 Fig. 201. — plaster-of-paeis hip splint removed 
 
 driving his wagon again, with scarcely any perceptible lameness in 
 walking. 
 
 Passive flexion and massage should be carefully carried out at the 
 hip- joint and daily repeated more and more freely. It should be 
 commenced at the end of the third week, and at the beginning of the 
 fifth week the child will be able to bear some weight upon the leg. 
 
 Excision of the epiphysial head. — Should it be found impossible 
 to replace the diaphysis in its normal position after severe dis- 
 placements, excision of the detached head is to be recommended. 
 
 Notwithstanding that there is sufficient blood supply to the head 
 through the ligamentum teres and periosteum, much of whicli 
 remains attached to its circumference, to carry on its nutrition, 
 still the impossibility of union taking place between the widely 
 
 r u 2 
 
660 EPIPHYSES OF LOWEE EXTEEMITY 
 
 separated surfaces, and the possibility of great permanent deformity 
 from eversion and shortening of the hmb, render this advisable. 
 
 The same operation should be performed in older cases of 
 displacement where a new acetabulum has not yet formed, and 
 there is a hope of remedying deformity. The end of the bone will 
 in all probability make a very efficient head, as exemplified by 
 Professor Sayre's and Kocher's cases, quoted above. For this opera- 
 tion the anterior incision will be found preferable to the posterior. 
 
 Union of recent separations with displacement. — Fastening the 
 fragments together by means of a steel pin has also been recom- 
 mended. If attempted, the most rigid antiseptic and aseptic 
 precautions should be carried out, otherwise suppuration may 
 result as in the following case, recorded by C. A. Sturrock 
 {Edinburgh Hospital Beports, vol. ii. 1894, p. 604). A boy of four- 
 teen, when at play, fell and twisted his hip ; his leg was examined 
 shortly after the accident by several medical men, when the 
 following points were made out — the presence of pain, unusual 
 mobility, shortening, eversion of the leg, with absence of crepitus. 
 The displacement was easily reduced, but at once recurred when the 
 leg was let alone. The leg was subjected to prolonged and some- 
 what severe manipulations, and shortly afterwards the great tro- 
 chanter was cut down upon and a rigid pin passed through it, the 
 neck of the femur, and into the head. Unfortunately suppuration 
 occurred in the wound, and the pin had to be withdrawn in two 
 days. At the time of the report (1894) — i.e. some years after the 
 accident — the leg was shortened and the thigh flexed, the patien^ 
 walking w^th a marked limp. 
 
 Osteotomy for deformity. — When much deformity results from a 
 separation which has been long overlooked and has united in a faulty 
 position, osteotomy or some other operative measure is required to 
 bring the limb into its normal position. 
 
 Professor Hoffa, of Wiirzburg, has performed osteotomy through 
 the neck of the femur with success m these cases. In Dr. E. H. 
 Bradford's case of osteotomy of the neck of the femur the deformity 
 arising from the eversion of the foot was entirely corrected, but the 
 shortening of one inch was not entirely overcome, although traction 
 was continued for several weeks. The result, he states, was satis- 
 factory, perfect movement at the hip-joint being re-established six 
 months later. 
 
661 
 
 CHAPTEE III 
 
 Separation of the Epiphysis of the Great Trochanter — Separation of the 
 Epiphysis of the Lesser Trochanter — Separation of the Epiphysis of 
 THE Third Trochanter. 
 
 SEPARATION OP THE EPIPHYSIS OP THE GREAT 
 TROCHANTER 
 
 ANATOMY. — The cartilaginous mass of this epiphysis is separated 
 from that of the lesser trochanter during the second year, althougii 
 it is still blended with the head. 
 
 At the commencement of the fourth year, when it is almost 
 isolated from the head of the bone by the growth of the neck, its centre 
 of ossification appears. At an earlier date, however, during the first or 
 second year, its site is often indicated by the appearance of a few 
 bony granules. Two additional smaller centres are frequently met 
 with close together, the anterior of which forms the anterior tubercle 
 of the great trochanter ; these soon unite, and about the fifth or sixth 
 year join the main centre, which is placed more posteriorly. Up to the 
 seventeenth year some cartilage is still to be found capping this 
 epiphysis ; beyond this date to the time of its final union with the 
 diaphysis, from the eighteenth to nineteenth year, it is entirely 
 osseous. Union usually takes place first towards the digital fossa. 
 
 This epiphysis is separated by its thin cartilaginous layer from the 
 broad rough irregular surface on the upper end of the diaphysis ; on 
 the posterior aspect of the latter a distinct ledge is seen, which acts 
 as a kind of buttress for the epiphysis and prevents its displacement 
 in this direction. 
 
 Included in this epiphysis is the whole of the digital fossa with 
 the insertion of the obturator externus, together with nearly the 
 upper half of the posterior inter-trochanteric line. Above it slightly 
 overlaps the upper border of the neck and corresponds to the limit 
 of the capsule in this situation. Its lower border, joining the 
 diaphysis externally, marks the insertion of the tendinous fibres of 
 the vastus externus, and to its anterior, outer, and inner surfaces 
 and upper border the powerful gluteal and other muscles are 
 attached. 
 
662 
 
 EPIPHYSES OF LOWER EXTREMITY 
 
 The line of junction of the epiphysis of the great trochanter with 
 the shaft of the femur corresponds to the ' tubercle of the quadratus ' 
 (Thane) situated on the posterior border of the great trochanter. 
 
 The lower edge of the epiphysial line where it joins the outer 
 aspect of the diaphysis is 3 cm. 4 mm. below the upper margin of the 
 trochanter at the thirteenth year ; at the eighteenth year, 4 cm. 3 mm. 
 
 The antero-posterior width of the epiphysis at the thirteenth year 
 is 3 cm. 5 mm. ; at the eighteenth year, 4 cm. 2 mm. 
 
 Fig. 202. — anterior view of epiphy- 
 ses AT UPPER END OP FEMUR AT 
 ABOUT THE FIFTEENTH YEAR, (^-size) 
 
 Fig. 203. — vertical section of upper end 
 of femur at sixteen and a half years. 
 
 posterior half of section, showing CAN- 
 CELLOUS STRUCTURE OF THE EPIPHYSES 
 
 (f-size) 
 
 AGE. — From the anatomical condition of this epiphysis it would 
 appear likely that separation should be most frequent between the 
 thirteenth and eighteenth years. In seven out of ten recorded 
 examples it occurred between thirteen and sixteen years of age. Out 
 of twelve published cases the author has collected, ten were confirmed 
 after death ; of these the age is given in seven — viz. four at sixteen, 
 two at thirteen years, and one at eight years. Of those in which the 
 age is not stated with any accuracy, one occurred in a boy and two 
 were old separations ; in one of the latter the injury was supposed 
 to have taken place between four and eighteen years of age. In 
 two simple cases one occurred at thirteen years of age, and one in a 
 young man. 
 
 From the anatomical condition it cannot occur beyond the 
 eighteenth or nineteenth year. 
 
 ETIOLOGY. — It appears that this injury is almost always the 
 result of direct violence, such as a fall on the hip or severe blow on 
 
EPIPHYSIS OF GREAT TPOClIANTEP 663 
 
 the trochanter. In one or two the blow was not severe. Out of five 
 cases observed during life, four were from this cause. 
 
 In Hutchinson's case it was also due to direct violence, a fall 
 from a tree ; and in W. B. Savage's, of a little girl aged eight, it was 
 caused by her little brother jumping upon her, as she lay upon her 
 left side on a floor. 
 
 In Hilton's case the separation was produced by a kick from a 
 man. 
 
 Packard draws especial attention to this {International Encyclo- 
 pcedia, of Surgery, vol. iv. 1884, p. 199). 'The cause of fracture of 
 the great trochanter would seem to be invariably direct violence ; and 
 the majority of the subjects are distinctly stated to have been below 
 the age at which this epiphysis becomes united to the shaft. In such 
 cases it may reasonably be supposed that the separation takes place 
 through the cartilaginous uniting substance, but that, as in separations 
 of other epiphyses, it may in part run through true bone, detaching a 
 layer of it of very irregular size, shape, and thickness.' 
 
 Muscular action. — From the number of powerful muscles attached 
 to the epiphysis, it would appear at first sight that the action of these 
 alone will be quite sufficient to cause it. Philipp Ingrassias alluded 
 io a very doubtful case of separation of the great trochanter by 
 muscular violence. A young man, whilst fencing with a halberd, is 
 said to have torn off this process by a violent movement. This is 
 the earliest record of this injury, but its exact nature was not 
 proved by anatomical examination. 
 
 Dr. Eoddick thought that the detachment in his case was due to 
 muscular action, the boy being a very athletic subject. 
 
 PATHOLOGICAL ANATOMY. Pure separations.— A separation of 
 this epiphysis is a rare one, and usually not complicated by any 
 fracture of the neck of the bone. Some particles of the cancellous 
 tissue of the diaphysis may, however, cling to the surface of the 
 epiphysis. 
 
 The first authentic specimen on record is that of Mr. Aston Key's 
 case, reported by Sir Astley Cooper (Sir Astley Cooper's Fractures 
 and Dislocations, 6th edit. 1829, p. 166 ; Cyclopedia of Practical 
 Surgery, vol. ii., art. on ' Special Fractures,' p. 375). There was 
 no displacement of the epiphysis during life. A girl, about sixteen 
 years of age, in crossing the street tripped, and in falling struck her 
 trochanter violently against the curb-stone. She immediately rose, 
 and without much pain or difficulty walked home ; on the fifth day, 
 in consequence of the increase of pain on the inner side of the thigh, 
 she was admitted into Guy's Hospital in 1822. Her constitutional 
 symptoms being evidently more violent than those which usually 
 arose from fractured femur, she was placed under the care of the 
 physician. Dr. Bright, at whose request Mr. Key examined the limb. 
 The right leg, which was the one injured, w^as considerably everted 
 and appeared to be about half an inch longer than the sound limli. . 
 
664 EPIPHYSES OF LOWEE EXTEEMITY 
 
 It admitted of passive motion in all directions, but in abduction gave 
 her considerable pain. She had perfect command over all the 
 muscles except the rotators inwards. The fact that she had walked 
 both before and since her admission into the hospital gave rise to some 
 doubts as to the existence of a fracture, and the closest examination 
 of the trochanter and body of the femur could not detect the slightest 
 crepitus or displacement of bone. Mr. Key repeated the examination 
 of the limb on the following day, but the result was equally unsatis- 
 factory. She died nine days after the accident from irritative fever. 
 At the post-mortem examination, wishing to ascertain the exact 
 nature of the injury, Mr. Key previous to removing the soft parts 
 moved the limb in every direction, fixing the trochanter and head of 
 the bone, but could perceive no deviation from the normal condition, 
 nor was the slightest crepitus under all the variety of movements 
 distinguishable. There was no swelling of the thigh to be observed, 
 and therefore the trochanter and head of the femur were as readily 
 distinguished and examined as in a healthy limb. 
 
 A fracture was found which had detached the trochanter from 
 the body and neck of the bone, but without tearing through the 
 tendons attached to the outer side of the process. These so 
 effectually prevented all movement of the fractured portion that, 
 when they were dissected from the body, not the least motion could be 
 produced except in one direction, upwards and downwards. It was 
 the untorn condition of tendons which allowed this hinge-like 
 motion, and it was evident that such motion could not have been 
 produced by any direction given to the limb ; hence it is also m.anifest 
 that the fracture could not have been detected during the life of the 
 patient. 
 
 An abscess was also discovered in front near the pectineus, 
 extending downwards towards the lesser trochanter and backwards 
 behind the bone to the great trochanter. The specimen is in the 
 Guy's Hospital Museum, Prep. 1195. 
 
 The precise condition of this lesion has also been established 
 by several other post-mortem observations. The London Hospital 
 Museum, Prep. No. 424, contains the very interesting specimen 
 reported by Mr. McCarthy {Trans. Path. Soc. vol. xxv., 1874, p. 200 ; 
 Hutchinson's Clinical Illustrations, Ease, xix., Plate Ixxi., fig. 1). 
 The patient, a girl aged eight, was brought to the hospital with a large 
 swelling over the back of the hip. She was considered by the house 
 surgeon too ill for examination, and died a few hours afterwards. 
 
 The post-mortem examination revealed ' an abscess in the right 
 sterno-clavicular articulation, pysemic pericarditis, pleurisy and 
 pneumonia, a large extra-peritoneal abscess in the pelvis, which was 
 connected along the tendon of the pyriformis muscle with another 
 abscess round the neck of the left femur. The trochanteric epiphysis 
 was completely detached from the shaft, but held in position by ten- 
 dinous attachments and the reflections of the capsule. The history 
 
EPIPHYSIS OF GREAT TEOCHANTER 665 
 
 of the case, as subsequently ascertained, was that the child, although 
 not strong, had never had any illness, previous to a fall on her 
 left side a week before while playing. Some days later a lump was 
 observed on the left hip, and the child was kept in bed in consequence, 
 but two or three days later she seemed to have such difficulty in 
 breathing that she was brought to the hospital. Even then the 
 child walked, holding by her mother's hand, for about half a mile, 
 and did not complain of any pain. 
 
 Mr. Hutchinson {Illustrations of Clinical Surgery, Ease. xix. 
 vol. ii. 1888, p. 109) mentions a specimen from the Croydon 
 Hospital exactly similar to Mr. McCarthy's. It was from a boy 
 of thirteen, who was crushed between a railway carriage and the 
 platform. 
 
 Dr. F. W. Warren {Proceedings of the Pathological Society of 
 Dublin, N.s. 1876, vol. vii. p. 102 ; Dublin Journal of Medical 
 Science, vol. Ixii. 1876, p. 69) gives the description of a specimen 
 obtained from the dissecting room of Steevens's Hospital, Dublin ; 
 consequently there was no history obtainable. It was removed 
 from the extremely muscular body of a man aged about fifty. 
 Before dissection nothing abnormal was observed. A distinct frac- 
 ture of the base of the trochanter was then found extending precisely 
 through the epiphysial line. The detached trochanter was firmly 
 united by dense ligamentous tissue to the shaft, although drawn 
 upwards and inwards so that its summit projected above the level 
 of the head of the femur. When compared with a bone prior to 
 the union of the trochanter to the shaft through its epiphysial line, 
 the fracture was found to take a direction exactly corresponding to 
 the epiphysial line. The tendinous expansion over this process was 
 intact ; the gluteus medius was inserted into its apex, and the gluteus 
 minimus into its anterior margin. Dr. Warren thought that in this 
 case the fracture had occurred through the epiphysial line between 
 the ages of four and eighteen years. On section the neck of the 
 bone was perfectly healthy, as was also the hip-joint itself, there 
 being no appearance whatever of any fracture implicating the cervix 
 femoris. 
 
 Professor Bennett informed Dr. Warren that there were three 
 examples of this fracture in the Museum of Trinity College, 
 Dublin. 
 
 Agnew {Treatise on Surgery, vol. i. p. 945) figures an example of 
 this injury. The specimen was in his own collection, but he gives 
 no details of the lesion beyond that ' there was present a con- 
 siderable amount of granular callus around the circumference of the 
 fracture, though there was none between the fragments.' 
 
 There was also in this case a fracture of the condyles of the 
 femur. 
 
 Mr. John Hilton relates another case, which is also of interest to 
 the medical jurist {Guy's Hospital Beports, 3rd series, vol. xi. 1865, 
 
666 EPIPHYSES OE LOWEE EXTEEMITY 
 
 p. 342). A man, seeing, as he thought, one of his boys idle on his 
 estate in the country, ' kicked him, causing a separation of the 
 epiphysis of the great trochanter from the shaft of the femur. The 
 age of the patient is not stated. Suppuration ensued at the 
 injured part, and the boy died. The farmer was indicted for 
 murder, havmg produced the boy's death, according to the report of 
 the medical man who made the post-mortem examination, by 
 " fracturing the thigh bone." The counsel for the defence took 
 advantage of this verbal inaccuracy in the indictment, and used it 
 successfully in his client's favour, proving satisfactorily that it was 
 not a fracture, but a simple separation of portions of bone from 
 disease ; and so the prisoner got off. The thigh bone, trochanter, 
 and adjacent parts were sent to Mr. Hilton in order to verify the 
 separation of the epiphysis ; and as no doubt could be entertained 
 about the character of the accident, the indictment for murder 
 failed from the inaccuracy of the designation of the injury to the 
 bone.' 
 
 J. H. Ashton records {Lancet, Eebruary 13, 1875, p. 231) the 
 case of (A. E.) a well-developed boy, aged sixteen years, who had 
 been swung by the arms and legs and ' bumped ' on the ground. 
 He was able to work for some days ; pain and stiffness in the hip- 
 joint then came on. When seen the whole thigh and parts around 
 the hip were greatly swollen and tender ; any movement of the 
 joint caused great pain. All movements were normal ; no crepitus. 
 Tongue black, pulse rapid, weak, and irregular, and constant 
 delirium; after a fortnight the constitutional state improved, but 
 the limb had lengthened to the extent of an inch or more, and 
 fluctuation was apparent. An abscess was opened in the West 
 Norfolk and Lynn Hospital, and crepitus felt by grasping the 
 trochanter and moving the limb. A diagnosis of fracture of the epi- 
 physis of the great trochanter was made by Dr. Lowe. A fortnight 
 later the boy died, and on post-mortem examination the trochanter 
 was found to be fractured and broken completely from the shaft. 
 The jomt was destroyed, and the neck and upper part of the femur 
 were in a state of necrosis. The author has been unable to obtain 
 any further account of this specimen. 
 
 The author reproduces a photograph presented to him by Professor 
 J. G. Adami, of McGill University, Montreal. It shows a very pure 
 separation of the trochanteric epiphysis. In a note of this specimen, 
 kindly supplied by Professor Adami, he remarks : ' It shows the 
 trochanter major completely separated from the rest of the bone, 
 probably from fracture, for the head and the lesser trochanter are com- 
 pletely joined. The history of the case had been lost.' (See fig. 204.) 
 
 Separation with fracture. — Mr. Jonathan Hutchinson junior's 
 specimen in the Eoyal College of Surgeons Museum, No. 1021a, 
 shows separation of the epiphysis of the great trochanter in the 
 upper end of a femur, from a lad, aged thirteen, who fell between a 
 
EPIPHYSIS OF GEEAT TKOCHANTEK 
 
 667 
 
 railway platform and the train. The epiphysis, taking with it the 
 attachments of the gluteus medius and minimus and the adjacent 
 periosteum, is raised up ; and the section shows that the line of 
 separation followed the epiphysial disc exactly at the outer side, but 
 passed above it on the inner (towards the neck of the bone) through 
 the structure of the great trochanter upwards for a short distance. 
 
 The same surgeon exhibited, on December 3, 1895, before the 
 Pathological Society, London (Trans. Path. Soc. vol. xlvii. p. 174), 
 a specimen of traumatic separation of this epiphysis, given to him 
 by Dr. Daniels, of British Guiana, and obtained from a native of 
 the latter place aged sixteen. The lad had fallen from a tree to 
 the ground, a distance of nearly twenty feet. He survived for 
 some eight weeks, dying from the effects of various internal 
 
 Fig. 204. — pure separation of great trochanter 
 (McGill University Museum, Montreal, Canada) 
 
 injuries, including rupture of the liver. After the accident he had 
 been able to stand and to raise the affected limb from the bed, 
 so that a positive diagnosis was not made. The post-mortem 
 examination showed that the trochanter had been separated exactly 
 at the epiphysial line, except at the lower and posterior corner, 
 where a small portion of the diaphysis was also detached. There 
 was a decided interval between the epiphysis and the femur, but 
 they were connected by the periosteum, which had been stripped off 
 the shaft for some inches whilst still retaining its attachment below. 
 No suppuration had occurred, and evidence of commencing repair 
 was shown in the production of new bone in the neighbourhood of 
 the injury. The specimen is in the Eoyal College of Surgeons 
 Museum, No. 1041h. 
 
668 EPIPHYSES OF LOWEE EXTKEMITY 
 
 SYMPTOMS. — From the symptoms given in many instances 
 by various authors the diagnosis is often a matter of considerable 
 difficulty. As the usual signs pointing to fracture of the neck of 
 the bone are absent, and as the shaft of the femur is uninjured, the 
 patient might continue his occupation until pain and sv^elling come 
 on — from irritation or inflammation of the surrounding structures. 
 This was so in Ashton's case. 
 
 Sepaeation without Displacement. — On account of the 
 dense tendinous aiid fibrous structures surrounding this epiphysis, 
 little or no displacemejit may be present at first, the trochanter 
 rotating freely with the shaft, through being held by the tendinous 
 fibres of the muscles passing from it to the shaft, the very tough 
 periosteum, and the outward prolongation of the fibres of the capsular 
 ligament. 
 
 In fact, displacement may not be present at any time, so that 
 the injury may be entirely overlooked. 
 
 The child may be able to stand, or even use his limb to raise it 
 from the bed, or even walk, as illustrated by several of the recorded 
 instances. 
 
 This fact may account in some measure for the peculiar mortality 
 from suppuration and pysemia in quite unsuspected cases, the 
 irritation of movements of the epiphysial fragment upon the dia- 
 physis producing severe inflammation and suppuration. 
 
 Pain at seat of injury, increased by movements of the limb 
 tending to separate the fragments or by pressure on the great 
 trochanter, and some loss of the natural functions of the limb, are present. 
 
 Inability to use the limb freely exists when the fragments are dis- 
 placed. As this may be absent at first, only supervening in the 
 course of a few days, the patient may even be able to walk for some 
 time after the injury, as in Eoddick's case. 
 
 Considerable swelling and extravasation are likely to be present 
 over the trochanter, especially if the injury, as is the case most 
 commonly, be caused by direct violence. 
 
 In relating his case. Professor Eoddick {loc. cit. supra) says : 
 ' The process being firmly held by the tendinous expansions covering 
 it, the patient was able to walk with comparative ease for several 
 days, until these suddenly gave way, either from ulceration or 
 periosteal effusion. None of the ordinary symptoms of fracture 
 were found at any time.' 
 
 For the same reason muffled crepitus is usually absent. It can 
 only be elicited by fixing the thigh in the abducted position, and 
 gently moving the trochanter to and fro, or by rotating the thigh 
 very fully. Any severe manipulation would, however, only hasten a 
 disastrous result ; this sign, therefore, should not be sought for too 
 persistently. In the same way the trochanter will move normally 
 in rotating the limb. 
 
 Even supposing some displacement were present, its detection 
 
EPIPHYSIS OF GREAT TROCHANTER 669 
 
 will be found very difficult on account of the distance between the 
 fragments and the surrounding extravasation of blood. 
 
 Separation with Displacement. Deformity. — The epiphysis 
 will be drawn upwards and somewhat backwards and inwards by 
 the powerful gluteal and rotator muscles attached to it, and a distinct 
 cleft felt between the shaft and epiphysis. 
 
 There is no shortening or twisting of the limb, while loss of 
 function of the limb, pain and swelling, may be even more marked 
 than in separation without displacement. 
 
 If the displacement is great the trochanter will not follow the 
 movements of the shaft ; but it is improbable that the flattened upper 
 end of the shaft can be felt, on account of the swelling present in 
 these instances of severe injury. The trochanter is fairly movable. 
 
 Crepitus. — The epiphysis will in this case have to be gently 
 drawn downwards to obtain crepitus. 
 
 Eversion of the foot and limb, if present, will only be slightly 
 marked. 
 
 Shortening of the limb, mentioned by Sir Astley Cooper, is im- 
 possible in an uncomplicated case of separation. 
 
 Packard says : * There cannot be shortening of the limb, and in 
 rotating the thigh the trochanter cannot describe a smaller arc than 
 normal, but will either fail to follow 
 the movements of the limb, or, if the 1 
 
 fibrous coverings are untorn, will I- ^ \ 
 
 behave as under normal conditions.' | \ 
 
 The late Mr. Alfred Poland (Bryant's | 
 
 Practice of Surgery, 4th edit. 1884, I ■<, - 
 
 vol. ii. p. 446) had a case of deformity | 1^' 
 
 of the hip following separation of this \. ? 1 
 
 epiphysis under his care in Guy's Hos- \ ] '} 4 
 
 pital, December 1871, which was cha- ' 
 
 racterised by thickening and projection Fig. 205.— separation of the 
 
 f J.] J. 1, f EPIPHYSIS OP THE GREAT TRO- 
 
 01 tne trocnanter. ^ chanter, alfred Poland's case 
 
 A. G., aged thirteen, ran up against (t. bryant) 
 a bar, striking his left hip. Some 
 
 swelling and pain were occasioned at the time, and were treated 
 by blistering. On examination four months after the accident, 
 flexion and extension were found to be normal, but abduction, 
 adduction, and rotation inwards and outwards were all limited. 
 There was projection, with thfckening of the great trochanter, the 
 tip of which was the same distance from the anterior superior 
 spine as that of the opposite side. No shortening of the limb 
 took place. When out of bed the patient complained of much 
 pain about the knee. 
 
 The following case, reported by Dr. W. B. Savage {Neio York 
 Medical Becord, 1895, xlvii. p. 690), differed from that of Sir A. 
 Cooper and others, inasmuch as the epiphysial fragment was freely 
 
670 EPIPHYSES OE LOWEE EXTEEMITY 
 
 movable and drawn from its natm-al position by the gluteus medius 
 and minimus muscles. 
 
 Ivy H., female, aged eight, on February 26, 1895, while playing 
 with her little brother, was jumped on by him as she lay on her 
 left side on the floor. The patient said that after the accident she 
 had walked across the floor unaided, and her attention was called to 
 her right hip ' by feeling something pricking her ' at that point. 
 Examination showed a portion of bone just protruding through the 
 skin, over the site of the great trochanter of the right side. This 
 fragment was found to be freely movable beneath the skin, and 
 apparently completely detached from the femur, and by moving it a 
 little to one side a depression could be distinctly felt at the tro- 
 chanteric site. 
 
 Upon pressing the fragment again in position, crepitus could be 
 easily made out. Flexion and extension could be effected with the 
 injured limb without discomfort, while abduction elicited pain. The 
 wound in the skin made by the edge of the epiphj^sis was so small 
 that it was deemed best to replace the piece of bone in position. 
 To this end an extension by weight was hit on, both to overcome 
 the eel-like tendencies of the child and to facilitate inspection of the 
 surface wound ; fixation of the epiphysis to the femur was made 
 with bands of adhesive plaster and pads ; the whole limb was then 
 steadied between heavy sandbags. The surface wound was dressed 
 antiseptically, and was completely healed six days later. On 
 March 23, about four weeks after the receipt of the injury, the child 
 was allowed to get up ; at this time the epiphysis was completely 
 united to the femur without any deformity. 
 
 DIFFERENTIAL DIAGNOSIS. Contusion of trochanteric region.— 
 "Where there is no displacement, as in Key's case, the diagnosis is 
 one of great difficulty from the swelling and bruising being present 
 in both. Mobility of the epiphysis is the only distinguishing sign, 
 but even this must frequently be less marked than in the case of 
 other epiphysial separations, on account of the closeness with 
 which the tough periosteum and tendinous expansion bind it to 
 the diaphysis. Muffled crepitus, if present, will be conclusive of 
 separation. 
 
 Dislocation of the hip. — The epiphysis, if displaced, comes to 
 occupy very much the same position as the femoral head in dorsal 
 dislocation. The mobility of the epiphysis and the comparative 
 rarity of dislocation in children are sufficient to distinguish it. 
 Crepitus, if obtainable on drawing the epiphysis downwards, with 
 the other signs is pathognomonic. 
 
 Packard says : ' When the trochanter is broken completely away 
 from the shaft, it will probably be drawn upwards, inwards, and 
 backwards by the action of the muscular fibres inserted into it ; and 
 in such a case it will be transferred from its normal place to that 
 occupied by the head of the femur in backward and upward luxation.' 
 
EPIPHYSIS OF GEEAT TROCHANTEK G71 
 
 Stanley, speaking of the danger of confusion between these two 
 lesions, urges ' the positive resemblance of the fractured portion of 
 the trochanter to the head of the femur, the former occupying the 
 same place which the latter would in dislocation ; and if with 
 these circumstances there should happen to be an eversion of the 
 injured limb, the difficulty of the diagnosis must be considerably 
 increased.' 
 
 Fracture of the neck of the femur (extracapsular). — Separation of 
 the trochanteric epiphysis is readily distinguishable from this injury 
 by the absence of shortening of the limb and neck of the bone, 
 and by the absence of rotation of the epiphysis during the move- 
 ments imparted to the shaft. 
 
 The latter symptom is only present when the trochanter is dis- 
 placed, otherwise it may be held by the tendinous and periosteal 
 structures to the shaft and rotate with it ; but in this case it will 
 describe the same arc on rotation of the thigh as on the uninjured 
 side. 
 
 An anaesthetic should be administered in all cases to render the 
 diagnosis certain. 
 
 PROGNOSIS AND RESULTS are favourable when there is but 
 little displacement of the epiphysis, although from the twelve 
 recorded cases it would appear to be a most fatal form of separation, 
 two cases only in which it was diagnosed during life having re- 
 covered. Even more frequently than in other epiphysial separations 
 displacement is absent, as we have seen in the above instances, and 
 the injury probably remains undetected in many cases. 
 
 A considerable amount of callus formed in Agnew's and Hutchin- 
 son's specimens, indicating a great disposition to natural repair, 
 but this apparently occurs less often than in other epiphysial 
 separations. 
 
 In Mr. Alfred Poland's case deformity was present four months 
 after the injury, with thickening and projection of the trochanter. 
 
 When there is great displacement, union will probably take 
 place by fibrous tissue, or be delayed for a considerable time ; this 
 is likely due to the thinness of the periosteal covering, which 
 will be more or less torn across in displacement of the epiphysis. 
 
 Complications. — Being more of an apophysis than a true epiphysis 
 at the end of a \oYighone, no arrest of growth or important deformity 
 of the limb or neighbouring joint need be feared. 
 
 Suppuration. — Separation of this process is perhaps of as much 
 interest to the pathologist as to the surgeon. In three out of six 
 cases suppuration with pyaemic symptoms rapidly ensued after 
 the accident. 
 
 It is not clear why this epiphysis should be more prone than 
 others to start infective disease after injury. It may be that (1) the 
 bruising of the epiphysial junction is more considerable by reason of 
 the greater amount of violence required to produce the injury ; and 
 
672 EPIPHYSES OF LOWEK EXTEEMITY 
 
 that (2) the extensive strippmg up of the periosteum from the very 
 vascular upper end of the bone must of necessity occur. 
 
 It is remarkable that out of six cases seen during life, the in- 
 jury in five (those of McCarthy, iVshton, Eoddick, Hilton, Key) was 
 rapidly followed by suppuration and death with pysemic symptoms, 
 as if the lesion to the epiphysial junction, whether from bruising 
 or simply from the separation of the process, afforded a peculiarly 
 favourable nidus for germs to develop and start this infective con- 
 dition, which is not so often found in simple separations of the other 
 epiphyses. Death from other injuries resulted in three out of the 
 twelve cases. 
 
 Jonathan Hutchinson junior says {British Medical Journal, 
 March 31, 1894, p. 671) : ' Out of eleven cases, no fewer than six 
 were followed by suppuration (five of these ending fatally).' 
 
 Hamilton says : ' The cases reported would seem to show that in 
 epiphysial separation of this process there is a peculiar tendency to 
 the formation of pus and of general pyaemic infection, and which 
 may perhaps find its explanation in the great vascularity of the 
 bony structure at this point, and in the fact that the lesion of this 
 spongy tissue especially exposes the patient to the absorption of the 
 septic materials.' 
 
 This cancellous tissue forming the base of the great trochanter, 
 which is in reality an apophysis, is certainly of a lighter and more 
 spongy character than that in contact with the true epiphyses of 
 the long bones. A considerable area of such structure is involved 
 in this injury. 
 
 The great trochanter being entirely extracapsular, the hip- joint 
 cannot readily be affected. 
 
 The most important case is reported by Professor T. J Eoddick, 
 of McGill University, Montreal, as having been caused by muscular 
 action, the lad being very athletic {Canada Medical and Surgical 
 Journal, November 1875-6, pp. 207-214 ; London Medical Becord, 
 January 15, 1876, vol. iv. p. 18). H. P., aged sixteen, thought he had 
 sprained his leg the previous week while hurriedly leaping a fence 
 in pursuit of a ball. This was followed on the fourth day by very 
 considerable pain in the lower part of the left thigh and knee, with an 
 aching sensation over the gluteal region, and inability to lie on the 
 left side. There was pain on pressure and slight swelling over the 
 outer side and front of thigh, so as to lead to a suspicion of periosteal 
 inflammation. No lengthening or shortening of limb took pjace. 
 
 Severe constitutional disturbance set in with coated tongue, 
 rapid pulse, rigors, swelling of both parotids, and pain in right 
 ankle and great toe with slight redness (temp. 101-5°, pulse 116). 
 Under chloroform a large abscess over the great trochanter was 
 opened by a long incision, and a quantity of unhealthy-looking 
 sanious pus excavated. The bone was found to be bare next day, and 
 the exposed surface extended towards the neck of the femur. Pain 
 
EPIPHYSIS OF GEEAT TEOCHANTEE 673 
 
 and swelling of joints and parotid regions rapidly began to subside, 
 and then disappeared (temp. 101°-103°). There was paralysis of the 
 left arm on the tenth day, which Dr. Eoddick thought might have 
 been due to pysemic abscess in the brain. Subsequently, five days 
 later, on making a counter-opening above the original one, the 
 great trochanter was felt to be loose, and drawn far away from the 
 shaft of the femur, but still held firmly by the muscles inserted into 
 it. The patient gradually sank, and died on the seventeenth day 
 from pygemic infection, thirteen days after admission to hospital. 
 The epiphysis of the great trochanter was found entirely detached 
 from the shaft, which lay in the centre of an immense abscess. 
 
 The periosteum was separated from the bone nearly to the 
 junction of the lower with the middle third. The detached 
 epiphysis was almost completely denuded of periosteum, so that it 
 could be removed from its muscular attachments with little diffi- 
 culty. 
 
 TREATMENT.— A carefully moulded sphnt of plaster of Paris or 
 other material, well padded with cotton-wool, should be applied to 
 the whole circumference of the pelvis and round the injured thigh, 
 in all cases in which this lesion is believed to have taken place. 
 
 Fig. 206. — long extebnal splint with joints in centre of interruption 
 
 AT hip permitting ABDUCTION OF LOWER EXTREMITY. BY MEANS OP THE 
 MOVABLE FOOT AND CROSS PIECE BELOW IT IS ADAPTABLE TO EITHER LIMB 
 
 If displacement is present, the fragment should be drawn down 
 and secured in position by means of a semicircular collar or by 
 compresses and strapping, and the limb fixed. The limb should be 
 straight and slightly abducted, in order, if possible, to bring the 
 lower fragment in contact with the upper if the epiphysis is much 
 displaced. Malgaigne suggested abduction and eversion of the limb 
 in similar fractures in the adult in order to bring the shaft towards 
 the displaced fragment. Passive movement should not be com- 
 menced as early as in other epiphysial separations. Some surgeons 
 might prefer a Thomas's hip splint, and its employment would 
 certainly be of service in epiphysial separation without displacement, 
 but in this case a surcingle as well should be applied round the hips 
 (see fig. 198). 
 
 Should inflammatory signs present themselves, a free incision is 
 to be made through the fibrous structures and periosteum, and tine 
 
 X X 
 
674 EPIPHYSES OF LOWEK EXTREMITY 
 
 process thoroughly explored ; if it is found to be in any way bare, 
 it should be excised. 
 
 Knowing the great tendency to suppurative inflammation in 
 these cases, it is most essential that the limb should be kept at rest, 
 even in the most simple case. In more than one case the move- 
 ments of walking after injury to the trochanter rapidly produced an 
 acute abscess and death. 
 
 A contrivance analogous to Malgaigne's patella hooks was 
 suggested by Packard for keeping the fragments in position, and 
 used by him for fractured olecranon. Seeing the great tendency to 
 suppurative inflammation in these injuries in children, its employ- 
 ment might be attended with some danger. A safer method would 
 be to fix the fragments together by carbolised silk, inserted in the 
 tendinous structures under strict antiseptic precautions in an open 
 operation. 
 
EPIPHYSIS OF LESSEE TKOCHANTEE 
 
 675 
 
 SEPARATION OF THE EPIPHYSIS OF THE LESSER 
 TROCHANTER 
 
 ANATOMY. — The cartilaginous process of the lesser trochanter is 
 separated from the upper end by the second year. Ossification 
 appears in its centre at the thirteenth year, but is sometimes delayed 
 till the fourteenth. A small oval-shaped process is rapidly formed, 
 convex on the outer side, and resting on a somev^hat triangular 
 prominence, which is flat on the surface. 
 
 This epiphysis joins on about the eighteenth year, somewhat 
 earlier than the great trochanter. 
 
 Separation of this small osseous 
 process can, therefore, only take 
 place between the thirteenth and the 
 eighteenth year. 
 
 In the only case of separation of 
 this process which has been recorded 
 the age was fourteen. 
 
 ETIOLOGY. — From its deeply 
 buried position amongst the muscles 
 on the inner and upper part of the 
 femur, it is difficult to conceive that 
 the lesser trochanter can be sepa- 
 rated from the shaft of the femur 
 except by violent muscular contrac- 
 tion, as in the case recorded below. 
 
 PATHOLOGICAL ANATOMY— The 
 only specimen of separation of this 
 epiphysis is that in the McGill Col- 
 lege Museum at Montreal, described 
 by the late Dr. Fenwick, of Mont- 
 real, in his lectures on surgery. 
 Thirty years ago, his own son, aged 
 fourteen, in climbing on to a fence, fell backwards on to his feet, 
 twisting his leg. The violent strain of the psoas and iliacus tore 
 away the lesser trochanter. This was verified by incision of an 
 abscess which formed. The boy died, on the seventeenth day after 
 the accident, of pyaemia, the direct result of the abscess occurring 
 about the separated epiphysis. For the notes of this case the 
 author is indebted to Dr. F. J. Shepherd, of Montreal, and for the 
 photographs (from which the accompanymg drawings were taken) 
 to Professor J. G. Adami, of Montreal, who kindly placed them at 
 
 Fig. 207. — posterioe view of liriniY- 
 
 SES AT UPPER END OF FEMOR AT 
 ABOUT THE FIFTEENTH YEAR. (|-size) 
 
676 
 
 EPIPHYSES OF LOWEE EXTEEMITY 
 
 his disposal, together with a number of photographs and notes of 
 other cases of separation of the epiphyses from the McGill College 
 Museum. 
 
 Fig. 208. — separation of the lessee Fig. 209. — sepaeation of the lesser 
 
 TEOCHANTEE (POSTEEIOE VIEW) TEOCHANTEE (eXTEENAL ^^EW) 
 
 (From McGill College Museum, Montreal) 
 
 SYMPTOMS. — In a case of fracture of the lesser trochanter in an 
 adult recorded by Julliard (' Fracture par arrachement du petit 
 trochanter,' Progres Med. Paris, 1879, vii. p. 825), the symptoms 
 were rotation outwards of the limb, as in fracture of the neck of the 
 femur, the outer border of the foot lying on the bed ; ecchymosis and 
 swelling on the inner side of the thigh ; inability to move the limb ; 
 deformity of hip and thigh. There was no shortening of the limb, 
 swelling of the knee, or crepitus. 
 
 On account of the powerful action of the ilio-psoas muscle 
 attached to the epiphysis, the retentive apparatus in the treatment 
 of the injury must be kept on the limb for four weeks or longer 
 before passive movement is commenced. If passive movement be 
 commenced earlier, a fibrous union may be the result. 
 
EPIPHYSIS OF THIED TEOCHANTEE 
 
 677 
 
 SEPARATION" OP THE EPIPHYSIS OF THE THIRD 
 TROCHANTER 
 
 Dr. A. F. Dixon (Eoy. Acad, of Med., Ireland, Lancet, June 13, 
 1896, p. 1646) lately exhibited and described three specimens showing 
 this special epiphysis. In each 
 example this epiphysis was small 
 and scale-like, and was placed 
 just above the groove present in 
 the region of insertion of the 
 gluteus maximus muscle. The 
 third trochanter is exactly like 
 the lesser trochanter, consisting 
 of a thin shell of compact tissue 
 enclosing cancellous tissue with- 
 in, while, according to Professor 
 Birmingham, the contiguous 
 gluteal ridge is composed alto- 
 gether of layers of compact bone, 
 showing that the ossification 
 of the third trochanter was a 
 special one. 
 
 Mr. Luther Holden {Human 
 Osteology, 4th edit. 1869, p. 183) 
 was the first to point out that 
 the ridge at the outer lip of the 
 upper bifurcation of the linea 
 aspera, to which the gluteus 
 maximus is attached, is some- 
 times so prominent as to re- 
 semble the third trochanter of 
 the lower animals. It has now 
 been conclusively proved by the 
 investigations of Waldeyer, 
 Fiirsty Dollo, and others, that 
 this epiphysis is really the 
 survival of the third trochanter, 
 and that it is found in about 
 thirty-two to thirty-three per 
 cent, of cases. 
 
 For a complete account of 
 this subject the reader must be 
 referred to M. Houze's paper : 
 chanter chez I'homme ' {Bull. 
 Bruxelles, 1884, p. 21, Plate iii.). 
 
 Fig. 210. — posterior aspect of femur of 
 addlt male, showing 
 
 A, third trochanter, and B, hypotrochanteric 
 fossa, f natural size. (After Houz6) 
 
 ' Sur la presence du troisieme tro- 
 de la Societe cV Anthropologie de 
 
678 EPIPHYSES OF LOWEE EXTKEMITY 
 
 CHAPTEK IV 
 SEPARATION OF THE LOWER EPIPHYSIS OF THE FEMUR 
 
 ANATOMY. — This is the only epiphysis whose ossification begins 
 before birth, with the exception of the occasional early appearance 
 of the osseous nucleus in the upper epiphysis of the tibia. Ossi- 
 fication commences in the middle of the cartilaginous end above 
 the intercondyloid notch from the second to the third week before 
 birth. 
 
 By the eighteenth month this centre has increased to a con- 
 siderable size, and is of an oval shape surrounded by osseous 
 granules, especially at the sides, which assist in forming the 
 condyles. The epiphysis at the fourth year is extensively occupied 
 by osseous material, the projecting portions of the condyles on 
 either side being still cartilaginous. 
 
 At the sixteenth year this enormous epiphysis is separated by its 
 cartilaginous lamina from the diaphysis, the extremity of which 
 presents a mammillated rounded surface divided by a slight furrow, 
 ranning in an antero-posterior direction and corresponding" to the 
 intercondyloid notch. 
 
 The upper surface of the epiphysis is cup-shaped, with a central 
 projection formed by the median centre of ossification and fitting 
 into the furrow just mentioned on the diaphysis. Its anterior lip 
 projects upwards, overlapping the front of the diaphysis, and, like 
 the articular surface, which it includes, projects higher on the outer 
 portion. The cartilaginous line of junction is at the outer portion 
 of the anterior lip about one-eighth of an inch above the articular 
 surface, and slopes downwards towards the lateral aspect of the 
 condyles, and thus presents a sinuous outline ; behind it reaches 
 the articular surface on each condyle and corresponds between 
 these with the upper limit of the intercondyloid notch. The 
 epiphysis is therefore seen to include the whole of the articular 
 surface, both front and back. 
 
 Separation of this epiphysis with displacement means, therefore, 
 injury to the synovial membrane of the joint. On a frontal section 
 the conjugal cartilage presents a somewhat wavy outline, corre- 
 sponding in direction very much with the articular surface of the 
 epiphysis. 
 
SEPAEATION OF LOWEE EPIPHYSIS OF FEMUE 679 
 
 The adduptor tubercle is attached to the extreme inner side of 
 the diaphysial end close to its junction with tiie epiphysis. 
 
 The two heads of the powerful gastrocnemius are attached to 
 the posterior limit of each condyle to some extent, but chiefly to 
 the diaphysis of the femur. The plantaris is also attached to the 
 diaphysis ; these two muscles are stripped off the shaft with the 
 periosteum and act solely upon the epiphysis when detached, and 
 cause it to rotate upon its axis. 
 
 The popliteus muscle, together with the external lateral liga- 
 ments, is attached to the outer side of the outer condyle. To the 
 inner side of the internal condyle is attached the powerful internal 
 lateral ligament ; while the anterior and posterior crucial ligaments 
 are attached respectively to the inner and outer aspects of the 
 external and internal condyles. 
 
 The medullary artery is directed upwards towards the proximal 
 end of the bone. 
 
 De Paoli gives the following table of measurements of the lower 
 epiphysis of the femur (in a median frontal section). 
 
 Age 
 
 Height 
 
 Greatest 
 Breadth 
 
 And principal periods 
 
 At the in- 
 tercondyl- 
 oid space 
 
 At the 
 
 middle of 
 
 the external 
 
 condyle 
 
 At the 
 
 middle of 
 
 the internal 
 
 condyle 
 
 At the 
 outer edge 
 
 At tlie 
 inner edge 
 
 Before birth (centra 
 osseous nodule) 
 
 10 mm. 
 
 16 mm. 
 
 19 mm. 
 
 16 mm. 
 
 19 mm. 
 
 30 mm. 
 
 1 year 
 
 12 „ 
 
 18 „ 
 
 20 „ 
 
 20 „ 
 
 21 „ 
 
 43 „ 
 
 2 years 
 
 12 „ 
 
 20 „ 
 
 22 „ 
 
 25 „ 
 
 21 „ 
 
 48 „ 
 
 4 „ . . 
 
 15 „ 
 
 17 „ 
 
 19 „ 
 
 16 „ 
 
 20 „ 
 
 45 „ 
 
 5 „ , , 
 
 j 16 „ 
 
 23 „ 
 
 25 „ 
 
 19 „ 
 
 23 „ 
 
 50 „ 
 
 
 . 15 „ 
 
 20 „ 
 
 23 „ 
 
 23 „ 
 
 26 „ 
 
 55 „ 
 
 H „ 
 
 
 19 „ 
 
 20 „ 
 
 25 „ 
 
 21 „ 
 
 27 „ 
 
 53 „ 
 
 6 „ 
 
 
 15 „ 
 
 21 „ 
 
 23 „ 
 
 23 „ 
 
 26 „ 
 
 58 „ 
 
 7 „ 
 
 
 17 „ 
 
 23 „ 
 
 25 „ 
 
 24 „ 
 
 28 „ 
 
 58 „ 
 
 8 „ 
 
 
 17 „ 
 
 22 „ 
 
 28 „ 
 
 27 „ 
 
 32 „ 
 
 62 „ 
 
 9 „ 
 
 
 18 „ 
 
 22 „ 
 
 26 „ 
 
 25 „ 
 
 28 „ 
 
 56 „ 
 
 13 „ 
 
 
 17 „ 
 
 24 „ 
 
 SO „ 
 
 28 „ 
 
 36 „ 
 
 68 „ 
 
 14 „ 
 
 
 17 „ 
 
 26 „ 
 
 29 „ 
 
 25 „ 
 
 32 „ 
 
 71 „ 
 
 16 „ (the ossifica- 
 tion extends up to 
 the lateral siu-faces) 
 
 18 „ 
 
 26 „ 
 
 33 „ 
 
 29 „ 
 
 37 „ 
 
 80 „ 
 
 17 years 
 
 16 „ 
 
 26 „ 
 
 25 „ 
 
 19 „ 
 
 28 „ 
 
 62 „ 
 
 20 „ . . 
 
 18 „ 
 
 28 „ 
 
 32 „ 
 
 27 „ 
 
 33 „ 
 
 72 „ 
 
 If the femur be sawn horizontally through at the level of the 
 epiphysial line of junction of its lower epiphysis, the cut will pass 
 below the upper edge of the cartilaginous surface of the articulation. 
 In a well-developed boy of eighteen years of age its level will be 
 
680 EPIPHYSES OF LOWEE EXTEEMITY 
 
 found to be 1-2 centimetres below the highest point of the epiphysial 
 line in front. 
 
 In a specimen taken from a subject of the same age, the 
 author found the vertical thickness of the epiphysis at the middle 
 of the intercondyloid notch to be 9-58 millimetres ; between 
 the condyles, anteriorly, 1-3 centimetres ; at middle of internal 
 condyle, 3-2 centimetres ; and at middle of external condyle, 
 2' 7 centimetres. 
 
 Konig has also given similar measurements in his manual of 
 surgery {Lehrhuch cler allg. Ghirurg. BerHn, 1883). 
 
 Procknow also gives the height of 
 the epiphysial line by placing a hori- 
 zontal line along the lowest part of the 
 articular surface of the epiphysis, and 
 taking the vertical measurement from 
 this along the edge of each condyle to 
 the epiphysial line : 
 
 In a girl In a boy 
 
 9 years of age 7 years of age 
 
 Intercondyloid notch . 2-3 cm. 2-3 cm. 
 Internal condyle . . 2-7 „ 2"7 „ 
 
 External condyle . . 2-3 „ 2-9 „ 
 
 The author's own measurements 
 confirm these precisely. 
 
 The height of the cartilage laterally 
 at the fourteenth year is 3"4 centimetres 
 from the lower edge of the internal 
 condyle ; from the lower edge of the 
 external condyle, 2-7. The height of 
 the cartilage at the eighteenth year is 
 4-2 centimetres from the lower edge of 
 the internal condyle ; from the lower 
 edge of the external condyle, 8"5. All 
 these measurements were found to be 
 somewhat less in the female subject. 
 F1G.211.-EPIPHYSES ATTHEKNEE- Tlic thickucss of the epiphysial or 
 
 JOINT AT THE NINETEENTH YEAR. . , . ., , , , n • ,i 
 
 OUTER SIDE (i natural size) conjugal cartilage at about the nmth 
 
 year is three to six millimetres. 
 
 This enormous epiphysis having been the first of all the 
 epiphyses in the body to ossify, will be the last to join to the shaft, 
 according to the usual law. 
 
 It unites with the diaphysis from the twentieth to the twenty- 
 third or even twenty-fifth year. 
 
 The growth in length of the femur occurs to a great extent at 
 this end of the bone. According to Oilier the growth from the lower 
 end is about twice that from the upper. 
 
 It is only in front above the articular surface in the middle 
 line and in front of each condyle, especially the external, that the 
 
SEPAEATION OF LOWEE EPIPHYSIS OF FEMUE 681 
 
 epiphysial layer of cartilage is in close proximity to the synovial 
 membrane of the joint. 
 
 Even here the membrane, v^hich extends somewhat above the 
 line of cartilage and overlaps the end of the diaphysis, v^ould be 
 protected from injury or laceration during the separation of this 
 epiphysis by reason of the layer of loose fat which intervenes between 
 it and the periosteum in this situation. The synovial membrane 
 
 Fig. 212. — frontal section of bones 
 forming the knee-joint between 
 the seventeenth and eighteenth 
 years of life. posterior half of 
 section, showing cancellous struc- 
 ture of the epiphyses and ends 
 of the diaphyses and the rela- 
 tion of the conjugal lines to the 
 
 ARTICULATION (J-size) 
 
 Fig. 213. — sagittal section of bones 
 forming the knee-joint 
 
 approaches the diaphysis behind much nearer than it does at the 
 sides. This relationship is well seen also in vertical sections through 
 the middle of each condyle. 
 
 At the sides the attachments of the powerful lateral ligaments 
 to the epiphysis widely separate the synovial cavity from the 
 epiphysial line, so that on a transverse section of the knee- 
 joint the synovial membrane is at a considerable distance from the 
 diaphysis. 
 
 We may therefore say that the knee-joint is comparatively 
 
682 
 
 EPIPHYSES OF LOWEE EXTEEMITY 
 
 secure against being opened in pure separations of this epiphysis 
 without much displacement. The presence of the large bursa 
 beneath the extensor tendon over the lower end of the diaphysis 
 must not be forgotten, inasmuch as it communicates freely with the 
 
 joint. It may escape injury, 
 however, through the quan- 
 tity of fat which separates it 
 from the periosteum. 
 
 AGE. — Both age and sex 
 appear to have a decided in- 
 fluence in separation of the 
 lower epiphysis of the femur. 
 Out of seventy-one speci- 
 mens and cases verified by 
 direct examination (i.e. com- 
 pound separations) sixty have 
 the age clearly stated ; of 
 these no less than thirty-one 
 were between the ages of 11 
 and 20 years : one at 20, two 
 at 19, two at 18, two at 17, 
 two at 16, five at 15, seven 
 at 14, three at 13, four at 12, 
 three at 11, one between 10 
 and 11, three at 10, two at 
 9^, six at 9, five at 8, one at 
 7, two at 6, one at 5, four at 
 one at 6 months, and one in 
 
 Fig. 214. — median sagittal section of the 
 loweb end oe the eemur, from a gikl aged 
 fourteen years 
 
 The synovial membrane in front extends above 
 the conjugal cartilage, a thick pad of fat 
 intervening between it and the front of the 
 diaphysis. Behind it passes off from the 
 crucial ligaments (seen on section) at the level 
 of the conjugal cartilage. The ligameutum 
 mucosum is seen below. 
 
 4, one at 3^, and one at 2 years; 
 a foetus. 
 
 Out of nine other compound separations not included in those 
 just mentioned, and which terminated in recovery, the age is given 
 in eight : in one at 15, one at 13|, one at 12, one at 11, one at 10, 
 one at 8|, one at 7, and one at 6^ years of age. 
 
 Taking all which have been confirmed anatomically of the total 
 eighty, we find the age given in sixty-eight ; of these, thirty-five 
 instances were from 11 to 20 years of age. 
 
 The age is given in thirty-two out of thirty-four simple cases. 
 The majority of these, twenty-three in number, took place also 
 between 11 and 20 years of age : one at 20, four at 18, one at 17, 
 four at 16, six at 15, one at 14, one at 13, three at 12, two at 11 ; 
 one at 10, one at 9, one at 8, four at 7, one at 6, and one at 4 years 
 of age. 
 
 Of the total 114 collected by the author, the age is given in 
 100, and of these the injury occurred in sixty-four between 10 and 
 20 years of age : two at 20, two at 19, six at 18, three at 17, six at 
 16, twelve at 15, eight at 14, one at 13|, four at 13, eight at 12, six 
 at 11, one between 10 and 11, five at 10, two at 9^, seven at 9, one 
 
SEPAEATION OF LOWEE EPIPHYSIS OF FEMUE 683 
 
 at 8|, six at 8, six at 7, one at G^, three at 6, one at 5, five at 4, one 
 at 3^, one at 2, one at 1-^ years of age, and one in a foetus. 
 
 Out of seventy-five cases the greatest number, twenty-eight, 
 occurred between the ages of 15 and 20, precisely what would be 
 expected in this epiphysis, which does not become completely 
 united to the shaft until so late a period. 
 
 M. Delens, in his valuable paper on ' Traumatic Separations 
 of the Lower Epiphysis of the Femur ' {Arcliives generalcs de 
 
 \ 
 
 Fig. 215. — sagittal section of the left 
 
 KNEE-JOINT THKODGH THE OUTER CON- 
 DYLE OF THE FEMUR ; THE KNEE IS IN 
 THE FLEXED POSITION. OUTER SURFACE 
 OF SECTION. FROM A GIRL AGED FOUR- 
 TEEN YEARS 
 
 In front the synovial membrane passes off 
 from above the conjugal line. Behind 
 it forms a pouch in this position of the 
 knee, and extends be3'ond the level of 
 the conjugal cartilage, but in the ex- 
 tended position it reaches only as far 
 as this point (|-size) 
 
 Fig. 216. — sagittal section through inter- 
 nal CONDYLE OF FEMUR AND INNER TUBER- 
 OSITY OF TIBIA IN A GIRL AGED FOURTEEN 
 YEARS 
 
 Neither in front nor behind does the synovial 
 membrane extend so far upwards as in the 
 median line of the joint. In the extended 
 position it passes off exactly at the con- 
 jugal line. (Above the outer condyle it 
 extends somewhat above the epiphysial 
 boundary.) Much more of the inner tuber- 
 osity of the tibia, anteriorly and posteriorly, 
 is covered by the membrane than in the 
 middle line (^-size) 
 
 Medecine, vol. cliii. March 1884, p. 272), has drawn attention to the 
 same influence of age. Out of twenty-eight cases of this injury he 
 found that nineteen were between 10 and 18 years of age. 
 
 The author has carefully excluded several examples mentioned by 
 Professor Paul Bruns {Arcliiv far Min. Chirurg. Bd. xxvii. 1882) in 
 his article on ' Traumatic Separation of the Epiphyses,' those related 
 by Madame La Chapelle, and some other writers, mostly on account 
 
684 EPIPHYSES OF LOWEK EXTEEMITY 
 
 of the inisufficient details rendering the diagnosis very doubtful, 
 but some on account of separation being caused by putrefaction of 
 the body or by disease. 
 
 In Madame La Chapelle's case traction of the foot during 
 delivery caused a separation of this epiphysis, and a separation of 
 the upper epiphysis of the tibia. The child was born dead. 
 
 The author has also omitted all cases of separation produced by 
 the surgeon in the necessary manipulations for hip disease. Volk- 
 mann {Virchoio's Jahresbericht, 1866, ii. S. 337) has three times 
 separated this epiphysis in hip disease by traction in applying a 
 plaster dressing, and by rotation in seeking for crepitus. It has also 
 been separated in many instances by other surgeons in using very 
 gentle force whilst applying a plaster-of-Paris bandage for the same 
 disease. 
 
 Numerous cases of this accident have also been recorded by sur- 
 geons, produced by attempts to straighten limbs ankylosed in a rectan- 
 gular or other bad position. Instances have been especially frequent 
 during rectification of ankylosis of the knee (Callender, Chauvel ; 
 Spillmann, Diet. Encyclopedique des Sciences medicales, tome xxiv. 
 art. ' Cuisse ') . The author has carefully avoided these and such 
 like cases of separation associated with a diseased condition, which 
 Packard and others have included in their accounts of this injury. 
 For example, Packard mentions the case of a girl, aged sixteen, 
 communicated to him by Dr. W. B. Hopkins. She had bony 
 ankylosis of one knee at a right angle, and had a fall, separating the 
 lower epiphysis of the femur from the shaft. Under ether the limb 
 was straightened and put up in plaster of Paris, and an excellent 
 result was ultimately obtained. 
 
 Any constitutional tendency to rickets, syphilis, or tuberculous 
 disease, or any liability to inflammatory change about the epiphysial 
 line, may influence the normal time of union of the epiphysis, either 
 accelerating or retarding it. We cannot therefore regard the age at 
 which separation occurs in these cases as of any assistance in deter- 
 mining the limits in which it usually takes place in healthy subjects. 
 Only a small amount of violence seems, under such conditions, to 
 readily produce this separation. In this connection the following 
 cases, which occurred at Guy's Hospital, are of interest. 
 
 Mr. Bryant had a case of this separation with marked rickets 
 under his care at Guy's Hospital in 1882. The patient was a girl, 
 aged two, who had fallen down stairs. There was no displacement, 
 but considerable swelling above the knee, with dull crepitus and 
 great pain on manipulation. A felt splint was applied, and the child 
 slowly but completely recovered. 
 
 Mr. Birkett diagnosed a similar case in a girl, aged two and a 
 quarter, under his care in 1874 at Guy's Hospital. Three days 
 before admission she had fallen off a chair. Extension with lateral 
 splints was applied, and the bones united in very good position. 
 
SEPAEATION OF LOWEE EPIPHYSIS OF FEMUE 685 
 
 Mr. Cock, at Guy's Hospital, May 1866, had a case of separation 
 of this epiphysis in a boy (Fred. Wm. D.), aged nine, the subject of 
 strumous diathesis. His leg had been caught between the spokes 
 of a wheel ; there was evidence of great contusion. The treatment 
 adopted was a back splint with the limb bent at an angle. 
 
 The author has seen two other cases in rachitic children ; in 
 one of them, a girl aged three and a half, there was slight displace- 
 ment inwards and backwards of this epiphysis, with dull crepitus 
 and great pain above the joint. The knee-joint was normal. The 
 child had been knocked over in the street, and fell on her hands and 
 knees. Under chloroform a plaster-of-Paris bandage was applied ; 
 union slowly took place, accompanied by considerable thickening 
 about the lower end of the femur. 
 
 Dr. Oscar H. Allis, of the Presbyterian Hospital, Philadelphia, 
 has kindly sent the author the following notes of a case previously 
 published by him {Trans. Path. Society, Philadelphia, 1878, p. 7). 
 
 The injury causing the separation of the upper and lower 
 epiphyses of the right femur and partial separation of the lower 
 epiphysis of the left femur ' was very slight,' and occurred in an 
 unhealthy rachitic infant. 
 
 ' J. K., eighteen months ; about two weeks before its death the 
 mother noticed that the child cried violently when she attempted to 
 put on the right shoe. A week later Dr. Allis saw the child once 
 and examined the ankle, knee, and hip, but did not detect any 
 unusual symptoms. The child cried, but no more than when he 
 examined the other limb or the abdomen. The child had a slight 
 cold and was teething. The urine was dark and turbid. At death 
 Dr. Allis was again sent for, and obtained permission to make an 
 autopsy. The abdominal viscera were sound ; the mesenteric glands 
 swollen or enlarged. The ribs at their sternal ends were beaded and 
 prominent. The head of the right femur was separated from the 
 shaft with loss of substance. The condyloid epiphysis was separated 
 from the shaft, and the periosteum free from the bone halfway up 
 the shaft. The extremity of the shaft was injected with blood, and 
 there was evidence that blood had been effused beneath the perios- 
 teum. There were no traces of inflammatory action, and it was 
 therefore not easy to state at what time the traumatism occurred. 
 
 ' On examining the left femur the neck was found intact, but a 
 partial separation of the condyloid epiphysis was detected, without 
 any evidence of effusion of blood. The mother attributed the injury 
 to the fact that an elder sister (three years of age) was seen sitting 
 on the infant two weeks before its death.' 
 
 In 1885, at Guy's Hospital, Mr. Howse had an instance of separa- 
 tion of the epiphysis nine years after excision of the knee for disease. 
 The boy was now aged eleven, and the accident happened by his 
 falling off a chair, catching his leg between the bars. The leg was 
 found to be slightly bent backwards and inwards. There was no 
 
686 EPIPHYSES OF LOA¥EE EXTEEMITY 
 
 crepitus, but a quarter of an inch of separation of the epiphysis in 
 front from the diaphysis. ConsoHdation rapidly ensued after the 
 employment of straight splints. 
 
 The case of a girl, aged one and three-quarter years, is referred 
 to in the St. TJiomas's Hospital Reports for 1875 (n.s. vol. vi. 1875, 
 p. 343) as having separated the lower epiphysis, recovery taking 
 place in eighteen days. 
 
 In concluding this subject of age it will be seen that the opinions 
 and statistics of the following writers are at great variance. 
 
 The author would regard the period from thirteen to eighteen 
 years as that in which we find pure epiphysial separations of the 
 lower end of the femur to be most common. 
 
 Packard's figures differ very considerably from those given above 
 by the author. He says : ' As to the age of the patients, the aver- 
 age of forty-five in which it is stated was a little over seven years. 
 The youngest was eighteen months, and the oldest eighteen years.' 
 
 Mr. Hutchinson says : ' The lower epiphysis of the femur may 
 be detached at any age under twenty, but the accident usually occurs 
 between eight and eighteen.' 
 
 Mr. Hutchinson junior has collected seventy-five cases,'of which 
 ten have not been previously published ; out of fifty cases, three of the 
 patients had attained the twentieth year, the average being ten years. 
 
 A. H. Meisenbach, of St. Louis, U.S.A., in collecting the statistics 
 previously published {Neiv York Medical Record, December 15, 1894; 
 Annals of Surgery, February 1895, p. 157), finds that traumatic 
 separation of the lower end of the femur occurs in about one- fifth to 
 one-third of all reported cases ; in the majority of instances previous 
 to the sixteenth year, seldom later. 
 
 SEX. — With regard to sex Packard found in over sixty cases 
 that there were nine in which the subjects are stated to have been 
 girls ; and of these, strangely enough, three sustained their injuries 
 by entanglement in the wheels of wagons, behind which they were 
 clinging. 
 
 Delens observes that out of twenty-three cases where the sex of 
 the patient was noted, twenty were males, and only three females. 
 
 In the author's figures, taking seventy- four examples there were 
 only eight girls, but the statistics of the total separations of the lower 
 femoral epiphysis are as follows : 
 
 Out of seventy-one specimens verified after death, the sex is 
 stated in fifty-six. Of these, forty-eight occurred in males, and 
 eight in females. 
 
 Of nine other compound separations, the sex is not given in one 
 instance ; of the remaining eight, seven were in males, one in a 
 female. 
 
 Of the total eighty verified by direct examination, nine occurred 
 in females ; all of the latter were from fourteen years of age down- 
 wards — none above, 
 
SEPAEATION OF LOWER EPIPHYSIS OF FEMUE 687 
 
 Of thirty-four simple cases, the sex is given in thirty-two. Of 
 these, twenty-eight were in males and four in females ; all the latter 
 were below the age of thirteen years. 
 
 Of the total one hundred and fourteen, the sex is given in ninety- 
 six, as eighty-three males and thirteen females. 
 
 It is not that this separation is more readily produced in males, 
 but that they are more exposed than females to injuries of this kind. 
 The natural muscular activity and the enterprising spirit of the boy 
 lead him into greater danger. The modern tendency for the female 
 sex to imitate the habits of the male may, however, in the future 
 considerably modify the truth of this statement. 
 
 ETIOLOGY. — To separate so broad and thick an epiphysis as that 
 of the lower end of the femur, it would appear that a very con- 
 siderable amount of violence is required ; but, as we shall see later 
 on, in certain forms of this injury, and under peculiar circumstances, 
 the violence may not be so very great, the tibia acting as a very power- 
 ful lever by means of the popliteus muscle and the crucial and other 
 ligaments during hyper-extension. 
 
 Experimentally on the dead subject it is one of the epiphyses 
 most easily separated. 
 
 Du-ect violence. — A broad line of distinction needs to be drawm in 
 this as in other diastases between separations caused by extreme 
 direct violence, such as violent contact with some heavy bodies, and 
 those due to other causes. Of the former w^e may mention as 
 examples the passage of a cart- or cab-wheel over the leg (five cases), 
 a heavy weight, timber, or bale of rope falling on the knee, a kick b}^ 
 a horse. Eleven cases were produced in this way by direct violence. 
 
 The author finds several other examples in which direct causes 
 are clearly stated, but the accounts cannot always be relied upon ; it 
 is often in these more indirect than direct, the exact mode or point 
 of infliction of the violence being obscure. 
 
 Mr. A. W. Mayo Robson thinks that extreme direct violence is 
 usually the cause ; but Packard in one of his earlier papers gave an 
 opposite opinion— viz. that in almost every case the cause of the 
 injury was indirect violence. 
 
 Indirect violence.— In a record of sixty cases in which the cause 
 of this diastasis is noted, the author finds that this occurred in fifty- 
 three from indirect violence. It is probable that many others which 
 at first sight seem to be due to direct violence — e.g. in Mr. Vv^heel- 
 house's case {loc. cit. infra), a fall of earth in a colliery accident — 
 are in reality the result of indirect violence. The difficulty of 
 exactly estimating all the factors of accidents of this nature is alone 
 sufficient to raise a doubt as to direct violence being considered the 
 cause. At any rate, we observe that the immense majority is 
 certainly due to indirect violence. 
 
 Out of the fifty-three cases just mentioned, a large proportion 
 (twenty-four) were produced by the entanglement of the leg in the 
 
688 EPIPHYSES OE LOWEE EXTKEMITY 
 
 spokes of a revolving ca.rriage-wheel, the child, having climbed up or 
 hanging on behind, letting the leg slip in between the spokes of the 
 wheel. In three cases the child had fallen forwards with its leg 
 fixed in a hole, or between the joists of a floor — e.g. M. Fontanelle's 
 case {loc. cit. infra) — or else had got the limb entangled in some 
 machinery. Separation occurred in one case from a fall from a 
 height of eighty feet ; in another from the patient — a boy — jumping 
 from a steamboat and getting the limb entangled in a rope. 
 
 Packard found in twenty-seven out of sixty-eight cases which 
 he had collected that it was produced by catching the leg in a 
 carriage wheel. 
 
 In a few instances the violence, though indirect, has been less 
 severe — e.g. a fall upon the curbstone of the pavement while running, 
 the knee being violently struck. In two at least of these (Maunder's 
 and Hilton's) the patient, after slipping, fell to the ground with the 
 leg bent beneath him. 
 
 In one instance a push on the outer side of the leg when the 
 patient was standing with his lower extremities wide apart w^as 
 said to be sufficient to separate the lower femoral epiphysis. In 
 another case a boy, whilst playing leapfrog, aHghted on his feet, 
 which were widely separated. A fall with the legs apart, a fall 
 down stairs, and lastly a simple fall on the edge of a pavement, have 
 all been mentioned as producing this injury. 
 
 This epiphysis is certainly placed at a great mechanical dis- 
 advantage. The knee-joint is the largest joint in the body, and the 
 large articular ends which form it, being but little supported by bony 
 cavities, are almost entirely dependent upon powerful and complex 
 ligaments for their great strength and proper apposition. Any over- 
 extension of the knee-joint is directly expended upon this huge 
 epiphysis by the great leverage of the tibia, which is firmly connected 
 to it by these powerful ligaments. 
 
 To this over-extension of the knee there is added some amount 
 of twisting and traction upon the leg. Either the body or the leg 
 at one end of the long lever may be the fixed point for the applica- 
 tion of the extending force. 
 
 According to a case, which must be a rare one, recorded by Dr. 
 E. E. Ware {Lancet, January 12, 1895, p. 92), it is possible, even 
 under these circumstances, for the limb to give way and separate 
 through the knee-joint without fracture. 
 
 A boy, aged seven years, was riding behind a four-wheeled cab 
 when his thigh became impacted between the axle and the spring. 
 In his struggles to extricate himself his leg became entangled in the 
 spokes of the wheel. The cab w^as moving at a medium pace, and 
 the boy's thigh being firmly fixed under the spring, and his leg 
 forcibly wrenched by the moving wheel, his limb was torn off at the 
 knee-joint. On examination at the East London Hospital for 
 Children, it was found that the right leg had been completely severed 
 
SEPAKATION OF LOA¥EE EPIPHYSIS OF FEMUE 689 
 
 from the thigh through the knee-joint. The skin of the lower third 
 of the thigh was extensively bruised and lacerated, and the muscles 
 exhibited torn and bruised ends, blood being extravasated into the 
 sheaths. The femoral artery was occluded apparently by torsion, 
 and was seen lying free in the remnant of Hunter's canal. The 
 sciatic nerve was also ruptured. The patella was situated in the 
 stump, and the ligamentum patellae was not ruptured, but had been 
 detached from the tibia by the separation of a small portion of the 
 tubercle ; the crucial ligaments also were entirely separated from 
 their femoral attachments, and the lateral ligaments of the joint 
 were completely torn away. The lower end of the femur was thus 
 completely exposed, and the external and a.nterior surface of the 
 bone had been denuded of periosteum. Under chloroform Dr. Ware 
 performed immediate amputation of the thigh at about the junction 
 of the upper two-fifths with the lower three-fifths. The wound 
 healed by first intention, and recovery was uneventful. 
 
 On examining the leg it was found that the semilunar cartilages 
 remained in situ and that the crucial ligaments maintained their 
 attachment to the tibia. The long external lateral ligament was 
 still attached to the fibula, and at the point of separation from the 
 femur had denuded an adjacent extensive surface of bone of its 
 periosteum. On dissection no fracture of the tibia or fibula could 
 be detected, and there was no epiphysial displacement ; the insertions 
 of the hamstring muscles also remained uninjured. 
 
 M. Delens compares this separation with that of the lower end 
 of the radius, and believes that the powerful posterior ligament of 
 the knee in forcible extension of the limb plays the same part with 
 reference to the femoral epiphysis as the anterior ligaments of the 
 wrist do to the lower extremity of the radius in falls upon the palm 
 of the hand. 
 
 The author would say that violent extension is the most 
 important force in producing this lesion. 
 
 Many surgeons have separated this epiphysis as a means of 
 straightening the limb in genu valgum, and the osteoclast of Colhns 
 has the same effect upon the lower end of the femur. 
 
 The exact mechanism in such cases has been ably described by 
 Delore, and by V. Menard {La Beviie de Chirurgie, 1881, ' Eecher- 
 ches experimentales sur le redressement brusque du genu valgum ') 
 and others. Menard also gives the age at which such operations 
 may be safely performed. 
 
 In straightening hmbs for genu valgum by other methods, it is 
 likewise the lower epiphysis of the femur which is usually detached. 
 
 M. Delore made an autopsy on a child, aged seven years, who had 
 died of measles twenty-one days after an operation of this kind, and 
 found separation of the lower epiphysis of the femur on either side, 
 whilst there was on the left a separation of the upper epiphysis of the 
 tibia ; on the right there was a separation of the head of the fibula. 
 
 Y Y 
 
690 EPIPHYSES OF LOAVEE EXTEEMITY 
 
 In these Ccases the force of torsion is replaced by a pushing force 
 in an outward or inward direction — that is, by violent abduction or 
 adduction of the leg on the thigh. 
 
 Violent torsion of the limb has produced epiphysial separation in 
 ten cases, eight of them by the limb being caught by machinery in 
 motion, two by the twisting of a cable round the limb on board ship. 
 
 Mr. Cock, at Guy's Hospital, in December 1866, diagnosed a case 
 as separation of this epiphysis in a young man (Joseph H.) aged 
 nineteen. While wrestling with another man he was thrown to 
 the ground and his leg twisted, and he was unable to stand. The 
 treatment adopted was a long outside splint and a short inner one. 
 Great swelling of the knee occurred, and on his discharge two 
 months later he was still unable to walk without crutches. 
 
 At the Medico-Chirurgical Society of Edinburgh, Mr. A. G. 
 Miller showed, on December 19, 1888, a fracture of the lower epi- 
 physis of the femur produced by torsion. 
 
 In fact, we may say that violent torsion, combined with forcible 
 or hyper-extension, is the common agent in producing this lesion; 
 this is probably the reason why we sometimes find a fragment of the 
 diaphysis on the inner or outer side still attached to the epiphysis, 
 y^hile the remaining portion of the separation is clean. 
 
 Again, in compound separations there seems to be some proof of 
 the existence of torsion combined with extension ; for although the 
 wound is frequently on the posterior aspect, it is sometimes found 
 on the posterior, internal, or external aspects. 
 
 ' Ce sont encore les torsions, les inclinaisons constatees sur le 
 fragment e]3iphysaire ' (Verneuil) . 
 
 M. J. Colignon, in his doctoral thesis, ' De la disjonction trau- 
 matique des epiphyses ' (These de doctorat, Paris, 1868), brought 
 forward a number of cases showing that separation of the lower 
 epiphysis of the femur in newly born children could be produced 
 by forcible extension or flexion. Twisting and lateral bending 
 inwards at the knee produced the same results. 
 
 Bruns quotes a case in which he detached the lower epiphysis of 
 the femur in correcting the deformity of chronic inflammation of 
 the hip-joint. The girl was aged sixteen. Bruns agrees with the 
 views the author has just stated. Although the epiphysial cartilage 
 is at a distance from the disease for which the manipulation is re- 
 quired, and to all appearance is unaffected by disease, yet it cannot 
 be said to be in a healthy condition — it must have undergone some 
 pathological change. Its unhealthy condition predisposes to separa- 
 tion of the epiphysis. This is confirmed by the small amount of 
 force required to separate so large an epiphysis as that of the lower 
 end of the femur under such conditions. 
 
 It need scarcely be stated that muscular action alone cannot 
 separate this epiphysis. 
 
 In an analysis of the seventy cases collected ' with a view to 
 
SEPAKATION OF LOWEE EPIPHYSIS OF FEMUK 691 
 
 determining the kind of violence most likely to produce this kind 
 of injury Dr. J. M. Elder, of Montreal {Montreal Medical Journal, 
 vol. XX. No. 9, March 1892, p. 645), gave the following results: 
 ' Entanglement of the limb in a moving wheel (as of a carriage), 
 thirty-three cases ; a fall while running, three cases ; one case of a 
 fall from eighty feet ; body thrown forwards while leg was in a hole 
 up to knee, two cases ; one case while boy was playing leapfrog 
 and alighted with feet widely separated ; direct blow to lower part of 
 limb (as in Dr. Elder's own case), four cases; run over by vehicles, 
 four cases ; and finally, as result of surgical procedures for cor- 
 rection of ankylosis or deformities, five cases. In thirty-three of the 
 cases the compound character of the lesion is mentioned.' 
 
 PATHOLOGICAL ANATOMY.— G. C. Keichel and Bertrandi give 
 the earliest description of anatomical specimens of this injury. The 
 specimen figured by Beichel may, however, have been a united frac- 
 ture in the adult or have been one due to disease. 
 
 The first (1824) authentic specimen of wdiich we have an accurate 
 account and illustration is that by Sir Charles Bell, preserved in the 
 Edinburgh Boyal College of Surgeons Museum. 
 
 From the number of specimens of separation of the condyloid 
 epiphysis of the femur now existing, it is evident that this accident 
 is by no means so rare as was a short time ago supposed. The 
 severity of the injury leading to a frequent fatal termination is 
 sufficient to account for this. Other separations — e.g. the lower 
 end of the radius — are less frequently noted or come under the 
 care of surgeons for operative treatment ; more often they are 
 entirely overlooked. 
 
 From the specimens, twenty-two in number, which are pre- 
 served in the London Hospital Museum and elsewhere, it would, at 
 first sight, appear that separation of the lower epiphysis of the 
 femur was the most frequent of all epiphysial detachments. Bruns 
 {loc. cit. supra) has noted twenty-eight, the highest nuinber, in his 
 table of 100 cases, but, as he remarks, this cannot represent the 
 exact relative frequency of the injury, by reason of the very serious 
 complications and secondary lesions which are so often met with 
 in this injury, and which necessitate immediate surgical interference. 
 These are the usual results of the great amount of violence which 
 alone can produce the displacement of so extensive an epiphysis. 
 It must also be remembered that Bruns has only taken into account 
 those cases in which the diagnosis was confirmed by direct anato- 
 mical examination or by an autopsy. 
 
 M. Delens collected twenty-eight cases, oinitting several of those 
 recorded by Bruns on account of their doubtful diagnosis. 
 
 Manquat {Sur les decollcments epiphysaires traumatiques, These 
 de Paris, 1877) collected 130 cases of epiphysial separation, of which 
 twenty-three were of the lower end of the femur. 
 
 Many other writers have followed Bruns's statement that separa- 
 
 Y Y 2 
 
692 EPIPHYSES OF LOWEE EXTEEMITY 
 
 tion of this epiphysis is the most frequent of all separations. This 
 view might be endorsed by the fact that the lower epiphysis of the 
 femm- is the largest in the body, and by the fact that it commences to 
 ossify first, and remains one of the last unattached to the diaphysis. 
 In the case of the lower femoral epiphysis a period of life is therefore 
 reached when considerable muscular activity, agihty, and restless- 
 ness, especially on the part of boys, are displayed. Such influential 
 causations we do not find in the case of other epiphyses, which only 
 remain separate from the shaft during the earlier periods of youth. 
 
 Dr. Joseph Prochnow, of Buda-Pest, writing in 1892 {Traumds 
 epiphysis-levdlds, Gijdgyds.zat, Buda-Pest, 1892, xxxiv. ; abstract in 
 Pest. Med. Cliir. Presse, Buda-Pest, 1893, xxix. p. 389), makes the 
 same observation. 
 
 The separation of the condyloid epiphysis of the femur which 
 Machse figures {Fractures and Dislocations, 1859, Plate xxxi. fig. 5), 
 and which has been quoted as a case of traumatic separation, is 
 probably the result of maceration. The figure represents a trans- 
 verse fractm-e of the lower third of the shaft of the femur united in 
 the angular position, while there is no evidence of the epiphysial 
 separation — which is perfect and without the slightest evidence of 
 fracture or displacement — having been due to the injury. 
 
 The length of the femm' forming a very powerful arm of a lever, 
 the early ossification, late union, and relative large size of this 
 epiphysis, especially in young children, and the strength of the 
 crucial and other ligaments binding it to the tibia, are all conditions 
 most conducive to its separation. Although resembling the supra- 
 condyloid fracture of an adult in some points, it cannot, as we shall 
 see later on, be considered as identical with it. 
 
 The whole limb has been known to have been torn off at this 
 epiphysis. Mr. T. Bryant {British Medical Journal, May 31, 1884, 
 p. 1044) reports the case of a girl, aged four, who was admitted into 
 Guy's Hospital on August 14, 1882. Her leg had been caught in the 
 driving-strap of a machine, and the limb torn off at the junction of 
 the shaft with the loM^er epiphysis of the femur. There had not 
 been much loss of blood. The knee-joint had been opened, and 
 there was much contusion and damage at the seat of separation. 
 Amputation was performed through the middle of the thigh. Tem- 
 perature from 99-2° to 104°. Death took place on August 29. At 
 the autopsy there was found suppurative meningitis and an acute 
 abscess in the psoas muscle. 
 
 Separation in infancy may be of the pure variety ; there is no 
 specimen in the London museums. 
 
 Separation in infancy with fracture of the diaphysis is represented 
 by a specimen in the AYestminster Hospital Museum, No. 42 {Cata- 
 logue of the Specimens in the Museum of Westminster Hospital, 
 1892, p. 18). In the left femur of a full-term foetus, the epiphysis 
 has been crmpletely separated by violence. The periosteum has- 
 
SEPAEATION OF LOWEK EPIPHYSIS OE EEMUE 093 
 
 been partly stripped off the middle of the shaft, which has been 
 incompletely fractured transversely, the line of fracture being- 
 limited to the anterior and outer surfaces of the bone. There is no 
 displacement of the diaphysis. In the account of the specimen, 
 which was presented by Mr. Holthouse, it is not stated whether the 
 lesion was the result of an experiment or occurred during life. 
 
 Pure separations. — In analysing the description of specimens in 
 various museums, and after carefully examining all the specimens 
 in the London hospitals and in other museums, the author found 
 that they afforded some of the best examples of pure epiphysial 
 separation. 
 
 In some few examples a few bony granules adhere to the 
 circumference of the epiphysis, but are not in any way sufficient to 
 justify the name of fracture. In 
 the ordinary cases the separa- 
 tion has passed through the 
 ossifying layer of the epiphysial 
 cartilage situated between the 
 epiphysis and the diaphysis. 
 
 In two instances the pro- 
 truding diaphysial end is stated 
 to have retained and been 
 covered by the epiphysial carti- 
 lage. In Richet's case the 
 appearance was that of a dis- 
 location, In Coural's (Julia 
 Eontenelle's) case the separa- 
 tion was through the middle of 
 the cartilage, so that a layer of 
 it remained attached to each 
 osseous fragment. The speci- 
 men is described by Delpech, in 
 whose possession it was. 
 
 In the museum of Guy's Hospital there are two preparations of 
 pure separation ; in one {Guy's Hospital Museum Catalog iLe,'^o. 1210''" 
 and No. 1210'^") a few very small flakes remain adherent to the 
 anterior edge of the separated epiphysis towards its outer side ; in 
 the other {Gui/s Hosjntal Museum Catalogue, No. 1210^''^) the 
 epiphysis has a few granules of the diaphysis still attached to its 
 inner part, but there is no fracture of the shaft. 
 
 The latter specimen (Mr. Cock's case, 1864) was taken from a boy 
 (W. C), aged seventeen, who was caught by the fly-wheel of some 
 machinery and carried upwards to the wheel, where ho was strangled. 
 The specimen is figured in Mr. Bryant's ' Surgery.' 
 
 The London Hospital Museum (Mr. Ward's case) {Londuii 
 Hospital Museum Catalogue, No. G h, P. 54) contains a specimen of 
 separation of the lower epiphysis of the femur {Transactions Path. 
 
 Fig. 217. — pube separation of lower 
 femoeal epiphysis 
 
 Mr. Cock's case. (Guy's Hospital Museum, 
 i-size) 
 
694 EPIPHYSES OF LOWEE EXTREMITY 
 
 Soc. vol. xiii. 1862, p. 183). The detachment is clean, there being 
 no fracture of the bone. The patient was a child two years old, 
 who was run over in the streets. The lower epiphysis of the femur 
 was completely detached and dragged forwards. With the epiphy- 
 sis the periosteum has been extensively lacerated and detached in a 
 sort of cup, thus leaving the lower end of the diaphysis quite denuded. 
 The limb was injured beyond all chance of recovery, and the artery 
 and vein were torn. Mr. Ward performed amputation at the hip- 
 joint. The exposed surface of the epiphysis was covered with car- 
 tilage, but that of the extremity of the shaft showed no cartilage 
 whatever. At the posterior border of the extremity of the shaft 
 corresponding to the outer condyle some small spicules of bone had 
 been broken off and dragged away with the epiphysis, but with this 
 exception the exposed surface was whole and uninjured. 
 
 The museum of St. Bartholomew's Hospital (No. 982) contains 
 another specimen, alluded to below, in which the end of the dia- 
 physis is quite entire. It is an excellent example of a perfectly 
 pure separation. In this case the epiphysis was displaced halfway 
 off the shaft. 
 
 A specimen in St. George's Hospital Museum is also one of pure 
 separation, and is figured by Holmes {Diseases of Children, 2nd 
 edition, 1869, p. 259). The case is related fully later on. The lower 
 epiphysis of the tibia and both epiphyses of the fibula were also 
 separated. The injury to the lower end of the femur was compound, 
 with extensive laceration of the skin of the groin. Death took 
 place from pygemia. 
 
 Compound Sepaeation. - The same condition of pure separation 
 has been found in many cases of compound separation where a direct 
 examination has been made of the detached surfaces. 
 
 M. Eichet {L' Union Medicale, Paris, 1876, 3rd series, vol. xxi. 
 p. 426) describes a case of epiphysial separation of the femur, with 
 protrusion of the end of the diaphysis through the skin. 
 
 A child, aged thirteen, under the care of M. Cusco, had his leg 
 caught in the strap of a machine and violently twisted, so that it 
 was bent upon the thigh to a right angle. The end of the bone, 
 covered with epiphysial cartilage, protruded through a large wound 
 on the outer aspect of the thigh at the lower part, a^nd gave the 
 appearance at first sight of a dislocation. The knee-joint was intact, 
 and the femoral condyles and patella remained in normal relation with 
 the tibia. There was no fracture of the diaphysis. Its narrower part 
 was held by the soft parts like a button. Through the wound the 
 condyles of the femur could be felt in position, as well as several small 
 scales of bone still attached to the periosteum at the outer side of 
 the separation, above the external condyle. Pulsation of the popliteal 
 artery was also distinctly felt. 
 
 There was a shortening of seven to eight centimetres. Eeduction 
 was effected without chloroform after considerable difficulty. This 
 
SEPAKATION OF LOWEE EPIPHYSIS OF FEMUR 695 
 
 was followad by cldliriam, elevation of tamp 3rat are, convulsive attacks, 
 and other signs of purulent infection. 
 
 Death took place on the sixteenth day from pyaemia. At the 
 autopsy, metastatic abscesses were found in the right lung, and 
 about seven ounces of recant sero-pus in the right pleura. The 
 joints were normal. As a result of the convulsive movements, the 
 end of the diaphysis was again displaced below and in front of the 
 femoral epiphysis ; it had perforated the synovial pouch, and pene- 
 trated the articulation, and was placed below the patella. There 
 was no trace of fracture except what had been found before death. 
 The condyles, imperfectly held by the lateral and crucial ligaments, 
 were displaced backwards, so that their fractured surface looked 
 towards the popliteal space ; they were otherwise intact. The intra- 
 articular fibro-cartilages and the tibia and fibula were uninjured. 
 
 Leisrinck {Archiv far hlin. Chir. 1872, Bd. xiv. S. 436) reports 
 the case of a boy, aged nine, who was caught and dragged along 
 while stepping from a carriage. There was found complete separa- 
 tion of the lower epiphysis of the femur with very extensive lacera- 
 tion of the soft parts, and protrusion of the diaphysis for a distance 
 of two inches from the wound. Amputation v/as performed through 
 the upper part of the thigh. 
 
 Dr. John H. wings records {Neiv York Medical Becord, 1891, 
 xxxix. p. 11) a case of compound separation of the condyloid epi- 
 physis in a girl aged ten years. The patient had had her left leg 
 caught in a wagon-wheel. The wound being examined under an 
 ana3sthetic, it was found that the condyloid epiphysis had been 
 separated from the diaphysis ; the shaft had lacerated the soft parts, 
 and was protruding through the skin fully five inches. 
 
 Attempts at reduction were made unsuccessfully, until three- 
 quarters of an inch of the end of the shaft of the bone had been 
 removed, when the bone was easily replaced. 
 
 The peculiar stellate radiations of the end of the shaft were 
 found to be perfect, except the right upper or anterior portion, which 
 had been ground off against the hub or spokes of the wheel. The 
 wound was well washed with bichloride solution, and antiseptic 
 dressings were applied. Professor N. R. Smith's anterior wire splint 
 was the one employed. The wound sloughed a good deal, but healed 
 completely after about three months. There was then good firm 
 union, and considerable motion of the knee-joint, with only about 
 one inch of shortening. The patient could walk without crutches, 
 with very little limping, and with a firm elastic step and a good sound 
 leg. 
 
 Dr. A. C. Post {Medical News, Philadelphia, 1883, xliii. p. 571) 
 describes a similar case of a boy (W. D.) aged eight. He was riding 
 in a wagon, when his left knee was caught between the spokes of 
 the wheel and violently wrenched. The lower epi^^hysis of tlie 
 femur was separated, and the end of the diaphysis protruded througli 
 
696 EPIPHYSES OF LOWEE EXTEEMITY 
 
 an extensive wound on the outer side of the knee. Amputation was 
 recommended, but was refused by the parents. Two months later, on 
 September 16, 1883, the patient was examined under chloroform. 
 The end of the diaphysis, detached from the epiphysis, still protruded 
 from an extensive wound in a state of necrosis. There were sinuses 
 in different parts of the thigh, leg, and foot, and sloughs over the 
 heel, exposing the os calcis. The tibia was also exposed and super- 
 ficially necrosed, and other suppuration existed about the foot. 
 Amputation was performed through the middle of the thigh. The 
 femoral epiphysis was found to be in situ, but eroded and almost de- 
 void of cartilage, and the head of the tibia was in the same condition. 
 The knee-joint was completely disorganised. Recovery took place. 
 
 Hamilton, in his Practical Treatise on Fractures and Dislo- 
 cations (7th edit. 1884, p. 530), relates the case of a boy (W. S.), 
 aged twelve ; on August 11, 1877, he had his right leg caught in 
 the spokes of a wagon-wheel, breaking his thigh at the junction 
 of the lower epiphysis with the diaphysis, the lower end of the 
 upper fragment protruding five inches through the flesh. The end 
 was nearly square. His father. Dr. S. B. Smallwood, of Astoria, 
 New York, the lad being under the influence of ether, reduced it 
 within one hour by violent extension and flexion of the leg over 
 his knee, one finger being in the wound and adjusting the frag- 
 ments. Lateral splints were employed. The wound closed in 
 about nine months, and in the meanwhile two small fragments of 
 bone escaped. The patient had also a sharp attack of synovitis. 
 Professor Hamilton examined him on April 18, 1880, and found the 
 leg straight, but shortened three-quarters of an inch. There v/as 
 complete ankylosis of the knee-joint, but the muscles of the leg were 
 well developed, and he walked with very little limp. 
 
 Mr. Chas. Hawkins, in a discussion at the Eoyal Medical and 
 Chirurgical Society on a case of dislocation of the knee on April 26, 
 1842 {Lancet, 1841-42, vol. ii. p. 202; ihid., March 11, 1848, 
 p. 280; Solly's Surgical Experiences, 1865, p. 334), related a case 
 of this kind which occurred in St. George's Hospital many years 
 before. The patient was a boy, between ten and eleven years 
 of age. The accident happened by his getting his leg entangled 
 between the spokes of the wheel when riding behind a carriage. On 
 admission, the end of the femur was situated in the popliteal space ; 
 there was a large wound through which the end of the bone had 
 passed ; there was great pain, but the vessels and nerves were un- 
 injured. • There was considered to be severe injury to the joint, and 
 the leg was amputated. On examining the limb, however, the joint 
 was found to be perfect and intact ; the end of the diaphysis had 
 been torn from its epiphysis. The boy did well. 
 
 At the same discussion Dr. Hocken mentioned a similar case he 
 had seen at the Exeter Hospital, in which attempts at reduction 
 were made, but failed. 
 
SEPAEATION OF LOWEE EPIPHYSIS OF FEMUR 697 
 
 Eutherford Alcock, in an article on ' Injuries of the Joints ' 
 {Trans, of Med. Gliirurgical Society, vol. xxiii. 1840, p. 311, case ix.), 
 describes the case of a boy, aged six and a half, whose leg was caught 
 in the wheel of a cab behind which he was riding. A large lacerated 
 wound extended across the ham from one condyle to the other, 
 through which the shaft of the femur — separated from its epiphysis, 
 and denuded of periosteum — protruded, projecting as far downwards 
 as the middle of the belly of the gastrocnemius. The epiphysis was 
 in position, and the patella uninjured. The capsule of the joint had 
 probably been opened, on account of the synovial-like fluid which 
 issued from the wound for some time. Eeduction was found to be 
 impossible ; Mr. White therefore removed a portion of the protruding 
 shaft with a saw, and reduced the remainder. The artery, vein, 
 and nerve in front of the bone were intact. The bone was then 
 easily replaced, and the limb was put in a semiflexed position on its 
 side, with a splint. The next day the apparatus was disarranged, 
 and the leg flexed upon the thigh. The progress of the case was 
 slow. At the end of nine months the joint did not appear to have 
 materially suffered. It was movable, but the leg was at an angle 
 of 75° with the thigh. A large piece of the shaft was evidently 
 undergoing exfoliation, a corner of dead bone projecting at the 
 wound. The child could get about with crutches, and bear some 
 weight on the leg. 
 
 A similar case is described by Mr. Gay {Lancet, 1867, vol. ii. 
 p. 456). 
 
 J. B., aged thirteen, was admitted into the Great Northern 
 Hospital on May 29, 1867, having been caught and thrown with great 
 violence by a carriage wheel. There was a simple fracture of the left 
 femur about the middle, and a compound fracture of the right at the 
 junction of its lower epiphysis. The end of the diaphysis, stripped 
 of periosteum and cartilage, protruded to the extent of two inches 
 through a very extensive transverse wound in the popliteal space. 
 There was no evidence of any injury to the vessels or nerves. Under 
 chloroform reduction could not be effected ; Mr. Gay removed with 
 a saw the protruding part of the shaft, and replaced the bone in its 
 normal position. An interrupted iron splint was applied with very 
 gentle extension. Some adduction of the upper fragment was over- 
 come by applying splints and altering the position of the limb. On 
 the fourth day there was effusion into the knee-joint, but this dis- 
 appeared by the end of the third week. Complete recovery took place 
 at the end of three months, so that the child was able to walk 
 perfectly. There was firm consolidation of both bones, and no over- 
 lapping of the left femur. Measurement of the two limbs gave half 
 an inch shortening on the right side. There was abundant callus. 
 
 Dr. E. H. Harte, of Philadelphia, cites {Trans. Amer. Surgical 
 Association, 1895, vol. xiii. p. 396) the following instance of pure 
 separation. It is also described by Dr. Packard. 
 
698 EPIPHYSES OF LOWEE EXTREMITY 
 
 William B., aged ten years, was admitted to the Episcopal 
 Hospital, September 30, 1890. While clinging to the back of a 
 vehicle his leg became entangled in the wheel. A compound separa- 
 tion of the lower epiphysis of the femur was produced, with a strip- 
 ping off of .a considerable portion of the periosteum. The lower 
 epiphysis was completely separated, and carried with it the ossifying 
 cartilage. The denuded shaft of the diaphysis projected through the 
 large wound. So great was the violence of the injury that the leg 
 was torn off below the knee. There was no rotation of the epiphysis, 
 perhaps (Dr. Packard suggested) because the lower connection of the 
 gastrocnemius was severed. The thigh was amputated in the middle 
 third, and the patient made an uninterrupted recovery. 
 
 In Dr. Meisenbach's case of compound separation the detachment 
 was perfectly smooth, no splinters being attached to the epiphysis. 
 
 A like pure separation of this epiphysis may occur at any age as 
 the result of severe direct crushing violence, but such cases cannot 
 be of so great value to the pathology of the lesions we are considering 
 as those we have just considered. 
 
 Mr. Ward's case at the London Hospital, mentioned by Mr. 
 Jonathan Hutchinson and described above, is an example of pure 
 separation the result of complete smashing of the limb by direct 
 violence. 
 
 M. A. Broca brought before the Societe Anatomique in 1885 
 {Bidletins cle la Societe Anatomique, Paris, serie iv., tome x. 1885, 
 p. 228) a most interesting case of pure separation with rupture of 
 the internal coats of the popliteal artery by direct violence. A 
 child, aged five years, was brought to the Hopital de la Pitie 
 (under Professor Verneuil), having been run over and crushed by a 
 carriage. The leg was almost completely separated from the thigh, 
 for in front of the thigh there was a very large, irregular, and rugged 
 wound, and an evident epiphysial separation of the femur. The 
 lower end of the upper fragment was somewhat displaced outwards 
 and completely separated from the patella. The femoral condyles 
 could be seen in contact with the exposed articular surfaces of the 
 tibia and presented their lower surface forwards, their posterior 
 surface having been drawn downwards by the action of the 
 gastrocnemii, and immovably fixed in this position by the post- 
 mortem rigidity of these muscles — for the leg was undoubtedly 
 dead; it was quite cold, insensible, and without any trace of 
 pulsation. There was no flow of blood from the wound of the soft 
 parts — only a slight bloody oozing from the osseous surface, which 
 continued till the following morning, when ampu^jation of the thigh 
 was performed. The child died the following day. 
 
 On dissection of the limb the following lesions were found : 
 (1) There was a complete epiphysial separation of the lower end of 
 the femur ; this separation was remarkable in that, contrary to the 
 rule, it was not accompanied by any fracture, but, on the other 
 
SEPAKATION OF LOWER EPIPHYSIS OF FEMUR 699 
 
 hand, some small cartilaginous processes remained adherent to the 
 diaphysial surface. The periosteum was torn across two or three 
 centimetres above the detached epiphysis, and formed a kind of 
 irregular collar round the epiphysial excavation. The examination 
 of the upper part of the femur, made after the death of the child, 
 showed that the periosteum was detached from the shaft up to the 
 great trochanter. The state of the popliteal vessels was particularly 
 interesting. Their continuity was unbroken. Externally the vein 
 seemed sound, but the artery presented a diminution in its calibre 
 for about two centimetres in extent, and, on opening this vessel 
 above, the two internal coats were seen to be lacera,ted and retracted. 
 There was a clot in the upper end ; the lower end was empty. 
 Between the two ends the external cellular coat alone maintained 
 the continuity of the vessel. The vein had resisted better than the 
 artery, but that it had undergone some stretching was proved by a 
 series of transverse markings or furrows on its internal surface. 
 
 The specimens from the case were placed in the Musee 
 Dupuytren. 
 
 Mr. Symonds had a like case under his care at Guy's Hospital. 
 Chas. A., aged nine, was admitted on April 9, 1886, his right leg 
 having been run over by the wheel of a wagon. There was a very 
 extensive lacerated wound eight inches long on the inner side, 
 exposing the internal lateral ligament and opening the joint at the 
 posterior part of its inner aspect. The tendons on the inner side of 
 the knee W3re also much exposed, and the lower end of the 
 diaphysis protruded into the wound. The epiphysial cartilage 
 remained entirely with the diaphysis, and a sheath of periosteum 
 was torn off the diaphysis for three and a half inches. The separa- 
 tion of the epiphysis was complete. Amputation of the thigh v/as 
 considered necessary, and the patient recovered. 
 
 Although the report states that the whole of the epiphysial 
 cartilage remained with the diaphysial fragment in this instance, it 
 is open to considerable doubt whether this condition actually existed 
 even as the result of the direct crushing violence. It must also be 
 borne in mind that at the ninth year — the age of the patient — 
 the cartilage which subsequently forms the conjugal disc is not yet 
 a distinct structure from the cartilage forming the epiphysis. 
 
 Julia Fontenelle's and Rougon's cases {loc. cit. supra) may 
 also be considered as examples of separation uncomplicated with 
 fracture. 
 
 In Rougon's case the greater part of the cartilage remained 
 adherent to the epiphysis, and Hutchinson says that the diaphysia 
 end in his case bore no traces of it. 
 
 In Julia Fontenelle's case, at many points of the rugged 
 extremity of the diaphysis, principally on the outer side, a white 
 material was visible, of a glistening aspect, which appeared to be 
 the ossifying cartilage ; but the greater part of this had followed the 
 
700 EPIPHYSES OF LOWEE EXTREMITY 
 
 condyles, which were siUTOunded by the capsule of the knee-joint 
 and were continuous above with the periosteum. 
 
 Menard, in his work, proves that the cartilage remains adherent 
 to the epiphysis in these cases. 
 
 In Eathbun's case, quoted below, it was found that the line of 
 separation followed the epiphysial cartilage throughout, and in no 
 place did it traverse the osseous tissue. 
 
 Dr. H. E. AATiarton mentions (University Medical Magazine, 
 Philadelphia, January, 1889, vol. i. No. 4, p. 214) a case of pure 
 epiphysial separation which he had seen. The lad had the shaft of 
 his right femur cleanly separated from its lower ex^iphysis and 
 driven through the skin by having his leg caught in a rajoidly 
 revolving wheel. 
 
 In a case of Fischer and Hirschfield the separation of this 
 epiphysis, although a simple and pure one, w^as accompanied by 
 other severe lesions (separation of the upper epiphysis of the tibia 
 and both epiphyses of the fibula) of the opposite limb, which proved 
 fatal from suppuration and necrosis. The separation of the lower 
 epiphysis of the femur was found at the time of death, eleventh 
 week, to be firmly consolidated, though with some rotation of the 
 epiphysis. This was rotated so that its internal condyle ascended 
 somewhat forwards, whilst the external condyle descended back- 
 wards. The knee-joint was not injured. 
 
 Another instance of pure separation is recorded by Jarjavay 
 {TraiU d'anatomie chirurgicale, 1852, tome i. p. 70) from the 
 practice of M. Velpeau. A girl, aged nine years, had been knocked 
 down in the street, and the wheel of an omnibus had passed over her 
 thigh. The lower end of the diaphysis, entirely denuded of its 
 periosteum, projected five centimetres on the outer side of the limb 
 through a wound of the soft parts. 
 
 This end of the bone, which was resected, was preserved by M. 
 Jarjavay, because in M. Gueretin's experiments the epiphysis always 
 dragged away some portion of the diaphysis ; in this instance the 
 surface of the bone was slightly undulating, smooth, and vdthout 
 any trace of fracture. 
 
 Dr. J. M. Elder showed, before the Canadian Medical Associa- 
 tion at Montreal, September 1891 (Montreal Medical Journal, 
 ' Traumatic Separation of the Lower Epiphysis of the Femur,' 
 March 1892, p. 643), the following case of compound separation in a 
 youth. 
 
 ' When seven years old he was standing on one foot, with the 
 other resting on the hub of a wagon-wheel ; a pile of lumber 
 behind him fell forward and struck the standing limb just below the 
 knee, driving the lower part of the leg violently forwards, and 
 letting the lower part of the femur impinge on and perforate the 
 popliteal space, through which the bone protruded for about three 
 and a half inches, lotting the boy down as it were. The two 
 
SEPAEATION OF LOWEE EPIPHYSIS OE FEMUE 701 
 
 nearest medical men were at once smnmoned, and diagnosed com- 
 pound dislocation backward of the femur, not noticing the absence 
 of the condyloid cartilage on the protruding bone. Two different 
 attempts under chloroform were made at reduction, but neither were 
 successful, so amputation above the knee was advised. To this the 
 boy's father strongly objected, and, failing this, they sawed off what 
 they could not reduce (about an inch and a half), tucked in the 
 remainder, and left the case in disgust a.t the obduracy of the 
 father. It was hot weather, and before the days of modern anti- 
 septicism, so that the neglected wound soon became septic. The 
 father (an intelligent French-Canadian blacksmith) then took the case 
 in hand, and henceforward was the only one who acted as surgeon. 
 He killed the maggots by pouring whisky into the wound, and im- 
 provised a sole-leather back-splint. In four weeks the lad was 
 propelling himself around the garden, and in two months was 
 walking, at first stiffly, but as time went on he got the perfectly 
 good knee-joint which he then presented. The injured limb was 
 shorter than the other by exactly the amount of bone removed 
 thirteen years ago (one and a half inches), but in every other 
 respect was as strong as its fellow, and he was able to do any kind 
 of work. The specimen of bone was not quite perfect, owing to the 
 father having singed it at his forge "to burn off the stink," but it 
 could be plainly seen to be the lower end of the femur.' 
 
 From the above-mentioned evidence, museum specimens, and 
 compound separations we see that the cartilaginous line of union 
 generally remains adherent to the condyloid epiphysis, and that 
 only a thin very fine layer occasionally adheres to the rounded 
 mammillated end of the diaphysis. The end is somewhat of the 
 shape of a wooden mallet, the separation occurring for the most 
 part through the ossifying layer of Eanvier, but it may be observed 
 that the separated cartilage more commonly drags off a few granules 
 of the spongy tissue of the diaphysis in the form of small scales 
 or flakes. Very frequently a somewhat larger chipping of the 
 diaphysis takes place. 
 
 Pure separation without displacement. — The tough periosteum of 
 the lower end of the diaphysis remains in this condition untorn, but 
 stripped off the diaphysis to a greater or less extent. 
 
 Mr. Hutchinson junior's specimen at the Eoyal College of 
 Surgeons from a lad aged fourteen is a good example ; in this case 
 there was also an intercondyloid fracture of the epiphysis, from 
 which a small fragment was broken off. 
 
 The accompanying drawing is taken from a photograph kindly 
 presented to the author by Professor J. G. Adami, of McGill Univer- 
 sity, Montreal. The specimen is in the McGill Medical College 
 Museum. It shows a pure separation with little displacement. 
 The epiphysis is only slightly rotated on its transverse axis, and a 
 slight gap is left between the epiphysis and posterior edge of the 
 
702 EPIPHYSES OF LOWEE EXTEEMITY 
 
 diaphysis. Professor Adami notes that ' the condyles are com- 
 pletely separated from the diaphysis at the epiphysial line without 
 any evidence of other injury to the bone. From the appearance of 
 the parts separation had evidently occurred some time before death. 
 Unfortunately there was no history.' 
 
 ^' 
 
 Fig. 218. — sepaeation with slight displacement 
 (McGill University Museum, Montreal, Canada) 
 
 Separation with fracture of tli9 diaphysis. — Although pure separation 
 is not uncommon, on the other hand the separation is more often 
 associated with a fracture of the diaphysis, which may be multiple 
 or more or less extensive in character. 
 
 A careful and minute description has been given of the form and 
 dimensions of the co-existing fracture in seventeen cases, in which a 
 direct examination has been made. Six of these are museum 
 specimens, eight were cases of compound fracture, and three were 
 cases in which amputation was performed for subsequent gangrene 
 or other complication. 
 
 The length of the portion of the diaphysis separated off from its 
 end and remaining attached to the epiphysis varies very much, from 
 one-third to two and a half inches. In others it is an insignificant 
 spicule or two of bone. It may be from the outer, inner, anterior, 
 or antero-internal part of the diaph5^siary extremity, according to 
 the direction of the displaced epiphysis and the violence causing it. 
 
 It is noticeable that in all six of the specimens in the London 
 museums associated with fracture this has taken place on the outer 
 side, and in the compound cases, mentioned above, four were com- 
 bined with fracture on the inner side, one at the antero-internal part, 
 and in one the situation is not stated. Of the three remaining cases 
 one was fractured on the outer side, another at the anterior part, and 
 in the third the position of the fracture is not stated. It is probable 
 that the fragment of the diaphysis is always situated on the side of 
 bone opposite to that upon which the violence first acts, consequently 
 the epiphj'sis is first separated on the one side by the violence before 
 the fracture takes place on the other. 
 
 The specimen in the Museum of St. Bartholomew's Hospital 
 {St. Bartliolonieu-' s Hospital Museum Catalogue, vol. i. p. 110), No. 
 
SEPAEATIOX OF LOWEE EPIPHYSIS OF FEMUE 703 
 
 758, is the lower extremity of the femur of a boy, aged fourteen, 
 showing a separation of the epiphysis from the diaphysis. In this 
 specimen the epiphysis is not rotated. On its outer side there 
 remains a small fragment of the diaphysis, about one-third of an 
 inch long and nearly one inch in length, still adherent to it. 
 
 The sx^ecimen in the Charing Cross Hospital Museum, No. 391 
 {Charing Cross Hospital Mussiwi Catalogue, 1888, p. 36), consists of 
 portions of the bones of the knee-joint removed by excision. 
 
 Separation of the epiphysis has taken place quite cleanly tlirough, 
 about the inner three-quarters of epiphysial junction, but on the 
 outer side a triangular piece of the diaphysis, one and three-quarters 
 of an inch in width and one inch in thickness, retains its connection 
 with the epiphysis. The patella and upper portion of the tibia are 
 shown uninjured. 
 
 The case is described by Mr. E. Canton in the Transactions of 
 the Fatliological Society (vol. x. 1859, p. 232), and is figured 
 in Treves's System of Surgery (vol. i. 1895, p. 847, fig. 291). A 
 boy, aged eight years, when ahghting from a cart, shpped, and, his 
 foot becoming entangled betw^een the spokes of one of the wheels, 
 he fell to the ground. On examination at Charing Cross Hospital, 
 Mr. Canton found the lower epiphysis of the femur torn from the 
 shaft, with considerable contusion of the soft parts. The fragments 
 w^ere reduced and adjusted in the hope that union would take place. 
 However, in the course of a few days, suppuration, sloughing, and 
 severe constitutional disturbance necessitated the performance of 
 excision of the whole articulation. Eecovery rapidly ensued. The 
 union of the soft parts was perfect, but the fibrous union between 
 the bones permitted very considerable 
 movement, so that the leg resembled 
 a flail. At the end of five months, 
 amputation, urged by the parents, 
 was performed through the lower 
 third of the thigh. Eecovery. {Dub- 
 lin Quarterly Journal, 1861, p. 74 ; 
 Lancet, vol. ii. 1858, August 28, 
 p. 231.) 
 
 The Museum of the Eoyal College 
 of Surgeons of England {Catalogue 
 of the Boyal College of Surgeons 
 Museum, Appendix 1. p. 30) contains 
 a specimen, No. 1041b, of the lower 
 end of a femur and the knee-joint, 
 
 showing a separation of the low^er epiphysis of the femur, associated 
 with fracture of the diaphysis, presented to the museum by W. 
 Spencer Watson, 1884. The separation is not a clean one, but a 
 portion of bone (more than one inch in length) broken from the 
 diaphysis is attached to the outer side. It was taken from a boy, 
 
 Fig. 219.— sepaeation with feactuke 
 of the di.aphysis 
 
 (Eoj'al College of Surgeons Museum, 
 No. 1041b) 
 
704 
 
 EPIPHYSES OF LOWEE EXTKEMITY 
 
 aged twelve, who was severely injured one week before his death 
 by being caught in some machinery. During hfe the lower end of 
 the diaphysis of the femur projected on the inner side of the hmb 
 and nearly penetrated the soft parts ; the periosteum covering the 
 lower third of the shaft of the femur was separated from the bone 
 by a collection of blood and pus. He died from exhaustion. 
 
 Another specimen, No. 1041a, in the Museum of the Eoyal 
 College of Surgeons of England, presented by F. S. Eve, Esq., 1887, 
 
 shows separation of the epi- 
 physis with fracture of the 
 diaphysis. The outer half of 
 the epiphysis, corresponding 
 to the external condyle, is 
 cleanly separated ; but at the 
 level of the intercondyloid 
 notch a dentate fracture ex- 
 tends upwards and inwards 
 through the shaft, leaving a 
 considerable fragment of it 
 attached to the epiphysis. 
 The part was removed by 
 amputation from a boy, who 
 sustained a severe injury to 
 the limb by the wheel of a 
 tramcar. 
 
 In Packard's case there 
 was an extremely small por- 
 tion of the diaphysis detached 
 from the inner side. 
 
 In some instances the frac- 
 ture of the diaphysis may be 
 so extensive and comminuted that the separation of the epiphysis can 
 only be regarded as of secondary importance ; but where the joint is 
 involved as well, as in the following specimen from St. Bartholomew's 
 Hospital, the lesion is increased so much more in its gravity. 
 
 The specimen in St. Bartholomew's Hospital Museum, No. 977, 
 of the lower two-thirds of the shaft of a femur, shows a comminuted 
 fracture of the lower end of the shaft and of the epiphysis, extending 
 into the knee-joint. The fracture extends almost vertically along 
 the centre of the shaft to the junction of the lower with the middle 
 third ; midway it is joined by a lateral fracture. The fractured 
 surfaces are partially united. Above the upper limit of the fracture 
 on the inner side is a projecting fragment of new bone, probably 
 formed by a portion of uptorn periosteum. The condyles of the 
 femur are separated, and the anterior portion of the articular surface 
 is detached from them. On the outer portion of the fractured epi- 
 physis none of the diaphysis adhered to the epiphysis. There is 
 
 Fig. 220. 
 
 -SEPARATION WITH EXTENSIVE ERACTUEE 
 OF THE DIAPHYSIS 
 
 (Royal College of Surgeons Museum, 1041a, 
 |-size) 
 
SEPAEATION OF LOWEK EPIPHYSIS OF FEMUK 70o 
 
 also new periosteal bone on both the lower fragments of the 
 diaphysis, as if from the result of suppurative periostitis, and the 
 cellular spaces of the whole of the shaft in the specimen are seen to 
 be opening out and becoming rarefied. 
 
 In Mr. A. H. Tubby's specimen of separation of the lower epiphysis 
 of the femur in the Royal College of Surgeons Museum, No. 1041g, 
 there is extensive stripping off of the periosteum from the lower 
 part of the shaft, probably the result of periostitis secondary to an 
 injury. Hovv^ever, the epiphysial line of cartilage does not appear 
 to have been destroyed by inflammation. The lower extremity of 
 the shaft is displaced forwards, and is somewhat splintered. No 
 history. 
 
 Compound Sepaeation with Fracture of the Diaphysis. — 
 P. Bruns relates (Archiv fill- hlinisclie Chirurg. 1882, Bd. xxvii. 
 S. 240) the case of a girl, aged eleven 
 years, who had been run over by a 
 waggon loaded with hay. On the outer 
 side of the knee there was a contused 
 wound which exposed the outer condyle 
 and opened the knee-joint. Death took 
 place on the sixth day from exhaustion, 
 primary amputation having been re- 
 fused. The separation of the epiphysis 
 on the outer side followed exactly the 
 epiphysial junction as far as the middle 
 line, and then passed upwards and in- 
 wards as a fracture through the spongy 
 tissue of the diaphysis. The fragment 
 of the diaphysis was still held in posi- 
 tion by an unbroken portion, one cen- 
 timetre in thickness, of the compact 
 tissue on the inner side. 
 
 Professor Jas. L. Little showed to the 
 New York Pathological Society, May 24, 
 1865 {New York Medical Journal, vol. ii. 1865-6, p. 131 ; The 
 Illustrated Qaarterhj of Medicine and Surgery, New York, vol. i. 
 No. 1, January 1882, p. 23, plate iii.), a specimen obtained from his 
 own practice. Wilhe B., aged eleven, while hanging on the back of a 
 waggon, had his right leg caught between the- spokes of the wheel, 
 which was in rapid motion. A few hours after the accident, Dr. 
 Little found a separation of the lower epiphysis, the upper fragment 
 of the femur projecting three inches through an opening in the 
 upper and outer part of the popliteal space — the upper fragment 
 completely overlapping the lower — and considerable contusion and 
 laceration of the soft parts. On examination, the wound did not 
 appear to communicate with the knee-joint. The protruding part 
 of the diaphysis was cleanly stripped of its periosteum. Under the 
 
 z z 
 
 
 Fig. 221. — partial separation of 
 lower femoral epiphysis, with 
 incomplete fracture of dia- 
 PHYSIS 
 
 (After Bruns, ' Deutsche Chirurg '.e.' 
 1886, S. 123) 
 
706 
 
 EPIPHYSES OE LOWER EXTREMITY 
 
 influence of ether, the fragments were reduced by strong extension 
 of the hmb and flexion of the leg upon the thigh, the reduction 
 occasioning a dull cartilaginous crepitus. There was at the time no 
 pulsation in the posterior tibial artery, and the hmb was cold. The 
 haemorrhage was free, but no ligatures were necessary. The limb 
 was laid over a double-inclined plane. The following day pulsation 
 and warmth returned, but the upper fragment had again become 
 displaced, and it was found that it could only be kept in place by 
 extreme flexion of the leg. This position was maintained by the 
 application of plaster bandages, binding the leg to the thigh. 
 
 Fig. 222. — professor ,t. l. little's case of 
 compound separation with displacement 
 inwards of the epiphysis 
 
 Fig. 223. — the same after amputation, 
 
 SHOWING slight FRACTURE OF THE 
 DIAPHVSIS 
 
 Considerable traumatic fever followed, with swelling, and on the 
 tenth day slight secondary haemorrhage from the wound. On the 
 thirteenth day serious secondary hasmorrhage occurred from the 
 anterior tibial artery near its origin, and it became necessary to 
 amputate. 
 
 The boy made a good recovery. The specimen showed (a) the 
 synovial membrane involved and intensely reddened throughout and 
 an almost perfect separation of the lower epiphysis, which at one 
 point (b) however traversed the bony structure. 
 
 J. R. Reverdin has given {Beviie Med. de la Suisse Romcmde, 
 Geneve, 1886, vi. p. 291, with figure) an accurate and detailed 
 
SEPAEATION OF LOWEK EPIPHYSIS OF FEMUK 707 
 
 account of an incomplete traumatic separation combined with 
 fracture. 
 
 Marie B., aged four years and two months, while endeavouring 
 to climb behind a carriage, had her right leg caught between the 
 spokes of the wheel. There was a transverse lacerated wound right 
 across the popliteal space, and the diaphysis, stripped of its perios- 
 teum, projected nearly four inches. Its end was convex, mammillated, 
 and much soiled with dirt. The pophteal nerves were both exposed 
 for a considerable distance, but appeared to be intact. On explora- 
 tion, pulsation of the popliteal artery was felt on the inner side of 
 the nerves, and a clean separation of the outer half of the epiphysis ; 
 at the inner part a largish pyramidal fragment of the diaphysis, 
 three centimetres in height above the epiphysial line, was still 
 attached to the epiphysis. Several loose scales of bone were also 
 felt. Under chloroform, an attempt was made to preserve the limb. 
 The soiled parts of the end of the diaphysis were soft enough to be 
 removed with a knife, the wound was thoroughly cleansed with a 
 five per cent, solution of carbolic acid, and iodoform dressings were 
 applied. While a Volkmann's splint was being applied, the limb 
 was noticed to be pale and cold. The next day the foot was still 
 cold and insensitive. On the fourth day there was gangrene of the 
 edges of the wound, ending at some distance on the inner side 
 in the calf. On the sixth day the external popliteal nerve was 
 found to be partially destroyed, the internal popliteal nerve reddened, 
 and there was suppuration of the entire wound extending into the 
 calf along the gangrenous part and into the thigh. There was also 
 necrosis of the femur externally. Amputation was consequently 
 performed. Eecovery was rapid, and the wound healed in six weeks. 
 
 Examination of the amputated limb showed the popliteal artery 
 full of pinkish grey clot, without any injury to its coats, and diffuse 
 suppuration of the calf and thigh, also a small slough on the heel. 
 It is probable that the vessel must have been compressed either by 
 the epiphysis or the reduced diaphysis. Separation of the epiphysis, as 
 previously seen, had occurred, and the pyramidal piece of the shaft was 
 surmounted by a small fragment incompletely separated from the 
 main piece. The epiphysial surface of the external condyle was formed 
 of cartilage only at the margins ; in the centre there remained ad- 
 herent to the cartilage a thin granular layer of hard osseous tissue. 
 A split with a slight interval between the epiphysis and the fragment 
 of the shaft could be detected on slightly separating these portions 
 of the bone. The periosteum was torn from the inner condyle 
 behind at the level of the epiphysis, but in front one centimetre 
 above this. The joint was opened by a small rent on the outer side, 
 and behind, where the periosteum was torn off to the level of the 
 cartilage, and contained a little sero-sanguineous fluid. The crucial 
 ligaments were inflamed and of a pinkish colour. 
 ' Taprct and Chenct have reported a similar case (Bull, de la Soc. 
 
708 EPIPHYSES OF LOAYEE EXTREMITY 
 
 Anatomique, Paris, January 8, 1875, 3eme serie, vol. x. p. 25) in 
 a boy aged nine and a half years. In climbing behind a carriage 
 he had his right leg caught in the spokes of a wheel. The skin 
 was transversely lacerated in the ham, and there was great articular 
 effusion. Considerable hsemorrhage took place before his admission 
 into the Hopital des Enfants Malades. The limb was put up in 
 an immoA'able plaster-of-Paris splint, leaving the popliteal region 
 free ; but after a few daj^s sloughing ensued, and evacuation of a strip 
 of muscle, which exposed the end of the shaft. Amputaiion was per- 
 formed at the middle of the thigh by M. de Saint-Germain. On 
 exaiTiination, the separation followed the line of union between the 
 epiphysial cartilage and the shaft, but towards the inner side it 
 deviated a little so as to include a small portion of the diaphysis at 
 this part. The popliteal vessels were intact and the articular liga- 
 ments uninjured. Death ensued five days after the amputation. At 
 the autopsy there were extreme muscular lacerations and collections 
 of blood about the stump, some of which had suppurated. 
 
 M. A. Broca brought before the Societe Anatomique, Paris, 
 May 30, 1884 (Le Progres Medical, Paris, 1885, 2eme serie, vol. i. 
 p. 170 ; Bull, de la Soc. Anatomique, 4eme serie, tome v. 1884, p. 407) 
 the case of a boy, aged three and a half, who had had his leg crushed 
 by a tramcar, so that it was completely divided at the anterior 
 tuberosity of the tibia. He was admitted into the Trousseau 
 Hospital under the care of M. Lannelongue. The fibula was not 
 fractured, but its upper end was detached at its articulation with the 
 tibia, and protruded. The wound was greatly contused and pulped, 
 and the lower epiphysis of the femur found to be movable. Am- 
 putation of the thigh was performed two and a half inches above 
 the joint. Death ensued from shock the nest morning. The epi- 
 phj^sial separation of the femur was combined with a fracture, which 
 extended upwards and inwards from the inner third of the separated 
 surface as far as the middle third of the diaphysis. This portion of 
 the diaphysis remained connected with the epiphj^sis. The epi- 
 physial cartilage was adherent to the epiphysis. 
 
 Mr. E. Canton reported a second case to the Pathological 
 Society in 1860 [Transactions of the Pathological Society, London, 
 vol. xi. 1860, p. 195, woodcut 10 ; Duhlin Quarterly Journal of 
 Med. Science, February 1861). W. J., aged fifteen years, w^as 
 admitted into Charing Cross Hospital on October 21, 1859. He 
 had received a violent kick from a horse on the left knee. On 
 admission there was shortening of the limb, complete eversion of 
 the foot, and slight flexion of the leg. The patella was directed 
 outwards with considerable and general swelling around the knee, 
 and with such distortion of the parts as to give the impression of 
 the tibia being dislocated backwards and somewhat outwards. The 
 inner femoral condyle appeared to project unduly, and the skin 
 covering it was tense and abraded. On the outer side, and above 
 
SEPAEATION OF LOAVEE EPIPHYSIS OF FEMUE 709 
 
 the patella, a forward elevation of bone could be felt. Careful 
 manipulation of the lower end of the femur elicited crepitus. By 
 extension and counter-extension the parts were easily reduced and 
 adjusted by means of splints, but towards the end of October they 
 became displaced through the restlessness of the patient. There was 
 also articular inflammation, and in two days' time a slough formed 
 on the inner side of the knee, which allowed slight projection of the 
 subjacent bone. Severe constitutional disturbance set in ; Mr. 
 Canton, therefore, on November 3, excised the articulation. The 
 boy recovered perfectly, and the bones were properly ankylosed 
 when he w^as discharged. 
 
 The specimen showed a separation running through about 
 .three-fourths of the circumference of the epiphysial line, while the 
 remaining fourth was still firmly held in its normal position. Thus 
 an oblique fracture of the shaft commenced at its outer side and ran 
 into the epiphysial separation below. There was also a comminuted 
 portion of the shaft displaced into the popliteal space. The patient 
 was able to walk a long distance. After being out of the hospital 
 for about two months he had a fall, which was thought to have 
 loosened the union between the bones. Amputation was performed 
 at his own desire. 
 
 Mr. Holmes {Surgical Diseases of Children, 1869, 2nd edit. 
 p. 260, fig. 45), in quoting the case, adds that the preparation at 
 Charing Cross Hospital proves that there was really no reason for 
 the amputation, and gives a figure showing the bones firmly 
 ankylosed, in good position, and free from disease. 
 
 G. Marcano relates {Bull, cle la Soc. Anatomique, 1875, 4eme 
 serie, x. p. 227 ; Le Progres Medical, August 14, 1875, p. 460) 
 the case of Chas. S., aged fifteen years, who was admitted into the 
 Beaujon Hospital under the care of M. Dolbeau. His arm had been 
 caught in the transmission strap of a machine and his body flung in 
 all directions till his arm was completely torn off. Comminuted 
 fractures of the left humerus and right femur were found, and at 
 the inner side of the left knee, just above the joint (the movements 
 of which were free), there was a large projection, presenting a sharp 
 wrinkled edge. 
 
 There was soft crepitation, and reduction was easy by means of 
 pressure on the upper fragment, but the displacement was repro- 
 duced as soon as the parts were left to themselves. Death occurred 
 the next day. At the autopsy the epiphysial separation was seen 
 to pass through the line of junction of diaphysis and epiphysis, 
 except quite at the outer side, where there was a fracture of the 
 diaphysis and a scale of bone detached, leaving an irregular surface 
 for the extent of three centimetres on the anterior aspect of the 
 femur. The periosteum was loosened at the inner side of the 
 diaphysis for eleven centimetres in length by five centimetres in 
 width, though it still adhered to the epiphysis. 
 
710 EPIPHYSES OE LOWEE EXTEEMITY 
 
 Dr. Davis Halderman, Professor of Surgery in the Starling 
 Medical College, reports {Neio York Medical Becord, vol. xxi.-xxii. 
 July 3, 1882, p. 600) a case in a mulatto boy, eighteen years old, 
 caused by a violent blow over the front and lower part of the right 
 thigh. Three hours after the accident the patient was brought to 
 St. Erancis Hospital, Starling Medical College. On examination there 
 was great swelling about the knee ; the leg and foot were cold, and 
 the dorsalis pedis artery was pulseless. Numbness, too, was com- 
 plained of below the joint, while in the latter excruciating pains 
 were experienced. The hmb was shortened two inches. Owing to 
 the swelling the line of separation could be with difficulty made out, 
 but it w^as finally located two inches above the articular plane in 
 front, and the lower end of the shaft could be distinctly felt directly 
 beneath the integument, in the popliteal space, on a level with the 
 anterior tibial tuberosity. Efforts were now made with the aid of 
 ansesthetics at adjustment, but without success ; for although the 
 limb, by means of extension and counter-extension, could be brought 
 down to nearly its natural length and the projection in the popliteal 
 space could be caused somewhat to recede, the moment the efforts 
 were relaxed the displacement would recur. In view of this, and the 
 crippled condition of the circulation, it was deemed advisable, for 
 the time being at least, to place the patient in bed, with the limb 
 slightly elevated and in as comfortable a position as possible, and await 
 results. 
 
 At the end of twenty-four hours the swelling had increased ; 
 some slight discoloration over the foot and leg had set in, but the 
 temperature was somewhat improved, and while the shock had been 
 for the most part recovered froin, the pains about the joint still 
 seemed out of proportion for injuries of this kind, and the dorsalis 
 pedis artery remained pulseless, as indeed it continued to the end. It 
 was determined to place the limb in a flexed position upon a double 
 inclined plane with moderate extension, and see if by this means 
 suffering might not be lessened. In its adjustment the limb was 
 brought down within half an inch of the length of its fellow, but no 
 weight sufficient to keep it there could be borne. The patient from 
 this time on felt easier, so far as the injured extremity alone was 
 concerned. By next day, however — the second after the accident — 
 considerable constitutional disturbance had supervened, pulse was 
 118, temperature 102°, and burning sensations in the foot and 
 under side of the leg were experienced, while the toes and plantar 
 aspects of the foot were dull on pinching and pricking. It was 
 thus evident gangrene of these parts was threatening, but it was 
 still thought the collateral circulation about the knee might arrest 
 the morbid action below this point, a hope that was warranted by 
 the natural warmth and sensibility over the upper part of the leg, 
 and that was maintained to the last, which was three days later. 
 Meantime the discoloration below this point spread and deepened ; 
 
SEPAEATION OF LOWEE EPIPHYSIS OF FEMUE 711 
 
 phlyctenulge finally formed over the lower, outer, and under part of 
 the leg and ham, and at the latter place also quite an eschar, from 
 the pressure of the end of the bone beneath the skin. The leg and 
 foot at last became cold and insensible to deep pricking, except near 
 the knee and along the inner aspect of the leg, corresponding to the 
 course of the great saphenous nerve, which, save at its termination, 
 remained intact. Accordingly, on the fifth day after the injury, the 
 limb was removed at the inferior part of the middle third of the 
 thigh, the damaged state of the tissues being such as to preclude 
 amputation lower down. 
 
 Dissection of the amputated limb revealed the fact that the tissues 
 about the injury had been severely damaged, the soft parts for some 
 distance around being extensively lacerated and pulped in the imme- 
 diate vicinity of the fracture. Blood was widely extravasated up and 
 down the limb, and filled the joint cavity through a rent on its inner 
 side. The lower end of the femur was completely denuded of 
 periosteum, muscle, &c., and lay bare amid the debris of the injury, 
 as did also a mass of broken-off cancellous bone, about the size of 
 the end of a man's thumb. The detached epiphysis, still connected 
 with the popliteus and gastrocnemius muscles, was tilted backwards 
 by their action, and at the same time was overlapped at its posterior 
 and outer aspect by the shaft to the extent of several inches. 
 Between them, and on the anterior and inner aspect of the latter 
 bone, lay the internal popliteal nerve, and the popliteal vein and 
 artery were impinged upon by the fragments — that is, these parts, in- 
 stead of being behind the bone, had been displaced to the front of it, 
 and were held there by the hook-shaped projection of the divided 
 internal condyloid ridge over which they had caught, so that any 
 effort at adjustment served only the more heavily to bear down 
 upon and closely embrace them, and thus to cut off the cir- 
 culation and innervation beyond. The artery was contused and 
 inflamed. Its walls were thickened, its interior roughened and 
 filled with clotted blood. The vein was in the same condition, and 
 the nerve too, as concerned its pressure. The outer popliteal nerve, 
 although still sustaining its proper relation to the bone, was dragged 
 down and also pressed upon severely by the latter in its malposition. 
 Death occurred from pyaemia on the thirtieth day after amputation 
 and the thirty-fifth day after the injury. 
 
 M. Delens says {loc. cit. supra), in his analysis of cases, there 
 will be found twelve in which epiphysial separation is mentioned 
 without the question of fracture or splinters. In nine cases, on the 
 other hand, there existed a fracture in association with the separa- 
 tion, generally represented by one or more fragments from the 
 extremity of the diaphysis. 'But,' he continues, 'it is very likely 
 that these figures do not express the exact proportion of true 
 separations and separations with the existence of fracture. These 
 latter cases appear to me to be the most frequent, and no douljt the 
 
'12 
 
 EPIPHYSES OF LOAYEE EXTEEMITY 
 
 observers of the cases above mentioned have more than once 
 neglected to mdicate the existence of small fragments when the 
 separation had chiefly taken place in the line of the cartilaginons 
 nnion." 
 
 Separation with iutercondyloid fractiu'e. — Three specimens in the 
 London mnsenms show that this separation is sometimes accom- 
 panied by an intercond^doid fracture. It is somewhat surprising that 
 this is not more frequently the case, seeing the comparatively thin 
 condition of the epiphysis at the iutercondyloid notch (see above). 
 
 Its existence has, however, been suspected in some cases of 
 compound diastasis. 
 
 The specimen in the Guy's Hospital Museum, Xo. 1-210'''^, 
 shows a vertical fracture of the separated epiphysis exactly in the 
 
 centre. It was taken from 
 a patient under the care of 
 Mr. Durham, CorneHus McC, 
 aged foui'teen, who had been 
 caught in the straps of some 
 machinery and whirled^round 
 before it could be stopped. 
 Three or four inches of the 
 shaft of the left femur pro- 
 truded through the skin. 
 Death occurred the same day. 
 There was found a fracture 
 of the skull with meningeal 
 ecchymosis, also fracttu'e of 
 the right tibia and fibula. 
 
 St. Bartholomew's Hos- 
 pital Museum {St. Bartho- 
 lomeic's Hosjjifal Musciiiii 
 Catalogue, vol. i. p. 140) con- 
 tains a specimen, No. 981, 
 exhibiting a separation of the 
 epiphysis from the shaft of 
 the femtu", and a vertical fractm'e extending between the condyles 
 into the knee-joint. The periosteum was stiipped from the diaphysis 
 to the extent of about six inches nearly all round, but remained 
 partly attached to the condyles. The halves of the epiphysis are 
 separated laterally for a distance of two inches in front, withotit 
 any rotation of either fragment. The shaft protrudes thi-ough the 
 muscles on the inner side of the thigh, and is intact. A line of 
 new bone is formed on the anterior part of the shaft along the 
 torn edge of that part of the periosteum which remained attached 
 to the shaft. The injury was produced by a rope being entangled 
 round the leg of a boy aged sixteen. .Yupulation was performed 
 three weeks afterwards. 
 
 Fig. 224. 
 
 -SEPAEATIOX WITH rNTERCOXDTLOID 
 FKACTUKE 
 
 (St. Bartholomew's Hospital Museum) 
 
SEPAEATION OF LOWEK EPIPHYSIS OF FEMUE 73 3 
 
 The specimeD in St. George's Hospital Museum, No. 55a (St. 
 George's Hos;pital Museum Catalogue, 1882, p. 12, No. 3443), shows 
 a separation of part of the epiphysis combined with an obHqne 
 fractm-e of the diaphysis, and is figured in Holmes and Hulke's 
 System of Surg erg (3rd edit. 1883, vol. i. p. 1025). 
 
 The condyles are separated from each other by a longitudinal 
 fracture through the intercondjdoid notch. 
 
 The internal condyle is detached from the shaft by a fracture 
 traversing the epiphysial line. . 
 
 The external condyle is not separated at the cartilaginous 
 junction ; this is still intact, but there is an oblique fracture of the 
 lower end of the diaphysis, thus separating the external condyle 
 with a portion of the diaphysis two inches in length. The 
 specimen was taken from a boy, who was stated to be only fifteen, 
 but who was fully developed and looked at least eighteen, judging 
 from the size of the femur. He was a baker by trade, and caught 
 his leg in the machine employed in bread-making. He was brought 
 to the hospital, where there was found to be such laceration of the 
 soft parts, conjoined with the fracture, that amputation was imme- 
 diately performed. He died the same day. 
 
 Mr. Porter, in 1873 {Proceedings of tlie Pathological Society of 
 Dublin, 1873-75, vol. vi. n.s. p. 117), exhibited at the Pathological 
 Society of Dublin a similar specimen showing a separation of the 
 lower epiphysis of the femur with a fracture between the condyles. 
 There was also a fracture of the os calcis. The specimens were 
 taken from a boy, aged thirteen years, who slipped in jumping on a 
 tramcar and the wheel of the vehicle passed along his lower 
 extremity, causing extensive laceration of the muscles with profuse 
 haemorrhage, for which the limb was amputated. 
 
 Mr. Mansell Moullin showed before the Pathological Society, 
 on November 15, 1887 (Pathological Society's Transactions, vol. 
 xxxix. 1888, p. 243), an interesting case of diastasis, associated 
 with intercondyloid fracture and other lesions, which is quoted 
 later on. 
 
 In the Eoyal College of Surgeons Museum, No. 1041d (Mr. 
 Jonathan Hutchinson junior's specimen, 1888), there are transverse 
 vertical sections of the left femur, from a lad aged fourteen, who 
 sustained a severe crush of the leg between two carriages. Primary 
 amputation was performed on account of the knee-joint being opened 
 and the soft parts much torn. The patient recovered. 
 
 Owing to the periosteum retaining the epiphysis in its place, the 
 detachment of the latter was not diagnosed before dissection. The 
 line of separation has passed chiefly above the epiphysial disc, and 
 in addition there is a vertical fracture of the epiphysis between the 
 condyles, and a loose portion of the epiphysis, three-quarters of an 
 inch long, at the intercondyloid notch. Some fragments of dirt are 
 embedded in the epiphysis. As usual, the periosteum is here more 
 
714 EPIPHYSES OF LOWES EXTEEMITY 
 
 extensively torn off the posterior than the anterior surface of the 
 shaft, and there is httle or no displacement of the epiphysis. 
 
 Displacement of the diapliysis is the usual accompaniment of 
 this separation ; it will be found to vary according to the causes 
 producing the injury, which have been mentioned above. There 
 have been various opinions up to the present as to the common 
 direction of the displacement. 
 
 It usually takes place backwards— Viz. into the popliteal space, as 
 a result of violent overextension of the limb, from the leg being 
 caught in the spokes of a wheel, or, as in Fontenelle's and Bell's 
 cases, from the leg being fixed in a hole and the body thrown violently 
 forwards ; see also cases mentioned by Coural, Little, Voss, and 
 Buck. Tillmans rightly states that in the majority of cases the 
 epiphysis is pushed forwards, and the diaphysis backwards, into the 
 popliteal space. Konig also distinguishes this same direction of the 
 fragments, and the very exceptional opposite direction. 
 
 Among the museum specimens and cases of compound separation 
 we find that thirteen were produced by the entanglement of the leg 
 in the spokes of a revolving wheel; in eleven of these (Listen's. 
 Bell's (second case), and those of Alcock, Gay, Hawkins, Little, 
 Hr.milton, Verneuil, Delens, Eeverdin, Tapret) the displacement 
 was backwards ; in the other two it was outwards. 
 
 Among the same cases we find that the same displacement may 
 occur from a fall from a height (eighty feet), from crushing of the 
 leg, or by the leg being run over by a vehicle. 
 
 From these instances we also see that the diaphysis may be dis- 
 placed outwards (Post's and Callender's cases, from the leg being 
 caught in the spokes of a wheel)— shghtly outwards in one of Broca's 
 cases, being completely separated from the patella ; or inwards, as 
 in Watson's case (Eoyal College of Surgeons Museum), where the 
 leg was caught in some machinery ; or forwards, as in Adams's 
 case (Eoyal College of Surgeons Museum) ; in a specimen (56a, 
 Museum of St. George's Hospital), caused by twisting of rope round 
 the leg ; and in Eichet's case, from twisting of the leg by the strap 
 of a machine. In the last instance the end of the diaphysis had 
 perforated the synovial membrane of the knee-joint, and entered 
 the articular cavity, and was actually situated beneath the patella in 
 front. 
 
 In this last mode of displacement, the diaphysis being thrust 
 forwards on to the trochlear surface of the condyles, the popliteal 
 vessels, as will be seen later on, are not so liable to be pressed upon, 
 being protected by their normal relations and retained in their posi- 
 tion in the intercondyloid notch of the condylar fragment. 
 
 The author has cursorily sketched out the directions of displace- 
 ment of the diaphysial end, since separation of the lower femoral 
 epiphysis has been described in this manner by a few writers. It is, 
 however, better to follow the plan adopted in the case of most of 
 
SEPAEATION OF LOWEE EPIPHYSIS OF FEMUK 715 
 
 ft; 
 
 the other epiphysial separations, and classify according to the dis- 
 placement of the epiphysis rather than of the diaphysis. 
 
 Displacement of the epiphysis forwards. — The most common position 
 for the epiphysis to be displaced is upon the front of the femur. 
 The forcible extension of the limb causes rotation of the epiphysis 
 upon its transverse axis, so that its separated surface looks backwards. 
 The obliquity of the epiphysial surfaces will facilitate its progress in 
 this direction. 
 
 The powerful muscles of the leg keep up the displacement or 
 render it more marked when once the epiphysis has been displaced 
 by the violence of the injury. Although the gastrocnemius muscle 
 is not entirely attached to the epiphysis, but is partly above the epi- 
 physial line, yet the action of the muscle in displacing the epiphysis 
 forwards is very complete ; for the 
 whole of the muscle becomes torn off 
 with the periosteum attached to the 
 epiphysis, which is very dense at this 
 point — the epiphysial junction. In 
 cases of less severe violence, without 
 great stripping of periosteum, the fact 
 of the partial attachment of the muscle 
 alone might tend to counteract the 
 ill effects which overextension might 
 otherwise have. 
 
 The epiphysis may be displaced 
 forwards and upwards, only halfway off 
 the diaphysis, as in a specimen in the 
 Museum of St. Bartholomew's Hospital, 
 No. 982 {Catalogue of St. Bartholomeio's 
 Hospital Museum, vol. i. p. 140). The 
 lower epiphysis of the femur is rotated 
 on its transverse axis and displaced 
 forwards and upwards, halfway off the 
 diaphysis, so that the inferior surface looks forwards and down- 
 wards. The popliteal vein was pressed upon by the projecting lower 
 extremity of the shaft, which is entire, and gangrene was thus 
 produced. The separation is a perfectly pure one. 
 
 The Museum of St. George's Hospital {Catalogue of the Museum 
 of St. George s Hospital, 1866, p. 45 ; Trans. Path. Soc. vol. xiii. 
 p. 187) contains a preparation [No. 56b (138)] showing complete 
 separation of the lower epiphysis from the shaft, with a few osseous 
 fragments of the diaphysis still adhering to its anterior lip in front 
 of each condyle, and slight rotation upwards and forwards on its 
 transverse axis ; this was said to be more marked when the parts 
 were fresh. There is also an opening into the knee-joint, exposing the 
 posterior part of the outer condyle, and communicating with a large 
 wound in the ham. The injury was caused by a fall of about eighty 
 
 Fig. 225. — incomplete displace- 
 ment OF EPIPHYSIS FOKWAEDS 
 OFF THE DIAPHYSIS 
 
 Bartholomew's Hospital Mu- 
 seum, No. 982. |-size) 
 
 (St. 
 
716 EPIPHYSES OF LOWEK EXTEEMITY 
 
 feet. The patient, Thomas P., aged sixteen, recovered after primary 
 amputation. 
 
 In many other instances the epiphj^sis is displaced forwards com- 
 pletely off the diaphysis, so that its upper fractured surface is in 
 contact with the front of the diaphysis, as in McDiarmid's case 
 and Eontenelle's case. 
 
 A specimen in the Museum of the Leeds Infirmary, No. 1099 
 {Brit. Med. Journal, vol. ii. 1869, p. 610, woodcuts ; Liverpool 
 MecUco-Chirurgical Journal, vol. iii. 1883, p. 262 ; Hutchinson's 
 Illustrations of Clinical Surgery, 1878, fasc. xi. plate xl.), shows 
 a complete and clean separation of the lower epiphysis of the femur 
 with, rotation. The lower end of the diaphysis has been dis- 
 placed backwards and downwards into the popliteal space, and the 
 nerves and vessels are visible tightly stretched over its edge, whereas 
 the detached epiphysis is seen lying in a flexed position, with its 
 fractured surface on the front of the femur, its articular surface 
 looking forwards, and its anterior margin upwards, its posterior 
 downwards. The periosteum has been completely stripped from 
 the end of the shaft and left as a sleeve in connection with the epi- 
 phj'sis. The gastrocnemius is attached to the diaphysis. 
 
 A boy, A. B., aged fifteen, under the care of Mr. AVheelhouse, 
 had his leg crushed in a colliery accident. The circulation in the 
 leg was impeded from the first, and on the forty-third day amputa- 
 tion of the thigh was performed for gangrene. The boy died of 
 pyaemia nine days later. 
 
 Mr. Wheelhouse mentions {British Medical Journal, March 7, 
 1885) a preparation showing a separation of the lower epiphysis of the 
 femur taken from a patient in the Leeds General Infirmary. The 
 patient was a youth, aged about seventeen, who had been caught in 
 some machinery, and had been violently twisted round. A fracture 
 very low down in the shaft of the femur was diagnosed, and it proved 
 impossible to rectify the displacement which had taken place. 
 When Mr. Wheelhouse took charge of the case, a few days later, 
 gangrene was found setting in both in foot and leg, and the limb was 
 amputated above the fracture. The lower epiphysis of the femur 
 had been torn from its connection with the shaft, and had remained, 
 with but little displacement, almost i)i situ. The shaft had been 
 driven down into the popliteal space, and had so stretched the vessels, 
 both artery and vein, and the popliteal nerve, that gangrene was 
 inevitable ; and it was clear that no power would have sufficed to 
 replace the fragments in position. Recovery ensued. 
 
 Since then Mr. Wheelhouse had seen an almost identical case in 
 the hands of Mr. Atkinson, and a knowledge of what had taken 
 place in his case enabled a correct diagnosis to be formed from the 
 first concerning it. Mr. Atkinson, to begin with, endeavoured to 
 excise the displaced epiphysis, but wiihout success, and was com- 
 pelled, as Mr. AVheelhouse had been, to resort to amputation, which, 
 
SEPAEATION OF LOWEK EPIPHYSIS OF FEMUE 717 
 
 as in Mr. AVheelhouse's case, proved successful so far as the life of 
 the patient was concerned. 
 
 The same museum contains a second similar specimen, No. 1067 
 (Mr. Mayo Eobson's paper on ' Separation of the Lower Epiphysis 
 of the Femur,' Liverpool Med.-Cliirurgical Journal, July 1883; 
 London Medical Becord, 1883, vol. xi. p. 422), of complete separation 
 of the lower epiphysis. 
 
 F. C, ac^ed six, was run over by a ca.b and brought to the infirmary 
 under the care of Mr. T. Hey. It was found that compound diastasis 
 of the lower femoral epiphysis had occurred, with severe laceration 
 of the soft parts. The lower end of the diaphysis projected for 
 three inches through a wound in the popliteal space, whilst the epi- 
 physis was displaced forwards. Primary amputation of the thigh 
 was performed with a good result. 
 
 These specimens just described are now in the museum attached 
 to the Medical Department of the Yorkshire College. 
 
 Mr. E. Atkinson gives {Brit. Med. Journal, July 14, 1883, p. 70, 
 woodcut ; Liverpool Medico-Cliirurgical Joi/riial, \o\. iii. 1883, p. 
 262) an account of a case in wdiich he resected the knee-joint and 
 this epiphysis, which had been displaced and united on to the front 
 of the femur. 
 
 Chas. F., aged fifteen, whilst adjusting a belt, was caught up 
 and whirled round the shaft several times. On being brought to 
 the Leeds General Infirmary the next day, February 3, 1883, he 
 was found to have such extensive swelling of both legs and thighs 
 that no diagnosis could be made for a time. Obscure crepitus was 
 felt about the head of the left tibia, and absence of pulsation below 
 the knees. Back splints were applied to both legs. Swelling of the 
 left knee subsiding at the end of a week, a fracture of the left tibia 
 was clearly demonstrated. On February 13 the right knee was 
 aspirated, and two and a half ounces of dark fluid blood removed. 
 On March 1 the right leg was thought to be dislocated forwards, the 
 condyles of the femur apparently projecting backwards. On March 14 
 nulsation in the tibials was fairly perceptible. On March 21 epi- 
 physial separation was diagnosed from the shortening of the thigh 
 (one and a half inch) and the projection of the lower end of the 
 shaft into the popliteal space, which was felt as a sharp margin, 
 with a prominent pointed angle at each extremity. The epiphysis 
 was displaced anteriorly on to the front of the shaft of the femur, 
 and could be felt as a large irregular mass of bone beneath the 
 patella ; there was also considerable oedema of the leg. 
 
 On April 26, with full antiseptic precautions, Mr. Atkinson made 
 the usual incision for excision of the knee, removed the patella, 
 which was lying upon the upturned condyles, and by means of a 
 chisel and mallet detached the condyles from the front of the femur, 
 where they had become firmly fixed by callus. He then sawed off 
 the rounded end of the diaphysis and the articular surface of the 
 
718 EPIPHYSES OF LOWEE EXTEEMITY 
 
 tibia, wiring the cut surfaces together. Complete recovery took 
 place. 
 
 A specimen in the Eoyal College of Sm^geons Museum, No. 
 1041c, from Guy's Hospital, 1889, shows the lower extremity of a 
 femur with separation of the lower epiphysis, displaced slightly 
 forwards and to the inner side. The periosteum is detached from 
 the whole circumference of the diaphysis to a height of two and a 
 half inches. 
 
 The patient, a boy aged nine, was injured by the passage of two 
 wheels of a van over his leg. There was a large wound on the inner 
 side of the knee, through which the lower end of the diaphysis of 
 the femur protruded. The knee-joint was open. 
 
 The epiphysis in this specimen appears to be only displaced 
 directly forwards about half an inch, and there is but little appear- 
 ance of its rotation. 
 
 Examples of the same displacement are seen in the specimens 
 in the Museums of St. Bartholomew's, St. George's, and the London 
 Hospitals, and in the Museums of the Eoyal College of Surgeons of 
 England and Edinburgh iloc. cit.), and in Fontenelle's case. 
 
 Wright and Ashby {Diseases of Children, 1889, p. 644) also allude 
 to a case of compound separation of the lower epiphysis with similar 
 displacement. 
 
 Dr. A. H. Meisenbach reports {Neio York Medical Record, October 5, 
 1895, p. 475) a case of compound separation of the lower epiphysis 
 of the femur in a boy (W. P.), aged eleven, who had his left leg 
 caught in the revolving wheel of a vehicle. The femur protruded 
 about four inches through a wound on the outer side of the popliteal 
 space. The arteries were intact. With great difficulty, under 
 chloroform, the dislocated epiphysis was reduced. The wound was 
 treated antisepticaUy, a drainage tube introduced, and the limb 
 placed on a posterior splint. Dr. Meisenbach saw the case the next 
 morning, but did not advise amputation, taking into consideration 
 the fact that the separated epiphysis had been perfectly reduced, 
 and that there was no evidence of injury to the vessels. The 
 patient's general condition was good. A plaster dressing was applied 
 the same evening, but ' delayed shock ' having appeared (fourteen 
 hours after the injury), the patient did not rally, and death ensued 
 within forty-eight hours after the receipt of the injury. At 
 the autopsy the separated epiphysis was completely reduced, and 
 there was considerable difficulty in evulsing the femur so as to separate 
 it. The femur was stripped of its periosteum for about four inches, 
 and the soft parts of the pophteal space were much lacerated. The 
 knee-joint was not involved, the capsule was intact, this being shown 
 by an absence of effusion of blood in the joint. The separation from 
 the shaft was perfectly smooth, no splinters being attached to the 
 epiphysis. 
 
 In some instances the epiphysis has undergone vertical rotation 
 
SEPAEATION OF LOWEK EPIPHYSIS OF FEMUE 719 
 
 in its displaced position on the front of the diaphysis. In one, 
 that of Atkinson's, one condyle was placed directly above the 
 other. 
 
 Displacement of epiphysis backwards. — The epiphysis has rarely 
 been found displaced backwards. 
 
 In Bichet's case of compound diastasis, the condyloid epiphysis, 
 imperfectly held by the lateral and crucial ligaments, was found 
 displaced backwards, so that its fractured surface looked directly 
 backwards towards the ham. The diaphysis appeared through the 
 skin at the inner and lower part of the thigh, penetrating the joint 
 as described above. 
 
 In Coural's specimen, described by Delpech {Cliirurgie Clinique, 
 t. i. 1823, p. 252), the lower fragment or epiphysis was displaced 
 backwards, so that the two surfaces were not in contact. 
 
 Mr. Hutchinson thinks that the usual displacement of the epi- 
 physis is backwards. He says : ' If the epiphysis has been com- 
 pletely disengaged from the shaft, the tendency will be for it to be 
 displaced by the gastrocnemius into the position of full flexion at 
 the knee ; this is the position shown in the woodcut. Much 
 must, however,' he adds, 'be allowed for the direction in which 
 the violence has been applied.' 
 
 The same author figures {Archives of Surgery, January 1893, 
 p. 287) a clean and complete separation of the lower epiphysis of the 
 femur. The muscles of the leg have been dissected in order to show 
 the relation of those of the calf to the epiphysis itself. The lower 
 half of the femur has been cleaned, in order better to exhibit the 
 form of its epiphysial end. The specimen was obtained by a primary 
 amputation in the case of a boy, aged fourteen, under Mr. Hutchin- 
 son's care some years ago in the London Hospital. 
 
 The displacement of the epiphysis here appears to be the back- 
 ward displacement so frequently seen in fracture of the femur above 
 the epiphysial junction. In adults the lower end of the upper frag- 
 ment penetrates the broad tendinous expansion of the quadriceps 
 extensor just above the patella, and effectually prevents reduction 
 and union. It usually necessitates operative measures and suture of 
 the fragments under strictest aseptic procedures, since the joint is 
 generally involved. 
 
 Dr. White at the Westminster Hospital had a similar case, in 
 which, however, the bone protruded in front. The extremity of the 
 protruded bone was sawn off, and the parts put in apposition. The 
 joint was uninjured. The limb was thereby saved, and resulted in 
 a useful one. 
 
 Hermann Lossen believes (Deutsche Chirurgie, ' Die Verletzungen 
 der unteren Extremitaten,' 1880, S. 110) that this displacement of 
 the diaphysis forwards is the more common form of injury, and that 
 the converse rarely takes place — namely, the displacement of the 
 diaphysis backwards. 
 
720 EPIPHYSES OF LOWEK EXTEEMITY 
 
 Displacement of the epiphysis laterally. — This displacement in an 
 unmixed condition has rarely been found after death. During life 
 the epiphysis is often found to be rotated when displaced laterally, 
 so that one condyle is above the other. 
 
 The epiph3'sis may therefore be described as displaced outwards, 
 and rotated upon its vertical axis, as well as slightly through its 
 transverse axis, so that the outer end of the shaft impinges against 
 the hollow of the condyle, the internal condyle presenting in the 
 popliteal space, the external condyle on the outer side. In this 
 position the cup-shaped epiphysis will be found to move with a see- 
 saw motion, 'mouvement de bascule.' This to-and-fro movement 
 of the distal on the proximal fragment serves to explain the frequent 
 absence of the characteristic 'muffled crepitus,' for no gliding move- 
 ment of the diaphysis is then allowed upon the epiphysis. It 
 undoubtedly shows the difficulty of reducing such a displacement 
 without operative measures ; in fact, it would be impossible to effect 
 this reduction without unlocking, as it were, the tw^o fragments. 
 
 M. Dolbeau reported a case to the Societe de Chirurg., Paris, on 
 March 28, 1866 {Gazette des Hopitaux, 1866, p. 162 ; Bulletin de 
 la Societe de Chirurg. de Paris, 1867, 2eme serie, vii. 120), in which 
 this condition was present. 
 
 Jules A., aged twelve, was knocked down by a bale of ropes, 
 W'hich fell from a second story and struck him on the lower part of 
 the left thigh. He was unable to rise, and was taken to the Hopital 
 Saint-Pierre de la Martinique, under the care of Dr. Rougon. The 
 next day the whole limb was swollen ; on its outer side there was a 
 bony projection elevating the skin and threatening to perforate it. 
 In the popliteal space there was a bony projection pressing upon the 
 popliteal vessels. The condyles of the femur and the tuberosities of 
 the tibia were felt to be in their normal relationship. It was found 
 to be impossible to reduce the deformity. Six days after the accident 
 a slough, which had formed at the upper part of the popliteal space, 
 separated, and some foul bloody serum discharged. There was 
 some constitutional disturbance. Amputation at the middle of the 
 thigh was performed the following daj". Examination of the am- 
 putated limb showed severe pulping and laceration of the soft tissues. 
 The knee-joint was intact, but contained about five ounces of bloody 
 serum. The epiphysis was completelj' separated wuth the epiphysial 
 cartilage, without any osseous connections, and moved readily over 
 the tibial tuberosities. This mobility, together with the see-saw 
 movement {mouvement de bascule), made it not only difficult, but 
 almost impossible, to reduce the epiphysis over the projecting edge 
 of the upper fragment and place the latter in its epiphj^sial cavity. 
 It was the external condyle which projected on the outer side, and 
 the internal condyle which was felt in the popliteal space. 
 
 St. George's Hospital Museum contains {St. George's Hospital 
 Museum Catalogue, 1866, p. 43, No. o6a) a third specimen of 
 
SEPAEATION OF LOWEK EPIPHYSIS OF FEMUE 721 
 
 separation of the lower femoral epiphysis. It was displaced out- 
 wards and backwards, and the diaphysis was on the inner side. 
 
 Anthony W., aged eighteen, was admitted into the hospital on 
 July 29, 1849, with considerable deformity of the knee, presenting 
 very much the appearance of a partial dislocation inwards of the 
 condyloid portion of the femur, with extensive laceration of the 
 lateral and crucial ligaments. There was also a compound fracture 
 of the leg at its lower third, as well as extensive laceration of the 
 skin of the inguinal region. The limb was quite cold below the 
 knee, and there was a good deal of sweUing, especially about the 
 knee, foot, and ankle. The accident happened a short time before 
 admission ; it appeared that the foot had been caught in the ropes 
 of a ship ; the rope, in twisting round the lad's leg, threw him into 
 the water, where he remained some time. Amputation of the thigh 
 was immediately performed, and a complete separation of the con- 
 dyloid epiphysis was found. The outer portion of the end of the 
 diaphysis was in contact with the internal condyle, and projected 
 forwards and inwards ; the periosteum was separated off the lower 
 third, but remained adherent to the epiphysis, forming a fold behind, 
 which hindered reduction. The epiphysial cartilage adhered to the 
 condyles, to which here and there some minute fragments of the 
 diaphysis were still attached. 
 
 The posterior Hgament was slightly torn at the internal part ; 
 the other hgaments were intact. A quantity of blood was present 
 in the articulation. There was laceration of the middle and internal 
 coats of the popHteal artery, the lumen of which was obliterated by 
 blood clot ; the nerves were intact. 
 
 Death occurred on August 12 from pygemia ; pus was present in 
 the femoral vein. In this case both epiphyses of the fibula and 
 the lower epiphysis of the tibia were said to have been separated. 
 
 Eeichel figures ijoc. cit. p. 34, and tab. ii. figs. 1 and 3) a specimen 
 representing a separation of the lower epiphysis completely displaced 
 towards the outer side, and there united by osseous material. As 
 Keichel supposes, the separation was probably the result of disease, 
 as distinct traces of caries were to be seen on the articular surfaces, 
 and numerous osteophytic formations, produced by periosteal in- 
 flammation extending a considerable distance upwards on the 
 diaphysis. 
 
 An instance of marked lateral displacement outwards of the 
 epiphysis is quoted by Dr. E. H. Harte. On admission it was 
 reported to be a lateral dislocation of the knee. Extensive suppura- 
 tion ensued, and the thigh was amputated {vide infra). The 
 separation was a pure one. 
 
 Displacement of the epiphysis inwards. — Halderman's case is the 
 only one in which, after death, the epiphysis has been found on the 
 inner side. It appears to have been lodged above the inner side of 
 the shaft in such a way that it would have been impossible to dis- 
 
 3 a 
 
722 EPIPHYSES OF LOWEE EXTEEMITY 
 
 place it by traction during life ; however, the description given is 
 somewhat vague : ' The epiphysis was tilted backwards, and also 
 overlapped at its posterior and outer aspect by the shaft to the 
 extent of several inches.' 
 
 An instance of lateral displacement, confirmed by dissection after 
 removal, is quoted by Dr. R. H. Harte, of Philadelphia {Trans. 
 Amer. Surg. Association, Philad. 1895, vol. xiii. p. 396). 
 
 Edward H., aged fourteen years, was admitted to the Episcopal 
 Hospital, March 23, 1894. While employed as a polisher in a glass 
 factory he became entangled in belting. On admission it was found 
 that he had sustained a fracture of the left femur, with a compound 
 comminuted fracture of the bones of the right leg, and an epiphysial 
 separation of the lower end of the femur in the same limb. The 
 deformity was very great, so that the knee and condyles could be 
 slipped to either side of the diaphysis, simulating lateral displace- 
 ment of the knee. As an amputation of the leg at a high point 
 was demanded, it was deemed expedient to amputate through the 
 thigh. On exposing the separation above the lower condyle, the 
 diaphysis was observed to be clearly separated from the epiphysis 
 and denuded of a large portion of its periosteum, particularly 
 over the popliteal surface. The patient made an uneventful 
 i^ecovery. 
 
 Displacement of the epiphysis forwards and inwards. — M. Chassaniol 
 resected in 1863 {Gazette des Hopitaux, 1864, p. 39) the end of the 
 diaphysis in a case of complete separation with displacement for- 
 wards and inwards of the epiphysis. The child (B.), a boy aged 
 nine and a half years, who was a perfectly healthy child, fell off a 
 door to the ground, striking, it is said, the inner and lower part of 
 the thigh. The lower end of the femur, deprived of its epiphysis 
 and periosteum, projected on the outer and posterior aspect of the 
 joint through a large laceration in the integuments on the outer 
 side, which also extended into the popliteal space. The leg was 
 slightly flexed, and the protruding femur made a very obtuse angle 
 with the direction of the wound. Notwithstanding the length of 
 the wound (four centimetres), its oblique direction made all efforts at 
 reduction quite unsuccessful, even after the administration of chloro- 
 form. Amputation of the limb was proposed, but refused by the 
 parents. Three and a half centimetres of the protruding diaphysis 
 were therefore removed by means of an ordinary saw. The femur 
 was immediately reduced, and the marked deformity of the knee which 
 was present vanished on making extension of the limb. The epi- 
 physis remaining in its place, it was thought that the knee-joint 
 had not been opened or the lateral ligaments ruptured. The limb 
 was put up in the extended position with two long splints, which 
 were replaced by a starch bandage on the fifteenth day. On the 
 twenty-second day the end of the femur appeared again in the 
 wound, and a second resection was attempted under chloroform, but 
 
SEPAKATION OF LOWEE EPIPHYSIS OF FEMUK 723 
 
 abandoned when it was found that consolidation had taken place 
 throughout the greater part of the diameter of the bone. 
 
 Although the end of the femur was not in the centre of the 
 epiphysis, good union ultimately took place, and the child was able 
 to walk with a raised heel. 
 
 The resected specimen was placed by M. Ange Duval in the 
 anatomical museum of the school at Brest. 
 
 Dr. F. J. Shepherd, of Montreal, says (Montreal Medical Journal, 
 vol. xviii. 1890, p. 199) that he had seen two cases of this accident. 
 
 In both the accident had occurred several years before, and the 
 patient had good use of the limb. 
 
 In one case, under the care of one of his colleagues at the 
 McGill University, the diaphysis had been displaced outwards, and 
 caused a remarkable obliquity and deformity of the lower end of the 
 femur which interfered with the lad's progression. The limb was 
 straightened by Macewen's osteotomy. 
 
 The other case was that of a boy, aged seven, who fell and 
 injured his leg. The lower end of the femur was found to be pro- 
 jecting through the skin on the outer side of the popliteal space. 
 Amputation was advised by the doctors, but this was refused, and on 
 failing to reduce the protruded bone they sawed off two inches. The 
 boy ultimately did well, and was able to go about in three weeks. 
 At the time of this report, ten years after the accident, he had perfect 
 use of his leg, and the knee had as wide a range of motion as the 
 other. He walked with only a slight limp, and measurement gave 
 some two inches of shortening. 
 
 Partial separation with fracture of one or other condyle. — It is quite 
 possible for a partial separation of the epiphysis to be associated 
 with a vertical or oblique fracture into the joint between the con- 
 dyles, in this way separating one or other condyle off without 
 displacing it. 
 
 Verneuil met with such an accident in the adult (specimen in 
 Dupuytren's Museum), but no specimen exists showing its actual 
 occurrence during youth. 
 
 In the account of the following case reported by Quain {Lancet, 
 March 11, 1848, p. 286) there is no positive evidence of a true 
 separation of the epiphysis. 
 
 It was under the care of Mr. W. P. Brookes, of Cheltenham, 
 and there was said to have been a compound fracture of the external 
 condyle of the femur, laying open the knee-joint, and complicated 
 with a simple transverse fracture of the lower third of the same bone. 
 
 The boy was aged eleven and a half years, and, in getting up 
 behind a coach, fell with his left leg entangled between the spokes 
 of the hind wheel in motion. There was a compound fracture of 
 the femur, extending obliquely downwards through the external con- 
 dyle, which was movable with the lower portion, projecting through 
 a wound in the popliteal space, and the leg was twisted inwards. 
 
 3 A 2 
 
724 EPIPHYSES OF LOWEE EXTEEMITY 
 
 The capsular ligament was lacerated and synovia escaped. Amputa- 
 tion was refused, and the limb was therefore adjusted and treated 
 with straight sphnts. The lad recovered the entire use of the limb, 
 and could bend the knee to a right angle. There was also no 
 shortening. 
 
 CoMPLiCATioxs. — Complications are very numerous and frequent, 
 on account of the great violence usually required to effect separation 
 of the lower epiphysis of the femur, and from the close proximity of 
 important structures (e.g. Halderman's case). They oxe i^rimary or 
 secondary, i.e. occurring at a later period. 
 
 Packard, in Ashhurst's EncyclopcBclia of Siirgery, 1884, vol. iv. 
 p. 216, mentions two specimens in the Museum of the Pennsylvania 
 Hospital {Pennsylvania Hospital Museum Catalogue, p. 31, No. 1132). 
 In one there was separation of the lower epiphysis of the femur, 
 with transverse fracture of the middle third of the femur, caused by 
 the patient being run over by a railroad-car. In the other specimen 
 there was epiphysial separation only, without history. 
 
 Wounds. — Separation of the lower epiphysis of the femur is very 
 frequently complicated with a contused or lacerated wound, occasion- 
 ally very extensive in character. 
 
 The author has collected fifty compound separations. In a large 
 proportion the laceration of the skin was in the popliteal space, and 
 the result of the over-extension of the limb, or was caused in a 
 large measure by indirect violence — i.e. by the diaphysial end pene- 
 trating the soft parts from within outwards. In some it was placed 
 towards the upper and outer part of the ham, and more seldom 
 towards the inner side of the knee ; in all the violence appears to 
 have been very severe. In Post's case it existed on the outer side 
 of the knee. In others we find a contused wound with lacerated 
 muscles caused by direct violence. 
 
 The plate given by Professor J. L. Little shows the situation of 
 the wound in his case at the upper and outer part of the poplitet^l 
 space. 
 
 In Eathbun's case the rent in the skin was oblique, and extended 
 right across the popliteal space, commencing two inches above the 
 internal condyle and terminating below at the head of the fibula. 
 
 In Owing's case the end of the diaphysis, with its peculiar 
 stellate radiations, protruded through the rent in the skin for fully 
 five mches, and in Hamilton's case it projected for the same distance. 
 
 Hsemorrhage may occur and recur from the wound without 
 laceration of the principal vessels of the limb. It may proceed 
 from the diaphysial end if this has been fractured, as it often is. It 
 may prove to be so serious as to be an important factor in deter- 
 mining the question of preservation of the limb. 
 
 Oozing of blood from the osseous surface was seen in one case 
 in which the separation was a pure one, and the plugging of the 
 popliteal artery prevented any loss of blood from the soft parts. It 
 
SEPARATION OF LOWER EPIPHYSIS OF FEMUR 725 
 
 continued for some hours until amputation was performed. It is 
 possible that the blood may delay or even cause serious interference 
 with union, by producing separation of the detached surfaces. 
 
 Dr. John A. Macdougall records {Edinburgh Medical Journal, 
 vol. xxxvi. Part ii. March 1891, p. 826) the following case, in which 
 haemorrhage recurred from the wound and the limb was amputated. 
 
 E. D., aged nineteen, while driving the horses attached to a 
 threshing mill, unfortunately slipped the heel of his right boot into 
 the cogs of the driving wheel. At once realising his danger, he threw 
 himself violently to one side in order to escape it. On examination 
 immediately afterwards there was found a markedly oblique fracture 
 of the lower part of the thigh, and with this a deep and ragged tear 
 of the soft parts, passing from one condyle to another across the 
 popliteal space. This wound, from which there had been free 
 haemorrhage, after being thoroughly cleansed, was brought together, 
 and the limb was placed in a retentive apparatus. Late on the day 
 following the accident severe arterial bleeding occurred from the 
 wound, the source of which could not be found, and which it was 
 difficult to check. 
 
 Early next day Dr. Macdougall saw the patient, and his con- 
 dition was then as follows : a pale and very exsanguine lad, with a 
 small, quick, and feeble pulse, with a temperature of nearly 103°, and 
 with a very exhausted look. The injured limb was much swollen, 
 and in the general fulness the calf of the leg was notably prominent. 
 Pulsation in the tibial was quite perceptible. On removal of the 
 sutures from the popliteal wound much sanious matter escaped. 
 Examination with the finger passed deeply into the popliteal space 
 detected bare bone, and, following this up, there was no difficulty in 
 entering the fracture gap. This examination led to a renewal of 
 the arterial bleeding, demonstrating pretty conclusively what was 
 its source. 
 
 In the knee-joint itself there was considerable effusion. This, 
 coupled with the facts that the fracture was low down and very 
 oblique, that the lad was under twenty, and that the limb had been 
 violently twisted, led to the belief that the epiphysis had shared in 
 the injury, and that the joint itself was probably involved. 
 
 In all the circumstances of the case it seemed to Dr. Macdougall 
 the wisest course to remove the limb. Although externally there 
 seemed little deformity or displacement, the space between the 
 fractured ends was nearly two inches wide, and it was filled wdth a 
 dense blood-clot. This clot extended downwards into the muscles of 
 the calf, and gave rise to the prominence in that region already 
 referred to. The periosteum, fairly closely adherent to the upper 
 fragment, was completely stripped from the low^er portion, and 
 widely separated along the line at which the epiphysis had given 
 way. 
 
 . Dr. Macdougall adds the following note : ' The specimen thus 
 
726 EPIPHYSES OF LOWER EXTREMITY 
 
 obtained is fraught with interest, for although at the time of its 
 removal it was believed by all who saw it that the line of fracture 
 passed obliquely through the epiphysis, it was ultimately found that 
 this was not so, that only on the outer third did the line of separa- 
 tion trench upon, but did not pass through, that of the epiphysis, 
 and that this structure, although gravely implicated, was still 
 attached to the femoral condyles.' Recovery took place. 
 
 Detacliment of the periosteum. — In all compound separations the 
 end of the diaphysis projects from the rent in the skin — always 
 stripped of its periosteal covering, sometimes to the extent of four 
 to five inches — and is often much soiled by dirt. 
 
 In one of the specimens in St. George's Hospital (56a) the 
 periosteum was stripped from the lower third of the shaft, and was 
 found to have formed a fold behind, which hindered reduction. In 
 other instances the detachment has been noted as high as the middle 
 third, while in two cases the periosteum is said to have been torn off 
 as high as the trochanter. 
 
 Mr. Hutchinson mentions {London Hospital Beports, vol. i. 
 1864, p. 88) a specimen removed by amputation from a boy of 
 twelve, in which the lower end of the femur had been detached 
 from the epiphysis. The latter remained in position with the tibia, 
 and the knee-joint was uninjured. The lower three inches of the 
 shaft of the femur were quite bare of periosteum. 
 
 The extent of the stripping of the periosteum with the protrusion 
 of the diaphysis will vary with the degree and direction of the 
 violence. It has also been found detached to a greater or less 
 extent from the diaphysis in the simple cases in which operative 
 interference has been considered necessary — e.g. in one simple case 
 of Dr. R. H. Harte's in which suppuration occurred. 
 
 That detachment of the periosteum occurs in all cases of dis- 
 placement of the epiphysis, even though they may be only simple 
 and not compound, and generally from the posterior aspect, is 
 proved by Professor Little's case. In this case it was found that 
 the vitality of the bone was not interfered with by this detachment. 
 
 The periosteum is never torn off the peripheral surface of the 
 cartilaginous disc or of the epiphysis, on account of the thick and 
 dense attachment it has to both lying beneath it. 
 
 The periosteum, as usual in epiphysial separations, remains 
 adherent to the epiphysis, and the diaphysis directed dow^nwards 
 by the violence penetrates the periosteum in a buttonhole manner, 
 which is stripped off, and the end of the bone is then thrust through 
 the skin. In some few examples it has been found torn more or less 
 away from the epiphysis, as in Reverdin's case, where it was detached 
 from the epiphysial margin behind, corresponding to the portion of 
 the detached shaft, and also to a slight extent in front of this. 
 
 The periosteum will not only be detached but lacerated in the 
 direction of the displacement of the diaphysis, and the extei^t of 
 
SEPAKATION OF LOWEK EPIPHYSIS OF FEMUK 727 
 
 this laceration usually corresponds to the amount and nature of the 
 displacement of the diaphysis. The laceration of the periosteum was 
 well marked in one of Broca's cases. 
 
 From the results of compound separations we find that, as a 
 rule, the periosteum becomes adherent again in the diaphysis, and 
 no ill results from its separation. 
 
 In some few cases, however, suppuration may ensue, and even 
 pyaemia, for which the periosteal detachment is largely responsible. 
 
 Injury to popliteal vessels. — These vessels are sometimes pressed 
 upon by the posterior margin of the femoral diaphysis in backward 
 displacement, without laceration of their coats. 
 
 Little, Tapret, Atkinson, and Wheelhouse note the absence of 
 pulsation in the posterior tibials below, without any lesion of the 
 popliteal vessels. In some instances these vessels are but slightly 
 stretched. In Eeverdin's case, pressure upon the artery gave rise 
 to thickening and clotting in its interior, plainly demonstrating that 
 it is not necessary for the coats to be ruptured for occlusion to take 
 place. Halderman states that the artery in his case was contused, 
 inflamed, thickened, and filled with clot, and that the vein was in the 
 same condition, from pressure by the anterior edge of the displaced 
 diaphysis. Between the epiphysis and the diaphysis, on the anterior 
 and inner aspect of the latter, lay the internal popliteal nerve and 
 popliteal vein and artery, which were pressed upon by the fragments, 
 and held there by the hook-shaped projection of the divided inter- 
 nal condyloid ridge, over which they had caught. 
 
 The artery, vein, and nerve anterior to the bone were uninjured 
 in Rutherford Alcock's case. 
 
 On the other hand the artery and vein have been found completely 
 lacerated in some instances by the diaphysial end impinging on them ; 
 in some they have been only partially lacerated. In others only the 
 inner and middle coats have been divided, these being rolled up to 
 a greater or less extent ; clotting soon takes place in the interior, 
 and leads to complete occlusion. 
 
 M. A. Verneuil relates {Memoires de Chirurgie, vol. iii. p. 400) 
 the case of Ferdinand S., aged eight, who was admitted into the 
 Lariboisiere Hospital on July 9, 1868. He had climbed behind 
 a carriage, and caught his left leg in the wheel. There was an 
 extensive wound of the leg, with contusion of the soft parts and 
 bones. In the thigh there was a wound and separation of the soft 
 parts, with rupture of the popliteal artery. M. Verneuil performed 
 amputation of the thigh the next day, and discovered complete 
 separation of the lower epiphysis of the femur, to which the 
 epiphysial cartilage adhered. The lower end of the diaphysis had 
 completely divided the popliteal artery and vein, and, displacing the 
 internal popliteal nerve outwards, protruded through the transverse 
 rent in the skin. The periosteum was separated from the end 
 of the bone, but remained adherent to the soft parts and to 
 
728 EPIPHYSES OF LOWEE EXTREMITY 
 
 the epiphysis. The knee-joint was uninjured. Recovery took 
 place. 
 
 The artery and vein were lacerated in both of Mr. Hutchinson's 
 cases. The second is described by him in the Transactions of the 
 Pathological Society, vol. xv. 1864, p. 206. 
 
 A lad, aged twelve, was brought to the London Hospital, having 
 been run over in the street. At first sight it was supposed that 
 there was a compound dislocation of the left knee-joint, and the 
 soft parts were severely injured. The projecting bone was found to 
 be the end of the shaft abruptly and completely detached from its 
 epiphysial extremity ; the latter was still connected with the tibia, 
 and the joint uninjured. Primary amputation was performed by 
 Mr. John Adams. The popliteal artery and vein were found to be torn 
 across, and the periosteum very extensively stripped from the lower 
 part of the shaft. The epiphysis, by the action of the gastrocnemius, 
 had been displaced so that its separated surface looked directly 
 backwards into the popliteal space. 
 
 The popliteal vessels were ruptured in Dr. W. T. Davison's case, 
 mentioned by Gross {System of Surgery, 1882, vol. i. p. 1019), while 
 in Glutton's case the artery was ruptured and the vein pressed upon. 
 
 In one of the specimens in St. George's Hospital Museum, 
 described above, rupture of the internal and middle coats of the 
 artery took place with the formation of coagulum obliterating its 
 lumen. 
 
 And in another case (Broca) , which was caused by direct violence, 
 the popliteal artery was obliterated, and the two inner coats torn 
 across and retracted, the external coat holding the ends in continuity. 
 In this instance the popliteal vein had undergone stretching, and its 
 inner coat was furrowed by transverse markings. 
 
 Dr. A. McDiarmid records a similar case of a simple clean 
 separation with displacement forwards of the epiphysis, and complete 
 laceration of the popliteal artery {Northern Lancet, Winnipeg, 1891-2, 
 vol. V. p. i). 
 
 A boy (Allen W.), about eight years of age, had his right leg 
 caught in the front wheel of a wagon, and on examination seven 
 hours later it was found that ' the condyles were still in contact with 
 the head of the tibia, but only by an edge, the whole epiphysis being 
 rotated so that the articular face looked forwards and the detached 
 surface backwards.' The skin being unbroken, and the precise 
 condition of the soft parts uncertain, an attempt was made to save 
 the limb. Chloroform was therefore given, the tendo Achillis divided 
 to allow coaptation of the fragments, and the limb put up moderately 
 flexed. Nearly twenty-four hours later, as the limb was found to 
 be cold, amputation of the thigh was performed. The patient made 
 an excellent recovery. The popliteal artery was found to be com- 
 pletely divided by the rough margin of the femur, and there was 
 great contusion of the soft parts. 
 
SEPAEATION OF LOWEE EPIPHYSIS OF FEMUE 729 
 
 In the following additional examples verified by dissection, the 
 popliteal vessels were seriously injured. 
 
 At the Birmingham and Midland Counties Branch of the British 
 Medical Association, December 14, 1893 {British Medical Journal, 
 January 6, 1894, p. 21), Mr. Haslam showed a specimen of a separa- 
 tion of the lower epiphysis of the femur, which had been complicated 
 with rupture of the inner and middle coats of the popliteal artery 
 and bruising of the vein, causing gangrene of the limb, in a lad aged 
 nineteen, apparently the result of injury. 
 
 M. Ardouin (Bulletins de la Societe anatoniique de Paris, tome xi. 
 gme s^rie, 1897, p. 539) exhibited before the Societe Anatomique the 
 lower epiphysis of the femur taken from a ^'^oung man, aged sixteen, 
 who had met with a serious injury on March 16, 1896. The patient, 
 a printer, had his leg seized in a transmission band and was taken 
 to the Hopital Broussais. Although there was extensive laceration 
 of the integuments, and a large opening through which the 
 diaphysis of the femur, completely separated from the epiphysis, pro- 
 truded, an attempt was made to preserve the limb. For fifteen 
 days the condition was satisfactory, but at last amputation of the 
 thigh had to be performed. On dissection, there was found a 
 perforation of the popliteal vein, which had given rise to extensive 
 extravasation of blood, and an abscess in the coats of the popliteal 
 artery. On the femoral epiphysis all the depressions and emi- 
 nences could be seen which corresponded to similar eminences and 
 depressions on the diaphysis. The patient recovered. 
 
 It is remarkable that the popliteal vessels have escaped laceration 
 or bruising in so many of the recorded cases, even of compound 
 separation. No doubt this immunity from injury may be explained in 
 some instances by the peculiar character of the lesion, the epiphysis 
 with the limb below being twisted at the time of the accident off 
 the diaphysis, which is more or less fixed. The popliteal vessels 
 and nerve in this twisting of the limb will follow its movements, 
 and tend to glide over the posterior margin of the diaphysial end 
 instead of being pressed upOn by it, as would be the case were the 
 epiphysis thrown directly forwards off the diaphysis. 
 
 At the Philadelphia Academy of Surgery, on February 2, 1891 
 {Medical News, March 21, 1891, p. 339 ; Annals of GyncBcology and 
 Pcediatry, November 1890 ; Archives of Pediatrics, 1891, p. 318), 
 Dr. J. H. Packard showed specimens of separation of the lower 
 epiphysis of the femur, taken from a boy nine years of age, who 
 was admitted to St. Joseph's Hospital on April 16, 1889, having 
 had his right leg caught in the wheel of a wagon behind which he 
 was clinging. From the appearance of the anterior aspect of the 
 limb, a forward luxation of the knee might have been suspected ; 
 but upon examination the true nature of the lesion was at once 
 apparent. At the lower and back part of the thigh there was a 
 large oblique wound, through which protruded the end of the dia- 
 
730 EPIPHYSES OF LOWEE EXTREMITY 
 
 physis of the femur, bare of periosteum ; the condyles were still 
 partly in contact with the tibia, but the whole epij)hysis was rotated 
 so that its articular face looked forwards, and the upper cup-shaped 
 surface backwards. This was due to traction by the tT\'0 heads of 
 the gastrocnemius muscle. The patella was not materiaUy dis- 
 placed, being still in relation with the joint, but was tilted up by 
 the action of the quadriceps muscle. Ether was given, and a careful 
 examination showed that although there was great bruising and 
 laceration of the soft parts, the vessels had not been torn, but, along 
 with the nerve, had slipped aside around the end of the diaphj-sis ; 
 they were, however, sharply stretched, and the blood in the artery 
 was coagulated, so that there was a probability of the limb becoming 
 gangrenous. Reduction of the protruding bone was found to be 
 impossible, and an attempt to save the limb by resection seemed to 
 be attended with so much risk, in view of the damage to the soft 
 parts, that amputation was performed, about an inch and a half of 
 the shaft being removed. The boy made a perfect recovery. Upon 
 dissection it was found that the epiphysis had been almost cleanly 
 separated ; entirely so, but for a very small splinter detached from 
 the end of the diaphysis on the inner side. The specimen is in the 
 Museum of the Pennsylvania Hospital. 
 
 In the following case described by Dr. John A. Macdougall {Edin- 
 h/rgh Medical Journal, vol. xxxvi. Part ii. March 1891, p. 826), the 
 vessels escaped injury, although there was very great displacement 
 backwards of the epiphysis. 
 
 C. G., an active j'oung fellow of twenty, was, while superintending 
 some w^ork, caught in the coils of an endless rope, and his right leg 
 was very violently twisted round. The surgeon, who did not see 
 him for some little time after the accident, found all the marked 
 signs of fracture close above the knee. The lower fragment was 
 small, and was very acutely drawn back, so much so as to stretch 
 the integuments over it, but there was no great displacement of the 
 upper portion of the bone. An attempt to reduce the displaced 
 fragment was not very successful, and the surgeon in attendance 
 ultimately succeeded in placing the limb in a Maclntyre splint fixed 
 at a not very acute angle. About a month after the accident. Dr. 
 Macdougall saw him. There was then still such pronounced dis- 
 placement of the lower fragment existing that the skin had ulcerated 
 over it, and the whole condition, owing in a measure to the shrmiken 
 state of the limb, left no doubt as to what the true nature of the 
 injury was. The absence of all attempt at union — for union in 
 the circumstances was wellnigh impossible — tended to confirm the 
 diagnosis of diastasis. Amputation was advised and performed, and 
 what it demonstrated was a transverse separation running almost 
 entirely through the epiphysial line, and the rather striking fact 
 that, in spite of the long stretching to which the popliteal vessels 
 had been subjected, they were quite uninjured. 
 
SEPAKATION OF LOWEE EPIPHYSIS OF FEMUK 731 
 
 In Dr. Donovan's case, although there was very extensive 
 laceration of the skin and soft structures, the popliteal artery 
 escaped laceration ; it was displaced by the backward escape of the 
 lower end of the femur. Eecovery took place in this case after 
 resection of two and a half inches of the diaphysis. 
 
 In Meisenbach's case, although the diaphysis protruded for four 
 inches on the outer side of the popliteal space, the vessels were un- 
 injured. 
 
 In Glutton's compound case the popliteal vessels appeared to 
 have been ruptured by the backward displacement of the diaphysis. 
 
 The special danger in these cases of injury to the popliteal vessels 
 is that the large veins may become, most frequently in compound 
 separations, the seat of infective thrombosis, leading to pysemia and 
 the death of the patient. 
 
 In one instance the anterior tibial artery was torn open. 
 
 Injury to nerves. — The popliteal nerves may be contused, lacerated, 
 or exposed for a considerable distance. 
 
 In Dr. Donovan's case the nerve trunks were injured, and re- 
 sulted in paralysis of the extensor muscles of the leg, although good 
 union had taken place. Tuberculous disease occurred in the limb 
 and necessitated amputation. 
 
 Pressure upon popliteal nerve. — Where the displacement has not 
 been reduced in simple cases, the upper fragment, being thrust 
 downwards and backwards, may stretch the internal popliteal nerve, 
 as well as the popliteal vessels over its edge. 
 
 In a case related by Professor J. L. Little {Illustrated Quarterly 
 of Medicine and Surgery, vol. i. No. 1, January 1882, p. 24), under 
 Dr. McBurney's care at St. Luke's Hospital, N.Y., the internal 
 popliteal nerve was so stretched, the pain so intense, and the 
 deformity so great, that amputation was resorted to. The case was 
 of two or three months' standing, and strong bony union had taken 
 place. The patient died of tetanus. The periosteum was completely 
 stripped from the end of the shaft, although the case was not 
 compound and union had taken place before amputation. The 
 vitality of the bone was not interfered with by this loss. 
 
 In other instances the internal popliteal nerve may, like the 
 vessels, escape the pressure of the lower end of the diaphysis by 
 slipping to one side of it. 
 
 Dr. J. B. Eoberts (Philadelphia) had seen a case {Annals of 
 Surgery, February 1896, p. 201) in which nerve injury was 
 accompanied by epiphysial separation, and he wanted to operate, 
 but delayed, finally finding it unnecessary. The child had been 
 injured about six weeks before. There had apparently been an 
 epiphysial separation of the lower end of the femur, with displace- 
 ment backwards into the popliteal space. The lower fragment could 
 be easily located, and there was 'foot drop,' showing injury of the 
 external popliteal nerve. He advised operation to release the nerve 
 
732 EPIPHYSES OF LOWEK EXTEEMITY 
 
 from pressure, but the other physicians preferred to wait. The 
 child obtained perfect use of its foot from regeneration of the in- 
 jured nerve, and could then (October 1895) walk well and had no 
 paralysis. 
 
 Gangrene of the limb, more or less extensive, is a frequent 
 consequence of pressure upon the vessels ; it occurred in the cases 
 described by Little, Beverdin, Tapret, Halderman, Wheelhouse (on 
 the forty-third day). Canton, and others. 
 
 Beverdin thought that the application of a 2| per cent, solution 
 of carbolic acid to the exposed popliteal nerves contributed to the 
 subsequent gangrene in his case. 
 
 Gangrene was present in one of the specimens in St. Bartholo- 
 mew's Hospital from pressure on the popliteal vein by the displaced 
 diaphysis. 
 
 A case is mentioned by S. Laugier in the Nouveau Dictionnaire 
 de Medecine et de Chirurgie Pratiques, Paris, 1869, tome dixieme, art. 
 ' Cuisse,' which was produced by the leg falling into a hole nearly 
 to the knee while the body was carried forwards. The inferior 
 fragment turned backwards, so that its broken surface rested on 
 the anterior aspect of the femur ; the lower end of the shaft of 
 the bone descended behind, and pressed out the popliteal space with 
 its vessels and nerves to an extreme degi'ee. Gangrene ensued, and 
 amputation did not save the patient. 
 
 The following is the earliest case of injury of the lower epiphysis 
 of the femur reported in a detailed manner : gangrene ensued on 
 the eighth day. 
 
 M. Julia Eontenelle relates {Archives Generales de Medecine, leme 
 serie, tome ix. 1825, p. 267 ; Boux (Brignolle), LaPresse Medicate, No. 
 55, 12 Juillet 1837, p. 436; also quoted by Gueretin, LaPresse Medi- 
 cale, 1837) the case of a boy (J. M.), aged eleven, who had plunged his 
 right leg into a hole up to his knee and fell forwards, separating the 
 lower epiphysis from the shaft, and at the same time driving the 
 shaft into the popliteal space. The child remained two days with- 
 out receiving any attention. He was taken to the hospital on the 
 third day, and there was found shortening of the limb with pro- 
 jection forwards of the condyles. The lower end of the shaft 
 pressed upon the vessels and nerves, and the epiphysis became 
 tilted in such a manner that its lower extremity was directed 
 forwards. There was considerable swelling of the limb. The limb 
 was put up in an ordinary apparatus, as reduction could not be 
 effected and the parents refused amputation. On the fourth day 
 there was numbness of the limb, pain in the joint, swelling, and 
 coldness of the foot. On the seventh day the foot was livid, and 
 small incisions were made. On the eighth day gangrene was 
 evident, and diarrhcea set in ; the parents still refused amputation. 
 On the eighteenth day the gangrene was limited at the knee, 
 and there was general emaciation. On the twenty-third day the 
 
SEPAEATION OF LOWER EPIPHYSIS OF FEMUE 733 
 
 foot separated from the leg ; the bones of the leg were bare at 
 certam points. On the twenty-fourth day (September 26) Dr. 
 Coural, of Narbonne, amputated four inches above the condyles. 
 The patient left the hospital cured on December 10. 
 
 Delpech describes {Chirurgie Clinique, torn. i. 1823, p. 252) as 
 follows the specimen of separation of the lower femoral epiphysis 
 in Coural's case, which was in his possession, whilst Eoux made 
 several coloured drawings of it : ' The epiphysis has been separated 
 from the shaft in the middle of the cartilaginous layer, so that a 
 layer of it remained attached to each osseous fragment. The two 
 surfaces are thus invested with soft material, and the lower fragment 
 had been displaced backwards, so that the two new surfaces were 
 not in contact.' 
 
 The popliteal vessels in Glutton's case were ruptured, leading to 
 gangrene of the foot, amputation, and death from pysemia. 
 
 In Dolbeau's case pressure of the internal condyle of the 
 epiphysis upon the popliteal vessels and skin produced ulceration 
 and sloughing in the upper part of the pox^liteal space, thereby 
 converting a simple into a compound diastasis. 
 
 Ulceration of the skin and protrusion of the diaphysis are also 
 mentioned in Bell's, Voss's, and Halderman's cases. 
 
 Secondary liaemorrhage. — Severe haemorrhage from the anterior 
 tibial artery, due to an injury close to its origin, occurred on the 
 thirteenth day in Little's case, and compelled him to amputate. 
 
 Mr. C. F. Maunder mentions {London Hospital Bepoj'ts, vol. iv. 
 1867-8, p. 239) the case of a male child (F. J.), aged six years, who 
 was run over, and sustained a simple fracture of the left thigh bone, 
 and also a compound separation of the lower epiphysis of the 
 femur. The wound was transverse in the popliteal space, and the 
 finger introduced found the lower end of the shaft of the femur 
 stripped of periosteum to the extent of at least an inch ; a small 
 fragment only of the femur was adherent to its epiphysis. The 
 limb was put up with the knee in the flexed position. The case 
 progressed fairly well, but with profuse discharge, until suddenly 
 copious haemorrhage arose from the depth of the wound. 
 
 As the little patient could not afford to lose blood, being already 
 much exhausted, amputation was at once performed. Symptoms of 
 pyaemia, including swelling of the opposite thigh, with deep fluc- 
 tuation, supervened, and death took place on the eighteenth day 
 after amputation. 
 
 Articular lesions. — Contrary to what we should expect to find 
 from the close proximity of the articulation and the actual contact 
 of the synovial membrane in front with the epiphysial line, the 
 joint is but seldom seriously involved. The crucial and other liga- 
 ments uniting the epiphysis to the bones of the leg are far more 
 powerful than the cartilaginous bond of union between the epiphysis 
 and the diaphysis, and are but rarely injured. The crucial ligaments 
 
734 EPIPHYSES OF LOWEE EXTREMITY 
 
 were, however, in E. Adams's case, torn from the femm', carrying 
 with them small portions of the bone. 
 
 In several examples — e.g. Eathbmi's case — it was especially stated 
 that the articular cavity was not opened, although in this particular 
 case the posterior ligament of the joint was slightly torn at its 
 upper part. 
 
 In Meisenbach's case of compound separation with displacement 
 backw^ards and outwards of the diaphysis for four inches, the knee- 
 joint was not involved, and the capsule was intact, as shown by the 
 absence of blood in the joint. 
 
 Injury to the articulation has, however, been occasionallj^ ob- 
 served in pure and uncomplicated separations— e.g. Bruns mentions 
 that the contused wound in his case opened the knee-joint, w^hilst 
 Eutberford Alcock thought that the capsule of the joint had pro- 
 bably been opened in his case, on account of the synovial-like fluid 
 which for some time issued from the wound. 
 
 In two of the specimens in St. George's Hospital the joint has 
 been injured : in one, of displacement of the epiphysis backwards 
 and outwards, the posterior ligament was slightly torn at the internal 
 part, but the other ligaments were intact ; in the other, of displace- 
 ment forwards of the epiphysis, there was an opening, exposing the 
 posterior part of the outer condyle. 
 
 In Halderman's case of displacement of the epiphysis inwards 
 and backwards there was laceration on the inner side of the cavity 
 of the knee-joint, which contained some blood. 
 
 In an article on ' Abnormal Conditions of the Knee-joint ' 
 {CijclopcBdia of Anatomy and Physiology, E. B. Todd, M.D., 1839-47, 
 vol. iii. pp. 68, 69), Eobert Ada^ms describes a case of simple separa- 
 tion in a boy, aged thirteen. The femoral condyles were detached 
 at their normal line of junction with the shaft, and where they are 
 covered w4th synovial membrane ; the anterior and posterior crucial 
 ligaments were separated from the femur, and had carried ydi\\ 
 them small portions of this bone. The result of the secondary 
 amputation is not recorded, but the specimen preserved in 
 the Museum of the Eichmond School of Medicine shows, besides 
 the injuries of the bones, traces of the very acute inflammation 
 which followed, particularly on the surface of the sjmovial membrane ; 
 the latter was covered with lymph. The periosteum of the femur in 
 the vicinity of the fracture was much thickened, and detached all 
 round from the femur. 
 
 At the Philadelphia Academy of Sm^gery in 1889 {Med. News, 
 Philadelphia, May 1889, p. 552) Dr. John H. Brinton exhibited a 
 specimen presented seven years previously to the Jefferson Medical 
 College by Dr. Wihis T. Davison, of Pennsylvania, 
 
 The patient was a boy, twelve years of age, who, while riding on 
 the back of a buggy, had his left foot caught between the spokes of 
 the wheel and carried forwards, producing a separation of the epi- 
 
SEPAEATION OF LOWEE EPIPHYSIS OF FEMUK 735 
 
 physis, with a slight nipping off of one portion of the edge of the 
 diaphysis. There was an obHque wound, four or five inches long, 
 extending across the upper portion of the popliteal space. The skin, 
 superficial fascia, and muscles were severely lacerated, and there 
 existed copious venous hasmorrhage and extensive extravasation 
 around the joint and upper part of the leg ; no pulse could be felt in 
 the posterior tibial artery. The boy was able to turn over and im- 
 perfectly raise the knee from the bed. An unsuccessful attempt 
 was made to save the limb, but amputation was necessary on the 
 fourth day, and the patient made a good recovery. 
 
 Careful dissection of the amputated limb showed that the epi- 
 physis had been torn from the diaphysis, and the artery injured in 
 such a manner that a probe could with difficulty be passed through 
 it. It was also found that there was a rupture at the posterior part 
 of the synovial membrane, opening the knee-joint. 
 
 Packard says : ' The epiphysial line is just above the boundary 
 of the knee-joint, and when a separation takes place exactly through 
 it, that cavity will not be involved, although it may become so 
 secondarily.' 
 
 Blood ill the joint has been found in two cases of simple diastasis 
 — viz. Dolbeau's and Atkinson's cases ; and in Eeverdin's case of 
 compound injury the articulation contained a little sero-sanguineous 
 fluid, and the crucial ligaments were inflamed and of a pinkish colour, 
 without any lesion of the joint being discovered. 
 
 It is probable that in some instances besides the one just alluded 
 to the crucial or other ligaments have been partially lacerated. 
 
 Great articular distension from effusion may ensue without any 
 discoverable lesion to account for it, beyond the close relationship 
 of the epiphysial line to the joint. 
 
 It has been especially noted by Hamilton, Tapret, Harte, and 
 others. 
 
 Fracture of the upper end of the tibia. — A transverse fracture of 
 the upper end of the tibia complicated separation of the lower epi- 
 physis of the femur in Dr. F. D. Rathbun's case {St. Louis Courier 
 of Medicine, vol. xi. No. 3, March 1884, p. 211). 
 
 On November 20, 1883 (C. S.), a boy, aged ten years, while 
 attempting to climb into the rear end of a wagon in motion, caught 
 his right leg in the spokes of the wheel in such a manner as to over- 
 extend the leg upon the thigh, thereby separating the lower epiphysis 
 of the femur, and driving the lower end of the shaft bacliwards 
 through the popliteal space. The lower end of the shaft was found 
 to present a broad slightly roughened extremity, which clearl}'- 
 showed its separation from the epiphysis, and protruded from a 
 wound which communicated with the point of separation. The 
 rent in the skin extended obliquely across the popliteal space, 
 beginning two inches above the internal condyle and terminating 
 over the head of the fibula, and the tissues were very much lacerated. 
 
736 EPIPHYSES OF LOWEE EXTEEMITY 
 
 By flexing the leg upon the thigh, the separated surfaces could be 
 brought into accurate apposition. There was considerable venous 
 haemorrhage, which was, however, easily controlled. On the follow- 
 ing morning the patient's general condition was good, and no 
 shortening of the limb existed while in the position of flexion. Some 
 swelling supervened, and the temperature of the limb was about 
 normal. No pulsation could be felt in the posterior tibial artery. 
 After ether had been administered and the hmb straightened, the frag- 
 ments became displaced, with marked shortening; the lower extremity 
 of the shaft projected backwards and outwards, but did not protrude 
 from the wound until the leg was carried forwards considerably 
 beyond a straight line w4th the thigh. By pressing the finger into 
 the wound the separated surfaces could be clearly felt, the shaft of 
 the bone being denuded of its periosteum to the extent of nearly 
 three inches. The tissues in the popliteal space were greatly 
 lacerated. Amputation of the thigh was performed, the femur 
 being divided four inches above the line of separation. The patient 
 made a good recovery. 
 
 After removing the soft parts it was found that the line of 
 separation followed the cartilage throughout. In no place did it 
 traverse the bone tissue. In addition, a fracture of the upper 
 extremity of the shaft of the tibia was discovered that had not been 
 previously suspected ; it was situated just below the epiphysial line, 
 and was nearly transverse in direction, being directed from without 
 inwards, slightly downwards and forwards. There was no displace- 
 ment of the fragments whatever. The posterior ligament of the 
 joint was slightly torn at its upper part. With this exception, no 
 laceration of ligaments occurred. The joint cavity was not opened. 
 
 Otter severe lesions. — Dr. J. A. Donovan, of Lew^iston, U.S.A., 
 has kindly furnished the author w4th the notes of a severe case of 
 compound separation of the lower femoral epiphysis accompanied 
 by other extensive injuries to the body {Transactions of the Maine 
 Medical Association, 1884, vol. viii. part ii. p. 345). 
 
 On November 13, 1882, Dr. Donovan was called to T. B., a 
 lad, aged ten, who had met with a severe accident twenty to thirty 
 minutes before, and was lying in an apparently lifeless condition. 
 After some hypodermic injections of brandy had been administered, 
 a careful examination under an anaesthetic showed a fracture of the 
 left parietal bone, with extensive infiltration of blood. The left 
 femur was fractured just below the trochanter major. The condyloid 
 epiphysis was separated and the intervening shaft much com- 
 minuted. Notwithstanding such complete breaking of the whole 
 femur, the skin w^as not torn, but was rendered very tense from 
 bloody effusion. A large and extensive wound across the popliteal 
 space of the right limb was found, through which the lower end of 
 the femur'projected about four inches. The epiphysis was separated 
 and retained its proper relation with the knee-joint. The popliteal 
 
SEPARATION OF LOWEE EPIPHYSIS OE FEMUE 737 
 
 wound was so extensive that only about three inches of skin on the 
 front of the Hmb remained intact. The laceration of connective 
 and muscular tissues was very extensive. The inner hamstring 
 tendons were stripped of their investments. The saphenous vein 
 was exposed, and the popliteal artery, though it escaped laceration, 
 was displaced by the backward escape of the lower end of the 
 femur. 
 
 The accident resulted from the boy becoming entangled in a 
 belt, which carried him round its pulley about forty times, the limbs 
 and head striking adjacent timbers at each revolution. Although 
 but little hope was entertained that the patient could survive the 
 profound shock of the injury, amputation of the right femur was 
 advised as the best course, but determinedly refused by the friends. 
 Two and a half inches in length of the shaft of the femur were 
 removed. So much was taken for two reasons : that the periosteum 
 was entirely separated as high as the point of section, and that the 
 sharp edges left by cutting the expanding shaft would probably have 
 injured the adjacent popliteal vessels. The limb was put up in an 
 anterior splint to afford an opportunity of dressing the wound. The 
 boy rallied fairly from the ether and the shock of the injury, and, 
 although in a very critical condition for several days, made an uninter- 
 rupted recovery. No cerebral symiptoms followed the cranial injury. 
 The left femur, that was so thoroughly comminuted, united well, no 
 apparent deformity resulting. Five months after the injury the 
 wound of the right limb was completely healed, and firm bony union 
 had occurred between the cut shaft of the femur and the separated 
 epiphysis, which had been allowed to remain in relation with the 
 knee-joint. Two years later (1884) the boy had grown and developed 
 well. There was good motion at the knee, and the growth was in 
 keeping with its fellow. But for the unfortunate circumstance that 
 the nerve trunks affording supply to the extensor muscles of the leg 
 were injured, leaving these muscles paralysed in motion, the boy 
 would scarcely have suffered serious loss by his injury. 
 
 Dr. Donovan, in a letter to the author dated October 31, 1893, 
 says : ' The very flattering condition in which the above report left 
 him did not very long continue. The boy grew rapidly, and the right 
 limb failed to keep pace with the left, which recovered fully. He 
 became "knocked" in the right knee. I confined him to his bed 
 with a correcting splint. The deformity was in part relieved, but 
 the limb became tuberculous and I amputated at the mid portion 
 of the femur. The young man subsequently did well.' 
 
 Fracture of shaft of femur. — Packard, in Ashhurst's Encydopadia 
 of Surgery, 1884, vol. iv. p. 216, mentions a specimen in the Museum 
 of the Pennsylvania liospital {Pennsylvanian Hospital Museum 
 Catalogue, p. 31, No. 1132) in which there was separation of the 
 lower epiphysis of the femur, with transverse fracture of the 
 , middle third of the femur, caused by the patient being run over by 
 
 3b 
 
738 EPIPHYSES OF LOWEE EXTEEMITY 
 
 a railroad-car. Fracture of the shaft of the femur as a concomitant 
 lesion has been noted in one other case. 
 
 Severe general symptoms, such as pallor, collapse, coldness, with 
 compressible pulse and other signs of general prostration, usually 
 accompany this injury in its more serious forms, of which the 
 instance quoted above is a good example. 
 
 Later Complications. Suppuration. — Diffuse suppuration 
 appears to be a frequent result, especially in compound separations. 
 Dr. Voss, at the same meeting of the New York Pathological Society 
 at which Dr. Little communicated his case {Neto York Medical 
 Journal, vol. ii. 1865-6, p. 133), remarked that he had met with a 
 similar one. The fracture was simple at the time of the acci- 
 dent, but subsequently an abscess formed and the upper fragment 
 protruded. In this condition Dr. Voss saw the case, and was 
 compelled to amputate. Dr. Buck mentioned a similar case of 
 separation of this epiphysis in a boy, aged fourteen, whose legs 
 had been caught by the spokes of a revolving wheel and twisted. 
 Dr. Buck could not recollect whether the fracture was compound 
 or not. 
 
 Mr. Jonathan Hutchinson junior's specimen (1888) in the Eoyal 
 College of Surgeons Museum, No. 1041b, shows the lower end of 
 the right femur divided vertically from side to side. It displays 
 detachment and partial crushing of the epiphysis, the epiphysial 
 disc having been destroyed by sjippuration. The periosteum is 
 stripped off the back of the diaphysis, but adheres in front ; the 
 popliteal vessels are uninjured, and the two heads of the gastro- 
 cnemius are attached to the displaced epiphysis and periosteum. 
 No trace of the epiphysial disc remains. Several pieces of the 
 epiphysis were broken off at the time of the injury. 
 
 The patient was a child, aged four years, whose thigh had been 
 run over by a van-wheel five weeks before death. The injury was 
 compound, but so little was the displacement that the separation 
 was not at first diagnosed. Amputation became necessary at the 
 end of ten days ; the cause of death was thrombosis of the vena 
 cava. 
 
 Acute periostitis and necrosis.^ — Acute periostitis is clearly exhibited 
 in not a few specimens. Necrosis of the diaphysis more commonly 
 ensues in compound than in simple separations. 
 
 The Museum of the Eoyal College of Surgeons of England 
 contains a specimen, No. 1041a {Catalogue of the Museum of theBoyal 
 College of Surgeons, Appendix I.), presented by Mr. W. Adams, 
 showing epiphysial separation followed by acute periostitis. In this 
 specimen the separation is through the greater part of the epiphysiary 
 junction, except for about the outer third, where a vertical fracture 
 passes upwards for one and a quarter inch, separating off this part 
 of the diaphysis, which remains firmly connected to the epiphysis 
 below. The end of the diaphysis projects forwards and inwards, 
 
SEPAEATION OF LOWER EPIPHYSIS OF FEMUE 739 
 
 and the epiphysis is slightly rotated ; otherwise its connections with 
 the tibia are normal. The joint also appears to be normal. 
 
 Suppuration beneath the periosteum had taken place in another 
 specimen in the Eoyal College of Surgeons of England, No. 1041b 
 (see page 703). 
 
 A specimen in the Museum of the Eoyal College of Surgeons of 
 Edinburgh, No. 139, xx. c, and figured by Charles Bell in his Observa- 
 tions on Injuries of the Spine and Thigh Bone (1824, PL IV. fig. 2), 
 shows evidence of suppurative and septic periostitis or osteomyelitis, 
 for on the anterior aspect of the shaft, two inches above the end, a 
 considerable amount of new periosteal bone is to be seen ; below 
 this the bone is bare, and appears about to exfoliate (see fig. 12, p. 120). 
 A small wedge-shaped piece, one inch by half an inch, of the diaphysis 
 has been split off from its front and outer aspect. The case was that 
 of a boy, aged thirteen, who fell through an open floor, between 
 the joists, in such a manner as to twist his leg, causing thereby 
 what was supposed to be a fracture near the knee-joint. The joint 
 suppurated, and the restlessness of the patient brought about 
 ulceration of the skin and a protrusion of bone which was readily 
 recognised as the extremity of the diaphysis. There were deep 
 sloughing spots upon the inner side of the knee. 
 
 The patient died some weeks after the accident, before amputa 
 tion could be performed. 
 
 The dissection exhibited great suppuration within the knee-joint, 
 and an immense abscess or cavity communicating with the articula- 
 tion and extending up the bone nearly to the hip. The periosteuin 
 could be torn with the fingers from half the length of the bone. 
 
 C. AV. Cathcart adds {Descriptive Catalogue of Museum Boyal 
 College of Surgeons of Edinburgh, 1893, p. 134, specimen No. 3, 
 248) a similar note on the condition of the bone. 
 
 ' The surface of the shaft at the lower end has at some places 
 a considerable crust of new periosteal bone, while at others the 
 vascular pores are opened out. A similar opening out is seen all 
 the way up the shaft. At the front of the neck a patch of the 
 surface is eroded. These changes have evidently been due to septic 
 osteomyelitis, an accidental consequent of the injury.' 
 
 Suppurative periostitis was probably the cause of the deposit of 
 new bone and the rarefaction of the old shaft in one of the specimens 
 in St. Bartholomew's Hospital, No. 977. There was extensive com- 
 minution of the shaft and fracture of the epiphysis into four pieces 
 (see page 704). 
 
 Mr. E. Willett had under his care at St. Bartholomew's Hospital 
 (Walsham, ' Surgical Consultations,' St. Bartholomew's Hospital 
 Beports, 1888, vol. xxiv. p. 288) a lad, aged nine, who had received 
 a fracture of the lower end of the femur about six months previously. 
 A piece of the femur, which had necrosed and separated, showed 
 clearly that the fracture had occurred through the epiphysial Ime. 
 
 3 B 2 
 
740 EPIPHYSES OF LOWER EXTREMITY 
 
 The knee-joint was healthy. On the outer side of the thigh, just 
 above the knee, was a mass of prominent granulations, an inch and 
 a half in diameter, covering a protruding" portion of bone. The 
 parts around were excessively tender. It was considered that he 
 had sustained a separation of the lower epiphysis of the femur, with 
 much unreduced displacement; that, owing to the outward pro- 
 trusion of the diaphysis, the integument had ulcerated, exposing the 
 bone ; and that, subsequent to the necrosis of a portion of the lower 
 end of the femur, the bone had united in a faulty position, leaving 
 the lower end of the upper fragment projecting on the outer side. 
 An incision was made over the prominence, and an inch or so of the 
 protruding portion of bone cut away. The patient made an excellent 
 recovery. 
 
 Dr. Post's case of compound separation likewise terminated in 
 necrosis of the diaphysis. 
 
 Dr. R. H. Harte, of Philadelphia, narrates {Trans. Amer. Surg.- 
 Assoc, Philad. 1895, vol. xiii. p. 397, and the American Journal of 
 the Medical Sciences, June 1896, p. 689) a simple case of epiphysial 
 separation with marked lateral displacement, terminating in ex- 
 tensive suppuration, for which amputation was performed. Harry 
 H., aged sixteen years, was admitted to the Episcopal Hospital 
 May 4, 1894. While running round a pile of heavy sheet iron, used 
 in shipbuilding, which was standing upon its edge, a plate fell, 
 striking the side of his leg a little above the knee, and producing a 
 marked lateral displacement, which on admission was reported to 
 be a lateral dislocation of the knee. On examination (under ether) 
 there was found to be much effusion in and about the knee-joint, 
 with distinct softening and a hgematoma over the lower end of the 
 vastus internus muscle. All deformity could be readily corrected 
 by extension and lateral support, but under lateral pressure, in 
 which the thigh was fixed and the lower or condyloid portion 
 pressed, the deformity would recur, simulating lateral displacement 
 of the knee. On careful examination the sharp outline of the 
 diaphysis of the femur could be distinctly outHned through the 
 softened or ruptured vastus internus muscle. Crepitus of a soft or 
 moist character could be readily detected. Extension was applied, 
 and long lateral splints with bran bags on either side of the limb. 
 With these the ends of the bones were kept in perfect apposition, 
 although with much effusion about the knee. In the course of a 
 few days there was evidence of suppuration in the region of injury, 
 which was opened and drained. Through the incision, made 
 on the inner side of the thigh, the line of separation could be 
 distinctly outlined in perfect apposition. A large portion of the 
 lower end of the femur was divested of its periosteum. Extensive 
 suppuration followed, and in order to prevent a fatal termination 
 the thigh was amputated in the middle third. From that time the 
 patient made an uneventful recovery. The drawing from a photo- 
 
SEPARATION OF LOWEE EPIPHYSIS OF FEMUE 741 
 
 graph which accompanies Dr. Harte's report, taken from the dried 
 specimen in his possession, displays a pure separation of tlie epiphysis 
 and manifest traces of suppurative periostitis. Dr. Harte thought 
 that the subsequent discharge of several pieces of bone might be 
 connected with the periosteum ; that these pieces might have been 
 developed from the osteogenic layer of the denuded periosteum, &s 
 there was found a number of such fragments attached to the 
 separated periosteum. 
 
 Dr. J. Prochnow, of Buda Pest, relates (' Traumas epiphysis- 
 levalas,' Gyogydszat, Budapest Nov. 1892, 546 ; abstract Pester 
 meclizinisch-cliiyurgische Presse, Budapest 1893, April 389) a case of 
 displacement backwards of the epiphysis, followed by necrosis of 
 the skin and the end of the diaphysis, in a boy ten years old. The 
 separation was at first a simple one. 
 
 The patient, whilst running (June 12, 1891), fell upon the curb- 
 stone of a pavement and violently struck his left knee. He was 
 unable to stand, and had to be carried home. The doctor called 
 in detected a fracture, and sent him to the hospital. There was at 
 once seen a notable displacement of the knee outwards and back- 
 wards from the thigh, causing an angular appearance of the limb. 
 At the lower part of the inner side of the thigh, in the normal 
 situation of the internal condyle, the skin was bluish, and stretched 
 over the sharp edge of the femur. This became more tense with 
 every movement. The lower fragment or epiphysis was displaced 
 backwards, the upper fragment inwards and forwards. The knee 
 was somewhat swollen, but the patella could be easily made out, being 
 placed towards the outer side. Both condyles were easily identified, 
 but the lower fragment could not readily be fixed. With every 
 movement crepitus was perceptible. Flexion of the knee failed to 
 adapt the fragments accurately. The upper end of the fracture pro- 
 jected completely forwards ; this became very marked on extension, 
 but less so on moderate flexion. The limb was therefore put up in 
 this position on an inclined plane. However, the skin necrosed from 
 the pressure of the bone, which, bare of its periosteum, became 
 exposed, and protruded for one to two centimetres. The protruding 
 end of bone gradually necrosed, and a moderate amount of suppura- 
 tion delayed the progress of the case. The inclined plane was 
 continued for many weeks, when the limb was placed upon a 
 cushion, as there was no movement at the seat of fracture. On 
 September 27 the necrosed bone came aw^ay, and two smaller pieces 
 on November 2 and 21. On February 6, 1892, the patient left the 
 hospital perfectly recovered, and, as Dr. Prochnow afterwards 
 learned, walked well, and up to the time of the report no alteration 
 in the length of the extremity had occurred. 
 
 The following account of a case of compound separation of the 
 lower epiphysis of the femur by Dr. E. H. Nichols (Medical and 
 Surgical Reports, Boston Cicy Hospital, U.S.A., 189(), 7. S. p. 118), 
 
742 EPIPHYSES OF LOWEE EXTEEMITY 
 
 examined by him at the Sears Pathological Laboratory of the 
 Harvard Medical School, gives an interesting description of the 
 appearances subsequently found in the traumatic osteomyelitis 
 which existed. 
 
 P. McD., a schoolboy, aged thirteen years, was admitted on 
 June 19, 1895. One hour previously he had tried to jump upon the 
 tailboard of a moving wagon, and his left leg was caught in the 
 revolving wheel. The boy's general condition was good, and he 
 showed little evidence of shock. There w^as a compound separation 
 of the lower epiphysis of the left femur from the diaphysis, the end 
 of which projected through the wound about eight centimetres, and 
 was denuded of periosteum for about five centimetres. The joint was 
 not opened, and the dorsalis pedis artery pulsated. Under ether it was 
 necessary to enlarge the superficial wound before the bone could be 
 reduced. The v/ound was cleaned, and a drain inserted at the 
 lower angle, the opening being closed by interrupted sutures. The 
 leg was put up in a plaster dressing, which extended from the toes 
 to the groin. The wound w^as dressed again on the second day on 
 account of staining of the dressing. In about a week the boy began 
 to lose ground, and two weeks after the first dressing pus was seen 
 in the wound. The patient steadily growing worse, amputation 
 was advised and refused. The discharge increased, and various 
 sinuses, leading down to dead bone, were formed. Seven weeks 
 from the day of admission there was sudden profuse haemorrhage 
 from the sinuses, which was controlled by packing. Hsemorrhages 
 recurred almost daily for nearly two weeks. Finally the parents gave 
 reluctant consent to amputation ; this was performed fifteen centi- 
 metres below the hip. Even then the flaps had to be trimmed and 
 curetted to free them of the infiltrated tissue. Improvement imme- 
 diately took place, and the patient was discharged four weeks later. On 
 examination the surface of the end of the shaft was roughened and 
 eroded, while its lateral surfaces for a distance of three to five centi- 
 metres were entirely denuded of periosteum, which had been stripped 
 back like a glove finger. Beginning at the level of the periosteal 
 detachment, the shaft was enlarged and irregular from new bony 
 formation. The fractured surface of the epiphysis was rough, shreddy, 
 and slightly eroded, and a small osseous fragment was torn from the 
 internal condyle. The articular surface was normal. Section of 
 the shaft showed the lower three centimetres to be spongy, with large 
 irregular areolar spaces. Above this area there was an irregular 
 transverse dense white band, and above the band the shaft was 
 apparently normal, except for a considerable layer of newly formed 
 periosteal bone outside the original dense walls. 
 
 On microscopical examination the articular cartilage appeared 
 normal. The marrov/ of the epiphysis, in which the cell elements 
 predominated (' red marrow '), was normal to within five millimetres 
 of the epiphysial line. At that level the areolar spaces began to be 
 
SEPAEATION OF LOWER EPIPHYSIS OF FEMUR 7-13 
 
 filled partly with young connective tissue containing numerous 
 large vessels (' granulation tissue '). Then came a transverse band 
 of dense fibrous tissue, completely filling the areolar spaces. Be- 
 tween this fibrous band and the hne of fracture was a layer of 
 lymphoid cells and of polynn clear leucocytes. 
 
 The shaft of the femur for the distance of over three centimetres 
 above the epiphysial line was entirely necrotic, the cells were fused into 
 a faintly staining granular mass, and the trabeculoe showed neither 
 laminas nor bone cells. This necrosis was less marked the greater 
 the distance from the epiphysial line. Above the area of necrosis 
 was an irregular obliquely transverse band of dense fibrous tissue, 
 the fibres of which completely filled the areolar spaces, while the 
 trabeculge were mostly necrotic. In places the fibrous tissue was 
 oedematous, and enclosed large numbers of lymphoid cells and 
 polynuclear leucocytes. 
 
 Outside the original shaft of the femur, beginning a little below 
 the level of the band of fibrous tissue just described, was a wide 
 layer of newly formed periosteal bone, having numerous trabeculse, 
 whose surface was covered by many bone-forming cells (osteoblasts) , 
 while the areolar spaces were filled with young connective tissue 
 cells and osteoblasts. Above the transverse band of fibrous tissue 
 the marrow v/as normal. With Weigert's stain many colonies, 
 large and small, of cocci, apparently staphylococci, could be seen 
 scattered throughout the necrotic lower end of the shaft. In the 
 transverse band of fibrous tissue no such colonies could be seen, 
 nor did they appear in the normal marrow above the band. In 
 the epiphysis only a very few colonies could be found, and in all 
 cases the colonies were outside the band of fibrous tissue. 
 
 From a consideration of this case it seemed certain to Dr. 
 Nichols that it would have been impossible to avoid infection. The 
 lower end of the shaft, stripped of periosteum, its blood supply cut 
 off, and its vitality lowered by injury, inevitably must have become 
 necrotic, he says, and been separated as a sequestrum. This necrotic 
 bone yielded easily to a shght infection. It is probable that, if the 
 periosteum had not been stripped, the bone would have been able 
 to resist infection, for the epiphysis did resist infection, except 
 directly along the edge of the line of fracture, while the shaft at the 
 level where the periosteum was intact completely walled off the 
 bacteria. The walling-off of so extensive and active a process 
 indicated that the infection came late, after the process of repair 
 was well advanced. 
 
 The case suggested to Dr. Nichols that it may be desirable, in 
 such a case of extensive stripping of the periosteum, to attempt to 
 replace the lacerated periosteum, or, if that is impossible, to excise 
 the denuded bone, since the resulting shortening would be of less 
 consequence than the practically certain infection wdth its attending 
 dangers. 
 
744 
 
 EPIPHYSES OE LOWEE EXTREMITY 
 
 Inflammation and suppuration of tlie knee-joint. — Suppuration of the 
 joint and popliteal space occurred in one instance three years after 
 the accident, when the epiphysis had united in its malposition on 
 the front of the femur. The specimen from the museum of Pobert 
 Liston is now in the Museum of the Eoyal College of Surgeons of 
 England, No. 1041, and is figured b}^ this surgeon in his Elements 
 of Surgery (second edition, London, 1840, p. 721), and by many 
 other surgical authors. The patient, a girl, was fourteen j'ears old 
 when her leg was caught between the spokes of a wheel and the 
 
 epiphysis separated. After the accident 
 the knee remained painful and swollen, 
 and she halted a little in walking ; but 
 nothing" particular ensued for three 
 years after her apparent recovery from 
 the accident, when a large abscess 
 formed in the ham and lower part of 
 the thigh, and communicated w^th the 
 knee-joint. Eor this the limb was 
 amputated, and the patient recovered. 
 The epiphysis has been displaced for- 
 wards and upwards about halfway on 
 to the front of the femur, and the dia- 
 physis forced downwards and back- 
 wards. In this position firm and 
 smooth reunion has taken place, with 
 very little shortening or distortion of 
 the limb. 
 
 Suppuration of the joint may occur 
 as the result of direct injury or lacera- 
 tion of the articular structures, or from 
 suppuration extending to it from the 
 vicinity of the epiphysial lesion. Dr. 
 Harte says that this articulation was 
 implicated in one of his cases (Edward 
 H.), possibly the result of secondary 
 infection. 
 
 Septic suppuration of the joint is 
 particularly prone to ensue in compound separations. 
 
 Mr. Charles Hawkins, at the Eoyal Medical and Chirurgical 
 Society in April 1842 [loc. ci?^. swj)r«), mentioned a case of compound 
 separation in Westminster Hospital where the end of the bone 
 was sawn off. Suppuration formed in the joint, which became 
 ankylosed. 
 
 Septic phlebitis and pyaemia are mostly represented in compound 
 separations. 
 
 An interesting example of compound separation with rupture of 
 the popliteal artery, followed by amputation, pyaemia, and death, is 
 
 Fig. 226. — sepaeation and dis- 
 
 PLACEilEXT FOEWAEDS OF THE 
 LOWEE EPIPHYSIS OF THE FE3IUE. 
 UNION IN THIS POSITION WAS FOL- 
 LOWED BY SUPPUEATION OF JOINT 
 AND POPLITEAL SPACE 
 
 (Royal College of Surgeons Mu- 
 seum.) 
 
SEPAEATION OF LOWEE EPIPHYSIS OF FEMUE 745 
 
 published by H. H. Glutton {St. TJwmas's Hospital lieports, is'.s. 
 vol. xxii. 1894, p. 13). 
 
 Jane B., aged eight years, was admitted- into St. Thomas's 
 Hospital on October 28, 1893. She had been running behind an 
 undertaker's cart, and had her left leg caught between the spokes 
 of one of the wheels. 
 
 On admission the left leg was held in a flexed position by the 
 child, who seemed in great pain. There was a hollow just above 
 the patella at the lower third of the thigh in front. An inch and a 
 half above the upper edge of the patella, on the outer side of the 
 thigh, was a wound which looked almost like an incised wound, 
 about one inch in length, extending through the deep fascia and 
 into the muscle, which was exposed. There was an extensive 
 heematoma on the outer side of the thigh. Under an anaesthetic 
 there was found a separation at the epiphysial line, with displace- 
 ment of the epiphysis forwards, so that the lower end of the diaphysis 
 was pressing against the popliteal vessels. The deformity could only 
 be reduced with difficulty, and reappeared on omitting extension. 
 The arteries could not be felt at the foot either before or after 
 reduction, and with a finger in the wound it was thought probable 
 that the popliteal artery was ruptured. As there was no hemorrhage, 
 an attempt was made to save the limb. The blood-clot was cleared 
 out of the popliteal space, and by constant irrigation the wound 
 rendered as aseptic as possible. A dressing of cyanide gauze was 
 applied, and the whole limb and abdomen enveloped in plaster of 
 Paris, with a window opposite the wound. The foot, which had 
 been previously cold and blanched, became warmer and redder. 
 Extension was kept up till the plaster had set, when it was found 
 that the deformity did not recur. Unfortunately a clove-hitch was 
 then applied to the ankle, and from this a weight suspended over 
 the end of the bed. The discharge from the wound became offensive 
 and the foot gangrenous ; a back splint in place of the plaster of 
 Paris was applied. Amputation of the thigh was performed on 
 November 10 at the line of the wound on the outer side of the thigh. 
 It was found necessary to remove a small portion of the femur. 
 Septic absorption still went on, and the temperature varied from 
 99° to 103°. The flaps retracted and exposed the end of the femur, 
 which was apparently dead. Mr. Glutton thought a septic osteo- 
 myelitis was taking place, and therefore on November 18 removed 
 the end of the femur. There was no pus in the medullary canal, 
 and the section of femur exposed was healthy. Suppurative 
 arthritis of the left shoulder-joint and many other signs of pyaemia 
 occurred, and the patient died on November 30. At the autopsy 
 there was suppurative thrombosis of the left femoral and external iliac 
 veins as high up in the vena cava as the entrance of the renal veins. 
 There was a similar clot softening here and there in the right iliac 
 and femoral veins, with a small collection of pus at the apex of 
 
746 EPIPHYSES OF LOWEP EXTEEMITY 
 
 Scarpa's triangle. The lungs were a little cedematous, and with the 
 exception of a drachm of thick pus in the left shoulder- joint, there 
 w^ere no other changes indicative of pyaemia, and Mr. Glutton con- 
 sidered that success would probably have followed a ligature of the 
 left femoral vein at the groin at any time before the thrombosis had 
 extended beyond Poupart's ligament. Before death, on November 24, 
 thrombosis of the right femoral vein became apparent, followed by 
 great swelling of the w^hole of the right thigh and leg, but, as Mr. 
 Glutton says, it was recognised too late to consider the advisability 
 of arresting the progress of pysemia from suppurative thrombosis 
 by ligature of the vein on the cardiac side of the furthest limit of 
 the clot. 
 
 Aneurism. — The presence of the end of the diaphysis in the 
 popliteal space by pressure on the popliteal artery may cause an 
 aneurism to develop, in after years, from ulceration or rupture. 
 
 This is well shown in a specimen in the Museum of the Royal 
 College of Surgeons, Edinburgh, No. 138, xx. c, of separation of this 
 epiphysis, united in its disx3laced position ; a beautiful illustration of 
 the same specimen is given by Sir Gharles Bell {Observations on 
 lujitries of the Spine and Thigh Bone, 1824, p. 86 ; Medico- 
 Chirurgical Bevieio, n.s. vol. viii. 1825, p. 49). (See p. 122, fig. 13.) 
 
 A boy, age not stated, in getting on to the back of a carriage, 
 caught his leg in the spokes of the wheel; twisting off the epiphysis 
 from the extremity of the diaphysis. Union took place after this 
 accident, but the broken portions united irregularly, and a point 
 projected. About twenty years after this accident the patient, now 
 grown into manhood, in jumping down from a chair, felt something 
 snap, and very soon after a pulsating tumour formed, which was 
 found to be an aneurism brought about b}^ rupture of the popliteal 
 artery, occasioned by the projecting extremity of the shaft. The 
 epiphysis is seen to be firmly, though somewhat irregularly, united 
 to the anterior aspect of the shaft, with its articular surface looking 
 forwards and slightly downwards, and its back part projecting down- 
 wards. The end of the diaphysis presents backwards into the 
 popliteal space behind the epiphysis, and is rough and irregular. 
 Although the epiphysis and the shaft are in bad position, the union 
 between them has been exceedingly solid. {Catalogue of Pathological 
 Specimens in the Royal College of Surgeons of Edinburgh, 1893, 
 p. 134, specimen No. 3, 249). 
 
 Mr. G. Mansell Moullin showed before the Pathological Society 
 (Transactions of the Pathological Society, vol. xxxix. 1888, p. 243) in 
 1887 a somewhat similar case, though the artery had ulcerated 
 through at a much earlier date. 
 
 The patient from whom the specimen was obtained was admitted 
 into the London Hospital at Ghristmas 1886. About a year before, 
 when he was fifteen years old, he sustained a compound fracture of 
 the lower end of the femur. From this he recovered completely, 
 
SEPAEATION OF LOAVER EPIPHYSIS OF FEMUE 747 
 
 and was able to get about again fairly well, with a slight amount of 
 deformity and a certain degree of stiffness about his knee-joint. A 
 few days before admission this stiffness began to increase, and he 
 found not only that he was unable to bend the joint, but that the 
 attempt was exceedingly painful. 
 
 On examination the popliteal space was found to be occupied by 
 a tense swelling, in which a slight degree of pulsation could be 
 detected, especially on the inner side. There was a scar on the 
 front of the limb ; the joint could not be bent to a right angle, and 
 even that was exceedingly painful. A faint bruit could be heard at 
 times where the pulsation was most distinct ; the limb itself was 
 fairly well nourished, but colder than the other, though the tibial 
 arteries could scarcely be felt. Pulsation was checked at once by 
 pressure on the femoral, but no change of any kind could be pro- 
 duced by direct pressure. An incision was made into the popliteal 
 space, rather to the inner side of the middle line, and a very large 
 quantity of recent coagulum turned out ; the end of the upper frag- 
 ment was found projecting backwards and pressing upon the popliteal 
 artery, in which there was a small opening with rounded edges, 
 evidently formed by gradual ulceration. The vessel was isolated as 
 well as it could be, and tied above and below, the projecting frag- 
 ment being removed by means of a chain saw. About the fourth 
 week the knee-joint began to enlarge, and finally suppurated, and 
 the limb was amputated. 
 
 After maceration the epiphysis was detached, and the line of 
 fracture could be followed on the posterior surface of the shaft, along 
 the intercondyloid notch, and upon the anterior surface of the epi- 
 physis. Evidently the condyles had been separated and w^ere united 
 again ; but while the cartilage still persisted between the epiphysis 
 and the shaft over the whole of the rest of the surface, along the 
 line of fracture it was replaced by bone, and this had to be broken 
 through before the epiphysis could be detached. 
 
 PROGNOSIS AND EESXILTS.— The prognosis would seem at first 
 sight to be extremely serious, if we consider the number of reported 
 cases in which amputation had to be performed. 
 
 Out of 125 separations of the lower epiphysis of the femur 
 collected by the author, although many compound separations were 
 complicated by extensive bruising and laceration of the soft parts, 
 or serious lesion of the vessels, and demanded immediate amputation, 
 yet it is impossible to deny the fact that many of these limbs 
 would now be saved by the antiseptic precautions of modern surgery. 
 
 Secondly, amputation would also be less frequent in simple as 
 well as in compound separations at the present day, when free 
 resection or reduction of the displaced epiphysis or diaphysis can 
 be safely and successfully carried out in those cases which would 
 formerly have been followed by gangrene, secondary haemorrhage, 
 or other complication. 
 
748 EPIPHYSES OF LOWEK EXTREMITY 
 
 Again, a very large number of simple cases are unpublished, or 
 not even diagnosed. This is particularly true when displacement of 
 the fragments is not present. 
 
 The mortality following separation of this epiphysis with dis- 
 placement will necessarily remain high, by reason of the numerous 
 complications w^ith which it is so commonly combined, but will 
 certainly in the future be greatly diminished from the present high 
 rate. 
 
 Delens observes with regard to this, that it is possible to ob- 
 tain relatively favourable results even in the most complicated cases, 
 and quotes his own case in proof of this. With the exception of 
 unavoidable shortening, the result in great measure of the resection 
 of the end of the diaphysis, the movements of the articulation 
 were rapidly and completely re-established. 
 
 In Alcock's and Gay's cases also, primary resection of the dia- 
 physial end was followed by an excellent result. 
 
 Union. — It is certain that in simple separations in which dis- 
 placement has not taken place or has been reduced, rapid consolida- 
 tion ensues, without impairment of the joint. 
 
 In Liston's case, and probably also in Bell's case, the separation 
 was not detected at the time of the accident, and the epiphysis 
 became displaced ; consolidation then took place with the shaft in 
 its malposition, and this impaired not only the usefulness of the 
 limb, but also was the cause of further disease in and around the 
 articulation. But even in these cases it is surprising how much 
 rounding off and moulding of the parts takes place ; in Liston's case 
 there was stated to be but little distortion of the limb. 
 
 In many others that have been properly observed and treated 
 accordingly, good union has occurred in a few weeks, with a straight 
 limb and free movement of the knee-joint, without atrophy. 
 
 In Callender's patient union took place in six weeks, and six 
 months later there was no sign of shortening. 
 
 Even in cases of severe displacement where reduction has been 
 fully carried out and maintained, there may, as in Mayo Bobson's 
 case, be no deformity. This surgeon alludes to another, diagnosed 
 early, in which reduction was easily effected, and the ultimate result 
 was very good. 
 
 In Puzey's case, eight months after the accident there was a 
 good straight limb and perfect movement of the knee-joint. At the 
 time of the injury the condyloid epiphysis was displaced incom- 
 pletely off the diaphysis, so that the leg was in the position of 
 genu valgum. 
 
 In Sturrock's patient, thirteen months after the accident the 
 circumference of the knee was only a quarter of an inch greater 
 than that of the sound knee. No definite thickening could be felt, 
 but the knee seemed bulkier ; as regards length, both limbs were 
 absolutely the same. The range of movements was perfect, the 
 
SEPAEATION OF LOWEK EPIPHYSIS OF FEMUE 749 
 
 boy walking without a limp. In this instance the epiphysis had 
 been displaced backwards. 
 
 Out of twenty-eight simple cases collected by J. Hutchinson 
 junior, sixteen were got into good position and recovered with very 
 useful or perfect limbs, while of the remaining twelve, in which 
 perfect replacement was not obtained, six were followed by sloughing 
 or suppuration. In four of these amputation had to be performed, 
 one recovered after excision of the knee, and one after resection of 
 the diaphysial end. In one case a popliteal aneurism formed twenty 
 years after, and led to amputation. The remaining cases recovered 
 with more or less useful limbs, the displacement persisting. 
 
 Ankylosis of joint. — Some stiffness of the joint may be expected, 
 even though the displacement has been corrected, and an otherwise 
 satisfactory recovery takes place from the injury. 
 
 In one of Hamilton's compound cases, complete ankylosis of 
 the knee-joint resulted, with shortening of the hmb three-quarters 
 of an inch. He had had a ' sharp ' attack of synovitis after the 
 injury. 
 
 Bryant says that these epiphysial separations ' are serious on 
 account of the joint complication, as some stiffness of the joint 
 generally, but not always, follows ; this result depending upon the 
 amount of inflammatory action that takes place after the injury.' 
 
 Spillmann quotes {Diet. Encyclopedique des Sci. Med. tome xxiv. 
 art. ' Cuisse,' 1880, p. 252) a case seen by Chauvel in 1872, in which 
 the separation had been produced by direct violence. The patient 
 was a youth, aged eighteen, whose leg was ankylosed to the thigh at a 
 right angle. The limb was straightened without any great violence, 
 but was followed by suppuration, septicsemia, and death. A separa- 
 tion of the lower epiphysis of the femur, which was still connected 
 with the tibia, was found after death. 
 
 The knee-joint being so seldom damaged in separations without 
 or with little displacement, no loss of function follows as a conse- 
 quence. 
 
 Deformity. — The character of the deformity of the knee varies 
 (1) according to the nature of the separation, whether simple, 
 or combined with a fracture of the epiphysis or diaphysis, and (2) 
 according to the displacement of the fragments, especially if they are 
 allowed to remain unreduced, or continue in their locked condition. 
 
 M. U. Trelat describes {Progres Medical, August 1875, p. 470) 
 a deformity of the knee arising from forward displacement of the 
 epiphysis ; but it was only seen by him four years after the accident. 
 A girl, aged eighteen, was admitted into the Hopital de la 
 Charite with pain in the left knee and difficulty in walking. At 
 the age of fourteen she slipped on the edge of the pavement and fell 
 on her knee, and was unable to rise. This was followed by acute 
 pains and swelling of the knee, and she remained in the Hopital 
 Sainte-Eugenie under the care of M. Marjolin for one year, the limb 
 
750 EPIPHYSES OE LOWEE EXTEEMITY 
 
 being kept fixed for four months in different forms of splints. She 
 had been lame ever since and the knee was somewhat deformed, 
 but movements of flexion, adduction, and abduction were free and 
 without pain. There was also a little fluid in the joint, and the 
 patella was displaced a little inwards, but it was not dislocated, since 
 it preserved its natural relation with intercondyloid space. At the 
 level of the upper border of the patella, a series of projections 
 belonging to the intercondyloid notch of the displaced femoral 
 condyles was felt, so that the external aspect of the condyles had 
 become more anterior, their internal aspect posterior. The epiphysis 
 was firmly united. Just below the middle of the popliteal space, the 
 projection of the lower end of the femur was felt as a hard mass, 
 and had evidently undergone a ' kind of rotation ' from within out- 
 wards and backwards. There was shortening of the limb to the 
 extent of four and a half centimetres. 
 
 In other cases which have not been treated or recognised, the 
 deformity may become more and more marked as the child walks 
 about, the epiphysis being gradually displaced off the diaphysis — e.g 
 Liston's case. 
 
 The knee may assume the varus position, from displacement 
 inwards of the epiphysis. 
 
 Dr. E. Winslow, Professor of Surgery, Baltimore, U.S.A., relates 
 (Maryland Medical Journal, Baltimore, June 21, 1884, p. 142) the 
 following case of diastasis of the inferior epiphysis of the femur, 
 causing genu varum. 
 
 On February 25, Mrs. E. brought her son to the hospital in 
 order to obtain treatment for a deformity of the left leg. The history 
 of the case was as follows : About four weeks previously, S. E., aged 
 eleven years, was struck by a large ' double-decker ' sled. According 
 to his own account the sled did not pass over the limb, but in some 
 way mashed or jammed it. He suffered pain, and, being unable to 
 walk, was taken home and put to bed, but received no medical 
 attention. He remained in bed two weeks, and at the end of that 
 time got up and began to use the limb. At first progression was 
 painful and difficult, but the soreness gradually subsided, and at the 
 expiration of four weeks from the time of the accident he walked 
 nearly a mile to the clinic. An examination made at that time 
 revealed the following conditions. The right leg was perfectly 
 straight and normal, but there was a marked bowing of the left leg, 
 so that the knees were separated two or three inches, and could not 
 be made to touch each other. At the same time there was slight 
 shortening of the left limb and some outward rotation of the foot. 
 
 The patient walked easily, scarcely limping, and only experienced 
 pain after long walking. There was no bruising of the integument 
 of the knee, little or no tenderness upon pressure, and no effusion 
 within the capsule of the joint. The knee appeared somewhat 
 broader than normal and unduly prominent. The condyles of the 
 
8EPAEATI0N OF LOWEE EPIPHYSIS OF FEMUE 751 
 
 femur preserved a normal relation to the tibia, and flexion and 
 extension were unimpaired. The patient could not stand alone upon 
 the hurt leg. The patella was in its proper position, and was freely 
 movable. The leg presented a marked varum, the knees being two 
 inches apart. Upon the outer condyle, about one inch above the 
 tibia, was a slight angular projection, and upon the inner side a 
 corresponding depression existed, the rotundity of the vastus internus 
 muscle being entirely destroyed. Immediately below this depression 
 the projection of the inner condyle could be felt. The mother 
 positively declared that no deformity existed previous to the 
 accident. 
 
 Taking into consideration the youth of the patient, the direct 
 injury to the knee, the peculiar defojinity, and the fact that the 
 motions of the joint were unimpeded, the diagnosis of separation of 
 the epiphysis was arrived at, with a sliding of the epiphysis inw^ards, 
 or a displacement of the shaft outwards, in which position union 
 had taken place. The nature of the lesion was explained to the 
 mother, and her sanction to infraction or subcutaneous osteotomy 
 was obtained. 
 
 On March 3 the boy was ansesthetised, and with the assistance 
 of Professor Jay it was found possible by the exhibition of con- 
 siderable force to completely break up the adhesions between the 
 fragments, and to restore the bones to their proper position. When 
 this was done the knees could be easily brought together, and all 
 deforiuity disappeared. The limb was now well padded and encased 
 from the foot nearly to the pelvis in a nicely fitting plaster-of-Paris 
 splint. The boy was placed in bed, and a sufficient amount of 
 morphine administered to relieve pain. The next morning he was 
 sitting up and clamouring to be taken home. Within a week he was 
 seen standing upon the splint, though against orders, and without 
 any discomfort. The apparatus was removed March 31. The limb 
 was found to be slightly shorter than normal, but the two knees 
 could be easily placed together. 
 
 Arrest of growth. — Many instances of separation of the lower 
 epiphysis of the femur have been recorded which have not been 
 followed by arrest of growth when examined some time after 
 the accident, so it must be reckoned that this is an unusual 
 occurrence. 
 
 Callender, in the St. Bartliolomew' s Hospital Beports (1873, 
 vol. ix. p. 34), mentions the case of a boy, F. W. P., aged eleven. 
 Whilst hanging on behind a cart he got his leg entangled in the 
 wheel. There was a lacerated wound on the inner side of the knee 
 leading down to the separated epiphysis. Firm union took place in 
 six weeks without shortening. Sixteen months later there was no 
 arrest of growth in the length of the femur. 
 
 J. Hutchinson junior alludes to a case under his own care in 
 which there was no arrest of growth. A lad, aged twelve, with very 
 
752 EPIPHYSES OF LOWEE EXTREMITY 
 
 marked forward and lateral displacement of the epiphysis, the dia- 
 physis pressing on the popliteal artery so as to almost stop the pulse. 
 Beduction under anaesthetic, Maclntyre's splint, and perfect recovery 
 is the brief history of the treatment and its results. AVhen the patient 
 was seen last, one year after the accident, there was no shortening 
 whatever. 
 
 Although bony union may have taken place, it is always to 
 be feared that the growth of the length of the femur may be sub- 
 sequently interfered with by the premature ossification or permanent 
 interference with the function of the epiphysial junction cartilage 
 consequent upon the injury. The proper proliferation of this 
 cartilage is mostly responsible for the growth in length of the bone. 
 
 Uffelmann was the first to direct attention to arrest of growth 
 (Anat.-cJiir. Beitrdge z. d. Lehre v. d. Knochen jugendl. Individ. 
 1865) following separation of this epiphysis. 
 
 The cases alluded to by Professor Humphry, Konig, Paschen, 
 and others show that very grave disturbances in the growth of the 
 femur and tibia follow resection of the knee-joint when the 
 epiphysial cartilage of either bone has been removed. 
 
 Turgis {Bull, de la Soc. de Chir. t. iv. 1878, No. 10, p. 787) 
 mentions the case of a boy ten years old who had been injured by 
 machinery ; amongst other lesions he received there was a separa- 
 tion of the lower epiphysis of the femur. When seen after the 
 lapse of twelve years the thigh was shortened three centimetres. 
 
 Delens gives a most accurate and detailed account {Arcliives 
 Generales de Medecine, vol. cliii. 1884, p. 272) of a case which he 
 had observed and taken measurements of during ten years — a case 
 of compound separation of the lower epiphysis of the right femur 
 with protrusion of the diaphysis, in which the lower end was 
 resected on account of the impossibility of reduction. 
 
 R. L., aged eight and a half, on January 15, 1873, when 
 climbing behind a carriage in motion, had his right leg caught 
 between the spokes of the wheel. He was seen by M. Delens 
 within an hour. The lower end of the femoral diaphysis, charac- 
 teristic in shape and covered with a thin yellowish layer, pro- 
 truded through a wound at the outer angle of the popliteal space. 
 There was no great haemorrhage, and pulsation of the posterior 
 tibial artery was felt. Exploration of the popliteal space by the 
 finger in the wound could not detect any pulsation of the popliteal, 
 but the condyles of the femur were felt in contact with the tibia. 
 Shght crepitus suggested intercondyloid fracture, but this was not 
 proved to exist. The periosteum was stripped off the lower end of 
 the diaphysis. Even after the patient had been placed under chloro- 
 form it was found impossible to reduce and replace the fractured 
 surfaces. This was again repeated the following day, with a similar 
 result. The protruding portion of the diaphysis was therefore 
 removed by means of a saw and bone forceps, and the bone easily 
 
SEPAEATION OF LOAVEE EPIPHYSIS OF FEMUK 753 
 
 reduced. On the antero-internal aspect of the diaphysial end a 
 triangular fragment two centimetres in height had been detached. 
 The limb was then put up in a trough splint. On February 3 
 an enormous abscess was found occupying the whole of the 
 outer part of the thigh, ex'tending almost to the great trochanter. 
 This was incised, and a drainage tube passed through to the 
 popliteal wound. From this time the wounds rapidly healed and 
 the bones quickly united, so that at the end of two months, on 
 March 16, the wounds had almost quite healed and the bones firmly 
 united. An immovable splint was applied, and the child allowed to 
 walk on crutches. In about another five weeks' time, on April 24, 
 the splint was finally removed, and it was found that the shape of 
 the limb was perfect with only a moderate amount of callus above 
 the condyles. The wound was now healed, and the child could move 
 its knee and walk easily with the aid of a stick. There was from 
 four to four and a half centimetres shortening. After June the 
 movements of flexion of the knee were perfect ; the heel could be 
 placed in contact with the buttock. 
 
 The patient could walk about without limping, using a boot 
 raised two centimetres, but there was a marked tendency to rotation 
 of the foot inwards. After this time he was seen only at long 
 intervals for the purpose of measurement. On March 15, 1874, it 
 was noted that the limb had almost regained its normal size, and 
 the position of the foot was good. Measurement of the two limbs from 
 the anterior superior iliac spine to the tip of the external malleolus : 
 left side, 65'5 centimetres ; right side, 62-5 centimetres. On April 
 8, 1875, the measurement was : left side, 67-5 centimetres ; right 
 side, 64-5 centimetres. On April 24, 1876 : left side, 70 centimetres ; 
 right side, 66 centimetres. On April 27, 1877 : left side, 77 centi- 
 metres ; right side, 72-5 centimetres. On January 3, 1878 : left 
 side, 80 centimetres ; right side, 74 centimetres. So that in the 
 five years following the accident the shortening, which was at first 
 about 4 centimetres, had increased to 6 centimetres. The patient 
 was seen again ten years after the accident, on July 30, 1883 ; he 
 was then a robust young man, and came to ask if he could enlist as 
 a soldier. From his gait it was impossible to perceive that he had 
 undergone such a severe operation ; there was only a slight dragging 
 of the leg. On measurement the left side was 89-5 centimetres, and 
 the right 80 centimetres, giving nine and a half centimetres short- 
 ening. During the ten years the sound limb had increased 24 centi- 
 metres and the resected limb 17^ centimetres. The difference was 
 entirely in the femur, for the tibiae had exactly the same length — 
 38 centimetres. The growth of the right femur had taken place 
 mostly through the upper epiphysial cartilage ; the lesion of the 
 lower epiphysial cartilage had only produced a. decrease of about 
 six centimetres in the total length of the bone. 
 
 In Dr. Donovan's case of severe compound separation the 
 
 3 c 
 
754 
 
 EPIPHYSES OF LOWEE EXTEEMITY 
 
 epiphysis united to the diaphysis after resection of two and a half 
 inches of the latter. The femur appeared to keep pace in its 
 growth in length with its fellow for about two years. The limb, 
 however, subsequently became knock-kneed, and failed to increase 
 in length. Tuberculous disease set in, for which amputation was 
 performed. 
 
 The following case of shortening came under the observation of 
 J. Hutchinson junior. A medical student, when aged fifteen, had 
 his knee severely injured at football. On examination at the age 
 of twenty-three there was fibrous ankylosis of the knee with one 
 and a half inch shortening-. 
 
 Table of cases in wJiich sJiortening folloioed separation of the 
 loioer epiphysis of the femur 
 
 Surgeon 
 
 Age of 
 patient 
 
 Sex 
 
 Amouut of 
 shorteuiiig 
 
 Date of 
 merisurement 
 after injury 
 
 Remarks 
 
 Gay . . . 
 
 13 
 
 Male 
 
 \ inch 
 
 9 months 
 
 Compound. Eesection 
 of end of diaphysis. 
 Simple fracture of 
 opposite femur 
 
 Trelat 
 
 18 
 
 Female 
 
 \\ inch 
 
 4 years 
 
 Displacement of epi- 
 physis forwards and 
 slightly inwards 
 
 Callender . 
 
 12^ 
 
 Male 
 
 None 
 
 16 months 
 
 Compound 
 
 Delens 
 
 18i 
 
 Male 
 
 9^ cm. 
 
 10 years 
 
 Compound. End of 
 diaphysis resected 
 
 Turgis 
 
 22 
 
 Male 
 
 3 cm. 
 
 12 years 
 
 Simple ? 
 
 Puzey 
 
 19 
 
 Male 
 
 1 inch 
 
 3 3 ears 
 
 Simple ? Displace- 
 ment outwards of 
 epiphysis 
 
 Hutchinson jr. . 
 
 23 
 
 Male 
 
 1^ inch 
 
 8 years 
 
 Fibruus ankylosis of 
 knee 
 
 Poland, John . 
 
 11 
 
 Female 
 
 3 inches 
 
 9 yf ars 
 
 Genu varum, Addvic- 
 tion of leg 
 
 Professor Nicoladoni, of Innsbruck, relates a very remarkable 
 case of deformity of the knee and lower extremity following gradual 
 obliteration of the epiphysial cartilage from behind forw^ards, the 
 result of injury. 
 
 A young man (L. A.), aged sixteen years, strong and well 
 developed both as to his muscles and bones, came under this surgeon's 
 observation in 1882 with marked flexion of the left low^er extremity, 
 so that he had to get about with an addition of about twenty-five 
 centimetres to the sole of the left boot. The left lower extremity was 
 remarkably short as compared with the right, and kept in a flexed 
 position as regards the knee-joint. Flexion of the knee could be 
 effected to an unusual extent, so that the muscles of the calf came 
 
SEPAEATION OF LOWEE EPIPHYSIS OF FEMUE 755 
 
 in contact with the very muscular upper part of the thigh. Ex- 
 tension was possible only up to an angle of 95° to 98°. However, 
 within this range of movement the patient could easily and very 
 powerfully move his leg. There was no other diseased condition 
 about the knee-joint, and the muscles of the left thigh, leg, and 
 foot were apparently as strong as on the right side. 
 
 The left leg and thigh were considerably shortened, the tibia bent 
 concavely inwards at its upper part, and the head of the fibula more 
 than two centimetres above the level of that of the tibia. The left 
 hip-joint and buttock were perfectly normal, and the trochanters of 
 the two limbs on the same level. The left cs innominatum appeared 
 to be much more developed than the right. The knees being placed 
 in similar positions, the measurement from the anterior superior spine 
 to the patella was forty-two centimetres on the left side and fifty- 
 two centimetres on the right, and from the head of the tibia to 
 the inner malleolus thirty-six centimetres on the left and forty-five 
 centimetres on the right. 
 
 After his memory had been assisted the patient stated that, 
 according to his mother, he fell at the age of seven — that is, nine 
 years previously — from his bed on to his left knee, but that nothing 
 abnormal was ever noticed about the joint as the result of this fall ; 
 that from this time (seventh year) it was certain the knee became 
 more and more flexed. Professor Nicoladoni believed that premature 
 ossification of the epiphysial cartilage of the lower end of the femur 
 and of the upper end of the tibia had given rise in the course of 
 nine years to a shortening of the thigh for ten centimetres, and of 
 the leg for nine centimetres. 
 
 At the same time that this shortening of the femur took place 
 there was a peculiar contraction of the knee-joint, consisting prin- 
 cipally of its range of movement being continually forced towaras 
 the side of flexion, whilst the free mobility of the joint was un- 
 altered. In the figure the condyles of the femur are seen to be 
 bent backwards, and the patella (disregarding the flexed portion of 
 the knee) rises in a very striking manner above the level of the 
 articular projections of the femur. This condition he thought had been 
 brought about by the gradual obliteration of the epiphysial cartilage, 
 commencing at the posterior part, i.e. that from behind forwards 
 premature ossification of this structure had taken place ; so that the 
 femoral condyles had come in this way to be attached to the 
 posterior aspect of the shaft, and to be directed backwards, while 
 the range of movement of the joint was completely preserved on the 
 side of flexion ; the range of movement of extension was limited to 
 the same degree. Both these movements were affected in proportion 
 as the condyles became displaced backwards, and it was to be hardly 
 considered a contraction of the knee-joint, but rather a bending of 
 the femur close to the condyles with the convexity to the front. 
 At the same time the upper epiphysial cartilage of the tibia became 
 
 s c 2 
 
756 
 
 EPIPHYSES OF LOWEK EXTEEMITY 
 
 obliterated, that of the fibula remained unaltered, and the inequality 
 of its growth with relation to the tibia resulted in a bending over of 
 the latter bone towards .the inner side. 
 
 Professor Nicoladoni also drawls attention to the fact that similar 
 contractions of the knee-joint have been alluded to by Konig as 
 the result of premature ossification from before backwards of the 
 epiphysial cartilage after excisions of the knee-joint in young persons, 
 although the wdiole of the epiphysial cartilage was preserved in 
 these cases. 
 
 Fig. 227. — aeeest of geowth or the femur and tibia with coxtkactiox of kxee 
 
 FOLLOWING INJURY TO THE LOWER EPIPHYSIS OF THE FEMUR AND UPPER EPIPHYSIS OF 
 THE TIBIA NINE YEARS PREVIOUSLY. (AFTER NICOLADONi) 
 
 The folloT^dng unique instance of arrest of growth of the femur 
 w^th a varus position of the knee came under the author's care at 
 the City Orthopaedic Hospital in October 1897. The girl (C. S.), 
 aged eleven, was sent to the Hospital by his Grace the Duke of 
 Fife. The history of injury was somewhat indefinite — that the 
 mother had placed the child when about two years old in the country 
 under the charge of some friends, and that on its return home it was 
 noticed to limp. This lameness had increased gradually up to the 
 present time. She had been to more than one hospital in London for 
 treatment, but nothing certain appears to have been detected ; at any 
 rate, no advice was offered as to the remarkable condition, and she had 
 not worn any boot or other appliance to correct the deformity, which 
 
SEPARATION OF LOWEE EPIPHYSIS OP FEMUE 757 
 
 I, 
 
 now existed in the right lower extremity. The whole limb was 
 shortened for four inches, and much smaller than the left. "When 
 she stood upright the right knee was thrown outwards into the varus 
 position, the pelvis tilted downwards on this side, and the spine much 
 curved (see fig. 228). On placing the spine and pelvis in their normal 
 position by raising the foot four inches, it was discovered that the 
 femur was rather more than three inches, and the tibia rather less than 
 one inch, shorter than the left (see fig. 229). The knee-joint could be 
 freely flexed and extended, but considerable movement was permitted 
 in a lateral direction by adducting and abducting the leg. During ab- 
 duction a very considerable gap 
 could be seen and felt on the ^ 
 
 inner side of the knee between $ 
 
 the internal condyle of the femur ^ 
 
 and the inner tuberosity of the |i 
 
 tibia. This was due to the ,. 
 
 slightly oblique direction of the ||| 
 
 lower epiphysis of the femur, f ■' 
 
 and its ill-developed condition. 
 The external condyle was the 
 most prominent of the two con- 
 dyles, and projected downwards 
 lower. This had probably been 
 brought about by the upward 
 pressure of the tibia upon the 
 internal condyle during progres- 
 sion. This upward displacement 
 of the internal condyle was a 
 very notable feature, especially 
 when the leg was adducted, the 
 inner tuberosity placed in con- 
 tact with the inner condyle, and 
 the shortening of the limb cor- 
 rected. The limb placed in this Fig. 228 
 position was across the front 
 of the left, so that the right 
 
 knee was just above the left (see fig. 230). The wasting and 
 smallness of the tibia on the affected side was probably the result 
 of the small amount of use that had been made of this hmb. 
 The hip-joints were normal. The shaft of the femur, especially 
 at its lower end as well as its lower epiphysis, was felt to be small 
 and atrophied as compared with the opposite side, and between 
 the internal condyle and the diaphysis a concavity could be felt. 
 The skiagraphs revealed the fact that the lower end of the diaphysis 
 of the femur was almost one inch less than the left in width just 
 above the epiphysial line, and that the chief atrophy of the diaphysial 
 end as seen in a lateral view was in the antero-posterior direction. 
 
 ATTITUDE OF PATIENT FEOM AEEEST 
 OF GEOWTH OF LOWER EXTllEMITY FOLLOWING 
 INJUKY TO LOWER EPIPHYSIS OF FEMUR 
 
758 
 
 EPIPHYSES OF LOWEE EXTEEMITY 
 
 The skiagraphic view of the leg placed almost in a line with the 
 thigh displayed the moderate gap in this portion between the internal 
 condyle and the inner tuberosity of the tibia. The femoral dia- 
 physis is also seen to be curved forwards and outwards at its lower 
 third. 
 
 Supracondyloid osteotomy was successfully performed just before 
 the time of this report. 
 
 SYMPTOMS.— From the severity of the injury and the numerous 
 complications often present, separation of the lower epiphysis of 
 the femur engages the attention of the hospital surgeon perhaps 
 
 Fig. 229.- -the same patient ^YITH limb elevated four inches 
 
 more than any other epiphysial separation. These injuries differ in 
 their symptoms very considerably, both from the variety of the 
 displacement and the numerous complications attending them. 
 
 We may at once dismiss the consideration of those examples of 
 compound injury where the square-shaped, rammerlike protruding 
 end of the femur, somewhat flattened from before backwards, with 
 its mammillated surface devoid of epiphysial cartilage, stripped of 
 periosteum, allows us to make a sure diagnosis, or where it is 
 possible to explore the fragments through the wound. 
 
 Some separations present much the same symptoms as those of 
 
ARREST OF GROWTH OP RIGHT FEMUR AFTER INJURY. LATERAL VIEW. 
 
 Author's case. 
 
ANTERO-POSXEKIOK VIEW OP SAME CASE. 
 
LEFT KNEE OF SAME CASE. 
 
SEPAEATION OF LOWEE EPIPHYSIS OF FEMUE 759 
 
 K.^' 
 
 
 transverse portions of the lower end of the femur ; the author there- 
 fore cannot but agree with Dr. Packard when he says that many of 
 the pubhshed cases have been so carelessly reported as to leave room 
 for doubt whether they were not simple supracondyloid fractures 
 instead of simple separations. 
 
 In some forms the group of symptoms is perfectly patho- 
 gnomonic of separation ; while in others the greatest difficulty is 
 present, there being little to 
 direct the surgeon in making 
 an exact diagnosis. I 
 
 PuEE Separation without 
 Displacement. — Here the dia- 
 gnosis must always be a matter 
 of considerable difficulty. In 
 this condition the surgeon can 
 be guided solely by the age of 
 the patient, by the manner in 
 which the injury has been re- 
 ceived, by the presence of abnor- 
 mal mobility of the epiphysis 
 at the conjugal line, and by the 
 existence of more or less acute 
 pain, especially at the same 
 point. Crepitus may be absent, 
 and the patient be even able 
 to use the limb ; yet in some 
 cases the limb may be rendered 
 powerless. 
 
 The author believes these 
 to be far from uncommon, but 
 curiously they had, as far as he 
 is aware, never been alluded to 
 by writers previous to his paper 
 on ' The Diagnosis of Traumatic 
 Separation of the Epiphyses,' 
 read before the West Kent 
 
 Medico-Chirurgical Society in 1886, in which special attention was 
 directed to the probable frequent occurrence of separation of the 
 lower femoral epiphysis without displacement. 
 
 Mr. Howard Marsh (since the above paper was written) agrees 
 with this opinion (art. ' Fract. of Femur,' Heath's Diet, of Pract. 
 Surgery, 1887, vol. i. p. 534), when he says that 'sometimes the 
 displacement is so slight that the injury may easily escape notice, 
 or be mistaken for a mere traumatic synovitis.' 
 
 Packard thought that separation of the ■ lower epiphysis of the 
 femur was a rare accident, but adds ' although perhaps it sometimes 
 occurs without being recognised.' 
 
 Fig. 230. — the same patient showing posi- 
 tion OF limb when the inner tuberosity 
 
 OF TIBIA WAS PLACED IN CONTACT WITH THE 
 INTERNAL CONDYLE OF FEMUR 
 
760 EPIPHYSES OF LOWEE EXTKEMITY 
 
 The violence producing separation without displacement appears 
 to be less than that which causes displacement of the epiphysis ; 
 still, there will be found some stripping up of the periosteum from 
 the diaphysis, as in the more serious displacements. 
 
 Sepaeation with slight Displacement. — Instances in which 
 the displacement exists to a slight extent are yet more common than 
 separations without displacement. 
 
 At Long Island College Hospital, New York, in 1860 {American 
 Medical Times, August 18, 1860, p. 116), Professor F. H. Hamilton 
 had under his care a girl, aged four, who had fallen down a flight of 
 stex^s. On examination of the left leg one hour after the accident, 
 sw^elling was found about the ankle-joint, and distinct crepitus, 
 more like that occasioned by the friction of cartilage than of bone. 
 The lower epiphysis could be moved slightly upon the diaphysis. 
 There was, however, no displacement, and the treatment adopted 
 was simple rest in bed without splints. A week later the limb was 
 still in good position and all crepitus ceased, but the ankle remained 
 swollen, as if from effusion into the joint. The same treatment was 
 continued. 
 
 A similar case was under the care of Mr. Howse at Guy's 
 Hospital in 1866. Walter K., aged eight, was running behind a 
 cab, when he caught his left leg between the spokes of the wheel. 
 
 There was great pain in the line of junction of the lower epi- 
 physis of the femur, but no shortening or displacement. There 
 was considerable swelling about the knee, and some fluid in the 
 joint. The patella was in its normal relations. A double interrupted 
 splint was applied, and the patient left the hospital seven weeks later 
 without any deformity or noticeable callus around the seat of injury. 
 
 Dr. E. H. Harte, of Philadelphia, records {Trans. Amer. Surg. 
 Association, 1895, vol. xiii. p. 399 ; American Journal of the Medical 
 Sciences, June 1896, p. 683) an instance of only slight displacement. 
 
 Louis S., aged fifteen j^ears, was admitted to the Episcopal 
 Hospital, June 14, 1895. While he was hanging on the back of a 
 wagon, a leg became entangled in a revolving wheel. On admission 
 there w^as effusion into the knee-joint, and marked softening over 
 the internal cond5de. Crepitus of a moist character could be de- 
 tected, although with slight displacement. Extension by means of 
 a weight and firm, lateral support, with bran bags and long lateral 
 splints, were employed. The patient made a good recovery, and left 
 the hospital, cured, in fifty-seven days. The mobility of the joint 
 was unimpaired. 
 
 That separation of the low^er epiphysis of the femur can occur 
 without giving rise to many definite s3'mptoms is also corroborated 
 by the following case of F. W. Eisner's {Australasian Med. Gazette, 
 July 20, 1895, p. 266). 
 
 A boy (C. W.), aged twelve years, was kicked on the left thigh, 
 a hand's breadth above the knee, on Christmas Day, 1891. On 
 
SEPAEATION OF LOWER EPIPHYSIS OF FEMUR 761 
 
 examination of the limb the next morning there was nothing but 
 increased mobihty and a pecuhar moist crepitus— no pain, no 
 shortening whatever, and not a trace of haemorrhage or swelHng. 
 With the exception of the foot rolHng outwards whenever it was let 
 go, there appeared to be very little the matter. A few rotatory 
 movements were sufficient to replace the parts in position. A long 
 Liston with a short inside spHnt was applied. On removing these 
 a fortnight later there was found half an inch of shortening ; the limb 
 was therefore placed on an inclined plane. Four weeks after the 
 injury the boy was able to lift his leg without pain off the bed, and 
 could a fortnight later get about well 
 on crutches. On account of imme- 
 diate union having taken place, there 
 was no distinct callus along the femur, 
 and the shortening was now (July 
 1895) less than half an inch. 
 
 Displacement may occur subse- 
 quently. — Although deformity will 
 be absent in separations without dis- 
 placement, it is not impossible that 
 some displacement of the epiphysis 
 may take place at a later period 
 than the accident. In Liston's case 
 the true nature of the injury was 
 evidently overlooked at the time, 
 there being no displacement, and the 
 patient merely halting a little in 
 walking. It is probable that in this 
 case {loc. cit. supra) the displacement 
 forwards of the epiphysis occurred 
 for the most part subsequent to the 
 accident. 
 
 In Eisner's case just mentioned, 
 in which there was no displacement 
 or shortening at the time of the 
 
 injury, a fortnight after it had been 
 
 Fig. 231. — normal epiphyses of the 
 knee-joint at the nineteenth yeak, 
 
 VIEWED FROM THE INNER SIDE. (hALF 
 NATURAL SIZE.) DIAGRAM TO SHOW 
 COMMENCING ROTATION AND DISPLACE- 
 MENT FORWARDS OF THE LOWER 
 FEMORAL EPIPHYSIS 
 
 placed on a Liston's splint half an 
 inch of shortening appeared ; the limb 
 was then placed on an inclined plane. 
 
 In others there may be felt, if the patient be seen soon after the 
 injury and no swelling be present, a slight projection of the epiphysis 
 commencing to be displaced into the popliteal space. 
 
 However, after the lapse of some hours, swelling takes place 
 with rapidity around the fragments, and is accompanied with effusion 
 around and beneath the separated periosteum, entirely obscuring 
 any projection of the diaphysis or epiphysis that might have been 
 detected previously. 
 
762 EPIPHYSES OF LOWEE EXTKEMITY 
 
 Although in the adult and uninjured youthful bone only a small 
 part of the two heads of the gastrocnemius muscle is attached directly 
 to the epiphysis, yet the whole of this muscle will act upon the epi- 
 physis or lower fragment, by reason of the great detachment of the 
 periosteum, to which the gastrocnemius is intimately connected. 
 The epiphysis thereby tends to be thrown backwards by the action 
 of this muscle, which no longer has any hold upon the diaphysis. 
 
 Mr. Durham had under his care in Guy's Hospital in 1884 
 (when the author was Surgical Eegistrar and had the opportunity 
 of carefully examining the case) a boy (Alfred B.), aged twelve, 
 who was struck on the left knee by some wood and knocked down. 
 There was a good deal of swelling about the knee, and some mobility, 
 but no crepitus. The movements of the joint were normal ; an 
 ordinary back splint was applied. About three weeks later a pro- 
 jection was felt in the popliteal space of the lower epiphysis of the 
 femur, commencing to rotate and be displaced backwards by the 
 action of the popliteus and gastrocnemius muscles. The limb was 
 placed on a double-inclined plane, and consolidation rapidly took 
 place in a few weeks without any displacement or shortening. 
 
 Dr. Clement Dukes, medical officer to Rugby School, relates 
 {Brit. Med. Journal, vol. ii. 1874, p. 402) the case of a youth, 
 aged eighteen, which he diagnosed as condyloid separation of the 
 femur. 
 
 While playing in the close at school, he was pushed on the outer 
 side of his right leg, his legs being extended laterally from the 
 median line, when he suddenly felt acute pain above the knee and 
 fell down, the limb becoming powerless. On examination the knee- 
 joint was not swollen, and no distortion was perceptible to the eye. 
 The leg lay powerless on the bed, but the foot was neither twisted 
 nor everted. The limb was slightly shortened, and on taking hold 
 of it no crepitus could be elicited, nor any abnormal movement, 
 though pain was felt whichever way it was moved. On slightly 
 flexing the leg, a rub as of two gliding smooth surfaces was felt, 
 with a slight depression about two inches above the knee. The 
 lower fragment formed a slight prominence posteriorly at the upper 
 part of the popliteal space, being rotated a little backwards by 
 the gastrocnemius. 
 
 A long outside and a short straight-back splint, with pad over 
 the situation of the epiphysis, were employed, with extension by 
 weight. At the end of six weeks there was firm union without 
 shortening, and there was not the slightest thickening at the seat 
 of injury, so that it was impossible to tell there had been any 
 separation. 
 
 Separation with Displacement. — Mr. Hutchinson {Archives 
 of Surgery, vol. iv. January 1893, p. 288) says : ' Fortunately the 
 complete displacement of the shaft from the epiphysis is rare, even 
 in cases where the separation is quite complete. The surfaces 
 
SEPAEATION OF LOWEE EPIPHYSIS OF FEMUE 763 
 
 separated are large, and that of the shaft does not usually leave the 
 whole of that of the epiphysis.' 
 
 Strong dissent must be expressed from the opinion given in a 
 recent text-book on surgery that ' the wide surfaces are seldom 
 completely separated.' 
 
 Should this opinion be accepted and the treatment recommended 
 carried out, a very disastrous result may ensue. ' The treatment 
 consists simply in supporting the limb for a few days on a back 
 splint till the swelling has subsided, when a starched bandage or 
 plaster-of -Paris splint may be applied.' 
 
 Displacement in a very marked degree, with its accompanying 
 deformity, is met with in a very large proportion of cases, and its 
 precise location is due chiefly to the character and direction of the 
 force apphed; a careful study, therefore, of the different osseous 
 projections should furnish us with signs not only for an exact 
 diagnosis but also for the necessary treatment. 
 
 Mayo Eobson thinks that 'the direction of the displacement 
 probably partly depends on the direction in which the violence has 
 been applied, but also on the attachment or otherwise of the gastro- 
 cnemius tendon to the lower end of the upper fragment.' 
 
 As a broad rule it may be said that the lower fragment or epi- 
 physis usually retains its normal connections with the head of the 
 tibia ; at the same time, it is often rotated on its transverse or vertical 
 axis. 
 
 Displacement forwards. — The most common displacement of the 
 epiphysis is forwards, more or less completely off the diaphysis, on 
 to the anterior aspect of the lower end of the latter, so that the 
 lower aspect of its articular surface is in contact with the patella. 
 This is largely due to the action of the heads of the gastrocnemius 
 tilting the epiphysis forwards, the nature of the violence being that 
 of forcible extension, which may be combined with rotation or 
 twisting, while one or other end of the limb is fixed. 
 
 The quadriceps extensor in front, and the hamstring muscles 
 behind, by their action will displace the diaphysial end backwards 
 and downwards into the popliteal space. 
 
 Mr. A. F. McGill described a typical case before the Leeds and 
 "West Eiding Medico-Chirurgical Society, May 1884 {Med. Times 
 and Gazette, London 1884, vol. i. p. 695) in a strong, well-developed 
 boy, aged fifteen, who was admitted into the Leeds General Infirmary. 
 While sitting at work with his feet on the ground, a heavy iron 
 plate struck the lower part of the femur just above the knee. He 
 was unable to walk, and his left leg was slightly flexed and everted. 
 There Avas general swelling of the knee-joint, with well-marked 
 deformity. The anterior aspect of the patella was one inch and a 
 half in front of that of the femur, and behind the patella a mass of 
 bone the shape of the lower epiphysis of the femur was felt in front 
 of the lower end of the diaphysis. The popliteal vessels were dis- 
 
764 
 
 EPIPHYSES OF LOWEE EXTEEMITY 
 
 placed backwards, and were felt beating directly under the skin. The 
 circumference of the left limb at the upper border of the patella was 
 fourteen inches and seven-eighths, while that of the right was thirteen 
 inches. The ilio-patellar line was shortened five-eighths of an inch. 
 Pulsation in the tibial arteries below was unimpaired. Under ether 
 the deformity was easily reduced by forcible flexion of the limb till the 
 heel touched the buttock. A back splint was applied, and the case 
 did well. 
 
 Mr. Mayo Eobson alludes {Annals of Surgery, July 1893, p. 2) 
 to six or seven cases which he had seen, in all of which the dis- 
 placement of the epiphysis 
 ■\ was forwards. 
 
 '\ The readiness with 
 
 which the diaphysis is 
 placed backwards into the 
 
 Fig. 233. — DisPLACEiiENT of 
 
 EPIPHYSIS EOKWAEDS 
 
 (Ashby and Wright) 
 
 i 
 
 Fig. 232. — diagram of complete displacement of 
 
 THE epiphysis FOBWAKDS AND ROTATION ON ITS 
 
 TKANSVEHSE AXIS 
 
 popliteal space may also 
 be explained by this being 
 in the direction of the 
 least resistance towards 
 the loose tissues of the 
 space, while on the front aspect there are the quadriceps extensor, 
 the patella, and the ligamentum patellae. 
 
 Combined with forward displacement there is often observed 
 some rotation of the leg and foot outwards, as in one of Mayo 
 Eobson's cases. 
 
 In some the leg and knee roll completely outwards, and rest on 
 their outer side. 
 
 The leg is usually semiflexed. — Mr. G. A. Wright, of Manchester, 
 figures (Ashby and Wright, Diseases of Children, 3rd edit. 1896, 
 
SEPAEATION OF LOWEE EPIPHYSIS OF FEMUK 765 
 
 p. 755) an example of separation of the lower epiphysis of the left 
 femur, in which the epiphysis is displaced forwards and the knee 
 flexed. 
 
 Sioelling about the joint may be very considerable. It has led 
 to error in diagnosis in several instances. 
 
 In one instance mentioned by Mayo Eobson (Atkinson's) the 
 swelling was so great at the time of the injury that it prevented a 
 diagnosis being made until a fortnight afterwards, when reduction 
 could not be effected, so that excision of the joint had to be performed, 
 as it was necessary that pressure should be removed from the 
 popliteal vessels. In this case, at the time of the injury, Atkinson 
 says the extensive effusion into 
 and about the joint completely 
 obliterated the natural outline, 
 so that none of the bony land- 
 marks — not even the superficial 
 outline of the patella — could be 
 defined. 
 
 Mr. Canton makes special 
 mention of very great swelling 
 of the lower part of the thigh 
 and knee in one of his cases. 
 
 Displacement backwards. — 
 When the epiphysis is begin- 
 ning to rotate forwards on its 
 transverse axis, its posterior 
 border will be the projection 
 felt in the popliteal space ; this 
 was so in Mr. Durham's case. 
 This rotation is largely due to 
 the attachment of the heads of 
 the gastrocnemius to the pos- 
 terior part of the epiphysis. 
 
 When the displacement is 
 not very great, the popliteal 
 vessels retaining their normal 
 relation to the intercondyloid notch will not be so liable to be 
 pressed upon as when the diaphysis is displaced backwards. When 
 the displacement is greater, the posterior margin of the condyloid 
 notch or either condylar margin may press upon and injure the 
 vessels ; this is the more likely to occur if any vertical rotation of 
 the epiphysis has taken place. 
 
 A few cases are recorded where the epiphysis is entirely dis- 
 placed backwards and the diaphysis forwards. 
 
 Mr. J. Hilton describes a case {Medical Times and Gazette, 
 February 12, 1859, p. 163) in which this form of displacement was 
 diagnosed. 
 
 Fig. 234.— diagram to show incomplete dis- 
 placement OF EPIPHYSIS BACKWARDS 
 
 (i-size) 
 
766 EPIPHYSES OF LOWER EXTREMITY 
 
 John H., aged eighteen, was admitted into Guy's Hospital on 
 May 20. In carrying a hod of bricks down the slope of an embank- 
 ment, he slipped and fell w4th his legs doubled under him and the 
 whole weight of his hod on his shoulder. After the fall he felt 
 severe pain in the left knee, and on attempting to rise was unable to 
 straighten the limb. The left thigh and knee were greatly swollen, 
 the knee semiflexed, and the foot slightly everted. One and a half 
 inches above the upper border of the patella the well-defined anterior 
 edge of the diaphysis could be distinguished projecting forwards. In 
 the popliteal space a considerable projection was easily felt ; the 
 outline of the parts was not ascertained, but it was clear, however, 
 that the condyles of the femur projected considerably beyond the 
 lower end of the diaphysis. No crepitus was felt. Mr. Alfred 
 Poland attempted reduction, but found it impossible either to flex or 
 alter the abnormal position of the fragments. Chloroform was given, 
 and the limb was straightened by means of extension, but some projec- 
 tion in front still remained. The following day, the deformity having 
 recurred, chloroform w^as again administered, and Mr. Hilton reduced 
 it by extension and by forcibly pushing the shaft of the bone backwards. 
 A back splint was then applied. On the 27th the apparatus was 
 disarranged, and the same displacement again took place. Reduction 
 was agpan effected with some difficulty by means of the same measures. 
 Back and side splints were applied, the limb elevated, and the thigh 
 flexed on the pelvis. In another three weeks, at the end of the 
 seventh week after the accident, the apparatus was removed. There 
 was firm union without any thickening about the bone, and the 
 movements of the knee-joint were perfect. 
 
 Dr. C. E. Sheppard gives a note {St. TJiomas's Hospital Beports, 
 vol. viii. N.s. 1877, p. 436) of the case of a boy, aged fifteen, the 
 subject of hsemorrhagic diathesis, who was in St. Thomas's Hospital 
 under Mr. Simon in 1875. The separation was caused by the boy 
 stumbling while running uphill and falling with his leg doubled up 
 under him. The end of the shaft projected forwards, and a back 
 splint was applied with the limb in a flexed position. 
 
 In one of Macdougall's cases {loc. cit. supra) the displacement 
 of the epiphysis backwards was so great and the skin so tightly 
 stretched over it that it ulcerated. Secondary amputation was 
 performed a month afterwards for deformity, which was still present 
 from the displaced epiphysis. Union was impossible from the 
 position of the fragments. 
 
 In Prochnow's case the displacement backwards and outwards 
 of the epiphysis was very marked, the diaphysial end being very 
 plainly felt on the inner side. Here also the skin was so tightly 
 stretched that sloughing of it ensued, with necrosis of the end of the 
 diaphysis. 
 
 In Fischer and Hirschfeld's case (see under Upper epiphysis of 
 THE tibia) the diaphysis was somewhat forwards, the . epiphysis 
 
SEPARATION OF LOWER EPIPHYSIS OF FEMUR 767 
 
 being rotated so that the internal condyle ascended a little in front, 
 whilst the external condyle descended a little backwards. 
 
 C. A. Sturrock gives {Ediiihurgh Hosjjifal Beports, vol. ii. 
 1894, p. 605) a marked case of displacement backwards of the 
 epiphysis. 
 
 H. C, set. eleven, was admitted to the Royal Infirmary, Edinburgh, 
 under the care of Mr. Hodsdon, on August 25, 1892, and gave the 
 history that a cab had run over his left knee. On inspection the 
 knee, which was very painful, was flexed, and showed an abnormal 
 gap above the patella, with a marked prominence immediately 
 above. The leg felt cold, and appeared slightly oedematous. When 
 the patient was anaesthetised, an unusual prominence could be felt 
 in the popliteal space, which was apparently the epiphysis, while 
 the lower extremity of the shaft of the femur could be distinctly felt 
 lying in front of it ; the separation appeared to be perfectly horizon- 
 tal ; the condyles could be moved while the femur was fixed, pro- 
 ducing smooth crepitus. When the leg was flexed, and traction 
 made upon it, the deformity was reduced, but on extending the limb 
 it again recurred. The limb was accordingly put up in splints, with 
 the thigh at right angles both to the abdomen and to the leg, and 
 by partially swinging the leg it was hoped to exercise a slight 
 amount of extension on the fragments. The limb was thus retained 
 for four weeks, and in the extended position for four more weeks, 
 when a plaster-of -Paris case was applied for a short time. Within 
 a month after the removal of the plaster case — during which time 
 passive movements, friction, and douching were regularly employed 
 ■ — the patient could walk without a limp. On examining the leg 
 thirteen months after the accident it was found that the circum- 
 ference of the injured knee was a quarter of an inch greater than 
 that of the sound knee ; that no definite thickening could be felt, 
 but the knee seemed bulkier ; that as regards length both limbs 
 were absolutely the same ; that the range of movements was perfect, 
 and that the boy walked without a limp. 
 
 Displacement backwards and outwards. — An example of displace- 
 ment backwards and somewhat outwards is described by C. E. 
 Sheppard {loc. cit. suijra, p. 433, Plate VIII.) in his SoHy Medal 
 prize essay, 1878. 
 
 Charles S., aged fifteen, was admitted into St. Thomas's Hospital 
 under Mr. Sydney Jones, April 9, 1877. He was riding behind a 
 cab in a sitting position, with his back towards the cab, when his 
 left leg became entangled in the spokes of the rapidly revolving 
 hind wheel. He was thrown violently into the road, and found he 
 was unable to stand. The left leg was slightly flexed, with con- 
 siderable displacement of the knee inwards (abduction of leg 
 on thigh). On the front and inner side of the 'knee' there 
 was a rounded smoothish prominence, evidently the lower cartila- 
 ginous end of the diaphysis. Below and to the outer side of this 
 
768 EPIPHYSES OF LOWEE EXTKEMITY 
 
 prominence could be felt the patella and its ligament in normal 
 relation to the tubercle of the tibia. The articular ends of the 
 femur and tibia were felt in normal relation to one another. The 
 knee-joint was uninjured. The epiphysis of the femur apparently 
 projected into the popliteal space, but could not be felt. The 
 whole knee-joint, including the femoral epiphysis, was displaced 
 outwards and backwards, the shaft projecting forwards and inwards. 
 This position of the fragments was to be accounted for by the nature 
 of the accident. The boy was sitting with his back towards the 
 vehicle, and the leg as a lever, being caught between the spokes, 
 was forced upwards against the spring or rail of the cab as a 
 fulcrum. The epiphysis would in this way be dragged backwards. 
 The leg could be abducted on the thigh to a right angle, aiid on 
 extreme flexion could be brought nearly parallel to it. Some 
 distinct crepitus was felt during manipulation. Genu valgum 
 was present on the other side. Eeduction of the displacement 
 was effected after considerable difficulty by means of traction 
 with the limb in the flexed position and the hand behind the 
 head of the tibia, combined with gentle manipulation of the end 
 of the diaphysis. Liston's back splint was applied in the slightly 
 flexed position. On April 10 there was sHght projection of the 
 diaphysis, with some effusion into the knee-joint. On April 11 a 
 long outside splint was applied, with 4 lb. extension. A month 
 later the splint was removed, and there was no trace of the 
 deformity, this limb being straighter than the other. On May 25 
 (seven weeks after the accident) the patient left the hospital ; the 
 movements of the limb were nearly perfect, and he could flex the 
 knee almost to a right angle. 
 
 Displacement outwards. — Many instances of this lateral displace- 
 ment have been recorded ; the deformity gives rise to an appearance 
 of the limb similar to genu valgum. Mr. Chauncey Puzey, in 
 relating two cases of this injury (loc. cit. infra), questions the cause 
 of the fixation of the limb in this position ; at first he was disposed 
 to think it was due to impaction of the shaft into the epiphysis, but 
 afterwards considered it was due to the separation of the epiphysis not 
 having been complete at its outer portion, and that here a vertical 
 tear of the lower and external expanded shaft took place, resembling 
 a greenstick fracture. He alluded to the two specimens in St. 
 George's Hospital Museum, related above, in which the separation 
 was complicated by a limited fracture of the diaphysis, and thought, 
 from the manner in which the accident occurred in his two cases, 
 that this limited fracture would be accompanied by a certain amount 
 of impaction of the fragments ; and that, this being the case, the 
 fixation of the limb would be readily accounted for. 
 
 As stated above, there cannot be impaction in the true sense of 
 the phrase, but rather an impingement of the outer part of the dia- 
 physis in the hollow of the epiphysis, rendering reduction almost 
 
SEPAEATION OF LOWEK EPIPHYSIS OF FEMUR 769 
 
 / 
 
 impossible by reason of the see-saw movement which has been 
 referred to above. 
 
 It is quite possible, however, that the fracture of the diaphysis 
 at the outer part may be incomplete and a greenstick one, but this 
 is not borne out by pathological facts. 
 
 With reference to the signs present, the knee is kept a little 
 flexed, and the foot slightly everted while the patella looks a little 
 outwards. 
 
 The anterior and inner 
 edge of the end of the dia- 
 physis is to be felt towards 
 the inner side of the patella. 
 
 The adductor magnus and 
 the other powerful adductor 
 muscles act strongly on the 
 shaft, and are powerful agents 
 in producing this form of 
 displacement. 
 
 In many cases, as men- 
 tioned above, the outer and 
 anterior part of the diaphysis 
 is lodged in the cup-shaped 
 hollow of the epiphysis — 
 this shape of the epiphysis 
 especially pertaining to young 
 children before twelve years 
 of age — and consequently 
 the epiphysis undergoes the 
 see-saw movement during 
 manipulation. 
 
 In this form of displace- 
 ment, as in the last described, 
 the lower angular margin of 
 the diaphysis will be placed 
 against or penetrate the front 
 or inner portion of the vastus 
 internus, and may possibly 
 be felt in this position if the 
 effusion is not too extensive. 
 
 As early as 1837 Mr. John Grantham, of Crayford, Kent {London 
 Medical Gazette, n.s. vol. i. 1838, p. 799 ; Facts and Ohservationa 
 in Medicine and Surgery, 1844), diagnosed a case of detachment of 
 this epiphysis by the unusual extent of the deformity, the knee 
 lying on its fibular side. S., aged twelve years, had his right thigh 
 run over by the wheel of an unloaded timber cart. On making 
 gentle extension, the limb appeared straight and the fracture ad- 
 justed; but on placing it over a pillow the knee fell again to the 
 
 3d 
 
 Fig. 235. — diageam of displacement of epi- 
 physis AND LEG DIEECTLY OUTWAEDS BEFORE 
 ABDUCTION TAKES PLACE. THE LIMB MUST BE 
 BEOUGHT INTO THIS POSITION BEFORE REDUCTION 
 CAN BE EFFECTED. (.^-sizc) 
 
770 EPIPHYSES OF LOWEE EXTEEMITY 
 
 outer side, as if it moved on a pivot. A transverse separation about 
 an inch above the patella was detected, and attended with a soft 
 inaudible crepitus. The femur was also fractured obliquely through 
 its middle, and the great trochanter separated, which conveyed the 
 same sensation as the separation above the condyles. The limb 
 was placed on a double-inclined plane, and anterior and lateral 
 sphnts adapted to the thigh. On the fourteenth day the union of 
 the epiphyses was found to be firm, and at the end of the fifth week 
 the boy was permitted to use the limb gradually. 
 
 El Marcano's case the displacement was very pronounced, for on 
 the inner side of and above the articulation a projection could be 
 felt about the nature of which there could be no possible mistake. 
 
 Mr. Puzey's first case is described {Liverpool Med. Chirurg. 
 Journal, 1885, vol. v. p. 42 ; Brit. Med. Journal, 1882, vol. ii. 
 p. 788) as follows : 
 
 Arthur L., aged sixteen, was playing at leapfrog, and, on alighting 
 wdth his legs rather further apart than usual, fell, and on attempting 
 to rise found his knee ' out of joint,' and was at once brought to the 
 Liverpool Northern Hospital (November 30, 1881). When seen 
 lying in bed on his back, he looked as if he was the subject of well- 
 marked genu valgum of the right knee, the limb lying flat on the 
 bed, but the leg being fixed at an angle of 130° with the thigh. 
 There was considerable fulness about the joint, more especially at 
 the inner side, and any attempt at movement appeared to cause 
 great pain. The patient was etherised, and it was then found that 
 the ordinary movements of the joint could be freely carried out, 
 showing that no true dislocation existed ; and in spite of the sw^elling 
 it was ascertained that the inner condyle bore its normal relation to 
 the head of the tibia, but the leg remained fixed laterally in its 
 extraordinary position. 
 
 The lower end of the thigh was now steadied, and by pushing 
 the leg firmly towards the middle line the limb was straightened ; 
 in so doing there was felt the soft crunch or crepitus which is 
 generally noticed in straightening out a ' greenstick ' fracture ; and 
 further examination made it evident that what had occurred was a 
 separation of the condyloid epiphysis, not quite complete at its 
 outer aspect. The limb was put on a MacEityre's splint. Con- 
 siderable swelhng occurred around the lower part of the thigh, and 
 there was also some effusion within the joint, which passed away 
 in the course of a week or two. After seven weeks the boy was 
 allowed to move the knee, and he returned home on January 30, 
 having fair movement of the joint. Six months later he was seen 
 again, and had a good straight limb, with perfect movement of the 
 knee-joint. On December 10, 1884, three years after the accident, 
 he had an absolutely sound limb ; but careful measurement showed 
 that the femur of the injured limb was nearly one inch shorter 
 than the other. 
 
SEPARATION OF LOWER EPIPHYSIS OF FEMUR 771 
 
 Mr. Puzey's second case, is given in the same volume of the 
 Liverpool Med. Gliirurgical Journal {loc. cit. supra, p. 439). 
 
 John M., aged fifteen, was admitted into the Northern Hospital 
 on June 2, 1884. The description of this case exactly coincided 
 with that just given, but in this instance the skin over the inner 
 condyle was much bruised, and the lower part of the inner aspect of 
 the thigh much swollen from extravasated blood. Any attempt at 
 lateral movement of the limb caused pain, but the knee could be 
 gently flexed to a considerable extent. 
 
 The patient was ansesthetised, and the joint found perfectly 
 movable. With some difficulty, owing to the swelling, the inner 
 condyle was made out holding its normal relation to the head of the 
 tibia, and above this a gap evidently existed. Reduction was effected 
 by pushing with some force the leg towards, and even a little beyond, 
 the middle line, and was accompanied by a sensation of rustling or 
 slight tearing under the hand. An ordinary long external splint 
 was applied. There was articular effusion for a considerable time 
 and swelling above the joint, evidently due to extensive deep 
 extravasation of blood, probably caused by laceration of the vastus 
 internus. This was to be accounted for by the manner in which 
 the injury was caused — i.e. by direct violence. The lad was walking 
 along a wall, and fell on to the low wall of an ash-pit, with which 
 the inner side of his knee came in contact, thus sustaining laterally 
 the whole stress of the fall. On July 16 the limb was put up in 
 plaster of Paris, and the patient was discharged from the hospital on 
 July 23 with very slight stiffness of the knee-joint ; on December 10, 
 1884, there was no difference between the two limbs, except that the 
 inner condyle was more prominent than that of the other limb. At 
 the time of the report there was no shortening, and the moveixients 
 of the joint were quite restored. 
 
 Mr. Maunder relates {Lancet, 1870, vol. i. p. 192) the case of a 
 lad, aged twenty, in the London Hospital, who slipped and found 
 himself on his back, with the leg bent upon the thigh and 
 unable to be straightened. As he lay upon the bed the limb had a 
 position of genu valgum ; he could flex the thigh slightly on the 
 pelvis, and in doing so the knee-joint appeared to be higher up the 
 thigh than usual. However, the condyles of the femur, the head of 
 the tibia, and the patella held their normal relations, and the loss 
 of continuity corresponded to the junction of the condyles with the 
 shaft of the femur. A soft crepitus was easily elicited. 
 
 Mr. Davies-Colley had a similar case under his care in Guy's 
 Hospital. 
 
 Henry T., aged seven, was admitted on February 14, 1884, 
 having been run over by a cab, and was at first thought to have 
 fractured his right femur. The knee was swollen, and there was 
 mobility apparently three or four inches above the joint, but no 
 crepitus. Ether was given to determine the diagnosis. The condyles 
 
 3 D 2 
 
772 EPIPHYSES OF LOWEE EXTEEMITY 
 
 could be displaced one inch and a half outwards, and at the inner 
 side of the patella the inner and anterior edge of the lower extremity 
 of the diaphysis could be felt, but no crepitus or even 'rubbing.' 
 The lower epiphysis seemed to rotate round an antero-posterior axis, 
 three to four inches up the femur. Mr. Davies-Colley explained this 
 by the curved surfaces upon which it moved. A ' Croft ' combined 
 with a Hodgen's splint was applied. On May 8 the patient was 
 wearing a trough splint to the outer and posterior aspects of the limb. 
 On June 30 he could walk well. There was no lateral movement and 
 no deformity. The injured leg was slightly the longer of the two. 
 
 Dr. Henry Wallace {The Baihuay Surgeon, Chicago, 1897, Novem- 
 ber 2, p. 283, and Brooklyn Medical Journal, 1897, vol. xi. p. 686) 
 also reports the following case of separation with displacement out- 
 wards of the epiphysis. 
 
 The patient (S. O'D.), aged seven years, was brought to St. John's 
 Hospital, Brooklyn, on March 31, 1897. He said that he had caught 
 his left leg between the spokes of a revolving wheel while jumping 
 from the backboard of a wagon. On examination the next morning, 
 the leg was seen to be much swollen and discoloured in the vicinity 
 of the knee-joint, which was partially flexed and in the position of 
 genu valgum. There was decided interference with the circulation, 
 as shown by the colour and temperature of the toes. Ether was 
 administered, and a diagnosis of epiphysial separation easily made. 
 Reduction by traction in the position of complete extension of the 
 leg proved ineffectual. Traction on the semiflexed leg, combined with 
 manipulation, succeeded in completely reducing the displacement. 
 There was no tendency for the fragments to become displaced after 
 they were once completely reduced. The entire limb was then put 
 up in a plaster splint in the position of slight flexion. As soon as the 
 plaster had set, the splint thus formed was divided into anterior and 
 posterior sections. The anterior being removed, the limb was now 
 resting on a perfectly fitting posterior splint. For several days the 
 injured limb was decidedly cold, with marked ecchymosis at the seat 
 of injury. The interference with the circulation was probably due 
 to the hsematoma which gradually formed in the popliteal space. 
 On the fortieth day the limb was put up in a complete plaster splint. 
 On the fifty-second day all dressings were removed, passive move- 
 ments were commenced, and the patient allowed full use of the limb. 
 He made an uninterrupted recovery, with the prospect of perfect 
 function of the knee-joint. Measurement showed the injured limb 
 to be three-eighths of an inch longer than the other, the probabilities 
 being. Dr. Wallace thought, that it was originally the longer and 
 that no shortening resulted from the accident. • The hsematoma had 
 been absorbed. A fluoroscopic examination showed good apposition 
 of the fragments and some callus in the popliteal space. 
 
 Displacement outwards and forwards.- — A case of separation of the 
 lower femoral epiphysis, with displacement laterally and forwards, 
 
SEPAKATION OF LOWEE EPIPHYSIS OF FEMUE 773 
 
 \ 
 
 ^ 
 
 is described by Mr. Mayo Eobson in the Annals of Surge rij, 
 vol. xvii. part 7, July 1893, p. 4. 
 
 J. C, aged fourteen, recovering from a severe compound fracture 
 of the right leg, for which a splint was still being worn, fell, 
 September 6, 1888, while getting about on crutches, with the left 
 leg under the splint of the right. Something in the neighbourhood 
 of the left knee was felt by the patient to have given way. When 
 seen he was sitting on the ground, pale, and complaining of intense 
 pain in the left knee. The left thigh was flexed on the abdomen 
 and the leg flexed on the thigh, the whole limb being rotated out- 
 wards. On measuring from the 
 anterior superior spine of the 
 left ilium to the lower border of 
 the patella, there was found to 
 be slight lengthening on the 
 left side. There was consider- 
 able swelling of the joint, and 
 immediately above the upper 
 border of the patella there was 
 a depression. No fracture of 
 the shaft of the femur was 
 made out. The relation of the 
 femoral condyles to the head of 
 the tibia was found to be normal, 
 but the whole joint could much 
 more than normally be moved 
 laterally, and especially out- 
 wards. This movement was 
 accompanied by a soft cracking 
 sound. The limb was straight- 
 ened and placed on a back 
 splint, lead lotion being applied 
 to the knee, which was much 
 swollen. September 7 : no pain ; 
 knee still swollen. September 8 : 
 on examination under ether, half 
 an inch of lengthening ; knee 
 swollen, distinct soft crepitus felt, and extensive lateral displacement 
 just above the knee-joint. Separation of lower epiphysis of femur, 
 with lateral displacement, diagnosed. Seduction effected, and limb 
 placed on back splint. September 15 : on admission to the Leeds 
 Infirmary Mr. Eobson found that there was still a good deal of 
 effusion into the knee-joint, and reapplied the back splint. Sep- 
 tember 25 : very little swelling ; back splint removed, and limb put 
 up in plaster from ankle to groin. October 20 : plaster removed. On 
 December 15 patient could walk well, and there was no deformity. 
 On May 25, 1893, no sign of the injury could be discovered. 
 
 m: 
 
 V 
 
 Fig. 2.36. — uiagham showing displacejient 
 directly inwakds at the age of seven- 
 TEEN AND A HALE YEAliS. (f-size) 
 
774 
 
 EPIPHYSES OF LOWEE EXTEEMITY 
 
 Displacement inwards. — The violence producing this form of dis- 
 placement is usually of a twisting, or rather lateral, character, or at 
 right angles to the axis of the limb. 
 
 The lower end of the shaft is felt and seen on the outer side of 
 the knee. 
 
 Mr. T. Bryant records {Brit. Med. Journal, May 31, 1884, 
 p. 1044 ; Practice of Surgery, 4th edit. 1884, vol. ii. p. 384, fig. 464a) 
 a case in which the epiphysis had been displaced inwards, and also 
 rotated in the same direction (see figure 237). 
 
 William B., aged six, was admitted into Guy's Hospital on 
 August 15, 1882. The patient was riding behind a brougham when 
 he slipped on one side, and his right leg became entangled in the 
 spokes of the wheel. The right leg was considerably deformed, the 
 lower epiphysis was wrenched off, and the diaphysis abducted, with 
 its lower end nearly projecting through the skin on the outer side. 
 
 The epiphysis with the tibia was driven 
 upwards and inwards, and the head 
 projected on the inner side. The limb 
 was shortened about two inches, and 
 the foot inverted. There was also con- 
 siderable effusion into the knee-joint, 
 with much pain. A Macintyre's splint 
 was applied after the parts had been 
 restored to their normal position by 
 manipulation and extension. On Sep- 
 tember 12 the bones had united and 
 the limb was in good position. On 
 September 20 there was felt to be a 
 little thickening on the outer side of 
 the lower end of the femur, firm union, 
 and a quarter of an inch shortening. 
 On October 19 the patient could walk with the aid of a crutch. 
 
 The late Mr. Alfred Poland had under his care at Guy's Hospital 
 in 1868 a girl, Margaret S., aged thirteen years. She had fallen 
 down three or four steps, and afterwards was unable to stand. On 
 admission, June 4, separation of the lower femoral epiphysis was 
 diagnosed, with displacement inwards and a little backwards. The 
 lower end of the diaphysis could be felt beneath the skin just above 
 the anterior, upper, and outer part of the joint. A long outside splint 
 wdth extension was used, and on July 30 a gum and starch bandage 
 applied. A good recovery resulted. 
 
 Dr. F. J. Shepherd, of Montreal, alludes to an instance of this 
 form of displacement in which Macew^en's operation had subsequently 
 to be performed for the obliquity and deformity of the lower end of 
 the femur. 
 
 In one of Canton's cases the projecting end of the diaphysis 
 could be felt on the outer side of the knee above the patella. 
 
 Fig. 237. — displacement inwaeds 
 and kotation of loweb epi- 
 PHYSIS OF FEMUK. (t. BEYANT) 
 
SEPAEATION OF LOWEE EPIPHYSIS OF FEMUK 775 
 
 Dr. J. C. Eeeve describes and figures {Cincinnati Lancet and 
 Clinic, 1878, n.s. vol. i. No. 21, November 23, p. 385) a case under 
 his care. 
 
 The patient, a German boy, aged sixteen, became entangled in a 
 belt, and was carried over a shaft between it and the floor above. 
 He received the following injuries — viz. compound fractures of the 
 right forearm and arm, with extensive laceration of the soft parts, 
 and separation of the lower epiphysis of the left femur. Under 
 A.C.E. mixture the arm was amputated at the upper third, and on 
 examining the lower extremity there was found to be extreme 
 deformity ; from the knee downwards the limb was rotated inwards, 
 so that the foot and patella looked directly towards the opposite 
 side, the line of fracture was immediately above the knee-joint, the 
 condyloid portion of the femur projected inwards nearly its whole 
 breadth, looking as if the knee might be dislocated, and on the outer 
 side, just below and behind the normal position of the joint, 
 a point of bone protruded through the skin, making a wound 
 about the size of a finger-nail. The limb was restored, as much 
 as possible, to its normal position and shape by applying very 
 considerable force. A long outside splint was applied to the leg 
 and trunk, and extension (of sixteen pounds) to the foot for about 
 ten days, when an immovable bandage of plaster of Paris and thick 
 pasteboard was applied, the knee being kept in a slightly flexed 
 position, as that was considered the best position if ankylosis should 
 occur. This w^as removed in about two weeks' time, when it w^as 
 found that the patient had considerable power of flexion of the knee- 
 joint, and ultimately had nearly as good a limb as the other. He 
 could walk well without the use of a stick, and had full use of the 
 joint except for extreme flexion. 
 
 Displacement forwards and inwards.^An instance of this displace- 
 ment inwards and slightly forwards came under the care of Mr. 
 Durham at Guy's Hospital in September 1886. A child, Harry N., 
 aged seven years, was run over by a butcher's cart, and received a 
 simple fracture of the left femur at the upper third, with separation 
 of the lower epiphysis, which was displaced forwards and inwards. 
 There was half an inch shortening. A double interrupted outside 
 splint was applied with extension, and after seven weeks a plaster- 
 of-Paris dressing ; there remained a quarter of an inch shortening. 
 
 Mr. John Birkett had a like case at Guy's Hospital in April 1867. 
 A girl, Fanny S. W., aged seven, was thrown backwards with her 
 leg doubled up beneath her. The limb was shortened one inch, and 
 there was a prominence in the popliteal space. Under chloroform 
 the end of the femur could be felt at the under and outer side of the 
 space, and a depression of the thigh caused by the backward dis- 
 placement of the femur could be seen and felt just above the patella. 
 There was some efl'usion into the joint ; a long outside splint was 
 applied, and a month later a starch bandage. At the end of May 
 
776 
 
 EPIPHYSES OF LOWEE EXTREMITY 
 
 the patient could walk without the assistance of a crutch, but turned 
 the foot inwards a little in walking. 
 
 Projecting diaphysis. — The end of the diaphysis in many of these 
 forms of displacement, especially when it projects forwards, may be 
 felt beneath the skin as a somewhat expanded flattened mass. 
 
 The patella is freely movable as a rule, but may be fixed if the 
 displacement of the fragments is very extreme. 
 
 Sliortening can usually be recognised whenever there is any 
 overlapping of the epiphysis on the diaphysial end, and its amount 
 depends upon the extent and form of the displacement. 
 
 It may not be present at the time of the accident, not until the 
 epiphysis has undergone rotation by the action of the gastrocnemius 
 and popliteus muscles. Although the greater part of the former is 
 attached to the diaphysis, yet this muscle is stripped off from the 
 bone with the periosteum. 
 
 Fig. 238. — DISPLArEMENT FORWARDS AND INWARDS OF LOWER EPIPHYSIS OF FEMUR 
 
 (Guy's Hospital Museum. Mr. Birkett's case) 
 
 At Guy's Hospital Mr. Cooper Eorster treated a case of this 
 separation in a boy (Chas. R.), aged sixteen, by means of a Hodgen's 
 splint. The injury occurred on November 4, 1878, by the patient's 
 leg being run over by the wheel of a light cart. The separation 
 was accompanied by three-quarters of an inch shortening, and but 
 little bruising. Effusion into the joint subsequently ensued, and the 
 boy left the hospital on December 29 with the movements of the knee 
 fairly free, but with much thickening of the lower end of the femur. 
 
 Crepitus is a most variable and inconstant sign. 
 
 It may be present in its typical form of a ' muffled character ' 
 when the surface of one fragment glides over that of the other, 
 and is often felt in compound separations, the finger being in the 
 wound, during reduction of the displacement. 
 
 In the majority of cases the crepitus has not the characteristic 
 smoothness, but partakes more of the nature of crepitus in fracture, 
 from the frequent presence of a more or less extensive fracture of the 
 diaphysis or an intercondyloid fracture. 
 
 As in other forms of fracture, the presence of shreds of the 
 periosteum or muscle between the fragments is sufficient to 
 
SEPAEATION OF LOWEE EPIPHYSIS OF FEMUE 777 
 
 account for the total absence of this sign ; though in this case locking 
 of the fragments may also be partly responsible. 
 
 Again, we may find crepitus absent from the loss of contact 
 between the separated surfaces, due to the complete displacement 
 of the epiphysis. 
 
 Pain is frequently very severe in some cases, but in a few 
 simple separations it may be almost entirely absent. 
 
 In other instances the intense pain may be attributable to the 
 stretching of the popliteal nerves, especially the internal. 
 
 Dr. E. H. Harte states, though the author does not know upon 
 what grounds, that ' the pain that is elicited in the production of 
 crepitus is not so severe as would be found in fractures of the femur 
 higher up.' 
 
 Mobility .—KhnoTTnoX mobility of the epiphysis exists in all cases 
 of this separation, with or without displacement, and consequently 
 is the most trustworthy of all the symptoms. In fact, the presence 
 of this symptom alone is quite sufficient in youth to suggest an 
 epiphysial separation. 
 
 It is felt to be situated above the knee-joint. It may be slight in 
 the antero-posterior or lateral direction, or may be marked, so that 
 the limb can be carried into any position. This is the case when 
 the two separated surfaces glide one over the other when they 
 are not completely displaced apart. If complete displacement of 
 the epiphysis has taken place, if the fragments are locked in one 
 another, or if the epiphysis is much rotated, mobility is but little 
 marked. Free lateral movement occurring at the epiphysial line, 
 without marked crepitus, should at once suggest the nature of the 
 injury. At a superficial examination it might from the mobility 
 appear that the knee-joint was higher than normal. In this con- 
 nection it should be borne in mind that the Hne of epiphysis slopes 
 slightly downwards and backwards. 
 
 If a separation of one condyle with intercondyloid fracture has 
 occurred, the looseness will be confined to that condyle. 
 
 The size of the lower fragment and the exact distance of the 
 seat of mobility from the lower edge of each condyle will materially 
 assist in forming a correct diagnosis. They both differ according to 
 the age of the patient (see under Anatomy). 
 
 Dr. E. H. Harte gives (Trans. Amer. Surg. Association, Phila- 
 delphia 1895, vol. xiii. p. 398) the following instance in which lateral 
 mobility was a notable feature. 
 
 Thomas M., aged eighteen years, was admitted to the Episcopal 
 Hospital, June 8, 1894. While he was riding in a freight car, and lying 
 on his back, with his leg extended out of the car door, the leg came 
 in contact with a telegraph pole, bending it round the edge of the 
 door laterally. On admission there was effusion about the knee, and 
 marked softening of the vastus internus muscle. Crepitus and 
 deformity could be elicited by moving the knee with the condyles and 
 
778 ■ EPIPHYSES OF LOWEK EXTEEMITY 
 
 diapliysis of the femur in opposite directions. When the deformity 
 was reduced there was httle or no shortening. Extension with 
 bran-bags and long lateral splints, and an ice-cap over the knee, 
 were used. The effusion gradually subsided, but the softening over 
 the internal condyle was persistent for nearly a month. The patient 
 was discharged cured August 14, 1894, with fair motion in the 
 knee-joint. 
 
 A more severe injury was recently diagnosed by Dr. F. W. 
 Schmidt {The Baihoay Surgeon, Chicago, U.S.A., vol. iv. June 29, 
 1897, p. 54) as an example of separation of the lower epiphysis of 
 the femur, with intercondyloid fracture from the free mobility and 
 separation of one condyle from the other. It is interesting to note 
 in this case that skiagraphs were taken one year after the accident, 
 and that by observing them closely the lines of fracture could be 
 noted. The patient, male, aged fifteen years, slim and ansemic, 
 a machinist, while crossing a slippery floor, fell, striking his knee 
 and doubling up his limb, so that the weight of the entire body bore 
 down upon it. The limb had been placed on a double-inclined 
 splint, and VN'hen Dr. Schmidt saw him four hours afterwards the 
 knee was so oedematous that he decided not to remove the splint 
 until the following day. The limb was then gently extended, and a 
 long sandbag placed on each side of it, with cooling applications to 
 the joint. In this position it was left until the third day, when it 
 was found that the swelling had sufficiently subsided to permit a 
 thorough examination under an ansesthetic. The condyles could be 
 freely moved and separated from each other, the diagnosis being 
 made of intercondyloid fracture with separation of the lower 
 epiphysis. A plaster-of-Paris dressing from the heel to the hip was 
 then applied. Counter-extension had to be discontinued after several 
 hours, owing to the intense pain which it caused. As on the following- 
 day the patient became very feverish and delirious, and complained 
 of great pain about the joint, a fenestrum was made into the dressing 
 and several bluish black spots were discovered. The fenestrum afforded 
 immediate relief. Five weeks after the accident the dressing was 
 removed, and passive motion attempted under an anaesthetic. It was 
 found that very extensive adhesions had formed, and considerable 
 force had to be used in flexing the limb. The dressing was reapplied 
 loosely, and daily massage employed. A few days later the dressing 
 was finally removed, and the patient commenced to employ passive 
 motion himself. He was placed on crutches, and in the course of four 
 months could walk with a support ; and he was subsequently able to 
 walk long distances after his day's work. There was ultimately one 
 inch shortening and only partial ankylosis, but the lower fragment 
 seemed to be rotated posteriorly. 
 
 Dr. Schmidt thought that, considering the fact that amputation 
 had been proposed before he saw the case, the patient had every 
 reason to be grateful for this apparently poor result. 
 
SEPAKATION OF LOWEE EPIPHYSIS OF FEMUK 779 
 
 Detachment of the periosteum. — Allusion has already been made 
 to the fact that detachment of the periostemn probably occurs in all 
 cases of separation of the epiphysis, however simple they may be. 
 Although the stripping up of this membrane may be at first only to 
 a slight extent, subsequent haemorrhage beneath it, either from the 
 primary injury or from undue manipulation, may greatly increase its 
 limits. 
 
 The periosteum was completely stripped from the diaphysial end 
 in McBurney's case, although the injury was a simple one. 
 
 This stripping of the periosteum is, even in simple cases, followed 
 by much thickening of the lower end of the femur during the process 
 of union. 
 
 The stripped-up periosteum remains mostly continuous with the 
 epiphysis ; this is an important fact, especially as regards treatment 
 of the displacement. The presence of a thick band between the 
 fragments adds very greatly to the difficulties of reduction. 
 
 It is undoubtedly true that extensive periosteal detachment will 
 in great measure be responsible for suppurative periostitis and 
 suppuration, which sometimes occur even in simple cases. Sub- 
 periosteal suppuration may extend the denudation of bone, and lead 
 to necrosis of the bone, small though it often is, through failure 
 of nutrition. 
 
 Complications. Pressure on vessels. — When the lower end of 
 the diaphysis projects into the popliteal space, it generally presses 
 upon the popliteal vessels, interferes with the circulation of the 
 limb, and later produces great oedema or gangrene of the leg. 
 
 If to this important sign of compression of the vessels we add 
 shortening, and the deformity arising either from the displacement 
 of the epiphysis on to the front of the diaphysis or from its partial 
 overlapping and the presence of the diaphysis in the popliteal space, 
 we find a group of symptoms perfectly characteristic of this form 
 of separation. 
 
 The displacement of the epiphysis backwards, although it does 
 not occur usually to a very great extent, may possibly cause, in 
 some cases, pressure upon the vessels. The popliteal vessels com- 
 monly escape by reason of the retention of their normal relation with 
 the condyloid notch, and their consequent protection from pressure. 
 This will not, however, be the case if the epiphysis has rotated. 
 
 In McGill's case the vessels, although much displaced and 
 pressed upon by the diaphysis, were not occluded ; for the popliteal 
 vessels were displaced backwards, and could be felt beating under 
 the skin, but pulsation in the posterior tibial and dorsalis pedis 
 arteries was unimpaired. 
 
 In J. Hutchinson, jun.'s, case of a boy, aged twelve, the pressure 
 of the diaphysis upon the popliteal artery almost stopped the pulse. 
 Ked action was effected under an anassthetic, and perfect recovery 
 ensued. 
 
780 EPIPHYSES OF LOAYEE EXTEEMITY 
 
 Mr. Bryant had under his care at Guy's Hospital (November 
 1876) the case of a boy, Thomas C, aged seventeen, in which 
 oedema of the leg indicated a certain amount of pressure on the 
 popliteal vessels. The accident happened by the boy's leg being- 
 caught in the wheels of some machinery and violently twisted. 
 There was also effusion into the knee-joint. He was treated by 
 means of a Hodgen's splint, and he left the hospital at the end of 
 six weeks with limited movement in the knee-joint. 
 
 In June 1884 Mr. AVaren Tay mentioned to the author a case 
 (at that time in the London Hospital) of separation of the lower 
 epiphysis of the femur, with pressure on the popliteal artery. 
 
 The following case came under the care of Mr. Mayo Eobson at 
 the Leeds Infirmary in December 1885 (Annals of Surgery, St. 
 Louis, vol. xi. 1889, p. 107). 
 
 A labourer (F. V.), aged sixteen, was admitted on account of 
 injuries produced by an unshod horse, which had kicked him 
 above the outer side of the left knee-joint two days previously. 
 He fell down, and was unable to rise. He was seen by a surgeon, 
 who applied evaporating lotions and sandbags. On admission 
 there was considerable swelling, with fluctuation round the knee. 
 The leg and foot were enormously swollen, due to oedema and 
 venous congestion ; the foot was everted, and the leg rotated out- 
 wards. No pulsation could be felt in either the anterior or posterior 
 tibial arteries, the circulation being arrested by the sharp edge of 
 the lower end of the diaphysis, which was pressing on the popliteal 
 vessels and making the skin bulge in the popliteal space. The leg 
 and foot were quite numb, but the patient suffered intense pain 
 when movement was attempted. The injured joint was in a state 
 of semiflexion, and extension could only be effected at the expense of 
 great pain. A marked depression existed above the patella, beneath 
 which could be felt a movable mass with rounded edges. The 
 heads of the tibia and fibula appeared to be normal. The limb was 
 shortened to the extent of about one inch and a quarter. A dia- 
 gnosis of epiphysial separation being made, the patient was placed 
 under ether ; when the limb was fully flexed on the thigh by an 
 assistant, another assistant placed his locked hands round the 
 femur, drawing it forwards. The epiphysis was then forced into 
 position and the leg extended. After two attempts the length of 
 the leg was fully restored, and the parts bore a proper relation to 
 one another. A Maclntyre's splint was adjusted, and evaporating 
 lotions applied. Pulsation at once returned in the tibial vessels, 
 the engorged veins emptied themselves, and normal sensation was 
 restored to the limb within a few hours. The swelling of the leg 
 gradually subsided. Nine days later a double-inclined plane was 
 substituted for the Maclntyre's splint, and twenty days after this a 
 Liston's long splint, there being no tendency to displacement, and the 
 effusion into the knee-joint having almost disappeared. A fortnight 
 
SEPAEATION OF LOWEE EPIPHYSIS OF FEMUE 781 
 
 later the splint was removed, there being firm union. At the end 
 of February the patient could raise the limb without pain, and a 
 Thomas's knee splint was applied. This he left off a month later, and 
 was allowed to use the limb. When seen two months afterwards 
 the joint was capable of being fully flexed, there was no deformity, 
 and the left leg was as useful as the right. 
 
 Another case of separation of the lower femoral epiphysis, with 
 displacement upon the front of the femur and pressure upon the 
 popliteal vessels, is recorded by Mr. Mayo Eobson {Annals of 
 Surgery, Philadelphia and London, vol. xvii. Part 7, July 1893, p. 2). 
 
 J. W. M., aged fifteen, was admitted to the Leeds General 
 Infirmary, December 11, 1891. The same morning the patient had 
 been struck over the lower part of the left thigh by a metal roller, 
 six feet long and five inches in diameter, weighing several stone ; he 
 at once lost all use of the limb. On admission a few hours later 
 there was very great swelling of the left knee, with evident displace- 
 ment forwards of the lower extremity of the femur, and projection 
 backwards into the popliteal space of the lower end of the upper 
 fragment. The lower segment could be felt riding altogether in front 
 of the upper portion, with its flat surface applied to the front of the 
 lower end of the femur. The lower end of the upper fragment 
 evidently 'compressed the vessels and arrested the circulation in the 
 leg, which was livid, cold, and swollen. There was an inch and a 
 half of shortening. The head of the tibia and the patella were 
 carried forward with the condyles of the femur. No crepitus was 
 obtainable. 
 
 Ether having been administered and the limb fully flexed, an 
 assistant locked his hands behind the femur and exerted traction 
 upwards, and another, grasping the foot, drew the leg downwards. 
 Mr. Eobson was then able to manipulate the epiphysis, which 
 slipped into position with a distinct sound. The length of the limb 
 was then found to be normal, and the circulation was immediately 
 resumed in the leg and foot. The limb was put up in a suspended 
 Maclntyre's splint. On January 18, 1892, the limb was taken off 
 the splint, and the bone found to be in very good position and 
 firmly united. Plaster of Paris was applied to fix the joint and 
 removed at the end of three weeks, when gentle massage was 
 employed. January 29, 1892, the patient walked to the infirmary, 
 and there was neither deformity, shortening, nor impairment of use in 
 the limb. On May 5, 1893, no sign of the injury could be made out. 
 
 Mr. Mayo Eobson alludes (Annals of Surgerij, Philadelphia, 
 vol. xvii. Part 7, July 1893, p. 5) to a similar case, in which reduc- 
 tion was successful and a useful limb resulted. The displacement 
 of the epiphysis forwards was incomplete. 
 
 Dr. E. II. Harte regarded the following case under his care as 
 an epiphysial fracture, its termination being similar to that of cases 
 quoted by Wheelhouse and others. 
 
782 EPIPHYSES OF LOWEP EXTEE^IITY 
 
 A lad, with ankylosis of the knee-joint and marked tiexion, fell, 
 producing a fracture above the condyles. The limb vras treated in 
 the extended position, rotating the detached lower fragment. A 
 fatal termination ensued in the second week, from hfemorrhage due 
 to pressure on the popliteal vessels. The diagnosis was not verified 
 by an autopsy. 
 
 Provided reduction can be effected, and other circumstances are 
 favourable, even laceration of the popliteal artery does not necessarily 
 demand amputation. 
 
 Pressure on nerves. — In backward displacement of the diaphysis 
 the internal popliteal nerve is the one most likely to be pressed upon, 
 as in Mayo Eobson's case. 
 
 DIFFEEEIiTIAL DIAG^^OSIS. Dislocation of tiie knee-joint.- Dr. 
 E. H. Harte says : ' In two of my own cases the idea of dislocation 
 would naturally be suggested by the distortion of the limb. In fact, 
 the displacement was so like what would be expected in lateral 
 luxation that it took some minutes to convince my house surgeon to 
 the contrary.' 
 
 Mr. C. Holthouse mentions (Holmes, System of Sin-gery, 2nd edit, 
 vol. ii. 1870, p. 915) the following case in discussing the diagnosis 
 of dislocations of the knee. 
 
 ' A little boy. four years of age, was riding behind a cart, when 
 his left leg got between the spokes of the wheel, and he was brought 
 into Westminster Hospital with an apparent dislocation of the tibia 
 inwards. AYith very slight extension of the limb, the deformity was 
 removed and distinct crepitus elicited ; the existence of this sign, 
 then, is conclusive as to the nature of the injury, viz. separation of 
 the lower epiphysis of the femur.' 
 
 The only difficulty in distinguishing between dislocation of the 
 knee and separation can arise when displacement has occurred. The 
 deformity has been described in many such cases as resembling a 
 dislocation of the knee backwards and outwards, or directly inwards. 
 In the absence of any very great sweUing about the knee, a careful 
 examination of the deformity, the different bony prominences of the 
 tibia, femur, and patella, the more or less normal motion in the joint, 
 and abnormal mobility corresponding to the epiphysis, should be 
 sufficient to distinguish it from dislocation. Dislocation, besides 
 being of so rare occurrence in young subjects, is accompanied by 
 fixation of the limb at the knee-joint, so that the movements of 
 flexion and extension on the thigh are very restricted. Crepitus is 
 so often absent that it cannot be relied upon. 
 
 The swelling about the knee occin's sometimes so rapidly and 
 to such an extent that some weeks have elapsed before an exact 
 diagnosis has been made, the osseous projections being entirely 
 obscured. 
 
 In compoimd epiphysial separations such a mistake could scarcely 
 occur, on account of the character and shape of the protruding 
 
SEPAKATION OF LOWEE EPIPHYSIS OF FEMUE 783 
 
 bone ; yet in one case (Eichet's) the diaphysial end, covered with 
 epiphysial cartilage, protruded through a large wound on the outer 
 aspect of the thigh and gave the appearance at first sight of a 
 dislocation. 
 
 In the more simple cases of displacement forwards of the epi- 
 physis there can be but little difficulty of diagnosis from (1) the 
 shortening of the limb, (2) the projection of the end of the diaphysis 
 in the popliteal space, and (3) the presence of the epiphysis in 
 front of the femur — to which may be added the signs of pressure 
 upon the popliteal vessels. 
 
 Sapra-condyloid fracture. — Besides being exceedingly rare in 
 children, the end of the upper fragment is more pointed and oblique 
 than in separation, and is more distant from the articulation. The 
 character of the crepitus cannot be relied upon on account of the 
 frequency with which the separation of this epiphysis is accompanied 
 by a certain amount of fracture of the shaft. In this case the 
 separation will very closely simulate a fracture. 
 
 The characteristic soft crepitus, if present, is pathognomonic of 
 separation. 
 
 Separations, except the more simple cases, are much more 
 difficult to reduce and maintain in position than similar fractures 
 about the same situation. 
 
 In transverse fracture of the lower end of the femur it is often 
 the lower fragment drawn backwards by the gastrocnemius which 
 presses upon the vessels, and not the lower end of the diaphysis, as 
 in epiphysial separation. This is, however, only true in instances 
 of great displacement ; in the more simple cases, where the lower 
 fragment or epiphysis is commencing to rotate, its posterior edge 
 is the first to project into the popliteal space. 
 
 Packard WTites : ' The age of the patient and the characters of 
 the fracture, its want of obliquity, its nearness to the joint, and the 
 smoothness of the fragments, will be the chief points to be relied 
 upon in distinguishing this lesion from ordinary supra-condyloid 
 fracture.' 
 
 In cases of old separations in which a considerable time has 
 elapsed after the occurrence of the injury, difficulty may at first 
 sight be experienced, as in the case of old separations of the epi- 
 physial head of the femur, in distinguishing it from distortions of 
 the joint from chronic disease, especially those of a tuberculous 
 nature. 
 
 TREATMENT. — There is no question of the gravity of the injury, 
 says Dr. E. H. Harte, as nearly half of sixty cases terminated in 
 amputation. 
 
 Cases of simple separation without displacement or complication 
 are best treated by immediately placing the knee in the position of 
 slight flexion. A Maclntyre's splint or a Croft's lateral plaster-of- 
 Paris sphnt should be applied to keep the fragments at rest, and 
 
784 
 
 EPIPHYSES OF LOWEE EXTEEMITY 
 
 prevent any subsequent displacement of the epiphysis by the action 
 of the gastrocnemius and other muscles. The plaster splint has this 
 advantage, that it allows inspection from time to time without 
 disturbing the fragments. 
 
 Where displacement has occurred from rotation of the epiphysis 
 on its transverse axis, and reduction has been effected under an 
 anaesthetic (which procedure might be facilitated by division of the 
 tendo Achillis), the same treatment in the flexed position on an 
 inclined plane or otherwise is essential. 
 
 In some cases reduction has apparently been effected after con- 
 siderable difficulty by pushing the diaphysis forwards, or by traction 
 of the leg in the flexed position when the epiphysis is in front of 
 the femur. 
 
 In all cases, under an anaesthetic, the leg and epiphysis should 
 be gently pressed in the opposite direction to which it has been 
 
 Fig. 239.— double-inclined plane with extension on leg 
 
 displaced, combined with gentle manipulation of the end of the 
 diaphysis. 
 
 Under ether Mr. McGill easily reduced the deformity in his 
 patient by forcibly flexing the leg until the heel touched the buttock. 
 
 In Dr. E. H. Harte's two simple cases the deformity was corrected 
 by extension, with the leg in the extended position. 
 
 The deformity does not readily recur in the more simple cases, 
 when the reduction has been easily and completely effected and a 
 suitable splint applied. 
 
 In simple displacement outwards or inwards, reduction and the 
 application of a plaster dressing, with or without an outside or 
 inside splint, are quite effectual, especially if they are a little bent, 
 so that the knee may be maintained in the slightly flexed position. 
 
 Mr. Hutchinson {London Hospital Beports, vol. ii. p. 347, 1(S65), 
 in a note on the best position of the limb in cases of this separa- 
 tion, advocates this plan of treatment by flexion. 
 
 Some prefer the extended position, or the use of a weight com- 
 bined with Liston's long splint. 
 
SEPAEATION OF LOWEE EPIPHYSIS OF FEMUE 785 
 
 Agnew {Surgery, vol. i. 1878, p. 969) recommends that the hmb 
 should be placed in the extended position, and the ham well supported 
 by a compress of oakum, covered with an immovable dressing, but 
 admits that this position may be changed for the semiflexed one 
 should there be any difficulty in properly adjusting the fragments. 
 
 Among the Guy's Hospital cases the author finds the case of a boy 
 (C. M.), aged four years, who had his right femur fractured in its upper 
 third, with separation of its lower epiphysis. The patient was under 
 the care of Mr. Cooper Forster in 1874, and was treated with a long- 
 outside splint and extension by weights to the foot. Forty-one 
 days after the accident there was said to be only a quarter of an 
 inch shortening, and on his discharge nine days later the patient 
 was commencing to walk. 
 
 In Eisner's case, there being no displacement, the treatment 
 adopted was a long Liston's splint. This was followed at the end 
 of a fortnight by half an inch shortening. A Maclntyre's splint was 
 then applied. A straight splint may, therefore, be even prejudicial. 
 
 Some writers recommend the same mode of treatment as in 
 supra-condyloid fracture — viz. by suspension in Hodgen's splint, 
 Smith's anterior splint, or plaster-of-Paris dressing. If plaster of 
 Paris is applied, lateral pieces should be used in the slightly flexed 
 position as just mentioned. Dr. E. H. Harte knew of a case in 
 which a fixed plaster-of-Paris dressing had been employed after 
 reduction, but had to be removed owing to pressure, as it caused 
 gangrene of two of the toes. 
 
 Mr. Davies-Colley had under his care at Guy's Hospital a boy 
 (Geo. B.), aged nine, who was admitted on March 11, 1885. His 
 right knee had been struck by timber falling from a passing cart. 
 
 The knee was slightly flexed and slightly displaced backwards. 
 There was also some crepitus of a blunted wooden character, and 
 free lateral passive movement, but no shortening. Under ether, 
 when the knee was extended and the tibia displaced outwards 
 through 50°, a depression could be felt above the internal condyle, 
 bounded below by a distinct ridge, which disappeared entirely on 
 adducting the tibia to its proper position. A ' Croft ' and straight 
 trough sphnt were applied, the latter composed of straight outside 
 and back pieces joined together at a right angle. On March 23 
 there was still some abduction ; the trough splint was therefore 
 alone applied. On June 11 the legs were both straight and equal 
 in length, and without deformity. 
 
 Packard advocates the straight position as the one in which the 
 limb should be placed if an effort is to be made to save it ; he says : 
 ' Something must probably depend upon the chances for a movable 
 knee ; if this is out of the question, there can be no doubt that the 
 straight position is the best. And where the epiphysial fragment is 
 rotated so that the condyles look upwards — the patient lying on his 
 back (and this rotation in my case was very obstinate), flexion of 
 
 3e 
 
786 EPIPHYSES OF LOWEE EXTKEMITY 
 
 the knee would, of course, carry the head of the tibia further away 
 from the articular surface of the condyles, unless the rotation is 
 overcome, and the condyles well brought down into place. But if 
 the natural relations of the parts can be restored, it seems to me 
 that, after a few days, flexion may be gently and cautiously tried, 
 and gradually increased, with passive movements, so as to prevent 
 the necessity for the breaking up of adhesions at a later date. For 
 the retention of the parts in shape, a "back splint" has been 
 generally employed, but I should prefer the application of sheet zinc 
 or of binder's board moulded along the whole length of the outer 
 and inner sides of the limb, well lined, and held in place by a very 
 accurately laid bandage. When flexion is to be made, fresh splints 
 with suitable angles should, of course, be prepared. Suspension 
 might very well be employed, and may add to the comfort of the 
 patient.' 
 
 The action of the gastrocnemius upon the epiphysis is so constant 
 that it is diflicult to see how proper coaptation of the separated 
 surfaces can be effected and maintained vdthout flexion of the limb. 
 
 Mr. Hutchinson says {Archives of Surgery, January 1893) : 
 ' It may be quite impossible to alter the position of the epiphysis ; 
 the best chance of doing so will be by first effecting reduction, with 
 the knee bent at right angles, and then partially straightening the 
 limb. The treatment of such cases is, however, extremely difficult 
 and unsatisfactory.' 
 
 Keduction of the displaced epiphysis must be immecliately and 
 completely effected, and the limb put up in the flexed position. 
 Any great eversion or inversion of the leg or foot should be carefully 
 guarded against by means of a foot piece. 
 
 Mr. Eobson thinks that reduction under ether would be the best 
 plan to try at first ; and this, he believes, will be certainly facilitated 
 by division of the tendo Achillis. After reduction he recommends 
 either the long splint, with weight and pulley, or the double-inclined 
 plane. 
 
 Whatever form of splint be employed, it should be kept on for 
 three or four weeks. The foot and toes should be carefully watched, 
 especially during the first few days, for any discoloration indicating 
 obstruction of the circulation or commencing gangrene. 
 
 Effusion into the knee and other inflammatory action should be 
 dealt with by evaporating lotions, ice-bag, &c. 
 
 Passive movement may be commenced at the end of four weeks 
 in simple cases. It should at first be of the most gentle character. 
 The ultimate mobility of the knee-joint in the more simple cases 
 should be unimpaired. 
 
 In displacements of the epiphysis, after firm consolidation has 
 taken place, and there is little or no deformity remaining, it will 
 likewise be found necessary to gently manipulate the joint should 
 any stiffness remain. 
 
SEPAEATIOX OF LOAYEK EPIPHYSIS OF FEMUE 787 
 
 These attempts should be made with or without an ansesthetic, 
 and accompHshed with the greatest caution. Even as early as the 
 fifth or sixth week gentle daily movements of the knee may be carried 
 out in these instances. The following statistics of simple separa- 
 tions of the lower epiphysis of the femur can be considered as any- 
 thing but a credit to surgery in the past. They prove conclusivelj^ 
 that operative measures should be undertaken much more frequently'- 
 than has been the case hitherto. 
 
 ' Out of twenty-eight cases (uncomplicated by wound) recorded 
 by Hutchinson junior, sixteen were got into good position, and 
 recovered with very useful and perfect limbs ; whilst of the remain- 
 ing twelve in which perfect replacement was not obtained, six were 
 followed by sloughing or suppuration. In four of these amputation 
 had to be performed, one recovered after excision of the knee, and 
 one after resection of the diaphysial end. In one case a popliteal 
 aneurism formed twenty years after, and led to amputation. The 
 remaining cases recovered with more or less useful limbs, the dis- 
 placement persisting.' 
 
 Among the author's collection of sixty-two cases of separation 
 which were not complicated by a wound the three cases treated by 
 open incision mentioned below may be excluded from the following 
 analysis. Of the fifty-nine cases, in twenty-six the fragments were 
 able to be replaced in good position, and the patients regained most 
 serviceable limbs without deformity. In one instance, after satis- 
 factory replacement, the patient died from shock, the result of other 
 injuries. Of the remaining thirty-two cases, recovery took place in 
 fourteen with a somewhat distorted though useful joint from more 
 or less persistent displacement of one or other fragment ; and one 
 recovered after excision of the epiphysis. In two cases primary 
 amputation was performed, one terminating in recovery, the other 
 in death from pyaemia due to other severe injuries. In one case 
 death "resulted from pyaemia, but it was not stated whether amputa- 
 tion was performed, and in another death ensued from exhaustion 
 after sloughing and suppuration. In thirteen cases secondary 
 amputation was performed for sloughing, ulceration, suppuration, 
 gangrene, injury to nerves, aneurism, &c. ; of these, four ended in 
 death, three from pyaemia and one from tetanus. In eight cases 
 recovery took place after amputation, one of them being a case in 
 which excision of the knee had been previously performed, and in 
 one case the result was not stated. 
 
 Replacement by open incision. — In cases uncomplicated with a 
 wound operative interference may be necessary, and the form 
 the operation should take will depend on the relative position 
 of the separated surfaces and on the condition of the joint and 
 surrounding soft parts. 
 
 In all displacements, on account of the danger to the popliteal 
 vessels, the precise condition of the latter must be ascertained ; 
 
 3 E 3 
 
788 EPIPHYSES OF LOWEE EXTREMITY 
 
 reduction may be effected, even where pressure exists upon these 
 vessels, and recovery may ensue. 
 
 In other cases of simple separation, where, from the locking of 
 the fragments or the interposition between them of a piece of 
 periosteum or muscle, reduction appears to be impossible even after 
 the administration of an ansesthetic, or where retention of the 
 fragments in their normal position is unattainable, an open operation 
 should be undertaken and the displaced fragments completely and 
 at once reduced. An incision being made four inches in length, down 
 to the bone, along the outer border of the tendon of the biceps, under 
 strict antiseptic precautions, the epiphysial fragment or fragments 
 should be reduced, and fixed in position on the diaphysis by means of 
 pegs or sutures. Eemoval of a portion of the diaphysial end may 
 be required in addition, and the epiphysis and diaphysis secured in 
 position in the same way by wire or other sutures. The limb 
 should be afterwards put up on a double-inclined plane after careful 
 irrigation of the wound with perchloride of mercury or some other 
 antiseptic solution and closure of the wound. 
 
 If the epiphysis be allowed to remain in its displaced position, 
 sloughing of the skin — rendering the injury a compound one — sup- 
 puration, gangrene, or subsequent great deformity may result. The 
 truth of this statement and the dangers of imperfect reduction are 
 amply verified by the statistics just quoted of cases of separation 
 uncomplicated by a wound. 
 
 As late as the twenty-first day after the accident an open 
 operation has been successfully carried out for simple separation. 
 It must be stated, however, that in the following case related by 
 F. W. Eisner {Australasian Med. Gazette, July 20, 1895, p. 265) 
 the diagnosis was not exactly made out before incision, and repeated 
 attempts at reduction had been ineffectual. 
 
 A little boy (B. M.), aged thirteen, was admitted to the Tamworth 
 Hospital on October 1, 1893, having been kicked by a horse just 
 above the knee on the outer side. On admission the right leg was 
 drawn up on the inner side of the shaft of the femur, the end of 
 which protruded externally as if about to perforate the skin ; the 
 tibia, fibula, and patella were all intact, but pulled together upwards 
 and inwards by the powerful muscles of the thigh. The leg, with 
 the femoral parts attached, was freely movable in all directions, but 
 there was no crepitus. There was enormous swelling, effusion, and 
 great ecchymosis from haemorrhage around the femoral protuberance. 
 A lengthy and unsuccessful attempt was made under chloroform to 
 reduce the displacement, the shortening recurring to the amount of 
 several inches. The leg was then put up in a long Liston's splint, 
 with weight at the foot and counter-extension. A week or so later 
 another attempt was made at reduction under chloroform, the tendo 
 Achillis being divided, and the limb placed on a Maclntyre's splint. 
 Very little improvement having been obtained — the femoral pro- 
 
SEPAEATION OF LOWEE EPIPHYSIS OF FEMUR 789 
 
 jection still threatening to perforate the skin, while the diagnosis 
 was not exact — an incision was made over the protruding bone. It 
 was found that the condylar epiphysis of the femur had become 
 detached, but was securely attached to the head of the tibia, whilst 
 the protruding part was the end of the femur, rough and bare, but 
 unlike an ordinary fractured surface. Even with the fracture 
 exposed it was impossible to bring the surfaces into apposition ; 
 this was only effected after two inches of the femur in successive 
 discs had been removed with a Butcher's saw. The limb after 
 dressing was placed on a back splint with foot-piece. Union took 
 place rapidly, and the boy was soon able to get about without 
 inconvenience in a plaster-of-Paris splint, putting his foot to the 
 ground. On his discharge, February 2, 1894, there was a perfect 
 limb and a fractional shortening. The report on January 24, 1895, 
 was ' that he walked without a limp, but a little lameness could be 
 noticed when he ran.' The limb developed well. 
 
 Walther has recently (Bev. de Clvir. May 1895) carried out most 
 successfully this treatment by sutare in the case of an adult. It 
 was a severe injury to the knee, in which the lower end of the 
 femur was broken into three fragments, and the tibia with the 
 internal condyle was displaced backwards. Fimctionally the result 
 was perfect. 
 
 Dr. Charles McBurney, of New York, reports {Annals of Surgery, 
 vol. xxiii. No. 6, May 1896, p. 506) two cases which possessed some 
 precisely similar characters. The deformity was exactly the same, 
 and in both all attempts at reduction by simple manipulation were 
 impossible. After the operations no deformity was left, and in one 
 there was only very slight limitation to flexion. 
 
 Case I. — David M., nine years of age, came under his care at 
 the Eoosevelt Hospital on November 16, 1895. The boy had fallen 
 from a height, alighting upon the feet, and had injured the left limb 
 near the knee. The case was brought to his notice on the twentieth 
 day after the injury. A considerable anterior displacement of the 
 leg forward at or about the knee-joint was noted. Externally at 
 the extreme lower end of the shaft of the left femur a sharp angular 
 projection of bone could be felt. This was clearly continuous with 
 the shaft. Anterior to this there was a considerably firm tumour 
 elevatmg the soft parts over the point of the femur and practically 
 continuous with the leg. Holding the tumour with one hand and the 
 femur with the other, false motion could be made between the two 
 without crepitus. Motion of the tibia — that is, flexion and extension 
 — was normal in quality and took place between the tumour and tibia. 
 The diagnosis of separation of the lower epiphysis of the femur was 
 deemed probable, and with the aid of anaesthesia attempts at re- 
 duction were made. Extension in the straight and flexed positions, 
 over-extension with pressure from above upon the epiphysis, and 
 lateral angular motions were all made without success. Partial 
 
790 EPIPHYSES OF LOWEE EXTEEMITY 
 
 reduction without crepitus was accomplished, but redisplacement 
 immediately took place. Ad incision was then made about five 
 inches long, beginning on the outer side of the limb just below the 
 projecting angle of the lower end of the shaft. The incision passed 
 vertically upwards. The soft parts were divided down to the bone, 
 and the lower end of the shaft was exposed. It was quite bare, the 
 periosteum having been stripped up from its face for several inches. 
 When the soft parts were still more freely lifted the whole lower end of 
 the diaphysis could be seen, and the characteristic appearance when 
 separation through a conjugal cartilage has taken place was plainly 
 recognised. The epiphysis could now be lifted on the fingers. A 
 superior, somewhat excavated, quite smooth surface could be felt 
 across its whole width. The epiphysis lay quite anterior to the 
 lower end of the diaphysis, markedly to the inner side, thus 
 accounting for the angular projection of bone externally already 
 mentioned. Even now there was difficulty in making reduction, 
 which was only successful with powerful extension, and at the same 
 time, with the aid of a periosteal elevator, the posterior lip of the 
 epiphysis was pushed over the anterior edge of the shaft. 
 
 After the reduction no difficulty existed in maintaining the 
 epiphysis in place when the leg was partially flexed. Full extension 
 reproduced the deformity. Partial flexion was therefore maintained, 
 the wound closed, and the limb put up in plaster of Paris. No 
 fever or other interruption to wound-healing occurred, and the 
 position remained good. 
 
 Case II. — Thomas B., five years of age, received an injury to 
 the region of the right knee, having been run over by a vehicle on 
 December 16, 1895. He was brought to the Eoosevelt Hospital on 
 the same day. The knee was swollen, very tender to touch, and 
 the leg partly flexed. No voluntary movement of extension could 
 be made. The general appearance of the limb was such as would 
 be produced by an anterior dislocation of the leg. Externally, and 
 just above the position of the external condyle, was a prominent 
 angular point of bone which was continuous with the shaft. In 
 front of this, and somewhat to the inner side, was a movable tumour, 
 evidently consisting of the articular end of the femur. This could 
 be moved laterally without crepitus. On this tumour the leg could 
 be partly flexed and extended. The ligamentum patellEe was 
 markedly tense. Efforts at reduction of the displacement, similar 
 to those made use of in the preceding case, were carefully made. 
 That is to say, extension in the straight and flexed positions, 
 over-extension with pressure from above upon the epiphysis and 
 lateral angular movements with extension and pressure, were all 
 carefully practised and all failed. An operation, precisely similar to 
 that done in the first case, was then at once performed, and re- 
 duction was readily accomplished. After reduction only soft car- 
 tilaginous crepitus could be produced by motion of the lower upon 
 
SEPAKATION OF LOWEE EPIPHYSIS OF FEMUE 791 
 
 the upper fragment. The wound was then closed with catgut 
 stitches and drainage, and the hmb immobihsed in a sHghtly flexed 
 position by means of plaster of Paris. Wound-healing was entirely 
 perfect, and took place under the primary dressing. The position 
 and the general condition of the limb were most satisfactory. 
 
 The report on April 1, 1896, states that in the younger of the 
 two patients the result was perfect in every particular ; while in the 
 other case, which first came under observation twenty days after the 
 injury, a minute necrosis of skin and bone at the extreme outer 
 
 Fig. 240. — diageam of complete displacement foewaeds of epiphysis 
 and peessuee upon popliteal vessels 
 
 Fig. 241.— diageam ; the same aftek eeduction 
 
 angle of the diaphysis took place. In other respects the result was 
 perfect, excepting that voluntary flexion was limited just after the 
 right angle is passed. 
 
 Such operative interference as above described is therefore im- 
 perative whenever there is evidence, by absence of pulsation of the 
 vessels below, of pressure by one or other fragment on the vessels 
 and nerves ; for, if the fragments are not reduced, gangrene of the 
 foot and leg may result, even when at first the vessels are not 
 severely pressed upon, or traumatic aneurism may develop later on, 
 while many examples afl'ord abundant pruuf that, under favourable 
 
792 EPIPHYSES OF LOWEE EXTKEMITY 
 
 circumstances, the limb can be saved, and that with but Httle detri- 
 ment to the powers of locomotion. The removal of a part or even 
 the whole of the diaphysial end does not produce so much decrease 
 in length of the femur as might be supposed, provided that of 
 course the epiphysial cartilage remains adherent to the epiphysis. 
 
 Packard, Mayo Eobson, and others suggest division of the tw^o 
 heads of the gastrocnemius muscle when difficulty is experienced in 
 reducing the epiphysis, due to the contraction of the heads of this 
 muscle, causing its rotation, either through the wound if this be 
 very large, or, if not, by a subcutaneous incision on either side. 
 
 Excision of epiphysis. — Mr. Canton {loc. cit. supra) successfully 
 excised the whole epiphysis in two cases of simple separation — 
 in one after a few days for suppuration and sloughing ; in the 
 other it was followed by amputation. 
 
 Mr. Atkinson, of Leeds, attempted in one case {loc. cit. supra) to 
 excise the epiphysis for threatened gangrene, but without success, 
 and was compelled to resort to amputation. 
 
 Eesection of the epiphysis or the whole knee-joint is not to be 
 recommended. It is only in exceptionally unfavourable cases as an 
 alternative to amputation that it may have to be considered. 
 Amputation will be the safer coui'se to pursue. 
 
 Massage is a useful adjunct to after-treatment. A light mill- 
 board or other moulded light splint may be applied during the 
 intervals, especially when the patient first gets about on crutches. 
 
 Compound Sepaeatiox. — If the epiphysial separation is com- 
 plicated with a wound of the soft parts, but without laceration of 
 the vessels or other serious complication, reduction must always be 
 effected, and an attempt made to save the limb. The wound, or even 
 the periosteal rent, should be enlarged, and the diaphysial end freed 
 from dirt, all soiled portions removed with a stout knife, and the 
 recesses of the wound thoroughly cleansed with antiseptic solution. 
 By the use of antiseptic dressings and a carefully moulded apparatus, 
 or Maclntyre's sphnt, the limb should be maintained in the best 
 possible position. 
 
 Besection of the diaphysial end is further necessary in cases 
 where the protruded diaphysis is irreducible, or where it is locked in 
 the ei3i]3hysis. Perfect drainage of the wound should also be carefully 
 attended to. 
 
 Delens thinks that the limits of the periosteal detachment should 
 generally indicate the point where the diaphysis should be divided, 
 and that even when the denudation of the bone is high up, resection 
 may be effected up to this point, and not limited to the terminal 
 part of the shaft. This seems to be an unnecessary procedure, for 
 the periosteum will rapidly again become adherent to the shaft, and 
 the nutrition of the bone will not be interfered with to any extent. 
 It would also entail much shortening of the bone subsequently. 
 
 No more of the diaphysis should be removed than is necessary 
 
SEPAEATION OF LOWEK EPIPHYSIS OF FEMUE 798 
 
 for reduction, unless it be soiled by dirt, &c. If the joint has been 
 opened, this as well as the wound should be rendered thoroughly 
 aseptic. 
 
 Three-quarters of an inch of the diaphysis was removed in 
 Owing's case, and the bone replaced ; good firm union resulted at 
 the end of three months. 
 
 "Whatever the precise lesions may be, they are sure to be pretty 
 extensive. Diffuse suppm^ation and septic infection must be carefully 
 guarded against by the complete and thorough disinfection of the 
 wound and removal of all soiled portions of the bones by means of 
 a chisel or strong knife. The author is confident that inabihty or 
 neglect to render the wound absolutely aseptic satisfactorily explains 
 the unfavourable termination of a great number of cases which 
 have occm-red in the past, and not a few of those at the present 
 day. Amputation has been, and is still, far too frequently recorded. 
 It must be remembered however that owing to the age of these 
 patients the employment of powerful antiseptics is not always without 
 danger, and constitutes in compound separations, as in Eeverdin's 
 case, a great difficulty. In this instance the subsequent gangrene 
 was thought to be due, in part at least, to the action of the carbolic 
 acid upon the exposed popliteal nerves. 
 
 The increase in length of the femur, although affected by resection 
 of the diaphysial end, is not arrested. Delens's and other cases are 
 examples of this. 
 
 In the cases collected by Keverdin, in only two instances was 
 the attempt to save the limb successful after compound separation. 
 
 In the author's ovm collection of fifty cases of compound sepa- 
 ration, in seven the diaphysis was resected and reduction effected, 
 the patient regaining a very serviceable joint and limb. In nine 
 others, reduction was effected without resection ; of these five re- 
 covered with an equally satisfactory result, while death resulted in 
 four, one from pyaemia and three from shock. In one of the last- 
 mentioned amputation had been refused by the parents. In one 
 instance the whole epiphysis and joint were excised without loss of 
 life. Of the remaining thirty-three compound separations, in twenty- 
 one cases primary, and in twelve secondary, amputation was per- 
 formed. 
 
 Packard found that ' reduction was successfully accomplished in 
 fourteen cases except in one instance (Eichet's), in which the 
 patient died of purulent infection on the fifteenth day. One boy 
 recovered with a stiff knee ; two had good motion ; of seven it is 
 merely said that they did well, or had useful limbs, while in two it 
 is only stated that consolidation occurred.' 
 
 Mr. W. Philpot Brookes, of Cheltenham, recorded {London 
 Medical Gazette, n.s. vol. iv. 1847, p. 56) a case of compound fracture 
 of the external condyle, with ruptme of the capsular ligament, 
 followed by recovery without amputation. It was probably an 
 
794 EPIPHYSES OF LOWEE EXTEEMITY 
 
 instance of compound separation of the femoral epiphysis combined 
 with an intercondyloid fractm^e, and has been ah^eady ahuded to on 
 page 723. 
 
 Henry T., aged eleven and a half years, while getting up behind 
 a carriage, had his left leg caught in the spokes of the hind wheel. 
 He was admitted into hospital June 28, 1845. On examination there 
 was found a compound fracture of the thigh extending into the popli- 
 teal space, and the lower end of the femur protruded. The capsular 
 ligament of the knee-joint was ruptured, and there was an oblique 
 fracture through the external condjde of the femur. There was 
 also a transverse fracture above the articulation, but the vessels 
 were intact. Two days later the finger could be passed between the 
 external condyle of the femur and the head of the tibia, through the 
 wound. Preservation of the limb was attempted, with the result 
 that at the end of a month the wound was almost healed. Two 
 months later a small piece (one inch long) of necrosed bone came 
 away. "When seen, December 1846, he had very good motion of 
 the joint, so that he could flex the leg completely on the thigh, and 
 could walk well with the aid of a stick, bearing the whole weight of 
 the body on the injured limb. 
 
 A similar case with almost as extensive lesions is described in Sir 
 
 Astley Cooper's work on Fractures. A child, Michael D , was 
 
 admitted into St. Thomas's Hospital, under the care of Mr. Travers, 
 on September 17, 1816, his leg having been entangled in the wheel 
 of a carriage in motion. There was a transverse fracture of the 
 lower end of the femur above the joint, complicated with a fracture 
 extending in the direction of the axis of the bone. There was 
 considerable displacement of the fragments, and a small wound 
 opposite the external condyle. The external condyle was movable, 
 and displaced as if by twisting of the limb inwards. The limb was 
 placed in a fracture-box in a semiflexed position. 
 
 The skin over the external condyle ulcerated, exposing its articular 
 surface. Two months later the protruded fractured surface of the 
 femur— viz. the external condyle with its articular surface — became 
 necrosed and exfoliated. The patient left the hospital three weeks 
 after this. On December 1 the use of the limb was almost 
 entirely recovered, extension and flexion were painless, and the 
 wound healed. In the following February he could walk without 
 any support, and all movements of the knee were recovered. 
 
 Many compound separations will therefore recover without 
 amputation — e.g. Owing's, Gay's, Delens's, Elder's, Chassaniol's, 
 Shepherd's, and Donovan's cases. 
 
 ' Out of thirty cases of compound separation collected {British 
 Medical Journal, March 31, 1894, p. 672) by Hutchinson junior, 
 four died from shock, &c. ; in eight reduction was more or less 
 effected, with four subsequent amputations and three deaths from 
 pyaemia. The remaining case recovered after suppuration and 
 
SEPAEATION OF LOWEE EPIPHYSIS OF FEMUE 795 
 
 some necrosis. In thirteen cases amputation was performed soon 
 after the injury, with at least three deaths (in one the Hmb was 
 removed at the hip-joint).' 
 
 Ligature of femoral vein. — The timely ligature of the femoral 
 vein in compound separations for infective thrombosis may arrest a 
 pygemic process, and possibly avert death. 
 
 Besection of the loliole epiphysis and joint will be rarely required ; 
 it will be necessary only in exceptional cases where extensive 
 suppuration of the joint and soft parts may be expected, after severe 
 lesions to them ; otherwise the joint will almost always completely 
 recover its normal movements. 
 
 Arthritic inflammation from contiguity with the separated 
 epiphysis will often be seen, or even some local suppuration, but 
 these need not necessarily destroy the function of the joint in these 
 young subjects. 
 
 Primary amputation is a very grave question, and its advisability 
 can only be determined by consideration of the particulars of each 
 case ; it is necessary only when there exists laceration or irreparable 
 injury of the popliteal vessels in either simple or compound separa- 
 tions, or in severe and extensive injury to the soft parts of the 
 limb. 
 
 The condition of the foot and leg should in all cases be carefully 
 watched for any interference with the circulation and consequent 
 danger of gangrene. 
 
 Dr. McDiarmid found that primary amputation was performed 
 in eleven out of nearly fifty cases, with four recoveries and three 
 deaths, and in four the result was not stated. 
 
 Primary amputation was performed in two of Dr. E. H. Harte's 
 cases ; in one the separation was compound and the leg torn off 
 below the knee, in the other the separation was simple, but 
 accompanied with a compound comminuted fracture of the bones of 
 the right leg and a simple fracture of the opposite femur. 
 
 In the total of sixty-eight cases, Packard found that amputation 
 had been performed in twenty-eight. In twelve it was primary, in 
 nine secondary, in five it was effected at a very late period, and in 
 two the time is not stated. In a number of the cases there were 
 other injuries, causing death in a short time, and in many others 
 the diagnosis was not satisfactorily established. 
 
 In the author's collection of fifty cases of compound separation, 
 twenty-one necessitated amputation at or soon after the time of the 
 accident. Of these no results are stated in six, while of the remain- 
 ing cases twelve recovered and three died, one from pygemia and 
 two from shock. 
 
 Secondary amputation. — -Should the judicious treatment above 
 indicated be carried out, secondary amputation for gangrene, 
 extensive suppuration of the limb, suppurative periostitis, pressure 
 upon the internal popliteal nerve, aneurism, or deformity from 
 
796 EPIPHYSES OE LOWEK EXTEEMITY 
 
 impossibility of keeping the fragments in position, will be less fre- 
 quent than they have been hitherto in simple separations. 
 
 Secondary amputation has also been sometimes resorted to in 
 compound separations for profuse suppuration, pressure upon 
 vessels and nerves, secondary haemorrhage, and suppuration of the 
 knee-joint. 
 
 Secondary amputation was performed (in Canton's, Atkinson's, 
 and other cases) for accidental fracture after resection, and at the 
 request of the patients' friends. 
 
 In these instances recovery not infrequently ensues. Dr. 
 McDiarmid however found secondary amputation performed in five 
 out of nearly fifty cases, with only one recovery, one death, and 
 three results not stated. 
 
 In Dr. McBurney's case, quoted by Little, secondary amputation 
 was undertaken, two or three months after compound separation, 
 in order to relieve the intense pain and deformity. Death ensued 
 from tetanus. In this instance strong bony union had taken place, 
 and the internal popliteal nerve was discovered to be stretched 
 over the edge of the diaphysial end of the femur. 
 
 In one of Dr. E. H. Harte's cases secondary amputation was 
 performed for suppuration after simple separation. 
 
 In Dr. Halderman's case amputation for impending gangrene 
 had to be performed, although the circulation through the main 
 artery and vein was greatly crippled, if not abolished, from the 
 commencement ; in this example also both popliteal nerves were 
 paralj^'sed from pressure, the joint cavity opened, and the surrounding 
 tissue badly damaged and the bone comminuted. All this condition 
 of affairs existed without a breach of integument. 
 
 By reason of the peculiar incarceration of the vessels between 
 the fragments, it is improbable that any manipulation or operative 
 interference in this case would have succeeded in freeing the 
 popliteal artery and vein, even though the adjustment of the frag- 
 ments had been accomplished. 
 
 Mr. Morven Smith, of Baltimore {American Journal of Med. Sci. 
 1838, 4th Ease), describes a somewhat similar example of secondary 
 gangrene following the injury, which was not diagnosed at the time 
 as a separation of the lower epiphysis of the femur. 
 
 A youth, aged nineteen, had a sack full of goods, which was 
 being let down from a vessel, fall on his knee. A ' fracture ' of the 
 femur near the condyles was detected, and at the end of five dsijs 
 the limb was attacked w4th gangrene and amputation was performed. 
 The popliteal artery and vein had been flattened by the edge of the 
 upper fragment, which was displaced backwards. 
 
 Among the author's collection of fifty cases of compound separa- 
 tion, twelve underwent secondary amputation for one or other of the 
 conditions just mentioned. Of these the result is not stated in one, 
 and of the remaining cases six recovered and five died, two of 
 
SEPAEATION OF LOWEE EPIPHYSIS OF FEMUE 797 
 
 pysemia, one of tetanus, one of thrombosis of the vena cava, and 
 one from shock. 
 
 Treatment of deformity some time after the accident. 
 
 Lateral displacement of the epiphysis, producing genu valgum 
 and genu varum, may be corrected by osteotomy of the femur above 
 the condyles. 
 
 In a case described by F. J. Shepherd the displacement of the 
 diaphysis outwards caused a remarkable obliquity and deformity of 
 the lower end of the femur, which interfered with the lad's pro- 
 gression. The accident had occurred several years before. The 
 hmb was straightened by MacEwen's operation, and the patient 
 had good use of the limb. 
 
 In the author's case of severe genu varum and arrest of growth 
 of the femur, following epiphysial injury in infancy, osteotomy was 
 performed upon it just before the time of the report for correction 
 of the deformity with success. 
 
 In displacement of the epiphysis forwards, osteotomy also may 
 be desirable in severe deformity. 
 
 If seen at an earlier period — a few weeks after the accident — 
 forcible replacement of the fragments may be attempted, and the 
 soft uniting osseous material broken through. 
 
 It required considerable force in Winslow's case to break up the 
 adhesions between the fragments four weeks after the injury. 
 The marked varus position — the knees being two inches apart — 
 was completely corrected, and at the end of four weeks the limb 
 was found to be slightly shorter than its fellow, but the knees could 
 be easily placed together. 
 
798 EPIPHYSES OF LOWEE EXTEEMITY 
 
 CHAPTEE V 
 SEPARATION OF THE TIPPER EPIPHYSIS OP THE TIBIA 
 
 ANATOMY. — Both ends of the tibia are usi-iahy cartilaginous at 
 birth. The ossific centre is distinguishable in the upper cartilaginous 
 end about two weeks after birth, but its appearance may be delayed 
 
 till the sixth or even as late as the 
 twelfth month. On the other hand, 
 it may sometimes appear just before 
 birth. 
 
 It is situated exactly in the centre 
 
 of the cartilaginous end, rather towards 
 
 I' -^1^^^^^ its lower limit, and surrounded by 
 
 scattered osseous granules, which are 
 most developed immediately beneath 
 the articular depressions above. These 
 rapidly coalesce with the main centre 
 during the first year, and form this 
 wide expanded epiphysis composed of 
 the two tuberosities. 
 
 The tubercle of the tibia is usually 
 developed in front in an extension 
 downwards of the cartilaginous epi- 
 physis, ossification proceeding from 
 the main centre forwards and down- 
 wards. It is often, according to Beclard, 
 Sappey, and others, ossified by a sepa- 
 rate centre, as in many of the lower 
 j| r'^'jtil^ animals, forming from about the eighth 
 
 li : ■' . ' to the twelfth year (thirteenth year, 
 
 ""*'*'" Sappey), and rapidly extends upwards, 
 
 Fig. 242. — upper epiphysis of the joining the epiphysis above later — that 
 SSef ^'^ '^^""^"'™ ^^^ IS, about the sixth or eighth month 
 
 after (Sappey) — and a short time after- 
 wards blends with the diaphysis. By the fom-teenth or fifteenth 
 year the upper epiphysis with the tubercle is almost completely 
 ossified, concave below, and merely separated from the diaphysis 
 by a thin layer of cartilage above and in front. 
 
SEPAEATION OF UPPEE EPIPHYSIS OF TIBIA 799 
 
 It is half an inch in thickness, and its outer tuberosity presents 
 at the posterior and outer aspect the whole of the articular facet 
 
 Fig. 243. — antero-lateral view of the fully formed epiphyses of the tibia 
 
 AND FIBULA AT THE NINETEENTH YEAR (Half natural Size) 
 
 for the head of the fibula, and affords attachment to' the capsular 
 ligament of the superior tibio-fibular 
 articulation. The upper end of the 
 diaphysis is generally slightly convex, 
 but a little depressed towards the 
 centre. The junction of the epiphy- 
 sis with the diaphysis occurs from the 
 twentieth to the twenty-second year, 
 at times as late as the twenty-third 
 year. Eighteen to twenty years, and 
 even as late as the twenty-fourth, are 
 given by Sappey. 
 
 The conjugal line of cartilage at the 
 fourteenth year is half an inch below 
 the level of the upper articular surface 
 of the tibia on the inner side, and five- 
 eighths of an inch on the outer. At 
 the eighteenth year it is five -eighths of 
 an inch below it on the inner side, and 
 three-quarters of an inch on the outer. 
 The epiphysis overlaps the diaphysis 
 much more on the outer than the inner 
 
 side; consequently the line pursues j '*«:;; ;,. ., ..ii/ 
 
 a longer course downwards on this 
 
 gicle. Fig. 244. — epiphyses of the knee- 
 
 rm .7 7 1? XI 1 JOINT AT THE NINETEENTH YEAR. 
 
 The synovial membrane of the knee- j^^^^r side (Half natural size) 
 joint at no part of its circumference 
 
 extends down to the epiphysial cartilage of the upper end of the 
 tibia, so that it is at a considerable distance from the diaphysis. 
 
800 
 
 EPIPHYSES OF LOWEK EXTREMITY 
 
 The epiphysial Hne, however, on the outer side approaches the 
 superior tibio-fibular articulation — a layer of periosteum and some 
 fibrous tissue, belonging mostly to the capsule of this joint, sepa- 
 rating the two. 
 
 The epiphysial line being directly below the tibio-fibular joint, 
 this joint is likely to be opened in separation of the upper epiphysis 
 of the tibia. As the synovial membrane of the former joint not 
 infrequently communicates with the large bursa beneath the ten- 
 don of the popliteus, which is an extension of the synovial membrane 
 of the knee-joint, an indirect opening of the knee-joint may take 
 place on the outer side in separation of the upper tibial epiphj^sis. 
 
 The following" table of measurements of the upper epiphysis of 
 the tibia and fibula in individuals of various ages is given by De 
 Paoli from frontal sections : 
 
 AGE 
 
 TIBIA 1 
 
 1 
 
 FIBULA 
 
 
 Height 
 
 1 
 
 Breadth 
 
 Height (at 
 
 the external 
 
 margin) 
 
 Breadth 
 
 At the outer 
 margin 
 
 At the inner 
 margin 
 
 At the ! At the 
 middle of ' middle of ; 
 the external the internal 
 tuberosity tuberosity | 
 
 Before birth 
 
 9 mm. 
 
 9 
 
 9 
 
 . 8 1 
 
 26 
 
 7 
 
 8 
 
 1 year 
 
 2 years . 
 4 „ 
 
 11 » 
 
 12 „ 
 10 „ 
 
 10 
 10 
 10 
 
 10 
 
 9 
 
 12 
 
 9 
 
 8 
 11 
 
 36 
 38 
 39 
 
 9 
 
 8 
 
 11 
 12 
 
 5 )) \ 
 
 12 „ 
 
 10 
 
 IB 
 
 11 
 
 45 
 
 6 
 
 13 
 
 15 „ 
 
 12 
 
 14 
 
 12 
 
 48 
 
 9 
 
 15 
 
 6 „ 
 
 14 „ 
 
 11 
 
 12 
 
 11 
 
 48 
 
 10 
 
 15 
 
 7 „ 
 
 12 ., 
 
 11 
 
 10 
 
 11 
 
 48 
 
 10 
 
 14 
 
 8 „ { 
 
 18 „ 
 
 16 
 
 15 
 
 13 
 
 60 
 
 12 
 
 15 
 
 14 „ 
 
 12 
 
 13 
 
 11 
 
 55 
 
 9 
 
 15 
 
 9 „ 
 
 15 „ 
 
 13 
 
 14 
 
 13 
 
 58 
 
 9 
 
 15 
 
 13 „ . 
 
 20 „ 
 
 18 
 
 16 
 
 14 
 
 61 
 
 — 
 
 — 
 
 14 „ 
 
 20 „ 
 
 19 
 
 15 
 
 13 
 
 66 
 
 — 
 
 — 
 
 16 „ 
 
 20 „ 
 
 15 
 
 18 
 
 15 
 
 68 
 
 10 
 
 20 
 
 17 „ 
 
 16 „ 
 
 14 
 
 12 
 
 11 
 
 62 
 
 — 
 
 — 
 
 20 „ . 
 
 16 „ 
 
 > 14 
 
 15 
 
 13 
 
 59 
 
 — 
 
 — 
 
 ETIOLOGY, — The disjunction of this epiphysis can only be 
 effected by great violence, and that for several reasons : its great 
 breadth, the fact that its somewhat cupped inferior surface mth 
 tonguehke process in front fits on to the diaphysis ; the presence 
 of powerful internal lateral and other ligaments, the semimem- 
 branosus and other tendons, and the way in which it is attached to 
 the diaphysis by the tough periosteum. 
 
 In the recorded examples the violence has usually been direct, 
 from some severe crushing force, such as the passage of a wagon- 
 wheel over the leg. In Ashhurst's case the boy was crushed 
 between the buffers of a railway carriage. The author found this 
 mode of violence to be the common cause in experiments on the dead 
 body, but separation could be more readily produced between the 
 ages of eight and fifteen years than later. 
 
SEPAEATION OF UPPEE EPIPHYSIS OF TIBIA 801 
 
 According to Poncet, the epiphysis of the tibia projects so Httle 
 at the knee that it does not allow direct violence to have much 
 play upon it. 
 
 In others the injury appears to have been indirect. 
 
 In Peuleve's case the leg was completely torn off at the level of 
 this epiphysis, having been caught in the spokes of the revolving 
 wheel of a carriage. 
 
 Verneuil (Lariboisiere) saw a leg, which had been completely 
 torn off at the level of the epiphysial cartilage of the tibia, of a child 
 
 Fig. 245.— diagkam of frontal section op 
 knee-joint, showing relation of synovial 
 membrane to the epiphysial lines at 
 the eighteenth year. posterior half 
 OF SECTION (Half natural size) 
 
 FiG. 246. MEDIAN SAGITTAL SEC- 
 
 ■ TION OF TIBIA IN A BOY AGED 
 THIRTEEN AND A HALF YEARS 
 
 The synovial membrane does not 
 extend so far anteriorly or pos- 
 teriorly over the upper surface 
 of the tibia as it does over the 
 tuberosities. The bursa under 
 the ligamentum patellfe is seen 
 in section in front of the epi- 
 physis and tubercle of the tibia, 
 separated from the knee-jcint 
 by a cushion of fat (-|-size) 
 
 six years old. The limb had been caught in the spokes of a wheel. 
 This is probably the same case as Peuleve's, the age being given 
 the same in both instances. 
 
 In Blasius's case the complete separation of the epiphysis and 
 displacement backwards of the diaphysis were effected by the boy s 
 right foot being caught in a threshing machine. 
 
 In Mr. Marsh's case the youth had been caught in the belt of a 
 machine and received other very extensive injuries. Mr. Marsh 
 thought that the blows on the os calcis, with the weight of the 
 
 3 F 
 
802 EPIPHYSES OF LOWEE EXTEEMITY 
 
 body moving in the opposite direction, were the cause of the 
 separation. 
 
 When the same force acts upon the epiphyses at the knee-joint, 
 as in straightening knock-knees, it almost always happens that the 
 lower end of the femur gives way rather than the upper epiphysis of 
 the tibia. 
 
 Monteggia and Bertrandi are both said by M. Eognetta to have 
 seen separation of this epiphysis in children, following a fall upon 
 the knee. Eognetta questions the mechanism of the separation 
 which these two authors describe. He does not think that separa- 
 tion of the tibia can occur in this way, but that the force in falling 
 upon the knee is received entirely upon the femur, and not upon 
 the tibia. 
 
 Gueretin separated this epiphysis on the bodies of newly born 
 infants by hyper-extension of the knee. 
 
 AGE. — Mr. Hutchinson junior collected the records of ten cases 
 (including three unpublished ones) mostly happening from wrenches 
 of the leg. The youngest patient was twelve months, the oldest 
 sixteen years. 
 
 In a total of twenty-four cases the author has brought together 
 the age ranged from three up to twenty years : one at 20, tw^o at 
 17, one at 16^, one at 11, one at 9, four at 8, two at 6, two at 4, 
 one at 3^, and two at 3 years of age. Of the remaining seven, 
 in four the age was not given, in one it occurred in a boy, another 
 in a youth, and a third in a porter. Of the seventeen in which the 
 age is stated, no less than twelve occurred between 3 and 9 years 
 of age, and out of these five were between 8 and 9 years of age. 
 
 Of thirteen cases verified by direct examination, one only was 
 compound, and terminated in recovery (girl, age not stated). Of the 
 other twelve, in which death occurred or the limb was amputated, 
 two occurred at 17, one at 16^, one at 11, two at 8, one at 6, and one 
 at 3 years of age (female) ; one occurred in a boy, one in a porter, one 
 in a youth, and in one the age was not stated. 
 
 Of the eleven sim]jle cases, one occurred at 20, one at 9, three at 
 8, two at 4 (one in a girl), one at 3i (girl), one at 3 years of age, and 
 in two the age was not stated. 
 
 SEX. — The sex is given in twenty out of the twenty-four cases ; 
 sixteen occurred in males, and only four in girls. 
 
 Among the thirteen cases verified by direct examination, two 
 were in female, the rest in male subjects. 
 
 PATHOLOGICAL ANATOMY.— The upper epiphysis of the tibia 
 is remarkably easy to separate experimentally in the dead subject, 
 especially in infants. 
 
 Separation of the epiphysis in infancy was first carefully con- 
 sidered during the second part of the present century. 
 
 However, the often-quoted case of the newly born infant recorded 
 by Madame Lachapelle {Prat, des Accoucli. tom. ii. p. 225, and 
 
SEPAEATION OF UPPEE EPIPHYSIS OF TIBIA 803 
 
 torn. iii. p. 180) cannot be relied on, inasmuch as the child was born 
 dead. The upper epiphysis of the tibia and the lower epiphysis 
 of the femur were separated by traction of the foot during par- 
 turition. In all probability there was some morbid condition of 
 bone present. 
 
 Delore separated the upper epiphysis of the tibia and lower epi- 
 physis of the femur on the one side, and the upper epiphysis of the 
 fibula and the lower of the femur on the other, in straightening the 
 knees of a boy affected with genu valgum. Death occurred from 
 measles twenty-one days after the operation. 
 
 Separation of the upper epiphysis of the tibia is a rare form of 
 injury according to the number of specimens in existence, yet there 
 have been thirteen examples verified by direct examination out of a 
 total of twenty-four. 
 
 The leg is sometimes completely torn off at this epiphysis, Hke 
 the lower femoral epiphysis. 
 
 M. Peuleve, before the Societe Anatomique, Paris {Bull, de la Soc. 
 anat. 1865, tom. x. 2 Ser. p. 305), described a case where this had taken 
 place, and showed the relative specimens. There was complete separa- 
 tion of the epiphysis from the shaft, and destruction of the superior 
 tibio- fibular articulation. The knee-joint, however, was quite intact. 
 The patient, a boy aged six years, had climbed behind a carriage 
 and caught his left leg in the revolving wheel. Amputation was 
 performed on account of the severity of the injury, and was followed 
 by recovery. 
 
 PuEE Sepaeations. — The tongue-hke process of the tubercle 
 goes with the epiphysis. Mr. Durham's specimen mentioned 
 below, in which the tubercle was broken off and remained attached 
 to the diaphysis, is therefore exceptional. There are several speci- 
 mens of this pure form of injury in the London museums. In those 
 instances the injury was caused by the limb being run over by the 
 wheel of a heavy vehicle, and was accompanied by severe lesions of 
 the soft structures and laceration of the skin. 
 
 The specimen (No. 541) in the London Hospital Museum 
 {Catalogue of the London Hospital Museum, 1890, p. 119) was taken 
 from a girl, aged three years, a patient of Mr. Jonathan Hutchinson's. 
 The upper epiphysis of the tibia has been completely and evenly 
 detached, taking with it also the tubercle. The epiphysial cartilage 
 goes with the epiphysis, as also a thick sleeve of periosteum detached 
 from the upper end of the shaft ; on the inner side a flap of the 
 periosteum was found doubled in so as to cover the under surface of 
 the epiphysis and prevent its coming in contact with the shaft. The 
 external lateral ligament is entire, and, the fibula being uninjured 
 and still connected with the epiphysis, no great displacement could 
 be effected at this part. On abducting the foot, the line of separation 
 gaped widely at the inner side, where all periosteal fibres, &c., had 
 been torn through. No doubt the direction of the original violence 
 
804 EPIPHYSES OF LOWEE EXTEEMITY 
 
 was such as to force the leg outwards. The injury w^as compound, 
 and was attended with great damage to the soft parts, requiring 
 primary amputation. A wagon had run over the hmb in the street. 
 The left forearm was also so injured as to require amputation. 
 
 The specimen in Guy's Hospital Museum (No. 1210^'^) shows a 
 complete separation of the low^er femoral epiphysis as well as of the 
 upper ex^iphysis of the tibia. In both the periosteum has been torn 
 off the adjacent portions of the diaphyses, while retaining its connec- 
 tion with the epiphysial ends. The popliteal artery was occluded by 
 laceration of its internal coats, and there was a greenstick fracture 
 of the upper end of the fibula on the same side. The patient, 
 George S., aged eight years, was under the care of Mr. Davies-Colley 
 in July 1886. He had fallen off a hearse, and a wheel passed over 
 his right knee. Amputation was performed on account of the 
 severity of the injury, and recover}'- took place. 
 
 There is another specimen in the same museum (Xo. 1260) 
 where the epiphysis was thought to have been loosened, from the 
 appearance of the preparation after it had been dried. Examination 
 of the specimen does not seem to supply much evidence of separa- 
 tion of the epiphysis, but its anterior lip, forming the tubercle of the 
 tibia, has been broken off. The tibia was grazed by the wheel of a 
 railway carriage. The patient, a porter, had his limb amputated for 
 the great injury to the soft parts (July 1863). 
 
 In one of the specimens in St. George's Hospital, referred to under 
 Separation of the Lower Epiphysis of the Femur, there is 
 besides this lesion a separation of the upper epiphysis of the tibia. 
 
 Messrs. Ashhurst's and F. Marsh's specimens may also be con- 
 sidered as pure separations ; the small scale of the peripheral border 
 of the diaphysial end in the latter's case was not sufficiently large 
 to constitute it a fracture of the diaphysis. 
 
 The tibia may sometimes give way, not through, but at a short 
 distance below, the epiphysial line, as in Rathbun's case of separation 
 of the lower epiphysis of the femur. In addition to the femoral 
 separation, there was in this instance discovered after death a 
 fracture of the upper extremity of the shaft of the tibia that had 
 not previously been suspected. It was situated just below the epi- 
 physial line, and was nearly transverse in direction, being directed 
 from without inwards, slightly downwards, and forwards ; there was 
 no displacement of the fragments whatever. 
 
 Separation with displacement forwards of the epiphysis. — In Hirsch- 
 feld and Fischer's case, related below, the displacement of the 
 diaphysis was backwards. 
 
 In St. Bartholomew's Hospital Museum, No. 990b, to show a 
 splendid instance of pure separation, there is the upper part of a 
 tibia which has been divided by a sagittal section of its upper epi- 
 phvsis. The specimen shows marked displacement forwards for 
 three-ei"-hthsof an incli of the epiphysis from the diaphysis. Union, 
 
SEPAEATION OF UPPEE EPIPHYSIS OF TIBIA 805 
 
 however, fibrous in nature, was extremely firm. There is no fracture 
 of the epiphysis. The Feparation is perfectly pure, there being no 
 fracture of the diaphysis or of its anterior process which forms the 
 tubercle. The periosteum, ligaments, and tendons surrounding the 
 upper epiphysis present great displacement. 
 
 The leg was removed by operation (1895) from a boy, aged sixteen, 
 who was admitted on account of his being caught by a machine ; 
 gangrene of the leg followed, and the leg was amputated thirty-six 
 days after the injury. 
 
 Mr. F. Marsh showed a specimen of complete separation of the 
 shaft of the tibia from the upper epiphysis {British MedicalJournal, 
 January 27, 1894, p. 216) before the Birmingham and Midland 
 Counties Branch of the British Medical Association, taken (ijost 
 Qiiortem) from a youth, aged seventeen, who had been caught in the belt 
 of a machine, and received very extensive injuries. Separation at the 
 line of the epiphysis was complete, the left knee-joint was uninjured, 
 and the left fibula was intact. Mr. Marsh pointed out the extreme 
 rarity of the specimen, and the difiiculty in this instance, the fibula 
 being intact, of satisfactorily explaining the mechanism of the 
 separation. 
 
 Subsequently this surgeon very kindly furnished the author 
 with the following detailed account of the case. 
 
 The specimen was taken from a youth, set. seventeen, who 
 had been caught in the belt of a machine, and had received the 
 following injuries. The left arm was almost torn off above the 
 elbow-joint, and there was also a compound fracture of the humerus 
 in its upper third ; both bones of the right forearm were badly 
 comminuted ; the right femur was fractured ; the tissues over the 
 heel and sole of the left foot were stripped off, and the os calcis was 
 split into three or four pieces ; the shaft of the left tibia was separated 
 from the upper epiphysis and displaced backwards ; the head, trunk, 
 and extremities were also much bruised. The condition was diagnosed 
 when the youth was ansesthetised, and Mr. Marsh was about to 
 amputate the foot. On raising the leg he noticed some unusual 
 mobility in the region of the knee-joint, and on examining found 
 what was evidently a separation of the epiphj^sis. The displacement 
 of the diaphysis was directly backwards, and was complete and very 
 marked. The reduction was easy, but the condition was as readily 
 reproduced. Supra-malleolar amputation of the left foot, and 
 amputation through the surgical neck of the left humerus, were 
 performed, and the patient rallied fairly well for a time, but died 
 thirty-six hours later, apparently from shock. The post-mortem 
 examination showed that no other injuries except those enumerated 
 had been received. Examination of the left leg showed that the 
 separation of the epiphysis was complete, that the knee-joint was 
 uninjured, and that the fibula was intact. 
 
 The youth w^as well developed and very muscular. Mr. Marsh 
 
806 
 
 EPIPHYSES OF LOWEE EXTEEMITY 
 
 was inclined to think that the blows on the os calcis, with the 
 weight of the body moving in an opposite direction, caused the 
 separation. 
 
 The specimen which Mr. Marsh also kindly sent the author 
 showed a very small flake of the diaphysis broken from the front of 
 the diaphysis ; the separation was otherwise quite pure. The 
 specimen is in the Mason College Museum. 
 
 Displacement forwards and out- 
 wards of the epiphysis. — Blasius 
 records (Poncet, Nouv. Diet. Med. 
 et cle Chir. t. 19, p. 513 ; also 
 E. Gurlt, Handhiich der Lehre 
 von den Knochenhrilchen, 1 Theil, 
 1862, S. 87) the case of a boy, 
 aged sixteen and a half years, who 
 was injured by his right foot being 
 caught in a threshing machine. 
 The upper epiphysis was com- 
 pletely separated from the shaft 
 exactly at the epiphysial line, even 
 to the tongue-like process in front : 
 the diaphysis being displaced back- 
 wards and inwards an inch beyond 
 the epiphysis, and large lacerated 
 wounds produced in the flexure of 
 the knee. The fibula was also 
 fractured below the head, and the 
 capsule of the joint was perforated 
 towards the posterior aspect by a 
 small splinter of compact tissue 
 detached from the inner side of 
 the diaphysis of the tibia. After 
 death, on the sixth day, foetid pus 
 was found in the knee-joint, and 
 the skin of the lower part of the 
 thigh and part of the leg was gangrenous. 
 
 Displacement backwards of the epiphysis. — No instance has been 
 recorded of this form of displacement. 
 
 Lateral displacement of the epiphysis. — A specimen of separation 
 from a crush of the leg, in which the extensive laceration of the soft 
 parts required amputation, is figured by Ashhurst {Principles and 
 Practice of Surgenj,SYd edit. p. 269, figs. 132, 133, Philadelphia, 1882). 
 The specimen is in the Museum of the Episcopal Hospital, and 
 was taken from a boy, eleven years old, who was caught between 
 the buffers of railway cars. 
 
 Dr. Ashhurst very kindly furnished the author with the following 
 drawings of the case (figs. 248, 249). 
 
 Fig. 247. — 5ie. frank marsh's specimen 
 (i-size, Mason College Museum, Bir- 
 mingham) 
 
SEPAEATION OF UPPEE EPIPHYSIS OF TIBIA 807 
 
 Separation with Fracture of Diaphysis. — A fracture of the 
 diaphysis often accompanies separation of the upper epiphysis of 
 the tibia in experiments on the dead subject. 
 
 Fig. 248. — lateral Dibi'LACEiiEXT of uppee Fig. 249. — Tiiii same hpecdien. 
 
 KPIPHYSIS OE TIBIA. POSTEIIIOR VIEW ANTEIIIOR VIEW 
 
 (After Ashhurst) 
 
 Fig. 250. separation of the upper epiphysis of the tibia, with 
 fractures of the diaphysis 
 
 (Royal College of Surgeons Museum) 
 
 The Koyal College of Surgeons Museum contains a specimen, 
 No. 1110a, showing upper extremity of a tibia with separation of 
 
808 EPIPHYSES OF LOWEE EXTKEMITY 
 
 the epiphysis. The diaphysial end is broken up into several large 
 fragments, and a longitudinal fracture extends downwards into the 
 shaft. The epiphysis of the tibia remains firmly attached to the 
 head of the fibula. The fractures are mostly of the posterior part 
 of the diaphysis, which are displaced backwards, while the anterior 
 part has been displaced forwards, Mr, A. H. Tubby says : ' Unfor- 
 tunately no history was obtainable in this case, as it was found 
 among a number of discarded specimens given to me from a private 
 collection' (Annals of Surgery, March 1894, p. 316), 
 
 Mr, Durham had the case of a boy, aged eight, under his care at 
 Guy's Hospital in April 1885, who was injured by the wheel of a 
 tramcar passing over his leg. Primary amputation was rendered 
 necessary on account of the extensive laceration of the skin on the 
 outer and front part of the leg, laying bare the gastrocnemius muscle 
 and upper part of tibia. The upper epiphysis was completely 
 separated from the shaft, but not displaced; the portion forming 
 the tubercle was broken from the epiphysis, which was otherwise 
 intact, and remained attached to the shaft. The upper end of the 
 diaphysis had been fractured vertically in three pieces, the innermost 
 piece being quite loose. The joint, fibula, and large vessels and 
 nerves were uninjured. The patient rapidly recovered. 
 
 Lefort gives the description {Bull, cle la Soc. de Chir. 1865, 
 p. 529) of the case of a girl in whom there was a compound 
 separation of the upper epiphysis of the tibia, accompanied by a 
 fracture of the diaphysis. Through a wound of the upper part of 
 the leg a movable fragment could be distinctly felt, so that the 
 fragments were completely separated. M. Guerin removed the frag- 
 ment of the diaphysis, one surface of which presented a mam- 
 millated appearance, corresponding to the epiphysial cartilage ; the 
 other aspect was rough, like fractured bone. 
 
 The patient completely recovered. 
 
 Complications. — Laceration of the capsular ligaments and open- 
 ing of the knee-joint is not a necessary accompaniment, even in 
 compound cases, although some effusion into the knee-joint must be 
 expected in all. In Blasius's case of compound separation the 
 capsule of the joint was perforated towards the posterior aspect by 
 a small splinter from the inner side of the diaphysis, and led to 
 suppuration of the knee-joint, discovered at death on the sixth day. 
 
 In Peuleve's specimen and in E. Marsh's the joint was intact, 
 yet in the former the leg had been completely torn off at the 
 epiphysial junction. 
 
 Dr. H. Fischer and Dr. E. Hirschfeld record {Berliner klinische 
 Wochenschrift, 6 Marz 1865, ii. S. 93) a case in which there occurred 
 separation of the lower epiphysis of the right femur, upper epiphysis 
 of the left tibia, and both epiphyses of the left fibula, exactly at the 
 epiphysial line. As regards the separation of the lower epiphysis of 
 the right femur, the injury was a simple one. The epiphysis was 
 
SEPAEATION OF UPPEK EPIPPIYSIS OF TIBIA 809 
 
 rotated so that the internal condyle ascended somewhat forwards 
 and the external condyle descended backwards, the upper fragment 
 being also a little forwards. Soft crepitus was distinct, and abnormal 
 mobility slight. The right knee-joint appeared normal. On the 
 left side the lower fragment of the tibia was displaced backwards 
 and upwards, forming an angular projection behind, and being over- 
 lapped in front by the upper fragment. This projection was plainly 
 visible on hyperextension of the knee-joint, and disappeared on flexion. 
 These movements were accompanied by distinct crepitus. The 
 upper fragment formed a small prominence in front, which ended 
 a little below the tubercle of the tibia ; its shape could be accurately 
 made out. At the upper and lower 
 epiphyses of the fibula, soft, yet dis- 
 tinct, crepitus was felt, with some 
 abnormal mobility of the epiphyses ; 
 there was, however, no displacement. 
 The knee- and ankle-joints appeared 
 to be free. 
 
 Under chloroform the displace- 
 ment of the tibia of the left leg was 
 reduced, and the limb put up in a 
 plaster splint. But in spite of care- 
 ful treatment, in the eleventh week 
 amputation through the upper part 
 of the thigh was obliged to be per- 
 formed for necrosis of the whole 
 separated lower epiphysis of the 
 fibula, partial necrosis of the upper 
 epiphysis of the fibula, and suppura- 
 tion of the knee- and ankle-joints. 
 The latter was quite destroyed, 
 having been opened from the outer 
 side. The epiphysis of the tibia 
 was found to be again displaced 
 forwards, and was firmly united in 
 this position, covering over the upper part of the tibia like a cap. 
 
 The patient was a lad, aged seventeen years, who was injured 
 by being caught in the driving shaft of a threshing machine, and 
 violently twisted round by it. Recovery took place, and the fracture 
 of the right femur consolidated, though with some displacement and 
 rotation of the epiphysis. 
 
 Suppuration and necrosis result most frequently in compound 
 cases. 
 
 Suppuration of the knee-joint. — This occurred in Blasius's case 
 of compound separation, in which the capsule was opened at the 
 posterior aspect. Gangrene of part of the leg and thigh ensued, 
 terminating in death on the sixth day. 
 
 Fig. 251. — displacement forwakds of 
 uppek epiphysis of tibia. united 
 at the eleventh week 
 
 (After Fischer and Hirsclifeld) 
 
810 EPIPHYSES OF LOWEE EXTEEMITY 
 
 PROGNOSIS. — Union has resulted in two instances — in Fischer 
 and Hirschfeld's, and in the St. Bartholomew's Hospital Museum 
 specimen — a firm union, although only a fibrous one, notwithstanding 
 the fact that gangrene of the leg supervened in both, and necessitated 
 amputation in the first case at the eleventh week, in the second on 
 the twenty-sixth day. 
 
 C. A. Sturrock records {Edinburgh Hosjyital Beports, vol. ii. 1894, 
 p. 605) a case in which no trace of the injury could be seen eleven 
 months after the accident. 
 
 A. L., aged eight, was admitted to the Royal Infirmary, Edin- 
 burgh, on January 27, 1893, under Professor Annandale's care. 
 When swinging, he got his foot caught and fell to the ground. On 
 admission, some time after the accident, the swelling round the 
 knee was so considerable that the precise nature of the injury could 
 not be ascertained; w^hen in three days the swelling had in great 
 measure disappeared by means of evaporating lotions, it was found, 
 on grasping the tibia, that the tuberosities could be moved from side 
 to side, and slightly from before backwards, cartilaginous crepitus at 
 the same time being elicited. There appeared to be no other injury 
 to the neighbouring bones, though there was some synovitis. The 
 most comfortable position was a flexed one, and it was with con- 
 siderable difficulty that the leg could be straightened and placed in 
 a box splint. It was retained thus for seventeen days, and encased 
 in plaster of Paris for three weeks. When heard of eleven months 
 after the accident the boy had no limp, and no trace of the injury 
 was to be seen. 
 
 Good union likewise resulted in Houston's case without much 
 displacement. 
 
 Ankylosis of the knee-joint and fixation of the tibial epiphysis to 
 the femur may ensue as the result of the synovitis due to direct 
 injury of the joint, or as the result of extra-articular inflammation 
 following the severe injury. 
 
 Deformity. — There will be no trace of deformity in separation 
 without displacement provided the injury be judiciously treated, as 
 in Bryant's, Annandale's, and Birkett's cases. In other separa- 
 tions the deformity after reduction will be inappreciable — e.g. 
 Heuston's case. It has been stated that if the separation remain 
 undetected, the epiphysis may unite with displacement inwards and 
 inversion of the knee-joint, but that this valgus condition may result 
 from rotation of the leg and foot without any lateral displacement. 
 M. Eognetta alludes to a case observed in 1625 by the celebrated 
 Severino at the Hospital for Incurables at Naples. In this case 
 twisting inwards of the knee took place in consequence of separation 
 of the upper epiphysis of the tibia. 
 
 Arrest of growth. — Some arrest of growth may take place after 
 separation of the upper epiphysis of the tibia, but since the lower 
 epiphysis also has a share in the growth of the tibia, the extent 
 
SEPAEATION OF UPPER EPIPHYSIS OF TIBIA 811 
 
 of the shortening following injury to its upper end is uncertain ; the 
 amount contributed by each epiphysis has not yet been determined, 
 although it appears from the experiments of Vogt that the increase 
 in length of the tibia takes place mostly through the upper epiphy- 
 sial cartilage, and this is borne out by the frequency with which 
 arrest of growth of the limb is met with after disease about this 
 epiphysis. 
 
 The truth of this is also often seen in the comparatively rapid 
 increase of the tibia in amputation of the leg in childhood, pro- 
 ducing a conical stump, and necessitating the removal of the end 
 of the quickly growing shaft. 
 
 Mr. Bryant (Practice of Surgery, 4th edit. 1884, vol. ii. p. 458) 
 figures a well-marked case of arrest of growth in the shaft of the 
 right tibia for one inch, with bowing of fibula, following injury to 
 the upper epiphysis two years before. 
 At the time of observation the child 
 was aged eight years. 
 
 The growth of the fibula continuing 
 unchecked, it becomes bowed outward, 
 as in this instance, and hypertrophied, 
 or else displaced upwards ; see fig. 252. 
 
 Volkmann records another case of 
 three centimetres shortening after 
 injury to the upper end of a tibia. 
 
 A boy, aged three, had been severely 
 knocked about by his drunken father. 
 At the age of four he began to limp, 
 and subsequently the tibia ceased to 
 grow at its upper end, so that the 
 shortening finally amounted to three 
 centimetres. A ridge could be felt, as 
 though the diaphysis had been displaced somewhat inwards and 
 forwards. It must be stated, moreover, that the femur and foot of 
 the same side, in fact the whole lower extremity, were less developed 
 than those of the opposite side (Hutchinson junior). 
 
 Mr. J. Jones reported {London Medical Becord, 1883, vol. xi. 
 p. 228 ; Lancet, March 1883, p. 403) a case of separation of this 
 epiphysis during traction by extension in hip disease, followed by 
 arrest of growth for one and a half inches in the bone two years 
 after the injury. However, this case must be considered as some- 
 what inconclusive, inasmuch as the separation, as well as the sub- 
 sequent rapid arrest of growth, was possibly much favoured by the 
 diseased condition of the patient. 
 
 SYMPTOMS. Separation without displacement. — Probably many 
 instances of separation of this epiphysis without displacement are 
 overlooked. 
 
 Plelferich is of the same opinion. He thinks that wherever there 
 
 
 Fig. 252. — arrest or growth of 
 
 TIBIA TWO YEARS AFTER INJURY 
 
 TO UPPER EPIPHYSIS (Bryant) 
 
812 EPIPHYSES OF LOWEE EXTKEMITY 
 
 has been a severe direct injury to the upper end of the tibia in a 
 child, our attention should be directed to the possibility of this 
 injury. 
 
 An accurate diagnosis can only be made under an angesthetic, 
 when abnormal mobility and characteristic cartilaginous crepitus 
 may be detected. The presence of the fibula on the outer side 
 attached to the epiphysis and articulating with it, and. the tongue-like 
 process in front forming the tubercle, tend to prevent displacement. 
 
 Among thirty-seven instances of tramnatic separation of the epi- 
 physes, Gueretin found only two of the upper epiphysis of the tibia. 
 
 Separation with, displacement of the epiphysis. — In milder cases the 
 displacement may be insignificant, especially if the fibula, wliich is 
 connected wholly with this epiphysis, be not fractured, and the 
 internal lateral ligament intact. X gap between the epiphysis and 
 diaphysis may be felt on the inner or outer side on carefully abduct- 
 ing or adducting the leg. 
 
 In Hutchinson's there was no displacement, but the periosteum 
 was tucked in between the fragments, being detached from the 
 diaphysis. This detachment is seen in the Guy's Museum specimen, 
 and is a constant complication in this injury, even in the less severe 
 cases, and may be followed by acute periostitis. 
 
 The displacement of the epiphysis in the more severe cases may 
 be completely forwards, and the diaphysis behind press upon or 
 lacerate the popliteal vessels. 
 
 Incomplete displacement forwards was found in Fischer's case. 
 The deformity is very prone to be reproduced. 
 
 In some instances, as in the cases of Lefort, &c., fracture of 
 the diaphysis complicates the injury. 
 
 Displacement of the epiphysis forwards and outwards occurred in 
 the case of Blasius ; directly outwards in the case of a youth, aged 
 twenty, under the care of Mr. Howse at Gny's Hospital in March 
 1888. The patient, Arthur E., was thrown off a bicycle in Cheapside, 
 and in falling the crank axle of the bicycle struck the inner side of 
 his left knee. On examination there was to be felt below the knee, 
 on the inner side, a distinct rounded edge, apparently the u^^per 
 edge of the diaphysis of the tibia, and a good deal of effusion into 
 the knee. Under chloroform, on applying pressure inwards to the 
 outer side of the knee, the upper fragment moved over the shaft, 
 and the projection on the inner side disappeared. This manipulation 
 was accompanied by slight cartilaginous crepitus. A ' Croft's ' 
 plaster-of-Paris splint was appHed to the Hmb, and firm union took 
 place at the end of a month. The case is also mentioned by Dr. 
 E. P. Manby {British Medical Journal, September 22, 1888). 
 
 Mr. Durham had a similar case at Guy's Hospital in IS'ovember 
 1877. 
 
 The patient (John H.), aged nine, got his right leg entangled in 
 the wheel of a cab, and was dragged along the ground for some 
 
SEPAEATION OF UPPEE EPIPHYSIS OF TIBIA 813 
 
 distance. The leg was found to be much twisted inwards, and a 
 projection felt just below the knee, the result of the displacement of 
 the epiphysis of the shaft. He was treated by a back splint, and 
 left the hospital at the end of six weeks able to walk with some 
 support. 
 
 Displacement of epiphysis inwards. — For displacement directly 
 inwards to occur, the upper epiphysial junction of the fibula must be 
 broken or the ligaments uniting the fibular head w4th the outer 
 tuberosity of the tibial epiphysis lacerated. 
 
 Swelling. — The amount of sw^elling is usually very considerable. 
 
 It was so great in Annandale's case that the precise nature of the 
 injury could not be ascertained for three weeks, when the swelling 
 had in great measure disappeared. 
 
 Mobility of the epiphysis, most noticeable in the lateral direction, 
 is the most trustworthy sign in this as in other epiphysial separations 
 with incomplete displacement. 
 
 In Annandale's case there was slight mobility of the tuberosities 
 from before backwards, as well as from side to side. 
 
 Dr. F. T. Heuston, surgeon to the Adelaide Hospital, Dublin, 
 relates {British Medical Journal, vol. ii. July 21, 1888) the case of 
 E. 1j., aged eight years, under his care. The boy, while running in 
 school, was caught between two desks, and injured his leg in 
 attempting to wrench it free. At the time there was little pain, 
 and he was able to walk home. Considerable sweUing supervened 
 in a few hours. On examination six days later there was acute 
 synovitis of the knee-joint, while free movement was obtainable 
 between the superior epiphysis of the tibia and the shaft, there 
 being, however, no crepitus. 
 
 Crepitus of the usual muffled character can be detected in many 
 of the simpler cases in which mobility of the epiphysis is present. 
 
 Mr. Bryant, at Guy's Hospital in 1885, diagnosed separation of 
 the upper epiphysis of the tibia from the dull crepitus and mobility 
 of this epiphysis in a girl (D. W.), aged three and a half, who 
 had slipped and fallen backw^ards. The injury was treated by a 
 posterior and two lateral splints, the patient being discharged three 
 weeks later with a ' Croft's ' plaster-of -Paris splint. 
 
 Under an anaesthetic the joint will be found to be perfectly 
 movable and free. 
 
 Complications. Articular lesions. — Some effusion into the knee 
 must be expected in all forms of severity of separation of the upper 
 tibial epiphysis. 
 
 It was marked in Annandale's case. In other instances the 
 knee-joint has been directly or indirectly opened at the time of the 
 accident. 
 
 DIAGNOSIS. — Dislocation of the knee in childhood is scarcely 
 known ; besides, the free movement of the joint in cases of separa- 
 tion is quite sufficient to distinguish it from this injury, while the 
 
814 
 
 EPIPHYSES OF LOAVEE EXTEEMITY 
 
 mobilitj^ below the articular interline at tlie epiphysial level is 
 conclusive. 
 
 AVlien little swelling is present and displacement marked, but 
 little difficult}^ will be experienced in the diagnosis. 
 
 Fig. 253. — pattern of lateral splints foe knee (croft's), foe a box of 
 
 fifteen tears 
 
 Eeduced to one-quarter size on scale of inches 
 
 'r*i*S?3SSJde^iSS^^fi^ 
 
 Fig. 254. — croft's lateral splints applied to knee 
 
 Fig. 255. — the sajie t^-ith outer piece laid aside after cutting 
 through gap in front 
 
 When, however, there is little or no displacement or mobiHt}^ 
 the injury may be mistaken for a sprain of the knee-joint. 
 
 TREATMENT.— Separation without displacement should be treated 
 according to general rules with a simple retentive apparatus. 
 
SEPAEATIOX OF UPPEE EPIPHYSIS OF TIBIA 815 
 
 In simple separation with displacement reduction can be easily 
 effected with the use of anaesthetics, the limb afterwards being 
 placed in a trough splint composed of posterior and lateral pieces, 
 or by ' Croft's ' lateral plaster-of-Paris splints. 
 
 In severe displacements of the diaphysis backwards or laterally 
 the leg should be flexed upon the thigh, and gentle pressure made 
 upon the diaphysial end in the opposite direction to which it has 
 been displaced. After the diaphysis has been restored to its normal 
 position, the limb should be placed in the flexed position in a trough 
 splint, or one composed of foot, thigh, and leg pieces with lateral 
 pieces and hinge at knee. 
 
 Section 
 
 Fig. 256. — posteeioe splixt foe thigh axd leg with foot-piece and hixge 
 at knee. foe separation of eithee of the epiphyses foeiiing the 
 knee-jorxt. veetical exteenal ok internal lateeal pieces abe ell- 
 ploted according to displacement of the epiphysis inwards oe out- 
 WARDS 
 
 Mr. Bryant and Mr. Birkett had each a case of this separation, 
 at Guy's Hospital, in 1872 (H. L.) and 1868 (T. M.) respectively, 
 and both were treated successfully by posterior and lateral splints. 
 In both the child was four years of age and did well. 
 
 Primary amputation is necessary only in exceptional examples 
 of compound separations, owing to the severity of the laceration to 
 the neighbouring parts. 
 
 If there be but little destruction, more especially if it is caused 
 by indirect violence, an attempt should always be made to preserve 
 the limb, and there is little doubt that this may be usually done. 
 
 Secondary amputation. — Amputation was resorted to in Fischer's 
 case in consequence of necrosis and suppuration in the knee- and 
 ankle-joints. In the St. Bartholomew's Hospital specimen ampu- 
 tation was performed on the thirty-sixth day, and in Fischer and 
 Hirschfeld's in the eleventh week, in both cases for gangrene of the 
 leg. 
 
816 
 
 EPIPHYSES OE LOWEP EXTEEMITY 
 
 CHAPTEE VI 
 
 SEPAEATION OF THE EPIPHYSIS OF THE TUBERCLE 
 
 OF THE TIBIA 
 
 ANATOMY. — x4.1thougii the cartilaginous tongue-like prolongation 
 of the upper ej)iphysis in front usually ossifies by a downward 
 extension of ossification of the upper epiphysis, yet the tubercle of 
 the tibia has sometimes an entirely separate centre of ossification, 
 and forms a distinct epiphysis,, which may be detached by direct 
 
 violence, or by the violent action 
 of the quadriceps extensor. 
 
 This centre appears, accord- 
 ing to Beclard, about the eighth 
 or tenth year, but is no doubt 
 often of later date — about the 
 twelfth or fourteenth j^ear 
 (thirteenth year, Sappey) . This 
 osseous nucleus rapidly invades 
 the whole of the cartilaginous 
 tubercle, spreading upwards to- 
 wards the thick epiphysial plate 
 above, and finall}^ joins with 
 it (six to eight months later, 
 Sappey) and shortly afterwards 
 with the diaphysis. The tu- 
 bercle serves for the insertion of 
 the powerful quadriceps tendon 
 at the lower part, while at the 
 upper end there is a smooth 
 surface for the bursa — between 
 the tendon and the bone. 
 
 Mr. Quain saw one instance 
 
 only of a separate epiphysis for 
 
 the tubercle. 
 
 It is quite possible, therefore, for the epiphysis when formed by a 
 
 separate centre to be torn off without any fracture — a true separation 
 
 of the epiphysis — but more commonly it is detached at its upper 
 
 end or neck, where it joins the front portion of the upper epiphysis 
 
 Fig. 257. — veeticu. section of the upper 
 end of the tibia between the foreteenth 
 and fifteenth tears 
 
 The upper epiphysis is completely ossified, 
 and there is a separate epiphysis for the 
 tubercle. The latter still presents some 
 cartilage at the lower part. Both epi- 
 physes are separated from the tibia and 
 from one another by a thin layer of carti- 
 lage (After Eambaud and Eenault) 
 
EPIPHYSIS OF TUBEKCLE OF TIBIA 817 
 
 of the tibia, and therefore the epiphysial separation is accompanied 
 by a fracture. 
 
 The relation of the synovial membrane of the knee-joint to the 
 upper end of the tubercle of the tibia is a very close one. Its 
 anterior aspect, as just stated, is covered by the bursa beneath the 
 ligamentum patellae. This bursa is separated from the cavity of 
 the knee-joint by a pad of fat. Professor Macalister states that 
 the bursa and knee-joint communicate in eight per cent, of limbs. 
 
 ETIOLOGY. — Of the ten cases recorded, we find that nine occurred 
 by violent muscular action of the quadriceps, powerfully contracting 
 and detaching the tubercle, and in male subjects. Three of these 
 patients were gymnasts, and the injury took place when they were 
 vaulting the horse or jumping from the spring-board. In five out of 
 the ten cases the injuries were caused by jumping and in one by an 
 attempt to save the body from falling, and in one the injury was 
 simply stated as due to a fall. With the exception of De Morgan's 
 patient, who was said to have been very scrofulous, all were powerful 
 and muscular young men. 
 
 All the three instances in which the injured side is stated were 
 on the right. 
 
 De Morgan notes that this injury is allied to fracture of the 
 patella, being, in fact, a tearing away of the attachment of the 
 rectus, taldng with it a portion of the bone into which it is inserted. 
 
 Although in Lauenstein's case the knee was directly struck 
 against the vaulting horse, it does not appear that this could have 
 been the sole cause of the detachment, and, as Mtiller states, 
 Lauenstein did not consider it as caused by direct violence. 
 
 In Weinlechner's case the detachment does not appear to have 
 been due to the action of the quadriceps, but to an overstretching 
 of this muscle during excessive flexion of the knee. The patient in 
 this case fell with his buttock resting on the calf of the leg. 
 
 The first recorded instance of detachment of the tubercle of the 
 tibia is De Morgan's {Medical Times and Gazette, N.s. vol. vi. 1853, 
 p. 208). It was produced by the muscular action of the rectus 
 femoris. The patient (J. C), aged seventeen years, was a very scro- 
 fulous lad, w^ith scars on his head and extremities, evidently con- 
 nected with diseased bones. Whilst walking in the street he slipped, 
 and saved himself from falling by catching hold of the railings. He 
 felt something give way in the knee, and immediately found he was 
 unable to walk. On admission into the Middlesex Hospital, April 7, 
 1852, the left knee was much swollen, the swelling taking the shape 
 of the joint, but extending downwards some inches over the inner 
 surface of the tibia. The patella on the injured side was drawn up 
 a quarter of an inch higher than on the other side. The tubercle of 
 the tibia, with a piece of bone about an inch long, could be felt as 
 if chipped off from the head of the tibia, the fragment remaining 
 attached to the ligamentum patella*, and being drawn up with it. 
 
 3 G 
 
818 EPIPHYSES OF LOWEE EXTEEMITY 
 
 On holding the fragment l)etween the fingers and moving it upon 
 the bone beneath, distinct crepitus could be felt. The limb was 
 placed in the extended position and raised, the thigh being flexed 
 on the body. After several attacks of inflammation of the knee- 
 joint, the effusion had quite disappeared at the end of three weeks. 
 After seven weeks the patient was able to get about with a posterior 
 splint, and a week or two after this he could walk and bend his 
 knee. Two months later he was discharged from the hospital ; 
 some necrosis of the fourth metatarsal bone followed, and was 
 removed. In December he had completely recovered the use of his 
 leg. The fragment was perfectly firm; the union being osseous, 
 with some thickening of the bone around it. 
 
 Dr. E. Mliller relates (Beitrdge zur Min. Chirur. zu Tilhingen, 
 1888, S. 257) a case from Bruns's clinic. 
 
 A. H., a gymnast, sixteen years of age, fell down whilst exercising, 
 as he was about to jump from the spring-board. He immediately 
 experienced acute pain in the right knee, and was unable to move. 
 On admission to the hospital, the right leg remained powerless in 
 the extended position, the knee-joint was swollen all round, and the 
 patella floated slightl}^ Over the upper end of the tibia in front of 
 the knee the skin was rendered prominent by a triangular fragment 
 of bone, with the base upwards measuring five centimetres, parallel 
 with the articular interline. Its apex was downwards, the inner side 
 measuring three centimetres, the outer side five centimetres. The 
 fragment moved freely both laterally and from above downwards, but 
 with pain to the patient ; and the motion was accompanied by crepitus. 
 The patella was about two centimetres higher than on the left side. 
 The fragment, which was clearly the detached tubercle of the tibia, 
 was drawn slightly downwards, and fixed in this position by means of 
 a bandage and plaster of Paris reaching from the toes to the upper 
 third of the thigh. On removing the plaster bandage eight days 
 later, the tubercle was still movable, but fourteen days afterwards it 
 had firmly united and the effusion into the joint had disappeared. 
 The plaster-of-Paris bandage was finally removed six weeks after the 
 injury ; the tubercle of the tibia and the patella were one centimetre 
 higher than the left. Three weeks later the functions of the limb 
 were perfectly normal, and no difference whatever could be observed 
 between the two knees. 
 
 Miiller records a second case observed by Lauenstein, of 
 Hamburg. 
 
 A gymnast, eighteen years of age, during his exercises, whilst 
 springing upon the vaulting horse, knocked his right knee against 
 it, and was unable to use his leg from that time. 
 
 Fracture of the patella was at first diagnosed, but on the second 
 day Lauenstein found the knee swollen, though without effusion into 
 the joint ; and three fingers' breadth below the apex of the patella he 
 found a fragment of bone over the head of the tibia, which could be 
 
EPIPHYSIS OF TUBEKCLE OF TIBIA 819 
 
 moved laterally with crepitus. The patella was drawn downwards by 
 strapping, and the tubercle pressed towards the tibia by the same 
 means. A plaster-of-Paris bandage was also applied, and allowed 
 to remain on five weeks. Perfect restoration of the functions of the 
 leg resulted. 
 
 AGE. — In eight of the ten recorded instances of detachment of 
 the tubercle the age is clearly stated. Two were verified by operation, 
 and all were between sixteen and eighteen years of age — ^viz., one 
 at 18 years, four at 17 years, and three at 16 years of age. Of the 
 two remaining cases, in one the injury occurred to a young man, and 
 in the other the age is not stated. 
 
 The whole ten were in male subjects. 
 
 PATHOLOGICAL ANATOMY.— A few examples have been verified 
 by operative measures. J. Landsberg reports {Medicinsk Bevue, 1889, 
 Juli (Norwegian) ; Centrcdhlatt fur Ghirurgie, September 28, 1889, 
 S. 704) a case of avulsion of the tuberosity of the tibia in a lad, 
 sixteen years old, by muscular effort in jumping. 
 
 The patella was displaced upwards for ten centimetres, and at 
 about the same distance below there could be felt a small movable 
 piece of bone ; an erroneous diagnosis of fracture of the patella was 
 made, and, because of the supposed wide separation of the fragments, 
 it was determined to wire them. A transverse incision was made, 
 and then the actual condition was recognised. A longitudinal 
 incision was carried downwards from the transverse one, and the 
 tuberosity was fastened in place by a nail ; this w^as removed at the 
 end of a fortnight. Complete recovery followed. 
 
 A case of fracture of the tubercle of the tibia is recorded by 
 J. C. Ogilvie Will (British Medical Journal, January 22, 1887, 
 p. 152), in which the signs of fracture of the patella were so exactly 
 simulated that it was mistaken for this before the operation, which 
 consisted in fastening the detached tubercle to its shaft by means of 
 a steel pin. The result proved eminently satisfactory, so that the 
 patient could at the end of three months execute all the ordinary 
 movements of the joint as readily as on the uninjured leg. The 
 functions of the limb were completely restored. 
 
 G. W., aged seventeen, a fairly muscular lad, a stonecutter, was 
 admitted to the Aberdeen Eoyal Infirmary on August 28, 1885. He 
 stated that a short time previously, when jumping with a pole, he 
 felt something give way in the region of the knee-joint when he had 
 risen about two feet from the ground. A diagnosis of fracture of 
 the patella was made, for the joint was largely distended with blood 
 and painful. There were two bony tumours with a considerable 
 interval between them, one at the upper, and the other, the smaller, 
 at the lower aspect of the joint, whose outlines could only be indis- 
 tinctly made out on account of the swelling. The power of extension 
 was entirely lost. The slightest movement caused the greatest pain. 
 On exposing the patella by a vertical incision, this was ascertained 
 
 3 u 2 
 
820 EPIPHYSES OF LOWEE EXTREMITY 
 
 to be intact, whilst the hgamentnm patellse was found to have torn 
 away the bony prominence into which it was inserted. The portion 
 of bone was about the size and shape of a small oyster shell, and its 
 fractmred surface was turned upwards from muscular contraction. 
 It was readily replaced and fixed in position with the steel pin of 
 an Ai-chimedean drill. The joint was then thoroughly cleared of 
 clots, and a stiff bandage applied with antiseptic dressings. On 
 September 17 the pin was loose, and therefore taken away. On 
 Xovember 2 the union was quite finn, and the splint was removed. 
 The patient completely regained the use of his knee, and could walk 
 without any limping. 
 
 From the rough diagram and the description given by ^Yill, it 
 would appear that some of the surrounding diaphysis was torn away 
 with the epiphysis, especially from the upper part of the tibia inter- 
 vening between the tubercle and the articular surfaces of the tibia. 
 
 Pitha says that it is exceptional for the ligamentum patellae to 
 rupture; that it usually does so at, or even in, its insertion, and 
 that a portion of the spine of the tibia remains hanging to the 
 ligament itself. 
 
 Injury to knee-joint. — The bui'sa lying between the u^^per part of 
 the tubercle, the front of the tibia and the lower portion of the 
 ligamentum patellse must always be lacerated in detachment of 
 tubercle. From the proximity of the tubercle to the front of the 
 synovial membrane of the knee-joint a laceration of the latter is 
 verj' likely to occur. In Y'ill's case the joint was full of blood clots. 
 
 Although in less severe lesions the knee-joint may escape direct 
 injary, vet it must always be remembered that only a small amount 
 of tissue intervenes between the articular cavity and the injured 
 bursa, and that inflammation of the knee-joint is likely to follow ; 
 while the possibility of a communication existing between the bursa 
 and knee-joint, though rare, deserves consideration as well. 
 
 SYMPTOMS. — The symptoms very closely resemble those of 
 fracture of the patella, more especially those transverse or oblique 
 fractures which so commonly occur in the lower third of the bone. 
 
 At the time of the injury the patient experiences a tearing 
 sensation or crackhng at the knee-joint. 
 
 Inability of tlie patient to extend the leg at the knee-joint from the 
 time of the accident is a prominent sign. 
 
 The patella is drawn upwards to a greater or less extent. In 
 Vogt's case this occurred to the extent of between two and two and 
 a half centimetres. 
 
 If the swelling be not too gi'eat, the natural outline of the patella 
 may be made out above the fragment, indicating that this bone is 
 not fractured. 
 
 The detached epiphysis or fragment of bone can be felt beneath 
 the skin, movable more or less freely in all directions. The size of 
 this frafoncnt varies vcrv jnuch in the recorded clinical cases. 
 
EPIPHYSIS OF TUBEECLE OF TIBIA 821 
 
 In Vogt's case a piece of a triangular shape with a base measur- 
 ing two centimetres, and a piece in one of Miiller's five centimetres, 
 was detected. The height of the fragment in Miiller's was three 
 centimetres. 
 
 A fragment or flake of the outer layer of the shaft below, or of 
 the front of the upper epiphysis of the tibia above, may remain 
 attached to this process. The outline of the detachment will there- 
 fore not exactly resemble the shape of the epiphysis. 
 
 Just below (quarter to half an inch) the apex of the patella the 
 fragment may be felt still attached to the ligamentum patella3, and 
 movable both laterally and vertically. In Vogt's instance the 
 mobility in the vertical direction was slight or entirely absent. 
 
 Crepitus has been present in the majority of the published cases, 
 due probably to the small amount of displacement of the epiphysial 
 fragment. 
 
 Effusion into the joint almost always takes place. 
 
 In Vogt's case there was thought to be considerable effusion of 
 blood into the joint, and in Will's case at the time of operation the 
 joint was full of blood-clots. 
 
 Possibly in more than one instance the tubercle was not a 
 distinct epiphysis, but the upper end of this process was con- 
 nected to the upper epiphysis, and its separation was therefore only 
 effected by fracture caused by more severe violence. 
 
 It cannot be supposed, however, that the articular cavity must 
 necessarily be involved in all instances, notwithstanding the close 
 proximity just mentioned of the upper end of the tubercle to the 
 knee-joint. 
 
 DIAGNOSIS. Transverse or oblique fracture of the lower part of 
 the patella. — This accident closely resembles separation of the tubercle 
 of the tibia. Fracture of the patella never occurs in childhood, and 
 is as rare as separation of the tubercle during adolescence. There 
 are, however, some distinguishing features at the latter period of 
 life which should render the diagnosis an accurate one. In separa- 
 tion the patella above may be felt to be intact. Below the apex of 
 the patella and over the upper end of the tibia a fragment of bone can 
 be detected. Crepitus is detected in separated tubercle by drawing 
 this fragment downwards, in fractured patella by drawing it upwards. 
 
 In both of the cases operated upon by Landsberg and Will the 
 lesion was mistaken for fracture of the patella, and suturing of 
 the fragments was undertaken. This in each case led to the recogni- 
 tion of the actual lesion. 
 
 TREATMENT. — In exceptional simple instances of little or no 
 displacement the treatment is similar to that for fractured patella : 
 the leg should be extended on the thigh and elevated, the body at 
 the same time being supported. The fragment should be held 
 firmly in position by strapping or by a bandage of plaster of Paris 
 carefully applied. 
 
822 EPIPHYSES OF LOWEK EXTREMITY 
 
 The retentive apparatus must be kept on for four weeks, on 
 account of the action of the quadriceps extensor attached to the 
 epiphysis. Passive motion may then be commenced. 
 
 In the majority of instances, however, the treatment wih differ 
 very considerably from that of fracture of the patella in its common 
 form at about the age of seventeen ; for in the former operative 
 measures are imperative, otherwise the utility of the limb will be 
 greatly impaired. 
 
 Under careful aseptic and antiseptic methods the upper end of 
 the tibia should be exposed by means of a flap incision, and all 
 blood-clot and shreddy tissue removed from the osseous surfaces. 
 The tubercle should be firmly attached to the tibia by means of 
 needles or pins, as in Landsberg's and Will's cases. In Will's 
 case the result was most satisfactory, and it was thought that in no 
 other way, apart from operation, could it have been obtained. 
 
 PROGNOSIS.— The result differs from that of fractured patella 
 inasmuch as osseous union may always be expected if the fragments 
 are brought well into apposition. 
 
 Mr. A. Shaw has recorded {Path. Soc. Trans, vol. v. 1853, p. 253) 
 the case of a boy, aged seventeen, who fell and tore the tubercle, 
 along with the ligamentum patellae, from the tibia ; the tubercle, 
 being an epiphysis, had not been firmly united to the shaft. He 
 thought it w^as owing to this and the immobility of the patella 
 from spurious ankylosis that the violence directed on the front of 
 the joint produced diastasis of this tubercle. Union occurred as in 
 ordinary fracture. 
 
 In P. Vogt's case (' Ein Fall von Abreissung der Tuberositas 
 tibiae durch willkurliche Muskelcontraction,' Berl. Min. Wochenschr. 
 1869, vi. 225 ; (abstr.) Deutsche Klinik, Berl. 1869, xxi. 217) the 
 patient was a gymnast sixteen years old. When about to jump 
 over the vaulting horse he slipped, with his right foot on the 
 spring-board, and endeavoured with a violent effort to save himself 
 from falling backwards. This he succeeded in doing, but felt at the 
 same time a sudden intense strain at the knee, and then observed 
 that he was not able to put his foot forwards or to move from the 
 place. Half an hour after the accident, there was found con- 
 siderable effusion of blood into the right knee-joint, and there 
 could be felt, six centimetres below the lower end of the patella, 
 the apex of a triangular osseous fragment, the bone of which was 
 two centimetres in extent, its inner margin perpendicular, and with 
 an oblique edge ; the apex was nearly two centimetres distant from 
 the tibial crest. The fj-agment was movable laterally with crepitus. 
 The patella was displaced upwards a distance of 2-5 centimetres. The 
 limb was placed on an inclined plane, and a plaster-of-Paris bandage 
 applied for five weeks. This was replaced during the next three weeks 
 by a simple posterior splint. Towards the end of this time the tubercle 
 of the tibia was still somewhat movable. A year afterwards there 
 
EPIPHYSIS OF TUBEKCLE OF TIBIA 823 
 
 was firm osseous union of the tubercle and complete return of 
 function in the limb, the only trace of injury being a small osseous 
 projection one centimetre in height from the tibial crest. 
 
 Miiller quotes a case (Bruns, Beitrdge, iii. 1888, S. 261 ; Wiener 
 medicin. Blatter, 1881, Nr. 51), observed by Weinlechner, of a student, 
 aged seventeen years, who in jumping" over a vaulting horse fell in 
 such a manner as to rest upon the calf of his left leg. There was 
 swelling of the knee-joint, and below the patella a movable piece of 
 bone as large as a walnut. The treatment consisted in drawung 
 the patella towards the tibia by means of a bandage and in the applica- 
 tion of extension. Four weeks after the accident a silicate bandage 
 was applied, which was removed after six weeks. Good use of the 
 limb was re-established in this case. 
 
 Pitha saw a case (' Verletzungen und Ivrankheiten der Ex- 
 tremitaten,' Handhuch der allg. u. speziell. Chirurgie, von Pitha- 
 Billroth, 1868, iv. Bd. 2 Abthlg. S. 268) many months after the 
 accident ; the use of the leg was greatly impaired, a loose band 
 only connecting the displaced tubercle with the tibia. He gives the 
 following account. A guide (age not stated), while jumping a puddle, 
 tried to save himself from falling backwards on the other side. The 
 ligamentum patellae was completely detached, and the tubercle of the 
 tibia and the patella drawn upwards four fingers' breadth. A loose 
 connection only united the quadriceps muscle with the tibia, and 
 the whole extremity, particularly the quadriceps, was wasted. 
 Walking was possible only with the aid of a stick and a strong 
 knee-cap to the joint. An osteophytic outgrowth on the tibia 
 indicated the locality of the detached bone. 
 
 F. Stabell (' Fractura Tuberositatis (spinas) Tibise,' TidsJcr. f. 
 prakt. Med., Kristiania, 1887, vii. 111-115, and La Semaine 
 Medicate, 1887, No. 18) mentions the case of a ' young man ' who, 
 in making a ' dangerous leap,' suddenly felt a rupture at the level of 
 the knee, and then found himself unable to hold himself upright. 
 Beneath the skin below the knee a hard rounded body could be 
 seen projecting. The patella was drawn upwards, and a detach- 
 ment of the tibial tuberosity diagnosed. The fragment of bone was 
 drawn downwards and held firmly in position by means of a silicate 
 bandage. The ultimate result was that consolidation took place, 
 and the patient obtained the perfect use of the limb. 
 
 In five examples out of nine which were treated in the recent 
 condition, a perfect restoration of the use of the limb with firm 
 union resulted in a longer or shorter period. In Miiller's case the 
 period was two months ; in Will's three months ; in Vogt's a year. 
 In three cases the mode of union was said to have been an osseous 
 one. In Pitha's case, seen for the first time several months after 
 the accident, the tubercle was drawn up for four fingers' breadth 
 and ununited. 
 
82 i 
 
 EriPHYSES OF LOWEK EXTEEMITY 
 
 CHAPTEE VII 
 SEPARATION OF THE LOWER EPIPHYSIS OP THE TIBIA 
 
 ANATOMY. — The lower epiphysis of the tibia is developed from 
 a single osseous nucleus, which appears in the centre of the horizontal 
 portion of the cartilaginous extremity about the eighteenth month. 
 
 Fig. 258. — frontal section tiekough 
 the lower end of tibia and fibula 
 before birth 
 
 I After Kiistner) 
 
 During the second year 
 nearly the whole of this 
 portion of the epiphysis is 
 ossified, and osseous granules 
 appear in the malleolar por- 
 tion and rapidly coalesce with 
 the main nucleus. 
 
 By the fourteenth or fif- 
 teenth year the whole lower 
 end of the tibia, comprising 
 the internal malleolus and 
 articular surfaces, is com- 
 pletely osseous. Its upper surface is more or less fiat, and presents 
 elevations and depressions of a somewhat peculiar arrangement, 
 corresponding to similar irregularities on the lower end of the 
 diaphysis. There are four prominent ridges, with depressions be- 
 tween, radiating in a stellate manner from a central point to each 
 angle of this quadrilateral-shaped epiphysis. They are well marked 
 
 Fig. 259. — lower epiphysis of the tibia 
 at the sixteenth year 
 
 Epiphysis removed to show the stellate 
 appearance of its diaphysial surface 
 (i-size) 
 
SEPAEATION OF LOWER EPIPHYSIS OF TIBIA 825 
 
 at the sixteenth year. At this age the plate of bone is about three- 
 eighths of an inch thick in the centre. 
 
 This epiphysis unites with the diaphysis in the eighteenth or 
 nineteenth year. (Sixteenth to eighteentli year according to Sappey.). 
 
 Beclard has once seen and described a special centre for the 
 internal malleolus immediately joining the principal portion, but the 
 author has never seen a distinct epiphysis, and its occurrence must 
 be extremely rare. 
 
 Fig. 2G0. — rKONTAL section tiihougii 
 
 THE rONES OF THE ANKLE-JOINT AT 
 SEVENTEEN AND A HALF YEARS. POS- 
 TERIOR HALF OF SECTION. RELATION 
 OF EPIPHYSIAL LINES TO THE SYNO- 
 VIAL MEMBRANES (|-Size) 
 
 Fig. 261. — sagittal section through 
 
 BONES of the ankle-joint AT SIX- 
 TEEN YEARS 
 
 On the outer side the epiphysial cartilage passes immediately 
 above the inferior tibio-fibular joint, eight millimetres above the 
 articulation of the ankle-joint, and comes in relation with the pouch- 
 like extension upwards of the synovial membrane between the tibia 
 and fibula, but is separated from it by the periosteum, continuous 
 here with the epiphysis. In infants this synovial pouch of the 
 inferior tibio-fibular joint is often but little marked. 
 
 Neither in front nor behind does the synovial membrane of the 
 ankle-joint come in contact with the epiphysial line, although it 
 overlaps the lower edge of the epiphysis a little in front. This 
 holds good for children of younger or older age. 
 
 In front the epiphysial line is half an inch above the level of the 
 ankle-joint, and posteriorly {' inch. In the centre of the epiphysis 
 
826 
 
 EPIPHYSES OF LOWEE EXTEEMITY 
 
 it is only f inch above the articular surface. On the outer side it is 
 from ^ to y\ inch above this level from the fifteenth to eighteenth 
 year. 
 
 On the inner side, from the apex of the internal malleolus, it is 
 distant at the twelfth year about f inch, at the fifteenth year 
 about 1 inch, at the eighteenth year about 1|- inch ; while on the 
 outer side it is above the apex of the external malleolus rather 
 more than |- inch at the eighth year, 1^ inch at the twelfth year, 
 and at the eighteenth year If inch. 
 
 De Paoli gives the following table of measurements of the lower 
 epiphysis of the tibia and the fibula in a frontal section (i.e. dividiii"' 
 them in halves, anterior and posterior). 
 
 Age 
 
 Tibia 
 
 FiBur.A 
 
 Height 
 
 Marimum 
 breadth 
 
 Height 
 
 Breadth 
 
 9 mm. 
 
 10 
 
 10 
 
 10 
 
 13 
 
 13 
 
 13 
 
 15 ! 
 
 12 
 
 16 
 
 11 
 
 16 
 
 17 
 
 16 
 
 15 
 
 15 
 
 At the 
 internal 
 malleolus 
 
 At the 
 outer edge 
 
 At the 
 middle 
 
 At the 
 external 
 malleolus 
 
 At the 
 
 internal 
 
 edge 
 
 Before birth 
 
 / Appearance \ 
 
 1 vpar J °^ "^'^ °^' I 
 ■^ J^'^^ 1 seous points [ 
 
 ( in both bones; 
 
 2 
 
 4 
 
 5 
 
 5h 
 
 6" 
 
 7 
 
 1 TJie ossifif ation \ 
 n 1 penetrates the 1 
 " ] base of the in- f 
 
 [ ternal malleolus j 
 9 
 
 13 
 
 14 
 
 / The ossification \ 
 
 1 /> J reaches the lateral [ 
 
 -■■" 1 aspect of the tibia [" 
 
 \ and the fibula ) 
 
 17 
 
 20 
 
 11 mm. 
 
 13 
 
 14 
 
 14 
 
 18 
 
 16 
 
 18 
 
 18 
 
 20 
 
 20 
 
 20 
 
 22 
 
 24 
 
 2-5 mm. 
 3 
 
 3-5 
 
 5 
 
 6 
 
 5 
 
 5 
 
 8 
 
 6 
 
 8 
 
 6 
 
 8 
 
 8 
 
 3 mm. 
 
 5 
 
 6 
 
 7 
 
 8 
 
 7 
 
 9 
 
 8 
 
 8 
 
 9 
 
 7 
 
 9 
 
 11 
 
 16 mm. 
 
 21 
 
 23 
 
 25 
 
 27 
 
 27 
 
 29 
 
 33 
 
 34 
 
 32 
 
 31 
 
 38 
 
 38 
 
 13 mm. 
 
 12 
 
 15 
 
 13 
 
 18 
 
 16 
 
 15 
 
 20 
 
 16 
 
 21 
 
 16 
 
 21 
 
 19 
 
 20 
 
 20 
 
 25 
 
 3 mm. 
 7 
 
 7 
 
 6 
 
 7 
 
 11 
 
 12 
 
 11 
 
 11 
 
 11 
 
 11 
 
 9 
 
 16 
 
 15 
 
 12 
 
 13 
 
 1 
 
 21 16 
 
 22 9 
 
 8 
 
 9 
 
 38 
 
 40 
 
 AGE. — The period between eleven and eighteen years appears to 
 be the time in which this separation is most likely to occur. 
 
 Of twenty-two cases in which the separation was compound, or 
 in which the limb had been amputated for extensive lesions of the 
 soft parts, and thus the separation verified by direct examination, the 
 age is known in eighteen and ranged from the ninth to the nine- 
 teenth year ; sixteen were between the tenth and nineteenth years. 
 
 Of eleven specimens and cases verified by direct examination, the 
 age is given in seven — viz. one at 19, one at 18, one at 17, one at 
 15, one at 13, one at 9, and one at 5 years of age. 
 
 The eleven compound separations were as follows : one case at 
 15, two at 14, four at 13, one at 11, and three at 10 years of age. 
 
 Of sixteen simple separations, ranging from three to seventeen 
 
SEPAEATION OF LOWEK EPIPHYSIS OF TIBIA 827 
 
 years of age, we find that eleven were between the ages of eleven 
 and seventeen years ; one was at 17, two at 16, one at 14 and 9 
 months, two at 14, one at 13, one at 12, three at 11, one at 10, one 
 at 6^, one at 6, and two at 5 years of age. 
 
 In eight cases of arrest of growth, the date of the injury producing 
 it is stated in four — two at 10, and one each at 9 and 8 years of age. 
 
 Of the total forty-six cases the age is given in thirty-eight ; of 
 these, thirty took place between the ages of 9 and 17 years. 
 
 Fracture of the lower end of the fibula or separation of the 
 epiphysis of the fibula is noted in twenty-three of the total (forty- 
 six) recorded examples. In two of these combined lesions the age 
 is not recorded, but of the remaining twenty-one the greatest number, 
 fifteen, occurred between 10 and 15 years of age : viz. one at 19, one 
 at 18, one at 17, two at 15, three at 14, four at 13, three at 11, three 
 at 10 (two in females), one each at 9, 6, and 5 years. Distinguishing 
 now between fracture of the fibula and separation of its epiphysis, 
 we find twelve of the former and nine of the latter lesion ; out of the 
 former, eleven were between 9 and 17 years of age ; while six of the 
 latter were between 10 and 15 years of age. 
 
 The author has rejected the oftsn-quoted cases described by 
 Champion (Journal complement, du Diet, des Sc. Med., 1818, p. 325) 
 and Carus (Gem. Deutsche Zeitschr. f. Gehurtskunde, 1828, Bd. ii. 
 31), the former being one of separation of this epiphysis of the 
 tibia in an infant, due to violent traction on the foot during 
 parturition. In the other the injury was caused in a foetus of four 
 months by a fall of the mother upon the abdomen from a height. 
 The diaphysis protruded through a wound at the inner ankle. 
 Death took place on the thirteenth day after birth. 
 
 Other cases recorded of separation of this epiphysis by midwives 
 during delivery are best omitted as untrustworthy. 
 
 SEX.— The injury mostly occurs in boys; all the seven patho- 
 logical specimens in which the age is given occurred in males, and 
 the same sex was noted in the whole of the eleven compound separa- 
 tions. The female sex has only been recorded in two instances of 
 simple separation among the total forty-six cases mentioned above ; 
 both occurred at ten years of age, and were associated with solution 
 of continuity of the fibula — one being a fracture, the other a separa- 
 tion of the lower end of this bone. 
 
 ETIOLOGY. — Indirect violence is the most common cause of separa- 
 tion of the lower epiphysis of the tibia. 
 
 It is commonly produced by the foot being fixed and the leg 
 violently flexed or extended. The history often given is that the 
 child, while in the act of jumping or climbing over a fence, has 
 caught his toes and fallen forwards ; or the foot has been fixed 
 between a cart, and the spokes of the wheel, and the leg violently 
 twisted between the spokes. At other times the injury may result 
 from a fall from a height on to the feet, the foot being doubled 
 
828 EPIPHYSES OF LOWEK EXTEEMITY 
 
 beneath ; or the foot has been injured in the same manner by 
 machinery, by being twisted by a ship's cable, or by a simple fall with 
 the foot doubled beneath and forcibly extended or twisted on the leg. 
 Again, a heavy blow on the side of the leg above the ankle may 
 produce the same effect if the foot be firmly placed on the ground. 
 
 In two cases at Guy's Hospital the injury was caused by a fall, 
 in one of them the patient falling down stairs and ' wrenching ' his 
 foot. This case of sex^aration of the lower epiphysis of the tibia 
 was under the care of Mr. Cooper Forster in January 1872, and the 
 boy (W. D.) was aged twelve. The other was under the care of the 
 same surgeon in April 1876, and was aged six years. Both were 
 treated with wooden posterior splints, and left the hospital in between 
 two and three weeks' time ; there was good union, and the patients 
 were able to walk without assistance. 
 
 The author cannot agree with the opinion that separation of the 
 lower epiphysis of the tibia combined with fracture of the fibula, 
 or with separation of the lower epiphysis of the fibula, may prac- 
 tically be said to take the place of Pott's fracture in young subjects, 
 and may occur either from extreme inversion or eversion. The 
 mechanism is not entirely of the same description, for in separation 
 of the lower epiphysis of the tibia the foot and epiphysis are fixed, 
 whilst the body is violently thrown to one side. Moreover, the 
 amount of violence requisite to separate the lower epiphysis of the 
 tibia is considerably greater than that causing Pott's fracture. 
 
 Severe twisting of the foot, however, may cause fracture of the 
 fibula or separation of its lower epiphysis, combined with separation 
 of a part of the tibial epiphysis ; but in these instances the violence 
 is never so great as that which produces separation of the whole of 
 the tibial epiphysis with displacement. 
 
 Experimentally this epiphysis has been separated by forcible 
 flexion. 
 
 M. Curtillet produced separation by letting a weight of fifty- 
 seven kilogrammes fall on the sole of the foot of an amputated 
 limb which rested by the tuberosities of the tibia firmly on the 
 ground, thereby combining powerful flexion with vertical shock, 
 analogous to that which is met with in a fall from a height on to 
 the heels. 
 
 In Gueretin's experiments upon the ankle in infants and children, 
 the fibular epiphysis was separated as well as that of the tibia. 
 
 The lower epiphyses of the tibia and fibula have a few times 
 been separated during forcible straightening of very severe club foot 
 (Helf erich) . 
 
 In his article, ' L'Entorse juxta-epiphysaire,' in the Bevue de 
 Cliirurgie, t. i. 1881, pp. 795 and 797, Ohier gives two figures to 
 represent the lesions of juxta-epiphysial sprain he has produced on 
 the lower end of the tibia in infancy by forcible adduction and 
 abduction of the foot. (See figs. 262 and 263.) 
 
SEPAEATION OF LOWER EPIPHYSIS OF TIBIA 829 
 
 Direct violence has in a few examples separated the lower epi- 
 physis of the tibia alone. Messrs. Durham, Howse, and Cooper 
 Forster at Guy's Plospital had cases of separation of the lower 
 epiphysis of the tibia, caused in the first two cases by the passage of 
 a cart-wheel over the ankle, and in the third by the fall of some 
 blocks of wood on to the leg, the foot being turned outwards. 
 
 Fig. 262. — juxta-epiphysial lesions pro- 
 duced BY FORCIBLE ADDUCTION OF THE 
 FOOT. FROM A SLIGHTLY RACHITIC SUB- 
 JECT EIGHT MONTHS OLD 
 
 A, lower epiphysis of the tibia ; B, astra- 
 gakis ; C, os calcis ; D, lower epiphysis 
 of the fibula; a, deep juxta-epiphysial 
 notch at about one centimetre above the 
 conjugal cartilage, the result of bending 
 inwards of the compact tissue of dia- 
 physis ; the latter is covered in by the 
 periosteum, b, which conceals it from 
 sight, but does not prevent its being 
 felt on pressure ; c, site of trabecular 
 fractures ; d, bending of the fibula in- 
 wards. (After Oilier) 
 
 Fig. 2G.S. — lesions of the tibia produced 
 
 BY forcible abduction OF THE FOOT. 
 oblique section. FBOBI an infant TWO 
 
 years old 
 a, periosteum on the inner aspect of the 
 tibia, not lacerated, but detached from the 
 bone ; b, diaijhysis separated from the 
 epiphysis for one -third of its width; 
 c, crushing and compression of the spongy 
 tissue towards the outer aspect of the 
 bone ; d, periosteum on outer aspect^ of 
 diaphysis ; e, subperiosteal extravasation 
 of blood extending up to e' ; f, continuity 
 of the periosteum with the conjugal carti- 
 lage. (After Oilier) 
 
 Their ages were respectively four (E. T., 1875), seven (C. P., 
 1885), and three years (T. H., 1879). 
 
 In another recorded example separation was the result of a fall 
 of a wall on the ankle. 
 
 Direct violence is always the cause of the more severe forms 
 of separation of the lower cjuphysis of the til)ia accompanied with 
 
830 
 
 EPIPHYSES OF LOWEE EXTEEMITY 
 
 displacement, and fracture of the lower end of the fibula, or separa- 
 tion of the lower fibular epiphysis. 
 
 PATHOLOGICAL ANATOMY.— Separation of the lower epiphysis 
 of the tibia alone is a much more rare form of injury in the living 
 subject than separation of the lower epiphysis of the tibia with 
 separation of the lower end of the fibula or with fracture of the lower 
 part of the shaft. Yet in experiments on the dead subject separation 
 of the lower epiphysis of the tibia is effected with the greatest ease, 
 although the solution of continuity is often transversely through the 
 diaphysis immediately above the conjugal line. 
 
 In the London Hospital Museum {London Hospital Museum 
 Catalogue, 1890, p. 115, No. 506) a preparation has been made 
 showing that in young persons fractures near to the extremities of 
 the bones do not always follow the hne of the epiphysis, being at the 
 same time an instance of intra-periosteal fracture and of fracture with 
 
 Fig. 264. — expeeimental specimen 
 (Royal College of Surgeons Mu- 
 seum, No. 1110b) 
 
 Fig. 2C5. — experimental specimen 
 (Royal College of Surgeons Mu- 
 seum, 1110b) 
 
 impaction. The tibia is fractured transversely half an inch above 
 the junction of the epiphysis. The portion of bone between the 
 epiphysial line and the fracture shows a vertical split about half 
 an inch from the anterior surface, which extends, though less dis- 
 tinctly, through the epiphysis itself to the articular cartilage. The 
 periosteum is everywhere entire, but the fibula is fractured four 
 inches above the outer malleolus. The foot and lower fragment 
 have been displaced forwards to a slight extent. 
 
 An experimental specimen in the Eoyal College of Surgeons 
 Museum (No. 1110b) by Mr. Jonathan Hutchinson junior consists 
 of the lower ends of the femur and of the bones of the leg from the 
 same subject. The diaphysis of the femur has been broken across 
 about three-quarters of an inch above the epiphysial disc. That of 
 the tibia has been partially detached at the inner side from its disc, 
 the fibula being broken within the periosteum somewhat higher up. 
 
 There is no displacement of the tibia, and the lesion is of the severe 
 
SEPAKATION OF LOWER EPIPHYSIS OF TIBIA 881 
 
 type of juxta-epiphysial sprain, while that of the femur is a fracture 
 of the lower end of the diaphysis well above the epiphysial line, 
 both of which forms of injury are commonly met with in experiments 
 on bones of infants. 
 
 The lower epiphysis with the foot is often torn off at the epi- 
 physial line in severe crushing accidents to the foot, &c. 
 
 There are three specimens in the London museums of separation 
 of the lower tibial epiphysis. Two of them are accompanied by 
 fracture of the diaphysis. The specimen in St. George's Hospital 
 Museum, No. 56a, is described by Mr. Holmes {Trans. Path. Soc. 
 p. 187), and has been already quoted (under Lower epiphysis 
 
 Xlll. 
 
 OF THE FEMUR). There was a compound separation of the lower 
 epiphysis of the tibia, with fracture of a small part of the posterior 
 aspect of the lower end of the diaphysis, one inch long and a quarter 
 of an inch broad, and separation of both epiphyses of the fibula ; 
 also detachment of the lower epiphysis of the femur, with laceration 
 of the popliteal artery and fracture of the shaft of the tibia. Death 
 occurred from pyaemia afier amputation in this case of a boy, aged 
 eighteen years. (See also Holmes, Dis. of Children, '2nd edit. 1869, 
 p. 263, fig. 44.) 
 
 The preparation in the Museum of the Eoyal College of Surgeons 
 of England [Catalogue of the Museum of the Royal College of Surgeons 
 of England, vol. li. p. 176, No. 1103) consists of portions of a tibia 
 from a patient of Sir Astley Cooper. The lowest portion, which 
 appears to be the separated lower end 
 of the shaft, protruded and was sawn 
 off. The other portions, i^j is probable, 
 were afterwards exfoliated. 
 
 The London Hospital Museum con- 
 tains a specimen of the lower epiphysis 
 of the tibia and fibula, together with 
 the upper two-thirds of the astragalus, 
 which are said to have exfoliated after 
 what was probably a compound separa- 
 tion of the epiphysis ; but no history 
 was obtainable. Firm ankylosis of both 
 malleoli to the articular surface of the 
 astragalus has taken place. 
 
 Separation with fracture of diaphysis. 
 P. Bruns describes (Langenbeck's Ar- 
 
 chiv fur Jclin. Chirurg. 1882, Bd. xxvii. S. 256) a case of separation 
 of this epiphysis which occurred exactly through the epiphysial 
 line, with the exception of the fracture of a small fragment of 
 the outer edge of the diaphysis. Besides this there was a spiral 
 fracture of the fibula and an oblique fracture of each thigh. Gan- 
 grene of both legs supervened, and death took place on the ninth day 
 from pyaemia. The patient was a boy seventeen years old, whose 
 
 Fig. 266. — After Bruns, Deutsche 
 
 Chirurgie ; Die Lchre von den 
 Knochcnbrilchen, 1886, S. 123 
 
832 
 
 EPIPHYSES OF LOWEE EXTKEMITY 
 
 legs had been caught between the spokes of a wagon-wheel 
 (see fig. 2G6). 
 
 A more extensive fracture of the outer side of the diaphysis was 
 found in a case reported and represented by Benjamin Anger {Traite 
 iconograpliique cles Maladies Chirurg kales, Paris, 1865, p. 18), 
 whereas on the inner side the separation passed precisely through 
 the epiphysial line. The accident occm'red in a boy aged fifteen, 
 whose leg was injured in a machine. The lower epiphysis of the 
 fibula was also detached. The specimen is also figured by Nelaton 
 in his Elements cle PatJio^ogie Cliirinrjicale. 
 
 n 
 
 
 Fro. 267. PARTIAL SEP.VHATION OF THE LOWEE EPIPHYSIS OF THE TIBIA WITH FRAC- 
 TURE OF THE DIAPHfSIS. SEP.ARATION OF THE L0'5\"ER EPIPHYSIS OF THE FIBULA 
 
 {After B, Anger) A, lower epiphysis of the tibia; B, lower epiphysis of the fibula; 
 C, diaphysis of the fibula ; D, portion of shaft of tibia ; E, epiphysial separation 
 at inner part ; F, epiphysial line of tibia ; G, epiphysial surface of the external 
 malleolus ; G', end of the diaphysis of the fibula 
 
 E. E. Klein relates (Inaugural Dissertation, Nonnulla de cjyi- 
 physium dissolutione cum descriptioiie accuratiore casus ejus morhi 
 ill inferiori tibia- epiphysi observati^ Gryphise, 18-54) the case of a 
 youth, aged thirteen years, who was injured by a threshing machine. 
 There was complete separation of the lower epiphysis of the tibia, 
 but this w^as accompanied by splintering and fracture of the lower 
 end of the diaphysis, as w^ell as by a fracture of the lower end of 
 the fibula. Amputation of the thigh was performed on account of 
 'compound fracture of the upper part of the tibia, and was followed 
 by death from collapse three-quarters of an hour afterwards. 
 
 In Dr. AVade's case, reported by R. AY. Smith {Dublin Quarterly 
 Journal, 1852, vol. xiii. p. 202), the fracture of the diaphysis was 
 more complicated and somewhat con^iminuted. A large triangular 
 
SEPAEATION OF LOWEE EPIPHYSIS OF TIBIA 888 
 
 portion of it was detached, and several fractures extended upwards 
 for two or three inches. Into one of these longitudinal fractures 
 some muscular fibres were found to be wedged. The separation of 
 the lower epiphysis of the tibia was complete, and the fibula was frac- 
 tured two inches from its lower extremity, but still retained its con- 
 vexity outwards on account of the dovetailing of the extremities of 
 the fragments. The patient, a boy, aged nine years, was injured by a 
 portion of a wall falling on his left leg, producing a large wound of 
 the front of the leg two inches above the ankle-joint, exposing the 
 extensor tendons and severely injuring the soft parts. There was 
 also free haemorrhage; therefore primary amputation was performed. 
 Shortening of the leg with inversion of the foot was noted at the 
 time. 
 
 Fracture of the end of the shaft is noted in Hutchinson's case 
 quoted below. 
 
 Compound Sepaeations. — In eight out of thirteen cases of com- 
 pound separation, the epiphysis was found on examination of the frag- 
 ments to be completely and cleanly detached ; but five were combined 
 with a fracture of the diaphysis of a greater or less extent, sometimes 
 consisting merely of a thin flake of one or other edge of the diaphysial 
 end. 
 
 Pure separation. — In dther examples of compound separation the 
 detachment has been found to be quite clean at the epiphysial line- 
 
 The protruded diaphysis, stripped of its periosteum for one or 
 more inches, and devoid of cartilage, can in such cases be readily 
 recognised by reason of the peculiar character of its rounded ex- 
 tremity — the stellate or radiating projections which have been already 
 described. 
 
 Dr. Stephen C. Martin mentions (Boston Medical and Surgical 
 Journal, September 27, 1877, p. 364) that he recognised this 
 stellate radiation of the end of the diaphysis, which was perfect, 
 after he had removed the dirt which was packed in between the 
 irregularities of this surface. No portion whatever of the shaft was 
 broken off ; the case was one of separation of tlife epiphysis purely. 
 The case was that of a boy, aged eleven, who fell from the top of a 
 telegraph pole, and produced a compound separation of the lower 
 epiphysis of the tibia, with protrusion of the diaphysis through the 
 wound on the inner side of the leg. It had been thrust into the 
 hard frozen earth, and was much soiled with dirt; The periosteum 
 was stripped from the shaft for a distance of about an liich and three- 
 quarters on the outer side, and the fibula was fractured four inches 
 above its lower end; After some difficulty reduction was efiected 
 by enlarging the wound. The wound healed slowly after -three 
 small pieces of bone had come away, and complete recovery took 
 place in two months; with perfect restoration of the functions of the 
 limb, so that the boy was about as usual. 
 
 Agnew (Surgertj, 1878, vol. i. p. 991 ; vol. ii. p. 30, fig. 909) 
 
 3 II 
 
834 EPIPHYSES OF LOWEE EXTEEMITY 
 
 figures and mentions a case of compound separation of the lower 
 tibial epiphysis with displacement outwards of the foot, the dia- 
 physis protruding some distance through the wound on the inner 
 side of the leg. The patient, a lad ten years of age, was admitted 
 into the Pennsylvania Hospital in 1876. 
 
 Spence figures {Lectures on Surgery, 2nd edit. 1875, vol. i. 
 plate xiv. p. 288) a case sketched from nature of compound diastasis 
 of the bones of the leg which was under his care at the Eoyal 
 Infirmary, Edinburgh. 
 
 The tibia was separated from its lower epiphysis, stripped of its 
 periosteum, and projected for the lower two-thirds of its extent, the 
 soft parts being extensively lacerated. The posterior tibial vessels 
 and nerve are seen torn and twisted. Primary amputation was 
 performed. 
 
 Fracture of the fihulcL, or separation of the lower epiphysis of the 
 same hone.- — A more frequent complication of compound separation 
 is that of fracture of the fibula an inch or more above the epiphysial 
 line ; it has been noted in seven cases ; in three of these combined 
 with displacement outwards of the tibial epiphysis. Outward dis- 
 placement may occur, however, without fracture of the fibula, as in 
 Clark's second case (just mentioned). 
 
 In Fischer and Hirschfeld's case of separation of the upper epi- 
 physis of the tibia, the lower epiphyses of the tibia and fibula were 
 found at the autopsy to be torn away close to the epiphysial line. 
 
 In Wade's and in Klein's cases the fibula was fractured at the 
 lower end. In Bruns's case the fracture of the fibula was a spiral 
 one, and accompanied by fracture of both femora. In Clark's case 
 the patella was fractured two inches above the tip of the external 
 malleolus. In Martin's case the fracture of the fibula was four inches 
 from its lower end. 
 
 AV. A. Albee reports a case in a boy, aged thirteen {Transactions 
 of the Maine Medical Association, Portland, U.S.A. 1886, ix. pt. i. 
 pp. 117-120) of compound separation of this epiphysis with fracture 
 of the fibula. The author has, however, been unable to obtain the 
 account of this case. 
 
 Separation of the lower fibular epiphysis was also found in 
 Annandale's case. The injury in this instance was compound, the 
 end of the diaphysis of the tibia protruding on the inner side. 
 
 Displacement of epiphysis outwards with fracture of the fibula. — 
 Among compound separations displacement most frequently takes 
 place outw^ards off the diaphysis. Its complete displacement in this 
 direction can only be caused by great violence, producing severe injury 
 to the soft parts. 
 
 Where the displacement outwards is not so complete, the dia- 
 physis of the fibula is also fractured tra.nsversely from one to two 
 inches above the tip of its malleolus. The fracture occurred in 
 three out of four cases of this form of displacement. By reason 
 
SEPAKATION OF LOWEE EPIPHYSIS OF TIBIA 885 
 
 of the lower part of the fibula below the fracture retaining its 
 normal relation to the tibial epiphysis, the inferior tibio-fibular and 
 ankle-joints escape injury. The anterior and posterior tibial vessels 
 and nerves usually remain uninjured. 
 
 Fracture of the fibula is mentioned in Wade's and Klein's cases 
 of compound separation quoted above. 
 
 Mr. Bryant {Practice of Surgery, 4th edit. 188i, vol. ii. p. 354) 
 mentions a case of compound separation of the lower epiphysis of 
 the right tibia with outward displacement of the foot. William D., 
 aged fifteen years, while getting into a van in motion, slipped and 
 caught his leg between the spokes of the wheel. The leg was 
 squeezed between these and the under part of the spring. He 
 was able to w^ithdraw the foot wdiile the wheel was revolving, but 
 could not stand. There was a transverse gaping wound five inches 
 long on the inner side of the ankle, laceration of the deeper struc- 
 tures, and exposure of the tendons behind the internal malleolus. 
 Through the wound the diaphysis protruded for over an inch, the 
 epiphysis with the foot being displaced outwards. The fibula was 
 fractured two inches above the malleolus, but the tibial vessels and 
 nerves and ankle-joint were intact. The epiphysis was easily re- 
 placed under chloroform, and the foot and leg put up in splints. 
 At the time of replacement it was thought that some flakes of the 
 epiphysial cartilage were attached to the diaphysial end. 
 
 The author had the opportunity of seeing this case, and of 
 observing the good recovery which followed ; the patient left the 
 hospital at the end of three months with good movement in the 
 ankle-joint. 
 
 Mr. Cooper Forster had under his care at Guy's Hospital in 
 January 1872 a boy (Eobert F.), aged thirteen, who had been run 
 over by a hansom cab, the wheel passing over his right ankle. 
 
 The lower end of the tibial diaphysis, torn from the epiphysis, 
 projected for about one inch through a rent in the skin. The foot 
 was much displaced and the fibula fractured one to two inches 
 above the malleolus. The tibial arteries pulsated below. An inch 
 of the lower end of the tibia had to be sawn off before reduction 
 could be effected. He left the hospital at the end of six months 
 with a perfectly sound limb. 
 
 Mr. H. E. Clark gives a detailed account {Glasgow Medical 
 Journal, vol. xxvi. November 1886, p. 3'29) of a somewhat similar 
 case. John McG., aged thirteen, was admitted into the Eoval 
 Infirmary on August 16, 1884, with what was at first supposed to 
 be a compound dislocation of the left ankle. He stated that a sheet 
 of iron fell forwards and struck him on the inner side of the leaf. 
 On examination there was found to be a wound, about two inches in 
 diameter, and much lacerated, through which protruded the end of 
 the shaft of the tibia. The end of the bone was rounded, and had 
 the character of a diaphysis from which the epiphysis had been 
 
 3 H 2 
 
836 EPIPHYSES OF LOWEE EXTEEMITY 
 
 separated, but showed no appearance of fracture. The periosteum 
 was completely stripped off the bone for about two inches from the 
 end on the inner surface, and somewhat less on the outer. The 
 ankle-joint was uninjured, as also were the tibial arteries and nerves. 
 The fibula was fractured about two inches above the tip of the 
 malleolus. It was found necessary to resect about three-quarters of 
 an inch of the diaphysis before it was possible to reduce the deformit3^ 
 The wound was dressed antiseptically, but suppuration ensued, 
 and healing took place by granulation. The patient was discharged 
 from the hospital on December 28, a sinus still remaining. The 
 cicatrix broke down a little the following September, and again in 
 July 1886. At the latter time the right tibia measured 30-5 centi- 
 metres, and the left 28-5, showing a shortening of two centimetres — 
 about the amount of the resected diaphysis. It would appear, there- 
 fore, that there had been no arrest of growth of the limb during the 
 year and ten months since the accident, and this was the more 
 evident as the lad had himself grown considerably in height in the 
 interval. The movements of the ankle-joint were perfect, and the 
 patient could use the limb with every freedom, and could put all his 
 weight on it. 
 
 In Martin's case the diaphysial end of the tibia protruded on the 
 inner side and the foot was displaced outwards, the separation, 
 which was entirely a pure one, being accompanied by fracture of the 
 fibula about four inches from its lower extremity. 
 
 Displacement of epiphysis outwards with separation of the lower 
 epiphysis of the fibula. — Dr. C. A. Sturrock says {Edinburgh Hospital 
 Beports, vol. ii. 1894, p. 606) that Professor Annandale had had at 
 least four cases under his care, two being simple and 'two compound. 
 The following are the notes of one of these. The displacement of 
 the epiphysis was outwards, and accompanied with separation of 
 the lower fibular epiphysis. 
 
 A boy ten years of age, when climbing a railing, slipped, 
 and was suspended from the railing by his left foot, remaining 
 hanging in this position until removed. He was seen a few hours 
 after the accident, when a lacerated wound, two inches in length, 
 was observed over the internal malleolus, through which protruded 
 (for two inches) the lower end of the shaft of the tibia partially 
 stripped of periosteum ; the epiphysis of the lower end of the fibula 
 was also separated and the ankle-joint opened. A counter-opening 
 was made over the outer ankle after the parts had been replaced in 
 position, and a drainage tube was passed through the wounds. The 
 patient made a good but tedious recovery. Eight years after the 
 accident Dr. Sturrock found the ankle considerably thickened and 
 two inches of shortening in the leg ; but the movements at the ankle- 
 joint were not impaired. The patient could walk eighteen miles, 
 and had cycled fifty miles in a day without fatigue. The injured 
 leo- felt the stronger of the two. 
 
SEPARATION OF LOWEE EPIPHYSIS OF TIBIA 887 
 
 Displacement of epiphysis outwards without fracture of fibula. — In 
 
 other instances in which this form of displacement is not so marked 
 the fibula is not broken. 
 
 Mr. II. E. Clark records a second case {loc. cit. supra, p. 330) of 
 compound separation in vv^hich there was this absence of frac- 
 ture of the fibula. J. W., aged thirteen years, was admitted 
 on December 29, 1885, with what was believed to be a compound 
 dislocation of the ankle. As he w^as standing on a tramway in a 
 mine, with his foot resting on the sleeper and supporting the weight 
 of his body, a truck came up and struck him on the outer side of 
 his left leg about the middle. The diaphysial end was found to be 
 forced through the skin, making a wound (two by one and a half 
 inches) on the inner side of the leg just above the ankle. The 
 periosteum was stripped off the diaphysis for about an inch and 
 much lacerated. The ankle-joint w^as not implicated. The fibula 
 was not broken, nor was there any separation of its lower epiphysis. 
 Corrosive sublimate dressings were employed and side splints applied. 
 The wound healed with a little suppuration, and the patient was 
 dismissed on February 2 with an excellent limb. The movements 
 of the ankle-joint were then perfect, and there was no measurable 
 shortening. 
 
 Displacement of the epiphysis outwards with fracture of the diaphysis. — 
 Mr. G. A. Wright, of Manchester {Diseases of Children, Medical and 
 Surgical, Ashby and Wright, 2nd edit. 1892, p. 707) has seen a 
 remarkable case of separation of the lower epiphysis of the tibia 
 in a boy of about ten years, who was under the care of his colleague 
 Mr. Hardie. The case was complicated by the presence of a vertical 
 fracture running upwards from the epiphysial line. The foot and 
 lower fragment were displaced outwards, and the deformity could 
 not be reduced until some weeks after the accident, when the ends 
 of the bone were exposed by operation and with some difficulty 
 replaced. The case was still under treatment. 
 
 Displacement of epiphysis inwards. — Mr. Bryant had a boy (Chas. 
 S.), aged fourteen, under his care at Guy's Hospital in September 
 of 1887, in whom compound separation of this epiphysis was 
 accompanied by great displacement of the foot inwards. The boy, 
 in climbing over an iron fence, fell towards the opposite side ; his 
 left foot remained fixed between two rails, and received the whole 
 weight of his body. The tibia protruded for nearly one inch through 
 the wound on the inner side, which measured about two and a half 
 inches transversely. The periosteum was stripped off the end of 
 the tibia, and the lower epiphysis of the fibula was tholight to have 
 been separated. Eeduction was easily accomplished by enlarging 
 the wound. The wound rapidly healed with little suppuration, and 
 the patient left the hospital iii two months' time quite recovered. 
 
 The foot isdescril)ed as inverted and the log shortened in Wade's 
 case (already described). 
 
838 EPIPHYSES OF LOWEE EXTEEMITY 
 
 Displacement backwards of the lower epiphyses of the tibia and 
 fibula. — A case of symmetrical separation of the lower epiphyses of 
 the tibia and fibula is related by Mr. Jonathan Hutchinson {Lancet, 
 1875, vol. i. June 19, p. 857). A sailor, aged nineteen, was admitted 
 into the London Hospital, having fallen a distance of twenty to 
 thirty feet on to the ship's deck, alighting heavily on his feet. On 
 examination there was a lacerated wound (three inches long) on the 
 inner side of the right foot. The os calcis was comminuted, and the 
 tibia and fibula fractured just above the ankle. On the left side 
 there were similar fractures of the tibia and fibula, and the fracture 
 of the OS calcis was a simple one. Both feet were displaced back- 
 wards, carrying with them the lower ends of the tibia and fibula. 
 Eeduction was easily effected, and a good position was maintained by 
 outside splints with foot pieces. On the sixth day erysipelas of the 
 right leg set in, and on the eighth day a large slough was removed 
 from the left leg. Death took place on the tenth day. 
 
 At the autopsy the right os calcis was comminuted, and the 
 scaphoid fractured vertically. The lower epiphysis of the tibia 
 was separated from the shaft and accompanied by a slightly 
 irregular line of fracture. The fibula was fractured through the 
 malleolus. On the left side the os calcis was even more comminuted 
 than the right, and the lower epiphyses of the tibia and fibula 
 were separated from their respective shafts exactly at the epiphysial 
 line, but remained connected with one another. There was also 
 considerable extravasation of blood in front of the spine and behind 
 the peritoneum, extending along the left psoas muscle ; but no frac- 
 ture was found to account for this. The lungs were studded with 
 tubercle, and completely adherent to the chest wall. 
 
 Besides the case just quoted, separation of the lower fibular epi- 
 physis was found in one of Bryant's cases of displacement inwards, 
 and in that of Anger mentioned above. 
 
 Articular lesions. — From the proximity of the synovial membrane 
 of the ankle-joint to the epiphysial line, it would at first sight appear 
 that the articular cavity will probably be opened. But it escapes 
 any gross injury, even at the inferior tibio-fibular mortice, by reason 
 of the periosteum attached to, and continuous with, the epiphysis. 
 
 This immunity of the ankle-joint has often been noted in cases 
 of compound separation, but effusion of blood into its cavity is a 
 constant sign from some minor lesion. 
 
 The joint was opened in Annandale's case of compound separa- 
 tion of the epiphyses of fibula and tibia. 
 
 Injury to vessels and nerves. — The anterior and posterior tibial 
 vessels escape injury in a remarkable manner, even in the most 
 complicated and compound cases. 
 
 In "Wade's case, besides the severe injury to the soft parts, there 
 was also free haemorrhage, for which reason primary amputation was 
 performed ; but no mention is made of the vessels which were injured. 
 
SEPAEATION OF LOWER EPIPHYSIS OF TIBIA 839 
 
 Detachment of periosteum. — Stripping off of the periosteum from 
 the protruding diaphysis in cases of compound separation is a 
 constant lesion ; it occurs chiefly, but not exclusively, from the side of 
 the diaphysis opposite to the displacement of the epiphysis. 
 
 In one of Clark's cases as well as in others already quoted, this 
 detachment of the periosteum did not in any way interfere with 
 the good result which followed. 
 
 Although in many of the examples related above there was more 
 or less sphntering or fracture of the diaphysis, the epiphysis seems 
 to escape injury. 
 
 Latee Complications. — Acute periostitis need not necessarily 
 follow, even though there be suppuration of the wound. 
 
 Necrosis. — In spite of the extensive separation of the periosteum 
 in compound injuries, there does not appear to be much risk of 
 subsequent necrosis, although Dr. Voss, of New York, relates a case 
 {New York Medical Journal, vol. ii. 1865-6, p. 133) in which this is 
 said to have taken place. 
 
 The separation of the lower end of the tibia occurred in a boy, 
 about fourteen years of age, who fell down from the first story of a 
 house, and caught his foot between two pieces of wood. The upper 
 fragment, protruding through the skin, was reduced, and the Imib 
 was placed on a double-inchned plane. A portion of the epiphysis (?) 
 became necrosed and was afterwards removed, but the boy finally 
 recovered with a useful joint. 
 
 In Martin's case, also, of compound separation, three very small 
 pieces of bone were discharged from the wound some weeks after 
 the injury. 
 
 Gangrene. — Krackowizer reports (American Medical Times, 
 November 7, 1863) a case of supposed traumatic separation of the 
 lower epiphysis of the tibia in a boy, aged five. The limb became 
 gang]'enous from tight bandaging, and the lesion was detected only 
 after amputation. 
 
 SYMPTOMS.— Professor E. W. Smith, in his address to the 
 British Medical Association at Dublin in 1867 {British Medical 
 Journal, 1867, vol. ii. p. 122), states that this is undoubtedly among 
 the rarest of this class of epiphysial injuries. 
 
 The recorded cases of simple separation are certainly very few. 
 
 J. Hutchinson junior has collected seventeen recent cases. 
 
 In Champion's case {loc. cit. supra, p. 325) of separation of this 
 epiphysis, brought about by violent traction by the midwife during 
 delivery, no autopsy was made, and in other respects it is a very 
 doubtful case. But few details are given, with the exception that 
 the foot, with the epiphysis, was displaced forwards, and after 
 reduction the thumb could be placed in a large gap at the seat of 
 detachment. 
 
 Swelling-. — If the patient be seen immediately after the accident, 
 this sign may be but little marked ; but soon considerable swelhng 
 
840 EPIPHYSES OF LOWEE EXTEEMITY 
 
 about the ankle-joint will ensue from effusion of blood, caused by 
 laceration of vessels by the edge of the diaphysis, and synovial 
 effusion of blood into the joint cavity itself. 
 
 Crepitus is usually absent, especially in cases of displacement 
 backwards where the lower epiphysis of the fibula is also separated, 
 while the ankle-joint, when uninjured, may be moved freely and 
 smoothly below this point. 
 
 Mobility about one inch above the flexure of the ankle-joint, in 
 the neighbourhood of the epiphysial line, is a more trustworthy sign. 
 Mr. F. M. Corner relates {Med. Times and Gazette, vol. i. 1859, 
 March 5, p. 239) a case which was diagnosed at the Poplar Hospital 
 as one of separation of the lower epiphysis of the tibia and fibula. 
 A boy, aged fourteen years and nine months, fell off the tail-board 
 pf a cart and alighted on his feet, the injured foot turning inwards. 
 
 The symptoms were great swelling about the ankle-joint and 
 a deformity looking like dislocation of the foot backwards, the os 
 calcis being drawn upwards and backwards. On tracing tlie spine 
 of the tibia, a depression was felt for one inch to an inch and a half 
 above the ankle-joint, and some motion at this part was noticed on 
 pretty forcible manipulation, but no crepitus ; the external malleolus 
 pointed more posteriorly than on the opposite side. The displace- 
 nient was reduced, and the limlp placed in a suitable splint on the 
 outer side in the flexed position. 
 
 Deformity is the most marked sign. Eognetta quotes M. A. 
 Severino as having seen this injury in two boys, followed by extro- 
 version of the foot, the foot being thus in the valgus position. The 
 injuries were not verified by anatomical examination. It is remark- 
 able that in all the four recorded cases of simple separation the 
 displacement of the foot with the tibial epiphysis was hachwards. 
 The internal malleolus preserves its normal relations with the 
 foot, but not with the rest of the leg or external malleolus. There is 
 a depression just above the ankle-joint and below the projection 
 forwards of the tibia. 
 
 In Dr. R. W. Smith's case {British Medical Journal, 1867, 
 August 17 ; Dublin Hospital Gazette, vol. vii. 1860, October 1, 
 p. 289 ; Proceedings of the Pathological Society of Dublin , N.s. vol. i. 
 1862, p. 130) th^ diagnosis made w^as that of separation of the lower 
 epiphysis of the tibia and partial displacement bacMoards with the 
 foot. The subject of it was a boy, aged about sixteen years, wdio 
 fell, while leaping, with his right foot violently doubled under him 
 and forcibly extended on the leg. He was admitted into the 
 Richmond Hospital under the care of Mr. Adams. On examination 
 six weeks after the accident it looked at first sight like a case of 
 dislocation of the lower end of the tibia forwards. The curve of the 
 tendo Achillis was greatly increased, and the lower end of the tibia 
 seemed to form a considerable projection in front of the normal 
 position of the ankle-joint. The foot was a little extended upon the 
 
SEPAEATION OF LOWEK EPirHYSIS OF TIBIA 841 
 
 leg when at rest, but the boy had the power of flexing it, and when 
 standing up he was able to place the sole flat on the ground. The 
 fibula was uninjured. Flexion and extension of the foot could be 
 performed. A very short examination was sufficient to show that 
 the injury was not a luxation of the tibia forwards at the ankle. 
 The integrity of the fibula, the freedom with which the perfect 
 application of the sole of the foot to the ground in walking was 
 carried out, were both circumstances opposed to the idea of a true 
 dislocation existing. The internal malleolus was placed further back 
 than natural, being on a plane posterior to the margin of the pro- 
 jecting portion of the tibia, which was rough and unlike the sharp- 
 ness of a fracture, or the smooth outline of the edge of the articular 
 surface of the tibia. The distance between it and the tubercle of the 
 tibia was a quarter of an inch or more shorter than that between the 
 tubercle and the articular niargin of the opposite tibia. From all these 
 conditions, together with the age of the patient and the nature of 
 the accident, it was inferred that the injury consisted in a separation 
 of the lower epiphysis of tl\e tibia, and partial displacement of this 
 process backwards with the joiip^t. The internal malleolus preserved 
 its normal relations with the foot, but not with the leg or outer 
 ankle ; whereas in the case of luxation of the lower end of the tibia 
 the normal bearings of the \njh.ex ankle to the foot were lost, while 
 those to the leg were preserved. 
 
 The parts had become so fixed in their abnormal position that 
 no attempt was made to replace them. A cast of the injury was 
 preserved in the Museum of the Kichmond Hospital. 
 
 Mr. Eichard Quain published a similar case (British Medical 
 Journal, 1867, vol. ii. August 31, p. 180 ; Biennial Betrospect of Medi- 
 cine and Surgery, 1867-8, p. 257), in which, however, the diagnosis 
 was made soon after the accident. On October 22, 1851, a healthy- 
 looking lad, seventeen years of age, was admitted into University 
 College Hospital, having a short time before slipped in the street 
 and fallen with his foot doubled under him. The tibia projected 
 forwards below, and between the prominence and the foot there was a 
 depression. This projection was one and a half inches higher than 
 the lower margin of the fibula, and three-quarters of an inch above 
 • the lower edge of the malleolar process of the tibia. The distance 
 between the prominent tibia and the end of the great toe was three- 
 quarters of an inch less than on the sound side. The ankle-joint 
 was uninjured. Two points were considered as diagnostic— viz. 
 (1) the end of the displaced tibia was rounded, smooth, and, as it 
 were, rugous, very unlike the hard, angular, almost sharp feel of 
 actual broken bone, and corresponding to the line of the epiphysial 
 junction ; and (2) there was an absence of the soft swelling which 
 surrounds the broken ends of bone where any displacement exists. 
 The deformity was easily reduced, and was maintained in position 
 by means of a starch splint. 
 
842 EPIPHYSES OF LOWEE EXTEEMITY 
 
 In many of the cases of backward displacement there is separa- 
 tion of lo'wer epiphysis of fibula as well. The continuity of the 
 diaphysis of the fibula is lost at the ankle-joint, and an irregularity 
 or depression may be felt just above the extended malleolus. 
 
 An instance of separation of the lower epiphyses of the tibia 
 and fibula was diagnosed by Mr. Adams at the London Hospital 
 {Med. Times and Gazette, vol. i. 1859, p. 163). 
 
 The subject in this case was a boy, aged fourteen, who, when 
 jumping off a bar of iron, caught his toes and fell forwards with 
 great violence. The signs were well marked, as the boy was seen 
 directly after the accident. The lower epiphyses of the tibia and 
 fibula were displaced off their respective shafts and dragged hack- 
 wards with the foot, the projection forwards of the lower end of 
 the tibial shaft being considerable. Eeduction was effected with 
 some difficulty, and splints apphed. Much swelling subsequently 
 ensued, but recovery took place with firm union. 
 
 In Corner's case just quoted, and in Hutchinson's, of separations 
 of both epiphyses the displacement was backwards. 
 
 The following cases were treated at Guy's Hospital, and appear 
 to have been unaccompanied by much displacement, although there 
 existed separation of both epiphyses. 
 
 No. 1. "William W., aged eleven years, under the care of Mr. 
 Durham, October 1874. Whilst riding behind a cart his right leg 
 was caught in the spokes of the wheel, and the lower epiphyses of 
 the tibia and fibula were separated. Treatment : posterior and lateral 
 splints. 
 
 No. 2. Alice B., aged ten years, under the care of Mr. Durham, 
 March 11, 1875. She caught her right foot in a step, and twisted 
 her leg under her, separating the lower epiphyses of the tibia and 
 fibula. There was some swelling about the ankle. Treatment : 
 lateral splints. Discharged from hospital April 7, able to walk very 
 well. 
 
 No. 3. George S., aged eleven years, under the care of Mr. 
 
 Birkett, April 21, 1874. Fell from a cart, with his foot caught in 
 
 the ' tail '-board. He was unable to walk after the accident. The 
 
 ower epiphyses of the tibia and fibula were separated, with very 
 
 slight displacement. 
 
 No. 4. Daniel E., aged five years, under the care of Mr. Birkett, 
 April 21, 1873. A truck fell on his ankle, causing separation of 
 lower epiphyses of the left tibia and fibula, and severe contusion of 
 the ankle. Treatment : suspension of leg on an interrupted sling. 
 
 In other simple separations the fibula has given way in its lower 
 third, somewhere above the epiphysial line. 
 
 Mr. Durham made the diagnosis of fracture of the loioer end of 
 the fibula, ivith separation of the loioer epiphysis of the tibia, in two 
 patients under his care at Guy's Hospital in 1885. Their ages were 
 respectively thirteen and six years of age. In the former case the 
 
SEPAEATION OF LOWEK EPIPHYSIS OF TIBIA 843 
 
 boy (David D.) fell towards the outer side of his leg, his foot being 
 fixed among some timber. The lesion was accompanied by consider- 
 able contusion over the ankle and the lower end of fibula. There was 
 but little deformity, the sole of the foot was everted, and there was 
 no shortening. Under chloroform the foot was replaced in good 
 position and fixed on a back splint reaching above the knee. 
 Three weeks later a ' Croft's ' plaster dressing was applied, and a 
 few days afterwards he was discharged with the foot in good position, 
 and with very little callus to be felt at the seat of fracture. In the 
 latter case the patient (Charles B.) had a truck fall on his right 
 leg, causing considerable contusion about the malleoli and lower part 
 of the leg, and a small wound one inch above the internal malleo- 
 lus, which, however, did not apparently conniiunicate with the 
 separation. A back splint was applied, and he left the hospital a 
 few weeks later without any deformity of the foot, with a ' Croft's ' 
 dressing. 
 
 Mr. Cooper Forster, at Guy's Hospital in January 1876, diagnosed 
 a fracture of the external mallcoliis and separation of the lower epi- 
 physis of the tibia in a boy (Henry W.), aged fourteen, who had his 
 right foot caught between the spokes of a wheel in rapid motion. 
 It was treated by posterior and lateral splints with a good result. 
 
 A case came under the author's care at the Miller Hospital, 
 December 3, 1895, in a boy, aged eleven years, in which there was 
 a partial separation of the lower tibial epiphysis with fracture of the 
 diaphysis, with very little displacement, but accompanied by fracture 
 of the fibula. 
 
 The accident happened while the patient was swinging on a 
 gate. He slipped and fell with his foot under the gate, by which it 
 was squeezed, and in trying to extricate his foot he twisted it. There 
 was intense pain at the left ankle, Avith swelling and ecchymosis 
 around it, extending halfway up the leg, and inability to use the 
 leg. The fibula was fractured about two inches above the tip of the 
 external malleolus without displacement. There was mobility and 
 crepitus precisely at the level of the epiphysial line of the tibia, 
 eleven- sixteenths of an inch above the apex of the malleolus. The 
 crepitus was of a dry character on account of the separation of 
 the lower epiphysis being a partial one, accompanied by a fracture 
 of the outer part of the end of the diaphysis. There was very little 
 displacement ; a slight ridge of the lower tibial diaphysis only could 
 be felt in front above the ankle at the epiphysial level. The slight 
 displacement was reduced, and the leg kept for two weeks upon a 
 posterior splint with a foot-piece. The patient left the hospital with 
 a starch bandage. The fragments were in good position, swelling 
 and deformity absent, and the movements of the ankle-joint perfectly 
 free. 
 
 Displacement outwards of foot. — Separation at the epiphysial junc- 
 tion will allow but slight displacement of the fragment, indicated 
 
844 EPIPHYSES OF LOWEE EXTEEMITY 
 
 by some amount of eversion of the foot, miless the fibula be fractured 
 or its lower epiphj^sis separated. 
 
 Some displacement outwards of the foot was noticed in a case at 
 Guy's Hospital under the care of Mr. Cooper Forster in March 
 1879. James B., aged sixteen years, fell a height of five feet with 
 his left foot under him. He was unable to walk after the accident. 
 There was found a separation of the lower epiphysis of the tibia, with 
 slight displacement outwards of the foot and much swelling about 
 the ankle. 
 
 Eversion of the foot was marked in one of Mr. Durham's cases, 
 associated with fracture of the fibula. 
 
 Displacement outwards of the foot has already been often alluded 
 to among compound separations. 
 
 Mr. Bryant mentions that he had seen an example of this kind 
 which was not compound. 
 
 Sepaeatios[ without Defoemity. — On the other hand, a large 
 number of cases have been diagnosed as separations in which there 
 was but little displacement ; in some there has been none at all. 
 
 Abnormal mobility above the ankle-joint and characteristic soft 
 crepitus, together with the history of the injury and the age of the 
 patient, are the chief points for guidance. 
 
 Mr. Birkett had the following case under his care at Guy's 
 Hospital in July 1872. 
 
 Fred M., aged twelve, in endeavouring to walk along the top of 
 a fence, fell, his left foot being caught between two of the rails. 
 The separation of the lower epiphysis of the tibia which was found 
 did not cause any deformity, but there was considerable contusion 
 over the internal malleolus. The injury was treated by a long outside 
 splint to the leg with a foot-piece, and the patient left the hospital 
 between three and four weeks afterwards with a good limb. 
 
 Mr. Durham, in June 1873, had an almost similar case of separa- 
 tion with little or no displacement in a boy (Charles H.), aged six 
 and a half, who had fallen whilst climbing on some palings. 
 Posterior and lateral splints were used, and he left the hospital five 
 weeks later able to walk well. 
 
 A third case was seen by Mr. Hilton in February 1869, in which 
 the separation of the epiphysis of the right tibia was associated 
 with very little displacement. The patient (Patrick G.) was aged 
 five, and was treated by means of a starch bandage. 
 
 In other instances in infancy the separation is only partial, and 
 more often of the nature described by Oilier under ' Juxta-epiphysial 
 sprain.' For the symptoms associated with this the reader is 
 referred to Part I. Chapter VII. 
 
 DIAGNOSIS. Compound dislocation. — It is quite possible that 
 even compound separation may be mistaken for compound dis- 
 location of the ankle, as indeed has happened in several cases — a 
 mistake liable to be followed by very serious consequences if not 
 
SEPAEATIOK OF LOWEE EPIPHYSIS OF TIBIA 845 
 
 detected. The somewhat rounded edge of the projecting diaphysis, 
 with its mammillated surface and devoid of periosteum, should be 
 sufficient to distinguisli it from the cartilaginous articular surface of 
 the tibia. Besides, in epiphysial separation the movements of the 
 ankle-joint are free. 
 
 In Clark's case of compound separation accompanied by fracture 
 of the fibula the injury was at first supposed to be a compound 
 dislocation of the ankle. 
 
 Dislocation of the ankle. — Simple cases with displacement are easy 
 of diagnosis when seen directly after the accident, before any great 
 amount of swelling occurs, yet they may also be confounded with 
 dislocation of the ankle. 
 
 We should always remember that in youths of from eleven to 
 seventeen years of age separation is much more likely to happen 
 than dislocation. In the former, the transverse ridge of the pro- 
 jecting end of the diaphysis is liable to be mistaken for the articular 
 end of the bone ; in these also the joint is usually intact and 
 movable. In displacement backwards of the epiphysis with the foot, 
 the distances between the malleolus and the various prominences of 
 the foot remain normal, while that between the projecting end of 
 the tibia and the great toe is shortened. . 
 
 In dislocation of the foot backw^ards the end of the tibia projects 
 forwards, and the distance between it and the toe or the base of the 
 first metatarsal bone is likewise shortened ; but its internal malleolus, 
 while losing its relations with the foot, retains them with the rest of 
 the leg ; that is, there is no interruption in the line of the tibial crest 
 about an inch or so above the ankle-joint^ aiid the outline of the 
 lower end of the fibula is also intact and regular. If there is a 
 question of the lower end of the fibula being detached as well, the 
 relation between the tip of external inalleolus and projecting base 
 of the fifth metatarsal bone will be also altered; 
 
 Dislocation of the tibia forwards at the aiikle might at first sight 
 much resemble an old separation which had not been detected foi' 
 some weeks after the date of the accident. 
 
 The integrity of the fibula, the freedom with which the motions 
 of flexion and extension of the foot can be performed, the perfect 
 application of the sole of the foot to the ground in walking, are all 
 signs opposed to the existence of a dislocation ; whereas in the 
 dislocation forwards the normal bearings of the inner ankle to the 
 foot are lost, while those to the leg are preserved. 
 
 Pott's fracture. — When the foot is displaced outwards, and the 
 lower epiphysis of the fibula is separated or the lower end of the 
 bone fractured, the diagnosis from a Potfs fracture may at first 
 sight appear very difficult. The latter is not a common injiiry ill 
 children. 
 
 If there be only a little swelling and the injury be seen soon after 
 the accident, the prominent smooth and rounded edge of the 
 
8i6 EPIPHYSES OF LOAVEE EXTEEMITY 
 
 diaphysial end may be recognised on the inner side, while the 
 internal malleolus and the whole of the lower end of the tibia pre- 
 serve their relations with the foot and ankle-joint. Muffled crepitus 
 may also be detected during the reduction of the displaced epiphysis. 
 In Pott's fracture the tip of the internal malleolus is usually broken 
 off, and may be felt to move with crepitus on the inner side. 
 
 Fracture of shaft of tibia. — The rounded, more or less smooth end 
 of the displaced diaphysis in epiphysial separation is quite unlike the 
 pointed and sharp end of an ordinary fracture, with its dry crepitus. 
 
 PEOGNOSIS, RESULTS, &c. Union.— The prognosis is not at all 
 unfavourable. In Adams's and other cases firm union took place. 
 
 M. A. Severino, a Neapolitan surgeon, was the first, in 1632, to 
 notice the deformities of the knee and foot which result from 
 separation of the upper and lower epiphyses of the tibia. 
 
 Deformity. — Even in compound cases there will be, with care, 
 but little subsequent deformity; in one of Clark's cases of compound 
 diastasis of the lower tibial epiphysis, at the end of five weeks the 
 patient left the hospital with an excellent limb, the movements of 
 the ankle-joint being perfect, and no measurable shortening having 
 resulted. 
 
 In E. "W. Smith's case, however, which was not seen until six 
 months after the accident, the displacement forwards of the dia- 
 physis had not been reduced, and gave rise to marked deformity. 
 
 Suppuration and necrosis of diaphysis.- In the recorded examples, 
 in spite of the extensive separation of the periosteum, necrosis has 
 seldom resulted. This, however, occurred in Voss's case. 
 
 Mr. Hutchinson alludes {London Hospital Beports, vol. i. 1864, 
 p. 89) to the case of a boy (G. A.) under his care in the London 
 Hospital in which there was considerable displacement of the lower 
 end of the right tibia though the skin was not injured. An abscess 
 formed, however, round the lower end of the shaft, and free incisions 
 were made, exposing the bone, which was perfectly bare over a large 
 extent. The correctness of the diagnosis w^as confirmed by observing 
 the end of the bone in the wound. The end of the shaft subsequently 
 necrosed, became loose, and was removed. 
 
 Arrest of growth of the tibia, and subsequent shortening of the 
 limb, with deformity, after epiphysial separation has not been of 
 common occurrence. 
 
 For instance, in one of Mr. H. E. Clark's cases careful measure- 
 ments were taken for two years with negative results ; indeed, the 
 loss of length at the end of this time was only about equal to the 
 size of the portion sawn off. 
 
 Being one of the two parallel bones, the overgrowth of the fibula 
 causes great deformity of the ankle and foot. The fibula appears to 
 be lengthened, much increased in thickness, if the injury has 
 occurred in early childhood, and becomes bowed outwards. The 
 foot becomes much inverted and acquires the varus position, the 
 
SEPAEATION OF LOAVEE EPIPHYSIS OF TIBIA 847 
 
 child walking on the outer side of the foot, and in extreme cases 
 even on the outer side of the ankle. 
 
 Mr. Wood exhibited before the Pathological Society of London 
 (Path. Soc. Trans, vol. xxxi. p. 249) a specimen of dwarfing of the 
 tibia after separation of the lower epiphysis. 
 
 Bouchut {Traite j^J'dii'qii'e des maladies des nouveau-nes, 5^™^ edit. 
 Paris, 1867, p. 898) observed an arrest of growth in the bone after 
 fracture of the lower epiphysis of the tibia, whilst the uninjured 
 fibula continued to grow and produced a varus condition of the foot. 
 M. Nelaton thought that the callus produced in the repair was the 
 cause of the arrest of growth in length of the bone. 
 
 Mr. Davies-CoUey showed before a meeting of the Medical 
 Society {Brit. Med. Journal, vol. i. 1888) the case of a girl 
 (Susan G.) who had come under his care on November 7, 1881. 
 At ten years of age she was said to have fractured her left tibia and 
 ruptured the internal lateral ligament. For this she was treated at 
 St. Thomas's Hospital, and discharged as cured after fortj^-four 
 days. When she first came under Mr. Davies-Colley's notice there 
 was great prominence of the external malleolus, and the internal 
 malleolus was small, flat, and high with respect to the external. 
 There was one inch shortening, and the child suffered pain below 
 the external malleolus and walked on the outer border of the foot. 
 As the deformity was increasing, Mr. Davies-Colley on November 11 
 (under ether) removed one inch of the fibula, and divided the tibia 
 subcutaneously. On April 4, 1884, he operated a second time, 
 removing a wedge from the tibia. When seen on February 21, 1887, 
 the patient could walk well, but still on the outer side of her boot. 
 
 At the same meeting Mr. William Eose alluded to another case 
 of a boy with fracture of the leg above the internal malleolus. The 
 boy subsequently returned to the hospital with marked deformity 
 and inversion of the foot, in consequence of the growth of the fibula 
 and the arrest of growth of the tibia. The surgeon removed an inch 
 and a half of the fibula and thus restored the symmetry of the limb. 
 
 Mr. Jonathan Hutchinson alludes {Wled. Press and Circular, 
 November 18, 1885) to the case of a boy who attended occasionally 
 at the Eoyal College of Surgeons for examination purposes, in 
 whom the deformity existed in the ankle from unsymmetrical 
 growth of one of the bones after epiphysial injury. 
 
 Mr. Edmund Owen describes {Lancet, October 3, 1891, p. 7G7) 
 the following case of arrested development of tibia. L. B., aged 
 fourteen, was admitted to St. Mary's Hospital at the beginning of 
 July on account of lameness due to inversion of the left foot. The 
 clinical history shows that five years previously she fell whilst 
 climbing over a gate, and that, catching her foot between the bars, 
 she broke her leg just above the ankle. The line of fracture passed, 
 apparently, across the junction cartilage of the tibia, and detached 
 the lower epiphysis. The effect of this injury Avas to check the due 
 
848 
 
 EPIPHYSES OF LOWEE EXTEEMITY 
 
 growth of the tibia. Careful measurement showed the left tibia to 
 be an inch and three-quarters shorter than the right, whilst the left 
 fibula was shorter than the right by only three-quarters of an inch. 
 (This arrested development of the fibula may have been due to its 
 epiphysis having been damaged by the hurt, or to the restraining 
 influence of the short tibia. The latter explanation is probably the 
 correct one, for the lower end of the fibula was not only much curved 
 but also greatly thickened.) The bowing of the fibula was outwards, 
 
 the tibia playing the part of 
 the bow-string. As the pre- 
 sence of the strong inter- 
 osseous ligaments between 
 the lower ends of the tibia 
 and fibula would have pre- 
 vented any improvement in 
 the position of the foot fol- 
 lowing resection of a piece 
 of the shaft of the fibula, and 
 as the girl walked with fair 
 comfort, Mr. Owen thought 
 that no speculative interfe- 
 rence with the bone seemed 
 justifiable. She was there- 
 fore discharged with a clumsy- 
 looking but useful leg and foot. 
 The following most inter- 
 esting case of deformity and 
 arrest of growth following 
 separation of the lower epi- 
 physis of the tibia came 
 under the author's care at 
 the Miller Hospital in March 
 1891. 
 
 John M., aged thirteen 
 years, had met with an 
 injury to his leg five years 
 previously, in 1886. He was 
 climbing over some iron 
 alings when he caught his foot in the top of the railings and fell 
 over the opposite side, and hung by his foot. A lady passing 
 released him and took him down. He was treated by wooden splints 
 for some weeks, but did not bear any weight on that leg for four or 
 five weeks. Some weeks after he had been walking about he felt 
 the ankle weak, but it was not until some time later that the ' ankle 
 began to grow out.' This steadily increased, getting much worse 
 the last twelve months. 
 
 The boy now walked very lame, placing the outer margin of the 
 
 Fig. 268. — arrest of growth of tibia and de- 
 formity (fd'e years) after in,tury to the 
 lower tibial epiphysis. previous to opera- 
 TION 
 
 In the photograph from which the drawing was 
 taken ihe shortened limb lias been too mucli 
 raised. (Autlior's case) 
 
SEPAEATION OF LOWEE EPIPHYSIS OF TIBIA 849 
 
 left foot upon the ground, the foot being in a varus position. The 
 whole leg was much wasted, the left calf being two and a quarter 
 inches smaller in circumference than the right. The tibia was much 
 smaller than that of the right leg, and measured exactly one inch 
 less in length from the inner tuberosity to the internal malleolus than 
 the right. 
 
 The fibula was much hypertrophied and uniformly enlarged, 
 especially at the lower part, and very prominent, but with no sign of 
 fracture. There was a very slight ridge and a concavity above the 
 epiphysial line of the tibia, but no displacement. The patient com- 
 plained of great weakness of the ankle without any particular 
 pain. The movements of the ankle-joint were good. 
 
 In April, under chloroform, the author removed a wedge of bone 
 from the fibula half an inch above the epiphysial line, and attempted 
 to replace the foot in its normal attitude. The corrected position not 
 being maintained, about a fortnight later the tibia was divided with 
 a saw just above the epiphysial junction, and the deformity of the foot 
 corrected by placing it in a valgus state and producing a depression 
 at the seat of operation on the fibula. The limb was put in a Croft's 
 splint. When seen some months later the position of the foot was 
 much improved and the sole was flat on the ground. The patient 
 was to wear a thick sole to his boot and a steel support to the 
 inner side of his leg and ankle. Four years later, August 1895, 
 the varus condition of the foot was almost corrected ; but this was 
 said to have increased slowly since the operation, and the statement 
 was borne out by careful measurement, showing that the fibula had 
 increased at a greater rate than the tibia. Notwithstanding the 
 age of the patient, which was now nineteen years, it was proposed 
 to remove the conjugal cartilage ; therefore on August 1, 1895, the 
 author operated upon the lower end of the fibula, and found only 
 the remains of the conjugal disc twenty-five millimetres above the 
 external malleolus as a very small nodule of cartilage at the anterior 
 extremity of the line ; the rest of the line could be traced as a 
 thickened track in the cancellous tissue. The bone was very hard 
 and sclerosed, as at the previous operation ; it was then divided by 
 a saw and a small piece removed. The gap left in the lower end 
 of the bone permitted the external malleolus to be gradually everted. 
 Dr. H. E. Maberly, of Peckham, who saw the case immediately 
 after the accident, kindly sent the author the following notes of 
 the condition then present. ' The patient was brought to my house on 
 November 29, 1886, directly after the accident. At the first glance 
 I thought it was an ordinary case of fracture of the lower end of the 
 fibula with very great displacement of the foot outwards, but on 
 examination found that the displacement loas only ajypareiit and 
 not real, the appearance being due to a very large effusion localised 
 over the lower end of the tibia. There was no crepitus of any kind. 
 The leg was put up in well-padded side sphnts, and when these 
 
 3 I 
 
850 EPIPHYSES OF LOWEE EXTEEMITY 
 
 were removed on December 21 there was absolutely nothing to show 
 that he had ever met with any accident, and the boy soon began to 
 run about as usual. It was only about a year ago (1890) I was told 
 that "his ankle was growing out." ' 
 
 By a curious coincidence this patient's cousin, Thomas B., aged 
 ten, was in the Miller Hospital under the author's care two years 
 previously with simple separation of the lower tibial epiphysis, com- 
 bined with fracture of the fibula, the injury having been caused in 
 precisely the same way — viz. climbing over a railing, getting his 
 foot fixed, and falling over. 
 
 An exactly similar deficiency of growth and deformity came 
 among the author's outpatients at the City Orthopaedic Hospital in 
 March 1896. In this case, however, the injury was to the diaphysis, 
 a transverse fracture above the epiphysial line. The author's 
 colleague, Mr, Chas. Gordon Brodie, to whom he transferred the case, 
 showed it at the Clinical Society {Lancet, May 2, 1896, p. 1226 ; 
 Clinical Society's Transactions, vol. xxix. 1896, p. 252). The 
 patient was a mian, twenty-two years of age, who was admitted 
 into the Middlesex Hospital twelve years ago for a transverse 
 fracture of the tibia caused by the overturning of a hand-cart, which 
 snapped the bone above the ankle and caused a good deal of bruising 
 about the joint. The patient was unable to recollect the precise 
 spot where the fracture occurred, but placed it well above the epi- 
 physial line. Examination showed that the end of the tibia was 
 dwarfed in its growth, with an inward curve of the lower fourth of 
 the bone, bringing the internal malleolus into strong relief, and 
 causing the tibio-fibular mortise to be inclined inwards slightly and 
 thus give the foot a list inwards. No irregularity could be detected 
 along the anterior border of the tibia. There was considerable 
 hypertrophy of the lower end of the fibula, while its subcutaneous 
 surface was marked by ridges, and projecting from the anterior 
 border of the malleolus was a large boss of bone, which made the 
 breadth one inch greater on this side than on the other. In order 
 to compensate for the position the foot was thrown into by the 
 inclination of the mortise, there was well-marked valgus, the tubercle 
 of the scaphoid coming out strongly when the patient pressed his 
 foot on the ground. Eontgen's rays revealed that there was 
 absolute continuity of the bone. 
 
 Mr. G. Mansell Moullin showed at the Clinical Society {Lancet, 
 February 1, 1896, p. 296 ; Clinical Society's Trcmsactions, vol. xxix. 
 1896, p. 235) a case in which impaired growth of the lower epi- 
 physis and shaft of the tibia was consequent on a severe strain, 
 and was probably accompanied with the juxta-epiphysial lesions 
 described by Oilier. Five years previously the lad (now seven- 
 teen) had caught his foot in a wheel and severely sprained it by 
 twisting. After that he was in bed for some weeks without treat- 
 ment, the case being deemed a simple sprain. Since the accident 
 the lower end of the tibia had failed to grow, while the fibula had 
 
SEPAEATION OF LOWEK EPIPHYSIS OF TIBIA 851 
 
 grown at its normal rate ; hence the external malleolus, by pro- 
 jecting extraordinarily downwards, had produced a spurious talipes 
 varus. The internal malleolus was exceedingly small, but the lower 
 end of the shaft of the tibia had also failed to grow, so that operative 
 measures were required. The boy was unable to walk for more 
 than half a mile, when he was prevented by severe pain in the shin. 
 He (Mr. MouUin) proposed to resect a portion of bone (about an 
 inch) from the fibula, dividing the tibia at the same time if necessary, 
 and thus to bring the foot into its normal plane position. 
 
 o / Dene's 
 
 Fig. 269. — pattern of lateral splints (croft's) for leg and ankle with 
 
 FOOT AT A right ANGLE. FOR A BOY OF FIFTEEN YEARS. REDUCED TO ONE 
 QUARTER SIZE ON SCALE OF INCHES 
 
 The author has had under his observation during the last 
 two years several examples of arrest of growth at the lower end of 
 the tibia and curving of the bone after intra-uterine fracture. In 
 one instance at birth the tibia was half an inch shorter than its 
 fellow, and at one year and nine months one inch. These cases of 
 intra-uterine injury and arrest of growth are not uncommon. 
 
 P)csides the seventeen cases of recent separation alluded to above, 
 
852 
 
 EPIPHYSES OF LOWEE EXTKEMITY 
 
 J. Hutchinson junior mentions two others of suppurative epiphysitis 
 following a wrench or sprain, and eight cases of arrest of growth at 
 this part after injury, with overgrowth of fibula and inversion of the 
 foot (making a total of twenty-seven separations of the lower epi- 
 physis of the tibia). 
 
 TREATMENT. Simple separation.— Eeplacement of the displaced 
 bone in simple separation is generally effected with ease by extension 
 
 i^^^^sgd^sjssttisffl^J^^ 
 
 ^,^0mmm 
 
 Fig. 270. — ceoft's lateeal splint applied to leg akd foot 
 
 Fig. 271. — the same with outer piece laid aside by cutting theough 
 
 THE gap along THE FOOT AND FEONT OF LEG 
 
 and counter-extension, for the almost flat separated surfaces do not 
 offer the difficulty which is met with in some other separations. 
 A starch or ' Croft's ' plaster-of-Paris splint is then applied. 
 
 In separation with displacement backwards, and in separation or 
 fracture of the lower end of the fibula, the thigh should be flexed 
 towards the abdomen and the leg towards the thigh with the foot 
 extended, on account of the action of the hamstring and leg muscles 
 tending to keep up the displacement, when reduction may easily be 
 effected with a little manipulation. The dorsum of the foot should 
 
SEPAEATION OF LOWEE EPIPHYSIS OF TIBIA 853 
 
 be held with one hand and the heel with the other, while an 
 assistant makes slight counter-extension by grasping the leg. A 
 Croft's or other form of moulded splint should then be applied. 
 Division of the tendo Achillis is rarely called for. 
 
 Compound separations. — Amputation should only rarely be resorted 
 to— when there are most extensive injuries to the soft parts, the 
 epiphysial separation being a small and unimportant element in the 
 
 Fig. 272. — posterior and lateral leg splints with rectangular eoot-pieces 
 
 AS USED AT guy's HOSPITAL 
 
 Fig. 273. — the same applied to leg 
 
 case. Lacerations of both the tibial vessels and even of the nerves, 
 although serious lesions, do not of themselves demand amputation, 
 
 Besection of the exposed diaphysis should be performed when it 
 is found to be impossible to otherwise reduce the deformity. There 
 is every reason to save the limb when the damage to the soft struc- 
 tures is not too extensive. Good firm union may be expected with 
 perfect use of the ankle-joint. 
 
 Erichsen performed resection of the displaced diaphysis of the 
 tibia at the ankle, and reduced the protruding shaft, with an 
 
854 EPIPHYSES OF LOWEE EXTEEMITY 
 
 excellent result both as to union and freedom of movement of the 
 articulation. 
 
 In compound separations, more especially where the violence has 
 been direct and the fibula also injured, the greatest care should be 
 taken to remove all soiled portions of the diaphysis and soft parts. 
 The bone may be easily cut away by a short knife or chisel ; and the 
 wound having been in every angle carefully washed out with per- 
 chloride of mercury or carboHc acid, so as to make it as aseptic as 
 possible, should be dressed with some antiseptic gauze. The bone 
 and soft parts must be carefully replaced in the position they were in 
 before the accident. 
 
 Fig. 274. — plastek-of-paeis splint with interruption at ankle 
 roK COMPOUND separations 
 
 Operations for deformity of ankle and foot due to arrest of growth of 
 the tibia. — Bemoval of osseous wedge from fibula, with or without trans- 
 verse division of the tibia, will meet with greater success than has 
 hitherto been the case, if performed after the limit of the period of 
 the growth in length is reached rather than when the fibula is in 
 an active state of development. 
 
 This operation was performed in Mr. Davies-Colley's and in 
 Mr. Rose's cases. 
 
 The simple operation of removal of the conjugal cartilages of 
 the fibula may be practised under aseptic precautions, conjugal 
 cJiondrectomy (Oilier), when the deformity has not existed any length 
 of time, and the period of fusion of the epiphysis with the diaphysis 
 is not a short distance off — before the eighteenth or nineteenth 
 year. 
 
 M. Oilier has successfully corrected the varus condition produced 
 by suppurative ostitis of the lower end of the tibia by chondrectomy 
 {Traits cles resections, 1891, p. 475, figs. 396, 397). He excised both 
 epiphysial conjugal discs of the fibula and succeeded in arresting its 
 growth, so that sixteen years after the operation the foot had lost 
 its deformity and the lower ends of the tibia and fibula were in 
 normal relationship. 
 
 Oilier says that the upper conjugal cartilages of the tibia and 
 
SEPAEATION OF LOWEK EPIPHYSIS OF TIBIA 855 
 
 fibula are best accessible for chondrectomy — the former on its 
 antero-internal aspect, the latter on its outer side. 
 
 The height of the end of the epiphysis from the epiphysial line 
 at this point he gives as follows : 
 
 At four years of age 
 At twelve years of age 
 
 Tibia 
 
 12 millimetres 
 
 16 millimetres 
 
 Fibula 
 
 6 millimetres 
 
 8 millimetres 
 
 He recommends a simple deep incision into the cartilage in the 
 first instance, and if, after the lapse of three months, sufficient arrest 
 of growth has not been produced, ex- 
 cision of the cartilage should be per- 
 formed. 
 
 As an alternative operation for 
 arrest of growth of the tibia he also 
 suggests exciting the growth of the 
 conjugal cartilage by indirectly irrita- 
 ting it — i.e. by irritation from a dis- 
 tance, such as by a nail penetrating 
 the bone into the medullary canal or 
 by successive cauterisations of the 
 surface of the tibia, to produce more 
 or less superficial necrosis. In both 
 these conditions the irritation must 
 be prolonged in order to produce the 
 necessary hyperplasia of the cartilage, 
 and consequently the operation must 
 be repeated many times. 
 
 In some instances Oilier has com- 
 bined the methods of excision of car- 
 tilage and of artificial irritation. In a 
 case of deviation of the foot inwards 
 following arrest of growth of the tibia, 
 probably the result of an old juxta- 
 epiphysial sprain, he inserted a leaden 
 nail in the middle of the tibia, and 
 
 excised the still growing epiphysial cartilage of the fibula. Although 
 the patient, who was fifteen years of age, had not grown much 
 since the operation, the deformity was completely rectified. The 
 presence of the nail was well tolerated and affected the growth of 
 the tibia, as four months afterwards it was more than three milli- 
 metres distant from the upper end, but continued the same distance 
 from the lower end. 
 
 Fig. 275. — steel leg-ieon with 
 foot and t-stkap tor spurious 
 talipes varus, the result op 
 arrest op growth of the tibi\, 
 after epiphysial separation 
 
85G EPIPHYSES OE LOWEE EXTEEMITY 
 
 CHAETEE VIII 
 
 Separation of the Upper Epiphysis (Head) of the Fibula— Separation of 
 THE Lower Epiphysis (External Malleolus) of the Fibula 
 
 SEPABATION OF THE UPPER EPIPHYSIS OP THE FIBULA 
 
 ANATOMY.— At birth both ends of the fibnla are cartilaginons ; 
 soon after bhth the diaphysis begins to take its characteristic 
 prismatic shape. 
 
 The upper end has no trace of ossification until about four or 
 four and a half years of age, when some osseous granules are dis- 
 tinguishable in the centre of the cartilage ; these rapidly coalesce 
 and form a distinct centre between the fifth and sixth years. At 
 the eighth year this centre is seen to be of an oval shape, rapidly 
 extending in all directions, and by the eighteenth year the epiphysis 
 is fully ossified. 
 
 The epiphysis includes the whole of the surface for the attach- 
 ment of the tendon of the biceps femoris and external lateral 
 ligaments. Its pointed styloid process behind gives attachment to 
 the short external lateral ligament, while the rest of the head in 
 front affords attachment to the biceps, long external lateral ligament, 
 and anterior bands of the superior tibio-fibular joint. To its peroneal 
 tubercle are connected some anterior fibres of the peroneus longus 
 and extensor longus digitorum muscles. Behind, below the anterior 
 tubercle, it gives attachment to the posterior bands of the superior 
 tibio-fibular joint and the uppermost fibres of the outer head of the 
 soleus. 
 
 Its outer aspect is prominent and subcutaneous, being covered 
 only w^th some fibrous expansions of the muscles and ligaments to 
 wEich the rest of the epiphysis gives attachment. 
 
 Its lower surface is almost flat, fitting upon the slightly convex 
 end of the diaphysis, and is on a level with the lower end of the 
 tonguelike process of the upper tibial epiphysis (forming the tubercle), 
 that is, its most prominent part. Behind the conjugal line is a 
 quarter to three-eighths of an inch below the oval articular surface 
 for the outer tuberosity of the tibia, and more externally it passes 
 directly below the surface for the biceps. 
 
 This epiphysis joins the diaphysis about the twentieth to the 
 
SEPAEATION OF UPPEE EPIPHYSIS OF FIBULA 857 
 
 Fig. 276. — postekioe aspect of the fully 
 foemed upper epiphyses of the tibia and 
 fibula, showing the fibular facet on 
 the outer tibial tuberosity 
 
 The fibula has been rotated to show its 
 articular surface 
 
 twenty-second year ; its union may be delayed as late as the 
 twenty-fifth year. Traces of the epiphysial line are often seen 
 for some years beyond this date. 
 
 The articular tibial surface 
 looks forwards, upwards, and 
 inwards, and is an almost plane 
 or slightly concave surface, 
 covered with cartilage, and 
 placed at an angle of 145° with 
 the axis of the shaft. 
 
 The apex of the styloid pro- 
 cess is three eighths of an inch 
 below the level of the articular 
 surface of the knee-joint in the 
 fully developed epiphysis at 
 about the twentieth year. 
 
 The epiphysial line at the 
 eighteenth year is fifteen milli- 
 metres below the apex of the 
 styloid process ; at the fifteenth 
 year it is twelve millimetres. 
 
 The synovial membrane of the superior tibio-fibular articulation 
 is quite above the epiphysial line of cartilage of the fibula in child- 
 hood. Its nearest point is on the lower or inner side, where at 
 eight years of age it is more than a 
 quarter of an inch above it ; but at 
 the thirteenth year, from the upward 
 growth of the diaphysis, the synovial 
 membrane quite reaches the epiphysial 
 disc on this side. The upper tibial 
 disc of cartilage on the outer side 
 approaches very intimately this joint, 
 and its level is a short distance above 
 the lower limit of the synovial mem- 
 brane. 
 
 Very rarely the synovial membrane 
 communicates with that of the knee- 
 joint by means of a small opening at 
 the posterior and upper part, where the 
 articular capsule is always the thinnest. 
 More frequently the author has found 
 a communication with the large bursa 
 beneath the tendon of the popliteus 
 tendon, which always opens widely into 
 the knee-joint, at the external semilunar cartilage of the joint. 
 
 ETIOLOGY. — Were it not for the articulation of the fibular head 
 with the inferior and outer aspect of the external tuberosity of the 
 
 Fig. 277. — epiphysis of the head 
 of fibula at the nineteenth 
 year, showing the facet for 
 the outer tuberosity of the 
 
 TIBIA 
 
858 
 
 EPIPHYSES OF LOWER EXTREMITY 
 
 tibia, its fixed-in position, and attachment to it by strong liga- 
 mentous bands (anterior and posterior ligaments of the superior 
 tibio-fibular joint), the action of the powerful external lateral liga- 
 ments and biceps tendon would prove a frequent cause of separation 
 of this epiphysis in lateral movements of adduction of the leg. In 
 the same way these peculiar anatomical safeguards may counter- 
 balance the tendency to which its prominent and subcutaneous posi- 
 tion below the outer side of the knee exposes it in direct blows in this 
 
 situation. However, forcible inward 
 flexion of the leg upon the thigh by 
 violent overstretching of the external 
 lateral ligaments attached to the fibular 
 head may, under certain conditions, 
 cause the conjugal junction of the latter 
 with the diaphysis to be torn through. 
 Stanley Boyd states that strong 
 action of the biceps has occasionally 
 torn off the upper fibular epiiphysis 
 (Treves, System of Surgery, vol. i. 1895). 
 AGE. — Of the three examples re- 
 corded here, one only was unassociated 
 with separation of the epiphyses of the 
 neighbouring femur or tibia — namely, 
 that of a child, aged eighteen months, 
 the injury being caused by direct crush- 
 ing violence. 
 
 M. Delore, as stated later on, sepa- 
 rated this epiphysis together with that 
 of the femur in a child aged seven. 
 
 In only one simple case has separa- 
 tion of the upper epiphysis of the fibula 
 been diagnosed during life, viz. at four- 
 teen years of age. 
 
 PATHOLOGICAL ANATOMY.— Sepa- 
 ration of this epiphysis alone can but 
 rarely be accomplished by any other 
 than direct violence. The close con- 
 nection of the fibula with the tibia in its whole length, and the 
 articulation with the outer tuberosity of the tibia above, prevent, 
 as stated just now, indirect violence having much effect upon the 
 upper epiphysial line. 
 
 It is remarkable that this epiphysis escapes injury in so large a 
 proportion of cases of separation of the upper epiphysis of the tibia ; it 
 was separated in Fischer and Hirschfeld's case and in Durham's case. 
 In the former instance both epiphyses of the fibula were com- 
 pletely detached. 
 
 The same lesions exist in the specimen in St. George's Hospital 
 
 Fig. 278. — section theough su- 
 peeior tibio-ribular articula- 
 tion, showing relation of its 
 synovial cavity to the conju- 
 gal cartilage of the tibia and 
 
 FIBULA AND THE SilALL AMOUNT 
 OF TISSUE INTERVENING BETWEEN 
 IT AND THE ARTICULATION OF THE 
 KNEE. FROM A BOY AGED THIR- 
 TEEN AND A HALF YEARS 
 
 C, external semilunar cartilage on 
 section 
 
SEPAEATION OF UPPEK EPIPHYSIS OF FIBULA 859 
 
 Museum (see above), but here the lower epiphyses of the femur and 
 tibia were separated as well as those of the fibula. 
 
 Dr. F. A. Stimson presented to the New York Surgical Society 
 (Medical Becorcl, New York, 1882, xxii. p. 77 ; Treatise on Fractures, 
 London, 1883, p. 586) a specimen of separation of the upper end of 
 the fibula by direct violence. 
 
 The child, aged eighteen months, was run over by a street car, 
 and received injuries which caused its death a few hours afterwards. 
 There was a lacerated wound on the outer side of the right leo-, 
 exposing the upper end of the fibula and opening the knee-joint. 
 
 The upper epiphysis of the fibula was completely and cleanly 
 detached from the shaft and from the tibia, and remained attached 
 to the external lateral ligament and the tendon of the biceps. 
 There was also an incomplete fracture of the shaft of the fibula 
 three-fourths of an inch below the epiphysial line, and the inter- 
 mediate portion was denuded of its periosteum, which remained 
 attached to the epiphysis. 
 
 M. Delore in straightening a case of knock-knee found on dissec- 
 tion that he had separated the upper epiphysis of the fibula as well as 
 the lower epiphysis of the femur. The child, aged seven years, 
 died of measles twenty-one days after the operation. 
 
 The proximity of the external popliteal nerve to the biceps 
 tendon and upper fibular epiphysis is a constant source of danger. 
 
 SYMPTOMS. — The detached epiphysis may be felt as a hard 
 fragment on the outer side of the knee, descending when the knee 
 is extended. There may also exist some lateral mobility, especially 
 inwards, of the knee, amounting in some instances almost to dis- 
 location at the joint. 
 
 "When displacement is absent, pain on pressure, localised to the 
 conjugal cartilage, and slight mobility, combined with other signs of 
 injury at this point, and the age of the patient, are the principal 
 factors upon which a diagnosis can be made. Signs of a severe 
 sprain to the knee and contusion on the outer side of the knee may 
 throw the surgeon off his guard. 
 
 At Guy's Hospital in May 1868 Mr. Hilton is reported to have 
 diagnosed a case of separation of the upper epiphysis of the left 
 fibula in a boy (John M.), aged fourteen. 
 
 The patient was standing under an arch, which gave way and 
 buried him in the bricks. There was effusion into the knee-joint as 
 v/ell as the epiphysial separation. The limb was put up in a pos- 
 terior splint in a slightly flexed position, and the patient left the 
 hospital four weeks later 'quite well,' without any impairment of 
 movement of the limb. 
 
 TREATMENT.— After reduction of any displacement of the dia- 
 physis that may exist, the knee should be kept flexed to a right angle 
 by plaster of Paris or other immovable splint, to allow relaxation of 
 the biceps muscle and secure apposition of the fragments. 
 
860 
 
 EPIPHYSES OF LOWEE EXTEEMITY 
 
 SEPARATION OF THE LOWER EPIPHYSIS OP 
 THE FIBULA 
 
 ANATOMY. — Osseous particles are deposited in the centre of the 
 lower epiphysis about the eighteenth to twentieth month after birth 
 — during the second year according to Beclard — but this may occa- 
 sionally be delayed till the end of the third year. This centre 
 rapidly increases in all directions, so that between the eighth and 
 ninth years this epiphysis is an almost osseous quadrilateral mass, 
 
 with the exception of the tip of the 
 malleolus, which is still cartilaginous ; 
 but this too is soon invaded, and the 
 whole is then quite ossified. 
 
 The lower epiphysis unites with 
 the diaphysis from the nineteenth, 
 twentieth, or twenty- second year — 
 before the upper epiphysis. 
 
 It is interesting to remark that 
 although the nutrient artery of the 
 shaft runs downwards, the fibula is 
 an exception to the general rule, 
 inasmuch as the lower epiphysis, 
 towards which it runs, is the first to 
 appear instead of the last. 
 
 In a boy of eight years the epi- 
 physial layer of cartilage will be 
 found to lie eight millimetres below 
 that of the tibia, and in a direct 
 horizontal line with the opposed 
 articular surfaces of the tibia and 
 astragalus. It is separated from the 
 synovial membrane of the ankle-joint 
 by a small amount of connective 
 tissue, which is readily torn through 
 in epiphysial separations, and the 
 articular cavity opened. It may 
 therefore be said to be almost exactly on a level with the plane of 
 the ankle-joint. 
 
 In the fully developed epiphysis at the eighteenth year, the epi- 
 physial line on the outer side is twenty-two millimetres (seven- 
 eighths of an inch) above the tip of the external malleolus ; at 
 about the fifteenth year it is rather less, about eighteen millimetres ; 
 at the eighth year sixteen millimetres. 
 
 Fig. 279. — normal relation of the 
 epiphysial lines of the tibia 
 and fibula to the ankle-joint, 
 from a subject aged eighteen 
 
 yEAKS 
 
SEPAEATION OF LOWEK EPIPHYSIS OF FIBULA 861 
 
 On taking the section of the ankle-joint at thirteen years of age, 
 the synovial membrane of the joint overlaps the diaphysis of the 
 fibula for five mihimetres (Sesary) . 
 
 Mr. J. Bland Sutton has recently drav^n attention to the com- 
 parative length of the external malleolus in man, v^^hich descends 
 much lovi^er in him than in the higher mammals — e.g. the ape. 
 
 ETIOLOGY. Indirect violence. 
 The mechanism of this separa- 
 tion is more closely allied to 
 that of Pott's fracture in the 
 adult than to any form of injury 
 about the ankle-joint. 
 
 In the author's case the 
 twisting of the foot after a fall 
 from a trapeze produced sepa- 
 ration v^ith displacement in- 
 v^ards of the foot, rather than 
 outwards as in Pott's fracture. 
 
 It is probable that separa- 
 tion of this external malleolar 
 epiphysis, with only slight dis- 
 placement, is a frequent result 
 of violent wrenches or twists of 
 the foot, but are undetected. 
 
 The author is unable to 
 refer to a single instance of 
 simple separation with or with- 
 out displacement which has 
 been correctly diagnosed and 
 described during life. 
 
 Direct violence. — Severe di- 
 rect violence to the ankle 
 generally produces separation 
 of the outer malleolus combined 
 with outer extensive lesions. 
 
 AGE. — Of the five recorded examples of separation of this epi- 
 physis, uncomplicated with partial or complete separation of the 
 lower tibial epiphysis, three were pathological specimens — two at 
 18 years of age and one at 6 ; while two were compound separations 
 — one at 12 years of age, and one at an age not stated. 
 
 In three of the above five cases the lesion occurred in males ; in 
 the two others the sex was not given. 
 
 PATHOLOGICAL ANATOMY.— There are only two authentic 
 specimens of this injury in the London museums, both compound 
 and caused by very severe violence. 
 
 The first is in the Museum of the Middlesex Hospital, No. 115 
 {Descriptive Catalogue of tlie Pathological Museum of the Middlesex 
 
 Fig. 280. — frontal section throdgh bones 
 forming the ankle-joint at the age op 
 seventeen and a half years. posterior 
 half of section, showing cancellous 
 structure of the epiphyses and the 
 relation op the conjugal lines to the 
 
 ARTICULATIONS (|-size) 
 
862 EPIPHYSES OF LOWEE EXTEEMITY 
 
 Hosjjital, 1884, p. 14), and is described by Mr. Bland Sutton in the 
 Pathological Society's Transactions, London, vol. xxv. 1884, p. 272. 
 
 It was taken from a lad, aged eighteen, whose left foot had been 
 entangled in some machinery. There was such severe laceration of 
 the structures about the ankle that it was found necessary to imme- 
 diately amputate at the middle of the calf. The operation was followed 
 by complete recovery. Besides severe injuries to the tendons and 
 soft tissues about the joint, the deltoid ligament was torn through 
 near the front of its attachment to the inner malleolus. The 
 lower epiphysis of the fibula, completely freed from the diaphysis, 
 remained attached to the astragalus and os calcis by means of the 
 external lateral ligament. The anterior and posterior bands of 
 the inferior tibio-fibular articulation were torn through at their 
 attachment to the outer malleolus, the foot remaining connected 
 with the leg by two or three tendons only. 
 
 In the second case, in the London Hospital Museum, the speci- 
 men (No. G. b. S. 37) was taken from a child, aged six, in whom 
 also primary amputation was performed for severe compound injury 
 to the foot. 
 
 The separation of the lower epiphysis of the fibula was complete, 
 the epiphysial cartilage remaining attached to it, but being fissured at 
 the posterior part. The diaphysis, which was stripped of its perios- 
 teum, was not fractured. The ligaments connecting the malleolus to 
 the tarsus were uninjured, and the periosteum was still attached to 
 this process. The internal malleolus was broken off by an obliquely 
 vertical fracture. As in the case of the fibula, the ligaments below 
 and the periosteum above were still connected with it. The dia- 
 physis of the tibia was likewise devoid of its periosteum.^ 
 
 The only other previously recorded specimen in London is that 
 in the Museum of St. George's Hospital, and is described by 
 Mr. Holmes in the Transactions of the Pathological Society 
 (vol. xiii. p. 187). The condyloid epiphysis of the femur, the lower 
 epiphysis of the tibia (compound) , and both epiphyses of the fibula, 
 were separated from the diaphysis. For the extensive injuries 
 amputation was immediately performed, and the patient (aged 
 eighteen) died of pyasmia on the thirteenth day. Mr. Holmes, 
 however, adds, with regard to this specimen, in his Surgical Treat- 
 ment of the Diseases of Children, 2nd edit. 1869, p. 237 : ' Very 
 unfortunately the bones have been -.macerated, so that it is impossible 
 to see whether the separations, which do certainly exist in the 
 specimen, are the result of injury or maceration.' 
 
 Nelaton, in his l^levients cle Pathologic Chirurgicale, 2'"*' edit. 
 tome 2^*"^, p. 234, gives an illustration of a specimen of pure 
 separation of the lower epiphysis of the fibula. The lower epi- 
 physis of the tibia was also separated in front on the inner side, 
 
 ' This si^ecimen, though in the old MS. catalogue, does not ai^pear in the recent 
 catalogue of the London Hospital Museum. 
 
SEPAEATION OF LOWEE EPIPHYSIS OF FIBULA 863 
 
 but on the outer side it was accompanied by a fracture of the 
 shaft. 
 
 M. Anger's drawing (fig. 267) of the specimen has already been 
 given (see under Lowee Epiphysis of the Tibia). 
 
 The only specimen known in London or elsewhere of this injury 
 caused by indirect violence is one which the author dissected some 
 years ago. Gangrene of the foot and part of the leg occurred on 
 the third day after the application of a plaster dressing to the limb, 
 and on the twenty-fifth day necessi- 
 tated amputation, which was followed 
 by recovery. 
 
 The lad, aged eighteen years, fell 
 off a trapeze a distance of eight feet on 
 to the outer side of his foot. There 
 was thought to be a fracture of the 
 fibula accompanied by displacement 
 inwards of the foot. The foot was 
 reduced soon after the accident. 
 
 The separation lay exactly and com- 
 pletely through the epiphysial cartilage, 
 and was accompanied by stripping up 
 of the periosteum from the lower end 
 of the diaphysis, especially on the outer 
 side. All the lateral ligaments were 
 intact, as were also the inferior tibio- 
 fibular ligaments, with the exception of 
 a few of the anterior bands of the latter 
 where they pass to the front of the 
 malleolus. There was blood in the 
 ankle-joint and beneath the separated 
 periosteum, as well as around the de- 
 tached epiphysis, which was only 
 slightly displaced outwards. 
 
 Hamilton was 'unable to refer to 
 any example of separation of the lower 
 epiphysis of the fibula.' 
 
 Compound Sepa-kation. — Dr. 0. H. 
 Allis, of Philadelphia, has kindly sent 
 the author the following note on an 
 unpublished case of compound separation of the lower epiphysis of 
 the fibula which proved fatal from tetanus. 
 
 ' Compound separation of lower fibular epiphysis, never reported : 
 E. S., about twelve years of age, fell between logs on which he 
 was playing, and was brought to the Presbyterian Hospi"tal imme- 
 diately after. There was a transverse wound about an inch long 
 that corresponded to the seat of separation at the lower epiphysis of 
 the right fibula. The bone was in full view, and the separation 
 
 Fig. 281. — teaumatic separation 
 of the lower epiphysis of the 
 left fibula with displacement 
 op the foot inwards 
 
 (Author's specimen) 
 
864 EPIPHYSES OF LOAVEE EXTEEMITY 
 
 was without sx^lintering. The wound had probably been made 
 from within outwards by the sharp edge of the diaphysis. 
 
 ' AVhen seen there was no displacement. The wound was dressed 
 and recumbency enjoined. Both wound and separation did appa- 
 rently well, but in about the third week symptoms of tetanus arose 
 that proved fatal in a few days. Date about 1875.' 
 
 Mr. G. A. Wright {Diseases of Children, Medical and Surgical, 
 Ashby and Wright, 3rd edit. 1896, p. 756) met with an instance 
 of compound separation of the lower epiphysis of the fibula, in which 
 the lower fragment became necrosed and was removed. 
 
 Mr. J. E. S. Barnett {Lancet, June 18, 1898, p. 1721) also briefly 
 notes an instance of compound separation of the lower epiphysis of 
 the fibula, with inversion of the foot and protrusion of the lower 
 end of the diaphysis. 
 
 Later Complications. Suppuration and necrosis. — As to these 
 later complications, suppurative epiphysitis occurred in one instance. 
 Necrosis may be expected in compomid separations. 
 
 Tetanus resulted at the third week in Dr. Allis's case of compound 
 separation. 
 
 Arrest of growth. — Should there be arrest of growth following 
 injury to the lower epiphysis, which is the most important epiphysis 
 of the fibula in this respect, there is little probability except in 
 early childhood of its giving rise to any marked curving of the tibia, 
 which is the main 'support of the lower extremity. 
 
 SYMPTOMS.— Although fracture of the fibula alone is rare in 
 children, it is exceedingly probable that the majority of examples of 
 supposed fracture of the lower end of the fibula occurring in youths 
 from twelve to nineteen years of age are really separated epiphyses. 
 The separation takes place, as in fracture, by lateral rotation of the as- 
 tragalus and foot either inwards or outwards, from a fall, sudden twist, 
 or adduction or abduction of the foot, but diifers from it in that the 
 solution of continuity is below the tibio-fibular interosseous liga- 
 ments. Although the anterior and posterior bands of the tibio- 
 fibular articulation may be ruptured in separation, in the more 
 common form of Pott's fracture this laceration often occurs. 
 
 In experiments upon the dead body the author found this to be 
 one of the most readily separated epiphyses of the long bones, in 
 the manner just mentioned, by violent adduction or abduction. 
 
 Without any marked displacement of the epiphysis and foot its 
 detection cannot be easy. Mobility of the epiphysis is here difficult 
 of recognition, and muffled crepitus may or may not be present. 
 Pain on pressure over the epiphysial line, or some slight irregularity 
 in the line of the fibula, is more likely to be present, and suggest a 
 separation. 
 
 Displacement of epiphysis and foot. — If, however, the force applied 
 has been such as to cause displacement of the foot, then the de- 
 formity should render the diagnosis a matter of comparative ease. 
 
SEPAKATIOX OF LOWEK EPIPHYSIS OF FIBULA 865 
 
 It may be outwards, as in a tj^pical Pott's fracture, of a mild 
 degree, and associated with more or less laceration of the internal 
 lateral ligament or tearing away of the extreme tip of the internal 
 malleolus. 
 
 The displacement may take place inicards, as in some rare forms 
 of dislocation of the foot in adults, combined with fracture of the 
 lower end of the fibula. This displacement existed in the author's 
 case quoted above. 
 
 Probably in both forms of displacement some of the anterior or 
 posterior fibres of the inferior tibio-fibular ligament will be lacerated. 
 
 Moreover, the articular cavity of the ankle-joint must necessarily 
 be opened in all examples of severe separation with displacement. 
 
 In these instances the careful recognition of the exact point of 
 mobility of the epiphysis at the epiphysial line is of the greatest 
 importance, and in them muffied crepitus is more easily obtained 
 than in others where no displacement has occurred. 
 
 Seeing that a separation of the lower fibular epiphysis will more 
 probably involve the ankle-joint than a fracture of the lower end of 
 the fibula just above the epiphysial line, it is for this reason alone of 
 considerable importance to the surgeon. 
 
 TREATMENT. — Reduction should be at once carried out where 
 there is displacement, and it will be foand to be more easily effected 
 than in the case of fracture in adults, where the displaced fibula has 
 too often caused permanent deformity. A plaster-of-Paris splint, in 
 the form of the Bavarian or, better, a ' Croft's,' splint, should then be 
 applied. There need be no fear of applying this when there is but 
 little swelling or extravasation of blood in the neighbourhood. The 
 patient is kept in bed for ten to fourteen days to make sure that the 
 plaster has not been applied too tightly ; he may then get about on 
 crutches for the following two or three weeks, when all apparatus 
 should be discarded. Plaster-of-Paris bandages should never be 
 employed in children on account of the danger attending them. 
 
 Fig. 282. — dupuyteen's splint for teactuee of the 
 exteexal malleolus 
 
 In the more severe cases it may be found necessary to make 
 use of wooden lateral and posterior splints with foot-pieces, wbile 
 some may prefer a long internal splint to the leg and foot applied 
 after the method of Dupuytren and with thick padding over the tibia. 
 
 It is improbable that any severe deformity or arrest of the proper 
 growth of the limb will be likely to result from the separation if 
 
 3k 
 
866 EPIPHYSES OF LOWEE EXTEEMITY 
 
 properly reduced, inasmuch as the tibia is the principal bone upon 
 which the leg depends for its increase in length, the fibula playing 
 a subordinate part ; in fact, in man the upper part of the latter bone 
 is in a comparatively rudimentary condition. 
 
 If arrest of growth of the lower end of the fibula ensue, it may, 
 as it affects one of the parallel bones, be followed in after years by 
 a talipes valgus condition of the foot. 
 
 Operation for deformity from arrest of growth. — If the valgus posi- 
 tion be extreme from the continued growth of the tibia in arrest 
 of groiuth of the fibula, it may be considered necessary to perform 
 Ollier's simple operation of removal of the lower cartilage of union 
 of tibia — conjugal chondrectomy (cJiondrectomie conjugale). The 
 lower epiphysial cartilage of the tibia, being subcutaneous, is easily 
 reached. 
 
 M. Oilier gives the approximate distance of the epiphysial lines 
 of the tibia and fibula laterally from the point of the malleoli : 
 
 Tihia Fibula 
 
 At four years of age . . 14 millimetres 15 millimetres 
 
 At twelve years of age . 17 millimetres 18 millimetres 
 
S67 
 
 CHAPTEE IX 
 
 SEPARATION OF THE EPIPHYSES OF THE 
 BONES OF THE FOOT 
 
 Separation of the epiphysis of the 03 calcis.— At birth the primary 
 osseous nucleus of the os calcis, which appears about the centre of 
 the cartilage at the fifth month of foetal life, has already invaded 
 much of it. By the tenth year nearly the whole bone is osseous, 
 and at this period the cartilaginous epiphysis which caps the posterior 
 extremity of the bone begins to ossify. Appearing just at the most 
 convex part of the epiphysis, this centre spreads very rapidly 
 throughout it, so that by the fourteenth year the epiphysis is entirely 
 osseous. To its lower part behind is attached the tendo Achillis, 
 and between its upper part and the tendon is situated a synovial 
 bursa. The junction with the body of the bone begins about the 
 
 
 AT 5^ 'V -X 
 
 r^ 
 
 Fig. 283. — right foot seen feom the outer side, sHo\\^NG epiphyses of os 
 
 CALCIS, METATARSUS, AND PHALANGES AT THE AGE OF FIFTEEN AND A HALF 
 
 YEARS (|-size) 
 
 sixteenth year at the lower part, and is usually completed by the 
 eighteenth year. Traces, however, of the line of union are some- 
 times to be seen at the upper part as late as the twenty-third year. 
 
 Occasionally a separate centre appears in the outer calcanean 
 tubercle at a somewhat later period than the centre for the main 
 epiphysis, but more usually this process is formed and ossified from 
 an extension forwards of the epiphysial plate behind. Even when 
 this calcanean tubercle has a separate centre, it is joined to the 
 epiphysis by a cartilaginous strip, by means of which it is soon 
 ossified on. In rare cases this tubercle has been found as a de- 
 tached process of bone. 
 
 3 K 2 
 
868 EPIPHYSES OF LOWER EXTREMITY 
 
 It is possible that separation of this epiphysis may be produced 
 by muscular action, and that cases which have been recorded of 
 fracture of this process in youth produced by muscular action are 
 really epiphysial detachments. 
 
 The author knows of no case where this separation has been 
 diagnosed during life, but he has seen the epiphysis crushed off by 
 the wheel of a tramcar in a case where other severe lesions from 
 crushing of the foot necessitated amputation of the leg. He has 
 also had to remove the epiphysis, which had become completely 
 necrosed and loose, in a girl aged ten years. Some weeks pre- 
 viously she had received a blow from a cricket-ball upon the 
 lieel. This led to suppuration Puud exfoliation of this process, 
 most probably from injury to the epiphysial line of junction, or 
 from its partial detachment. 
 
 Perfect recovery of the use of the foot may result even if some 
 displacement liars occurred. 
 
 Separation of the occasional epiphysis of the astragalus. — The author 
 reproduces one of four photographs given to him by Professor 
 
 J. G. Adami of specimens from the 
 McGill University Medical College 
 Museum, which show a separate 
 centre or ossification called the os 
 trigonum, remaining isolated from 
 the rest of the bone. This forms the 
 outer posterior tubercle of the astra- 
 galus, for the attachment of the 
 posterior astragalo -fibular ligament 
 (posterior fasciculus of external 
 lateral ligament of ankle-joint). 
 
 Fig. 284. — under surface of astraga- , , i ^ 'i „j „ 
 
 I.US sHowiNa occAsioN-AL EPIPHYSIS E. H. Beuuett has described a 
 
 (From a specimen in the Museum of case of separation of the secondary 
 
 McGill Medical College, Montreal) epiphysis of the astragalus W^hich is 
 
 occasionally met with. 
 
 Separation of the epiphysis of the first metatarsal bone. — The first 
 metatarsal bone is regarded by some anatomists as a phalanx, as it 
 has its epiphysis at the proximal end or base. The centre for this 
 is often found commencing as two osseous nuclei on either side of 
 the middle axis of the bone at the third year. M. Mayet describes 
 {Bulletins cle la Societe anatomique, Paris, Avril-Mai 1895, p. 384, 
 ' Developpement de I'extremite posterieure du premier metatarsien ') 
 one nucleus as forming the principal part of the epiphysis, and a 
 small accessory one appearing about the same time — viz. from 
 two to six years of age, and soon uniting with it. This epiphysis 
 joins w^ith the shaft a little earher than the epiphysis of the other 
 metatarsal bones, i.e. about the nineteenth 3-Gar. 
 
 There is very frequently found another distinct epiphysis at the 
 head or distal extremity. A more common condition, however, is 
 
NORMA.L EPIPHYSES OF ANKLE AND FOOT OP A FEMALE CHILD AGED SEVEN YEARS. 
 Six seconds exposure. Taken by Mr. Wm. Webster. 
 
SEPAEATION OF EPIPHYSES OF BONES OF FOOT 869 
 
 to find the osseous nucleus of the epiphysis at this end extending 
 forwards from the middle line of the diaphysis and then spreading 
 out in a mushroom-like manner into the epiphysis, so that a section 
 taken through either side at the middle line would represent the 
 epiphysis ossified by a distinct centre and separated from the shaft 
 by a complete layer of cartilage. 
 
 This anterior epiphysis (when present) is overlapped both above 
 and below by the synovial membrane of the metatarso-phalangeal 
 joint, and the latter is therefore likely to be opened in separation of 
 this epiphysis. 
 
 Fig. 285. — median sagittal section through great toe and inner row of 
 tarsal bones in a boy aged fourteen years 
 
 Relation of synovial membranes of tarso-metarsal, metatarso-phalangeal, and 
 interphalangeal joints to the epiphysial lines. None quite reach the epiphysial 
 boundary. If an anterior epiphysis exists to the first metatarsal bone, it will 
 be overlapped above and below by the synovial membrane (|-size) 
 
 Separation of the epiphyses of the four outer metatarsal bones. — The 
 
 shafts of the metatarsal bones are advanced in the process of ossifica- 
 tion at the time of birth, the ends being still cartilaginous. 
 
 In the four outer metatarsal bones a separate osseous centre 
 appears in the distal end or head between the third and the fifth 
 or even the eighth year. This head is entirely osseous by the tenth 
 to the twelfth year, and is separated from the shaft only by the thin 
 layer of epiphysial cartilage. These epiphyses unite with the shafts 
 from the eighteenth to twentieth year. 
 
 Occasionally the tuberosity of the fifth metatarsal bone is de- 
 veloped, according to Gruber, by a separate epiphysis. On the upper 
 and under aspects the synovial membrane of the metatarso-phalangeal 
 joint overlaps the epiphysial cartilage line (especially on the plantar 
 aspect) , whereas on the lateral aspects it extends only as high as the 
 attachment of the lateral ligaments, and hence it is at these points 
 below the level of the epiphysial junction. On the plantar aspect 
 there is a considerable amount of dense connective tissue separating 
 the latter from the synovial cavity of the joint, as well as from the 
 sheath of the flexor tendons lying more superficially. 
 
 In the London Hospital Museum Mr. Holmes states {Surgical 
 TreaUnent of Diseases of Children, 2nd edit. 1869, p. 238) that there 
 are two specimens of separation of the metatarsus associated with 
 slight fracture. The author has been unable to find these, and they 
 
870 EPIPHYSES OF LOWEE EXTEEMITY 
 
 are not contained in the recent catalogue of the museum of that 
 hospital (Joe. cit. sujjra). 
 
 The following case is recorded by Mr. James Mason {Lancet, 
 September 24, 1887) as a case of separation of the epiphysis of the 
 second metatarsal hone, but from the report it appears that it was 
 probably due to some disease at the epiphysial line. 
 
 A girl, aged seventeen years, complained of pain and swelling 
 over the root of the second toe of the left foot. She stated that the 
 ' lump ' had been there for some time ; it occasionally disappeared 
 when she put her foot in a certain position, but immediately she 
 tried to walk it reappeared. On examination it could be easily 
 reduced, but as readily returned to its old position when pressure 
 was removed. The movement at the joint was perfect. Well-marked 
 crepitus could be felt about a quarter of an inch behind the joint. 
 The fragments were put in apposition, and a pad applied. She 
 could not remember having received any injury or twist, and 
 considered it simply an 'enlarged joint.' She had been able to 
 walk about for a long time. The result of the treatment is not 
 recorded. 
 
 The author has seen a similar case of painless displacement, 
 due to disease, of the second metatarsal diaphysis of the left foot in 
 a boy, aged seven years. 
 
 Separation of the epiphyses of the phalanges of the toes. — At birth 
 the shafts of all the phalanges are well advanced in ossification, 
 their ends being cartilaginous. 
 
 The epiphysial ends of all the phalanges are formed at the 
 proximal extremity, and their ossific nuclei, often two in number on 
 either side of the middle line, appear about the fourth to the sixth 
 year, and form flattened plates about the tenth year, concave on 
 their articular aspect, and separated from the shafts by a layer 
 of cartilage. 
 
 These epiphyses join the shaft from the seventeenth to the 
 twentieth year, and ossification usually takes place in these phalanges, 
 like the metatarsal bones, from the first to the fifth toe. Beclard 
 gives the appearance of the ossification of the epiphyses of the first row 
 of phalanges as about the fourth year, and union with the shaft at the 
 eighteenth year ; that of the second row about the sixth year, and 
 union about the seventeenth year ; that of the third row about the 
 seventh year, and union about ihe seventeenth year. 
 
 The synovial cavity in none of the corresponding articulations 
 comes in contact with the epiphysial lines. 
 
 L. A. Stimson (Treatise on Fractures, London, 1883, p. 51) 
 relates a case of compound separation of the first phalanx of the 
 great toe. 
 
 A boy, aged thirteen years, caught his foot in machinery, and 
 received a compound comminuted fracture of the proximal phalanx 
 of the great toe. The smooth cartilaginous disc limiting the epi- 
 
SEPAKATION OF EPIPHYSES OF BONES OF FOOT 871 
 
 physis could be seen and felt through the wound. The patient 
 made a good recovery, and had a movable joint. 
 
 Mr. Gascoyen relates (British Med. Journal, April 1871, vol. i. 
 p. 338) the case of a child, eight years of age, who was under his 
 care at St. Mary's Hospital. The case at first sight might have 
 been mistaken for one of talipes equinus, as the child walked on 
 the outer side of the foot ; but on further examination it was 
 found that the head of the metatarsal bone of the great toe was 
 unnaturally prominent, and the extensor longus poUicis extremely 
 tense, the end of the toe being raised. All these appearances passed 
 away when the heel was put to the ground. There was a little pain 
 on manipulation, but no grating. The head of the metatarsal bone 
 could be felt intact, with a rounded movable piece adherent to it, 
 upon which the toe appeared to play. Extension completely reduced 
 the distortion, which, however, returned when the extension was 
 removed. Mr. Gascoyen accordingly thought that the case was an 
 example of separation of the epiphysis of the first phalanx of the 
 toe. The injury was produced by the child getting the toe under a 
 door whilst at play, and struggling to release herself. This was 
 three months previous to admission into hospital. Mr. Gascoyen 
 divided the extensor longus pollicis, and, after the wound had healed, 
 put the foot in a gutta-percha splint, which was firmly moulded to 
 the toe. The patient did well, and in about three weeks was able 
 to walk about almost naturally. 
 
PAET IV 
 
 SEPABATION OF THE EPIPHYSES OF THE 
 VEBTEBRM AND BIBS 
 
 CHAPTEE I 
 
 SEPARATION OF THE EPIPHYSES OF THE 
 VEKTEBRJE GENERALLY 
 
 Most of the vertebrae at the time of birth consist of three separate 
 osseous pieces, one for the body and one for each lamina, corre- 
 sponding to the three lyrimary centres. During the first year of life 
 the laminae become united behind in the cartilage of the spinous 
 process, which remains cartilaginous for some time, usually till the 
 age of puberty. Between the third and fourth years the body is 
 joined to the arch on each side; first in the third cervical vertebra 
 about the third year, and last in that of the fourth lumbar vertebra 
 about the sixth year. 
 
 Five secondary epiphyses are formed as follows : 
 
 One or two for the tips of the spinous processes at sixteen years 
 of age. 
 
 One for the end of each transverse process at sixteen to eighteen 
 years of age. 
 
 Two thin circular plates, or, more often, irregular rims of bone, 
 one on the upper, and the other on the lower surface of the body of 
 the vertebra ; the former piece being usually the thicker and appear- 
 ing from the eighteenth to the twentieth year, but showing itself 
 first in the lumbar region somewhat earlier, viz. at the seventeenth 
 year. They are present in all the vertebra except the atlas and the 
 last three coccygeal vertebras. 
 
 These epiphyses unite at the twenty-fifth year or even later. 
 
 Two specimens in the London hospital museums show the 
 ease with which the epiphysial discs of the bodies of the vertebrte 
 may be detached by severe crushing violence. As shown however 
 by the following example, the intervertebral cartilage may give way 
 at the junction with the epiphysis of the body of the vertebra rather 
 than the epiphysis at its line of union with the body. 
 
 Before the Pathological Society in March 1886 {Transactions of 
 the Pathological Society, London, vol. xxxvii. 1886, p. 385) Mr. 
 G. H. Makins showed a specimen of diastasis of the cervical spine 
 taken from the body of a male patient, aged twenty. Knocked down 
 
874 
 
 EPIPHYSES OF VEETEBE^ AND EIBS 
 
 in a street brawl, twenty-four hours before death, he had struck his 
 head on the paved tram-hne and become unconscious. He was 
 subsequently severely kicked. No more precise details could be 
 obtained. 
 
 When admitted he was conscious, but there was entire loss of 
 motive power from the neck downwards, and of sensation below the 
 third rib. Eespiration was entirely diaphragmatic ; pulse 60, 
 regular ; temperature in axilla, 95-0° ; semi-erect condition of 
 
 Fig. 286. — lumbae veetebra about the nineteenth xeae. veetical section 
 A, body of vertebra ; on its upper and lower surfaces osseous gi'anules (n n, o o) 
 appear in the cartilaginous plates and are most numerous and thick towards the 
 circumference ; p p, osseous centres, upper and lower, for the apex of the spinous 
 process ; S, additional centre in lumbar vertebife for the back part of the supe- 
 rior articular process (mammillary process) (Eambaud and Kenault) 
 
 X^^-- 
 
 ^ 3_ r 
 
 X. 
 
 Fig. 287. — antekioe view or lumbae veetebea 
 
 A, body ; o, lower epiphysial plate ; n, upper epiphysial plate, thicker in circumference 
 than in centre ; r, epiphysis for apex of transverse process (Eambaud and Eenault) 
 
 penis. He complained of tenderness over the mid-region of the 
 cervical spine when the fingers were passed along the processes, 
 but there was no deformity. He vomited occasionally, and had a 
 catch in the breath. The teinperature began to rise eight hours 
 after admission, and rose to 106° shortly before death. At the 
 autopsy a considerable amount of dark blood was seen effused into 
 the muscles and coverings of the spine in the neck and upper dorsal 
 
EPIPHYSES OF VEETEBR^ GENEEALLY 875 
 
 region of the spine. On examining the bodies of the vertebrse, there 
 was distinct gaping between the bodies of the fifth and sixth cervical ; 
 they were stih attached, however, by a portion of the anterior 
 common hgament. When this was divided the head at once feU 
 back, the bodies gaping widely, the intervertebral disc remaining 
 attached to the under surface of the fifth vertebra. There was 
 some effusion of blood between the bones and the dura mater, but 
 the sheath was untorn. 
 
 In the London Hospital Museum, No. 218, there is a specimen 
 of part of the spinal column of a young child in which the upper 
 epiphysis of the fourth dorsal vertebra has been torn off, and the 
 third dorsal, to which it is attached, is displaced backwards. The 
 child was brought to the hospital dead, having sustained fracture of 
 several ribs and laceration of the left lung by being run over. 
 
 Mr. J. Jackson Clarke kindly drew the author's attention to 
 the following specimen which he had placed in St. Mary's Hospital 
 Museum, No. 196. Dislocation forwards of the twelfth dorsal 
 vertebra had occurred, with complete dislocation of the last three ribs 
 on the left and partial dislocation of those on the right side. The 
 intervertebral disc and the lower epiphysial plate of the twelfth dorsal 
 vertebra remained attached to the first lumbar vertebra. The cord was 
 completely crushed. On section the other epiphysial plates of the 
 bodies appeared to be just uniting. The specimen was taken from a 
 man, aged about twenty-three, who was caught between the buffers 
 of two railway trucks. 
 
 The author has already drawn attention in this volume to the 
 probable origin of many cases of tuberculous disease of the spine, 
 viz. a partial separation or sprain of the upper or lower laminar 
 plate, giving rise in a tuberculous patient to caries and abscess. 
 
 Mr. Howse, at Guy's Hospital in 1887, removed a small nodule of 
 bone from an abscess cavity situated over the eighth to eleventh 
 dorsal spines in a boy (Thos. K.), aged thirteen years. He believed it 
 to be a separation of the epiphysis of the dorsal spinous process. The 
 abscess had developed after the use of the horizontal bar eighteen 
 months previously. There was no evidence of other disease of the 
 spine. Complete recovery ensued. 
 
876 
 
 EPIPHYSES OF VEETEBE/E AKD EIBS 
 
 SEPARATION OF THE EPIPHYSES OF THE DIFFERENT 
 
 VERTEBRA 
 
 Separation of the epiphyses of the cervical vertebrae. — In addition to 
 the centres common to the vertebrse generally, the anterior or 
 costiform parts of the transverse processes of the seventh, sixth, 
 and sometimes the fifth and second cervical vertebrae are developed 
 from separate osseous centres. They appear before birth (sixth 
 month of foetal life), and join at the fifth or sixth year, and are 
 analogous to the ribs in the dorsal region. 
 
 Fig. 288. — a cervical veetebba. the epiphtsial plate ox the upper surface 
 OF the body conceals the junction of the body with the lateral mass on 
 
 EITHER side 
 
 A, body of vertebra ; c, laminse ; e, e, costiform epiphyses of transverse processes 
 joining at j -with the lateral mass and at i with the extremity of the transverse 
 process. (After Eambaud and Eenault) 
 
 The spinous processes usually develop by two well-marked epi- 
 physial centres. 
 
 Eambaud and Eenault figure {Origine et cUveloppement ties os, 
 1864, p. 97, ' Atlas,' Plate VI., fig. 13) and describe a specimen of an 
 axis, communicated to them by M. Faucher, in which the right 
 epiphysial tubercle of the spine of the axis is believed to have been 
 separated by muscular action. 
 
 This portion of the spinous process has been displaced outwards, 
 but is still held to the bone by a well-marked ligamentous bundle, 
 and to its apex the rectus capitis posticus major and inferior oblique 
 muscle are still attached. It is, moreover, connected by fibrous 
 bands to the inferior articular process of the axis, and to the 
 corresponding bifurcation of the spinous process of the third cervical 
 vertebra. 
 
EPIPHYSES OF DiFFEPENT VEPTEBE.E 877 
 
 Separation of the epiphysial parts of the atlas. — The atlas at the 
 time of birth consists of two lateral portions of bone, comprising 
 the posterior arches and the greater part of the articular processes. 
 These two lateral pieces are separated behind by a small cartilaginous 
 interval and in front by the cartilaginous anterior arch. Ossification 
 commences in the anterior arch of the atlas at the end of the first 
 year, and consolidation with the lateral portions does not take place 
 till the fifth or sixth year. The posterior arches unite about the 
 third year. 
 
 For a detailed account of the development of the atlas the 
 reader is referred to Professor A. Macalister's article, ' Note on the 
 Development and Variation of the Atlas,' Journal of Anatomy and 
 Physiology, n.s. 7, 1892-93, p. 519. 
 
 Fro. 289. — atlas at the end op the first year of life, the centres of ossification 
 
 ALREADY GREATLY DEVELOPED 
 
 A, median centre ; B, B, lateral arclies ; a, a, cartilage between the body and the 
 lateral masses, the last vestige of the cartilaginous body ; b, cartilage separating 
 the arches behind ; c, c, transverse process ; e, e, foramen for vertebral artery. 
 (After Eambaud and Renault) 
 
 J. Macdonnell mentions {CycJopcedia of Practical Surgery, vol. ii., 
 article on ' Fracture ') that cases are recorded of rupture of the atlas 
 into its two lateral halves and of the odontoid process from the axis ; 
 but of these the author has been unable to obtain any account. 
 
 They will be exceedingly difficult to diagnose from external 
 symptoms, while as regards treatment every care should be taken to 
 prevent movement of the head or spine. 
 
 Separation of the epiphyses of the axis. — At birth the axis is com- 
 posed of four pieces of bone — one for the odontoid process (originally 
 formed of two nuclei before birth), another for the lower part of the 
 body and base of the odontoid process, and one for each arch and 
 lateral process. 
 
 The base of the odontoid process joins the body of the bone and 
 the neural arches on each side between the third and fourth year. 
 Soon after this time the lateral portions of bone join in front and 
 behind, completing the neural arch. Traces of the intervertebral 
 cartilaginous disc between the odontoid process and the body of the 
 Iwne are clearly to be seen at the twelfth year in a vertical section, 
 and traces may even persist throughout life. 
 
878 EPIPHYSES OF VEETEBE^ AND EIBS 
 
 The apex of the odontoid process is often formed by a distinct 
 centre of ossification appearing at the beginning of the second year, 
 and joining from the fourth to the twelfth year. 
 
 The centres for the spinous and transverse processes appear 
 about the seventeenth year. 
 
 There is a circular lamellar epiphysis as in the other vertebrse on 
 the lower aspect of the body. 
 
 For a minute account of the development of the axis see an 
 article by Professor A. Macalister, ' The Development and Varieties 
 of the Second Cervical Vertebra,' Journal of Anatomy and 
 Physiology, n.s. 8, Jan. 1894, p. 257. 
 
 A 
 
 Fig. 290. — axis towards the middle of the second yeah, vertical section 
 through odontoid process, exposing five cartilaginous lines 
 
 Tlie pedicle on each side is received into the retiring angle formed by the body, 
 A, and odontoid process, G. These two parts are separated by a cartilaginous 
 layer, thicker in centre than at either extremity, where it meets the apex of the 
 angles. An osseous centre, H, at this period appears in the cartilaginous apex, 
 g, of the odontoid process, which is soon invaded by it (Rambaud and Renault) 
 
 The examples of separation of the odontoid process of the axis 
 and of other parts of the cervical vertebrse given by Eognetta and 
 other writers are untrustworthy, and were in all probability due to 
 caries or other disease. 
 
 Separation of the epiphyses of the lumbar vertebrse. — In addition 
 to the centres common to the other vertebrse, the lumbar vertebrae 
 have separate centres of ossification for the mammillary processes 
 which are placed upon the superior articular processes. These 
 small epiphyses appear from the sixteenth to the twentieth year, 
 and unite, like the rest of the secondary epiphyses, about the 
 twenty-fifth year. 
 
 The whole of the transverse process of the first lumbar vertebra 
 is sometimes developed as a separate process. 
 
SEPAEATION OF EPIPHYSES OF SACKUM 879 
 
 SEPARATION OP THE EPIPHYSES OP THE SACRUM 
 
 . Besides the lamellar plates on the upper and mferior surfaces of 
 the bodies of the sacral vertebrae (especially marked in the first three) , 
 and the centres for each lamina and spinous tubercle, several centres 
 appear at the twentieth year in the lateral cartilages at the level of 
 each vertebra, which coalesce to form three epiphysial laminoa, while 
 
 Fig. 291. — anterior surface of the sacrum at the twenty-third year 
 
 M, epiphj'sis of the transverse process of the first sacral vertebra ; M', M", M'", 
 centres in the epiphysial plate of the lateral masses constituting three epi- 
 physial centres, which unite to one another and with the rest of the bone at 
 the twenty-eighth year (Rambaud and Renault) 
 
 the epiphysis of the transverse process of the first sacral vertebra 
 remains also distinct. 
 
 The three masses just mentioned often join to form a single 
 plate ; other anatomists describe them as two plates, one at the 
 annular surface, the other for the rest, or thinner portion of the 
 lateral margin below. 
 
830 EPIPHYSES OF VEETEBE^ AND EIBS 
 
 SEPABATION OP THE EPIPHYSES OP THE RIBS 
 
 Separation of the epiphysis of the head of the rib.— Towards the end 
 of puberty (about the eighteenth year) an osseous centre appears in 
 the cartilaginous head of the rib. Tliis soon assumes the form 
 of a small osseous plate, extends to the peripheral border of the 
 cartilage, and blends with the body of the bone about the twenty- 
 fourth or twenty-fifth year. 
 
 No instance has been recorded from injury. 
 
 2:. 
 
 Fig. 292. — last two ceevical akd first dorsal vertebra, between the 
 eighteenth and nineteenth tear 
 A A, bodies of vertebras ; e, cervical rib articulating at j with the lateral part of 
 seventh cervical body, and at i with the apex of the transverse firocess, c, of the 
 same vertebra. This represents the costiform centre so often seen in this and 
 occasionally in other lower cervical vertebrs, forming the front part of the 
 foramen for the vertebral artery. V, first rib ; K, epiphysis of head of first rib 
 (Ramband and Renault) 
 
 Separation of the epiphysis of the tuberosity of the rib. — About 
 the same time as the centre of the head there appears an epiphysis 
 for the articular portion of the tuberosity (corresponding to the 
 transverse process of vertebrae) . MM. Eambaud and Eenault have 
 also found in subjects of twenty-five years another osseous centre 
 for the non-articular portion for the posterior costo-transverse liga- 
 ment. 
 
 The articular epiphyses of the tuberosities of the eleventh and 
 twelfth ribs are either very slightly developed or, more usually, quite 
 absent. 
 
 These epiphyses unite with the body of the ribs at the twenty- 
 fifth or twenty-sixth year. 
 
 No instance of traumatic separation has been recorded. 
 
 [Separation of the three pieces of which the sternum is composed is not con- 
 sidered in this volume.] 
 
APPENDIX 
 
 LITEBATUBE INACCESSIBLE TO THE AUTHOB 
 
 ScHNiEBS (R. H.), Einiges i'lber Epiphysenlosung. 8". Leipzig 1869. 
 
 Earth (0.), ' Ueber Epiphysenlosimg und dereii Heilung,' Arch. d. Heilk. Leipz. 
 
 1870, xi. 263 571, 1 pi. 
 Earth (0.), ' Epiphysenlosung im spateren Alter ; hochgradige Arthritis deformans,' 
 
 ibid. 1872, xiii. 477-79. 
 Fischer (G.), ' Epiphysentrennung,' Mitth. a. d. cliir. Univ. Klin, zu Gottingen, 
 
 1861, 82-107. 
 Von Gerichten (C.E.), XJeher die Ahtrennung der Knochenansdtze,lnau.g.-Dissei't. 
 
 8°. Erlangen 1841. 
 Klose (C. W.), ' Die Epiphysentrennung, eine Krankheit der Entwickelungszeit,' 
 
 Prager Vierteljahrsschrift, 1858. Bd. 57, 97-124. For abstract see Archiv. 
 
 gen. de Med. 1858, 5. 2eme serie 146-55. 
 Eayer (G.), XJeher entziindliche Epijphysenahlosung. 8". Tubingen 1877. 
 SoHLiCHTiNG (W.), Ein Fall von Epijpliysentrennmig. 8°. Eostock 1863. 
 MiCHNiovsKi (S.), Izsliedovanija zajivlenija otorvannich ej^ijjJiezov (' On the 
 
 Separation of the Epiphysis '). St. Petersburg 1864. 
 Mazziotti (G.), 'Del distacco delle epifise, e sue differenze dalle fratture,' Gior. 
 
 internaz. d. sc. med. Napoli 1880, ii. 957-72. 
 Guidone (P.), ' Contribute alia etiologia e patogenesi del distacco epifisario,' Biforma 
 
 med. Napoli 1891, vii. 579-83. 
 Zappala (C.), ' Contributo alia patologia ed alia clinica del distacco. epifisario,' 
 
 Baccoglito remed. Forli 1885, 4 s. xxiii. 187, 217. 
 
 Upper Epiphysis of the Humerus 
 
 Harris (E.), ' Case of P'racture through the Articulation of the Epiphysis with the 
 
 Shaft of the Humerus, with impaction and remarkably speedy recovery.' 
 
 New York Medical Times, 1852-3, ii. 379-82. 
 Peterson (F.), ' A Case of Epiphysial Fracture of the Humerus, with dislocation.' 
 
 Buffalo M. and S. Journal. 1877-8, xvii. p. 449. 
 NovARO (G. F.), ' Divulsione traumatica, dell' epifisi superiore dell' omero destro,' 
 
 Osservatore. Torino 1875, xi. 785, 801, 818. 
 FuQUA (W. M.), ' Epiphysial Fractm-e of the Superior Extremity of the Humerus,' 
 
 Medical Herald. Louisville 1881-2, iii. 420. 
 
 Loiver Epiphysis of the Humerus 
 
 BoTTiNi (E.), ' Distacco traumatico dell' epifisi inferiore dell' omero sinistro,' 
 
 Osservatore. Torino 1880, xvi. p. 296. 
 EoTTiNi (E,), Bulletin Gen. de Thcrapcid, Paris 1850, xxxix. pp. 167-170. 
 
 3l. 
 
882 APPENDIX 
 
 McDiARMiD (J. L.), ' Case of Separation of the Lower Epiphysis af the Humerus,' 
 
 Canada Lancet. Toronto 1875-6, viii. p. 63. 
 Stuart (A. B.), 'A Case of Supposed Separation of the Lower Epiphysis of the 
 
 Humerus,' Trans. Minnesota Med. Sec. St. Paul 1876, p. 49. 
 Werner, ' Diductio epiphj^seos inferioris humeri,' Ztsch. f. Wunddrzte u. Gehurtsh. 
 
 Stuttg. 1865, xviii. p. 89. 
 Wight (J. S.), ' Partial Fiacture of both Bones of the Forearm near the wrist-joint 
 
 and Separation of the distal Epiphysis of the Humerus from a fall on the 
 
 palm of the hand,' Med. and Surg. Bejwrter. Phila. 1880, xliii. 141. 
 
 Upper Epiphysis of the Baclius 
 
 Stuart (A. B.), ' Separation of the Upper Epiphysis of the Radius,' Pacific M. and 
 S. Journal. San Fran. 1878-9, xxi. 164-166. 
 
 Lmver Epiphysis of the Ulna 
 
 TucKERMAN (L. B.), ' Separation of the Lower Epiphysis of the ULna,' The Trans- 
 actions. Youngstown. Ohio 1879-80, i. 101. 
 
 Anterior Superior Spine of the Ilium 
 
 Albertin, ' Note sur un cas d'arrachement de I'epine iliaque antero-superieure par 
 la contraction musculairc du coutiirier,' Province Med. Lyon 1887, ii. 741. 
 
 Upper Epiphysis of the Tibia 
 
 Watson (J.), N. YorTc Med. Times. 1853-4, iii. 187. 
 
 Powell (N. A.), 'Bilateral Diastasis at the Superior Tibial Epiphyses,' Canada 
 
 Lancet. 1880-81, xiii. 39.4. 
 PoucEL, Marseille Med. 1869, vi. 847-58. 
 
 Tubercle of the Tibia 
 
 Mazzoni (G.), ' Un caso di distacco della tuberosita della tibia per avulsione 
 (arrachement), Bull. d. Soc. Lancisiana d' osj). di Boma. 1882, ii. 71-74. 
 
 Loioer Epiphysis of the Tibia 
 
 Albee (W. a.), ' Compound Separation of the Lower Epiphysis with Fracture of 
 the Fibula,' Tr. Maine Med. Assoc. Portland 1886, ix. pt. i. 117-20. 
 
INDEX OF NAMES 
 
 Abbe, Bobert, treatm°,nt of recent deformity 
 in separation of lower end of humerus, 
 330 
 
 Adami, J. G. (Montreal), specimen of separa- 
 tion of liead of femur, 628 ; specimen of 
 separation of epipiiysisof great trochanter, 
 666 ; specimen of separation of epiphysis 
 of lesser trochanter, 675 ; specimen of 
 separation of lower epiphysis of femur, 
 701 ; specimen of occasional epiphysis 
 of astragalus, 868 
 
 Adams, John, case of fracture of neck of 
 femur in young man, 646 ; specimen of 
 separation of lower epiphysis of femur, 
 728 ; case of simple separation of lower 
 epiphyses of tibia and fibula, 842 
 
 Adams, Eobert, condylo-trochlear fracture 
 of humerus, 407 ; specimen of separation 
 of lower epiphysis of femur, 734 
 
 Adams, W., specimen of separation of lower 
 epiphysis of femur, 738 
 
 Agnew, separation of upper epiphysis of 
 humerus, 208; condylo-trochlear fracture 
 of humerus, 413 ; separation of lower 
 epiphysis of radius, 527 ; specimen of 
 fracture of great trochanter, 665 ; treat- 
 ment of separation of lower epiphysis of 
 femur, 785 ; case of compound separation 
 of lower epiphysis of tibia, 834 
 
 Albee, W. a., case of compound separation 
 of lower epiphysis of tibia, 834 
 
 Alcock, Eutherfohd, case of compound 
 separation of lower epiphysis of femur, 
 697 
 
 Allis, Oscar H. (Philadelphia), straight 
 position for injuries of elbow, 323; 
 condylo-trochlear fracture of humerus, 
 415 ; treatment of fractures of humerus 
 penetrating elbow-joint, 418 ; relaxation 
 of fascia lata in fracture of neck of femur, 
 641 ; case of separation of lower epi- 
 physis of femur, 685 ; case of compound 
 separation of lower fibular epiphysis, 
 863 
 
 Amazons, custom of separating the epi- 
 physes of male children, 1 
 
 Amesbory, Joseph, no allusion to epi- 
 physial injury, 13 
 
 Anger, Benjamin, specimen of separation of 
 lower epiphysis of radius, 484, 489, 526 ; 
 specimen of separation of lower epiphyses 
 of tibia and fibula, 832 
 
 Annandale, T. (Edinburgh), specimen of 
 condylo-capitellar fracture of humerus, 
 429 ; case of fracture of olecranon, 465 ; 
 specimens of separation of lower epi- 
 physis of radius, 498, 504 ; case of simple 
 separation of lower epiphyses of radius 
 and ulna, 539 ; case of simple separation 
 of upper epiphysis of tibia, 810 ; case of 
 compound separation of lower epiphysis 
 of tibia, 837 
 
 Apple YARD, J., case of arrest of growth of 
 radius after separation of lower epiphysis, 
 570 
 
 Aedouin, specimen of separation of lower 
 epiphysis of femur, 729 
 
 Arthaud, earlier ossification of epiphyses 
 at ginglymoid joints, 22 
 
 AsHHUEST, John, junior, case of Compound 
 separation of lower epiphysis of humerus, 
 278 ; case of separation of lower epi- 
 physis of radius, 575 ; specimen of separa- 
 tion of upper epiphysis of tibia, 806 
 
 AsHTON, J. H., specimen of separation of 
 epiphysis of great trochanter, 666 
 
 Atkins, F. D. (Sutton), case of separation of 
 lower epiphysis of humerus, 298 ; case of 
 separation of epiphysis of metacai-pal 
 bone of index finger, 593 
 
 Atkinson, E. (Leeds), specimens of separa- 
 tion of lower epiphysis of femur, 716, 717 
 
 Austric, Gabriel, synovial burs® in relation 
 with external epicondyle of humerus, S9 5 ; 
 etiology of fracture of external epicondyle 
 of humerus, 395 ; experiments in fracture 
 of the external epicondyle of humerus, 
 398 ; cases of displacement of fractured 
 external epicondyle of humerus, 399, 
 400, 402 
 
 Bahr, experiments in fracture of lower end 
 of radius, 483 
 
 Bailly, possibility of epiphysial separation 
 at birth, 41 
 
 Baldwin, F. B. Judge (Rotherham), case of 
 compound separation of lower epiphysis 
 of humerus, 339 
 
 Barbarin, Emile, epiphysial disjunctions 
 rare, 1873, 11 ; experiments in patho- 
 logical anatomy, 59, 68 ; no arrest of 
 growth after correction of genu valgum, 
 107 ; specimen of separation of lower 
 epiphyses of radius and ulna, 504 ; cases 
 
 3 L 2 
 
884 
 
 INDEX OF NAMES 
 
 of arrest of growth of radius after sepa- 
 ration of lower epipliysis, 5G9 ; separa- 
 tion of lower epiphyses of ulna and 
 radius, 583 
 
 Bardeleben, epiphysial separations rare 
 injuries, 8 ; fracture of external epieon- 
 dyle of humerus, 397 
 
 Baedenheuee, cases of epiphysial separation 
 of the upper end of the humerus, 201 ; 
 etiology of separation of lower epiphysis 
 of humerus, 270 ; pathological anatomy 
 of separation of lower epiphysis of 
 humerus, 271, 274 ; cases of partial sepa- 
 ration of lower end of humerus, 274 ; 
 case of compound separation of lower 
 epiphysis of humerus, 280, 282, 283 ; ex- 
 tended position in treatment of fractures 
 at the elbow, 319, 323 ; treatment of de- 
 formity after separation of lower end of 
 humerus, 331 ; separation of lower epi- 
 physis of humerus, 336 ; etiology of 
 separation of lower epiphysis of humerus, 
 339 ; symptoms of separation of lower 
 epiphysis of humerus, 341, 344; frequency 
 of separation of internal epicondyle of 
 humerus, 353 ; treatment of separation 
 of internal epicondyle of humerus, 387 ; 
 fracture of external epicondyle of humerus 
 in adult, 397 ; separation of lower epi- 
 physis of radius, 487 
 
 Baediee, immediate massage treatment, 
 127 
 
 Baenett, J. E. S., case of compound separa- 
 tion of lower epiphysis of fibula, 8G4 
 
 Baeeos, etiology of detachment of external 
 epicondyle of humerus, 394 
 
 Baeton, J. M. (Philadelphia), cases of sepa- 
 ration of epiphysial head of femur, 639, 
 652 
 
 Battle, W. H., cases of separation of epi- 
 physial head of femur, 638 ; statistics of 
 intra-capsular fracture of neck of femur in 
 early life, 648 
 
 Bauby, immediate massage treatment, 127 
 
 Bauby and Baediek, result of fixation of 
 epiphysial fractures of lower end of 
 radius, 555 ; massage in separation of 
 lower epiphysis of radius, 576 
 
 Beach, case of compound separation of 
 lower end of humerus, 3t;9 
 
 Beaueieux (Orleans), case of dislocation 
 of ulna with fracture of internal epi- 
 condyle, 320 
 
 Beclaed, experiments in animals on the 
 growth in length of long bones, 17, 28 ; 
 union of coracoid process to scapula, 
 157 ; development of iliac crest, 606 ; 
 anatomy of epiphysis of spine of pubes, 
 6li>; development of upper epiphysis of 
 tibia, 798 ; development of tubercle of 
 tibia, 816 ; development of lower epi- 
 physis of tibia, 825 ; ossification of lower 
 epiphysis of fibula, 860 ; ossification of 
 epiphyses of phalanges of toes, 870 
 
 Bell, Sir Chas., suppurative periostitis 
 after eiwphysial separation, 120 ; aneu- 
 rysm produced by projecting diaphysis, 
 122 ; case of separation of upper epiphy- 
 sis of humerus, 171, 193; eondylo-tro- 
 chlear fracture of humerus, 406 ; etiology 
 of sepavatiortof head of femur, 621 ; speci- 
 
 mens of separation of lower epiphysis 
 of femur, 691, 739, 746 
 
 Bell, JosbPH (Edinburgh), on separate 
 acromion process, 151 ; treatment of 
 fractures near the elbow, 327 
 
 Bennett, E. H. (Dublin), no knowledge of 
 arrest of growth after epiphysial separa- 
 tion, 107 ; specimen of compound separa- 
 tion of coracoid process, 159 ; specimen 
 of compound separation of upper epi- 
 physis of humerus, 182 ; specimens of 
 separation of lower epiphysis of radius, 
 498, 511 ; symptoms of separation of 
 lower epiphysis of radius, 527 ; result in 
 a case of separation of lower epiphysis 
 of radius, 554; specimens of detachment 
 of great trochanter, 665 ; separate occa- 
 sional epiphysis of astragalus, 868 
 
 Berard, law regarding the direction of the 
 nutrient canal and the union of the 
 normal epiphyses, 22 
 
 Beeges, thesis on epiphysial separation of 
 the upper end of the humerus (1890), 14; 
 case of displacement subsequent to simple 
 separation of upper epiphysis of humerus, 
 191; cases of separation of upper epiphy- 
 sis of humerus, 200, 210 
 
 Beegmann, experimental operations in 
 animals on tlie conjugal cartilage, 33 
 
 Beethomiee, experiments in separating 
 lower epiphysis of humerus, 270 ; com- 
 plete extension in treatment of fractures 
 at elbow, 319 ; straight position for injuries 
 of elbow, 323, 324 ; experiments in 
 separating internal epicondyle of humerus, 
 351, 372 ; treatment of separation of 
 internal epicondyle of humerus, 387 ; on 
 detachment of external ejpicondyle of 
 humerus, 394, 395, 396, 401 ; detachment 
 of olecranon epiphysis, 460 
 
 Beeteanpi, Ambeosio (Turin), disjunction 
 of upper humeral epiphysis during de- 
 livery (1787), 3, 175 ; separation of upper 
 humeral epiphysis at birth, 40, 43 ; cir- 
 cular ecchymosis in epiphysial separa- 
 tion, 91 ; non-union after separation of 
 upper epiphysis of humerus, 253 ; case of 
 separation of lower epiphyses of radius 
 and ulna, 538, 583 ; specimen of separa- 
 tion of lower epiphysis of femur, 691 ; 
 separation of upper epiphysis of tibia, 802 
 
 BicHAT, case of compound separation of 
 upper epiphysis of humerus, 182 
 
 Bidder, experiments in animals regarding 
 arrest of growth of long bones, 104 ; cause 
 of arrest of growth, 108 ; arrest of growth 
 of humerus due to inflammation, 259 
 
 BinwELL, L. A., case of condylo-capitellar 
 fracture of humerus, 437 
 
 Billroth, experiments on the conjugal 
 cartilage, 33 ; sti-aight position for injuries 
 of elbow, 323 
 
 BiEKETT, John, arrest of growth due to 
 inflammatory affections near the epiphy- 
 sial cartilage, 120 ; case of separation of 
 upper epiphysis of humerus, 222 ; arrest 
 of growth of humerus due to inflamma- 
 tion, 259 ; case of separation of lower 
 epiphysis of femur, 684 ; case of displace- 
 ment forwards and inwards in separation 
 of lower epiphysis of femur, 775 ; case of 
 
INDEX OF NAMES 
 
 885 
 
 simple separation of upper epiphysis of 
 tibia, 815 ; cases of simple separation of 
 lower epiphysis of tibia and fibula, 842, 
 844 
 
 Birmingham, A. (Dublin), anatomy of 
 epiphysis of third trochanter, (577 
 
 Bitot, specimen of separation of upper end 
 of humerus produced during delivery, 
 43, 175 
 
 Blasius, specimen of separation of upper 
 epiphysis of tibia, 806 
 
 Blot, opinion as to occurrence of epiphy- 
 sial separation (1865), 10 
 
 BcECKEL, E., case of compound separation 
 of lower epiphysis of radius, 513 
 
 BoEBHAAVE, detachment of head of femur, 
 621, 652 
 
 BoNAMY, experiments in pathological ana- 
 tomy, 59 
 
 Bond, C. J. (Leicester), case of separation 
 of lower epiphysis of humerus with dis- 
 location of elbow-joint, 284 
 
 Bokck, Edward, erroneous views as to union 
 after epiphysial separation, 98 
 
 BoTTiNi, E., views upon separation of lower 
 epiphysis of humerus, 335 
 
 BoucHUT, description in 1867 of separation 
 of the epiphyses, 10 ; muscular violence 
 a cause of separation of the upper 
 humeral epiphysis, 42 ; several epiphyses 
 separated from syphilis, 85 ; dull crepitus 
 in epiphysial separation, 92 ; case of 
 separation of upper epiphysis of humerus 
 by muscular action, 174 ; case of arrest 
 of growth of tibia after fracture of lower 
 epiphysis, 847 
 
 BouEGDET, painful pronation of the arm in 
 young children, 95 
 
 BoussEAU, specimen of separation of anterior 
 spines of ilium, 608 ; specimen of separa- 
 tion of epiphysial head of femur, 625 
 
 Boyd, Stanley, muscular action causing 
 detachment of upper epiphysis of fibuhx, 
 42, 858 
 
 BoYER, possibility of epiphysial separation 
 at upper end of femur and humerus 
 (1815), 4 ; causes sufficient to produce 
 separation of the neck of the humerus, 
 38 ; rarity of separation of upper epiphy- 
 sis of humerus, 176 ; symptoms of sepa- 
 ration of epiphysial head of femur, 632 
 
 Bradford, E. H. (Boston, U.S.A.), cases of 
 separation of epiphysial head of femur, 
 637, 650, 660 
 
 Bret, J., histological features of epiphysial 
 separations, 60 
 
 Brinton, John H., specimen of separation 
 of lower epiphysis of femur, 734 
 
 Bristow, compression of brachial artery in 
 simple separation of lower end of humerus, 
 294 
 
 Broca, a., epiphysial separation easily pro- 
 duced on the dead subject (1865), 10 ; 
 difference in the growth of the ends of 
 the bones (1852), 18, 104; growth in 
 length of long bones due to greater thick- 
 ness of chondroid layer of conjugal 
 cartilage, 28; anatomy of the conjugal 
 cartilage, 32, 33 ; experiments in patho- 
 logical anatomy of epiphysial separations, 
 ■ 60 ; case of compound separation of the 
 
 lower end of femur through the conjugal 
 cartilage, 73, 698 ; epiphysial cartilage 
 remains with the epiphysis, 76 ; speci- 
 men of separation of lower epiphysis of 
 femur, 708 
 
 Brodie, Chas. Gordon, case of arrest of 
 growth of tibia after transverse fracture, 
 850 
 
 Brookes, W. P. (Cheltenham), case of com- 
 pound fracture of external condyle of 
 femur, 723, 793 
 
 Brown, C. Haig, case of separation of 
 anterior superior spine of ilium, 607 
 
 Browv, W. H., case of arrest of growth of 
 radius after separation of lower epiphysis, 
 568 
 
 Bruce, W. (Dingwall), treatment of fractures 
 of the elbow-joint, 326 
 
 Brun-Bourgeret, osteotomy for deformity 
 after fractures of external epicondyle of 
 humerus, 404 
 
 Brunn, a. v., relation of synovial mem- 
 branes of joints to conjugal cartilages, 37 ; 
 anatomy of epiphyses of phalanges of 
 digits (fig. 180), 600 
 
 Brunner, Conrad (Zurich), case of tetanus 
 from pressure of callus in simple separa- 
 tion of lower epiphysis of radius, 121, 
 518 
 
 Bbuns, Paul (Tlibingen), monograph in 
 1882 on cases of epiphysial separation 
 verified by an autopsy, 14 ; statistics as 
 regards age in epiphysial separation, 48 ; 
 frequency of the various separations, 52 ; 
 seventy-eight cases in 1882 verified by 
 direct examination, 54 ; pure separations, 
 73 ; number of instances of pure separa- 
 tions, 74 ; statistics of separation with 
 fracture of the diaphysis, 81 ; compound 
 separations, 86 ; union after separation 
 of the epiphyses, 98 ; non-union after 
 separation, 100 ; statistics of arrest of 
 growth in one hundred cases, 106 ; arrest 
 of growth of humerus after separation 
 of upper epiphysis, 106; lengthening of 
 femur after fracture, 116 ; arrest of 
 growth due to intiammatory affections 
 near the epiphysial cartilage, 120 ; com- 
 plications in epiphysial separations, 121 ; 
 replacement of diaphysis by operation 
 in simple cases, 130 ; resection of dia- 
 physial end in old separations, 132; case 
 of separation of the upper epiphysis of 
 the humerus, 171 ; statistics of sj)ecimen 
 of separation of upper epiphysis of 
 humerus, 177, 193 ; statistics of com- 
 pound separation of upper epiphysis of 
 humerus, 185; necrosis following com- 
 pound separation of upper epiphysis of 
 humerus, 187 ; symptoms in separation 
 of upper epiphysis of humerus, 196, 203 ; 
 case of separation of upper epiphysis of 
 humerus, 207 ; operative treatment of 
 recent separation of upper epiphysis of 
 humerus, 226 ; operative treatment of 
 old separation of upper epiphysis of 
 humerus, 233 ; cases of arrest of growth 
 of humerus after separation of upper 
 epiphysis, 256 ; etiology of separation of 
 lower epiphysis of radius, 483 ; statistics 
 of separation of lower epiphysis of 
 
886 
 
 INDEX OF NAMES 
 
 radius, 486, 526 ; statistics of com- 
 pound separations of lower epiphysis of 
 radius, 515; statistics of separation of 
 lower epiphysis of ulna, 581 ; etiology of 
 separation of head of femur, 621 ; se- 
 paration of lower epiphysis of femur, 
 683 ; separation of lower epiphysis of 
 femur :— etiology of, 690 :— statistics of, 
 691 :— specimen of, 705 ; cases of separa- 
 tion of epiphysis of tubercle of tibia, 
 818, 823 ; specimen of separation of 
 lower epiphysis of tibia, 831 
 
 Bryant, Thos., cases of separation of the 
 epiphyses, 13 ; case of stimulated growth 
 of epiphysial canilage after amputation, 
 31 ; two cases of arrest of growth of 
 humerus, 106 ; cases of arrest of growth 
 of humerus after fracture of diaphysis, 
 106, 260 ; specimen of arrest of growth 
 due to inflammatory affection near the 
 epiphysial cartilage, 120 ; cases of se- 
 paration of upper epiphysis of humerus, 
 198, 209, 220 ; case of arrest of growth 
 of humerus after separation of upper 
 epiphysis, 258 ; case of compound se- 
 paration of lower epiphysis of humerus, 
 282 ; cases of injury to brachial artery 
 in simple separation of lower end of 
 humerus, 293 ; specimen of condylo- 
 capitellar fracture of humerus with 
 dislocation of elbow, 429 ; case of com- 
 pound separation of olecranon epiphysis, 
 400 ; specimen of separation of lower 
 epiphysis of radius, 502 ; case of de- 
 formity after separation of lower epi- 
 physis of radius, 556 ; cases of separa- 
 tion of lower epiphysis of femur, 684, 
 774, 780 ; case of ablation of lower ex- 
 tremity at lower epiphysis of femur, 692 ; 
 case of arrest of growth after injury to 
 upper epiphysis of tibia, 811 ; cases of 
 simple separation of upper epiphysis of 
 tibia, 813, 815 ; cases of compound se- 
 paration of lower epiphysis of tibia, 835, 
 837 ; case of simple separation of lower 
 epiphysis of tibia, 844 
 
 Buck, ease of simple separation of lower 
 epiphysis of radius, 530 ; case of separa- 
 tion of lower epiphysis of femur, 738 
 
 BuscH, function of articular layer of carti- 
 lage of epiphysis, 36 
 
 BuTTNEE, O., Eontgen process in epiphysial 
 injuries, 304 
 
 Callaway, Thomas, cases of fracture of 
 surgical neck of humerus in children, 
 218 
 
 Callender, fracture of lower end of 
 i-adius by muscular action, 484 ; specimen 
 of fracture of lower end and of separation 
 of lower epiphysis of radius, 498; sepa- 
 ration of lower epiphysis of femur in 
 straightening ankylosed knee, 684 ; case 
 of compound separation of lower epiphy- 
 sis of femur, 751 
 
 Camper, treatment of fractured olecranon, 
 467 
 
 Canton, E., specimen of incomplete separa- 
 tion of lower epiphysis of ulna, 582 ; 
 specimens of separation of lower epiphy- 
 sis of femur, 703, 708 
 
 Caeus, intra-uterine separation of the lower 
 tibial epiphysis, 43, 827 
 
 Cathcart, C. W. (Edinburgh), specimen of 
 separation of lower epiphysis of femur, 
 739 
 
 Cesae, a., etiology of fracture of internal 
 epicondyle of humerus, 349, 350 ; 
 cases of separation of internal epicondyle 
 of humerus, 352, 374 ; injury to ulnar 
 nerve in displacement of internal epicon- 
 dyle of humerus, 365 ; case of dislocation 
 of elbow with separation of internal epi- 
 condyle of humerus, 368 ; treatment of 
 fracture of internal epicondyle of humerus, 
 386 
 
 Champenois, case of epicondylo-capitellar 
 fracture of humerus, 423 
 
 Champion, examination of epiphysial in- 
 juries after death (1817), 4 ; forcible 
 torsion in separation of humeral epi- 
 physes, 41 ; cases of separation of lower 
 tibial epiphysis at birth, 40, 43, 44 ; 
 specimen of separation of upper epiphy- 
 sis of humerus, 178 ; case of separation 
 of lower end of humerus, 273 ; case of 
 separation of lower epiphysis of tibia in 
 foetus, 827, 839 
 
 Championnikre, Lucas, immediate massage 
 treatment, 127 
 
 Champmas, thesis dealing with separations, 
 1840, 6 ; inability to produce dislocation 
 in the newly born, 44 ; table showing in 
 1840 order of frequency of the various 
 separations, 53 
 
 Charvot, etiology of fracture of extei'nal 
 epicondyle of humerus, 395 
 
 Chassaignac, true separation of the epi- 
 physes very rare in 1865, 10, 72 ; painful 
 pronation of the arm in young children, 95 
 
 Chassaniol, case of compound separation of 
 lower epiphysis of femur, 722 
 
 Chaussier, case of intra-uterine separation 
 of an epiphysis, 43 
 
 Chauvel, allusion to separation of coracoid 
 epiphysis, 161 ; specimen of separation 
 of lower epiphysis of femur after 
 straightening ankylosed knee, 684, 749 
 
 Cheever, D. W., diagnosis of separation of 
 upper epiphysis of humerus, 217 ; separa- 
 tion of the internal epicondyle of humerus, 
 360, 373 ; separation of olecranon epi- 
 physis, 461 
 
 Chelius, symptoms of separation of epi- 
 physial head of femur, 632 
 
 Cheyne-Watson, primary operations for 
 irreducibility, 130 
 
 Chiene, John (Edinburgh), on separate 
 acromion process, 151 
 
 Clark, F. Le Geos, case of simple separa- 
 tion of the epiphysis of the clavicle, 140 ; 
 cases of separation of upper epiphysis of 
 humerus, 203, 211 ; case of simple separa- 
 tion of lower epiphysis of radius with 
 displacement forwards, 552 
 
 Clark, H. E. (Glasgow), compound separa- 
 tion of upper epiphysis of humerus with 
 wound of axillary artery, 185 ; case of 
 simple separation of lower end of humerus 
 in infancy, 290 ; case of separation of 
 upper epiphysis of humerus, 200, 202 ; 
 diagnosis of separation of upper epi- 
 
INDEX OF NAMES 
 
 887 
 
 physis of humerus, 215 ; cases of 
 compound separation of lower epiphysis 
 of tibia, 835, 837 
 
 Clabke, F. E., case of compound separation 
 of lower epiphysis of humerus, 337 
 
 Clabke, J. Jackson, specimen of separation 
 of upper epiphysis of body of dorsal 
 vertebra, 875 
 
 Clay, Augustus, case of arrest of growth 
 after separation of lower epiphysis of 
 radius, 564 
 
 Cloquet, Jules, specimen of separation of 
 lower epiphysis of radius, 9, 482, 488 
 
 Glutton, H. H., case of compound separa- 
 tion of lower epiphysis of femur, 745 
 
 Cock, E., case of compound separation of 
 lower epiphysis of radius, 514 ; case of 
 suppurative periostitis of ulna after 
 injury to lower epiphysis, 583 ; cases of 
 separation of lower epiphysis of femur, 
 685, 690 ; specimen of separation of 
 lower epiphysis of femur, 693 
 
 CoLiGNON, Jules, thesis on traumatic dis- 
 junction of the epiphyses in 1868, 11 ; 
 epiphysial separations mostly between 
 twelve and thirteen years of age, 45 ; 
 epiphysial separations more frequent 
 during adolescence, 48; lower epiphysis 
 of radius most frequently separated, 53 ; 
 experiments in pathological anatomy on 
 newly born children, 59, 68 ; experiments 
 as regards periosteum, 63 ; experiments in 
 indirect violence on the epiphyses of long 
 bones of infants, 65, 67 ; experimental 
 separation of the upper epiphysis of the 
 humerus, 170 ; separation of olecranon 
 epiphysis, 461 ; etiology of separation of 
 lower epiphysis of radms, 481 : — statistics 
 of, 487 ; specimen of separation of lower 
 epiphysis of radius, 496 ; symptoms of 
 separation of lower epij)hysis of radius, 
 523, 530, 538 ; dislocation of wrist in 
 children, 544 ; arrest of growth of radius 
 after separation of lower epiphysis, 572 ; 
 cases of separation of epiphysial head of 
 femur, 632 ; etiology of separation of 
 lower epiphysis of femur, 690 
 
 Collins, osteoclasis in genu valgum, 689 
 
 Columbus, Eealdus, possible occurrence of 
 epiphysial separation (1559), 1 
 
 CooPEK, Sir AsTLEY, epiphysial separa- 
 tions mistaken for dislocations, 1842, 6 ; 
 separation of the upper epiphysis of 
 humerus, 193, 209 ; case of separation of 
 upper epiphysis of humerus, 2l)2 ; separa- 
 tion of lower epipliysis of humerus, 28S ; 
 fracture of external epicondyle of hume- 
 rus, 396 ; case of injury to ulnar nerve in 
 separation of internal epicondyle of hu- 
 merus, 380 ; cases of condylo-trochlear 
 fracture of humerus, 406, 407, 409 ; 
 cases of epicondylocapitellar fracture of 
 humerus, 423, 425, 432, 436, 443, 445; 
 case of fracture of olecranon epiphysis, 
 463 ; treatment of fractured olecranon, 
 467; subluxation of radial head, 475; 
 experiments upon lower end of radius, 
 483 ; dislocation of wrist in children, 544 ; 
 dorsal dislocation of femur in childhood, 
 643 ; specimen of separation of epiphysis 
 of great trochanter, 663 ; case of com- 
 
 pound fracture of lower end of femur, 
 794 ; specimen of separation of lower 
 epiphysis of tibia, 831 
 
 Cooper, Bransby B., case of fmcture of 
 anterior spine and crest of ilium, 609 
 
 CoppiNGER, Chas., Rontgen rays in dia- 
 gnosis of separation of lower epiphysis of 
 radius, 549 
 
 CoRLETTE, C. E., case of fracture of anterior 
 superior spine of ilium, 607 
 
 ConxER, F. M., case of simple separation 
 of lower epiphysis of tibia, 840 
 
 CossEEET, A. T., thesis in 1866 on divul- 
 sion of the epiphyses, 10 
 
 CouDRAY, case of displacement of fractured 
 external epicondyle of humerus, 399 ; 
 result in a case of fracture of external 
 epicondyle of humerus, 402 
 
 CouLON, A., rarity of traumatic separations, 
 1861, 8, 71 ; cases of fracture of the 
 surgical neck of humerus in children, 217 ; 
 extended position in transverse fracture 
 of lower end of humerus, 324 ; cases of 
 separation of epitrochlea of humerus, 
 362 ; treatment of separation of internal 
 epicondyle of humerus, 387 ; symptoms of 
 fracture of external epicondyle of hume- 
 rus, 398 ; case of condylo-trochlear 
 fracture of humerus, 411 ; cases of epi- 
 condylo-capitellar fracture of humerus, 
 438 ; fracture of lower end of radius, 484 
 
 CouLsoN, cases of separation of internal 
 epicondyle of humerus, 352, 379 
 
 CouRAL (Narbonne), specimen of separa- 
 tion of lower epijphysis of femur, 733 
 
 Croft, J., plaster-of-Paris splints, 314 
 
 Cbuveilhieb, published cases of epi- 
 physial separation not trustworthy, 1849, 
 7 ; formation of the epiphyses, 17 ; order 
 of union of the normal epiphyses, 28 ; 
 putrefaction the cause of epiphysial 
 separation during childbirth, 43 ; experi- 
 ments in pathological anatomy of epi- 
 physial separations, 59 ; experimental 
 detachment of upper end of ulna, 460 ; 
 experiments in detaching lower epiphysis 
 of radius, 482 ; case of separation of epi- 
 physial head of femur, 632 
 
 CuKNOW, ununited coracoid epiphysis, 160 
 
 Cdrtillet, Joseph, proportion of cases of 
 epiphysial injury to fracture in children, 
 1891, 15 ; statistics of twenty-one epi- 
 physial separations, 47 ; histological fea- 
 tures of epiphysial separations, 60, 63, 
 62 ; twenty-four cases of arrest of growth, 
 106 ; separations considered histologically 
 as fractures, 111 ; necrosis of diaphysis 
 after separation, 118 ; massage in separa- 
 tion of upper epiphysis of humerus, 244 ; 
 cases of arrest of growth of humerus 
 after separation of upper epiphysis, 257 ; 
 case of compound separation of lower 
 epiphysis of radius, 514 ; cases of arrest 
 of growth after separation of lower 
 epiphysis of radius, 563 ; case of arrest 
 of growth of ulna due to suppuration 
 following compound separation of lower 
 epiphysis, 585 ; experimental separation 
 of lower epiphysis of tibia, 823 
 
 Cusco, case of compound separation of 
 lower epiphysis of femur, 694 
 
888 
 
 INDEX OF NAMES 
 
 Dale, symptoms in separation of upper 
 epijjhysis of humerus, 204 
 
 Da:s"iels (British Guiana), specimen of 
 separation of epiphysis of great tro- 
 chanter, 667 
 
 Davaixe, case of displacement subsequent 
 to simple separation of upper epiphysis 
 of humerus, 191 
 
 Davies-Cqllet, case of separation of upper 
 epiphysis of humerus, 210 ; case of 
 separation of olecranon epiphysis, 461 ; 
 case of simple separation of lov/er epi- 
 
 . physis of radius, 540 ; case of separation 
 of portion of iliac crest, 609 ; specimen 
 of separation of epiphysial head of femur, 
 628 ; case of separation of epijphysial 
 head of femur, 640 ; cases of separation 
 of lo^Yer epiphysis of femur, 771, 785 ; 
 specimen of separation of upper epiphysis 
 of tibia, 804 ; case of arrest of gr'owtli of 
 tibia after injury to lower epiphysis, 847 
 
 Davison, W. T. (Pennsylvania), case of 
 compound separation of lower epiphysis 
 of femur, 728, 734 
 
 Deaneslt, Ed. (Wolverhampton), cases of 
 injury to nerves in separation of lower 
 epiphysis of humerus, 310 
 
 Dicbeuyn, specimen of detachment of in- 
 ternal epicondyle with dislocation of 
 elbow, 358 
 
 De la Motte, epiphysial separation during 
 childbirth, 43 ; separation of upper end 
 of humerus during delivery, 175 
 
 Delens, monograph in 1884 on separation 
 of the lower epiphysis of the femur, 14 ; 
 sex in separation of the lower epiphysis 
 of the femur, 50 ; frequency of separation 
 of the lower epiphysis of the femur, 63 ; 
 fracture of inner end of clavicle, 136 ; 
 separation of lower epiphysis of fe- 
 mur :— statistics of, 683, 686, 691, 
 
 . 711: — etiology of, 689; case of com- 
 pound separation of lower epiphysis of 
 femur, 752 ; treatment of compound 
 separation of lower epiphysis of femur, 
 792 
 
 Deloee, no arrest of gi'owth after correc- 
 tion of genu valgum, 107; straightening 
 limb in genu valgum, 689 ; separation of 
 upper epiphysis of tibia in straightening 
 genu valgum, 803 ; case of separation of 
 upper epiphysis of fibula, 859 
 
 Delop.me, gunshot fractures of the epiphyses, 
 09 
 
 Delpech, J., doubts in 1S23 as to the 
 reality of Eeichel's specimens, 3 ; doubts 
 in 1816 as to existence of epiphysial 
 separations, 4 ; specimen of separation 
 of lower epiphysis of femur, 733 
 
 De Morgan, case of separation of epiphysial 
 head of femur, 634 ; case of separation 
 of epiphysis of tubercle of tibia, 817 
 
 Demoulin, a., case of separation of upper 
 epiphysis of humerus by indirect violence, 
 172, 197 
 
 Denonvilllebs, case of compound separa- 
 tion of lower epiphysis of radius, 514 ; 
 case of displacement forwards (compound) 
 of lower epiphysis of radius, 520 ; re- 
 section of diaphysis in compound separa- 
 tion of lower epiphysis of radius, 578 
 
 Dexuck, fracture of inner condyle of humerus 
 by muscular action, 349 ; separation of 
 internal epicondyle of humerus, 352 ; 
 neuralgia of ulnar nerve in displaced 
 internal epicondyle of humerus, 359 ; 
 fracture of external epicondyle of humerus, 
 395 ; condylo-trochlear fracture of hu- 
 merus, 406 
 
 De Paoli, Ekasmo, monograph in 1882 on 
 epiphysial separations, 15 ; frequency of 
 the various separations in one hi^ndred 
 and five cases, 53 ; measurements of upper 
 epiphysis of humerus at different ages, 
 165 ; separation of upper epiphysis of 
 humerus through conjugal cartilage, 
 177 : — statistics of, 193 ; cases of opera- 
 tive treatment of recent separation of 
 upper epiphysis of humerus, 228 ; table 
 of measurements of lower epiphysis of 
 humerus, 265 ; measurements of lower 
 epiphysis of radius and ulna, 480 ; 
 etiology of separation of lower epiphysis 
 of radius, 481, 483 ; age in cases of 
 separation of lower epiphysis of radius, 
 485 : — statistics of, 487 ; specimens of 
 separation of lower epiphysis of radius, 
 494, 496 ; symptoms of incomplete separa- 
 tion of lower epiphysis of radius, 524 ; 
 complications in separation of lower epi- 
 physis of radius, 538; specimen of frac- 
 ture of lower end of radius, 548 ; case of 
 deformity after separation of lower epi- 
 physis of each radius, 555 : — specimen 
 of, 556 ; arrest of growth after separation 
 of lower epiphysis of radius, 562 ; table 
 of measurements of upper epiphysis of 
 femur, 618 ; incomplete separation of 
 head of femur, 631 ; table of measure- 
 ments of lower epiphysis of femur, 679 ; 
 table of measurements of upper epiphysis 
 of tibia, 800 ; table of measurements of 
 lower epiphyses of tibia and fibula, 
 826 
 
 Desault, condylo-trochlear fracture of 
 humerus, 406 ; compound fracture of 
 condylo-capitellar portion of humerus, 
 431 
 
 Desormaux, dislocation of wrist in children, 
 544 
 
 Devekgie, case of intra-uterine separation 
 of the lower tibial epiphysis, 43 
 
 DiTTJiATER, thesis on arrest of growth 
 following traumatic separations, 1887, 
 15 ; cases of arrest of growth of humerus 
 after separation of upper epiphysis, 257 
 
 Dixox, A. F., anatomy of epiphysis of third 
 trochanter, 677 
 
 DoLBEAU, two specimens of separation of 
 the lower epiphysis of the radius in 1865, 
 10, 498; signs of separation of lower 
 epiphysis of radius, 526 ; case of separa- 
 tion of lower epiphyses of ulna and 
 radius, 582 ; case of compound separation 
 of lower epiphysis of femur, 720 
 
 DoLLO, anatomy of epiphysis of third tro- 
 chanter, 677 
 
 Donovan, J. A. (Lewiston, U.S.A.), case 
 of compound separation of lower epi- 
 physis of femur, 736, 753 
 
 Dorset, J. S., treatment of fractures of 
 humerus penetrating elbow-joint, 416 
 
INDEX OF NAMES 
 
 889 
 
 Dowu, C. N., dislocation of humerus witli 
 fracture of surgical neck, 186 
 
 DcBKOCA, epiphysial separation of upper 
 end of humerus during childbirth, 43, 175 
 
 DuGAS, L. A., test for dislocation of head 
 of humerus, 216 
 
 DuHAMEL, anatomy and physiology of the 
 ends of the bones, 17, 18, 104 ; intimate 
 connection of the epiphyses with the 
 periosteum, 35 
 
 Dukes, CiiEJiENT (Rugby), case of separation 
 of internal epicoudyle of humerus, 349 ; 
 case of simple separation of lower epi- 
 physis of femur, 762 
 
 Dumont-Pallier, articular epiphyses sepa- 
 rated in scurvy, 86 
 
 Dunn, L. A., case of separation of capi- 
 tellum of humerus, 454 
 
 DuPLAY, case of separation of upper epi- 
 physis of humerus by indirect violence, 
 173 
 
 DupuT, case of suppuration following com- 
 pound separation of upper epiphysis of 
 humerus, 188 
 
 DupuYTP.EN, dismissal of subject of epiphy- 
 sial injuries in 1815, 4 ; case of simple 
 separation of lower end of humerus 
 mistaken for dislocation, 287, 301 ; treat- 
 ment of fractured olecranon, 467 ; sepa- 
 ration of lower epiphysis of radius, 487, 
 526 ; specimen of dwarfed radius with 
 displacement forwards of its lower epiphy- 
 sis, 521 ; case of separation of os innomi- 
 natum into its original i^arts, 605 ; separa- 
 tion of epiphysial head of femur, 625 
 
 DuRHAii, A. E., case of simple separation of 
 upper epiphysis of humerus, 191 ; cases 
 of separation of upper epiphysis of 
 humerus, 213, 220, 223 ; case of separa- 
 tion of lower end of humerus, 296 ; 
 case of condylo-trochlear fracture of 
 humerus, 411 ; case of simple separation 
 of lower epiphysis of radius, 530 ; speci- 
 men of sex^aration of lower epiphysis of 
 femur, 712 ; cases of simple separation of 
 lower epiphysis of femur, 762, 775 ; speci- 
 men of separation of upper epiphysis of 
 tibia, 803, 808 ; case of simple separation 
 of upper epiphysis of tibia, 812 ; case of 
 separation of lower epiphysis of tibia, 
 829 ; cases of simple separation of lower 
 epiphyses of tibia and fibula, 842, 844 
 DuROCHEE, Ch.\pelain, Separation of humeral 
 epiphysis at birth, 41 ; separation of 
 upper end of humerus in the newly born, 
 176 ; non-union after separation of upper 
 epiphysis of humerus, 100, 253 
 Duval, Ange, case of compound separation 
 
 of lower epiptiysis of femur, 723 
 Duverney, G. J., fractures and separations 
 of the neck of the femur, 1751, 3 ; sepa- 
 ration of epiphysial head of femur, 624, 
 632 
 DwiGHT, times of union of epiphyses, 25, 
 27, 28 
 
 Eames, William, case of fracture of 
 olecranon epiphysis, 462 
 
 Elder, J. M. (Montreal), etiology of separa- 
 tion of lower epiphysis of femur, 691 ; 
 
 case of compound separation of lower 
 epiphysis of femur, 700 
 
 Elsner, F. W., case of simple separation 
 of lower epiphysis of femur, 760 ; case 
 of separation of lower epiphysis of femur 
 treated by operation, 788 
 
 Erdmann, J. F. (New York), case of separa- 
 tion of upper epiphysis of humerus mis- 
 taken for dislocation, 214 ; case of im- 
 paired growth of humerus after separa- 
 tion of upper epiphysis, 256 ; case of 
 simple separation of lower epiphyses of 
 radius and ulna, 540 
 
 Erichsen, Sir John E., articular lesions 
 often absent in epiphysial separations, 84 ; 
 resection of diaphysial end in compound 
 separations, 128 ; erroneous view of ana- 
 tomy of lower epii^hysis of humerus, 265 ; 
 case of compound separation of lower 
 end of humerus, 329 
 
 Esjiarch, case of separation of the upper 
 end of the humerus through the conjugal 
 cartilage, 73 ; suppuration after epiphysial 
 separation, 118 ; resection of diaphysial 
 end in compound separation, 128 ; case 
 of compound separation of u^iper epi- 
 physis of humerus, 178, 241 ; suppura- 
 tion following separation of upper epi- 
 physis of humerus, 186 
 
 Eve, F. S., specimen of compound separa- 
 tion of lower epiphysis of femur, 704 
 
 Eyssonius, H., diseases and separations of 
 the bones in children (1625), 2 
 
 Fabeice de Hilden, allusion in 1646 to 
 separation of the upper epiphysis of the 
 femur, 2 ; case of separation of epiphy- 
 sial head of femur, 624, 642 
 
 Fallier, age and sex in separation of 
 external epicondyle of humerus, 352 ; 
 detachment of internal epicondyle with 
 dislocation of elbow, 358, 361, 362, 368 ; 
 cases of dislocation of ulna with fracture 
 of internal epicondyle, 370, 371, 372, 
 382 
 
 Farabeuf, article on separation of the lower 
 epiphysis of the humerus (1886), 14, 
 270 ; views upon separation of lower 
 epiphysis of humerus, 335, 341; etiology 
 of separation of lower epiphysis of 
 humerus, 339 ; epicondylo-capitellar 
 separation of humerus, 422 
 
 Faucher, specimen of separation of epi- 
 physis of spine of axis, 876 
 
 Fenwick (Montreal), specimen of separation 
 of ej)iphysis of lesser trochanter, 675 
 
 Fergusson, Sir William, epiphysial separa- 
 tion the same as fracture, 1846, 12 ; 
 diagnosis of separation of the epiphyses, 
 95 ; non-union of acromion process, 149 
 
 FiNLEY, Harry, case of compound separa- 
 tion of lower epiphysis of humerus, 279 
 
 Fischer, F., resection in old condylo-capi- 
 tellar fractures of humerus, 446 
 
 Fischer, H., suppuration of joint following 
 epiphysial separation, 103 ; necrosis of 
 epiphyses of fibula after separation, 120 ; 
 arrest of growtli due to inflammatory 
 affections near the epiphysial cariilage, 
 120 ; case of separation of lower epiphysis 
 
890 
 
 INDEX OF NAMES 
 
 of femur, 766 ; specimen of separation of 
 upper epiphysis of tibia, 808 
 
 FiiETCHEE,specimen of fracture of olecranon, 
 465 
 
 Flourens, p., anatomy and physiology of 
 the ends of the bones, 17, 18, 22, 31, 104 
 
 FoNTENELLE, JuLiA, case of compound 
 separation of lower epiphysis of femur, 
 67, 732 
 
 FoESTEB, Cooper, case of separation of 
 upper epiphysis of humerus in partial 
 paralysis, 175 ; case of compound separa- 
 tion of lower epiphyses of radius and 
 ulna, 506 ; case of simple separation of 
 lower epiphysis of radius, 541 ; cases 
 of simple separation of lower epiphysis of 
 femur, 776, 785 ; cases of simple separa- 
 tion of lower epiphysis of tibia, 828, 
 829, 844 ; case of compound separation 
 of lower epiphysis of tibia, 835 ; case of 
 simple separation of lower epiphysis of 
 tibia with fracture of external malleolus, 
 843 
 
 FoucHEE, classification and experiments in 
 traumatic disjunction of the epiphyses, 
 1860, 8 ; collection of cases of epiphysial 
 separation in 1863, 8 ; muscular violence 
 a cause of separation of the ujoper end of 
 humerus, 42 ; site of epiphysial separa- 
 tion, 58 ; numerous experiments on the 
 dead body especially as regards mechan- 
 ism, 60 ; experiments on the epiphyses of 
 long bones of infants, 65, 66, 67 ; classifi- 
 cation of separations according to site, 72 ; 
 incomplete separation, never seen by him, 
 77 ; prognosis in intra-articular epiphysial 
 separations, 102 ; from one to five years 
 of age osseous tissue clings to epiphysial 
 cartilage in separations, 79 ; stripping up 
 of periosteum, 82 ; case of separation of 
 upper epiphysis of humerus by muscular 
 action, 174 
 
 FouLERTON, A., case of separation of upper 
 epiphysis of radius, 472 
 
 FouRNiER, case of separation causing ostitis, 
 &c., 85 
 
 Franchet, etiology of fracture of external 
 epicondyle, 395 
 
 Fraser, dislocation of head of humerus in 
 a boy, 214 
 
 Freeman, L. (Denver, U.S.A.), Eontgen 
 rays in deformity after epiphysial separa- 
 tion of lower end of radms, 559 
 
 Freee, a. Hanbury, straight position for 
 injuries of elbow, 323, 324, 326; treat- 
 ment of separation of internal epicon- 
 dyle of humerus, 387, 388 
 
 Fdllerton, Andrew, specimen of separa- 
 tion of cartilaginous parts of scapula in 
 infancy, 144 ; case of simple separation 
 of lower epiphysis of humerus, 342 
 
 FiJEST, epiphysis of third trochanter, 677 
 
 Galand, case of compound dislocation of 
 elbow with separation of lower epiphysis 
 of radius, 516 
 
 Gascoyen, case of separation of epiphysis 
 of first phalanx of great toe, 871 
 
 Gay, resection of diaphysial end in com- 
 pound separations, 128 ; case of com- 
 
 pound separation of lower epiphysis of 
 femur, 697 
 
 Gegenbauer, anatomy of the conjugal car- 
 tilage, 33 
 
 Geoghegan, specimen of complete displace- 
 ment of lower epiphysis of radius, 491, 
 506 
 
 Ghillini, C, experiments on the conjugal 
 cartilage, 113 
 
 Gill (U.S.A.), operation for deformity after 
 fracture of lower end of radius, 579 
 
 GiRALDES, views upon separation of lower 
 epiphysis of humerus, 335 ; epicondylo- 
 capitellar fracture of humerus, 423 
 
 Goodspeed, a. W., case of arrested growth 
 of ulna at distal epiphysis, 587 
 
 GossELiN, case of separation of cartilaginous 
 crest of ilium, 608 
 
 GoYRAND, G., observations on separation of 
 the lower radial epiphysis, 1836, 5 ; pain- 
 ful pronation of the arm in young children, 
 95 ; subluxation of radial head, 475 ; 
 case of normal growth of lower end of 
 humerus after epiphysial separation, 312 ; 
 separation of lower epiphysis of radius : — 
 symptoms of, 528, 536, 537, 538 :— simple 
 cases of, 52. i, 536 ; arrest of growth after 
 separation of lower epiphysis of radius, 
 662 : — cases of, 569 
 
 Granger, Benjamix, fracture of inner con- 
 dyle of humerus, 348 ; displacement in 
 fracture of internal epicondyle of humerus, 
 360, 361, 362, 365, 366, 374; dis- 
 location of elbow combined with separa- 
 tion of internal epicondyle of humerus, 
 366 ; inflammation about elbow following 
 separation of internal epicondyle, 373 ; 
 ankylosis of elbow after separation of 
 internal epicondyle of humerus, 377 ; 
 injury to ulnar nerve in separation of 
 internal epicondyle of humerus, 380 ; 
 treatment of fracture of internal epicon- 
 dyle of humerus, 386 
 
 Grantham, John (Cray ford), case of se- 
 paration of lower epiphysis of femur, 769 
 
 Gbipat, case of compound separation of 
 lower epiphysis of radius, 513 
 
 Gross, an epiphysis never detached by 
 muscular violence, 42 ; no characteristic 
 symptoms of epiphysial separations, 88 ; 
 deformity after separation of internal 
 epicondyle of humerus, 377; case of 
 compound separation of lower epiphysis 
 of femur, 728 
 
 Gruber, occasional epiphysis of tuberosity 
 of fifth metatarsal bone, 869 
 
 GuEDENEY, C, relative frequency of fractures 
 and separations at the elbow-joint, 55 ; 
 statistics of injuries to elbow-joint in 
 children, 302, 303 ; modification of com- 
 plete extension in treatment of fractures 
 at the elbow, 319 ; cases of separation 
 of internal epicondyle of humerus, 388 ; 
 cases of fracture of external epicondyle 
 with dislocation at elbow, 401 ; cases of 
 fracture of external epicondyle of humerus, 
 403 ; cases of condylo-capitellar fracture 
 of humerus, 445 ; cases of fracture of 
 olecranon in children, 464 ; cases of 
 separation of upper epiphysis of radius, 
 470 
 
INDEX OF NAMES 
 
 891 
 
 GuENEAU DE McssY, condylo-ti'ochlear frac- 
 ture of humerus, 406 
 
 GuEKETiN, experiments on epiphysial 
 separations in 1837, 5 ; direction of 
 nutrient canal of the diaphyses and 
 non-union after fracture, 22 ; intra-uterine 
 separation of an epiphysis, 43, 70 ; in- 
 ability to produce dislocation in the newly 
 born, 44 ; experiments on the dead sub- 
 ject, 45 ; frequency of various separations 
 in thirty-seven cases, 53 ; experiments 
 in pathological anatomy, 59, 64 ; epiphy- 
 sial separations always with fracture, 76 ; 
 union of separated epiphyses in the upper 
 and lower extremity, 99, 100 ; case of 
 compound separation of upper epiphysis 
 of humerus, 182 ; separation of olecranon 
 epiphysis, 461 ; case of separation of 
 epiphysis of metacarpal bone of index 
 finger, 594 ; separation of epiphysial head 
 of femur, 625 ; case of compound separa- 
 tion of lower epiphysis of femur, 782 ; 
 experimental separation of upper epi- 
 physis of tibia, 802 ; frequency of se- 
 paration of upper epiphysis of tibia, 812 ; 
 separation of lower epiphyses of tibia 
 and fibula, experiments in infants, 828 
 
 GuEKiN, case of compound separation of 
 upper epiphysis of tibia, 808 
 
 GxjERSANT, few instances of epiphysial 
 separation met with, 1865, 9 ; ankylosis 
 after separation of lower epiphysis of 
 humerus, 309 
 
 GuELT, E., literature of epiphysial separa- 
 tions up to 1862, 8, 13 ; violence seldom 
 sufficient to produce epiphysial separa- 
 tion, 38 ; statistics as regards age in 
 epiphysial separations, 48 ; late union 
 of the epiphyses, 49 ; frequency of the 
 various separations, 52 ; eighteen cases 
 in 1862 verified by autopsy, 54 ; experi- 
 ments in pathological anatomy on newly 
 born children, 58, 65, 67, 68 ; results of 
 different experimentalists, 64 ; separation 
 seldom pure after two years of age, 74 ; 
 incomplete separations clinically fre- 
 quent, 77 ; no characteristic symptoms 
 of ei^iphysial separations, 89, 92; non- 
 union after epiphysial separation, 100 ; 
 reunion osseous after epiphysial separa- 
 tion, 111 ; etiology of separation of the 
 upper epiphysis of the humerus, 170; 
 statistics of specimens of separation of 
 upper epiphysis of humerus, 177 ; separa- 
 tion with fracture of upper epiphysis of 
 humerus, 183 ; statistics of articular lesion 
 in separation of upper epiphysis of 
 humerus, 186 ; etiology of separation of 
 lower end of humerus, 270; etiology 
 of separation of lower epiphysis of 
 humerus, 339 ; separation of epiphysis of 
 internal epicondyle of humerus, 353 ; 
 specimen of fracture of internal condyle 
 of humerus, 355 ; case of dislocation of 
 elbow with separation of internal epi- 
 condyle, 368 ; epiphysial separations of 
 internal condyle of humerus, extra- 
 articular, 372 ; fracture of external epi- 
 condyle of humerus, 395 ; specimen of 
 fracture of external epicondyle of 
 humerus, 397 ; condylo-trochlear fracture 
 
 of humerus, 406, 407, 408, 412 ; epicon- 
 dylo-capitellar fracture of humerus, 423 ; 
 compound fracture of condylo-capitellar 
 portion of humerus, 431 ; fracture of 
 trochlea of humerus, 449, 451 ; fracture 
 of capitellum of humerus, 453 ; statistics 
 of separation of lower epiphysis of radius, 
 486, 487 ; separation of epiphysial head 
 of femur, 625; specimen of separation of 
 upper epiphysis of tibia, 806 
 
 GuTHEiE, ease of deformity after separation 
 of upper epiphysis of humerus, 248 
 
 GuYON, dislocation of wrist in children, 
 544 
 
 Haiin (Stuttgart), fracture of capitellum 
 of humerus, 458, 454 
 
 Haldekman, Davis, specimen of separation 
 of lower epiphysis of femur, 710 
 
 Hales, anatomy and physiology of the ends 
 of the bones, 17, 104 
 
 Halle, specimen of fracture of lower end 
 of humerus above epiphysial line, 303 
 
 Hamilton, F. H., experience and opinion 
 as to occurrence of epiphysial separa- 
 tion, 14; case of separation of upper 
 epiphysis of humerus in an infant, 44 ; 
 separation of olecranon during reduction 
 of dislocated elbow, 67 ; prosecution 
 of medical men for malpractice, 100 ; 
 non-union after separation, 101 ; non- 
 union of acromial process, 149, 152, 153 ; 
 cases of separation of upper epiphysis of 
 humerus, 205, 207, 225 ; delayed union 
 after separation of upper epiphysis of 
 humerus, 245 ; non-union after separa- 
 tion of upper epiphysis of humerus, 
 253 ; specimen of partial separation of 
 lower end of humerus, 274 ; injury of 
 nerves in fractures at elbow in children, 
 309 ; case of fracture of inner condyle 
 of humerus by muscular action, 349 ; 
 cases of separation of internal epicondyle 
 of humerus, 352, 374 ; specimen of 
 separation of internal epicondyle of 
 humerus, 353 ; displacement in sei^ara- 
 tion of internal epicondyle of humerus, 
 361, 362, 365, 878, 379; case of disloca- 
 tion of elbow with separation of internal 
 epicondyle, 369 ; ankylosis of elbow after 
 separation of internal epicondyle of 
 humerus, 876, 877 ; treatment of separa- 
 tion of internal epicondyle of humerus, 
 388 ; specimen of fracture of external 
 epicondyle of humerus, 396 ; fracture of 
 external epicondyle of humerus, 397 ; 
 condylo-trochlear fracture of humerus, 
 407, 408, 414 ; epicondylo-capitellar 
 fracture of humerus, 425, 435, 437 ; 
 fracture of olecranon, 464, 465, 466, 467; 
 separation of upper epiphysis of radius, 
 473 ; separation of lower epiphysis of 
 radius, 486 ; separation of lower epiphy- 
 ses of radius and ulna without displace- 
 ment, 525 ; case of separation of epi- 
 physis of metacarpal bone of index fin- 
 ger, 598 ; case of fracture of proximal 
 end of first phalanx of ring finger, 601 ; 
 specimen of fracture of neck of femur in 
 a girl, 633; separation of epiphysial 
 
892 
 
 INDEX OF NAMES 
 
 head of femur, 625, 633 ; cases of se- 
 paration of epiphysial head of femur, 
 637, 657 ; suppuration following sepa]a- 
 tion of epiphysis of great trochanter, 
 672 ; case of compound separation of 
 lower epiphysis of femur, 696 ; case of 
 simple separation of lower epiphysis of 
 femur, 760 
 
 Hancock, necrosis following separation of 
 upper epiphysis of humerus, 187 ; case 
 of separation of upper epiphysis of 
 humerus, 195 
 
 Harte, E. H. (Philadelphia), etiology of 
 separation of head of femur, 622 : — pain 
 in, 642:— cases of, 651; case of com- 
 pound separation of lower epiphysis of 
 femur, 697 ; specimens of seisaration of 
 lower epiphysis of femur, 721, 722, 740 ; 
 cases of simple separation of lower epi- 
 physis of femur, 760, 777 : — pain in, 
 777 :— case of pressure on vessels, 781 : — 
 diagnosis of, 781 : — treatment of, 783, 
 785 
 
 Hartmann, H., case of compound separation 
 of lower epiphysis of radius, 507 
 
 Harvey, case of separation of epiphysial 
 head of femur, 635 
 
 Haslam, case of arrest of growth of radius 
 after separation of lower epiphysis, 570 ; 
 case of separation of lower epiphysis of 
 femur, 729 
 
 Hawkins, Chas., cases of compound separa- 
 tion of lower epiphysis of femur, 696, 744 
 
 Hearnden, W. a. (Sutton), case of separa- 
 tion of lower epiphysis of humerus, 296 
 
 Hearnden, W. F. (Sutton), case of separa- 
 tion of lower epiphysis of humerus with 
 fracture of diaphysis, 299 
 
 Heath, Chkistophee, muscular violence 
 causing detachment of clavicular epi- 
 physis, 42, 136 ; case of simple separa- 
 tion of the epiphysis of the clavicle, 140 ; 
 Hexed position for fractures at elbow, 
 318 ; case of separation with fracture 
 of lower epiphysis of humerus, 339 
 
 Helferich, experiments on growth of bones, 
 105 ; arrest of growth due to inflammatory 
 affections near the epiphysial cartilage, 
 120 ; operations for deformity due to 
 arrest of growth, 134 ; cases of separation 
 of upper epiphysis of the humerus, 201, 
 226 ; operative treatment of recent 
 separations of upper epiphysis of humerus, 
 226, 230 ; case of arrest of growth of 
 humerus after separation of upper epi- 
 physis, 257 ; specimen of partial separa- 
 tion of lower end of humerus, 275 ; case 
 of dislocation of elbow with separation 
 of internal epicondyle, 369 ; specimen of 
 separation of olecranon epiphysis of ulna, 
 460 ; separation of upper epiphysis of 
 tibia, 811 ; separation of lower epiphyses 
 of tibia and fibula in straightening club- 
 foot, 828 
 
 Henle, ossification of lower end of humerus, 
 262 
 
 Herring, E. K. (Ballarat), case of separa- 
 tion of epiphysis of metacarpal bone of 
 index linger, 595 
 
 Heuston, F. T. (Dublin), case of simple 
 . separation of upper epiphysis of tibia, 813 
 
 Het, T., specimen of separation of lower 
 epiphysis of femur, 717 
 
 Hilton, John, epiphysial injuries at Guy's 
 Hospital, 13 ; jurisprudential aspect of 
 epiphysial separations, 76 ; case of com- 
 pound separation of lower epiphysis of 
 radii, 490 ; specimen of compound separa- 
 tion of lower epiphysis of radius, 503 ; 
 cases of separation of epiphysial head of 
 femur, 632 ; specimen of separation of 
 epiphysis of great trochanter, 665 ; case 
 of displacement backwards in separation 
 of lower epiphysis of femur, 765 ; case of 
 simple separation of lower epiphysis 
 of tibia, 844 ; case of simple separation 
 of upper epiphysis of fibula, 859 
 
 Hippocrates, allusion to separation of the 
 epiphyses, 1 ; extended position in treat- 
 ment of fractures of the elbow, 319 
 
 Hirschfeld, suppuration of joint following 
 epiphysial separation, 103 ; necrosis of 
 epiphyses of fibula after sepai'ation, 120 ; 
 specimen of separation of upper epiphy- 
 sis of tibia, 808 
 
 HiRTZ, E., case of separation of internal 
 epicondyle of humerus by muscular 
 action, 349 
 
 HocKEN, case of compound separation of 
 lower epiphysis of femur, 696 
 
 HoDSDON, case of displacement backwards 
 in separation of lower epiphysis of femur, 
 767 
 
 HoFFA, Albert (Wiirzburg), case of arrest 
 of growth of humerus after separation of 
 upper epiphysis, 255 ; specimen of fracture 
 of neck of femur in a girl, 633 ; osteotomy 
 after separation of epiphysial head of 
 femur, 660 
 
 HoLDEN, Luther, anatomy of epiphysis of 
 third trochanter, 677 
 
 HoLLis, H., case of dislocation of wrist in 
 a boy, 544 
 
 Holmes, Timothy, study of museum speci- 
 mens of epiphysial separation existing 
 in London in 1868, 11, 13, 93 ; symptoms 
 of traumatic separation, 92, 93 ; cause of 
 arrest of growth, 108 ; case of old separa- 
 tion of upper epiphysis of humerus, 198 ; 
 specimen of fracture of lower end of 
 humerus above epiphysial line, 272, 302 ; 
 detachment of trochlea and capitellum 
 of humerus, 456 ; specimen of separa- 
 tion of lower epiphysis of radius, 492 ; 
 specimen of separation of os innomina- 
 tum into its original parts, 605 ; separa- 
 tion of upper epiphysis of femur, 625 ; 
 specimen of separation of lower epiphysis 
 of femur, 694 ; specimen of separation of 
 lower epiphysis of tibia, 831 ; specimen 
 of separation of lower epiphysis of fibula, 
 862; specimens of separation of meta- 
 tarsus, 869 
 
 Holthouse, C, separation of lower epiphysis 
 of femur in infancy, 692 ; case of simple 
 separation of lower epiphysis of femur, 
 782 
 
 Hopkins, W. B., case of separation of 
 lower epiphysis of femur in ankylosis of 
 knee, 684 
 
 HoRNiDGE, J. K.^ intra-uterine separation, 
 70 
 
INDEX OF NAMES 
 
 893 
 
 HossACK, Jas., case of dislocation of wrist 
 in a boy, 545 
 
 H>uzE, anatomy of epiphysis of third tro- 
 chanter, 677 
 
 HowsE, H. G., case of separation of upper 
 epiphysis of humerus, 220 ; case of sepa- 
 rated lower end of humerus, 296 ; cases 
 of simple separation of lower epiphysis of 
 radius, 483, 541 ; cases of separation of 
 lower epiphysis of femur, 685, 760 ; case 
 of simple separation of upper epiphysis 
 of tibia, 812 ; case of separation of lower 
 epiphysis of tibia, 829 ; case of detach- 
 ment of dorsal spine, 875 
 
 HuGuiEK, etiology of fracture of external 
 epicondyle of humerus, 394 
 
 HuiDEKOPER, E. S., abscess following 
 separation of the lower femoral epiphysis 
 in a girl, 119 
 
 HuLKE, fracture of olecranon, 465 
 
 Humphry, Sir Geo., importance of the 
 occurrence of epiphysial injuries, 13 ; 
 anatomy of the ends of the bones, 18, 
 19, 23, 31, 32, 104 ; order of union of the 
 normal epiphyses, 28 ; stimulated growth 
 of epiphysial cartilage after amputation, 
 31 ; advantages of the conjugal cartilages, 
 32 ; articular layer of cartilage of epi- 
 physis, 36 ; arrest of growth due to in- 
 flammatory affections near the epiphysial 
 cartilage, 120 ; epiphysis of the acromion 
 process, 145 ; case of arrest of growth of 
 humerus after separation of upper epi- 
 physis, 258 ; ossification of lower end of 
 humerus, 262 ; specimen of detachment 
 of internal epicondyle of humerus, 358 ; 
 anatomy of anterior-inferior spine of 
 ilium, 609 ; arrest of growth at lower 
 end of femur, 752 
 
 Hunter, John, experiments in animals on 
 the growth in length of long bones, 17, 
 104 
 
 HusE, E. C, case of separation of coracoid 
 epiphysis, 161 
 
 Hutchinson, Jonathan, chief exponent in 
 this country of traumatic separation of 
 the epiphyses, 13 ; case of separation of 
 lower epiphysis of femur in an infant, 
 44 ; epiphysial junction the weakest part 
 of the bone, 70 ; arrest of growth after 
 epiphysial fracture, 107 ; necrosis of dia- 
 physis after epiphysial separation, 118 ; 
 arrest of growth due to inflammatory 
 affections near the epiphysial cartilage, 
 120 ; cases of shortening and deformity 
 after separation of upper epiphysis of 
 humerus, 250, 251 ; deformity after sepa- 
 ration of upper epiphysis of humerus 
 resembles dislocation, 252 ; case of arrest 
 of growth of upper end of humerus due 
 to inflammation, 259 ; cases of compound 
 separation of lower epiphysis of humerus, 
 275, 280, 283 ; cases of separation and 
 displacement backwards of lower end of 
 humerus, 289, 306 ; pressure on vessels 
 in separation of lower epiphysis of hu- 
 merus, 294 ; case of displacement for- 
 wards of lower epiphysis of humerus, 
 308 ; suppuration following epiphysial 
 separation of lower end of humerus, 312 ; 
 flexed position for fractures at elbow, 
 
 318 ; flexed position in separation of 
 lower end of humerus, 325 ; cases of 
 detachment of internal condyle of hu- 
 merus, 362, 379 ; case of dislocation of 
 elbow combined with separation of inter- 
 nal epicondyle, 367 ; epicondylo-capi- 
 tellar fracture of humerus, 441, 444 ; 
 cases of complete displacement of lower 
 epiphysis of radius, 491, 527 ; specimen 
 of separation of lower epiphysis of radius, 
 492 ; separation of lower radial epiphysis 
 analogous to Golles's fracture in adult, 
 527 : — symptoms of, 537 ; cases of simple 
 separation of lower epiphysis of radius 
 with complications, 541, 542 ; case of 
 deformity after separation of lower epi- 
 physis of radius, 554 ; specimens of arrest 
 of growth of radius after separation of 
 lower epiphysis, 565 ; case of arrest of 
 growth of radius after separation of lower 
 epiphysis, 570 ; case of arrest of growth 
 of ulna after injury to lower epiphysis, 
 584 ; separation of upper end of femur 
 in infants, 619 : — diagnosis, 632 ; speci- 
 mens in animals, 631 : — cases of separa- 
 tion of epiphysial head of femur, 636, 
 649 : — cases of non-union, 652 ; specimens 
 of separation of epiphysis of great tro- 
 chanter, 664 ; age in separation of lower 
 epiphysis of femur, 686 ; specimens of 
 separation of lower epiphysis of femur, 
 716, 719, 726, 728 ; displacement in 
 separation of lower epiphysis of femur, 
 762 ; treatment of separation of lower 
 epiphysis of femur, 784, 786 ; specimen 
 of separation of upper epiphysis of tibia, 
 803 ; case of compound separation of 
 lower epiphysis of tibia and flbula, 838 ; 
 case of simple separation of lower epi- 
 physis of tibia, 846 ; case of unsymmetri- 
 cal growth of leg after epiphysial injury, 
 847 
 Hutchinson, Jonathan, junior, Jacksonian 
 Prize Essay and Lectures at the Royal 
 College of Surgeons of England in 1891, 
 15 ; collection of 350 statistics of epiphysial 
 separation, 56 ; age in separation of lower 
 epiphysis of humerus, 269 ; specimens of 
 partial separation of lower end of humerus, 
 273 ; injury to median nerve in simple 
 separation of lower epiphysis of humerus, 
 295 ; suppuration following compound 
 separation of lower epiphysis of humerus, 
 312 ; compound separation of lower end 
 of humerus, 329, 330 ; age in cases of 
 separation of internal epicondyle of 
 humerus, 352 ; specimen of detachment 
 of internal epicondyle of humerus, 358 ; 
 cases of separation of internal epicondyle 
 of humerus, 374, 377, 380, 381 ; separa- 
 tion of capitellum of humerus, 453 ; 
 experimental detachment of olecranon 
 epiphysis, 462 ; case of separation of 
 upper epiphysis of radius, 473 ; sub- 
 luxation of radial head, 475 ; case of 
 separation of lower epiphysis of .radius, 
 484, 486 ; specimen of separation of 
 lower epiphysis of radius, 493 ; statistics 
 of compound separation of lower epiphy- 
 sis of radius. 515 ; shortening affeer 
 separation of lower epiphysis of radius, 
 
89^4 
 
 INDEX OF NAMES 
 
 ^563 ; treatment of separation of lower 
 epiphysis of radius, 575 ; statistics of 
 compound separation of lower epiphysis 
 of radius, 578 ; specimen of separation 
 of lower epiphysis of ulna, 581 ; case of 
 arrest of growth of ulna following injury 
 to lower epiphysis, 587 ; case of separa- 
 tion of epiphysis of metacarpal bone of 
 thumb, 590 ; separation of epiphysis of 
 great trochanter : — specimen of, 666 : — 
 statistics of suppuration following, 
 672 ; separation of lower epiphysis of 
 femur, statistics as regards age, 686 : — 
 specimens of, 713, 738: — cases of, 751, 
 754: — statistics of simple cases, 787: — 
 statistics of compound separations, 794 ; 
 statistics of cases of separation of upper 
 epiphysis of tibia, 802 ; experiment in 
 detaching lower epiphysis of tibia, 830 ; 
 statistics of separation of lower epiphysis 
 of tibia, 839 ; statistics of suppuration 
 and arrest of growth after injury to lower 
 epiphysis of tibia, 852 
 HuTTON, case of compound separation of 
 lower epiphysis of humerus, 277 
 
 Illingworth, straight position for injuries 
 of elbow, 323 
 
 Ingham, Sam., trans, by, of Duverney's 
 work on diseases of the bones, 1762, 3 
 
 Ingrassias, J. Philipp, supposed case of 
 separation of the great trochanter of 
 femur (1603), 2 ; muscular violence, 
 causing separation of great trochanter, 
 a case of, 42: — separation of epiphysis 
 of great trochanter, 663 
 
 IscovESCo, epiphysial fracture from forcibly 
 straightening white swelling of joints, 
 39 
 
 Jackson, J. B. S., specimens of separate 
 acromion process, 154 
 
 Jahn, experiments on the conjugal cartilage, 
 113 
 
 Jarjavay, difficulty of determining epiphysial 
 separations from fractures, 1825, 5 ; ex- 
 periments in pathological anatomy of 
 epiphysial separations, 59 ; case of com- 
 pound separation of lower epiphysis of 
 femur, 700 
 
 Jeannel, immediate massage treatment, 
 127 ; specimen of fracture of neck of 
 femur in childhood, 646 
 
 Jetter, G., cases of epiphysial separation 
 at twenty-first and twenty-third year, 48 ; 
 frequency of the various separations, 55, 
 statistics of deformity of the humerus 
 after separation, 102 ; statistics of age 
 in separation of the upper epiphysis of 
 the humerus, 170 ; etiology of separa- 
 tion of the upper epiphysis of the hu- 
 merus, 171 ; pure separations of upper 
 epiphysis of humerus, 177 ; suppuration 
 and necrosis following separation of 
 upper epiphysis of humerus, 187; case of 
 displacement subsequent to simple sepa- 
 ration of upper epiphysis of humerus, 
 192 ; displacement in separation of upper 
 epiphysis of humerus, 196 ; cases of 
 separation of upper epiphysis of humerus, 
 
 204, 206, 222 ; separation 6f upper epiphy- 
 sis of humerus mistaken for dislocation, 
 214 ; opei-ative treatment of separation 
 of upper epiphysis of humerus, 232 ; 
 operative treatment of old separation of 
 upper epiphysis of humerus, 234, 239 ; 
 cases showing return of function of 
 shoulder after epiphysial separation of 
 humerus, 246 
 
 JoHxsoN, Athol a., specimen of separation 
 of lower epiphysis of radius, 489 
 
 Johnson, John, specimen of fracture of neck 
 of femur in childhood, 644 
 
 Johnson, Thomas, translation of the chirur- 
 gical works of Ambrose Parey in 1634, 2 
 
 Johnson, case of avulsion of biceps tendon 
 in adult, 477 
 
 Johnston, specimen of separation of lower 
 epiphysis of radius, 495 
 
 Jones, Arnallt (Aberavon), dorsal disloca- 
 tion of femur in childhood, 643 
 
 Jones, J., case of separation of upper epi- 
 physis of tibia, 811 
 
 Jones, Sydney, case of displacement back- 
 wards in separation of lower epiphysis of 
 femur, 767 
 
 JuLLiARD, fracture of lesser trochanter, 
 symptoms of, 676 
 
 Kammerer, specimen of detachment of 
 internal epicondyle of humerus, 355 
 
 Key, Aston, separation of great trochanter 
 by direct violence, 69 ; specimen of 
 separation of epiphysis of great tro- 
 chanter, 663 
 
 King, T. W., specimen of separation of os 
 innominatum into its original parts, 605 
 
 KiRMissoN, immediate massage treatment, 
 127 ; case of separation of upper epi- 
 physis of humerus, 211 ; operative treat- 
 ment of recent separation of upper 
 epiphysis of humerus, 228 
 
 Klein, E. E., thesis on epiphysial separa- 
 tions in 1854, 7 ; specimen of separation 
 of lower epiphysis of tibia and fibula, 
 832, 862 
 
 Knox, R. W., case of compound separation 
 of upper epiphysis of humerus, 182 
 
 Kocher, Theo., indirect violence a cause of 
 separation of the upper epiphysis of the 
 humerus, 171 ; cases of separation of 
 upper epiphysis of humerus, 205 ; resec- 
 tion in old separation of upper epiphysis 
 of humerus, 241 ; paralysis of ulnar 
 nerve in separated internal epicondyle 
 of humerus, 359 ; specmens of separation 
 of epiphysial head of femur, 628 
 
 KoLLiKER, difference in the growth of the 
 various epiphyses of the long bones, 31 
 
 KoNiG, straight position for injuries of 
 elbow, 323 ; cases of separation of epi- 
 physial head of femur, 628 ; anatomy of 
 lower epiphysis of femur, 680 ; arrest of 
 growth of lower end of femur, 752 
 
 KoRTE, W., junior, specimen of complete 
 displacement of lower epiphysis of 
 radius, 491, 512 
 
 Krackowizer, case of separation of lower 
 epiphysis of tibia, 839 
 
 Kramer, case of compound dislocation of 
 
INDEX OF NAMES 
 
 895 
 
 elbow with compound separation of lower 
 epiphysis of radius, 516 
 KusTNEE, 0., experimental separation of 
 lower epiphysis of femur in infants, 64 ; 
 literature of epiphysial separations at 
 birth, 71 ; experimental separation of 
 the upper end of the humerus in newly 
 born children, 170, 175 ; separation of 
 upper cartilaginous end of femur in 
 foetus, 622 
 
 Labadie-Lageave, case of compound sepa- 
 ration of lower epiphysis of radius, 512 
 
 La Chapelle, Madame, cases of separation 
 of epiphyses at birth by traction, 40 ; 
 separation of lower epiphysis of femur in 
 fcetus, 683 ; case of separation of upper 
 epiphysis of tibia in foetus, 802 
 
 Landsbekg, J., case of separation of epi- 
 physis of tubercle of tibia, 819 
 
 Lane, L. C. (San Francisco), straight posi- 
 tion for injuries of elbow, 323, 325, 327 ; 
 treatment of separation of internal epi- 
 condyle of humerus, 387 ; treatment 
 of fracture of external epicondyle of 
 humerus, 403 ; treatment of fractures 
 of humerus penetrating elbow-joint, 419 ; 
 treatment of condylo-capitellar fractures 
 of humerus, 445 
 
 Lane, W, A., fracture of acromion process, 
 152 
 
 Lange, Feed. (New York), operative treat- 
 ment of recent separation of upper epi- 
 physis of humerus, 227 ; case of com- 
 pound separation of lower epiphysis of 
 humerus, 276, 329 ; case of injury to 
 median nerve in supra-condyloid fracture 
 of humerus, 311 
 
 Langenbeck, experiments on the conjugal 
 cartilage, 33 ; case of arrest of growth of 
 humerus due to inflammation, 259 ; speci- 
 men of detachment of internal epicondyle 
 with dislocation of elbow, 358 ; case of 
 separation of internal epicondyle with 
 dislocation of elbow, 384 ; case of con- 
 dylo-trochlear fracture of humerus, 412 ; 
 case of fracture of trochlea of humerus, 449 
 
 Lannelongue, bulbar region of the long 
 bones, 39 ; site of infective osteomyelitis, 
 76 ; case of displacement subsequent to 
 simple separation of upper epiphysis of 
 humerus, 191 ; cases of displacement of 
 fractured external epicondyle of humerus, 
 400, 402 ; specimen of separation of 
 lower epiphysis of femur, 708 
 
 Laeoyenne, complete extension in treat- 
 ment of fractures at elbow, 319 ; ex- 
 tended position in transverse fracture of 
 lower end of humerus, 324 
 
 Lauenstein (Hamburg), extended and 
 prone position in fractures at elbow, 323 
 
 Laugiee, S., fracture of trochlea of humerus, 
 448, 450 ; specimen of separation of lower 
 epiphysis of femur, 732 
 
 Laueent, article on epiphysial separations 
 in 1818, 4 
 
 Lawson, Geoege, case of condyle-trochlear 
 fracture of humerus, 410 
 
 Leblois, Alfred, allusion to epiphysial 
 separations in 1894, 11 ; epiphysial sepa- 
 
 rations mostly in first decade, 45 ; mas- 
 sage and early movement in epiphysial 
 separations, 127 
 
 Lediaed, conical stump at upper end of 
 humerus, 254 ; case of compound separa- 
 tion of lower epiphysis of humerus, 279 
 
 Lefoet, case of compound separation of 
 upper epiphysis of tibia, 808 
 
 Leiseinck, case of compound separation of 
 lower epiphysis of femur, 695 
 
 Lejaes, Felix, operative treatment of old 
 separation of upper epiphysis of humerus, 
 235 ; conical stump at upper end of 
 humerus, 254 
 
 Leonaed, Char. J., case of partial I'esection 
 in old separation of upper epiphysis of 
 humerus, 240 ; skiagraphy in a case of 
 separation of lower epiphysis of humerus, 
 304 
 
 Leeoux (Versailles), case of simple separa- 
 tion of lower epiphysis of radius, 537 
 
 Lesser, L. von (Leipzig), anatomy and 
 physiology of the long bones, 17 ; case of 
 deformity of radius after separation 
 remedied by operation, 578 
 
 Ley, a., case of operation for separation of 
 upper epiphysis of humerus, 237 
 
 LiSTON, EoBEET, straight position in treat- 
 ment of supra-condyloid fracture of 
 humerus, 319 ; separation of epiphysial 
 head of femur, 625 ; specimen of separa- 
 tion of lower epiphysis of femur, 744 
 
 Little, Jas. L., specimen of partial separa- 
 tion of lower end of humerus, 274 ; 
 specimens of separation of lower epiphysis 
 of femur, 705, 731 
 
 Lizaes, John, non-union of acromion pro- 
 cess, 149 
 
 LoBSTEiN, separations from diseased con- 
 dition of the bones, 39 
 
 LoNGAKEB, etiology of separation of head of 
 femur, 621 ; specimen of separation of 
 epiphysial head of femur, 627 
 
 Lonsdale, E. F., case of simple separation 
 of the epiphysis of the clavicle, 141 ; 
 locking of fragments in separation of 
 upper epiphysis of humerus, 221 ; mode 
 of fracture of olecranon, 462 
 
 LossEN, Heemann, separation of lower epi- 
 physis of femur, 719 
 
 Lowe (Lynn), specimen of separation of 
 epiphysis of great trochanter, 666 
 
 Lucas, Championnieee, immediate massage 
 treatment, 127 
 
 Lucas, R. Clement, separation of coracoid 
 epiphysis, 158 ; case of simple separation 
 of epiphysis of metacarpal bone of thumb, 
 589 
 
 LuDwiG, case of separation of head of femur, 
 652 
 
 Lynn, Wm., case of deformity after separa- 
 tion of upper epiphysis of the humerus. 
 248 
 
 Maas, cause of arrest of growth after epi- 
 physial separation, 108 
 
 Mabeely, H. E., case of simple separation 
 of lower epiphysis of tibia followed by 
 arrest of growth, 849 
 
 Macalister, Alex., development of epiphy- 
 sis of acromion process, 146, 147, 148 ; 
 
896 
 
 INDEX OF NAMES 
 
 calcar femorale, 616 ; bursa beneath 
 ligamentuna patella?, 817 ; development 
 of atlas, 877 ; development of axis, 878 
 
 McBuRXEY, Chas. (New York), dislocation 
 of humerus with fracture of surgical 
 neck, 186, 243 ; case of operation on 
 recent separation of upper epiphysis of 
 humerus, 231 ; specimens of fracture of 
 external epicondyle of humerus, 397 ; 
 osteotomy for deformity after Colles's 
 fracture of radius, 579 ; specimen of 
 separation of lower epiphysis of femur, 
 731 ; cases of separation of lower epi- 
 physis of femui' treated by open opera- 
 tion, 789 
 
 McCarthy, specimen of separation of epi- 
 physis of great trochanter, 664 
 
 MacCokmac, Sir William, specimen of 
 separation of lower end of humerus, 271 ; 
 case of separation of epiphysial head of 
 femur, 638 
 
 McDiAE^HD, A. (Winnipeg, U.S.A.), case of 
 compound separation of lower epiphysis 
 of femur, 728 ; statistics of separation of 
 lower epiphysis of femur, 795, 796 
 
 MacDonxell, J. (Dubhn), case of separa- 
 tion of upper epiphysis of humerus, 198 ; 
 case of separation of epiphysis of first 
 phalanx of forefinger, 601 ; case of se- 
 paration of epiphysial parts of atlas, 877 
 
 Macdougall, J. A., case of compound sepa- 
 tion of lower epiphysis of humerus, 279 ; 
 specimens of separation of lower epiphy- 
 sis of femur, 725, 730 
 
 McGiLL, A. F., case of displacement forwards 
 of lower epiphysis of femur, 763 
 
 MacKell.oi, a. 0., case of separation of 
 epiphysial head of femur, 638 
 
 Macleod, no distinctive signs of separation 
 of lower radial epiphysis, 527 
 
 Maclise, doubtful case of separation of 
 lower epiphysis of femur, 692 
 
 Mahood, a. E. (Devon), non-union of 
 acromial epiphysis, 149 
 
 Maisonneuve, separations from diseased 
 condition of the bones, 39 ; case of com- 
 pound separation of lower epiphysis of 
 humerus, 276, 328 ; case of compound 
 separation of lower epiphysis of radius, 
 512 
 
 Makixs, G. H., specimen of separation of 
 bodies of vertebra at junction of inter- 
 vertebral cartilage, 873 
 
 Malgaigxe, distinction in 1855 between se- 
 parations and fractures, 7 ; non-union of 
 fractures and the direction of the nu- 
 trient canals, 22 ; epiphysial separation 
 only caused by indirect violence, 41 ; no 
 instance known of epiphysial separation 
 above fifteen years, 44 ; all cases known 
 to him in male sex, 49 ; separation of the 
 lower epiphysis of radius most frequent, 
 52 ; separation beyond two years of age 
 rarely perfect, 79 ; stripping up of perios- 
 teum, 82 ; no characteristic symptoms of 
 epiphysial separations, 89, 91, 93; re-union 
 of separated epiphyses, 98, 100; fracture 
 of acromion process, 153 ; rarity of sepa- 
 ration of upper epiphysis of humerus, 
 176 ; specimen of separation of upper 
 epiphysis of humerus, 178 ; disjunction 
 
 of lower epiphysis of humerus, 271 ; case 
 of fracture of epitrochlea, 351 ; sepai'a- 
 tion of epiphysis of internal epicondyle 
 of humerus, 353, 365, 376, 377, 386 ; 
 fracture of external epicondyle of 
 humerus, 395 ; condylo-trochlear fracture 
 of humerus, 406, 407 ; epicondylo-capi- 
 tellar fracture of humerus, 439, 443 ; 
 separation of lower epiphysis of radius, 
 486, 526 ; case of simple separation of 
 lower epiphysis of radius with fracture 
 of styloid process of ulna, 532 ; case of 
 epiphysial disjunction of fourth meta- 
 carpal bone, 597 ; treatment of fracture 
 of great trochanter, 673 
 
 Manby, E. p., case of simple separation of 
 upper epiphysis of tibia, 812 
 
 Manocry, case of dislocation of elbow with 
 separation of internal epicondyle, 368 
 
 Maxquat, Alex., thesis and collection of 
 one hundred and thirty cases of epiphy- 
 sial sejjaration in 1877, 12 ; frequency of 
 the various separations in his collected 
 cases, 52 ; erroneous view of ossification 
 of lower end of humerus, 264; age in 
 separation of lower eiDiphysis of radius, 
 486 ; case of compound separation of 
 lower epiphysis of radius, 514 ; sj^m- 
 ptoms of separation of lower epiphysis 
 of radius, 523, 535, 538 ; statistics of 
 separation of lower epiphysis of femur, 
 691 
 
 Maecano, G., specimen of separation of 
 lower epiphysis of femur, 709, 770 
 
 Maechand, case of displacement of frac- 
 tured external epicondyle of femur, 399, 
 402 
 
 Maejolin, separation of the epiphyses ex- 
 tremely rare, 10, 71 ; arrest of growth 
 due to inflammatory aiiections near the 
 epiphysial cartilage, 120 ; extended posi- 
 tion in transverse fracture of lower end of 
 humerus, 324 ; fracture of external epi- 
 condyle of humerus, 395 ; symptoms of 
 fracture of external epicondyle, 398 ; 
 condylo-trochlear fracture of humerus, 
 412 ; specimen of separation of lower 
 epiphysis of radius, 496 ; case of separa- 
 tion of epiphysial head of femur, 632 ; 
 case of separation of lower epiphysis of 
 femur, 749 
 
 Maekoe, Th., condylo-trochlear fracture of 
 humerus, 406, 408 
 
 Maesh, F. (Birmingham), specimen of 
 separation of upper epiphysis of tibia, 
 805 
 
 Maesh, Howard, separation of lower epiphy- 
 sis of femur with slight displacement, 759 
 
 Maetin, Stephen C, ease of compound 
 separation of lower epiphysis of tibia, 833 
 
 Masox, James, case of separation of epi- 
 physis of second metatarsal bone, 870 
 
 Matchixsky, observations on the periosteum 
 in the human subject, 35 
 
 Mauclaiee, dislocation of humerus with 
 fracture of surgical neck, 186 
 
 Mauxdee, C. F., . compound epiphysial 
 separations, 86 ; case of compound se- 
 paration of clavicular epiphysis, 139 ; 
 case of separation of anterior-inferior 
 spine of ilium, 610 ; case of separation 
 
INDEX OF XAMES 
 
 897 
 
 of epiphysial head of femur, 640 ; case 
 of compound separation of lower epi- 
 physis of femur, 733 ; case of displace- 
 ment outwards in separation of lower 
 epiphysis of femur, 771 
 
 Mayet, ossification of trochlea of humerus, 
 448 ; development of epiphysis of first 
 metatarsal bone, 868 
 
 Maylakd, a. E. (Glasgow), case of separa- 
 tion of epiphysial head of femur, 649 
 
 Mazziotti, Gr., article in 1880 on the dis- 
 tinction between epi^jhysial separation 
 and fracture, 15 
 
 Meisenbach, a. H. (St. Louis, U.S.A.), 
 case of separation of lower femoral 
 epiphysis produced by osteomyelitis, 86 ; 
 statistics of separation of lower epiphysis 
 of femur, 686 ; case of compound sepa- 
 ration of lower epiphysis of femur, 
 718 
 
 Menard, V., experiments in pathological 
 anatomy, 60, 68 ; straightening limb in 
 genu valgum, 689 
 
 MiCHNiowsKY, experimental studies in sepa- 
 rations (1864), 9 ; experiments on living 
 animals, 58, 68 ; experiments in animals 
 as to union after separation of epiphyses, 
 99 ; opinion as to separation of upper 
 
 - epiphysis of humerus through conjugal 
 cartilage, 177 
 
 MiDDELDOKPF, cascs of Separation of upper 
 epiphysis of humerus with nerve sym- 
 ptoms, 812 
 
 Miller, A. G. (Edinburgh), case of de- 
 tachment of lower epiphysis of femur 
 by torsion, 690 
 
 MiLLiKEN, Sam. E., case of separation of 
 humeral ends during delivery, 41 
 
 MiRAULT, case of separation of epiphysis of 
 metacarpal bone of index finger, 594 
 
 Mitchell, Weir, case of condylo-trochlear 
 fracture of humerus, 41.3 
 
 MoLDENHAUER, casc of epiphysial separation 
 during childbirth, 43 
 
 MoNTEGGiA, cases of upper tibial and lower 
 humeral detachments in 1814, 4 ; case 
 of intra-uterine separation of an epiphy- 
 sis, 43 ; case of separation of upper 
 epiphysis of tibia, 802 
 
 MooRE, E. M. (Rochester, U.S.A.), incom- 
 plete separation of upper humeral 
 epiphysis, 83 ; planes of upper end of 
 diaphysis of humerus, 168 ; separation 
 of upper epiphysis of humerus, 195, 196 ; 
 treatment of separation of upper epiphysis 
 
 ■ of humerus, 221, 224 ; gradual flexion in 
 treatment of fractures at the elbow, 319 ; 
 specimen of separation of lower epiphysis 
 of radius with dislocation of ulna, 513 
 
 Moore, Thomas (Blackheath), case of frac- 
 ture of neck of radius, 476 ; case of dis- 
 location of metacarpo-phalangeal joint 
 of index finger, 596 
 
 MoRGAGNi, quotation from Colombus re- 
 garding epiphysial separation, 1 ; fracture 
 of neck of femur in children, 633 
 
 MoRisoN, A. E., case of wiring for frac- 
 tured olecranon, 469 
 
 Morris, Henry, case of dislocation for- 
 wai-ds of upper end of humerus in an 
 
 •• infant. 213 ; separation of epiphysial 
 
 head of femur, 625 ; specimens of intra- 
 capsular fracture of neck of femur in 
 children, 633, 643 
 
 Morton, T. H. (Sheffield), case of disloca- 
 tion of wrist in a boy, 544 
 
 Morton, T. S. K., reduction of fractures 
 of lower end of radius, 576 
 
 MoscATi, case of separation of upper epi- 
 physis of humerus, 200 
 
 MoTTE, De la, cases of epiphysial injury, 4 
 
 MouLLiN, C. W. Mansell, case of impaired 
 growth of tibia following severe sprain to 
 lower epiphysis, 110, 850 ; specnnen of 
 separation of ujjper epiphysis of radius, 
 472 ; specimens of separation of lower 
 epiphysis of femur, 713, 746 
 
 MiJLLER, E., cases of separation of epi- 
 physis of tubercle of tibia, 818, 823 
 
 MuLLER, K., Rontgen process in epiphysial 
 injuries, 304 
 
 Murray, F. W., operative treatment of 
 recent separation of upper epiphysis of 
 humerus, 227 
 
 Nanula (Naples), late union of the epi- 
 physes, 49 
 
 Nelaton, views on epiphysial separation, 
 6 ; doubt as to muscular action causing 
 epiphysial detachment, 42 ; symptoms of 
 epiphysial separations, 89, 92 ; union of 
 separated epiphyses, 99 ; subluxation of 
 I'adial head, 475 ; separation of lower 
 epiphysis of radius, 526 ; specimen of 
 separation of lower ej^iphyses of tibia 
 and fibula, 832 
 
 Nichols, E. H. (Boston, U.S.A.), case of 
 compound separation of lower epiphysis 
 of femur, 741 
 
 NicKERSON, case of fracture of anterior 
 superior spine of ilium, 607 
 
 NicoLADONi (Innsbruck), specimen of arrest 
 of growth of radius after separation of 
 lower epiphysis, 115, 568 ; case of arrest of 
 growth of ulna following injury to lower 
 epiphysis, 586 ; case of deformity after 
 injury to lower epiphysis of femur, 754 
 
 NiMiER, cases of separation of upper epi- 
 physis of humerus, 200, 210 
 
 NovARO, allusion in 1877 to epiphysial se- 
 parations, 12 
 
 Nov£-.JossERAND, G., histological investiga- 
 tion of injury to the conjugal cartilage, 
 108, 113 
 
 NuNN, T. W., straight position for injuries 
 of elbow, 323 
 
 Oger, dislocation of humerus with fracture 
 of surgical neck, 186 
 
 Ogston, function of articular cartilage of 
 epiphysis, 36 
 
 Ollier, physiology and anatomy in 1867 
 of the conjugal cartilage and of the ex- 
 tremities of the long bones, 10, 17, 18, 
 19, 22, 23, 29, 30, 33 ; increase in 
 length of the bone dependent on the 
 direction of the nutrient canal, 22, 104 ; 
 experiments on the conjugal cartilage, 
 33 ; experiments on the pci iostcuui in 
 
 3 M 
 
898 
 
 INDEX OF NAMES 
 
 animals, 33 ; anatomy of the juxta-epi- 
 physial region, 34 ; function of articular 
 cartilage of epiphysis, 36 ; epiphysial 
 separation in rickets, 39 ; violence produc- 
 ing juxta-epiphysial sprains, 42 ; experi- 
 ments on living animals, 58, 68 ; experi- 
 ments on the bodies of children, 59 ; site of 
 epiphysial separations, 76 ; anatomy of 
 juxta-epiphysial sprains, 77 ; detachment 
 of periosteum in juxta-epiphysial sprains, 
 82 ; symptoms of juxta-epiphysial sprains 
 in infancy, 94 ; re-union of separated 
 epiphyses in animals, 98 ; new diaphysis 
 formed by periosteum, 101 ; experiments 
 in animals regarding arrest of growth of 
 long bones, 104 ; infrequency of arrest of 
 growth, 105 ; cause of arrest of growth, 
 108, 109, 110, 111 ; importance of arrest 
 of growth in articular resections, 108, 109 ; 
 lengthening of long bones from chronic 
 irritation, 116 ; case of arrest of growth 
 from juxta-epiphysial sprain, 117 ; the 
 end of bone which increases most also 
 most frequently the seat of inflammation 
 or new growth, 119 ; arrest of growth due 
 to inflammatory affections near the epi- 
 physial cartilage, 120 ; position of drain- 
 age in compound separations, 128 ; case 
 of death from hremorrhage in juxta-epi- 
 physial fracture, 129 ; operations for 
 deformity due to arrest of growth, 132, 
 133, 134 ; juxta-epiphysial separation of 
 upper end of humerus, 183 ; conjugal 
 cartilage of lower end of radius and ulna, 
 579 ; incomplete juxta-epiphysial separa- 
 tion of upper end of femur in infants, 
 622 ; growth in length of femur from 
 lower epiphysis, 680 ; experiments in 
 infants on juxta-epiphysial sprain of 
 lower end of tibia, 828; conjugal chon- 
 drectomy of fibula for arrest of growth 
 of tibia, 854 ; conjugal chondrectomy 
 of tibia for arrest of growth of fibula, 
 866 
 
 Otto, late union of the normal epiphyses, 
 25 
 
 Owen, Edmund, cases of separation of lower 
 epiphysis of femur associated with tuber- 
 culous disease, 86 ; case of simple separa- 
 tion of the epiphysis of the clavicle, 
 141 ; case of separation of upper epi- 
 physis of humerus by indirect violence, 
 172 ; growth of upper end of humerus, 
 254 ; specimen of separation of olecranon 
 epiphysis of ulna, 459 ; case of arrest of 
 growth of ulna after injury to lower epi- 
 physis, 585 ; case of arrest of growth of 
 tibia after separation of lower epiphysis 
 of tibia, 847 
 
 OwiNGs, J. H., case of compound separation 
 of lower epiphysis of femur, 695 
 
 Ozi NNE, case of separation of lower epi- 
 physes of radius and ulna without dis- 
 placement, 524 ; arrest of growth after 
 separation of lower epiphysis of radius, 
 562 
 
 Packakd, J. H., frequency of the various 
 Eeparqtions. 53 ; diagnosis of separation 
 of ths epiphvses, 95; abscess following 
 
 separation of the lower femoral epiphysis 
 in a foal, 119 ; specimen of incomplete 
 displacement in separation of upper epi- 
 physis of humerus, 178 ; separation of 
 upper epiphysis of humerus, 196, 197, 
 202 ; treatment of separation of upper 
 epiphysis of humerus, 224 ; pasteboard 
 splint for elbow, 316 ; separation of the 
 epitrochlea of humerus, 359 ; treatment 
 of fractures of humerus penetrating 
 elbow-joint, 416 ; specimen of fracture of 
 trochleaof humerus with dislocation, 449, 
 450 ; specimen of fracture of olecranon, 
 465 ; fracture of lower end of radius, 482, 
 483 ; separation of lower epiphysis of 
 radius, 523 ; etiology of separation of epi- 
 physial head of femur, 624 ; case of 
 separation of epiphysial head of femur, 
 659 ; separation of epiphysis of great tro- 
 chanter : — etiology of, 663 :— symptoms, 
 669 : — diagnosis, 670 :— treatment, 674 : 
 separation of lower epiphysis of femur 
 in ankylosis of knee, 684 ; separation of 
 lower epiphysis of femur, 759 : — age, sex, 
 and statistics of, 686 : — etiology, 687, 
 688 :— specimens, 724, 729, 737 ; dia- 
 gnosis of, 783 :— treatment, 785, 792, 793, 
 795 
 
 Page, H. W., acute osteomyelitis in separa- 
 tion of lower epiphysis of radius, 519 
 
 Paget, Sib J., arrest of growth due to in- 
 flammatory affections near the epiphysial 
 cartilage, 120 
 
 Pajot, detachment of cartilaginous end of 
 bones during delivery (1853), 7, 41, 65 ; 
 experiments on the limbs of infants at 
 full term, 65, 66 ; experimental separa- 
 tion of the upper end of the humerus in 
 newly born children, 170, 176 
 
 Paletta, J. B., cases of epiphysial detach- 
 ment, in 1820, 4 ; allusion to separation of 
 upper epiphysis of humerus, 176 ; loss of 
 function of shoulder after epiphysial 
 separation of humerus, 253 
 
 Park, Ambeoise, allusions to epiphysial 
 separation (1614), 2 ; separation of epi- 
 physial head of femur, 632, 642 
 
 Paret, dislocation of wrist in children, 544 
 
 Parker, E. W., case of separation of epi- 
 physis of tuber ischii, 614 ; separation of 
 epiphysial head of femur simulating hip- 
 joint disease, 648 
 
 Parker (New York), case of separation of 
 epiphysial head of femur, 657 
 
 Pakkes, Chas. T., case of deformity after 
 separation of upper epiphysis of humerus, 
 250 
 
 Partridge, specimen of separation of lower 
 epiphysis of radius, 488 
 
 Paschen, arrest of growth at lower end of 
 femur after resections of knee joint, 752 
 
 Paton, E. Percy, specimen of compound 
 separation of lower epiphyses of radius 
 and ulna, 505 
 
 Paulet, specimen of detachment of internal 
 epicondyle of humerus, 355 
 
 Pauly, case of resection of internal epi- 
 condyle of humerus, 390 
 
 Pean, case of compound separation of lower 
 epiphysis of radius, resection of diaphy- 
 sis 128 514, 578 ; case of displacement 
 
INDEX OF NAMES 
 
 899 
 
 forwards of lower epiphysis of radius, 
 520 
 
 Peey, G., case of suppuration following 
 compound separation of upper epiphysis 
 of humerus, 188 
 
 Petit, J. L., fractures and separations of 
 the neck of the femur (1705), 3 ; separa- 
 tion of epiphysial head of femur, 624, 
 632, 642 
 
 Petit-Eadel, article on epiphyses, 4 ; ex- 
 periments on bodies of infants, 66 
 
 Peuleve, case of avulsion of leg at upper 
 epiphysis of tibia, 801, 803 
 
 PiiZEKAT, extended position in transverse 
 fractures of lower end of humerus, 324 ; 
 cases of fracture of epitrochlea, 351, 363; 
 treatment of separation of internal epi- 
 condyle of humerus, 887 
 
 Physick, angular splints for elbow, 317 
 
 PiCHON, case of separation of epiphysis of 
 metacarpal bone of index finger, 593 
 
 Pick, T. P., frequency of the various epi- 
 physial separations, 53 
 
 PiNGAUD, separations to be considered as 
 true fractures (1878), 12; treatment of 
 fracture of internal epicondyle of humerus, 
 386 ; fracture of external epicondyle of 
 humerus, 395 ; epicondylo-capitellar 
 fracture of humerus, 422, 441 ; specimen 
 of fracture of trochlea of humerus, 449 ; 
 specimen of fracture of trochlear and 
 capitellar portions of humerus, 455 ; 
 subluxation of radial head, 475 
 
 PiscAET, traumatic separation during de- 
 livery (1840), 6 ; intra-uterine separation 
 of an epiphysis, 43 
 
 PiTHA, disjunctive dislocation of humerus, 
 341 ; cases of separation of lower epi- 
 physis of humerus, 344, 345 ; case of 
 separation of epiphysis of tubercle of 
 tibia, 823 
 
 Platner, J. Z., late union of the epiphyses, 
 49 
 
 PoiNsoT, case of separation of internal epi- 
 condyle of humerus by muscular action, 
 349 ; case of dislocation of elbow with 
 separation of internal epicondyle, 370 
 
 PoiEiER, dislocation of humerus with frac- 
 ture of surgical neck, 186 ; synovial bursas 
 in relation with external epicondyle of 
 humerus, 393 
 
 PoLAiLLON, fracture of inner end of clavicle, 
 136 ; case of separation of lower end of 
 humerus, 271 ; cases of separation of epi- 
 physis of metacarpal bone of index 
 finger, 593, 597 
 
 Poland, Alfred, case of separation of epi- 
 physis of great trochanter, 669 ; case of 
 displacement inwards in separation of 
 lower epiphysis of femur, 774 
 
 Poland, John, first allusion in 1886 to 
 displacement subsequent to epiphysial 
 separation, 15 
 
 PoNCET, A. (Lyons), arrest of growth of 
 parallel bones after lesions to the epi- 
 physial cartilage (1872), 11, 114, 115 ; 
 case of arrest of gi'owth of ulna due to 
 suppuration following compound separa- 
 tion of lower epiphysis, 585 ; etiology of 
 separation of upper epiphysis of tibia, 
 801 ; specimen of separation of upper 
 
 epiphysis of tibia, 806 ; cases of arrest of 
 growth of radius after separation of lower 
 epiphysis, 569 ; resection of diaphysial 
 end in old separations, 132 
 
 PooLEY, J. H., case of deformity after separa- 
 tion of upper epiphysis of humerus, 250 
 
 Portal, frequency of epiphysial separations 
 in various bones, 4 ; separation of upper 
 epiphysis of radius, 473 
 
 Porter, specimen of separation of lower 
 epiphysis of femur, 713 
 
 Post, A. C, case of separation of head of 
 femur by indirect violence, 620 ; case of 
 compound separation of lower epiphysis 
 of femur, 695 
 
 Poucel, case of separation of upper epi- 
 physis of radius, 473 
 
 PouPART, epiphysial separation in smallpox 
 and scurvy, 2 
 
 Power, D'Arcy, epiphyses most frequently 
 separated, 55 ; age in separation of the 
 upper epiphysis of the humerus, 169 ; 
 age in separation of lower epiphysis of 
 humerus, 269 ; age in separation of lower 
 epiphysis of radius, 486; diagnosis of 
 separation of lower epiphysis of radius, 
 547 
 
 Powers, C. A. (New York), age in separation 
 of lower epiphysis of humerus, 269 ; flexed 
 position^for separation of lower epiphysis 
 of humerus, 318 ; cases of separation of 
 internal epicondyle of humerus, 360, 378 ; 
 case of condylo-trochlear fracture of 
 humerus, 412 ; case of epicondylo- 
 capitellar fracture of humerus, 441 ; 
 case of separation of trochlear epiphysis 
 of humerus, 451 
 
 Prochnow, Joseph (Buda-Pest), lower epi- 
 physis of femur most frequently sepa- 
 rated, 55, 692 ; measurements of lower 
 epiphysis of femur, 680 ; case of separa- 
 tion of lower epiphysis of femur, 741, 
 766 
 
 Puzey, Chauncey, cases of separation of 
 upper epiphysis of humerus, 205, 209 ; 
 case of compound dislocation of elbow- 
 joint, 301 ; cases of displacement out- 
 wards in separation of lower epiphysis 
 of femur, 768, 770, 771 
 
 QuAiN, case of compound fracture of ex- 
 ternal condyle of femur, 723 ; develop- 
 ment of tubercle of tibia, 816 
 
 QuAiN, Richard, case of simple separation 
 of lower epiphysis of tibia, 841 
 
 Radel, Petit, experiments on bodies of 
 infants, 66 
 
 Rambaud, order of union of the normal epi- 
 physes, 28 
 
 Rambaud and Renault, epiphysis of in- 
 ternal epicondyle of humerus, 348 ; de- 
 velopment of upper epiphysis of radius, 
 470 ; development of upper end of femur, 
 615 ; specimen of separation of epiphysis 
 of spine of axis, 876 ; epiphysis of 
 tuberosity of rib, 880 
 
 3 M 2 
 
900 
 
 INDEX OF NAMES 
 
 Kanviee, anatomy of the conjugal cartilage, 
 32, 3b 
 
 Bathbun, F. D. (New Windsor, 111.), speci- 
 men of separation of lower epiphysis of 
 femur, 735 
 
 Eecamier, case of separation of epiphysial 
 head of femur, 632 
 
 Eeolus, immediate massage treatment, 127 
 
 Eeeve, J. C. (Ohio), frequency of the 
 various separations, 53; case of com- 
 pound separation of lower epiphysis of 
 humerus, 279 ; case of displacement 
 inwards in separation of lower epiphysis 
 of femur, 775 
 
 Eeichel, Geo. Chbistian, reality of epi- 
 physial lesions (1759), 3; separation of 
 humeral head from lifting child, 40 ; 
 forcible rotation as a cause of disjunction 
 of upper humeral epiphysis, 41 ; non- 
 union after epiphysial separation, 100 ; 
 non-union after separation of upper 
 epiphysis of humerus, 253 ; case of 
 separation of head of femur, 652 ; speci- 
 men of separation of lower epiphysis of 
 femur, 691, 721 
 
 Eenault, order of union of the normal epi- 
 physes, 28 
 
 Eevekdin, J. E., specimen of separation of 
 lower epiphysis of femur, 707 ; statistics 
 of compound separation of lower epi- 
 physis of femur, 793 
 
 EiCABD, violent torsion in separation of 
 upper epiphysis of humerus, 41 ; epi- 
 physial separation mostly before twelfth 
 or fifteenth year, 45 ; separation of the 
 upper epiphysis of humerus by violent 
 torsion, 68 ; pure separations in newly 
 born, 81 ; case of separation of upper 
 epiphysis of humerus by indirect 
 violence, 172 ; specimen of deformity 
 after separation of upper epiphysis of 
 humerus, 251 ; rectangular position in 
 treatment of fractures at the elbow, 319 
 
 EicHET, opinion as to traumatic separa- 
 tion of the epiphyses, 8, 9, 72 ; experi- 
 ments in pathological anatomy, 60 ; case 
 of epiphysial separation through conjugal 
 cartilage, 73 ; epiphysial separation with 
 detachment of bone, 79 ; resection of 
 diaphysial end in compound separations, 
 128 ; case of dislocation of elbow with 
 separation of internal epicondyle, 368 ; 
 case of compound separation of lower 
 epiphysis of radius, 514 ; case of dis- 
 placement forwards (compound) of lower 
 epiphysis of radius, 520 ; resection of 
 diaphysis in compound separation of 
 lower epiphysis of radius, 578 ; case of 
 compound separation of lower epiphysis 
 of femur, 694 
 
 RicHMONP, Chas. H., case of se^Daration of 
 upper epiphysis of humerus, 224 ; case 
 of deformity after separation of upper 
 epiphysis of humerus, 251 
 
 RrviNGTON, Walter, case of separation of 
 the epiphysis of the clavicle, 140 
 
 Egbert, case of simple separation of lower 
 epiphysis of radius, 538 
 
 Eobehts, J. B. (Philadelphia), position of 
 elbow in fractures of elbow-joint, 326 ; 
 anterior displacement in separation of 
 
 lower epiphysis of radius, 484 : speci- 
 men of, 523 ; cases of fracture of lower 
 end of radius with displacement for- 
 wards, 548 ; case of separation of lower 
 epiphysis of femur, 731 
 
 EoBiN, anatomy of the conjugal cartilage, 
 32,33 
 
 EoBsoN, A. W. Mayo, difference in treatment 
 of epiphysial separation and fracture, 
 124 ; case of sub-coracoid dislocation 
 of humerus in a youth, 214 ; extra- 
 articular suture in separated olecranon 
 epiphysis, 469 ; case of separation of 
 upper epiphysis of radius, 474 ; case of 
 separation of epiphysial head of femur, 
 624 ; measurement of shortening at 
 neck of femur, 639; separation of lower 
 epiphysis of femur, etiology of, 687 : — • 
 specimen, 717 : — displacement in, 763, 
 764 : — case of displacement outwards 
 and forwards, 773 : — simple cases of, 
 with pressure on vessels, 780, 781 : — 
 treatment, 786, 792 
 
 Roddick, T. J. (Montreal), case of separa- 
 tion of epiphysis of great trochanter, 
 668, 672 
 
 Eognetta, memoir in 1834 on traumatic 
 separation of the epiphyses of the long 
 bones and trunk, 5 ; intra-uterine se- 
 paration of an epiphysis, 43 ; epiphysial 
 separation during pregnancy, 43 ; late 
 union of the epiphyses, 49 ; deformities 
 of upper and lower extremities after 
 undetected epiphysial separations, 104 ; 
 experimental separation of the upper end 
 of the humerus in newly born children, 
 170 ; cases of separation of lower epi- 
 physis of radius, 482, 484, 489 ; case of 
 gangi'ene following separation of lower 
 epiphysis of radius, 517 ; symptoms of 
 separation of lower epiphysis of radius, 
 525, 535 ; separation of epiphysial head 
 of femur, 631, 642 ; separation of upper 
 epiphysis of tibia, 802 ; case of deformity 
 after separation of upper epiphysis of 
 tibia, 810 ; case of separation of lower 
 epiphysis of tibia, 840 ; case of detach- 
 ment of odontoid process of axis, 878 
 
 Eollet, E., anatomy of the juxta-epiphy- 
 sial region, 34 ; juxta-epiphysial detach- 
 ment, 76 ; etiology of separation of the 
 upper epiphysis of the humerus, 171 ; 
 operative treatment of separation of 
 upper epiphysis of humerus, 228, 239 
 
 RoNALDSoN, bilateral non-union of acro- 
 mial process, 151 
 
 Eose, William, case of arrest of growth 
 of tibia after fracture of lower end, 847 
 
 EouGON, case of compound separation of 
 lower epiphysis of femur, 720 
 
 Eoux (de Brignolle), description in 1822 
 and 1837 of specimens of separation of 
 the lower epiphyses of femur and radius, 
 5, 6 ; occurrence of epiphysial separation 
 as late as eighteenth year, 44 ; statements 
 as to results of separations near joints 
 of different sizes, 119 ; rules of treatment 
 (1837), 123; case of resection in com- 
 pound separation of upper epiphysis of 
 humerus, 241 ; case of simple separation 
 of lower epiphysis of humerus, 290 : 
 
I^'DEX OF NAMES 
 
 901 
 
 treatment of fractured olecranon, 467 ; 
 case of separation of lower epiphysis of 
 radius, 487 ; case of compound disloca- 
 tion of elbow with separation of lower 
 epiphysis of radius, 516 ; specimen of 
 displacement forwards of lower epiphysis 
 of radius, 520 ; good union in a case 
 of separation of lower epiphyses of 
 radius and ulna, oo'S ; case of deformity 
 after separation of lower epiphysis of 
 each radius, 554 ; gangrene in fracture 
 of forearm, 574 ; case of separation of 
 epiphyses of phalanges of digits, 600 ; 
 case of compound separation of lov>er 
 epiphysis of femur, 732 
 
 Rowland, Sydney, clinical application of 
 the Eontgen rays in diagnosis of epi- 
 physial separations, 97 ; skiagram of case 
 of separation of epiphysis of metacarpal 
 bone of index finger, 593 
 
 EuGE, Carl, epiphysial separation during 
 delivery often unsuspected, 41 
 
 EusHMORE, J. D., case of separation of head 
 of femur, 622 
 
 EuYaCH, experiments on new-born children, 
 2 ; earliest experimentalist in 1713, 64 
 
 Sabatier, case of separation of epiphysial 
 
 head of femur, 624, 632 
 Salmon, P. A., experiments in 1845 in de- 
 taching epiphyses of the upper extremity, 
 6 ; experiments in 1845 on the elbow- 
 joint, 59 ; conclusions from experiments, 
 63, 66, 67 ; experimental separation of 
 the upper end of the humerus in newly 
 born children, 170 ; experimental se- 
 paration of upper end of femur in in- 
 fants, 619 
 Sandifort, Ed., translation of Eeichel's 
 treatise on detachments of the epiphyses 
 (1768), 3 
 Sappey, order of union of the normal epi- 
 physes, 24, 28 ; union of the epiphyses 
 from eighteenth to twentieth year, 49 ; 
 ossification of epiphysis of clavicle, 137 ; 
 ossification of lower end of humerus, 
 263 ; development of upper epiphysis of 
 tibia, 798 ; development of tubercle of 
 tibia, 816 ; development of lower epiphy- 
 sis of tibia, 825 
 Savage, W. B., case of separation of epi- 
 physis of great trochanter, 669 
 Sayke, Lewis, specimen of separation of 
 epiphysial head of femur, 626 ; case of 
 separation of epiphysial head of femur, 
 656 
 Sayre, E. H., diagnosis between separation 
 
 of femoral head and hip disease, 649 
 Schmidt, F. W., case of simple separation 
 
 of lower epiphysis of femur, 778 
 ScHMiTZ, Franz, specimens of condylo-capi- 
 
 tellar fracture of humerus, 427 
 ScHOTT, experiments on the conjugal car- 
 tilage, 33 ; transient arrest of growth in 
 fracture of diaphysis, 112 
 ScHiTLLER, Max, lengthening of long bone, 
 from irritation of conjugal cartilage, 
 116 ; operations for deformity due to 
 arrest of growth, 134 
 SiHULTz, specimen of frnctme of neck of 
 femur in a girl, 633 
 
 ScHWALBE, nutrient canals and the growth 
 
 of the long bones, 18, 31 
 Schwartz, J. M., allusion to epiphysial 
 separations in 1736, 3 ; late union of the 
 epiphyses, 49 
 ScHWEGEL, relation of synovial membrane 
 
 to conjugal cartilage, 36 
 SiiE, ankylosis of elbow due to periarticular 
 
 effusions, 309 
 Senftleben, Hugo, specimen of detachment 
 of internal epicondyle with dislocation 
 of elbow, 358 ; case of dislocation of 
 elbow with separation of internal epicon- 
 dyle, 368 ; condylo-trochlear fracture of 
 humerus, 406, 409, 412 ; epicondylo- 
 capitellar detachment of humerus, 
 422 
 Sequeira, .1. H., case of separation of epi- 
 physis of metacarpal bone of ring finger, 
 598 
 Serres, anatomy of epiphyses of phalanges 
 
 of digits, 599 
 Sesary, relation of synovial membranes to 
 conjugal cartilages, 37 ; relation of 
 synovial membrane of shoulder- joint to 
 upper epiphysial line of humerus, 167 ; 
 relation of synovial membrane of ankle 
 to lower epiphysis of fibula, 861 
 Severincs, Marcus Aurelius, deformities 
 following separation of the upper and 
 lower epiphyses of the tibia (1632), 2 ; 
 case of cleformity after separation of 
 upper epiphysis of tibia, 810; cases of 
 separation of lower epiphysis of tibia, 
 840 
 Shattock, S. G., specimen of separation of 
 
 lower epiphysis of radius, 501 
 Shaw, A., case of separation of epiphysis of 
 
 tubercle of tibia, 822 
 Shearer, F., cases of arrest of growth of 
 
 humerus due to inflammation, 259 
 Shepherd, F. J. (Montreal), specimen of 
 separation of epiphysis pt lesser tro- 
 chanter, 675 ; cases of separation of lower 
 epiphysis of femur, 723, 797 ; case of 
 displacement inwards in separation of 
 lower epiphysis of femur, 774 
 Sheppard, C. E., cases of separation of 
 lower epiphysis of femur, displacement 
 backwards, 766, 767 
 Simon, case of separation of lower epiphysis 
 
 of femur, 766 
 Simpson, A. Eussell, mechanism of separa- 
 tion of lower epiphysis of femur during 
 version, 64 ; diastasis of bones of lower 
 extremity produced by accoucheur, 71 ; 
 separation of upper cartilaginous epi- 
 physis of femur in foetus, 622 
 Smallwood, S. B. (Astoria, U.S.A.), case of 
 compound separation of lower epiphysis 
 of femur, 696 
 SiuTH, E. Noble, case of separation of epi- 
 physial head of femur, 634 
 Smith, H. L. (Boston, U.S.A.), experiments 
 on position of elbow in treatment of 
 fractures involving joint, 326 
 Smith, Morven (Baltimore, U.S.A.), case of 
 separation of lower epiphysis of femur, 796 
 Smith, E. W. (l->ublin), description in 
 1847 of separation of the epiphyses of 
 the humerus and )'afliuR. 7; pnpf'vs on 
 
902 
 
 INDEX OF NAMES 
 
 epiphysial injuries in 18C5 and 1867, 8 ; 
 knowledge of the anatomy of the epi- 
 physes important, 16 ; separations follow 
 exactly the epiphysial cartilage, 72; 
 symptoms of epiphysial separations, 88 ; 
 rarity of complete displacement in separa- 
 tion of upper epiphysis of humerus, 178 ; 
 separation of upper epiphysis of humerus, 
 193, 197 ; case of separation of upper 
 epiphysis of humerus, 198 ; diagnosis of 
 separation of upper epiphysis of humerus, 
 216 ; specimen of upper end of humerus 
 after fracture through epiphysial line, 
 249 ; case of compound separation of 
 lower epiphysis of humerus, 277 ; case of 
 injury to brachial artery in compound 
 separation of lower epiphysis of humerus, 
 283 ; views upon separation of lower epi- 
 physis of humerus, 333 ; specimen of com- 
 pound separation of lower epiphysis of 
 humerus, 337 ; symptoms of separation of 
 lower epiphysis of humerus, 340, 341, 
 344, 345 ; specimens of separation of 
 lower epiphysis of radius, 499, 509 ; case 
 of gangrene following separation of lower 
 epiphysis of radius, 517 ; symptoms of 
 separation of lower epiphysis of radius, 
 530 ; diagnosis of separation of lower 
 epiphysis of radius from dislocation of 
 wrist, 545, 550, 551 ; treatment of separa- 
 tion of lower epiphysis of radius, 573 ; 
 separation of lower epiphysis of tibia, 839 : 
 — specimen of, 832 : — case of, 840 
 
 Smith, Stephen, treatment of condylo-tro- 
 chlear fracture of humerus, 415 ; treat- 
 ment of fractures of humerus penetrating 
 elbow joint, 418 
 
 SiiiTH, W. Johnson, case of operation in 
 old separation of upper epiphysis of hu- 
 merus, 132, 237 ; case of resection in 
 compound separation of upper epiphysis 
 of humei'us, 241 
 
 SoNNENBURG, treatment of injuries of elbow, 
 324 
 
 South, J. F., case of condylo-trochlear frac- 
 ture of humerus, 407 ; case of separation 
 of epiphysial head of femur, 623 
 
 Spence, case of compound separation of 
 lower epiphysis of tibia, 834 
 
 Spencer, Herbert R., ossification of upper 
 epiphysis of humerus, 163 
 
 Spillmann, E., case of compound separation 
 of lower end of humerus, 128, 276 ; cases 
 of separation of epiphysial head of femur, 
 632, 642 ; separation of lower epiphysis 
 of femur in straightening ankylosed 
 knee, 684, 749 
 
 Stabell, F., case of separation of epiphy- 
 sis of tubercle of tibia, 823 
 
 Stanley, disturbance of growth after epi- 
 physial separation described in 1849, 
 104 ; case of arrest of growth of tibia 
 after suppuration, 117 ; case of frac- 
 ture of neck of femur in a child, 633, 
 643 ; diagnosis of fracture of great tro- 
 chanter, 671 
 
 Stehr, Wilhelm, thesis, in 1889, on arrest 
 of growth of radius following epiphysial 
 separation, 15 ; cases of arrest of growth 
 after separation of lower epiphysis of 
 radius, 563 
 
 Stetter, G., case of separation of head of 
 femur by indirect violence, 620 
 
 Stijison, L. a., experience of epiphysial 
 separations (1863), 13 ; arrest of growth, 
 105 ; dislocation of humerus with fracture 
 of surgical neck, 186 ; specimen of separa- 
 tion of lower end of humerus, 271 ; 
 straight position for injuries of elbow, 
 323 ; cases of separation of internal epi- 
 condyle of humerus, 352, 374 ; specimen 
 of separation of upper epiphysis of fibula, 
 859 ; case of compound separation of first 
 phalanx of great toe, 870 
 
 Stokes, Sir W. (Dublin), specimen of 
 separation of os innominatum into its 
 original parts, 605 
 
 Stonham, C, specimen of compound separa- 
 tion of lower epiphyses of radius and 
 ulna, 505 
 
 Strelzoff, difference in the growth of the 
 various epiphyses of the long bones, 31 
 
 Struthers, Sir John, separate aci-omion 
 process simulating fracture, 149 ; separate 
 acromion process and osteo-arthritis of 
 shoulder-joint, 154 
 
 Sturrock, C. a., epiphyses most frequently 
 separated, 55 ; good union in separation 
 of lower end of humerus, 306 ; case of 
 separation of internal epicondyle of 
 humerus, 375 ; case of compound separa- 
 tion of lower epiphyses of radius and 
 ulna, 504 ; case of simple separation of 
 lower epiphyses of radius and ulna, 
 539 ; case of separation of epiphysis of 
 head of metacarpal bone of thumb, 590 ; 
 case of separation of epiphysial head of 
 femur, 660 ; case of displacement back- 
 wards in separation of lower epiphysis 
 of femur, 767 ; case of simple separation 
 of upper epiphysis of tibia, 810 ; case 
 of compound separation of lower epi- 
 physis of tibia, 836 
 
 Sutton, J. Bland, new rule for centres of 
 ossification of the epiphyses, 22 ; stimu- 
 lated growth of epiphysial cartilage after 
 amputation, 31 ; comparative length of 
 external malleolus in man, 861 ; specimen 
 of compound separation of lower epiphysis 
 of fibula, 861 
 
 Stme, epiphysial separation the same as 
 fracture (1842), 12, 13 
 
 Symonds (Oxford), case of separation of 
 anterior-inferior spine of ilium, 612 
 
 Symonds, C. J. (London), case of compound 
 separation of lower epiphysis of femur, 
 699 
 
 Tapret and Chenet, specimen of separa- 
 tion of lower epiphysis of femur, 707 
 
 Tay, Waren, case of separation of lower 
 epiphysis of femur, 780 
 
 Taylor, J. Gurney, case of separation of 
 upper epiphysis of humerus by indirect 
 violence, 173 
 
 Teale, case of deformity after simple sepa- 
 ration of lower end of humerus, 307 
 
 Telke, 0., experiments in growth of bones, 
 105 
 
 Terrier, immediate massage treatment, 
 127 ; case of compound separation of 
 lower epiphysis of radius, 507 
 
INDEX OF NAMES 
 
 903 
 
 Terrillon, experimental separation from 
 indirect violence at the knee-joint, 68 
 
 Thane, anatomy of epiphysis of great 
 trochanter, 662 
 
 Thompson, Allan, anatomy of second meta- 
 carpal bone, 591 
 
 Thomson, Geo. S., case of compound sepa- 
 ration of lower end of humerus, 277 
 
 Thudichum, J. LuDW., papers upon epiphy- 
 sial separations in 1855, 7 ; specimen of 
 separation of upper epiphysis of humerus, 
 180 ; separation of upper cartilaginous 
 epiphysis of femur in foetus, 622 
 
 TiLiiMANNS, transient arrest of growth in 
 fracture of diaphysis, 112 
 
 Todd, R. B., specimen of separation of 
 lower epiphysis of femur, 734 
 
 Todd and Bowman, anatomy of the con- 
 jugal cartilage, 32 
 
 TopiNARD, individuality as regards the rate 
 of growth in length of the long bones, 18, 
 24 
 
 Trelat, U., epiphysial separation the same 
 as fracture (1865), 10 ; case of old separa- 
 tion of lower epiphysis of femur, 749 
 
 Treves, case of separation of capitellum of 
 humerus, 453 ; case of separation of 
 anterior-inferior spine of ilium, 611 
 
 Tripier (Lyons), immediate passive move- 
 ment in fracture of elbow- joint, 327 
 
 Troschel, case of displacement upwards of 
 internal condyle of humerus, 362 
 
 Tubby, A. H., case of arrest of growth of 
 humerus after separation of upper epi- 
 physis, 259 ; specimen of separation of 
 lower epiphysis of femur, 705 ; specimen 
 of separation of upper epiphysis of tibia, 
 807 
 
 Tdkgis, case of separation of lower epiphy- 
 sis of femur, 752 
 
 Uffelmann, J., relation of synovial mem- 
 branes to conjugal cartilages, 37 ; epi- 
 physes disunited beyond thirty years of 
 age, 46 ; cartilaginous and osseous epi- 
 physes, 75 ; shortening of the limb after 
 separation (1865), 104 ; ossifications of 
 epiphysis of acromion process, 146, 148 ; 
 arrest of growth after separation of lower 
 epiphysis of femur, 752 
 
 Valleix, several epiphyses separated from 
 syphilis, 85 
 
 Van Arsdale, subluxation of radial head, 
 475 
 
 Van Lennep, W. B. (Philadelphia), skia- 
 graphy in separation of lower epiphysis 
 of humerus, 304 
 
 Van Swieten, muscular action a cause of 
 separation of femoral head, 42 ; non- 
 union after separation of head of femur, 
 621, 652 
 
 Varris, non-union of epiphyses and the 
 direction of the nutrient canals, 22 
 
 Velpeau, intra-uterine separation of an 
 epiphysis, 43 ; case of separation of upper 
 epiphysis of humerus by muscular action, 
 174 ; prognosis in traumatic lesions of 
 the elbow in children, 313 ; case of com- 
 pound separation of lower epiphysis of 
 femur, 700 
 
 Verchkre, specimen of separation of clavi- 
 cular epiphysis with wound of pleural 
 sac, 137 
 
 Verduc, Jean B., allusion in 1693 to 
 separation of the upper epiphysis of the 
 femur, 3 ; case of separation of epiphy- 
 sial head of femur, 632, 642 
 
 Verneuil, a. (Lariboisi^re),case of separa- 
 tion of clavicular epiphysis, 138 ; separa- 
 tion of lower epiphyses of femur, 690 ; 
 cases of compound separation of lower 
 epiphysis of femur, 698, 727 ; specimen 
 of fracture of external condyle of femur, 
 723 ; case of avulsion of leg at upper 
 epiphysis of tibia, 801 
 
 Vincent (Lyons), statistics of sixty cases 
 of fracture or separation at the elbow- 
 joint in about seven years, 55, 302 ; 
 modified extended position in treatment 
 of disjunction of lower epiphysis of 
 humerus, 320 ; cases of separation of 
 internal epicondyle of humerus, 388 ; 
 cases of separation of upper epiphysis of 
 radius, 477 
 
 VoGT, P. (Griswald), monograph in 1878 
 on epiphysial injuries, 14 ; difference in 
 the growth of the various epiphyses of 
 the long bones, 31 ; experiments in 
 pathological anatomy, 58, 59, 68 ; carti- 
 laginous and osseous epiphyses, 75 ; 
 separation of cartilaginous epiphyses 
 mostly pure, 81 ; growth in length of 
 long bones, 105 ; cause of arrest of, 
 108, 109, 112, 115; case of arrest of 
 growth of humerus after separation of 
 upper epiphysis, 106, 256 ; rate of 
 growth of lower end of humerus, 312 ; 
 case of separation of epiphysis of tuber- 
 cle of tibia, 822 
 
 Voillemier, mechanism of detachment of 
 lower epiphysis of radius (1842), 6 ; ex- 
 perimental separation of lower radial 
 epiphysis at twenty-fourth year, 45 ; 
 separation of lower radial epiphysis by 
 hyperextension, 67 ; persisting conjugal 
 cartilage of lower epiphysis of radius, 
 478 ; separation of lower epiphysis of 
 radius by cross strain, 483 ; case of 
 separation of lower epiphyses of radius 
 and ulna, 506 
 
 VoLKMANN, epiphysial separation during 
 childbirth, 43 ; arrest of growth after 
 epiphysial injury, 114 ; specimen of sepa- 
 ration of upper end of humerus during 
 delivery, 176 ; cases of separation of 
 lower epiphysis of femur in manipula- 
 tions for hip disease, 684 ; case of arrest 
 of growth after injury to upper epiphy- 
 sis of tibia, 811 
 
 Voss (New York), case of compound sepa- 
 ration of lower epiphysis of femur, 738 ; 
 case of compound separation of lower 
 epiphysis of tibia, 839 
 
 Wade, specimen of separation of lower 
 
 epiphysis of tibia, 832 
 Wagner, treatment of injuries of elbow, 
 
 324 
 Waldeyer, anatomy of epiphysis of third 
 
 trochanter, 677 
 
904 
 
 INDEX OF NAMES 
 
 Wallace, David (Edinburgh), on separate 
 acromion process, 151 ; case of separa- 
 tion of epiphysial head of femur, 655 
 
 Wallace, Heney, case of displacement 
 outwards in separation of lower epiphysis 
 of femur, 772 
 
 Walsh, D., Rontgen rays in medical work, 
 305 
 
 Walsham, W. J., case of separation of lower 
 epiphysis of femur, 739 
 
 Walther, C, operative treatment of recent 
 separation of upper epiphysis of humerus, 
 230 ; operative treatment of old separa- 
 tion of upper epiphysis of humerus, 240 ; 
 open operation in a case of fracture of 
 lower end of femur, 789 
 
 Ward, Nathaniel, specimens added to the 
 London Hospital Museum by, 13 ; speci- 
 men of separation of lower epiphysis of 
 femur, 693 
 
 Wardner (Cairo, Illinois), case of separation 
 of epiphysial head of femur, 637 
 
 Ware, E. E., ablation of leg at knee-joint, 
 688 
 
 Warren, F. W., specimen of detachment 
 of epiphysis of great trochanter, 665 
 
 Warren, J. C. (Boston, U.S.A.), straight 
 position for injuries of elbow, 323 ; treat- 
 ment of fractures of humerus penetrating 
 elbow-joint, 419 
 
 Watson, John, case of simple separation of 
 lower end of humerus in infancy, 291 
 
 Watson, W. Spencer, specimen of com- 
 pound separation of lower epiphysis of 
 femur, 703 
 
 Weber, C. 0., cases of epiphysial separa- 
 tion in 1859, 52 
 
 Wegener, cause of arrest of growth, 108 
 
 Weinlechner, experiments on the conjugal 
 cartilage, 33 ; case of separation of epi- 
 physis of tubei'cle of tibia, 823 
 
 Wharton, H. R. (Philadelphia), age in 
 separation of the upper epiphysis of 
 humerus, 169; case of disjunction of 
 upper epiphysis of humerus, 200 ; de- 
 formity after separation of upper epi- 
 physis of humerus, 249 ; inter-condyloid 
 fracture of humerus, 420; case of com- 
 pound separation of lower epiphysis of 
 femur, 700 
 
 Wheelhouse, C. G., case of deformity after 
 simple separation of lower end of 
 humerus, 307 ; specimens of separation 
 of lower epiphysis of femur, 716 
 
 White, J. W. (Pennsylvania), case of 
 arrest of growth of ulna at distal epi- 
 physis, 587 
 
 White (London), case of compound separa- 
 tion of lower epiphysis of femur, 719 
 
 Whitelocke, R. H. a., cases of separation 
 of anterior-inferior spine of ilium, 611 
 
 Whitman, Royal, cases of fracture of neck 
 of femur in childhood, 646 
 
 Wight, J. S. (Brooklyn), fracture of bones 
 of the forearm with separation of lower 
 epiphysis of humerus, 295; cases of 
 fracture of lower end of humerus treated 
 in the extended position, 326 
 
 Will, J. C. 0., case of fracture of tubercle 
 of tibia, 819 
 
 Wlllett, E., case of separation of lower 
 epiphysis of femur, 739 
 
 Williams, Chas., case of compound separa- 
 tion of upper epiphysis of humerus, 181 
 
 Williams, Roger, anatomy of anterior- 
 inferior spine of ilium, 610 
 
 Wilson, Jas., mechanical experiments in 
 separating the epiphyses of long bones 
 of infants (1820), 4, 58, 65, 66 
 
 Winchester, tin splint for elbow, 317 
 
 WiNDLE, ununited acromial epiphysis, 149 
 
 WiNSLOw, R. (Baltimore, U.S.A.), case of 
 separation of lower epiphysis of femur, 
 750 
 
 WoELFLER, case of operation for recent 
 separation of upper epiphysis of humerus, 
 226 
 
 Wood, John, specimen of epicondylo- 
 capitellar separation of humerus, 424; 
 case of arrest of growth of tibia after 
 separation of lower epiphysis, case of, 
 847 
 
 Wright, G. A. (Manchester), injury to 
 periosteum at lower end of humerus, 
 285 ; case of occlusion of brachial artery 
 in simple separation of lower end of 
 humerus, 293; injury to nerves in simple 
 separation of lower epiphysis of hu- 
 merus, 295 ; case of condylo-trochlear 
 fracture of humerus, 412 ; test lines for 
 injuries about elbow, 436 ; case of frac- 
 ture of capitellum of humerus, 453 ; 
 case of compound separation of olecranon 
 epiphysis wired, 470 ; case of arrest 
 of growth of radius after separation of 
 lower epiphysis, 570 ; case of separation 
 of upper femoral epiphysis, 632 ; case of 
 compound separation of lower epiphysis 
 of femur, 718 ; case of displacement for- 
 wards in separation of lower epiphysis of 
 femur, 764 ; case of separation of lower 
 epiphysis of tibia, 837 ; case of compound 
 separation of lower epiphysis of fibula, 
 864 
 
 ZucKERKANDL, E. (Vienna), specimen of 
 separation of internal epicondyle of 
 humerus, 353 ; specimen of fracture of 
 external epicondyle of humerus, 396, 397 
 
 Zuehlke, C. R., thesis in 1859 on epiphysial 
 separations, 7 
 
INDEX OF SUBJECTS 
 
 Abduction and adduction of limb in experiments for separating epiphyses, 68 
 Acetabulum, anatomy of, 603 : — pathological anatomy of separation of its epiphysial 
 
 parts, 605 
 Acromion process, anatomy of, 145 
 
 separation of epiphysis of, 145 : — etiology, 148 : — pathological 
 anatomy, 149: — symptoms, 154: — diagnosis, prognosis, and 
 treatment, 155 : — symmetrical non-union, 153 
 Age, in epiphysial separations, Bruns's and Gurlt's statistics, 43, 45, 48 
 separation of epiphysis of clavicle (statistics), 137 
 coracoid epiphysis, 158 
 upper epiphysis of humerus, 169, 170 
 lower end of humerus before puberty, 268 
 lower epiphysis of humerus in youths, 337 
 internal epicondyle of humerus, 351 
 external epicondyle of humerus, 394 
 epicondylo-trochlear and condylo-trochlear fractures of humerus, 406 
 condylo-capitellar and epicondylo-capitellar fractures of humerus, 423 
 separation of capitellum of humerus, 453 
 upper epiphysis of ulna, 461 
 upper epiphysis of radius, 472 
 lower epiphysis of radius, 485 
 lower epiphysis of ulna, 583 
 epiphysis of metacarpal bone of thumb. 589 
 epiphyses of true metacarpal bones, 592 
 epiphyses of phalanges of digits, 599 
 epiphyses of anterior superior iliac spine, 608 
 epiphysial head of femur, 618 
 epiphysis of great trochanter of femur, 662 
 lower epiphysis of femur, 682 
 upper epiphysis of tibia, 802 
 epiphysis of tubercle of tibia, 819 
 lower epiphysis of tibia, 826 
 upper epiphysis of fibula, 858 
 lower epiphysis of fibula, 861 
 Amputation, primary, in epiphysial separations, 129 
 
 sepai'ation of lower end of humerus, 330 
 
 epiphysis of metacarpal bone of thumb, 591 
 lower epiphysis of femur, 795 
 upper epiphysis of tibia, 815 
 lower epiphysis of tibia, 853 
 secondary, in epiphysial separations, 130 
 
 separation of lower end of humerus, 330 
 
 lower epiphysis of radius, 578 
 lower epiphysis of femur, 795 
 upper epiphysis of tibia, 815 
 Anatomical character of separations in 1845, 6 
 
 specimens of epiphysial separation in 1862 (Gurlt), 8 
 Anatomy of epiphyses important, 16 
 epiphysis of clavicle, 135 
 epiphysis of acroTuion process, 145 
 upper epiphysis of humerus, 163 
 lower end of humerus before puberty, 262 
 
906 INDEX OF SUBJECTS 
 
 Anatomy of lower epiphysis of humerus in youths, 333 
 internal epieondyle of humerus, 346 
 external epieondyle of humerus, 392 
 trochlea of humerus, 448 
 capitellum of humerus, 452 
 upper epiphysis of ulna, 457 
 upper epiphysis (head) of radius, 470 
 lower epiphysis of radius, 478 
 lower epiphysis of ulna, 580 
 epiphysis of metacarpal bone of thumb, 588 
 epiphyses of true metacarpal bones, 591 
 epiphyses of phalanges of digits, 599 
 epiphysial parts of acetabulum, G03 
 epiphyses of superior iliac spines and crest, GOG 
 anterior inferior spine of ilium, G09 
 epiphysis of symphysis pubis, 613 
 
 epiphysis of spine of pubes, 613 j 
 
 epiphysis of sciatic spine, 614 
 tuberosity of ischium, 614 
 epiphysial head of femur, 615 
 epiphysis of great trochanter of femur, 661 
 lesser trochanter of femur, 675 
 lower epiphysis of femur, 678 
 upper epiphysis of tibia, 798 
 epiphysis of tubercle of tibia, 816 
 lower epiphysis of tibia, 824 
 upper epiphysis of fibula, 856 
 lower epiphysis of fibula, 860 
 epiphysis of os calcis, 867 
 occasional epiphysis of astragalus, 868 
 outer metatarsal bones, 869 
 phalanges of toes, 870 
 epiphyses of vertebrfe generally, 873 
 epiphyses of cervical vertebrae generally, 876 
 epiphyses of axis, 877 
 atlas, 877 
 
 epiphyses of lumbar vertebrae, 878 
 epiphyses of sacrum, 879 
 epiphyses of ribs, 880 
 Aneurysm after epiphysial separations, 121 
 
 following separation of lower epiphysis of femur, 746 
 Ankylosis of shoulder, after separation of upper epiphysis of humerus, 189 
 elbow, after separation of lower end of humerus, 309 
 
 after separation of internal epieondyle of humerus, 376 
 after coudylo-trochlear fracture of humerus, 410 
 after condylo-capitellar fracture of humerus, 439 
 after fracture of capitellum of humerus, 455 
 after separation of olecranon epiphysis, 466 
 wrist, after separation of lower epiphysis of radius, 561 
 hip, after separation of epiphysial head of femur, 657 
 knee, after separation of lower epiphysis of femur, 749 
 upper epiphysis of tibia, 810 
 Anterior inferior spine of ilium, anatomy^ 609 : — separation of, etiology, 609 : — symptoms, 
 
 611 
 Apophyses of bones, 37 
 Appendix, 881 
 
 Arm, gangrene of, in separation of upper epiphysis of humerus, 189 
 Arrest of growth in one of the parallel bones (Poncet, 1872), 11 
 Dittmayer's thesis in 1887, 15 
 after epiphysial separation, 103 
 after fracture of diaphysis, 105 
 after separations in first decades of life, 105 
 statistics of, 107 
 causes, 108, 114 
 transient. 111, 112 
 due to mobility of fragments, 112 
 experiments in, and histology of, 113 
 deformity after, 114 
 
 from ostitis, &c., following epiphysial sprain, 117 
 deformity from, due to epiphysial injury, 118 
 operations for deformity alter, 132 
 
INDEX OF SUBJECTS 907 
 
 Arrest of growth of humerus after separation of upper epiphysis, 254 
 
 from inflammation due to injuries at upper epiphysis, 259 
 after separation of lower end, 312 
 after condylo-trochlear and epicondylo-trochlear fractures of humerus, 
 
 414 
 after epicondylo-capitellar and condylo-capitellar fractures of humerus, 
 
 439 
 of radius, after separation of lower epiphysis, 562 : — specimens of, 564 : — 
 
 table of, 571 : — clinical cases, 568 : — treatment of, 578 
 of ulna, after injury to lower epiphysis, 583 
 of femur, after injury to upper epiphysis, 657 
 
 after separation of epiphysis of great trochanter, 671 
 after injury to lower epiphysis, 751 
 of tibia, after separation of upper epiphysis, 810 
 
 after separation of lower epiphysis, 846 : — cases of, 847 
 of fibula, after separation of lower epiphysis, 864 
 Artery, axillary, wound of, in separation of upper epiphysis of humerus, 185, 211 
 brachial, injury to, in separation of lower end of humerus, 283, 292 
 radial, injury to, in separation of lower epiphysis of radius, 516, 541 
 popliteal, injury to, in separation of lower epiphysis of femur, 727, 779 
 tibial, injury to, in separation of lower epiphysis of femur, 733 
 
 of tibia, 838 
 Articular capsule, relation to conjugal cartilage, 36 
 
 cartilage of epiphyses, anatomy of, ossification of, 36 
 lesions, in epiphysial separations, 84 
 
 in separation of upper epiphysis of humerus, 186 
 
 elbow, in separation of lower end of humerus, 296, 309, 376 
 
 in separation of internal epicondyle of humerus, 357, 372, 376 
 in separation of external epicondyle of humerus, 400, 402 
 in condylo-trochlear and epicondylo-trochlear fractures of hu- 
 merus, 409, 413 
 in condylo-capitellar and epicondylo-capitellar fractures of 
 
 humerus, 439 
 in separation of upper epiphysis of ulna, 464, 466, 470 
 wrist, in separation of lower epiphysis of radius, 500, 519 
 knee, in separation of lower epiphysis of femur, 712, 723, 733, 749: — 
 suppuration of, 744 
 in separation of upper epiphysis of tibia, 808, 809, 810, 813 
 in separation of epiphysis of tubercle of tibia, 820, 821 
 ankle, in separation of lower epiphysis of tibia, 838 
 Astragalus, occasional epiphysis of, 868 
 Atlas, anatomy and separation of epiphysial parts of, 877 
 
 Axillary artery, wound of, in separation of upper epiphysis of humerus, 185, 211 
 Axis, anatomy, separation of epiphyses of, 877 
 
 Bicipital epiphysis of radius, 477 
 
 Birth, pathological anatomy of separations at, 70 
 
 Brachial artery, injury to, in separation of lower end of humerus, 283, 292 
 
 plexus, pressure upon, in separation of upper epiphysis of humerus, 212 
 
 Callus, exuberant, in epiphysial separations, 103 
 
 in separation of lower end of humerus, 308 
 in condylo-trochlear fractui-e, 410 
 in condylo-capitellar fracture, 439 
 Capitellar and trochlear epiphyses of humerus, separation of, 455 
 
 Capitellum of humerus, anatomy, 452; separation of, 453: — pathological anatomy, 453: — 
 age, 453 : — etiology, 454 : — symptoms, 454 : — complications, prognosis, and treatment, 
 455 
 Cervical vertebrae generally, separation of, anatomy, cases, &c., 876 
 Chondrectomy, conjugal, of lower end of ulna for arrest of growth of radius, 578 
 for arrest of growth of one of parallel bones, 133 
 of fibula, for arrest of growth of tibia, 854 
 of lower end of tibia for arrest of growth of fibula, 866 
 Clavicle, epiphysis of, anatomy of, 135 
 
 separation of epiphysis of, 135 : — age, 137 : — etiology, 137 : — pathological 
 anatomy, 137: — symptoms, 139: — diagnosis, 141: — prognosis, 142; — treat- 
 ment, 142 : — treatment of compound separation, 143 
 Colles's fracture, diagnosis from separation of lower epiphysis of radius, 546 
 Complete displacement of epiphyses, pathological anatomy, 83 
 Complications in epiphysial separations, 83 
 
908 INDEX OF SUBJECTS 
 
 Complications in separation of coracoid process, 162 
 
 separation of upper epiphysis of humerus, 183, 211 
 lower end of humerus, 283, 292 
 internal epicondyle of humerus, 357, 365, 389 
 external epicondyle of humerus, 400, 403 
 epicondylo-trochlear and condylo-trochlear fractures of humerus, 408 : — 
 
 treatment of, 420 
 epicondylo-capitellar and condylo-capitellar fractures of humerus, 429, 
 
 435 
 separation of trochlea of humerus, 449, 451 
 capitellum of humerus, 455 
 lower epiphysis of radius, 497, 517, 538, 542 
 epiphysis of metacarpal bone of thumb, 590 
 epiphysis of great trochanter of femur, 671 
 lower epiphysis of femur, 724, 738, 779 
 upper epiphysis of tibia, 808, 813, 839 
 lower epiphysis of fibula, 864 
 Compound dislocation, compound separation mistaken for, 97 
 separations, 86 
 
 I'esults, 121 
 treatment, 128 
 separation of clavicular epiphysis, treatment of, 143 
 coracoid epiphysis, 159 
 upper epiphysis of humerus, 185 
 
 followed by suppuration, 187, 261 
 operative treatment, 241 
 lower end of humerus, 275, 279, 295, 328 
 internal epicondyle of humerus, 372, 391 
 external epicondyle of humerus, 404 
 
 epicondylo-trochlear portion of lower epiphysis of humerus, 420 
 condylo-capitellar portion of humerus, 430 
 upper epiphysis of ulna, 460, 470 
 lower epiphysis of radius, 485, 490,503, 505, 513, 577 
 epiphysis of metacarpal bone of thumb, treatment of, 591 
 lower epiphysis of femur, 694, 705, 724, 726, 733, 736, 738, 740, 
 
 741, 744, 746, 751, 752, 782, 792 
 lowpr epiphysis of tibia, 826, 833, 853 
 lower epiphysis of fibula, 863 
 Compression separations, 42 
 
 Condylo-capitellar fracture of humerus, 421 : — etiology, 422 : — age, 423 : — pathological 
 anatomy, 423: — complications, 429, 435 :— symptoms, 431: — -diagnosis, 435: — pro- 
 gnosis, 436 : — treatment, 442 : — primary operations for irreducibility, 446 
 Condylo-trochlear fracture of humerus, 405 : — etiology, 405 : — age, 406 : — pathological 
 
 anatomy, 406 : — symptoms, 407 ; — 
 complications, 408 : — diagnosis, 
 410 : — prognosis, 410 : — treatment, 
 414: — primary opei'ations for irre- 
 ducibility, 420; compound separa- 
 tions, 420 
 Conical stumps, 31 
 Conjugal cartilage, direction of line of, 28, 31, 33 
 
 chondroid layer in relation to activity of growth, 28, 29 
 thickness according to age, 29 
 value of each, 31 
 
 increased growth of, causing conical stumps, 31 
 advantages from, 32 
 histology of, 32 
 
 its function, experiments on its physiological rate, 33 
 site and relation of, by means of Rontgen ray process, 33 
 relation to articular capsule and synovial membrane, 36 
 Conjugal chondrectomy, for arrest of growth of one of parallel bones, 133 
 
 of lower end of ulna for arrest of growth of radius, 578 
 of fibula for arrest of growth of tibia, 854 
 of lower end of tibia for arrest of growth of fibula, 866 
 Coracoid epiphyses, anatomy of, 156: — specimens of ununited, 160 
 
 separation of, etiology, 158 : — pathological anatomy, 158 ; — symptoms, 
 161 : — complications, 162 : — specimen of, 160 
 Crepitus, in epiphysial separations, 92 
 
 in Reparation of epiphysis of clavicle, 140 
 acromial epiphysis, 154 
 coracoid epiphysis, 161 
 
INDEX OF SUBJECTS 909 
 
 Crepitus, in separation of upper epiphysis of humerus, 203 
 
 lower end of humerus, 290 
 
 lower epiphysis of humerus, 342 
 
 internal epicondyle of humerus, 364 
 
 external epicondyle of humerus, 399 
 in condylo-trochlear fracture, 407 
 in condylo-capitellar fracture, 431 
 in separation of trochlea, 449 
 
 capitellum, 454 
 
 olecranon epiphysis, 463 
 
 lower epiphysis of radius, 537 
 
 epiphysis of metacarpal bone of thumb, 590 
 
 epiphyses of true metacarpal bones, 594 
 
 epiphyses of phalanges of digits, 601 
 
 epiphysis of iliac crest, 608 
 
 epiphysis of anterior inferior spine of ilium, 611 
 
 epiphysial head of femur, 636 
 
 epiphysis of great trochanter of femur, 668, 669 
 
 lower epiphysis of femur, 776 
 
 upper epiphysis of tibia, 813 
 
 epiphysis of tubercle of tibia, 821 
 
 lower epiphysis of tibia, 840 
 Croft's splints, in epiphysial separations, 125 
 
 Cross strain, producing separation of lower epiphysis of radius, 482 
 Cubitus valgus, after condylo-capitellar fracture of humerus, 428, 438, 439 
 Cubitus varus, after epicondylo-trochlear fracture, 412 
 after condylo-capitellar fracture, 439 
 
 Deformities of knee and foot from separation of the tibial epiphyses, 2 
 Deformity, after epiphysial separations and modelling process, 101, 102 
 from arrest of growth, 114 
 refracturing in recent cases of, 131 
 operations for, after arrest of growth, 132 
 after separation of upper epiphysis of humerus, 246 
 lower end of humerus, 306 
 lower epiphysis of radius, 553 
 internal epicondyle of humerus, 377 
 condylo-trochlear fracture, 407 
 epicondylo-capitellar fracture, 432 
 separation of olecranon epiphysis, 463 
 
 lower epiphysis of radius, 525, 553, 579 
 epiphysis of metacarpal bone of thumb, 589 
 epiphyses of ti'ue metacarpal bones, 592 
 epiphyses of phalanges of digits, 601 
 epiphysial head of femur, 639 
 epiphysis of great trochanter of femur, 669 
 lower epiphysis of femur, 749, 797 
 upper epiphysis ©f tibia, 810 
 lower epiphysis of tibia, 840, 844, 846, 854 
 Delivery, epiphysial separations of humerus during (1787), 3 
 
 traumatic separation during and after birth (1840), 6 
 cartilaginous ends detached during (1853), 7 
 direct traction during, 40, 43 
 Deltoid muscle, laceration of, in separation of upper epiphysis of humerus, 185 
 Diagnosis of separation of the epiphyses from fracture, 95 
 
 from dislocation, 96 
 Rontgen ray process in, 97 
 Diagnosis, differential, in separation of epiphysis of clavicle, 141 
 
 acromion process, 155 
 upper epiphysis of humerus, 213 
 lower end of humerus, 300 
 lower epiphysis of humerus in youths, 343 
 internal epicondyle of humerus, 373 
 in condylo-trochlear and epicondylo-trochlear fractui'e of 
 
 humerus, 410 
 in condylo-capitellar and epicondylo-capitellar fractures of 
 
 humerus, 435 
 in separation of trochlea of humerus, 451 
 
 upper epiphysis of ulna, 464 
 upper epiphysis of radius, 475 
 
910 INDEX OF SUBJECTS 
 
 Diagnosis, diflerential, in separation of lower epiphysis of radius, 543 
 
 epiphysis of metacarpal bone of thumb, 590 
 epiphyses of true metacarpal bones, 596 
 epiphyses of phalanges of digits, 601 
 epiphysial head of femur, 642 
 epiphysis of great trochanter of femur, 670 
 lower epiphysis of femur, 782 
 upper epiphysis of tibia, 813 
 epiphysis of tubercle of tibia, 821 
 lower epiphysis of tibia, 844 
 Diaphysis, its vascular supply, 18 
 
 increase in growth of, in individuals, 18 
 difference in growth of, of long bones, 18, 23, 30 
 increase inter stitially, 19 
 lesions of, giving rise to lengthening, 116 
 resection of, in old separations, 132 
 resection of, in compound separation, 128 
 Digits, epiphyses of metacarpal bones of, anatomy of, 591 ; separation of, etiology, 591 : — 
 age, 592 : — pathological anatomy, 592 : — symptoms, 592 : — clinical 
 cases of, 593 : — diagnosis, 596 : — prognosis, 597 : — treatment, 598 
 epiphyses of phalanges of, anatomy of, 599 ; separation of, etiology, 599 : — age, 
 599 : — pathological anatomy, 600 : — symptoms, 600 : — diagnosis, 601 : — pro- 
 gnosis and treatment, 601 
 Direct traction, in epiphysial separations, 40 
 Direct violence, in epiphysial separations, 41 
 
 experiments in pathological anatomy, 69 
 Disease, cause and consequence of epiphysial separations, 85 
 Dislocation of epiphyses, in epiphysial separation, 84, 93 
 diagnosis from epiphysial separation, 96 
 with separation of upper epiphysis of humerus, 186, 213, 243 
 of head of humerus forwards, diagnosis from separation, 213 
 of elbow, combined with separation of lower end of humerus, 284 
 
 differential diagnosis, from separation of lower end of humerus, 300 ; 
 from separation of lower epiphysis of humerus 
 in youths, 343 
 with separation of internal epicondyle of humerus, 358, 366, 384 
 with separation of external epicondyle of humerus, 400 
 with condylo-trochlear and epicondylo-trochlear fractures of hu- 
 merus, 408 
 ■with condylo-capitellar and epicondylo-capitellar fractures of hu- 
 merus, 429, 435 
 of ulna, with separation of lower epiphysis of radius, 495, 513 
 
 forearm backwards, with separation of lower epiphysis of radius, 516 
 carpus backwards, diagnosis from separation of lower radial epiphysis, 543 
 hip, diagnosis from separation of epiphysial head of femur, 643 
 
 from separation of epiphysis of great trochanter, 670 
 knee-joint, diagnosis from separation of lower epiphysis of femur, 782 
 
 upper epiphysis of tibia, 813 
 Displacement often absent in epiphysial separations, 93 
 
 forwards of diaphysis in separation of upper epiphysis of humerus, 178, 
 
 193, 206, 221 
 backwards of diaphysis in separation of upper epiphysis of humerus, com- 
 plete and incomplete, 179, 180, 206 
 backwards of lower end of humerus, 278, 287, 320 
 
 outwards of diaphysis in separation of upper epiphysis of humerus, 181, 206 
 backwards of epiphysis of metacarpal bone of index finger, 594 
 outwards of epiphysis of metacarpal bone of index finger, 595 
 outwards of lower end of humerus, 282, 296 
 forwards of lower end of humerus, 280, 308 
 forwards of epiphysis of metacarpal bone of index finger, 592 
 in separations of internal epicondyle of humerus, 353, 360, 377 
 forwards in separation of lower epiphysis of radius, 484, 520, 552 
 forwards in fracture of lower end of radius, 548 
 backwards in separation of lower epiphysis of radius, 488, 491 : — symptoms, 
 
 525 : — diagnosis, 543 : — deformity, 553 
 in separation of epiphysis of true metacarpal bones, forwards, 592 ; back- 
 wards, 594 ; outwards, 595 
 subsequent to accident, in separation of upper epiphysis of humerus, 191 
 in separation of epiphysial head of femur, 656 
 in separation of lower epiphysis of femur, 761 
 in separation of epiphysial head of femur, 633 : — treatment of, 658 
 
INDEX OF SUBJECTS 911 
 
 Displacement in separation of epiphysis of great trochanter of femur, 668 
 
 absent in separation of upper epiphysis of humerus, 189 
 of lower end of humerus, 285, 321 
 of epiphysis of great trochanter of femur, 668 
 of lower epiphysis of femur, 701, 759, 783 ; slight, 760 
 
 of diaphysis in separation of lower epiphysis of femur, 714 
 
 in separation of lower epiphysis of femur, 762 : — forwards, 715, 763, 722, 
 775 :— backwards, 719, 741, 765, 767 :— inwards, 721, 774 :— outwards, 
 720, 768, 772 
 
 in separation of upper epiphysis of tibia, 812 : — forwards, 804, 808 : — for- 
 wards and outwards, 806, 812 :— backwards, 806 :— laterally, 806, 818 
 
 outwards of epiphysis, cases of compound separation of lower epiphysis of 
 tibia, with fracture of fibula, or separation of lower epiphysis, 834, 836 
 
 inwards of epiphysis, lower epiphysis of tibia, 837 
 
 inwards, lower end of humerus, 283, 299 
 
 outwards of epiphysis, lower epiphysis of tibia, 837, 843 
 
 outwards, lower end of humerus, 289, 296 
 
 backwards, in separation of lower epiphysis of radius, 488, 491 : — symptoms, 
 525 : — diagnosis, 543 :— deformity after, 553 
 
 backwards in separation of lower end of humerus, 278, 287, 320 
 
 backwards, lower epiphyses of tibia and fibula, 838 
 
 outwards of diaphysis in separation of upper epiphysis of humerus, 181 
 
 outwards, separation of lower epiphysis of fibula, 864 
 
 inwards, separation of lower epiphysis of fibula, 865 
 
 Elbow dislocation, with separation of lower end of humerus, 284 
 
 with separation of internal epicondyle of humerus, 358, 366, 384 
 differential diagnosis, from separation of lower end of humerus, 300 
 from separation of lower epiphysis of humerus, 
 343 
 complicating separation of external epicondyle of humerus, 400 
 complicating condylo-trochlear and epicondylo-trochlear fracture of 
 
 humerus, 408 
 with condylo-capitellar and epicondylo-capitellar fractures of humerus, 
 429, 435 
 Elbow, excision, in compound separation of lower end of humerus, 329 
 
 extended position in treatment of separation of lower end of humerus, 319, 327 
 flexed position in treatment of separation of lower end of humerus, 313, 325 
 Elbow-joint, frequency of separation or fracture, 55 
 
 Epicondyle, internal, of humerus, anatomy, 346; separation of, 346: — etiology, 348: — 
 age, 351 : — sex, 352 : — pathological anatomy, 353 : — complications, 357, 
 365, 380, 389 ; symptoms, 359 :— differential diagnosis, 373 :— pro- 
 gnosis, 373 : — treatment, 385 
 external, of humerus, anatomy, 392 : — separation of, 392 : — age, 394 : — 
 etiology, 394 : — pathological anatomy, 395 : — symptoms, 898 : — com- 
 plications, 400 :— prognosis, 401 : — treatment, 403 
 Epicondylo-capitellar fracture of humerus, 421 : — etiology, 422 : — age, 423 : — pathological 
 anatomy, 428 : — complications, 429, 435 :— symptoms, 431 : — diagnosis, 435 : — pro- 
 gnosis, 436 : — treatment, 442 
 Epicondylo-trochlear fracture of humerus, 405 : — etiology, 405 : — age, 406 : — pathological 
 anatomy, 406 : — symptoms, 407 : — complications, 408 : — diagnosis, 410 : — prognosis, 
 410 ; treatment, 414 
 Epiphyses, anatomy of, important, 16 
 
 relative size of, in infants and adults, 17 
 
 connection of periosteum with, 17 
 
 structure of, 19 
 
 blood supply of, 20 
 
 process of ossification of, 20 
 
 those of ginglymoid joints ossify earlier, 22 
 
 new rule for date of appearance of ossification of, 22 
 
 earlier junction with diaphysis not due to greater activity, 22 
 
 relation of ossification to direction of nutrient canals, Berard's law, 22, 29 
 
 individuality in union of, with diaphysis, 25 
 
 table of date of appearance of centres of ossification, 24 
 
 times of union with diaphysis. 25, 28, 29 
 
 tables of times of union, 26, 27 
 
 individual variation in union of (Topinard's table), 26 
 
 times of union (Dwight's table), 27 
 
 Rontgen ray process, 28 
 in different races, 28 
 
912 INDEX OE SUBJECTS 
 
 Epiphyses, articular cartilage covering, 36 
 
 chronological table of times of ossification, 46 
 
 of union to the diaphyses, 47 
 date of ossification of the chief epiphyses of long bones, 51 
 Epiphysial regions, two periods of growth recognised clinically in epiphysial separations, 
 
 75 
 Epiphysial sprains in infancy, symptoms of, 94 
 
 followed by ostitis and arrest of growth, 117 
 Epiphysis of metacarpal bone of thumb, anatomy, 588; separation of, 588: — etiology, 
 588 : — age, 589 : — pathological anatomy, 589 : — symptoms, 589 : — complications, 
 590 :— diagnosis, 590 : — treatment, 590 
 Etiology of separations of the epiphyses, 38 
 
 separation of epiphysis of clavicle, 136 
 acromion process, 148 
 coracoid epiphysis, 158 
 
 upper epiphysis of humerus, experiments in, 170 
 lower end of humerus, 269 
 lower epiphysis of humerus in youths, 339 
 internal epicondyle of humerus, 348 
 external epicondyle of humerus, 394 
 epicondylo-trochlear and condylo-trocblear fractures of humerus, 405 
 epicondylo-capitellar and condylo-capitellar fractures of humerus, 422 
 separation of trochlea of humerus, 449 
 
 capitellum of humerus, 454 
 upper epiphysis of ulna, 461 
 upper epiphysis of radius, 472 
 lower epiphysis of radius, 481 
 lower epiphysis of ulna, 583 
 epiphysis of metacarpal bone of thumb, 588 
 epiphyses of true metacarpal bones, 591 
 epiphyses of phalanges of digits. 599 
 epiphysis of anterior-superior iliac spine, 606 
 anterior-inferior spine of ilium, 609 
 epiphysial head of femur, 620 
 epiphysis of great trochanter of femur, 662 
 epiphysis of lesser trochanter, 675 
 lower epiphysis of femur, 687 
 upper epiphysis of tibia, 800 
 epiphysis of tubercle of tibia, 817 
 lower epiphysis of tibia, 827 
 upper epiphysis of fibula, 857 
 lower epiphysis of fibula, 861 
 E version of limb, in separation of epiphysial head of femur, 635; in separation of epi- 
 physis of great trochanter, 669 
 Excision of head of humerus after epiphysial separation, 241 
 
 elbow, in compound separation of lower end of humerus, 329 
 internal epicondyle of humerus for separation, 390 
 epiphysial head of femur, 659 
 separated epiphysis of great trochanter, 673 
 
 epiphysis in compound separation, lower epiphysis of femur, 792, 795 
 Experiments on upper and lower extiemity by Salmon in 1845, 6 
 
 on separation of the epiphyses by Michniowsky in 1864, 9 
 on the dead body by Col gnon in 1868, 11 
 on separation of the epiihyses, by De Paoli in 1882, 15 
 in pathological anatomy, 68 
 
 in 1860, 8 
 traction of limb, 65 
 
 hyper-flexion and hyper-extension of limb, 66 
 direct violence, 69 
 author's views, 81 
 on living animals, in epiphysial separations, 68 
 in abduction and adduction, in epiphysial separation, 68 
 in torsion, in epiphysial separations, 68 
 Extended position of elbow in treatment of separation of lower end of humerus, 319, 327 
 
 condylo-trochlear fractures of humerus, 417 
 condylo-capitellar fractures of humerus, 445 
 knee in treatment of separation of lower epiphysis of femur, 784 
 External epicondyle of humerus, anatomy of, 392 :— separation of, 392 :— age, 394 : — 
 etiology, 394 :— pathological anatomy, 395 :— symptoms, 398 :— complications, 400 :— 
 prognosis, 401 : — treatment, 403 
 
INDEX OF SUBJECTS 913 
 
 Femoral vein, ligature of, for infective thrombosis, 795 
 
 Femur, epiphysial head, anatomy, 615 ; separation of, 615 : — age, 618 : — etiology, 620 : 
 
 pathological anatomy, 624 :— symptoms, 631 :— diagnosis, differential, 
 642 : — prognosis, 649 : —treatment, 657 
 fracture of neck of, in children, 633, 643 
 
 great trochanter, anatomy, 661 ; separation of epiphysis of, 662 : — age and 
 etiology, 662 :— pathological anatomy, 663 :— symptoms, 668 :— differential 
 diagnosis, 670 : — prognosis, 671 : — complications, 671 : — treatment, 673 
 lesser trochanter, anatomy, 675 ; separation of epiphysis of, 675 : — etiology, 
 
 675 : — pathological anatomy, 675 : — symptoms, 676 
 third trochanter of, anatomy, 677 
 
 lower epiphysis, anatomy, 678 ; separation of, 678 ; — age, 682 : — statistics, 682, 
 686 : — sex, 686 : — etiology, 687 : — pathological anatomy, 691 : — complications, 
 724, 738: — prognosis, 747: — symptoms, 758: — differential diagnosis, 782; — 
 treatment, 783 
 separation of lower epiphysis in infancy, 692 ; 
 
 with fracture of diaphysis, 702, 705 
 supra-condyloid fracture of, diagnosis from separation of lower epiphysis of femur 
 783 
 Fibula, upper epiphysis of, anatomy, 856 ; separation of, 856 : — etiology, 857 : — a"e and 
 pathological anatomy, 858 : — symptoms, 859 : — treatment, 859 
 
 lower epiphysis of, anatomy, 860 ; separation of, 860 ; — etiology, and age, 861 : ■ 
 
 pathological anatomy, 8G1 : — complications later, 864 : — symptoms, 864 : — 
 treatment, 865 
 First allusion to separation of the epiphyses in 1559, 1 
 First special treatise on epiphysial separation in 1759, 3 
 First metatarsal bone, anatomy, 863 
 Flexed position, elbow, in treatment of separation of lower end of humerus, 313, 325 
 
 knee, in treatment of separation of lower epiphysis of femur, 784 
 Foot, separation of the epiphyses of bones of, 867 
 
 Forward displacement in separation of lower epiphysis of radius, 484, 520, 552 
 
 lower epiphysis of femur, 715, 763 
 lower epiphysis of humerus, 280 
 of diaphysis in separation of upper epiphysis of humerus, 193 
 in fracture of lower end of radius, 548 
 Fracture, diagnosis from epiphysial separation, 95 
 Fracture of diaphysis, arrest of growth after, 105 
 
 (partial) in separation of upper epiphysis of humerus, 184 
 in separaiion of lower end of humerus, 273, 298, 299, 328 
 lower epiphysis of radius, 491 
 epiphysial head of femur, 631 
 great trochanter, 666 
 lower epiphysis of femur, 702, 705 
 upper epiphysis of tibia, 807 
 tubercle of tibia, 820, 821 
 loAver epiphysis of tibia, 831 
 of epiphysis in separation of upper epiphysis of humerus, 183 
 lower epiphysis of humerus, 339 
 lower epiphysis of radius, 497 
 lower epiphysis of femur, 712, 723, 778 
 of shaft of ulna, with separation of lower epiphysis of radius, 507, 548, 549 
 bones of forearm, diagnosis from separation of radial epiphysis with fracture 
 
 of ulna, 548 
 upper end of tibia, with separation of lower epiphysis of femur, 735 
 shaft of femur, with separation of lower epiphysis, 737 
 surgical neck of humerus in children, diagnosis, 216 
 lower end of radius, diagnosis from separation, 547 
 Frequency of the various separations, 51, 52, 53, 54 
 
 table (Champmas), 53 
 statistics (Colignon), 53 
 cases (Gueretin), 53 
 cases (Gurlt), 54 
 table (Bruns), 54 
 separations about elbow-joint, 55 
 
 Gangrene, after epiphysial separations, 121 
 
 after separation of upper epiphysis of humerus, 189, 261 
 lower end of humerus, 285, 311 
 
 lower epiphysis of radius, 504, 517, 572 ■ 
 
 lower epiphysis of femur, 732 
 
914 INDEX OF SUBJECTS 
 
 Gangrene, after separation of lower epiphysis of tibia, 839 
 lower epiphysis of fibula, 863 
 Great trochanter, supposed instance of separation described in 1603 by Ingrassias, 2 
 
 anatomy of, 661 ; separation of epiphysis, 661 : — etiology, 662 : — age, 
 662 :— pathological anatomy, 668 -.—symptoms, 668 :— differential 
 diagnosis,67 ■ — Prognosis, 671: — complications, 671: — treatment, 
 673 
 Growth in length of long bones of extremities, 23, 29, 31 
 in irregular bones, 23 
 
 H.EMOKRHAGE in compouud separations, 87 
 
 of lower epiphysis of femur, 724 
 secondary, in compound separation of lower epiphysis of femur, 733 
 Head of femur, anatomy of, 615 ; separation of, 615 : - age, 618 : — etiology, 620 : — patho- 
 logical anatomy, 624 : — symptoms, 631 : — differential diagnosis, 642 : 
 — prognosis, 649 : — treatment, 657 
 of rib, epiphysis of, anatomy, 880 
 Hip disease, due to epiphysial separation, 120 
 
 diagnosis from separation of epiphysial head of femur, 048 
 Histological features of epiphysial separations (experimental), 60 
 History of traumatic separation of the epiphyses, 1 
 
 of injury, important in epiphysial separations, 89 
 Humerus, fracture of surgical neck in children, diagnosis, 216 
 
 upper epiphysis of, anatomy, 163 ; separation of, 163 : — age, 169, 170 : - statistics 
 as regards sex, 170: — etiology, 170: — pathological anatomy, 175: — com- 
 plications, 183, 211 : — differential diagnosis, 213 : — treatment, 218 
 lower end of, before jjuberty, anatomy, 262 ; separation of, 262 : — age, 268 : — sex, 
 269: — etiology, 269: — pathological anatomy, 270: — symptoms, 285: — 
 complications, 283, 292 : — differential diagnosis, 300 : — prognosis, 304 :— 
 treatment, 313 
 lower epiphysis of, in youths, anatomy, 333 ; separation of, 333 : — age, 337 : — 
 pathological anatomy, 337 : — symptoms, 340 : — differential diagnosis, 343 : 
 — prognosis, 345 : — treatment, 345 
 internal epicondyle of, anatomy of, 346 ; separation of, 346 : — etiology, 348 : — 
 age, 351 : — sex, 352 : — pathological anatomy, 353 : — complications, 357, 365, 
 380, 389 : — symptoms, 359 : — differential diagnosis, 373 : — prognosis, 373 : — 
 treatment, 385 
 external epicondyle of, anatomy, 392 ; separation of, 892 : — age, 394 : — etiology, 
 394 : — pathological anatomy, 395 : —symptoms, 898 : — complications, 400 : 
 — prognosis, 401 :— treatment, 403 
 condylo-trochlear fracture of, 405: — etiology, 405: — age, 406: — pathological 
 anatomy, 406 : — symptoms, 407 : — comx^lications, 408 : — diagnosis, 410 : — 
 prognosis, 410 : — treatment, 414: — primary operations for irreducibility, 
 420 : — compound separation, 420 
 condylo-capitellar fracture of, 421 : — etiology, 422 : — age, 423 : — pathological 
 anatomy, 423 : — complications, 429, 435 : — symptoms, 431 : — diagnosis, 
 435 : — prognosis, 436 : — treatment, 442 : — primary operations for irreduci- 
 bility, 446 
 epicondylo-trochlear fracture of, 405 : — etiology, 405 : — age, 406 : — pathological 
 anatomy, 406 : — symptoms, 407 : — complications, 408 : — diagnosis, 410 : — 
 prognosis, 410 : — treatment, 414 
 epicondylo-capitellar fracture of, 421 : — etiology, 422 : — age, 428: — pathological 
 anatomy, 428 :— complications, 429, 435: — symptoms, 431: — diagnosis, 
 435 : — prognosis, 436 : — treatment, 442 
 trochlea of, anatomy, 448 ; separation of, 448 : — pathological anatomy, 448 : — 
 complications, 449, 451 : — etiology, 449 : — symptoms, 449 : — diagnosis, 451 : 
 
 — treatment, 452 
 
 capitellum of, anatomy, 452 ; separation of, 452 : — pathological anatomy, 453 : 
 
 — age, 453: — etiology, 454: — symptoms, 454: — complications, prognosis, 
 and treatment, 455 
 
 capitellar and trochlear epiphyses of, separation of, 455 
 Hyper-flexion and hyper-extension of joints, experiments in pathological anatomy of 
 epiphysial separations, 66 
 
 Ilium, superior spines and crest, anatomy of, 606 ; separation of, 606 : — etiology, 606 : 
 — age, pathological anatomy, symptoms, 608: — treatment, 6C9 
 anterior-inferior spine, anatomy, 609; separation of, 609 :— etiology, 609: — sym- 
 ptoms, 611 
 Incomplete separation of the epiphyses, 77, 82 
 Increase in length of long bones, 17 
 
INDEX OF SUBJECTS 915 
 
 Indirect violence, in epiphysial separations, 39 
 
 experiments in, 64 
 Individuality in union of the epiphyses, 25, 46 
 Injury to nerves in separation of upper epiphysis of humerus, 212 
 
 lower end of humerus, 294, 309 
 internal epicondyle of humerus, 359, 365, 380 
 in condylo-trochlear fracture of humerus, 409, 413 
 in separation of lower epiphysis of radius, 516, 518 
 
 femur. 731, 782 
 tibia, 838 
 Internal epicondyle of humerus, anatomy of, 346 ; separation of, 346 : — etiology, 348 :— age, 
 351 : — sex, 352 : — pathological anatomy, 353 :— complications, 357, 365, 380, 389 : — 
 symptoms, 359 : — differential diagnosis, 373 : — prognosis, 373: — treatment, 385 
 Intra-uterine separations, 43 
 
 Inversion of limb, in separation of epiphysial head of femur, 636 
 Irreducibility, primary operations for, 129 
 Ischium, tuberosity of, anatomy, 614 ; separation of, 614 
 spine of, anatomy, 614; separation of, 614 
 
 Joint, impaired after epiphysial separations, 102 
 
 suppurative inflammation, 103 
 Jurisprudential aspect of epiphysial separations, 76 
 Juxta-epiphysial region (Oilier), 34 
 Juxta-epiphysial separation, 42, 73, 76 
 
 upper end of humerus, 183 
 femur, 622 
 Juxta-epiphysial sprains, 42 
 
 pathological anatomy, 77 
 
 of upper end of femur, 622 
 
 Gf lower end of tibia (experiments in infancy), 828 
 
 Knee-joint, suppuration, in separation of lower epiphysis of femur, 744 
 
 Lengthening, after lesions of the diaphysis, 116 
 
 Lesser trochanter of femur, anatomy of, 675 ; separation of epiphysis of, 675 : — etiology, 
 
 675 : — pathological anatomy, 675 : — symptoms, 676 
 Loss of function of limb after epiphysial separation, 131 
 
 Lower end of humerus before puberty, anatomy of, 262 ; separation ef, 262 ; — sex, 269 : 
 
 etiology, 269 : — pathological anatomy, 270 : — displacement backwards, 278, 287, 320 ; 
 —displacement outwards, 282, 296 : — differential diagnasis, 300 ; — prognosis, 304 : — 
 treatment, 513: — compound separations, 275, 279, 295, 328 
 Lower epiphysis of humerus, anatomy of, 263 
 
 in youths, separation of, 333 :— symptoms, 340 : — differential 
 
 diagnosis, 343 : — prognosis and treatment, 345 
 displacement forwards after fracture above epiphysial line, 
 280, 299 
 radius, anatomy of, 478; separation of, 478: — etiology, 481: — age, 
 485 : — sex, 486 : — pathological anatomy, 486 : — complica- 
 tions, 497, 517, 538, 542 :— symptoms, 523 :— diagnosis, 
 543 : — progHGsis, 553 : — treatment, 572 
 separation without displacement, symptoms, 523 : — treat- 
 ment, 572 
 ulna, anatomy, 580 ; separation of, 580 : — pathological anatomy, 581 :— 
 etiology, age, symptoms, and prognosis, 583 : — treatment, 587 
 separated with lower epiphysis of radius, 504, 524, 538 
 femur, anatomy of, 678 ; separation of, 678 : — age, 682 ; statistics, 682, 
 686 ; sex, 686 : — etiology, 68 7 :— pathological anatomy, 691 : 
 —complications, 724, 738 :— prognosis, 747 :— symptoms, 
 758 : — differential diagnosis, 782 : — treatment, 783 
 separation in infancy, 692 
 
 tibia, anatomy of, 824 ; separation of, 824 : — age, 826 : —sex, 827 : 
 
 etiology, 827 :— pathological anatomy, 830 :— complications, 839 : 
 — symptoms, 839 :— differential diagnosis, 844 :— prognosis, 846 : 
 — treatment, 852 
 fibula, anatomy of, 860 ; separation of, 860 : — etiology, 861 : — age, 861 : 
 — pathological anatomy, 861 :^complications, 864 :— symptoms, 
 864 : — treatment, 865 
 Lower epiphyses of tibia and fibula, separation of, 827, 834 
 Lumbar vertcbroB, epiphyses of, anatomy, 878 
 
916 INDEX OF SUBJECTS 
 
 Massage, treatment by, 126 
 
 immediate treatment by, 127 
 in loss of function of limb, 131 
 in separation of upper epiphysis of humerus, 244 
 
 immediate treatment by, in separation of lower epiphysis of radius, 576 
 and passive motion in separation of epiphysial head o£ femur, 659 
 in separation of lower epiphysis of femur, 792 
 Measurements of epiphysis of clavicle, 135 
 
 upper epiphysis of humerus, 165 
 lower epiphysis of humerus, 264 
 internal epicondyle, 348 
 external epicondyle, 392 
 lower epiphysis of radius, 479 
 lower epiphysis of ulna, 580 
 epiphysial head of femur, 618 
 great trochanter of femur, 662 
 lower epiphysis of femar, 679 
 upper epiphysis of tibia, 799 
 lower epiphysis of tibia, 825 
 upper epiphysis of fibula, 857 
 lower epiphysis of fibula, 860 
 Mechanism of traumatic separation of the epiphyses, 58 
 Mechanism, and experiments, in epiphysial separations, 63, 64 
 
 Metacarpal bone of thumb, anatomy of, 588; separation of, 588 :— etiology, 588 :- age, 
 
 589 : — pathological anatomy and symptoms, 589 : — compli- 
 cations, 590 ; diagnosis, 590 ; treatment, 590 
 bones, true epiphyses of, anatomy of, 591 ; separation of, 591 :— etiology, 591 : 
 — age, 592 : — pathological anatomy and symptoms, 592 : — clinical cases of, 
 593 :_diagnosis, 596 :— prognosis, 597 :— treatment, 598 
 Metatarsal bone, first, anatomy, 868 
 
 banes, outer, anatomy of, 869 ; separation of, specimens of, 869 : — case of, 870 
 Mobility of fragments, cause of arrest of growth, 112 
 
 in separation of upper epiphysis of humerus, 202 
 lower epiphysis of radius, 535 
 epiphysial head of femur, 642 
 lower epiphysis of femur, 777 
 upper epiphysis of tibia, 813 
 lower epiphysis of tibia, 840, 844 
 Morton's method of reduction of fracture of lower end of radius, 576 
 Multiple separation of epiphyses, 83 
 Muscular action in epiphysial separations, 42 
 
 in separation of upper epiphysis of humerus, 174 ^ . 
 
 epiphysis of great trochanter of femur, 663 
 epiphj sial head of femur, 621 
 Muscular atrophy, after epiphysial sepan tions, 103 
 
 Necrosis, after separation of upper epiphysis of humerus, 186, 260 
 lower epiphysis of femur, 738 
 
 tibia, 839, 846 
 fibula, 864 
 Nerve lesions, in separation of upper epiphysis of humerus, 212 
 
 lower end of humerus, 294, 309 
 internal epicondyle of humerus, 359, 365, 380 
 condyle-trochlear and epicondylo-trochlear fractures of humerus, 409, 413 
 separation of lower epiphysis of radius, 516, 518 
 
 femur, 731, 782 
 tibia, 838 . ■ 
 
 Newly born infants, first allusion to separation in, 1 
 experiments on, by Euysch, 2 
 
 separation of upper epiphysis of humerus in, 175, 176 
 Non-union, after epiphysial separations, 100 
 
 due to mobility, 101 
 of acromion process, 149 
 after separation of upper epiphysis of humerus, 253 
 
 internal epicondyle of humerus, 353, 354 
 condylo-trochlear fracture of humerus, 427 
 separation of lower epiphysis of radius, 561 
 epiphysial head of femur, 652 
 Nutrient canals, relation with union'of epiphysis to diaphysis (Btrard's law), 22 
 influence on union of fractures, 22 
 direction in long bones, 22 
 
INDEX OF SUBJECTS 917 
 
 OccuEEENCE of epiphysial separation alluded to by Par6 in 1614, 2 
 Operations for recent irreducibility, 129 
 
 replacement of diaphysis in epiphysial separation, 129 
 recent separation of upper epiphysis of humerus, 226, 231, 241 
 displacement of internal epicondyle of humerus, 390 
 separation of external epicondyle of humerus, 404 
 in condylo-trochlear fractures of humerus, 420 
 in condylo-capitellar fractures, 446 
 for separation of epiphysis of metacarpal bone of thumb, 590 
 
 recent separation of epiphysial head of femur, with displacement, 660 
 simple separations of lower epiphysis of femur for irreducibility, &c., 787 
 separation of epiphysis of tubercle of tibia, 822 
 old separations of upper epiphysis of humerus, 233, 238, 241 
 replacement of old separations of lower epiphysis of radius, 578 
 deformity, after arrest of growth, 132 
 
 arrest of growth of fibula, 866 
 separation of lower epiphysis of tibia, 854 
 Os calcis, anatomy of, 867 ; separation of epiphysis of, 867 
 Os innominatum, separation of epiphyses of, 603 
 
 Ossification of epiphyses, chronological table of dates of appearance of, 46 
 date of, in chief epiphyses of long bones, 51 
 of long bones, 20, 22 ; table, 24 
 Osteotomy, for deformity after separation of lower end of humerus, 332 
 
 epiphysial head of femur, 660 
 lower epiphysis of femur, 797 
 fracture of lower end of radius, 579 
 Outer metatarsal bones, anatomy of, 869 ; separation of, specimens of, 869 : — case of, 870 
 
 Pain in separation of upper epiphysis of humerus, 202 
 epiphysial head of femur, 642 
 epiphysis of great trochanter, 668 
 lower epiphysis of femur, 777 
 Parallel bones, arrest of growth of one of, Poncet (1872), 11 
 Paralysis, not a predisposing cause of epiphysial separation, 39 
 
 as a predisposing (?) cause in a case of separation of upper epiphysis of 
 humerus, 174 
 Passive movement in epiphysial separations, 127 
 
 separation of lower end of humerus, 327 
 
 internal epicondyle of humerus, 389 
 condylo-trochlear and epicondylo-trochlear fractures of humetus, 
 
 419, 420 
 condylo-capitellar fractures of humerus, 445 
 separation of capitellum of humerus, 455 
 upper epiphysis of ulna, 468 
 lower epiphysis of femur, 786 
 epiphysis of tubercle of tibia, 822 
 Patella, transverse fracture, diagnosis from separation of epiphysis of tubercle of tibia, 821 
 Pathological anatomy, site of separation, 70 
 separation at birth, 70 
 pure separations, 71 
 Foucher's classification, 72 
 complications, 79 
 fracture of the diaphysis, 79 
 detachment of periosteum, 81 
 separations without displacement, 82 
 complete displacements, 83 
 fracture of epiphysis, 83 
 separation of epiphysis of clavicle, 137 
 acromion process, 149 
 coracoid epiphysis, 158 
 upper epiphysis of humerus, 175 
 lower end of humerus, 270 
 lower epiphysis of humerus in j'ouths, 337 
 internal epicondyle of humerus, 353 
 external epicondyle of humerus, 395 
 epicondylo-trochlear and condylo-trochlear fractures of humerus, 
 
 406 
 epicondylo-capitellar and condylo-capitellar fractures of humerus, 
 
 423 
 separation of trochlea of humerus, 448 
 
 capitellum of humerus, 453 
 
918 INDEX OF SUBJECTS 
 
 Pathological anatomy, separation of upper epiphysis of ulna, 459 
 
 upper epiphysis of radius, 472 
 lower epiphysis of radius, 486 
 lower epiphysis of ulna, 581 
 epiphysis of metacarpal bone of thumb, 589 
 epiphyses of true metacarpal bones, 592 
 epiphyses of phalanges of digits, 600 
 epiphysial parts of acetabulum, 605 
 epiphyses of superior iliac spine and crest, 608 
 epiphysial head of femur, 624 
 epiphysis of great trochanter of femur, 663 
 epiphysis of lesser trochanter, 675 
 lower epiphysis of femur, 69=1 
 upper epiphysis of tibia, 802 
 epiphysis of tubercle of tibia, 819 
 lower epiphysis of tibia, 830 
 upper epiphysis of fibula, 858 
 lower epiphysis of fibula, 861 
 Pathological separations, 39 
 Periods of age in epiphysial separations, 45, 48. 
 sex in the different, 50 
 of growth in the epiphysial region, 75 
 Periosteum, anatomy of, its functions, 34, &5 
 experiments on, 35, 63 
 detached in epiphysial separations, 81 
 
 separation of upper epiphysis of humerus, 184 
 lower epiphysis O'f radius, 500 
 
 femur, 726, 779 
 tibia, 839 
 lacerated when diaphyais completely displaced, first proof in 1845, 7 
 Pe?iostitis, suppurative, and necrosis, after separation of lower epiphysis of femur, 733 
 
 upper epiphysis of humerus, 186 
 after separation of lower epiphysis of radius, 491, 505 519 
 
 tibia, 839, 846 
 Permanent deformity with vicious union, 102 
 Phalanges of toes, epiphyses of, anatomy of, 870 ; separation of, cases of, 870 
 
 digits, epiphyses of, anatomy of, 599 ; separation of, 599 : — etiology, 599 : 
 — age, 599 : — pathological anatomy and symptoms, 600 : — diagnosis, pro- 
 gnosis, and treatment, 601 
 Phlebitis, septic, in compound separation of lower epiphysis of femur, 744 
 Popliteal vessels, injury of, in separation of lower epiphysis of femur, 727, 779 
 nerves, injury of, in separation of lower epiphysis of femur, 731, 782 
 Pott's fracture, diagnosis from separation of lower epiphysis of fibula, 845 
 Pre-epiphysial fracture, 67, 73 
 
 Primary amputation in separation of lower end of humerus, 330 
 
 upper epiphysis of tibia, 815 
 lower epiphysis of femur, 795 
 lower epiphysis of tibia, 853 
 Prognosis in separation of epiphysis of clavicle, 142 
 acromion process, 155 
 upper epiphysis of humerus, 244 
 lower end of hunreiais, 304 
 lower epiphysis of humerus in youth, 345 
 internal epicondyle of humerus, 373 
 external epicondyle of humerus, 401 
 condylo-trochlear and epicondylo-trochlear fractures of humerus, 410 
 condylo-capitellar and epicondylo-capitellar fractures of humerus, 436 
 separation of capitellum of humerus, 455 
 upper epiphysis Of ulna, 465 
 upper epiphysis of radius, 474 
 lower epiphysis of radius, 553 
 lower epiphysis of ulna, 583 
 epiphyses of true metacarpal bones, 597 
 epiphyses of phalanges of digits, 601 
 epiphysial head of femur, 649 
 epiphysis of great trochanter of femur, 671 
 lower epiphysis of femur, 747 
 upper epiphysis of tibia, 810 
 epiphysis of tubercle of tibia, 822 
 lower epiphysis of tibia, 846 
 Projecting processes, function of, 37 
 
INDEX OF SUBJECTS 910 
 
 Pronator quaclratus, laceration of, in separation of lower radial epiphysis, 500 
 Pubes, separation of the epiphysis of symphysis of, 613 
 
 of spine of, 613 
 Pure separations, pathological anatomy, 71, 81 
 Foucher's classification, 72 
 three kinds, 73 
 at different ages, 74 
 
 upper epiphysis of humerus, 177 
 lower end of humerus, 275 
 lower epiphysis of femur, 693, 694, 701, 759 
 upper epiphysis of tibia, 803 
 lower epiphysis of tibia, 833 
 Py<Tmia, after epiphysial separation, 121 
 
 in separation of epiphysis of great trochanter, 672 
 
 in compound separation of lower epiphysis of femur, 744 
 
 Eadius, arrest of growth, Stehr's thesis in 1887, 13 
 
 upper epiphysis of, anatomy of, 470 ; separation of, 470: — etiology, 472 :~ age 
 and pathological anatomy, 472 : — symptoms, 473 : — prognosis, 474 : — dia- 
 gnosis, 475 : — treatment, 476 
 lower epiphysis of, anatomy of, 478 ; Goyrand's first observations in 1836, 5 ; 
 mechanism of separation, 6 ; separation of, 478 : — etiology, 481 : — age, 485 ; 
 — sex, 486: — pathological anatomy, 486 : — complications, 497, 517, 538, 542: — ■ 
 symptoms, 523 : — diagnosis, 543 : — pi'ognosis, 553 : — treatment, 572 
 lower epiphysis of, separation of, without displacement, symptoms, 523 : — treat- 
 ment, 572 
 and ulna, separation of lower epiphyses of, 504 : — symptoms, 524, 538, 582 
 separation of bicipital epiphysis of, 477 
 Eefracturing in recent cases of deformity, 131 
 liesection of diaphysis in old separations, 132 
 
 recent separation of upper epiphysis of humerus, 226 
 old separations of upper epiphysis of humerus, 233, 238 
 compound separation of lower end of humerus, 328 
 
 lower epiphysis of radius, 577 
 femur, 792 
 tibia, 836, 853 
 Besection, partial, of elbow in condylo-trochlear fracture of humerus, 420 
 
 in old condylo-capitellar fractures with dislocation, 446 
 Eesection of epiphysis in separation of lower epiphysis of radius, 578 
 Eibs, epiphyses of, anatomy, 880 
 
 Eontgen ray process, regarding union of epiphyses to diaphyses, 28 
 site and relations of conjugal line, 33 
 diagnosis in traumatic epiphysial separations, 97 
 diagnosis in separation of lower end of humerus, 304 
 
 lower epiphysis of radius, 549, 559 
 in arrest of growth of ulna, 587 
 Eotation, forcible, cause of epiphysial separation, 41 
 
 Sacrum, epiphyses of, anatomy, 879 
 
 Scapula, cartilaginous parts of, anatomy of, 144 ; separation of glenoid and coracoid 
 cartilage, 144 
 separation of epiphyses of, 144 
 
 epiphysis of base of (supra-scapular) anatomy, separation, 145 
 Sciatic spine, anatomy, 614 
 Secondary amputation, 130 
 
 in separation of lower end of humerus, 330 
 
 lower epiphysis of radius, 578 
 femur, 795 
 upper epiphysis of tibia, 815 
 Separation of the epiphyses, first allusion to, in 1559, 1 
 
 following small-pox and scurvy, 2 
 description by Eyssonius in 1659, 2 
 attempt at general description of, in 1787, 3 
 attention to subject in 1803 and 1814, 4 
 subject dismissed briefly in 1815, 4 
 doubts in 1816 as to real existence, 4 
 cases in support of occurrence of (1820), 4 
 specimens obtained by Eoux in 1822, 5 
 
920 INDEX OF SUBJECTS 
 
 Separation of the epiphyses, occurrence after the first few years of life (1822), 5 
 Eognetta's elaborate memoir in 1834, 5 
 new cases by Eoux in 1836, 6 
 mistaken for dislocation (1842), 6 
 during delivery and after birth (1840), 6 
 Nelaton's opinion, 6 
 anatomical character of (1845), 6 
 cartilaginous ends detached during delivery (1853), 7 
 E. W. Smith's clear conception in 1847, 7 
 Cruveilhier's opinion in 1849, 7 
 Klein's thesis in 1854, 7 
 Zuehlke's thesis in 1859, 7 
 Thudichum's account in 1855, 7 
 Malgaigne's opinion in 1855, 7 
 Gurlt collection in 1862, 8, 13 
 mechanism of lesions known in 1863, 8 : — experiments in 
 
 mechanism, 63 
 classification by Foucher in 1860, 8 
 frequent and common, E. W. Smith, 1867, 8 
 Guersant's clinical experience, 9, 10 
 discussion at the Societe de Chirurgie, Paris, in 1865, 9 
 Tr^lat's opinion, 10 
 Broca's opinion (1865) on ease of production in dead subject, 
 
 10 
 Ollier's researches permit complete study of, 10 
 Holmes's study of museum specimens in London (1868), 11 
 Barbarin's views in 1873, 11 
 Manquat's opinion in 1877, 12 
 Novaro's brief description in 1877, 12 
 all cases to be considered as fractures, Pingaud, 1878, 12 
 symptoms resemble those of fracture, Sjme (1842), 12, 13 : — 
 
 Fergusson (1846), 12 
 JQO allusion by Amesbury, 13 
 Stimson's limited experience (1863), 13 
 symptoms resemble those of fracture. Holmes (1869), 13 
 chief exponent in this country (Hutchinson), 13 
 important details at Guy's Hospital, 13 : — at London Hos- 
 pital, 13 
 classification with fractures by Hamilton (1884), 14 
 contradictory opinions at present day, 14 
 collection of cases by Vogt and Bruns in 1878 and 1882, 14 
 special articles on, by Delens, Farabeuf, Berg^s, 14 
 cases and experiments by De Paoli, 15 
 difference from fracture, Mazziotti, 1880, 15 
 gradual displacement first mentioned by J. Poland (1886), 15 
 absence of displacement and its consequences first mentioned 
 
 by J. Poland (1886), 15 
 Dittmayer's thesis on arrest of growth in 1887, 15 
 proportion of cases to ordinary fractures in children, Curtillet, 
 
 (1891), 15 :— statistics, 47 
 essay by Jonathan Hutchinson jun. in 1891, 15 
 condition of periosteum in, 35 
 etiology, Gurlt 's views, 38 
 pathological separations, 39 
 in infantile paralysis, 39 
 from indirect violence, 39 : — experiments in indirect violence, 
 
 64 
 from direct traction at birth, 40 
 from forcible torsion, 41 
 juxta-epiphysial, 42 
 by severe crushings, 42 
 by muscular violence, 42 
 
 age, intra-uterine separation, at childbirth, 43, 45 
 periods of age, 44, 48^ 
 sex in the various, 50 
 
 sex, cases occurring in three most frequent situations, 49 
 frequency of the various, 51-55 
 
 statistics (Jonathan Hutchinson jun.) : — (the author's), 56 
 mechanism of, 58 
 
 experiments in pathological anatomy, 68 
 histological anatomy (experimental), 58 
 
INDEX OF SUBJECTS 921 
 
 Senaration of the epiphyses, histological features in newly born children (experimental), 
 '- 60, 61 
 
 detachment of periosteum, 63 
 
 three kinds of iDure, 73 
 
 two periods of growth recognisable clinically and patho- 
 logically, 75 
 
 jurisprudential aspect, 76 
 
 incomplete, 77 
 
 with fracture of the diaphysis, 79 
 
 with complications, 79 
 
 author's experiments in pathological anatomy, 81 
 
 without displacement, 82 :— symptoms of, 93 
 
 with fracture of epiphysis, 83 
 
 multiple, 83 
 
 dislocation of epiphysis, 84, 93 
 
 cause and consequence of disease, 85 
 
 compound, 86 
 
 symptoms and diagnosis. 88, 95 
 
 history of injury important, 89 
 
 crepitus, 92 
 
 Eontgen ray process in diagnosis of, 97 
 
 union of, 98 
 
 no specimen of recent union, 99 
 
 non-union, 100 : — due to mobility, 101 
 
 deformity after, 101, 102 _ 
 
 impairment of neighbouring joint, 102 
 
 exuberant callus, 103 
 
 suppurative inflammation of joint, 103 
 
 muscular atrophy after, 103 
 
 arrest of growth, 103 :— after separation in first decades of 
 life, 105 :— statistics of, 107 :— causes of, 108, 114:— 
 transient. Ill, 114:— deformity after, 114 
 
 suppuration and necrosis following, 117, 118 :— followed by 
 arrest of growth, 118 
 
 giving rise to hip disease, &c., 120 
 
 gangrene in, 121 
 
 tetanus, 121 
 
 pyaemia, 121 
 
 aneurysm after, 121 
 
 treatment, Eoux's rules in 1822, 123 
 
 treatment of, with or without displacement, 124 
 operations for recent irreducibility, 129 
 
 replacement of the diaphysis by operation and secondary 
 
 amputation, 130 
 refracturing in recent cases for deformity, 131 
 treatment of loss of function, 131 
 operations for deformity due to arrest of growth, 132 
 resection of diaphysis in old separations, 132 
 of the epiphysis of clavicle, 135 
 
 glenoid and coracoid cartilage, 144 
 epiphyses, scapula, 144 
 epiphysis, base of scapula, 145 
 
 acromion process, 145 
 
 coracoid process, 156 
 apical epiphysis of coracoid process, 161 
 upper epiphysis of humerus, 163 
 either tuberosity of humerus, 218 
 lower end of humerus before puberty, 262 
 lower epiphysis of humerus in youths, 333 
 internal epicondyle of humerus, 346 
 external epicondyle of humerus, 392 
 epicondylo-trochlear epiphysis of humerus, 405 
 epicondylo-capitellar epiphysis of humerus, 421 
 trochlea of humerus, 448 
 capitellum of humerus, 452 
 
 capitellar and trochlear epiphyses of humerus, 455 
 upper or olecranon epiphysis of ulna, 457 
 upper epiphysis of radius, 470 
 bicipital epiphysis of radius, 477 
 lower epiphysis of radius, 478 
 lower epiphysis of ulna, 580 
 
922 INDEX OF SUBJECTS 
 
 Separation of the epiphysis of metacarpal bone of thumb, 588 
 true metacarpal bones, 591 
 epiphyses of phalanges of digits, 599 
 epiphysial parts of acetabulum, 603 
 
 epiphysis of iliac crest and anterior and posterior superior iliac spines, GOG 
 anterior inferior spine of ilium, 609 
 .symphysis pubis, 613 
 spine of pubes, 613 
 tuber ischii, 614 
 sciatic spine, 614 
 head of femur, 615 
 great trochanter, 661 
 lesser trochanter, 675 
 third trochanter, 677 
 lower epiphysis of femur, 678 
 upper epiphysis of tibia, 798 
 tubercle of tibia, 816 
 lower epiphysis of tibia, 824 
 upper epiphysis of fibula, 856 
 lower epiphysis of fibula, 860 
 epiphysis of os calcis, 867 
 astragalus, 867 
 first metatarsal bone, 868 
 outer metatarsal bone, 869 
 phalanges of toes, 870 
 epiphyses of vertebree generally, 873 
 
 cervical vertebrse, 876 
 epiphysial parts of atlas, 877 
 epiphyses of axis, 877 
 
 lumb9.r vertebrae, 878 
 sacrum, 879 
 
 head and tuberosity of ribs, 880 
 Separation with partial fracture of diaphysis, upper epiphysis of humerus, 184 
 
 lower end of humerus, 273, 298, 299, 328 
 lower epiphysis of radius, 491 
 epiphysial head of femur, 631 
 great trochanter, 666 
 lower epi]3hysis of femur, 702, 705, 725 
 upper epiphysis of tibia, 807 
 tubercle of tibia, 819 
 lower epiphysis of tibia, 831, 837 
 fracture of epiphysis, upper epiphysis of humerus, 183 
 lower epiphysis of humerus, 339 
 radius, 497 
 femur, 712, 723, 778 
 Severe lesions, in separation of lower epiphysis of radius, 516, 640 
 
 lower epiphysis of femur, 736 
 Sex, in epiphysial separations, 49 : — in the different epiphysial separations, 50 
 separation in the different periods of age, 50 
 separation of upper epiphysis of humerus, 170 
 
 lower end of humerus before puberty, 269 
 internal epicondyle of humerus, 352 
 lower epiphysis of radius, 486 
 lower epiphysis of femur, 686 
 upper epiphysis of tibia, 802 
 epiphysis of tubercle of tibia, 819 
 lower epiphysis of tibia, 827 
 Shortening of arm, in separation of upper epiphysis of humerus, 204, 211 
 
 lower end of humerus, 291 
 lower epiphysis of humerus, 343 
 forearm, in separation of lower end of humerus, 291 
 radius, in separation of its lower epiphysis, 535 
 finger, in separation of epiphysis of metacarpal bone, 593 
 limb, in separation of epiphysial head of femur, 633 
 lower epiphysis of femur, 776 
 Shoulder-joint, injury of, in separation of upper epiphysis of humerus, 186, 205 
 
 ankylosis following separation of upper epiphysis of humerus, 189 
 Smith's fracture of radius, 549 
 Sprains, symptoms of epiphysial, in infancy, 94 
 
 shoulder, diagnosis, 218 
 •^Statistics of epiphysial separation, 47, 56 
 
INDEX GF SUBJECTS 923 
 
 Statistics of age in separation of the epiplayses, 48 
 sex in separation of the epiphyses, 49 
 arrest of growth, 107 
 separation of epiphysis of clavicle, 137 
 
 upper epii)hysis of humerus, 169, 170, 177 
 lower end of humerus, 268, 269 
 lower epiphysis of humerus in youth, 337 
 internal epicondyle of humerus, 352 
 external epicondyle of humerus, 394 
 epicondylo-trochlear fracture of humerus, 406 
 epicondylo-eapitellar fracture of humerus, 423 
 Keparation of lower epiphysis of radius, 485, 575 
 trochlea of humerus, 446 
 epiphysial head of femur, 619 
 
 lower epiphysis of femur, 682, 68G, 747, 787, 793, 791 
 upper epiphysis of tibia, 802 
 tubercle of tibia, 819 
 lower epiphysis of tibia, 826 
 lower epiphysis of fibula, 801 
 Sternum, not considered in volume, 880 
 
 Styloid process of ulna fractured, in separation of lower epiphysis of radius, 501, 532 
 Superior iliac spines and crest, epiphysis of, anatomy of, 606; separation of, 606: — ■ 
 
 etiology, 606 :— age, pathological anatomy, and symptoms, 608 : — treatment, 609 
 Suppuration following sepai'ation of upper epiphysis of humerus, 173, 174, 187 
 in separation of lower end of humerus, 285, 312 
 lower radial epiphysis, 54-2 
 epiphysial head of femur, 657 
 epiphysis of great trochanter, 671 
 lower epipljysis of femur, 738 
 lower epiphysis of tibia, 846 
 lower epiphysis of fibula, 864 
 and arrest of growth, after epiphysial injury, 118 
 
 necrosis of bone, after epiphysial injuries, 117, 118 
 
 after separation of upper epiphysis of tibia, 809 
 Suppuration of knee-joint, in separation of lower epiphysis of femur, 744 ' 
 
 upper epiphysis of tibia, 809 
 Suppurative inflammation of joint in epiphysial separation, 103 
 Supra-condyloid fracture of femur, diagnosis from separation of lower epiphysis of femur, 
 
 783 
 Supra-scapular epiphysis of scapula, anatomy, 145 
 Suture, extra-articular, for separated upper epiphysis of ulna, 469 
 Symphysis pubis, anatomy of epiphysis of, 613 , 
 
 Symptoms of epiphysial sprains in infancy, 94 
 
 epiphysial separation without displacement, 93 
 separation of epiphysis of clavicle, 139 
 acromion process, 154 
 coracoid process, 161 
 
 upper epiphysis' of humerus, 189, 193, 206, 211 
 cartilaginous upper end of humerus, 192 
 lower end of humerus, 285 
 lower epiphysis of humerus in youths, 340 
 internal epicondyle of humerus, 359 
 external epicondyle of humerus, 398 
 epicondylo-trochlear and condylo-trochlear fractures of humerus, 407 
 condylo-capitellar and epicondylo-eapitellar fractures of humerus, 431 
 separation of trochlea of humerus, 449 
 
 capitellum of humerus, 454 
 
 upper epiphysis of ulna, 462 
 
 upper epiphysis of radius, 473 
 
 lo\Yer epiphysis of radius, 523 
 
 lower epiphysis of ulna, 583 
 
 epiphysis of metacarpal bone of thumb, 589 
 
 epiphyses of true metacarpal bones, 592 
 
 epiphysis of phalanges of digits, 600 
 
 epiphysis of iliac crest, 608 
 
 anterior inferior spine of ilium, Gil 
 
 epiphysial head of femur, 631 
 
 epiphysis of great trochanter of femur, 668 
 
 epiphysis of lesser trochanter, 676 
 
 lower epiphysis of femur, 758 
 
 upper epiphysis of tibia, 811 
 
924 INDEX OF SUBJECTS 
 
 Symptoms of separation of epiphysis of tubercle of tibia, 820 
 lower epiphysis of tibia, 839 
 upper epiphysis of fibula, 859 
 lower epiphysis of fibula, 864 
 Synovial membrane, relation to conjugal cartilage, 37 
 
 of shoulder-joint, relation to upper epiphysis of humerus, 166, 167, 
 168 
 elbow-joint, relation to conjugal line, 266 
 wrist-joint, relation of, to epiphyses, 480 
 relation of, to epiphyses of phalanges and metacarpal bones, 592, 600 
 hip-joint, relation of, to epiphyses of upper end of femur, 619 
 knee-joint, relation to lower epiphysis of femur, 680 (figs. p. 683) 
 upper epiphysis of tibia, 800 
 epiphysis of tubercle of tibia, 817 
 ankle-joint, relation to lower epiphysis of tibia, 825 
 superior tibio-fibular articulation, relation to upper epiphysis of 
 
 fibula, 857 
 great toe and foot, relation to epiphyses adjoining, 869 
 phalangeal joints of toes, relation to epiphyses of phalanges, 870 
 
 Tetanus, after epiphysial separations, 121 
 
 after compound separation of lower epiphysis of radius, 490, 505, 518 
 separation of lower epiphysis of fibula, 863, 864 
 Third trochanter of femur, anatomy, 677 
 
 Tibia, upper epiphysis of, anatomy of, 798 ; separation of, 798 : — etiology, 800 : — age and 
 sex, 802 : — pathological anatomy, 802 : — complications, 808, 813 : — prognosis, 
 810: — symptoms, 811 : — diagnosis, 813 :— treatment, 814 
 tubercle of, epiphysis of, anatomy of, 816 : — separation of, 816: — etiology, 817: — ■ 
 age and sex, 819: — pathological anatomy, 819: — symptoms, 820: — diagnosis, 
 821 : — treatment,- 821 : — prognosis, 822 
 lower epiphysis of, anatomy of, 824 ; separation of, 824 : — age, 826 : — sex and 
 etiology, 827 : — pathological anatomy, 830: — complications, 839 : — symptoms, 
 839 :^dili'erential diagnosis, 844 : — prognosis, 846 : — treatment, 852 
 Tibial vessels, injury to, in separation of lower epiphysis of femur, 733 
 
 lower epiphysis of tibia, 838 
 Toe, first metatarsal bone, anatomy, 868 
 Toes, outer metatarsal bones, separation of epiphyses of, 869 
 
 phalanges of, anatomy of, 870 ; separation of, cases of, 870 
 Torsion, forcible, in causing epiphysial separations, 41 
 of the limb, experiments in, 68 
 
 in separation of the upper epiphysis of humerus, 68 
 lower epiphysis of femur, 690 
 Traction on limb, Pajot's experiments, 65 
 Trans vei-se fracture of diaphysis near epiphysial line, 76 
 
 upper end of humerus, 216 
 
 lower end of humerus, 281, 302 
 
 lower epiphysis of radius, 547 
 
 epiphysial head of femur (intra-capsular fracture), 
 
 643 
 lower epiphysis of femur (supra-condyloid fracture), 
 
 783 
 lower epiphysis of tibia (experimental), 830 
 Treatment, epiphysial separations, 123 : — by massage, 126 ; by passive movement, 127 : — of 
 suppuration, 128 ; of compound separations, 128 ; of resection of 
 diaphysis in old separations, 132 
 separation of epiphysis of clavicle, 142 : — compound, 143 
 acromial epiphysis, 155 
 coracoid process, 162 
 upper epiphysis of humerus, 218 
 lower end of humerus, 313 
 lower epiphysis of humerus in youths, 345 
 internal epicondyle of humerus, 385 
 external epicondyle of humerus, 403 
 condylo-trochlear and epicondylo-trochlear fractures of humerus, 414 
 epicondylo-capitellar and condylo-capitellar fractures of humerus, 442, 446 
 separation of trochlea of humerus, 452 
 
 capitellum of humerus, 455 
 upper epiphysis of ulna, 466 
 radius, 476 
 
INDEX OF SUBJECTS 925 
 
 Treatment, separation of lower epiphysis of radius without displacement, 572 : — with dis- 
 placement, 573 
 lower epiphysis of ulna, 587 
 true metacarpal bones, 598 
 metacarpal bone of thumb, 590 
 epiphyses of phalanges of digits, 601 
 epiphysis of iliac crest, 609 
 epiphysial head of femur, 657 
 epiphysis of great trochanter of femur, 673 
 lower epiphysis of femur, 783 
 upper epiphysis of tibia, 814 
 epiphysis of tubercle of tibia, 821 
 lower epiphysis of tibia, 852 
 upper epiphysis of fibula, 859 
 lower epiphysis of fibula, 865 
 .Trochanter, great, of femur, epiphysis of, anatomy of, 661 ; separation of, 661 : — age 
 . and etiology, 662 : — pathological anatomy, 663 : — symptoms, 
 668: — differential diagnosis, 670 : — prognosis and complica- 
 tions, 671 : — treatment, 673 
 lesser, of femur, epiphysis of, anatomy of, 675 ; separation of , 675 : — etiology 
 
 and pathological anatomy, 675 : — symptoms, 676 
 third, anatomy, 677 
 Trochlea of humerus, anatomy of, 448 ; separation of, 448 : — pathological anatomy, 448 : — 
 complications, 449, 451 : — etiology, 449 : — symptoms, 449 : — dia- 
 gnosis, 451 : — treatment, 452 
 Tuber ischii, anatomy of, 614; separation of, 614 
 
 Tubercle of tibia, epiphysis of, anatomy of. 816 ; separation of, 816 : — etiology, 817 : — age, 
 sex, and pathological anatomy, 819 : — symptoms, 820 :— diagnosis 
 and treatment, 821 : — prognosis, 822 
 Tuberosities of humerus, separation of, diag-nosis, 218 
 Tuberosity of rib, epiphyses of, anatomy, 880 
 
 Ulna, upper epiphysis, anatomy of, 457 ; separation of, 457 : —pathological anatomy, 459 : — ■ 
 age and etiology, 461 :— symptoms, 462: — diagnosis, 464: — • 
 prognosis, 465 : — treatment, 466 
 lower epiphysis of, anatomy, 580 ; separation of, 580 : — pathological anatomy, 581 : 
 — etiology, age, symptoms, and prognosis, 583 : — treatment, 
 587 : — separation with lower epiphysis of radius, 504, 524, 538 
 fracture of shaft of, with separation of lower epiphysis of radius, 507, 548, 549 
 dislocation of, with separation of lower epiphysis of radius, 513 
 Union of epiphysis with diaphysis, earlier junction not due to greater activity, 23 
 
 relation with direction of nutrient canals, 22, 29 
 times of, difference in females and males, 25 
 individual difference, 25 
 investigations in the order of, 28 
 times of (Dwight's table), 28 
 Eontgen ray process, 28 
 variations in different races, 28 
 investigations on, 31 
 chronological table of times of union, 47 
 Union after epiphysial separations, 98 
 
 separation of upper epiphysis of humerus, 244 
 lower epiphysis of humerus, 304 
 internal epicondyle, 377 
 external epicondyle, 401 
 condylo-trochlear fracture of humerus, 410 
 epicondylo-capitellar fracture of humerus, 436 
 separation of olecranon epiphysis, 465 
 
 lower epiphysis of radius, 553 
 epiphysis of metacarpal bone, 597 
 epiphysial head of femur, 649 
 great trochanter, 671 
 lower epiphysis of femur, 748 
 upper epiphysis of tibia, 810 
 tubercle of tibia, 822 
 lower epiphysis of tibia, 846 
 Ununited acromial epiphysis, 149 
 coracoid epiphyses, 160 
 internal epicondyle of humerus, 353, 354 
 condylo-capitell-ar fracture of humerus, 427 
 
926 INDEX OF SUBJECTS 
 
 Upper epiphysis of humerus, anatomy of, 163 ; separation of, 163 :— age, 169 : — sex, 170 : — 
 
 etiology, 170 : —symptoms, 189, 193, 211: — pathological 
 anatomy, 175: — complications, 183, 211: — muscular ac- 
 tion in, 174 : — differential diagnosis, 213 : — treatment, 
 218 : — operative treatment of recent separation, 226, 
 231, 241 : — resection of diaphysis in old cases, 233, 
 238 : — prognosis, 244 : — deformity after, 246 : — arrest 
 of growth, 254 
 ulna, anatomy of, 457; separation of, 457; — pathological anatomy, 
 459 : — age, 461 : - etiology, 461 : — symptoms, 462 : — dia- 
 gno-is, 464 : — prognosis, 465 : — treatment, 466 
 radius, anatomy of, 470 ; separation of, 470 : — etiology, 472 : — age and 
 pathological anatomy, 472 : — symptoms, 473 : — prognosis, 
 474 : — diagnosis, 475 : — treatment, 476 
 femur, anatomy of, 615 ; separation of, 615 : — age, 618 : — etiology, 
 620 : — pathological anatomy, 624 : — symptoms, 631 : — diffe- 
 rential diagnosis, 642 : — prognosis, 649 : — treatment, 657 
 tibia, anatomy of, 798 ; separation of, 798 : — etiology, 800 : — age, sex, 
 and pathological anatomy, 802 : — complications, 808, 813 : — 
 prognosis, 810 : — symptoms, 811 : —diagnosis, 813 : — treat- 
 ment, 814 
 fibula, anatomy of, 856 ; separation of, 856 : — etiology, 857 : — age and 
 pathological anatomy, 858: — symptoms and treatment, 8£9 
 
 Veetebe^e, epiphyses of (generally), anatomy, specimens, &c., 873 
 
 cervical (generally), anatomy, separation of, 876 
 lumbar, epiphyses of, anatomy, 878 
 Violence, indirect, in epiphysial separations, 39 
 direct, in epiphysial separations, 41 
 muscular, in epiphysial separations, 42 
 
 WiEiNG of fragments in separation of upper epiphysis of ulna, 469 
 
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 CLINICAL MANUAL for the STUDY of MEDICAL CASES. 
 
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 The MINERAL WATERS and HEALTH RESORTS of 
 
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 ELLIS'S DEMONSTRATIONS of ANATOMY: being a 
 
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 A JUNIOR COURSE of PRACTICAL ZOOLOGY. By the 
 
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 On the PRINCIPLES and EXACT CONDITIONS to be 
 
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