LIBRARY OF CONGRESS, Chap..i:.„ Copyright No. Shell, Mf UNITED STATES OF AMERICA. NOTES ON THE MODEEN TEEATMENT OF FEACTUEES .J* BY JOHN B. ROBERTS, A. M., M. D. PROFESSOR OP SURGERY IN THE PHILADELPHIA POLYCLINIC, MUTTER LECTURER ON SURGICAL PATHOLOGY OP THE COLLEGE OP PHYSICIANS OP PHILADELPHIA WITH THIRTY-NINE ILLUSTRATIONS NEW YORK D. APPLETON AND COMPANY 1899 COPYSIGHT, 1S99, ET Dr. JOH>~ B. EOBEKTS. TWO COPIES REC ; *»« PKEFACE. Ko injuries require more careful and judicious treatment than fractures; and in no branch of surgical therapeutics is the exercise of common sense followed by more satisfactory results than in the treatment of these lesions. A blind reli- ance upon therapeutic dogmas and the adoption of routine measures, without due consideration of the mechanical and pathological problems presented, have led to many disasters in this department of surgery. The essays brought together in this little volume represent the views announced at vari- ous times by the author, who has always believed that inde- pendent thinking leads to the abandonment of false theories, and aids in the search for truth. Some alterations have been made in the papers to bring them into accord with the author's present views. J. B. K. 1627 Walnut Street, Philadelphia, April 1, 1899. CONTENTS. i. PAGE Exploratory Incision in the Treatment of Closed Fractures and Dislocations 1 II. Subcutaneous Nailing in Fractures with Unusual Tendency to Displacement, 10 III. The Pretention op Deformity in Fractures of the Extremi- ties, 13 IV. Subcutaneous Tenotomy as an Aid in the Reduction of Frac- tures 20 V. False Doctrine in the Treatment of Fractures, ... 23 VI. Recent Advances in Treatment of Fractures of the Ex- tremities 31 VII. Simplicity in the Treatment of Fractures, .... 34 VIII. Refracture for the Relief of Deformity after Fracture, . 44 IX. Fractures of the Cranium 65 VI CONTEXTS. PAGE Subcutaneous Nailing, Exploratory Incision and the Ex- tended Elbow in Condyloid Fractures of the Humerus, 78 XI. Treatment of Fractures of the Lower End of the Humerus and of the Base of the Eadius, 92 XII. The Ignorance of Surgeons Regardestg Fracture of the Lower End of the Radius, 118 XIII. Deductions from Forty-three Cases of Fracture of the Lower End of the Radius, Treated Withln Three Months, 121 XIV. Heedlessness of Spltnts in Fracture of the Lower End of the Radius, . 124 XV. The Necessity of Force in the Treatment of Colles' Fracture of the Radius 130 XVI. Fracture of the Lower End of the Radius with Forward Displacement 133 XVII. A Case of Fracture of the Lower End of the Radius with Anterior Displacement of the Carpal Fragment, . 140 XVIII. Fracture of the Lower End of the Radius with Displace- ment of the Lower Fragment Forwards, .... 142 XIX. The Treatment of Fractures of the Lower Part of the Tibia and Fibula, 154 THE MODERN TREATMENT OF, FRACTURES. EXPLORATORY INCISION IN THE TREATMENT OF CLOSED FRACTURES AND DISLOCATIONS. Complete reduction, exact restitution of contour, and per- fect retention are the conditions of full success in the treatment of fractures. Deformity, impairment of articular movement, non-union and neuralgic pains are remote results of failure to obtain these desirable conditions. Since aseptic surgery has made possible the prevention of infective inflam- mations in most open fractures, it is quite probable that bet- ter reduction, coaptation and retention result in open than in closed fractures of the same grade and character of bony lesion. The recent application of skiagraphy to surgical diagnosis has proved that fractures seemingly well reduced and properly dressed with splints may be the seat of considerable deviation from the normal skeletal relations. At the Polyclinic Hos- pital recently, for example, a fracture of the middle of the radius, supposed to be well reduced and dressed, was shown, by the use of the Eoentgen ray, while the splints were in po- sition, to have its fragments overlapping to the extent of about half an inch. In another case a painful swelling at the seat of a former injury to the fibula was discovered to be due to unrecognized non-union at that point. The rigidity of the tibia prevented the lack of union of the smaller bone being detected, but skiagraphy showed it plainly. 2 THE MODERN TREATMENT OF FRACTURES. Nearly fifteen years ago I advocated conversion of closed fractures of the cranium into open fractures by incision of the scalp, whenever uncertainty as to the character of the cranial lesion was prejudicial to intelligent treatment.* As part of my argument I said that no surgeon would hesitate to con- vert a closed recent fracture of the thigh or leg into an open one if it were impossible to replace fragments which were threatening life. I admitted that closed wounds are less seri- ous than open ones, but asserted that, with modern surgical methods, open wounds are preferable to closed wounds having inherent dangers that cannot be recognized without opening them. Further consideration and experience convinced me that this method should be extended to fractures in the limbs, even when life was not threatened, if obscurity of lesion or difficulty in reduction jeopardized function. Accordingly, a few years later, f I gave it as my opinion that recent fractures of the lower end of the humerus might with propriety be sub- jected to exploratory aseptic incision, if satisfactory coaptation was not obtainable under anaesthesia; and that such action, though it involved opening the elbow joint, was as legitimate in properly selected cases as the recognized exploratory inci- sion made in obscure abdominal conditions. My belief in the propriety and value of exposure of the fragments in a certain limited number of closed fractures has been strengthened as years have passed. The method, which I do not claim as novel, has, however, not been sufficiently impressed upon the profession to cause its adoption by sur- geons in general. Allis of Philadelphia has advocated it t- in rebellious fractures of the upper third of the shaft of the femur, in order to apply steel screws for retentive purposes. In England, Lane has employed it § in oblique fractures of * " Transactions American Surgical Association," vol. iii. (1885), pp. 6 and 105. t " Transactions American Surgical Association," vol. x. (1892), p. 58. \ Medical News, November 21, 1891, p. 590. § " Transactions Clinical Society of London " (1894), p. 167. EXPLOEATOEY INCISION W CLOSED FEACTUEES. 6 the tibia and fibula near the ankle, for the same reason. Mc- Burney * and others have resorted to it in fracture of the upper end of the humerus complicated with dislocation. Dennis t and Eicard t also approve of it in cases where there is difficulty in obtaining correct apposition of fractures. Other writers may have mentioned the subject, and cases may have been occasionally reported ; but, except in fractures of the cranium and patella, I think that most surgeons are more apt to be satisfied with imperfect results than to advise immediate exposure of the fragments before the patient comes out of the anassthesia induced for the purpose of examining and reducing the fracture. This attitude of the profession in general has been evident in societies at which I have incidentally mentioned my views, § and is due to conservatism bred by the fear of open fractures felt by all in the pre-antiseptic period of surgery. The method has suggested itself to many practical surgeons, but it needs to be ever before our minds as a legitimate pro- cedure. My advocacy of cutting down upon closed fractures is limited to cases in which ignorance of the exact lesion, im- possibility of reduction, imperfect immobilization, or failure to deal efficiently with complicating lesions makes the incision the less of two evils. An aseptic incision is almost devoid of risk, even if it opens a joint; but that slight risk should not be added to the patient's burdens unless the probability of de- formity, of interference with joint movements or other func- tions, of pain, of paralysis, or of non-union justify it. Here, as in all departments of surgery, it is the surgeon's duty to exercise care and good judgment in selecting the method of treatment. To illustrate my meaning I cite fracture of the * Annals of Surgery, May, 1890. f "System of Surgery," vol. i. i " Traite de Chirurgie," Duplay and Reclus, ii., 376. § Annals of Surgery, April, 1895, p. 457, and- Philadelphia Polyclinic, August 21, 1896. 4 THE MODERN TREATMENT OF FRACTURES. patella, which I have never treated by incision and suture of the bone, because I have thus far always been able to satis- factorily bring the fragments together by hooks, subcutane- ous suture, or splint. In one or two instances I have almost decided to lay open the overlying tissues in order to obtain approximation by direct appliances, but I have finally not been obliged to do so. The open operation I believe to be legiti- mate, and probably needful in a very few selected cases, but I am opposed to it as a routine treatment. It is self-evident that the wound exposing a fracture must be aseptic, and that the operator who adopts incision must be familiar with the steps to be pursued at the inception of infective inflammation. A man who will hesitate to reopen the wound or drain the joint, at the moment septic premo- nitions show themselves, should associate a more energetic sur- geon with himself in such operative treatment of fractures. The risk of incising muscles and opening joints, if done in an aseptic manner by an operator familiar with truly aseptic and antiseptic surgery, is unquestionably very slight. Pri- mary union without disturbance of joint-function will be almost universal. If it once be admitted that the seat of a fracture can be ex- posed by incision, with little or no risk to life, there are many advantages that will at once suggest themselves: 1. The exact lines of separation can be seen, and the sig- nificance of lines of comminution in relation to subsequent reconstruction can be fully appreciated. 2. Coaptation need no longer be guessed at by the sensa- tions imparted to the examiner's fingers, separated as they are from the bone by varying thicknesses of muscle, fat and skin; nor need it be dependent upon the possibility of having con- veniences for taking a skiagraph. 3. The fragments can be accurately fitted together, torn periosteum replaced, and muscular and facial bands, nerves and muscles disentangled from undesirable positions between EXPLORATORY INCISION IN CLOSED FRACTURES. 5 the pieces of broken bone. This prevents deformity by per- mitting restoration of normal contour of the limb and lessens occurrence of non-union, neuralgia, atrophy, and anchylosis. 4. When the osseus, muscular, and vascular relations have been restored, they can be perfectly maintained by the appli- cation of sutures, pegs, nails, screws or ferrules to the bone, and sutures or ligatures to the muscles, nerves, and vessels. 5. The pain, due to extravasation of blood, rapid inflamma- tory exudation, or traumatic synovitis, is relieved by the re- moval of the clots and leaking out of exudation and synovial fluid. The interstitial pressure caused by extravasated blood and exudate has often heretofore caused surgeons to split the skin and deep fascia by long incisions, in very bad fractures, in order to avert threatened gangrene. A similar relief of tension in less urgent cases will undoubtedly lessen pain and suffering, though such operative treatment would ordinarily not be adopted. The incisions employed to uncover the frac- tures are therefore indirectly of value as relievers of pain. 6. Pain is also lessened, in the few cases requiring direct retentive apparatus, because the sutures, nails or screws pre- vent motion between the fragments better than external splints. Muscular spasm or incautious movement has there- fore little opportunity to cause suffering. 7. Fat embolism is probably less likely to occur in fractures liable to its occurrence, if early escape of the fatty debris is permitted by incision. 8. Anchylosis from faulty position of fragments, irregular formation of callus due to stripped-up periosteum, and gluing down of tendons, will seldom occur after the fracture has been disclosed to the scrutiny of a competent surgeon. 9. Eepair of the broken bone and functional restitution of the surrounding tissues occur more rapidly than when coapta- tion is imperfect, or when damaged muscular and other struc- tures are left to the unaided efforts of nature. Impairment of digital movements after fractures is probably often due to 6 THE MODERN TREATMENT OF FRACTURES. coincident rupture or laceration of muscles, which might have heen repaired by suturing with catgut, if the surgeon had known of the existence of the complication. The aseptic wound affords him this opportunity: and afterward usually heals so rapidly that it is of no disadvantage to the patient's period of convalescence. This early restoration of wage- earning capacity is of great value to many patients. 10. It not infrequently happens that a closed fracture seems to have been well set. and to have little deviation from the normal; and yet the patient has lost some of his availability as a machine. This is most likely to occur in the lower limb which, during locomotion, carries the entire weight of the man. A slight change in the axis of a bone or in the plane of an articulating surface may perhaps throw the weight upon the hip, knee, or ankle in an abnormal way, and induce a con- siderable and ever increasing disability. This contingency is usually avoidable after the accurate inspection of the injured bone permitted by uncovering the fracture by an incision. In vicious ttnion of fractures due to absence of treatment, or to injudicious treatment, I believe that it is sometimes much better to expose the seat of deformity and divide the deformed bone with an osteotome than to refracture subcutaneously by an osteoclast or the surgeon's hand. Many cases can indubi- tably be well treated by refracture withotit incision or by sub- cutaneous osteotomy: but if there be a reasonable doubt as to one of these methods enabling the surgeon to accomplish re- lief of the deformity, free exposure, such as I have just been advocating in recent fractures, is the proper treatment. A similar method of dealing with luxations which are not readily reduced by manipulation under anaesthesia is, in my opinion, preferable to a long continuance of unsuccessful ma- nipulations, the application of great power by apparatus, or the relinquishing of the attempt to restore the integrity of the joint. It is true that in all dislocations, except that of the spinal column and the backward luxation of the second EXPLORATORY INCISION IN CLOSED FRACTURES. 7 phalanx of the thumb, reduction is usually readily accom- plished by skillful manipulation under anaesthesia, provided the attempt is made while the injury is recent. My conten- tion is that in recent dislocation, when this is not the case, and in old dislocations, arthrotomy should be promptly done. No surgeon would recommend allowing the displacement to remain without attempting reduction ; and I believe that com- pound pulleys or other methods of applying great force are usually more risky than prompt and thorough exposure by in- cision. Immediately before making the incision it Avould be well in most cases to make a final effort to reduce by ma- nipulation ; but this should not be earned to a sufficient extent to cause much bruising or muscular laceration. The presence of such traumatism would increase the liability to septic proc- esses, if imperfect asepsis allowed germs to gain access to the wound during the operation. Arthrotomy for irreducible dislocations is not a novel sug- gestion, for it has been repeatedly clone by many surgeons in old injuries. It has not, however, I think, been often adopted until after vigorous efforts have been made to subcutaneously replace the articular surfaces. Its use in luxations a few hours or a few days old, except perhaps in the fingers and toes, is probably almost unknown as an accepted surgical procedure. I believe it ought to be the approved treatment in a small number of cases. The advantages of the open method will at once be patent when the accidents that occasionally follow the employment of the older method are recalled. Fracture of the bone or laceration of artery, vein, or nerve is only likely to occur when the region is not exposed to the operator's eye. In case of impossibility to properly reduce the dislocation, moreover, the end of a luxated bone can be excised. This will probably nearly always give a better functional result than to allow the previous condition to persist. Excision is not infrequently required after attempts to reduce old luxa- tions without incision having proved unavailing. In an at- 8 THE MODERN TREATMENT OF FRACTURES. tempt to reduce an old luxation of the humerus I have dis- placed the head of the bone in such a way that it rested on the brachial plexus and caused more tro\ible than the original de- formity. This would not have been the result, I think, if I had exposed the luxated bone by arthrotomy. If the open treatment is to be adopted it is evident that the patient will receive the greatest advantage if it be instituted before the head of the bone is altered in shape, the socket changed, and muscle and fascia contracted or adherent to surrounding tis- sues. The open method in addition gives opportunity to di- vide any ligaments, tendons, fascia?, and muscles which restrain reduction, to scrape out any material filling the socket, and to make provision for preventing recurrence of dislocation by retrenching the capsule or other plastic measures. Skiagraphy may have a field in this department of surgery, as in fractures, by indicating the character of the luxation be- fore the incision is made. It may, perhaps, be urged to this plea for a more general employment of exploratory incision in closed fractures and dislocations that there are great ob- jections to making a closed lesion of the osseous system an open one. I know of no objection except the risks inherent in anaes- thesia, the possibility of infection, the occurrence of serious bleeding, and the production of anchylosis. The objections are of no force when the injury is one requiring exploratory incision. Anaesthesia will have been used in such instances for diagnosis or attempted reduction. Its moderate prolonga- tion for the necessary time will add practically nothing to the risk. Bleeding is no contra-indication, except in that rare condition, hemorrhagic diathesis. Anchylosis is more liable to occur from displaced fragments of articular surfaces, irregular callus clue to stripped-up periosteum, and interference with articular contact, than from aseptic incision into the joint and readjustment of the joint structures. The possibility of in- fection is, then, the only factor that reqiiires consideration. EXPLORATORY INCISION IN CLOSED FRACTURES. Fifteen or twenty years ago, even subcutaneous tenotomy at the heel, recommended by the surgeons of the Pennsylvania Hospital in cases of marked displacement after fracture of the tibia, was undertaken with some hesitation. Now operative infection in muscular and osseous lesions is so preventable and so readily managed by prompt action that it is no longer a valid objection to incision in a closed fracture or dislocation, if functional disability is liable to occur unless this operation is performed. For some years it has been the practice of sur- geons to incise open fractures freely in order to thoroughly cleanse the deep recesses, obtain an antiseptic condition of the lesion, and get rid of the effused blood. An extension of operative surgery is, in my opinion, now warranted in closed fractures and dislocations in which ordinary methods of reduc- tion prove unavailing or unsatisfactory. II. SUBCUTANEOUS NAILING IN FRACTURES WITH UNUSUAL TENDENCY TO DISPLACEMENT. The safety with which fractures may be explored by aseptic incisions and the success of direct fixation, obtained by mechanical devices, have begun a revolution in the treat- ment of complicated injuries of bone. My attention has recently been directed, as a. result of read- ing, experience and some experimental work, to the value of fixation of closed fractures by subcutaneous nailing. All sur- geons use at times wires, screws, pegs, or nails to hold frag- ments together after adjustment of an open fracture or the operation of resection. It is now pretty well conceded that it is entirely proper to lay open the soft parts, and accurately examine with the fin- gers and eyes an obscure fracture which is difficult to reduce or to keep reduced; provided that the surgeon is familiar with the exact details of aseptic surgery and knows how to promptly meet the first evidences of septic contamination. I believe that it is similarly proper for a surgeon, with the same quali- fication and a sufficient knowledge of regional anatomy, to deliberately nail together the fragments of a broken bone with an aseptic wire nail, driven through the unbroken skin as a tack or nail is driven through a carpet into the boards of the floor. This operation will naturally be found most serviceable in oblique fractures of superficial bones like the tibia, and in fractures without comminution. It will be adopted with less safety in fractures involving joints, because of a greater risk of faulty asepsis; but even there a skillful and conscientious 10 SUBCUTANEOUS NAILING IN FRACTUEES. 11 surgeon with a rigidly aseptic techniqxie will find no reason to reject the method. The careless surgeon who calls him- self an aseptic or antiseptic operator, but continually breaks the simplest rules of aseptic surgery, has no real right to operate in serious cases, and must be considered as debarred from operative undertakings of this kind. In comminuted fractures it may be impossible to employ satisfactorily subcutaneous nailing, because the exact reposi- tion of the pieces is impossible through the overlying swollen tissues; and because the avoidance of nerves and blood-vessels may be difficult, when driving the two or three nails which will be needed to fix the fragments firmly in place. In these cases an exploratory incision will disclose the nature and extent of the fracture line and permit the nails to be driven with accuracy. They should be so used, of course, only when their use is shown to be better than indirect fixation by splints ap- plied externally. Ordinary wire nails and a hammer are the only instru- ments needed in fixing fragments by the method here advo- cated. As wire nails are not tempered and often are not pointed, and as the exterior of the bone consists of compact tissue, it is rather better to have tempered steel nails or drills of various lengths made for the purpose; but this refinement is not at all necessary. Surgical needles, if long enough, will answer the purpose. I have had made slender steel nails of different lengths with drill-shaped points and long square heads. These fit into a common handle which is used while forcing the nail through the soft tissues and compact outer layer of bone. As soon as the hard bone has been perforated, the handle is detached and the nail driven into the fragments, held in correct position by the fingers; the long head is allowed to protrude. At the end of two, three, or four weeks, the nail is seized by the head with a pair of forceps and withdrawn. During the time the nail is in position the small wound of entrance is dressed with aseptic or antiseptic gauze; and a 12 THE MODERN TREATMENT OF FRACTURES. slight additional support is given to the broken bone by any form of dressing which will prevent strain at the seat of frac- ture. A very light metal, wooden, paper, or gypsum splint may be employed for this purpose. This manner of dealing with fractures is by no means rec- ommended as a routine procedure, but is a legitimate and val- uable adjunct in dealing with broken bones having an un- usual tendency to displacement, whether the displacement be due to great obliquity of the line of fracture or to exceptional muscular contraction. Its advantages are simplicity of technic, effectiveness in meeting the mechanical requirements, and the ease with which the instruments required can be universally obtained. The only objection to the method in cases requiring such active treatment is the necessity for absolutely aseptic materials, and the observance, on the surgeon's part, of the same conscien- tious care, as to sterility of hands and skin, as is required in a successful intra-abdominal operation. Subcutaneous nailing will probably be found very valuable also in certain dislocations, such as dislocations of the clavicle from the sternum and the scapula from the clavicle. III. THE PREVENTION OF DEFORMITY IN FRACTURES OF THE EXTREMITIES. The deformity following broken bones is a frequent cause of litigation because the disability and unsigbtliness of the condi- tion are readily apparent to the patient and his friends. For the same reason the surgeon is more often subject to unfavor- able criticism than the physician, whose failure to do the best possible is often unknown to the public. So annoying is the sight of a deformed limb and so great are the responsibility and anxiety assumed in taking professional care of a bad fracture that some practitioners feel glad to have such cases fall into the hands of other physicians or to receive treatment at hospitals. Mistaken diagnosis is a common cause of deformity after fracture. It is necessary not only to know that a frac- ture exists, but also to be acquainted with the situation and general character of the lines of separation, if the surgeon is to obviate deformity. Many physicians fail in this important part of the treatment because they neglect to compare the in- jured with the uninjured limb; because they have forgotten the anatomical outlines of the region and do not take the trou- ble to look at the dry bones of the part while studying the injury; or, because they fail to examine the patient under gen- eral anaesthesia which prevents pain and relaxes the muscles. I have seen fractures overlooked because these precautions have been omitted. This is perhaps most often the case in fractures near joints where the normal mobility of the part and the irregular contour of the bones obscure the deformity 13 14 THE MODERN TREATMENT OF FRACTURES. and preternatural mobility due to the fracture. It has at times surprised me to find a peculiar curve in a bone of an in- jured limb existent also in the skeleton of the opposite side, proving that, which I at first supposed was an abnormal- ity due to fracture, to be natural configuration peculiar to the patient. Every doctor should have in his office the parts of a human skeleton. At times nothing so clearly straightens out an obscure diagnosis as a moment's inspection of the bare bones. An articulated skeleton is not necessary, and is rather expensive. The separated bones can be obtained through any medical student at very little cost from a dissecting room. Finer and more costly preparations, but no better for study, can be bought from the surgical instrument makers. General anaesthesia is not employed as often as it should be in obscure injuries. A few inhalations of ether will relax the tightened muscles and permit the surgeon to freely manipu- late the injured limb. The freedom from pain thus obtained is also desirable and prevents the unwise hurry which some- times is the cause of erroneous treatment at the hands of skill- ful and careful medical men. \Yhen it is impossible to make out the exact character of the fracture even under etherization and there exists bony de- formity which the surgeon is unable to correct, it may, in my opinion, be wise to make an aseptic incision down to the broken bone. This clears up the diagnosis, permits proper readjust- ment of the fragments, and only converts a closed fracture into an open one. "With our present aseptic and antiseptic methods of operating, the incision adds little risk to the case ; and may be of incalculable value in overcoming displacement and pre- venting premature deformity and disability. If the practi- tioner having charge of the case is not familiar with aseptic- surgery, he should seek the aid of a modern surgeon familiar with aseptic details. Suppuration must, of course, be avoided, and energetic relief measures must be promptly instituted if septic contamination occur. The wound, even if it look well PREVENTION OF DEFORMITY IN FEACTUEES. 15 superficially, must be opened and drained if septic process begin in it. The Roentgen ray now gives us an almost perfect metbod of discovering tbe lines of fracture without incision. It is unfortunately not always available. When the diagnosis of fracture has been made, complete reduction of the fragments should be promptly accomplished. This is usually not a difficult task if the medical man is ac- quainted with the normal outline of the bone, compares the in- jured limb with the normal one and uses the skeleton of the arm or leg as a test of accuracy. The swelling which some- times obliterates the outlines may often be greatly diminished by elevating the limb for a few minutes, rubbing it with the hands from the fingers or toes toward the body, and encircling it for a few minutes with a rubber or flannel bandage firmly applied by spiral or spiral and reverse turns. These manipu- lations urge the serum upwards toward the heart and lessen the distention of the subcutaneous cellular tissue. The band- age must not be allowed to remain on the limb for more than a few minutes, lest it cause gangrene. It usually cannot be applied unless the patient be etherized, as it gives pain. In the green-stick fracture of childhood much force may be demanded to bring the bone into its normal shape. This should usually be done, even if the fracture is thereby made complete. The exception I make to this rule is in green-stick fractures of the clavicle. Complete fractures of the clavicle are often difficult to keep in perfect apposition. I therefore frequently desist from applying force sufficient to cause com- plete separation of the fragments in little children with green- stick fractures of this bone. I believe that the slight deform- ity which is left after partial restitution of the normal outline by moderate force, is likely to be less conspicuous than that which may result if I carefully separate the fragments and unavailingly try to keep the ends in perfect coaptation. If the child is very young, the deA'iation in shape will probably 16 THE MODERN TREATMENT OF FRACTURES. diminish as the bone grows in length and thickens. If the child is nearly full grown, I am much more apt to attempt complete reduction, even if the bone does give way under the pressure of my fingers. In impacted fractures, considerable force is frequently needed to disentangle the interlocked ends. Unless this is ac- complished, reduction is incomplete, and deformity will per- sist. I think, at present, of but one instance in which it is unwise to attempt to separate the impacted fragments. Frac- tures of the neck of the femur in the aged have a character- istic indisposition to repair by bony union. Hence the inter- locked ends of the broken bone should not be pulled apart in the attempt to make a diagnosis or to obtain perfect restoration of the bony outline of the femoral neck. The deformity that will occur from the impaction is far less important than the dis- ability certain to remain after treatment, if the fragments are separated and non-union occurs. If the bony entanglement is undisturbed, osseous or cartilaginous union becomes more probable. This advice to avoid meddlesome activity applies only to fractures of the femoral neck in the aged. Under other cir- cumstances the impaction should be overcome and careful coaptation of the fragments sought. The fracture which probably most often gives rise to deformity is that of the lower end of the radius, with backward displacement of the lower fragment. In this injur}' the lower fragment is very often impacted or caught upon the dorsal edge of the upper fragment. It re- quires force suddenly applied with all the power of the sur- geon's hands to drive the lower fragment forward into its proper relation with the shaft of the bone. This is neglected, I fear, by a great majority of practitioners. Deformity much greater than necessary and a protracted convalescence, with pain and stiffness of the fingers are the consequences of the error. Immediate and thorough reduction will usually result PREVENTION OF DEFORMITY IN FRACTURES. 17 in a rapid cure with little or no noticeable deformity. I have sometimes bent the lower end of the radius across my knee before I could disentangle the fragments and bring the lower one into place. This is not often necessary unless the fracture is some days old when first subjected to treatment. Deformity after unsuccessfully treated fractures may be prevented or relieved by refracturing the callus which unites the fragments. This is occasionally necessary in instances where no treatment has been given. The bone is bent across the edge of a padded table or over the surgeon's knee, and, after the bond of union has been ruptured, is treated as a recent accidental fracture. This may be done with success at the expiration of even six months since the seat of fracture re- mains weaker than the rest of the bone for a long time. There are various methods of applying the power of the surgeon who wishes to refracture such vicious union of a fracture; and the bone may be weakened or divided by drills, the osteotome, or the saw ; but these matters are foreign to the present discus- sion. To obviate the occurrence of distortion after reduction and coaptation of a fracture have been accomplished, some sort of retentive apparatus is required. In fractures of the thigh I usually employ permanent traction by means of a weight at- tached to the limb with adhesive plaster. This overcomes the tendency to overlapping. Any tendency to lateral displace- ment I antagonize by sand-bags laid along the sides of the thigh and leg or by molded splints. The molded splints may be made of bookbinders' pasteboard wet with water and applied to the limb before becoming dry or of gauze saturated with plaster of Paris and water. The best, and probably the cheapest, splints for fractures of the extremities are molded gypsum splints. Plaster of Paris, or gypsum, is obtainable in every region from store- keepers or druggists and costs but a few cents a pound. When added to water it forms a creamy mixture, which, as 18 THE MODERN TREATMENT OF FRACTURES. everybody knows, soon " sets " or hardens into the familiar plaster used for covering the inner walls of our houses. A few strips or layers of cheese-cloth or mosquito-netting, saturated .with a moderately thick solution of plaster and laid upon the broken limb after the fracture has been set, soon stick together and harden, forming a splint which accurately fits every inequality of the limb's surface. The rigidity of the hardened gauze and plaster splints may be made as great as the surgeon pleases by placing more layers of gauze satu- rated with the plaster mixture upon the outside of the first layers, before the plaster in them has " set." If there is a tendency for any fragment to become displaced, the surgeon's fingers pressed for a few minutes on the outside of the splint so as to hold the piece of bone in position, makes a permanent prominence on the inside of the splint which acts as a substi- tute for his finger and does the same service as long as the splint is worn. These molded splints are held in place by a roller bandage :and are far better than any carved or manufactured splint ever made. They fit as a man's skin fits and need no padding to prevent bedsores. One splint may be applied on each side of the limb, or a single splint may be made so as to encircle the whole or nearly the whole of its circumference. Neigh- boring joints may be covered and therefore supported by the splint; or openings may be made in the splint where a wound needs frequent dressing or inspection. A little common salt added to the plaster mixture or the use of hot water for the mixture hastens its " setting "; borax or cream of tartar makes it harden more slowly. Such splints when applied as a first dressing should never be made to entirely encircle the limb; since the swelling incident to the fracture may make them too tight and cause much pain and even gangrene. If the plaster dressing is applied so as to encircle the limb, it should be cut open on one side its entire length before the surgeon leaves the patient. PREVENTION OF DEFORMITY IN FRACTURES. 19 To prevent late deformity the surgeon must insist that no strain be put upon the newly formed callus until it is hard enough to bear the burden. This is particularly important in fractures of the femur and tibia, which in locomotion carry the entire weight of the patient's body. Oblique fractures of these bones are especially liable to bend at the seat of union, if the patient walks on them to early, without proper artificial support. It often requires very little additional support, but that amount may be essential. Quite recently I saw a gentleman with a deformed hand be- cause he had insisted upon rowing shortly after being treated for fracture of a metacarpal bone. The callus was too soft, and he now has a curved bone instead of a normally shaped one. The so-called ambulant treatment of fractures of the lower limb is very valuable in selected cases; but requires the gyp- sum splint to be adjusted in a special manner. It must be made so thick and firm as to carry the weight of the patient in walking and at the same time allow none of the weight to come upon the broken bone. IV. SUBCUTANEOUS TENOTOMY AS AN AID IN THE REDUC- TION OF FRACTURES. The treatment of fractures lias received much consideration in recent years and many suggestions of value have been made. Some practitioners, however, seem to regard fractures as in- juries belonging to a department of surgery in which no ad- vances have been made, and continue the routine measures of the last generation. It is this conservatism, or want of prog- ress, in surgical practice that leads me to call attention to tenotomy as an aid in the reduction of fractures with displace- ment. The suggestion was made a good many years ago by some- one; and has been used by many surgeons with great satisfac- tion. It is not employed as often as it should be, because its simplicity and effectiveness have received such scant recogni- tion. Its adoption by every physician who knows how to per- form an aseptic subcutaneous division of a tendon would, I am convinced, result in lessening the number of cases of de- formity after fractures — especially of the tibia and fibula. Surgical specialists are well aware of its usefulness in oblique fractures of the leg near the ankle; but I am not sure that even they adopt it as often as is desirable in fractures of the shafts of the tibia and fibula. One who has cut the tendon of Achilles in tibial fractures in which the ordinary fracture dressings seemed unavailing in preventing overriding and de- formity, will be pretty sure to adopt it in subsequent cases. The ease with which reduction is obtained and coaptation maintained is a source of much satisfaction, after such an operation. SUBCUTANEOUS TENOTOMY. 21 It is essential that the skin and tendons be made aseptic and that the whole tendon be cut. If a few fibers are left undi- vided, the heel will still be drawn up by the calf muscles and the operation will fail of its object. If the operator can feel through the skin a distinct gap between the cut ends of the tendon, showing that the whole width and thickness of the tendon has been severed, the fragments will be easily adjusted and will lie in proper position with any simple form of reten- tive fracture dressing he may prefer. The pain due to spas- modic contraction of the calf muscles will be absent after such a tenotomy and the patient's comfort thereby greatly in- creased. The puncture made by the tenotome is to be covered by a compress of aseptic gauze or sealed with a little aseptic cotton or gauze held in place with collodion. This little operation, to which I have been resorting for years in selected cases, does not appear to impair the subse- quent power and usefulness of the foot. It obviates the neces- sity for complicated fracture appliances, to overcome spasm of the calf muscles which are causing pain and displacement of the ends of the broken bone. I have, so far as I recollect, only employed tenotomy in this manner for aiding the reduction of fractures of \h.e leg. It would probably be available in fractures of the upper part of the femoral shaft, when the iliopsoas muscle flexes and everts the upper fragment. The operation here would prob- ably require open incision and inspection of the parts, in order to devide the tendon without injuring important structures in its neighborhood. Tenotomy would perhaps take the place of cutting down upon and wiring the fragments in these troublesome fractures. The tilting up of the inner fragment in some fractures of the clavicle could probably be avoided by subcutaneous tenot- omy of the clavicular portion of the sterno-cleido-mastoid muscle. The upward displacement of the olecranon after 22 THE MODERN TREATMENT OF FRACTURES. fracture might be managed in the same way, if it were diffi- cult to obtain and maintain coaptation. There is a possibility that intra-articular operations for bringing together the fragments in transverse fracture of the patella may be avoided by a free tenotomy and myotomy of the four-headed extensor muscle of the thigh. V. FALSE DOCTRINE IN THE TREATMENT OP FRACTURES. It is my desire to call attention to some points in connec- tion with the treatment of fractures which I believe to be errors, but which I think are accepted as axiomatic truths by many members of the profession. The idea is entertained by many that every fracture of the extremities should be treated by a special splint or apparatus. The simplicity with which fractures are treated by us in the Philadelphia hospitals has caused surprise to those practi- tioners who come to us for post-graduate instruction. Their previous teaching or reading has evidently created the mis- taken impression that complicated special devices are essential for each variety of broken bone. The fact that treating a fracture is a simple mechanical problem capable of solution by any device that will secure correct apposition and immobili- zation, while at the same time inflammatory conditions are prevented, is not recognized. The quite frequent use of a bandage, next to the skin, be- fore the splint is applied to the extremity is due to false teach- ing, and is fraught with danger because of the possibility of its causing unexpected constriction in the event of rapid in- flammatory swelling. This primary bandaging has been ad- vocated to prevent swelling and muscular spasm. That it does either to any beneficial extent is doubtful. We possess other and less dangerous methods that are more effectual for such purposes. It is quite commonly believed that ensheathing callus is one of the essentials of proper union after fracture, while the truth seems to be that ensheathing callus is seldom found except in 24 THE MODERN TREATMENT OF FRACTURES. fractures of the ribs and other fractures where immobilization of the fragments is imperfectly accomplished. A fracture so held in proper coaptation that motion cannot occur heals with- out ensheathing callus in nearly all instances. Cicatrization goes on in bone wounds essentially as it does in wounds of soft parts. Early institution of passive motion during the treatment of fractures near joints or involving joints is still insisted upon by many practitioners. One of the greatest sources of anxiety to the young and inexperienced doctor is to know when to be- gin passive motion. He fears to begin too early lest he dis- turb the process of union ; he dreads to leave it too late lest he have an anchylosed limb as the result of his tardiness. The proper course, it seems to me, is something like this: If the joint is involved in the line of fracture passive motion at an earty stage will not prevent anchylosis, but may increase it by causing a greater degree of arthritis; if the joint is not in- vaded by the fracture line early passive motion is not needed, because anchylosis will not occur unless violent inflammation of the soft parts arises, which inflammation passive motion is more likely to increase than to decrease. In accordance with this view no vigorous passive motion should be made earlier than two or three weeks in any case. The adoption of such motion earlier than this has often in energetic but injudicious hands given much unnecessary pain, and perhaps in many cases increased the arthritis and subsequent stiffness. The degree of restoration of function possible after articular frac- tures is only determinable after many weeks. Passive motion should certainly not be commenced while arthritis is acute, and not as a rule until union of the fracture is pretty well ac- complished. When it is attempted the occurrence of arthritic reaction is an indication that it must be still longer postponed. The permanent stiffness of articulations after fractures in- volving the joint surfaces is nearly always due to imperfect reduction of the fragments or to infective synovitis. Passive FALSE DOCTRINE IN TREATMENT OF FEACTUEES. 25 motion will not lessen the rigidity resulting from these causes. Massage and passive motion are, however, useful in nearly all fractures, by hastening absorption of effused blood and exu- date, stimulating the nutrition, and keeping the muscles sup- ple. They may be instituted immediately after the coaptation of the fracture, and be kept up during the entire period of treatment. Pain is an evidence that the passive motion or massage is doing harm, because arthritis exists or the move- ments are too vigorously employed. Splints and dressings are often continued too long, and thereby the disability of the patient for attending to his busi- ness is prolonged. In uncomplicated fracture of the tibia and fibula the patient should be able to go on crutches to his store or office in two or three weeks; provided that a silicate of sodium or a gypsum dressing has been applied. After frac- ture of the fibula of ordinary severity one week's confinement to the house is sufficient, provided that some supportive dress- ing be thereafter worn and crutches used. The usual un- comminuted fracture of the lower end of the radius needs no splint after ten days or two weeks. Although, of course, function is not perfectly restored, the hands and fingers can be used for many purposes involving little muscular effort. While not wishing to advocate rapid convalescence when cau- tion requires a few days' additional confinement, I hold that it is improper to keep a patient from pursuits that need his at- tention, merely because of the traditional idea that a fracture means six weeks' enforced idleness. Loss of money, mental anxiety, and continued disappointment of business connections are penalties too great to endure because of a tardy convales- cence insisted upon by routine practice. It is false doctrine that still insists upon the great risk in- curred when a closed fracture of the cranium is converted by the surgeon into an open one, in order to explore supposed dangerous characteristics which, if present, threaten life from probable secondary encephalic inflammation. Hb THE MODERN TREATMENT OF FRACTURES. The possibility of septic infection is increased, I admit, but so little that the danger of obscurity in diagnosis and conse- quent erroneous treatment is often much greater. Fractures of the nose have long been, and still are, often treated by useless dressings. The conventional application to broken nasal bones is a strip of adhesive plaster placed across the bridge of the nose Avith the idea that it will by its adhesion to the skin hold the broken fragment upward, and prevent de- pression of the nasal arch. That it is quite impossible for a flexible tissue like adhesive plaster to act in this manner will be recognized with the mere statement. If comminution tends to allow displacement, the plaster will not give sufficient rigidity to obviate the tendency. If it does no good, why dis- figure the patient by making him wear it? The proper method of retaining fragments in position when great ten- dency to displacement exists, is by transfixing pins: but as the object of this paper is not to deal with plans of treatment. I will not discuss the procedure at this time. Another custom quite prevalent is to put tubes in the nostrils after nasal frac- tures or operations, when we would all prefer mouth breathing to wearing nasal canulas. which are unsightly, uncomfortable, dirty, and which as a rule soon become clogged. Breathing through the mouth for a few days is easily borne when an acute nasal catarrh is contracted: therefore its performance after nasal injuries is not intolerable. If a plug is required in the nostril to maintain position of the fragments let it be intro- duced, and let it be a tube if you choose: but it will usually become clogged and offensive. A solid plug will in most in- stances be more cleanly. Deformities of the nasal bones and cartilages often become permanent after fracturing injuries because it is believed that there is little relief for the displacement, Properly con surgical treatment at the beginning or operative measures afterward will relieve much of the unhappiness resulting from unseemly lateral deviations and irregular contortions of the FALSE DOCTRINE IN TREATMENT OF FRACTURES. 27 nose. The importance of this feature in the facial lines ren- ders defects in conformation so noticeable that in hypersensi- tive persons mental characteristics are often due to nasal deformity in childhood. It may be remembered that a com- mander of ancient times gave the order " aim at their noses " knowing that the enemy feared facial disfiguurement more than actual death. The false doctrines prevalent concerning nasal fractures should therefore meet an early overthrow. It is more important to treat a broken nose well than a broken leg. The use of the axillary pad in treating fractured clavicle is of little or no value. The important factor in the treat- ment is to so fix the inferior angle of the scapula that the- scapula cannot slide forward upon the lateral wall of the thorax, as it tends to do, because the clavicle, which is its only bony attachment to the trunk, is broken. Displacement of the fragments in broken clavicle is to be prevented by steadying the lower end of the scapula; and not by an axillary pad, which is ineffectual as a fulcrum against which to use the humerus as a lever to throw the acromial end of the clavicle outwards and backwards. The axillary pad is useless unless large and hard; if large and hard it cannot be worn without discomfort, that would usually be accompanied by danger of injurious pressure to soft parts. The employment of an internal angular splint for fractures in the vicinity of the surgical neck of the humerus is founded on false premises. The axillary muscles prevent the upper end of the splint extending high enough into the axilla to con- trol the upper fragment. Hence the splint does not keep the upper fragment at rest, and, by its projection beyond the elbow or hand, gives more leverage by which unexpected blows may cause motion of the lower fragment. It is better to use the thorax as a splint, and bandage the arm to the chest with per- haps a small amount of packing such as absorbent cotton or lint, in the axilla to steady the upper fragment. 2b THE MODERN TREATMENT OF FRACTURES. The fallacy of treating fractures of the condyles of the humerus by anterior or posterior rigid angular splints, and thereby causing deformity and disability by impairing the external angular deviation of the axis of the upper extremity, was shown by A His some years ago.* Yet this is probably the method by which such fractures are treated by most of the members present to-day. The loss of the carrying angle of the arm after treatment of condyloid fracture by such splints, is, I have no doubt, a common experience, though many may not have recognized the cause. In fractures at the middle of the forearm, interosseous pads are seldom, if ever, required if the fragments are molded into proper position and the forearm is put in a position midway between pronation and supination. The interosseous space cannot easily be preserved by the use of an interosseous com- press, if the molding and the position mentioned will not do it. The bones are too much enveloped in muscles to be con- trolled by a superficial pad, even if it is long and narrow and hard. At least such will be found the case in most instances. A lamentable practice, founded on false doctrine, is the use of a straight — that is, flat — splint for the ordinary fracture of the lower end of the radius. The palmar surface of the lower end of the radius is concave, therefore the splint must be curved. Yet the practice of employing a Bond splint or some other form of flat splint is common. A convex splint or a splint with a hard pad, with a convex upper surface, is the only form of splint proper to use on the palmar aspect of the fracture, A straight splint Avill do well on the dorsal, but not on the palmar surface. Use, therefore, either a curved palmar or a straight dorsal splint if you desire cure with the least possible deformity. The stiffness of fingers and deformity, so fre- quently seen after these fractures, are due to imperfect reduc- tion of the fragments and improper splints. In some cases reduction without the application of any splint will give better results than reduction with the use of a flat splint. * "Transactions of Medical Societv, State of Pennsylvania," 1881. FALSE DOCTRINE IN TREATMENT OF FRACTURES. 2y The teaching that fractures of the shafts of metacarpal bones should be treated by palmar splints may not be univer- sal, but it is very common. In oblique fractures the deformity can often be overcome best by continuous extension adjusted to the finger by means of adhesive plaster, as it is done in fractures of the femur. Strips of adhesive plaster attached to the finger and an extending cord, preferably of rubber, fastened to a splint, placed under the wrist and palm and extending beyond the finger tips, is a serviceable dressing for correcting overriding in metacarpal fractures. The habit of measuring the length of the lower extremities in suspected fracture of the femur is founded on a mistaken impression that the legs are of the same length. The fre- quent asymmetry in length of normal limbs has been so often demonstrated that it is surprising to see surgeons constantly employ this method of diagnosis. Even if the legs were known to be of equal length, the measurement would probably be inaccurate, because of the difficulty of avoiding tilting of the pelvis and of applying the tape to exactly similar points on each side. When it is known that normal legs differ in length, the folly of placing any diagnostic dependence on the figures obtained is apparent. The disability liable to follow fractures of the femoral neck in patients beyond middle life is not as great as it is often stated to be. Whether this is due to a mistaken diagnosis between intracapsular and extracapsular fracture, I know not ; but I am convinced that the impression prevails to a great extent among the profession, that fracture of the neck of the femur in an old person means almost helpless lameness. Such is not the case. Very good use of the limb quite frequently happens. In oblique fractures of the legs with overlapping, reduction can at times be facilitated by tenotomy of the tendo Achillis. This means of overcoming displacing muscular action is per- haps not as often resorted to as it should be. 30 THE MODERN TREATMENT OF FRACTURES. Extension by traction applied to the head and legs should be better known, I think, as a possible method of reducing fractures of the vertebrae. In many cases it will do no good, but in others it may. The aversion to applying coapting hooks to the patella and olecranon, Avhen apposition is otherwise impossible, is, in my opinion, the result of false teaching and observation. There are many points of this character upon which I might dwell, but I have said enough to indicate my disbelief in many of the popular traditions of surgical practice. I shall now wait to hear in the discussion that will follow, what justifica- tion for my beliefs or disbeliefs I can get from the practical men here present. VI. RECENT ADVANCES IN THE TREATMENT OF FRACTURES OF THE EXTREMITIES. Stjegeoks have recently made notable advance in the inves- tigation of fractures by the employment of the Eoentgen rays, which by means of the fluoroscope or photographic plates show the exact condition in obscure cases of fracture. In other instances, fractures which were supposed to have been properly reduced have been shown by the use of the Eoentgen rays to be still the seat of deformity. Another improvement is the freedom with which obscure fractures may be investigated by aseptic incision of the soft parts, which discloses the exact nature of the bony lesion. The treatment of fractures has been much improved in re- cent years by the more extensive adoption of plastic splints made of gauze and plaster of Paris. These should substitute to a great extent the manufactured splints of metal and wood, which instrument makers sell at a high price for use upon fractured limbs which they seldom fit. It is possible to prop- erly pad a wooden splint or successfully adjust a metal or felt one to the injured limb. It is, however, far better to make a splint out of plastic material like gauze filled with gypsum, which will absolutely correspond with all the inequalities of the surface of the patient's limb. Ambulant splints which permit patients with fractiu-es of the leg to get out of bed and walk upon the injured member at a comparatively early period are also the result of the ad- vance in fracture treatment that has come by study of the im- perfections of older methods. The employment of massage during the entire period of treatment of a fracture will be found to lessen the rigidity of muscles, stiffness of joints, and 32 THE MODERN TREATMENT OF FRACTURES. inflammatory infiltration aronnd the seat of fracture which so often retard the patient's full recovery of function. Mas- sage should be used with discretion, but may be employed with much satisfaction to the patient every time the splint is re- moved for the inspection of the seat of fracture. The desir- ability of this method of establishing a healthy condition of the soft parts makes it desirable to remove the splints much more often than used to be thought necessary. Tenotomy of the tendon of Achilles to prevent muscular displacement in fractures of the leg near the ankle is another accessory of treatment often neglected. This little operation will probably be found of avail in some cases of fracture of the olecranon, and perhaps in other regions where muscular contraction leads to difficulty in maintaining reduction of •fragments. The surgeon should not forget that where ac- curate coaptation of the broken bone cannot be readily accom- plished, an aseptic incision will add practically nothing to the patient's risk. Such an incision not only gives a better under- standing of the condition of the parts which may be essential to proper treatment, but permits disentanglement of frag- ments of bone from lacerated muscles, thereby averting non- union of the fracture. It also permits the use of wire or cat- gut sutures in cases demanding such direct methods for main- taining apposition. It is probable that few surgeons, and perhaps almost no general practitioners, realize how easy it is to keep a frac- tured bone in position when the surgeon sees the exact line of break. Much of the deformity of many fractures would be overcome and the anxieties of the period of treatment lessened, if the medical attendant after finding the line of fracture simply drove a nail through the soft tissues into the broken bone in such a manner as to hold the pieces together. It is not improbable that the time is near at hand when many frac- tures will be treated by some such direct method. Ordinary wire nails or long tacks made aseptic can be driven through TREATMENT OF FRACTURES OF THE EXTREMITIES. 33 aseptic tissues into the bone without disadvantage. This could be done in closed fractures as well as in open ones. An ordi- nary straight surgical needle does very well for this purpose. If necessary, an ordinary brad-awl may be used to drill the bone. Refracture or osteotomy of deformed union after fracture should be used much more frequently than it is. It is probable that much of the difficulty in fractures about joints comes from imperfectly apposed fragments. Investigation of such cases by free incision, and the use of nails or sutures in the bone to hold the fragments in proper position, would probably lead to more perfect restoration of function than is usual in fractures involving the joints. Many surgeons who fearlessly investigate fractures associated with wounds experience un- reasonable hesitation in making aseptic incisions down to the seat of fracture in obscure and troublesome cases. The recent advances here outlined in the treatment of frac- tures of the extremities have brought about the following re- sults: The restoration of the patient to a condition of health, permitting him to transact business in much less time than formerly; the establishment of this desirable end with little or no pain during the period of treatment; and the much less frequent occurrence of troublesome anchylosis after fractures involving joints. VII. SIMPLICITY IN THE TREATMENT OF FRACTURES. The essential factors in the treatment of broken bones are, undoubtedly, the early replacement of fragments, the preven- tion of recurrence of displacement, attention to the condition of the soft parts and due consideration of the patient's general health. After the reduction has been satisfactorily accom- plished, displacement may occur through the action of gravity, muscular contraction, or restlessness of the patient, and the surgeon must guard against such recurrence by applying some form of fracture dressing which retains the fragments in proper position. The best form of dressing will, as a rule, be that which corrects the tendency to displacement and at the same time steadies and immobilizes the limb. Special tend- ency to displacement varies with the line and position of the fracture, and should be recognized by the surgeon before he decides upon a form of dressing. Fracture dressings may be classed under three divisions: First, those which give moderate continuous traction or main- tain the extension which was applied when the fracture was first adjusted; second, those which by virtue of their rigidity or fixedness resist retraction ; and finally, those which by vir- tue of their inflexibility prevent angular or lateral displace- ment by furnishing lateral support to the fracture. These statements, which are almost axiomatic, will probably meet the approval of all the members of the society; but it is more than likely that in a general discussion of the subject there would be advocated a dozen different ways of treating the same fracture. It seems to me that surgeons often lose sight of the fact that simplicity in fracture dressing is as much SIMPLICITY IN THE TREATMENT OF FRACTURES. 35 a surgical virtue as simplicity in the form of instruments used in surgical operations. Simplicity in the treatment of fractures is often neglected because of an obsequious reverence for the names of former surgical teachers, which have become attached to a splint or method of dressing. It is stated that legends and traditions, connected with historical places, never die; it is, unfortu- nately, true that surgical traditions have a similar lasting and often deleterious influence upon the progress of surgery. Il- lustrations of this are seen in the present use of Bond's splint for fracture of the lower end of the radius, an appliance founded upon an erroneous understanding of the nature of the injury, and one of the worst splints which can be used in its treatment. Physick's long splint for fracture of the femur is still used in this injury by many surgeons, who fail to realize that a more modern method of dressing is less trouble- some to the attendant and more comfortable and safe for the patient. Desault's dressing for fracture of the clavicle has now no value except as a puzzle with which to entangle un- happy students under examination; yet it is probably still em- ployed. Many books are filled with elaborate descriptions of fracture dressings, whose number seems to be limited only by the pa- tience of the author. Hamilton's " Treatise on Fractures " is so full of these complicated splints and devices that the young practitioner is hopelessly lost in selecting a method for treating a fracture under his immediate care. Individuals, as well as races, are born with mental characteristics which drive them to invent and advocate complicated methods in all the pur- suits of life. The English and German surgeons perhaps illustrate this tendency to an extreme degree. Some Ameri- can surgeons, partly from individual traits and partly from overdeveloped imitative faculties, are led in the same direc- tion. A truly Avonderful illustration of this perversion of the :- - :- : ■■:-. 1 iz. 1 :r.ri__T ■;-■; - j~ 1~ v : . Zr^izzL^" : "_.-.- I - - : : . . .. . .- : in proof of bit statement. ConH anything be more prepos- : not give the result, but I can see no reason to doubt that the coaptation continued satisfactory. If the operative field was * "Transactions American Surgical Association," ix. ( 1891, p. 272. CONDYLOID FRACTURES OF THE HUMERUS. 8< free, and kept free, of septic complications, the result ought to have been good. I have had made special " fracture nails " of tempered steel, with a drill-shaped point and a long, square head. -71" Fig. 14. Fracture Nails and Drill. These are readily pushed through the skin, muscles and com- pact exterior of the bone by means of a handle which fits the head. The handle is then detached and the nails are driven into the deeper portions of bone with a hammer. After two, three, or four weeks the nails should be pulled out by the claw- Fro. 15. Hammer Forceps. like forceps. For convenience I have had a hammer-head made upon one side of the forceps. During the driving of the nail or nails the fragments already adjusted are held by the fingers of the operator or as- sistant; and after fixation is accomplished an aseptic dressing 88 THE MODERN TREATMENT OF FRACTURES. and a light splint of wood, metal, paper, or gypsum are ap- plied. Ordinary wire nail? and a hammer may be used with satis- faction, but the want of temper and point makes them rather less convenient. If the nail first inserted does not effectively fix the pieces of broken bone, it should be withdrawn and re-inserted, or one or two additional nails should be used. The placing of the nails will be found much more easy in open than in closed fractures; and will require more skill and patience in com- minuted fractures than in those in which there are but two fragments. There will be but a limited number of fractures in which this operation is demanded, but it will, I believe, be found valuable in a certain proportion of cases. Xo one should at- tempt the operation unless he is a believer in asepsis and a conscientious exponent of modern aseptic surgical methods. Careless or incomplete asepsis is not permissible. It is as rep- rehensible as in abdominal or cerebral surgery. 4. Previous skiagraphs may be needed to aid in determin- ing the point at which the nails should be introduced and the direction in which they arc to be driven. If the exact direction of the fracture lines cannot be deter- mined by palpation and manipulation, the use of the fluoro- seope or better the study of skiagraphs will often permit the surgeon to determine how best to nail the fragments together. If sufficiently definite information cannot be obtained by palpation, manipulation, and the use of Roentgen rays, ex- ploratory incision is the safest course in severe injuries of ob- scure character. 5. Obscure or severe fractures may demand exploratory incision for replacement of fragments and prevention of anchylosis. Such incisions are not employed as often as they should ho. Aseptic incision of joints, being in competent hands prac- CONDYLOID FRACTURES OF THE HUMERUS. 89 tically free from risk to life, is demanded in a certain number of elbow fractures, because the anatomical integrity of the joint and its functional usefulness are jeopardized by the sur- geon's ignorance of the lesion and his consequent inability to repair the structural damage. After incision, the fragments can be accurately adjusted, the torn periosteum replaced; muscles, fascias and nerves disentangled from undesirable positions between the bone fragments, and sutured if lacer- ated; and fixation of the fragments consummated. It is probable also that cure will be hastened and pain lessened by the removal of bloodclots and the leakage of synovial fluid and inflammatory exudate, permitted by the incision; and that fat embolism and non-union will be less likely to occur. The well-informed modern surgeon, who must know the safety of aseptic operations, should not hesitate to adopt ex- ploratory incision in appropriate cases. The patient with a bad fracture of the elbow lias an intrinsic right to the benefit derivable from incision in competent aseptic hands. 6. The best route for this exploratory investigation is through the groove between the biceps and lorn) supinator. My investigations at the Laboratory of the Philadelphia Polyclinic have led me to adopt, for exploration of the con- dition of the lower end of the humerus, a curved incision on the outer portion of the anterior aspect of the elbow joint, Avhich turns up a flap exposing the biceps and long supinator. The cut begins at a point about ft cm. above the tip of the external condyle and ends about cm. below the tip of the condyle. It is about 15 cm. long and convex towards the middle line of the arm with the center of the curve correspond- ing with the point midway between the condyle-. \Vhen this cellulo-cutaneous flap has been raised, the inter-muscular groove between the biceps and long supinator is seen. Blunt dissection down this pathway discloses the front of the humerus and the anterior ligamentous covering of the joint. The muscular-spiral nerve will perhaps be seen, but is easily THE MODERN TREATMENT <'F FRACTURES. preserved from injury. Tlie entire width of the hone and joint is rendered accessible to touch and inspection. 7. The extended position of the elbow is less likely than right-angled -flexion of the joint to be followed by impairment of the normal humero-ulnar angle, which gives the u carrying function upper extremity; and it is therefore the lyloid fractures of ordinary severity. It has been my practice to treat these fractures with the elbow extended and to carefully compare the injured with the sound limb, in order to preserve by my splints the humero- ulnar angle. I reduce the fragments, compare the two arms. and apply a splint of wood or of gauze and gypsuni - : the joint not quite fully extended. Full extension is more apt to be irksome to the patient : and it is a wise precaution to run no risk of displacing the fragments by hyperextension of the injured joint. A thin narrow board is usually laid on the front of the normal arm and the direction of the axes of the humerus and ulna marked on it. A penknife is then em- ployed to whittle the board into proper shape, and, by revers- ing it. a proper splint is made for the broken bone. The splint is padded, a little cotton laid in the flexure rf 1 and bandages used to hold the splint in position. A gyj - splint molded to the arm is more elegant, but is not alway- 50 conveniently obtained. The extended elbow in these fractures has been adv for various reasons. It has been said that it enables th - - geon to appreciate more readily any change in the deviation of axes than the right-angled position, which crowds up tih sofl tissues in front of the joint and obscures the position I fragments. The angular deformity, to be avoided, has attributed to the displacing influence of the triceps, which is relaxed by employing the extended posture. If the extended elbow is combined with supination of the radius the tri also considerably relaxed. The position advocated - . therefore to relax the important displacing muscles, with the CONDYLOID FRACTURES OF THE HUMERUS. 91 exception of the anterior brachial. Some writers allege that the displacement of the condyles and the destruction of the " carrying function " by right-angle splints are due to the fact that the radius lies at a higher level than the ulna, and that the splint and bandaging tend to bring them on the same level, thereby raising the internal condyle or depressing the external. I am inclined to believe from experimental evidence on the cadaver, that this is to a certain extent true, though too much importance may heretofore have been accorded to it by us who advocate the extended elbow. Strong clinical evidence of the worth of the extended posture is the assertion * of Thompson of Washington, who was able in two open fractures to keep the fragments in posi- tion when the arm was extended, but found that they were displaced if he attempted to keep them in position with the elbow at right angle. Taylor of San Francisco reports f a similar experience with a closed fracture. It is unnecessary to intimate to this audience that Liston treated elbow fractures in the straight position, if I am correct in my belief. Thomas of Liverpool, Jones of Liverpool, as well as Dulles t of Philadelphia; LL L. Smith § of Boston, and Bruce || of Dingwall, Scotland, recommend acute flexion in the man- agement of these injuries; but I have never tried it, though some of my colleagues at the Philadelphia Polyclinic have had, I understand, satisfaction in its employ. * "Transactions American Surgical Association," x., 1892, p. 58. f " Transactions American Surgical Association," x., 1892, p. 65. X Boston Medical and Surgical Journal, August 30, 1894. § Boston Medical and Surgical Journals October 25, 1894, and July 4. 1895. 1 British Medical Journal, 1896, ii., p. 1201. XI. TREATMENT OF FRACTURES OF THE LOWER END OF THE HUMERUS AND OF THE BASE OF THE RADIUS. The frequency of fractures at the lower end of the humerus and at the base of the radius and the necessity of maintaining functional integrity of the joints of the upper extremity, make the consideration of such injuries of primary importance. The desirability of an accepted and usually practiced method of treatment for these fractures will be unquestioned: while the value of establishing such rules of practice is fully recog- nized by all interested in surgical jurisprudence. The great diversity of opinion exhibited by the members of this Association last year, when the subject of elbow injuries was introduced by Dr. L. A. Stimson, was a revelation to me. I had, up to that time, believed that my own views, derived from the study of surgical literature and clinical cases, were not very different from those of other surgeons. Hence, I was somewhat unprepared for the remarks of many of the speakers on that occasion. A pretty thorough examination of the text-books in the hands of the practitioners and students of this country and an investigation of some of the writings of foreign surgeons have led me to believe that much bad surgery is taught and prac- ticed. This state of affairs must be due to ignorance of recent advances in surgical pathology or to an indisposition to accept statements and methods of treatment which appear to me to appeal very strongly to surgical experience and intelli- gence. As an illustration I quote from a recent work of M. Amiand Despres, published in 1S90. The author, in speak- ing of fractures at the lower end of the radius, says : * " I am * " Treatise oq Fractures," translated by Dr. E. P. Hurd, p. 4. FRACTURES OF HUMERUS AND RADIUS. 93 of Nekton's opinion that the reduction is not necessary: the apparatus when well applied reduces the fracture by degrees and without pain." He, moreover, does not apply the splints until from twenty-four to thirty-six hours after the injury, but uses up to that time warm fomentations or cataplasms. Such a method of treatment seems to me so totally opposed to surgi- cal principles and the advice of such a dangerous character to give students that any discussion which will neutralize the effect of this author's words cannot be without value. Again, I find in Dr. Henry R. Wharton's valuable treatise on " Minor Surgery and Bandaging," published in 1891,* the direction given that, before applying any splint in fractures of the lower end of the humerus, " it is well in many cases to apply over the region of the fracture several folds of lint saturated with lead water and laudanum, and to cover this dressing with wax paper or rubber tissue, to diminish as far as possible the swelling which is very marked after these in- juries." My own belief is very strong that such dressing is not only useless but harmful; because the application of these poultices over the injured limb often gives rise to the occur- rence of cutaneous vesication in the inflamed region. Evapo- ration of the lotion is prevented by the rubber tissue or wax paper and the encouragement of serous exudate beneath the cuticule is not infrequently followed by large blebs. Such applications are never required in fractures, since the swell- ing and oedema, due to the aseptic traumatic inflammation, rapidly subside if the fragments are properly adjusted and kept at rest. I have a continual struggle with young hospital residents to prevent their following this pernicious advice, which appears to be taught by more than one lecturer. In cases where the swelling and oedema will not subside by co- aptation of the fragments and rest, more active surgical interference than applications of lead water and laudanum is required. The unfortunate tendency to use complicated fracture dress- *P. 325. 94 THE MODERN TREATMENT OF FRACTURES. ings, which obtained in the early history of surgery, still re- mains to be overthrown by the continued advocacy of mechanical simplicity. Most of these appliances appear to have been invented by those more interested in the construc- tion of machinery than in a simple solution of the mechanical problems presented by osseous injuries. The application of these complicated dressings is nearly always expensive and uncomfortable to the patient, confusing to the average practi- tioner, and unintelligible to the student. Their use, more- over, tends to direct the attention of the surgeon to the kind of apparatus rather than to the conditions presented by the special injury under his care. Xo better illustration of this tendency to devise unnecessary appliances for fractures is needed than this drawing of an apparatus of Professor Bar- denheuer for fractures of the lower end of the radius. You see the patient confined to bed, on the framework of which are fastened six pulleys, through which five cords with weights make traction on as many different parts of the arm and hand. You will be surprised perhaps when I tell you that this device of the Inquisition is described in his book published in Stutt- gart in 1891.* The other splints and dressings represented and advocated by this writer in like manner strike the practical surgeon with amazement. If it were not for the indisputable evidence of the title page, the book might be regarded as the work of a mediaeval author. Think of a man with fracture of the lower end of the radius, which usually needs no splint and often need not keep him from his business for one hour, being confined to bed with five weights pulling on his unhappy arm! These considerations make me believe that a discussion by tliis representative body of the treatment of some of the com- mon fractures of the upper limb will not be valueless. Sim- plicity in dressings, comfort to the patient and very early restoration of function are the demands made by the public when fractures require treatment. I believe these demands * " Leitfaden der Beliandlung von Fracturen mid Luxationen," p. 96 FRACTURES OF HUMERUS AND RADIUS. 95 can and will be met in nearly all fractures, if surgeons will but use their intelligence, instead of blindly following the advocates of special splints; and if systematic authors will resist the temptation of describing and cataloguing every de- vice that has been employed for these lesions. Believing that the methods which I have been led to adopt are founded upon good anatomical and pathological reasoning, I cannot but think that a trial of the simple dressings proposed in this paper will lead to a recognition of their value. I ven- ture to hope that their adoption by surgeons generally will change the opinion, apparently existing in many minds, that good results after fractures at the elbow and wrist are rather the exception. I adhere strongly to the statement which I made at last year's meeting — that I approach ordinary frac- tures at the lower end of the humerus and of the base of the radius with a feeling that I shall almost certainly obtain re- sults satisfactory to myself as well as to the patient. It is proper to explain what is meant here by the term " uncomplicated " fractures, since a proper understanding of the word as used in this communication is essential to the subsequent discussion. I mean fractures in which there is no dislocation of the joint, no rupture of large vessels, no laceration of the nerve trunks and no unusual contusion or laceration of surrounding tissues. In many of the cases which I am considering there is involvement of the adjacent joint by lines of fracture, splitting the lower fragment. I consider these cases uncomplicated, if the fractures are closed ones and if the comminution of the lower fragments is not extraordinarily great. I am aware that this involvement of the joint by fissures is technically a complication; but it is so common in the fractures which I desire to bring before you, and so unimportant so long as the injury is free from septic contamination, that I have used the word uncomplicated in connection with it. In order to facilitate discussion I shall at once state my 96 THE MODERN TREATMENT OF FRACTURES. opinions and the methods cf practice Avhich I have come to adopt in these injuries. They are as follows: 1. In the treatment of fractures of the lower end of the humerus the divergent angle between the axes of the arm and forearm must be preserved; and hence dressings which inter- fere with the normal difference in level of the radius and ulna are not permissible. 2. Fractures of the lower end of the humerus of ordinary severity are, as a rule, more successfully treated in the ex- tended than in the flexed position; because the carrying func- tion is less liable to be impaired. 3. Passive motion at an early date is unnecessary, and may be deferred until union has occurred and the dressings have been finally removed. 4. Good results as to anatomical conformation and as to motion are generally to be expected and can usually be ob- tained. 5. Recent fractures in which satisfactory coaptation is not obtained under anesthesia may with propriety be subjected to exploratory aseptic incisions. Old fractures in which de- formity and impairment of function are marked may, within certain limitations, be subjected to refracture or osteotomy for the relief of these conditions. 1. Fractures of the lower end of the radius vary compara- tively little in their general characteristics, because but one form is usual. 2. Muscular action has little or nothing to do with produc- ing or maintaining the deformity. 3. Immediate reduction of the fragments is the essential of treatment. FRACTURES OF HUMERUS AND RADIUS. Vi 4. Many of the splints devised for the treatment of this fracture have been constructed in ignorance of the pathology of the condition. 5. The ordinary fracture of the lower end of the radius usually requires no splint, and should be dressed with a wrist- let of adhesive plaster or bandage. 6. When a splint is required a narrow short dorsal splint fixing the wrist is all that is necessary. 7. The method of dressing here advocated is the best, be- cause it, by avoiding cumbersome appliances, annoys the patient as little as possible, and it permits free voluntary move- ments of all of the finger joints. 8. Passive motion is unnecessary until union has occurred and the dressings have been finally removed. 9. Good use of the wrist and fingers is early obtainable and the antomical conformation is restored as well as, and perhaps better than, by other more complicated dressings. 10. Fractures which have been improperly treated by omis- sion of immediate reduction, may, Avith considerable success, be subjected to refracture even after the lapse of several months. At later periods readjustment may be possible only by osteotomy, which is a legitimate means of treatment. FRACTURES OF THE HUMERUS. Surgeons now generally recognize the necessity of maintain- ing the so-called carrying function of the upper extremity, and methods of treatment which tend to alter the relations of the axes of the arm and forearm should be discarded. The reasons assigned by Allis * for the frequent occurrence of " gunstock " deformity after fracture of the lower end of the humerus are, I think, correct. The commonly employed splints, and the displacing influence of the ordinary sling, tend to bring the ulna and radius on the same level, and thereby * " Annals of Anatomical and Surgical Society," Brooklyn, August, 1880. 98 THE MODERN TREATMENT OF FRACTURES. destroy the divergent angle of the bones at the elbow or create an angle in the opposite direction. It is asserted that the ascent of the internal condyle one-quarter of an inch will de- Normal angle of bones of forearm. (Allis.) stroy the normal angular deflection at the elbow.* The direc- tion of line of fracture and the point at which it enters the joint have, it must be remembered, a great influence on the Fig. 17. Differing planes of the radius and ulna. (Allis.) possible occurrence of change in the axes of the arm and fore- arm. The principle is the same as that utilized in condyloid and supracondyloid osteotomy in knock-knee. *Stimson, "Fractures and Dislocations," p. 403. FRACTURES OF HUMERUS AND RADIUS. 99 Packard makes the important assertion * that the place of the articular surface of the humerus corresponds with the oblique furrow of the skin on the anterior part of the joint. We know, moreover, that when the elbow is flexed at a right angle the axes of the arm and forearm coincide. For this rea- son, it is much more difficult to be sure that the fragments are in the proper position to insure integrity of the angular de- flection, when the arm is about to be dressed in the flexed Fig. 18. Kelatioa of articulating portions of radius and ulna to humerus, in fracture of internal condyle ; showing ease with which ulna and broken con- dyle can be forced up by splints and bandage, or sling, thus destroy- ing carrying function of the arm. (Allis). position, than when the surgeon compares the two arms and replaces the fragments while the injured limb is extended. In my experience the angle of deviation is greater in mus- cular persons than in those of opposite development. In women and children it sometimes scarcely exists. It is well to remember that Pilcher says f that there is a variation in the degree of this angular deviation in normal arms of the same individual. He found as much as five and one-half degrees difference in the two arms of one of the children whom he * " International Encyclopaedia Surgery," vol. iv., p. 144. + " Annals of Anatomical and Surgical Society," Brooklyn, September, 1880, p. 367. 100 THE MODERN TREATMENT OF FRACTURES. measured. In Iris opinion muscular action, particularly the action of the triceps, has much to do with the creation of the angular distortion which often occurs when elhow fractures are treated in the flexed position. I see no objection to the surgeon cutting down upon the displaced fragments when it is impossible to properly coapt the irregular surfaces. An aseptic exploration of a closed fracture is better surgery than the conservatism which gives a rigid and distorted elbow. A surgeon who fully realizes the probability of impairment of the carrying function in these fractures can without doubt treat them equally well in either the flexed or the extended position. Accurate adjustment of the fragments and provi- sion for a careful maintenance of the coaptation will usually produce good results. In the flexed position plastic dressings, made with gypsum and similar agents, are far preferable to angular splints of wood, metal or other rigid material. The former are made to accurately conform to the limb immedi- ately after the surgeon has reduced the fracture ; hence there is not much opportunity for subsequent displacement to pro- duce a change in the normal outline. If rigid splints are ap- plied, however, the movable fragments are liable to be forced into undesirable relations by the bandage and sling. This oc- currence is possible for many days after the fractured portions of the humerus have been skillfully adjusted by the surgeon. Practitioners who see comparatively few cases are, how- ever, less liable than surgeons to appreciate the probability of a " gunstock " deformity. In the flexed position of the elbow, moreover, the deviation of the axes of the arm and forearm does not exist : hence in this position a slight displacement of the plane of the articular surface of the humerus is easily overlooked. For these reasons the extended position is the better for general adoption, since the angularity of the un- broken arm is then noticeable, and any interference with the normal deviation is very apparent. FRACTURES OF HUMERUS AND RADIUS. 101 If the sentiment of the profession Avas in favor of usually treating these fractures in the extended position there would be very many less deformed arms. A specialist will vary his methods to suit each case; but for general use is needed a rule that will lead the practitioner of average experience and intelligence to get good results in the greatest possible number of cases. The extended position will, I believe, secure this result. By " extended position " I mean that position in which the elbow is extended almost, but not quite, fully. The forearm and hand are to be supine. Complete extension would be exceedingly uncomfortable to the patient, and is not what is meant. Dr. Lane gave in his paper in the " Transactions " of last year a very interesting account of the views of various surgi- cal authorities on this question. I have for a number of years used a narrow, light wooden splint, long enough to extend from the upper part of the arm to the wrist, having a divergent angle at the elbow. I usually make this splint out of a thin board at the time of dressing the fracture, using the sound arm as a guide. A little pad- ding of cotton or oakum is laid in the bend of the elbow, to fill the hollow present there, because the joint is not fully ex- tended. This padding is not intended to make pressure on the fragments. In eases where there is too much swelling to permit extension of the arm I apply an anterior obtuse angle splint or a posterior obtuse angle trough for a few days; but I soon change it for the anterior deviating splint above de- scribed. This method of treating fractures above the elbow has been fully discussed by me elsewhere.* In supracondyloid fractures, however, I have employed the flexed position, maintaining it by an anterior right- angle splint or a posterior right-angle trough. The reading and investigation necessitated by the preparation of this paper have, however, caused me to incline towards the adoption of *" Modern Surgery," Lea Bros. & Co., Philadelphia, 1890. P. 399. 102 THE MODERN TREATMENT OF FRACTURES. the extended position for supracondyloid as well as condyloid fractures. The relaxation of the triceps so induced seems to me to be desirable, especially as the supination of the forearm and hand relaxes the biceps, one of the main opponents of the triceps. This position, therefore, relaxes two of the strong factors tending to produce the backward displacement, which is so much feared by many in supracondyloid fractures or epiphyseal descriptions. Allis,* Pilcher,f Verneuil,t Gibney, Powers,§ and others are correct when they deprecate zeal in the use of passive motion in fractures about the elbow and other joints. Stim- son puts it very ably when he says,|| " that the anchylophobia of the surgeon is more dangerous to the patient than the traumatism." Orthopedic surgeons give the same evidence in the study of the collateral topic of rest in joint diseases. Phelps H has seen normal joints immobilized for ten, twelve and eighteen months without anchylosis occurring in either the normal or the inflamed articulations. Experimental study on dogs has shown the same fact. In 1885 I stated in an article on " False Doctrine in the Treatment of Fractures " ** that passive motion need not be commenced until union of a fracture is pretty well accom- plished. My belief is that it may be best for some prac- titioners to delay it until union has occurred and the retain- ing dressings have been finally removed. If begun earlier it may be harmful by giving pain, causing arthritis, or displac- ing the fragments. Massage and very slight movements of the joint, in judicious hands, will hasten restoration of muscu- lar movements and do great good, if begun at the time of * " Annals of Anatomical and Surgical Society," Brooklyn, August, 1880, p. 306. t Idem, September, 1880, p. 369. X Quoted by Pilcher. § Medical Record, New York, December 22, 1888. I " Transactions American Surgical Association," 1891, p. 269. 1 " Proceedings Philadelphia County Medical Society," 1891, p. 439. ** Journal American Medical Association, May 30, 1885, p. 589. FRACTURES OF HUMERUS AND RADIUS. 103 fracture and continued daily. This is not what is usually meant by " passive motion " after fractures, and requires skill for its proper use. If the doctor does not feel sure of his ability in this direction, it is better not to move the joint un- til the union is nearly or quite firm. It is interesting to note that Dr. L. C. Lane * believes that the flexed position of the elbow during treatment of fractures of the region under consideration is more favorable to anchylosis than the extended; because there is more room for neoplastic deposits in the anterior muscular and fibrous struc- tures, which are plicated during flexion. Deformity and impaired mobility may at times be improved by refracture or osteotomy done with careful asepsis. Cases for such radical measures must be judiciously chosen. Correspondence Avith the Fellows of the American Surgical Association, the Members of the New York Surgical Society, and the Fellows of the Philadelphia Academy of Surgery, shows me that I am correct in the opinion that such uncom- plicated fractures of the lower end of the humerus as I am discussing usually recover, if judiciously treated, with little or no deformity and with good motion. My experience, then, is simply corroborative of that of other surgeons. Letters sent to these surgeons elicited eighty-eight replies: I. a. The number Avho preferred the flexed position in treatment were, . . . . . . .65 b. The number who preferred the extended position in treatment were, . . . . . .15 c. The number who employed both positions in treat- ment were, ........ 7 d. The number who gave no definite answer to the query was, ........ 1 Toial, . • 83 *" Transactions American Surgical Association," 1891, p. 413. 104 THE MODERN TREATMENT OF FRACTURES. II. a. The number who preferred the flexed position because it was thought to insure better coaptation were, . 37 b. The number who preferred tbe flexed position because there was a fear of anchylosis were, . . .18 c. The number who preferred the flexed position because it was more convenient and comfortable for the pa- tient were, ........ 6 d. The number who gave no definite reason or answer, . 4 Total, 05 III. a. The number who began passive motion within four weeks were, . ....... 64 b. The number who began passive motion after four weeks were, ......... 7 c. The number who did not use passive motion at all were, ......... 15 d. The number who gave no definite answer to the query were, ......... 2 Total, 88 IV. a. The number who usually expect to obtain good use of the joint were, . . . . . . -80 b. The number who are doubtful about obtaining use of the joint were, ....... 8 Total, . 88 In studying these tables it must be remembered that the manner in which some of the correspondents replied made it a little difficult for me to determine under which heading they FRACTURES OF HUMERUS AND RADIUS. 105 should be classed. I have endeavored to classify the replies correctly by studying the apparent feeling of the writer as well as his phraseology. In some cases several reasons were given for the choice of the flexed position; in these I tabu- lated the one to which most importance seemed to be attached. FRACTURES OF THE RADIUS. It is unfortunate that the name of Colles is still associated with fractures of the base of the radius. Such personal no- menclature is always objectionable; and is especially so here, since Colles placed the seat of lesion at a higher point than that at which fractures of the base of the radius usually occur. Fractures of the lower end of the radius vary very little in their essential clinical details. The degree of displacement, comminution, or impaction is not always the same; but through all the variations, due to the character and continu- ance of the vulnerating force, the surgeon sees the same es- sential lesion, situated at nearly the same point of the bone. The treatment, too, needs little variation, and consists in im- mediate forcible reduction. The usual line of fracture is situated at from one-third to three-quarters of an inch above the articular surface of the bone, and is generally more or less transverse in direction, though some tendency to lateral or antero-posterior obliquity is not infrequent. Displacement of the lower fragment back- ward upon the lower end of the upper fragment is the ordinary deformity, and is due to the fracturing force, not to muscular contraction. Some impaction is not unusual from driving of the dorsal wall of the upper into the cancellated structure of the lower fragment, and actual loss of substance from crush- ing of the bony tissue is not infrequent. When impaction does not exist, entanglement of the fragments by interlocking of the irregular surfaces is very common. At times there is no displacement; at others it occurs only at the radial, and 106 THE MODERN TREATMENT OF FRACTURES. not at the ulnar side of the lower fragment, which then is tilted obliquely backward. The styloid process of the radius is carried upward and backward by this displacement, and therefore the radial styloid process is often as high as, or even higher (that is, further from the hand) than, the ulnar styloid process. This angular displacement tends to throw the articu- lar surface with the attached carpus upward, backward, and to the radial side, and produces the peculiar deformity so recog- nizable. Sometimes the integument over the ulnar head is torn asunder by this radial displacement of the hand, and the ulna may even protrude through the laceration. Such a wound by no means implies an open or compound fracture of the radius, for frequently the wound has no communication with the fractured surfaces. The fracture just described, with or without comminution of the inferior fragment, is the one usually seen. Associated fracture of the lower end of the ulna, of the ulnar styloid process, or synchronous rupture of the radio-ulnar liga- ments; and epiphyseal fracture may, however, occur. Frac- ture of the lower end of the radius with forward displacement is rather rare. Fractures identical in pathology and deformity with those found clinically can readily be produced in the surgical labo- ratory by sudden hyperextension of the hand caused by blows. As there is no opportunity for living muscles to assist in the production or maintenance of deformity here it is reason- able to suppose that muscular action has little influence upon the fracture in patients. The tonic contraction of the mus- cles of the forearm may be an agent in holding the fragments in their abnormal position, when there is simple entanglement of the rough surfaces without true impaction, and the ten- dons may similarly cause the normal relations to be main- tained after reduction by the surgeon. Further than this, muscular influences are unimportant, if my experience has taught me correctly. The conditions in a transverse fracture FRACTURES OF HUMERUS AND RADIUS. 107 of the base of the radius are very different from those in an oblique fracture of the shaft of this or other long bone sur- rounded by muscular bellies. The statement * that there is a great tendency to displacement by muscular action after re- duction has been accomplished is unconfirmed by clinical ob- servation, unless there be unusual comminution of the lower fragment. When the radius is broken at two and a half inches above the joint, or in the middle third of the shaft, the Fig. 19. Deformity in the usual fracture of lower end of radius. Taken from cast made before reduction and treatment. conditions are probably different; but I am not considering such fractures at this time. It seems impossible that any surgeon would think of advo- cating the omission of an immediate or complete reduction of the lower fragment in this fracture in which non-union is practically unknown. Yet, as I have stated in the earlier para- graphs of this communication, M. Despres does so. Equally astonishing to me is the advice of Dr. Wyeth f that " in aged patients, who have considerable impaction, it is not ad- visable to break up the impaction." Mr. Southam $ speaks of cases in which the deformity cannot be made to disappear, and another writer § says that the impaction should be undone if possible, implying that impossibility of reduction is not very unusual. About ten years ago I treated a woman of perhaps ♦Holmes' "System of Surgery," Am. ed. by Packard, 1881, vol. i., p. 864. t " Text-Book on Surgery," 1888, p. 296. X Treves' " Manual of Surgery," vol. ii., p. 54. § Druitt's "Modern Surgery," edited by Stanley Boyd. Twelth Am. ed., p. 256. 10S THE MODERN TREATMENT OF FRACTURES. seventy years of age who had fallen from a roof to the ground, breaking both radii with great displacement. My duty would not have been done, in my opinion, if I had not used the same force in overcoming the interlocking of the fragments in this old woman as I would have employed in a young person. She rapidly recovered, with perfect use of wrists and fingers, though distortion at the wrist was marked, because of the probable comminution of the lower fragment and the fact that Deformity produced by aa experimental fracture of the lower end of the radius in a cadaver preserved by zinc chloride. A heavy blow was struck on pilm, while hand was fully extended, and forearm verti- cally placed with elbow on table. the woman was imbecile and consequently pulled off the splints and dressing. That reduction is at times impossible may perhaps be true, but I have never seen an instance which the power of my two hands, aided by leverage across my knees, could not reduce under anaesthesia. Eeduction is to be accomplished by force, not by gentle pressure and manipulation, as some would have us believe. I usually accomplish it by extension and counter- extension applied to hand and forearm, aided by sudden flex- ion of the wrist with simultaneous pressure on the dorsum of the lower fragment. This maneuver is repeated, if necessary, until I feel no ledge of bone at the seat of fracture, when I carry my forefinger or thumb along the dorsal surface of the lower third of the radius. The reduction is so quickly done that anaesthesia is generally omitted. In recent eases this manipulation is generally sufficient, but in unreduced cases of several weeks' duration, and sometimes in recent cases. I have been obliged to bend the limb over my knee so as to break up FRACTURES OF HUMERUS AND RADIUS. 109 the connection between the misplaced fragments. Very firm impaction, entanglement of the fragments in the tendons, or dorsal periosteal bands may require the surgeon to bend the hand and attached lower fragment strongly backward, in order to release the interlocking, before making traction, flex- ion and pressure. This manipulation is, however, seldom necessary. It has been asserted that the long supinator or square pro- nator opposes reduction of the deformity ; this is undoubtedly a fallacy in so far as real obstacle is offered by these muscles. Mr. Howard Marsh* makes this extraordinary statement: " Should reduction not be accomplished on the first trial, the attempt should be repeated a week later, when the fragments may have become somewhat loosened on each other, and when, swelling having subsided, manipulation can be more accu- rately directed." Dr. John Ashhurst in a publication issued several years ago f makes statements equally misleading and, in my opin- ion, exceedingly dangerous. The deservedly high reputation of Professor Ashhurst will cause many practitioners to follow his words implicitly. The result will, I fear, be the production of many unnecessarily stiff wrists and fingers after fracture of the base of the radius. He says, " The important part of the treatment is, of course, to keep the fragments in their proper position. If you bear in mind the mode in which the fracture occurs, you can at once see how the compresses which we use should be applied to counteract the deformity.*' Two compresses, a dorsal and a palmar, and a Bond's splint, are used by Dr. Ashhurst, who continues, " "When the compresses are brought together, the bones are necessarily pushed into position. Even if yoit cannot accomplish this at once, you will find that, by careful dressing, in a few days the deformity will disappear." * Heath's " Dictionary of Practical Surgery," vol. ii., p. 293. t "International Clinics," vol. i., p. 201, Philadelphia, 1892. 110 THE MODERN TREATMENT OF FRACTURES. It is possible that this method of dealing with a fracture of the lower end of the radius might be admissible and do well at the hands of this eminent surgeon in the case he was dis- cussing, in which the lower fragment may have been greatly comminuted. I feel very sure, however, that the omission to call attention to the necessity of immediate and complete re- duction, as the first step in all these fractures, is a grave error, and that the apparent or intentional direction to rely upon the compresses to overcome the deformity is most unwise. Further on in his clinical lecture, which was delivered at the University Hospital, Dr. Ashhurst states, " I have seen sloughing occur from the pressure of the compresses when this precaution has not been adopted." The precaution to which he has reference is the use of " lead water and lauda- num or some other soothing fomentation," in the early stages of the treatment, or when there has been much bruising. Is it not possible that the sloughing was the result of injurious pressure by the compresses rather than the omission of local fomentation? The use of the latter, as I have previously said, in speaking of fractures of the elbow, is always unde- sirable and useless. In a paper * read before the Philadelphia Academy of Sur- gery nine or ten years ago I mentioned that I had re- peatedly been obliged to refracture and reduce fractures of the lower end of the radius after treatment in splints by other physicians. In a series of forty-eight cases reported at that time six cases came to me with the lower fragment still unre- duced, though a splint had been applied in each instance. This personal experience can be duplicated, doubtless, by nearly every surgeon who sees many fractures in hospital or consultation practice; and is due to the fact that teachers and text-books do not sufficiently emphasize the necessity for re- duction. The profession should be shown that the treatment of fractures of the lower end of the radius is reduction, and not a splint, either with or without compresses. * Medical News, December 13, 1890, p. 615. FRACTURES OF HUMERUS AND RADIUS. Ill The ignorance of the true pathology of this fracture was formerly so great that many ridiculous splints have been de- vised for its treatment. Many were constructed on the theory that the extensor muscles of the thumb were a cause of the de- formity; and not a few were employed that failed to recog- nize the curvature of the palmar surface of the lower portion of the radius. These errors are intelligible and were excu- sable; but I fail to appreciate the acumen of the authors who still figure these useless antiquities in their text-books or of the surgeons who advocate and use them. After reduction, the ordinary fracture of the inferior ex- tremity of the radius rarely requires such rigid support as the Fig. 21. Fracture of the lower end of the radius dressed with a wristlet of adhesive plaster. splint, because the transverse character of the fracture gives a broad, rough surface of contact, and the extensor tendons running over the dorsal surface of the bone act as tense straps to hold down the lower fragment. If there is much comminution or if the patient is a careless man or a romping boy, it may be wise to use a short and narrow dorsal splint upon the back of the wrist. It may be made of a piece of cigar box, a strip of metal, or consist of two or three whalebones, such as are used in ladies' dress waists. It should only extend from the middle of the metacarpal bones to the junction of the middle and lower thirds of the forearm, being, therefore, about six inches long. Its width need not be over one inch. It can be held in place by adhesive plaster 112 THE MODERN TREATMENT OF FRACTURES. or a bandage encircling the limb. This dressing should not be employed longer than ten days or two weeks at the most, during all of which time the patient should use his fingers as freely as pain and swelling will permit. In the great majority of cases this dressing is unnecessary. and a simple roller bandage, or a wristlet made of two or three superimposed strips of rubber adhesive plaster, is all that is required. It makes no difference whether the hand is main- tained in the prone or supine position during treatment. The patient holds it first in one and then in the other, varying the position at pleasure. This simple method of treating the frac- ture gives the patient the necessary freedom in moving his fingers, from the instant the fracture is set, does not prevent his wearing a sleeve, allows inspection of the parts, and is in- conspicuous, light, clean and efficient. If the surgeon is un- willing to use either of these forms of dressing, the molded metal splint devised by Levis for application to the palmar aspect of the forearm and hand is the best of the special splints. The arched or curved nature of the palmar surface of the lower third of the radius prohibits a straight splint be- ing applied there: but on the dorsal surface a straight splint may be used. Passive motion need not be employed in fractures of the lower end of the radius, for the reasons that I have given in speaking of humeral fractures. It is not needed for the wrist joint; and the finger joints are being moved constantly by the patient during the entire treatment, except when pain or swelling makes this impracticable. "When, in ten days or two weeks, sufficient union has oc- curred for the dressings to be removed, soaking in warm water, friction with liniments, and passive motion are useful to hasten the restoration of function. This is usually very little impaired except in rheumatic subjects, and in cases where great associated injury to the soft parts has occurred. The dressings employed may usually be discarded in ten FRACTURES OF HUMERUS AND RADIUS. 113 days or two weeks in ordinary cases, and in three or four weeks in comminuted fractures. Long retention of the ap- pliances is unnecessary, and even deleterious when splints are employed, because of the greater tendency to stiffness induced. In properly treated cases of ordinary severity, perfect use of wrists and fingers is obtained within a few weeks after in- jury. Patients can often write a little and use the hand for dressing themselves within ten days or two weeks. This fa- cility varies with the amount of comminution and inflam- mation. Persons of rheumatic or gouty tendencies are proba- bly more liable to stiffness of the fingers and wrist than others. Fractures in other regions present the same complications in such individuals. Much of the rigidity of the wrist and fin- gers attributed to rheumatic and gouty causes, or to the se- nility of the patient, I believe to be due to imperfect reduction of the fragments and to unscientific and unwise treatment. I have not recognized the stiffness and rigidity after this frac- ture in the aged, which some authors mention with empha- sis. I expect the same early and perfect freedom of motion in them as in the young, except in so far as the aged are more liable to rheumatism and gout. It is the opinion of Bryant * that " after this form of frac- ture the wrist-joint rarely recovers its normal movement." My belief is that after this fracture the wrist-joint usually, if not always, perfectly recovers normal movement, provided that reduction has been complete at the outset of the treat- ment and the case well managed. Moderate deformity, due to shortening of the radius, alteration in the plane of its articu- lar surface and abnormal prominence of the head of the ulna, is not unusual, but is unimportant if motion is perfect, as it generally is. Mears t advocates early passive motion, and recommends that after the removal of the splints, at the end of five or six * "Practice of Surgery," fourth American edition, 1885, p. 880. f " Practical Surgery," 1885, \\ 206. 114 THE MODERN TREATMENT OF FRACTURES. weeks, the manipulation should be continued to restore func- tion and "' remove the rigidity of the articulation which in- evitably follows fracture at this point, and enable the patient to regain, to a great degree, if not completely, the function of flexion, extension, supination, and pronation." This seems to indicate his belief that final restoration of motion is possible after a long interval. My experience teaches me that it is usual almost as early as the date at which Dr. Mears discards the splint. The statement of Stimson * in discussing this topic is, " This rigidity of the fingers is due in part to their prolonged immobilization and in part to inflammation within the sheaths of their tendons in the forearm.'* This is probably correct and indicates the harmfulness of many methods of treatment in which the fingers are confined for from four to six weeks. Under prognosis, Hamilton f gives the essence of the matter in these words, " In cases treated by myself, where I have exercised great care in reducing the fragments thoroughly, and where the bandages and splints have not been applied too tightly, or kept on too long, deformity to any con- siderable extent is the exception, and the stiffness is soon dis- sipated.'' If great comminution or crushing has been incidental to the fracture, perfect restoration of the anatomical contour of the wrist may be impossible. Eecurrence of deformity may take place after reduction has been well accomplished, if there be unusual comminution of bone and laceration of ligaments. Such cases show preternatural mobility and marked crepitus as symptoms. These cases, and even those of less severity. quite often present, after union and recovery of normal mo- tion, an undue prominence of the ulnar head and a deflection of the hand to the radial side. This deformity is due to * " Fractures and Dislocations," p. 460. f '• Fractures and Dislocations," edition of 1S91. edited by Dr. Stephen Smith, p. 284 FRACTURES OF HUMERUS AND RADIUS. 115 shortening of the radius, the result of imperfect coaptation of fragments, absorption of small particles of the bone separated by crushing, change in the plane of the articular surface of the radius or interference in young patients with the normal growth at the epiphyseal cartilage. This alteration in the anatomical conditions of the lower end of the radius may make it possible for the patient to voluntarily incline or abduct the hand to the radial side very much more than normal. In March, 1882, I presented to the Philadelphia County Medical Society * several cases of fracture of the lower end of the radius. One was a man of sixty years who, after mount- ing a high bicycle, had fallen with the machine down a high bank. He fractured the left radius and two ribs. The cure was so perfect that many members of the Society could not tell which had been the broken arm. He was by no means young, but never had any stiffness, such as is attributed by some writers to age. He has, however, to this day much unnatural latitude of motion when he deflects the hand to the radial side as the plaster casts of his forearms and hands show. When the fragments have not been reduced and vicious union therefore results, the surgeon should, as in malunion of fractures in other regions, resort to refracture. This can be done by bending the limb across the operator's knee, while the patient is under anaesthesia; aided, perhaps, by a hyper- extension of the hand and wrist. I have successfully done this as late as eight weeks after injury and have seen it done five and a half months subsequent to the original traumatism. The correction of deformity will not be as perfect as in cases treated properly from the beginning; nor should such good results, as to complete and early mobility of fingers and wrist, be expected. Dr. Richard H. Harte f has reported cases in which he did osteotomy to overcome the vicious union. I am inclined to believe that refracture would have been possible * " Proceedings 1881-82," p. 159. f University Medical Magazine, 1887. 116 THE MODERN TREATMENT OF FRACTURES. in his cases, as they were seen early. Osteotomy is undoubt- edly the proper treatment when refracture requires force lia- ble to do serious damage to the soft parts. An aseptic or antiseptic osteotomy gives no real risks and allows the surgeon to see the bone and choose the exact line of his osseous in- cision. Questions similar to those mentioned in the discussion of fractures of the humerus were sent to the Fellows of the American Surgical Association, the Members of the New York Surgical Society, and the Fellows of the Philadelphia Academy of Surgery. This correspondence elicited replies from eighty-eight. a. The number who frequently treat fractures of the lower end of the radius without any form of splint were, ........ 9 b. The number who always use some form of splint were, ......... 78 c. The number who made no definite answer to this par- ticular query was, ...... 1 Total, . . . . . . .88 II. a. The number who use passive motion within four weeks were, ......... GS b. The number who use passive motion after four weeks were, ......... 3 c. The number who do not use passive motion at all were, . . . . . . . • .15 d. The number who made no answer to this query were, 2 Total, 88 FRACTURES OF HUMERUS AND RADIUS. 11 7 III. a. The number who usually expect to obtain good use of the wrist and fingers were, . . . .69 b. The number who usually expect to obtain good use of the wrist and fingers except in aged, rheumatic or gouty patients, were, . . . . .13 c. The number doubtful about obtaiuing good results were, ........ -4 d. The number who made no definite ansAver to this query were, ....... 2 Total, 88 The same conditions attach to the compilation of this table as are mentioned after the similar table relative to fracture of the humerus. XII. THE IGNORANCE OF SURGEONS REGARDING FRACTURE OF THE LOWER END OF THE RADIUS. A Xew Yoek journal published a few months ago an article on fracture of the base of the radius, in which the author, a Professor of Surgery, stated that skiagraphic investigation showed that these fractures of the radius were frequently as- sociated with transverse fracture of the head of the ulna. The statement would perhaps have gained professional ac- ceptance had the author not reproduced the skiagraphs on which his opinion was based, and given the ages of his patients. These details made it evident that the supposed fracture was the skiagraphic picture of the normal unossified epiphyseal cartilage between the shaft and lower end of the ulna. Some weeks ago I incidentally saw a fracture of the lower end of the radius under the care of a well known surgical teacher and writer. It was being treated with anodyne lotions and a Bond's splint. I stated that in my opinion the fracture was the usual injury with backward displacement of the lower fragment, that it had not been reduced and that it ought to be immediately subjected to sufficiently great force to drive the upper fragment down into position, even if anaes- thesia was necessitated for the accomplishment of this essen- tial step. To my profound astonishment the surgeon in charge said that he believed the fragments were partially impacted (to which I fully agreed): that the position was prettv good; and that he preferred to leave such cases alone, since manipulation such as I proposed would probably in- crease the mobility at the point of fracture: and that a com- press over the elevation due to the displacement might per- FRACTURE OF LOWER END OF RADIUS. 119 haps be judicious. My surprise at these statements can scarcely be expressed. That fractures at the base of the radius must be reduced, if deformity, protracted convales- cence, prolonged rigidity of joints, and pain are to be avoided, was, I thought, accepted by every surgeon of the present day. That a compress, applied over the deformity due to impacted and unreduced fragments, was a futile substitute for the mus- cular force to be exerted on first seeing the injury was, I sup- posed, recognized by all surgical teachers. My arguments, supplemented by a diagram giving my idea of the bony conditions present, failed to convince my col- league of the danger of inaction; and, as I had no professional connection with the case, I retired from the room before the splint was reapplied to the unreduced fracture. These two instances are sufficient evidence that much, that has been learned regarding anatomy, pathology and surgical therapeutics during the last ten or fifteen years, needs con- stant reiteration in journals, societies and class rooms. It has been my experience to be obliged to set many frac- tures of the lower end of the radius, which had previously been put up in splints without reduction of the displacement. This oversight I have found very prevalent among general practitioners, and resident physicians in hospitals. I have at- tributed the neglect to reduce the fragments by the former class to the teaching of twenty years ago, when the pathology of the lesion was misunderstood; by the latter to insufficient attention to the instructions of their surgical teachers. Among resident physicians and general practitioners, I never expect to see the fracture completely reduced. Some of them, however, do appreciate the supreme importance of immediate and complete reduction and accomplish it; and in other instances the fracture has been attended with little or no displacement and the neglect to reduce the fragments is not demonstrable. I now have come to feel that perhaps the oversight in re- 120 THE MODERN TREATMENT <>F FRACTURES. cent graduates is due to the fact that their teachers do not insist upon reduction being important: and that undergradu- ate students do not see this fracture properly treated in the clinical amphitheater and classroom. These reflections have induced me to present for discussion by the Academy of Surgery the present topic : for I know that much physical suffering will be avoided and the surgical art advanced by having the young graduates, whom the Fellows of this body teach, impressed with the idea that failure to re- dtice, as soon as possible, a fracture of the base of the radius is an injustice to the patient and an opprobrium of surgery. In conclusion, I state my position in regard to this fracture in sis propositions: and would be glad to have every Fellow do likewise for record in the discussion. 1. Fracture of the lower end of the radius is one of the most satisfactory of all fractures to treat, 2. The patient, as a rule, has little discomfort after the first twenty-four hours, except from the disability and the annoyance of the sling and dressing. -"iffness of the fingers and wrist-joint is seldom present to any marked extent after a week. 4. Deformity is usually so slight as to be unnoticeable to the average observer, except in cases where there has been marked comminution of the lower fragment. •;■. These assertions are only justified when the surgeon insists upon forcing the lower fragment into its proper ana- tomical relation with the upper fragment. This is to be done by the exercise of such a great amount of force as will break up all impaction or entanglement and bring the broken sur- faces into accurate coaptation. This sometimes, but not usu- ally, requires general anaesthesia: and may demand that the surgeon bend the broken bone across his knee in order to dis- entangle the interlocked fragments. XIII. DEDUCTIONS FROM FORTY-THREE CASES OF FRACTURE OF THE LOWER END OF THE RADIUS, TREATED WITHIN THREE MONTHS. Fkacture of the lower end of the radius is, in all proba- bility, treated improperly more frequently than fracture of any other part of the skeleton; yet, if treated in a rational manner, it results in a more rapid and better functional cure than any other similar injury. A large number of otherwise intelligent practitioners, sur- geons not excluded, do not understand the mechanism of the fracture, nor the exact cause of the peculiar deformity ; hence it is not uncommon to see such fractures woefully mismanaged and the patient subjected to months of unnecessary disability. The usual cause of the injury is forced extension of the radio-carpal articulation, which produces a transverse fracture of the lower end or base of the radius, about three-eighths or half an inch above the articular surface. The line of break is not always exactly transverse, but for practical pur- poses, it may be considered transverse. The characteristic deformity is due to the fracturing force driving the lower or basal fragment upward and backward upon the shaft or the shaft downward and under the basal fragment, so that the basal fragment becomes caught or even impacted upon the dorsal edge of the shaft fragment. Muscu- lar action has little or nothing to do with the production or continuance of the deformity. In some cases no deformity exists, because the fracturing force was not sufficient to cause displacement; then the diag- nosis may rest entirely upon a localized point of great and per- 121 122 THE MODERN TREATMENT OF FRACTURES. sistent tenderness, about half an inch above the joint, and the occurrence of a ridge of callus as a later symptom. In sprains of the wrist the point of tenderness and the swelling due to consequent synovitis, will be half an inch lower than in these fractures without displacement. If the lower fragment is comminuted, as occurs in severe fractures, the characteristic pain and swelling of svnovitis will probably be present in addition to the symptoms of fracture. When the fracture shows no deformity, there usually exists no com- minution and hence no synovitis, and diagnosis is to be made only by the localized and persistent pain and the subsequent ridge of callus. The reduction of the fracture is the most important element in the treatment of the injury, and is often ineffectually ac- complished, because of the ignorance or carelessness of the attendant. In many cases reduction is not even attempted before the dressings are applied. TVhen reduction has once been thoroughly accomplished, the displacement is not apt to recur, unless the lower fragment be comminuted. Traction, sudden flexion of the wrist, and direct pressure upon the dorsal aspect of the lower fragment are the proper means of effecting reduction. Many cases need no splint if the patient is sufficiently in- telligent to avoid subjecting the injured bone to sudden strains. Comminuted fractures, of course, need more support, such as is afforded by splints, than do non-comminuted ones; while fractures without original displacement probably never need the support of a splint. It is probable that no transverse fracture of the base of the radius ever requires a splint longer than from ten to four- teen days. Perfect function of the fingers is the rule a very few weeks after the accident, provided that reduction has been promptly and fully effected immediately after the injury, and the treat- FRACTURE OF LOWER END OF RADIUS. 123 ment such as not to restrain the motion of the fingers during the wearing of the splint. Slight stiffness of the wrist may be expected to exist for some six weeks after the receipt of injury; and some thicken- ing about the seat of fracture will persist for two or three months. Permanent shortening of the radius, producing a slight in- clination of the hand to the radial side, is to be expected in all cases, but often is detected by very close scrutiny. The statement of many authorities, that long-persistent disability from stiffness of wrist and fingers may be expected, is I am sure, in the majority of cases, absolutely incorrect, and is due to observation of cases improperly treated. I have made no reference to methods of treatment, because such teaching is apt to lead to unintelligent practice, whereby a described form of dressing or a delineated splint is applied without the attendant having properly appreciated the char- acter of the injury or having effected reduction. A fracture of the lower end of the radius, once properly reduced, will do better without any professional attention whatsoever, than will one only partially reduced, dressed with the most perfect splint. In my own practice I use Levis's metal radius splint, ap- plied to the palmar surface, for cases where there is need of a good deal of support. In other cases I use a short steel or wooden splint about six inches in length and a half -inch wide, applied to the dorsum of the wrist by adhesive plaster or a bandage. A piece of corset steel is convenient for the pur- pose. Cases with no displacement need nothing more than a band of adhesive plaster around the wrist. This is a suffi- cient splint for many other cases after reduction. XIV. HEEDLESSNESS OF SPLINTS IN FRACTURE OF THE LOWER END OF THE RADIUS. The treatment of fracture of the lower end of the radius is exceedingly satisfactory, because the character of the injury seldom varies and because the results obtained are usu- ally good both in rapidity of cure and in perfect restoration of the function. This statement is, perhaps, unexpected, since it is not un- usual to find the opinion expressed in text-books that this frac- ture is troublesome to treat and very liable to be followed by deformity of the wrist and stiffness of the fingers. I am con- vinced that such unfortunate results usually come from mis- management of the fracture, and are due to a want of appre- ciation of the nature of the lesion and of the necessity for forcible reduction immediately after its receipt. These errors of judgment and treatment are perpetuated by the current belief that the essential treatment of a fracture is the appli- cation of a splint. I purpose showing that in a great proportion of cases frac- ture of the lower end of the radius needs no splint; and hence that splints for this injury are usually needless. If the ten- dency to use a splint impels the practitioner to neglect the all important reduction of the fracture, my position, it seems to me, is strengthened. The innumerable forms of splint devised for fracture of the lower end of the radius show how much this very common in- jury has interested the profession. Some of these splints have done great harm because the}' have misled the practitioner as to the nature of the lesion. A few of them are very good, in FRACTURE OF THE RADIUS. 125 that they have been devised in accordance with the anatomy and pathology of the osseous lesion. As, however, in the vast majority of cases, none of them is really needed they are prac- tically useless. The fact that positive harm is liable to be done by their use is a point in advocacy of the abandonment of all such appliances. The usual cause of the injury is forced extension of the radio-carpal joint, which produces a transverse disruption through the lower end of the radius from three-eighths to one-half an inch above the articular surface. The character- istic deformity is caused by the fracturing force driving the lower fragment upward and backward upon the shaft, or thrusting the shaft downward and under that fragment, so that it is caught or impacted upon the dorsal edge of the shaft fragment. Occasionally there is a tendency to lateral or antero-posterior obliquity of the line of fracture, but this is quite unimportant. The displacement sometimes occurs much more markedly at the radial than at the ulnar side of the lower fragment, which is then tilted obliquely backward, carrying the styloid process of the radius upward and back- ward, so that it is on a level with, or even higher than, the styloid process of the ulna. This angular displacement tends to throw the articular surface with the attached carpus up- ward and backward to the radial side, causing thereby undue prominence of the lower end of the ulna. Muscular action has nothing to do with the production or the continuance of the deformity. In cases in which the fracturing force has not been sufficient to cause displacement, no deformity exists, and in such instances the diagnosis rests upon a localized point of great tenderness about half an inch above the wrist-joint. Sometimes comminution of the lower fragment takes place so that lines of fracture enter the radio-carpal joint. The ligaments and cartilages are sometimes extensively injured, and sometimes there occurs actual loss of substance by crush- 126 THE MODERN TREATMENT OF FRACTURES. ing and pulverizing of the bone tissue. These complications, except that of comminution, are quite rare. Reduction of the fracture, the most important element in the treatment of the injury, is often ineffectually accom- plished, or, indeed, not attempted. This is owing to ignorance rather than carelessness on the part of the attendant. "When reduction is once thoroughly accomplished, displacement is not apt to recur, because the broad rough surfaces of bone are held together by their serrations, and because there are no muscular masses tending to displace the fragments. The condition, it will be observed, is quite different from oblique fracture of the shaft of the bone, in which it is often difficult to maintain accurate apposition because of the mus- cular displacing forces. Hence if reduction, which is the essential in treatment, is properly performed, no splint is needed. On the other hand, if reduction is neglected, no splint will act as a substitute for it. If reduction has been properly accomplished, an improper splint may displace the lower fragment and cause recurrence of the deformity. Hence, abandonment of splints is often a proper course to pursue. Comminuted fractures, of course, need more support than non-comminuted ones; but even here, the simple support of a bandage applied in a circular manner or of strips of adhesive plaster wound around the wrist like a collar will usually be found sufficient. In uncomplicated fractures treatment is required for about three weeks. Perfect function of the wrist and fingers may be expected in nearly all cases; provided that reduction has been properly effected immediately after the injury, and provided that the fingers have not been restricted in motion at any time during the treatment. Slight stiffness of the wrist may be expected for a few weeks in complicated cases; and in such injuries some thickening about the seat of the fracture will persist FRACTURE OF THE RADIUS. 127 for two or three months. Slight shortening of the radius, due to loss of tissue by crushing and absorption, occtirs in most cases, but the resulting inclination of the hand to the radial side in well-treated cases of average severity can usually be detected only by very close scrutiny. The statement of some authors that long-continued dis- ability of the wrist and fingers is to be expected is, I believe, untrue in the average case of fracture of the lower end of the radius; and is due to observation of cases improperly treated. The danger of many of the splints advocated for this frac- ture is due to the non-recognition by their respective inventors of the curved or arched shape of the palmar surface of the lower third of the radius. The dorsum of the bone when covered with the tendons is straight, but the palmar surface is curved. It is readily understood, therefore, that the appli- cation of any straight splint (such as that called Bond's splint) to the palmar surface of the broken radius has a ten- dency to displace the lower fragment upward again, as soon as the bandage which retains the splint in position is applied. A straight splint may, however, be applied with propriety to the back of the wrist. I have used with satisfaction two or three pieces of whalebone held in position by a strip of ad- hesive plaster. Any rigid article, such as a piece of steel or wood, half an inch wide and five or six inches long, will an- swer the purpose. The truth is, however, that in a person of ordinary intelligence, who will avoid subjecting the bone to severe strains, there is no need of any rigid splint or support. Exceptions to this rule may perhaps be found in the case of refractoiy children and of ignorant or stubborn adults. The fact that these persons are liable to itse the hand at an early period, and in such a way as to cause a slight risk of displace- ment of the fragments, is evidence of the simplicity and pain- lessness of the injury and of the satisfactory manner in which union takes place, if reduction has been properly effected. That the treatment of the fracture is misunderstood by 128 THE MODERN TREATMENT OF FRACTURES. many practitioners is evident to me from the fact that I have repeatedly been obliged to refracture and reduce partially united fractures of this kind after several weeks' treatment in splints. In a number of instances an exceedingly good splint had been applied though the fracture had not been re- duced. A quite recent experience of this kind in which I refractured the bone eight weeks after the injury has forcibly brought the subject to my mind. Osteotomy, for the purpose of correcting such deformities, is seldom if ever required. I have known a deformed fracture of the radius to be broken for re-adjustment five and a half months after the injury. To do this requires considerable power, but it can generally be accomplished by forcibly bend- ing the bone across the operator's knee. A few years ago, while holding a position as out-patient surgeon in one of the hospitals of this city, I had occasion to treat, within less than three months, forty-two cases of fracture of the lower end of the radius. Some of these were treated with the molded metal splint recommended by Dr. Levis: others were dressed with a straight dorsal splint of wood: while in some the wrist was immobilized by means of a single strip of steel, or two or three strips of whalebone applied to the dorsum of the joint by means of adhesive plaster encircling the limb. A few were treated during a part of the time by applying to the palmar surface a curved steel strip, such as the " busk-bones " of corsets. It will be observed that six cases came to me with the lower fragment still unreduced, although in each instance a splint had been applied. In five of these cases Levis' molded splint, the best splint manufactured for this fracture, had been applied. This fact proves my assertion that it is the cus- tom of many to apply a splint, and often a very proper one. without reducing the fracture. It is this belief in the thera- peutic value of the splint which causes many physicians to have bad results in the treatment of this fracture. If the FKACTURE OF THE EADIUS. 129 profession were made to understand that no splint can be con- structed which will take the place of reduction, better results would be more frequent. . It is interesting to note that all, or nearly all, of the cases tabulated had been originally dressed by the resident physi- cians belonging to the wards of the hospital. It is also worthy of notice that these residents belonged to a hospital with which at the time were connected two surgeons who have written and done most effective work in teaching the pathol- ogy and proper treatment of this particular injury. The table is instructive, I think, as showing that perfect motion without special deformity was obtained in almost every case. It must be remembered, in addition, that these records were made a few weeks after the receipt of the injury, and that the results, so good at that time, probably became more perfect after the lapse of a longer period. At the present time I should be inclined in nearly all cases to treat the fracture without using any splint at all; or, at most, I should employ only a thin strip of steel or zinc, or a couple of pieces of whalebone, six inches long, applied to the dorsum of the wrist, and held in place by strips of adhesive plaster. When the tabulated cases were treated the time during which restrictive dressings were continued was probably less than would be advocated by most surgeons. I have seen no reason to alter my practice in this regard, except perhaps to shorten the time still more. I am now convinced that a roller bandage or a strip of adhesive plaster applied to the wrist in a circular manner is all that is necessary, except in unusually complicated fractures. All ordinary forms of splints should, as a rule, be discarded as useless, needless, or dangerous. The proper treatment of fracture of the lower end of the radius is reduction. Little else is required in the ordinary cases. XV. THE NECESSITY OF FORCE EN THE TREATMENT OF COLLES' FRACTURE OF THE RADIUS. Tms paper is presented to call attention to the fact that it usually requires a great deal of force to fully reduce the ordinary fracture of the lower end of the radius. Much has been written on the pathology and treatment of this injury, but sufficient stress has not been laid on the need of force — great f orce — to fully replace the lower fragment. This frag- ment is driven backward by the impact of the hand against the ground when the patient falls and sustains the injury. The displacement is nearly always accompanied by entangle- ment of the two fragments with each other, or by impac- tion of the dorsal edge of the upper fragment and the cancel- lated tissue of the lower fragment. Very generally the physician or surgeon who sees the case (and I include the Avord surgeon advisedly) fails to apply sufficient power, while setting the fracture, to disentangle the pieces of bone, and the backward displacement is not overcome. As a result the so- called silver-fork deformity is only partially corrected or not corrected at all, and the patient has a prolonged convales- cence with neuralgic pain, oedema, and stiffening of the fin- gers. If, on the other hand, the amount of power applied is great enough, the lower fragment will be detached from the upper and driven forward into its place, so as to restore the concavity of the palmar surface of the lower end of the radius and make the dorsal surface practically level. Then there will be little pain or discomfort, and no marked or pro- longed oedema or stiffness of the fingers. It would, perhaps, be well if fractures of the lower end of FRACTURE OF THE RADIUS. 131 the radius were treated by laving the patient's arm flat on the table and, after covering the dorsal surface with a folded towel, striking a good blow on the back of the wrist with a heavy wooden mallet. This would compel the practitioner to employ force enough to drive the lower piece of bone into position, which the average man seems afraid to do with his hands. These statements are made — in fact this paper has been prepared — because last month I had under my care at the same time two cases in which I was obliged to refracture a united but unreduced Colles' fracture of the radius. One was a woman who had broken the bone six weeks before, and had gone for treatment to the dispensary of one of the largest Philadelphia hospitals; the other was a woman who had been treated for nearly four weeks in the wards of one of the college hospitals of this city. In neither case had the fracture been reduced, and the deformity of the wrist and stiffness of the fingers were such as would be expected under such circumstances. By bending tbe bone across my knee I ruptured the bone of union, put the fragments in better po- sition, and have had quite satisfactory convalescence. I do not want to be understood as saying that I advocate a blow from a wooden mallet as the best method of reducing these fractures; but I use the illustration to show that it re- quires unusual force to accomplish the necessary replacement of the fragments. The physician has the needed strength in his own hands, but ordinarily he does not use it. Sudden flexion of the wrist, with great pressure upon the back of the lower fragment, will nearly always crush the piece of bone into place. This gives great pain, but anaesthesia may be em- ployed if preferred. The setting is done so suddenly that usually no ether is necessary. AVhen the prominence on the back of the arm, caused by the backward displacement of the lower fragment, does not disappear, the effort at reduction must be repeated. On rare occasions it may be well to bend 132 THE MODERN TREATMENT OF FRACTURES. the hand and lower fragment strongly backward, to disen- tangle the fragments, before making flexion and pressure to push the basal fragment forward. As soon as all practitioners adopt these forcible manipu- lations to set the fracture and abandon the dangerous Bond's splint, little will be heard of unsatisfactory results and long periods of disability in Colles' fracture. The reduction, which is the essential of treatment, is the step usually neg- lected. A straight splint on the back of the wrist, a molded splint fitting the palmar surface, or a wristlet of adhesive plaster applied around the lower end of the radius is the proper treatment after reduction. The reduction must be accomplished by force, except in the few cases where there is no displacement. XVI. FRACTURE OF THE LOWER END OF THE RADIUS WITH FORWARD DISPLACEMENT. My object this evening is not so much to discuss the pa- thology and treatment of this injury as to show some casts and photographs of the lesion, which. I purpose placing in the Mutter Museum, and to exhibit to the Fellows three interest- ing specimens already belonging to that valuable collection. A recent study * of this fracture has convinced me that its occurrence is not very rare, and that its recognition is not gen- Fig. 22. Probable Epiphyseal Fracture. (Mutter Museum.) eral. Within a few years I have seen four cases, all of which had previously been under professional care. Yet in none of them had the deformity been reduced; and in the history of three, if not of all four, it was evident that the true character of the injury had not been suspected. Well known is the widespread ignorance in the profession of the necessity for very forcible primary reduction of the inferior fragment in the usual fracture of the lower end of the radius with backward displacement. It seems as if there * " Transactions American Surgical Association," 1896. 134 THE MODERN TREATMENT OF FRACTURES. exists an even greater degree of ignorance or forgetfulness of the possibility of the displacement occasionally being for- ward instead of backward. If the possibility of snch displace- ment is generally recollected, it must be that the necessity for forcible primary reduction is not appreciated, for in the cases seen by me and in the collection of photographs here exhibited the deformity had not been reduced. This lesion, sometimes termed " Smith's fracture of the radius." at otber times called " Reversed Colles"s fracture " Fig. 23. Fracture with Probable Stripping up of Periosteum, i Mutter Museum.) may be produced, if my experimental and clinical studies are correctly interpreted, in three ways: 1. Tearing off of the lower end by a cross-breaking strain exerted through the posterior Ligaments during extreme flex- ion, when the force is applied to the back of the hand in front of the anterior surface of the radius. 2. Crushing of the anterior petition of the bone between the wrist-bones and the shaft, or mutual penetration of the diaphyseal and epiphyseal portions. 3. Rupture of the bony tissue of the weakest point by decomposition of the force to which the limb is subjected. It is possible that there may be at times a combination of more than one method. In a recent case, treated by my colleague. Dr. 31. J. Stern, at the Polyclinic Hospital, the character of which was proved by an immediate skiagraph taken by Dr. Stem, the boy seemed to have received the blow on the palmar surface RADIAL FRACTURE DISPLACED FORWARDS. 135 Fig. 24. Skiagraph of Dr. Stern's Case before Reduction. 136 THE MODERN TREATMENT OF FRACTURES. of the ulnar side of the hand. He was getting upon a horse and fell over on the opposite side of the animal. When examined shortly afterwards the damage done to the skin of the hand by impact on the ground was shown on the palm of the hypothenar eminence and on the ulnar border of the hand. The displacement forwards, of the lower fragment and the over-riding of the upper fragment upon its dorsum are beautifully shown in the skiagraph, which Dr. Stern has brought here to-night. Forcible reduction was at once per- Fig. 2.3. Oblique Fracture. (Museum, Trinity College, Dublin.) formed and the boy now has an excellent arm with little or no deformity. It can be understood, I think, how such a blow might tend to displace the radial base forward rather than backward. A fall directly upon the whole palm usually tends to forcibly extend the wrist-joint and is one of the methods of producing the classic fracture with backward displacement. This blow coming on the ulnar portion of the hand might readily, it seems to me, drive the lower fragment forward without ex- tending the wrist-joint. The deformity in this fracture is quite different from that in the ordinary injury with backward displacement. The degree naturally varies with the amount of displacement and the obliquity or transverse character of the line of fracture. It may be almost absent or be very great. Sometimes the dis- RADIAL FRACTURE DISPLACED FORWARDS. 137 placement is almost entirely forward, at other times it is comparatively slight forward, but very marked in a radial direction. The photographs here shown illustrate these varia- tions very well. The Edinburgh and ISTew York specimens Fig. 27. Two Views of Fracture with great forward displacement. (Museum Royal College of Surgeons, Edinburgh.) have marked forward displacement; the specimens from the Royal College of Surgeons in Ireland marked lateral displace- ment towards the radial aspect of the forearm. The deform- ity of the forearm and wrist is characteristic in instances where 138 THE MODERN TREATMENT OF FRACTURES. the carpal fragment is much displaced forward. An elevation is seen across the hack of the forearm, running obliquely up- ward from the ulnar to the radial side. The ulnar portion of this elevation is the more prominent, and is made by the head of the ulna, which was left behind when the carpal fragment of the radius Avith the attached hand was carried forward by the injury. On the radial side of the limb the elevation is further from the hand and is less prominent. It is due to the lower end of the upper fragment of the radius. This dorsal prominence is quite different in appearance from the hump on the radial side of the dorsum seen in the Fig. 2i Two views of specimen in Museum of St. Thomas's Hospital, London. fracture of the lower end of the radius with backward displace- ment of the carpal piece. In the latter ease the elevation is great on the radial half of the limb, and the surgeon's finger carried along the back of the shaft of the radius can readily feel the ledge of bone corresponding to the dorsal surface of the lower fragment. The ulna makes little or no prominence on the back of the forearm in the classic fracture, though in both forms it is apt to be prominent on the ulnar edge of the limb, because the outward displacement, common in both in- stances, carries the hand away from the head of the ulna. In the fracture under consideration the surface slants down- RADIAL FRACTURE DISPLACED FORWARDS. 139 ward from the dorsal elevation toward the back of the hand, whose plane is at a lower level than that of the forearm, but more or less parallel to it. This slant in the surface below the dorsal elevation causes somewhat the appearance of a furrow across the forearm, which is deeper just below the head of the ulna. Pressure with the fingers will make this hollow more evident, and show that the lower end or base of the radius occupies a position more anterior than normal. This sulcus is, as the elevation, a little further from the hand on the radial side. The lowe^* fragment will usually be felt &s a hard mass under the flexor tendons, evidently not pertaining to the ulna. Lateral deviation towards the radial side of the forearm is probably usual. This specimen, from the Mutter Museum, is an extreme example of this lateral deformity due to a crushing or absorption at an oblique line of fracture. This tendency to lateral displacement causes the radial styloid to ascend towards the elbow in this fracture as in that with backward displacement of the lower fragment. The treatment is simple if the fracture be only recognized, — immediate and forcible reduction to restore the contour of the lower portion of the radius, followed by the application of a molded splint of metal or gypsum to the palmar surface or a straight splint to the dorsum. There is little or no danger of muscular displacement. The displacement is due, as in the classic fracture, to the vulnerating violence, not to muscular action. It is possible that the eoneave shape of the palmar siirface of the lower end of the radius and the great strength of the flexor muscles may sometimes lead to displacement from muscular action. This is practically never present in the common fracture with posterior displacement of the lower fragment. The so-called Bond's splint often injudiciously employed in the classic fracture is equally undesirable here. XVII. A CASE OF FRACTURE OF THE LOWER END OF THE RADIUS WITH ANTERIOR DISPLACEMENT OF THE CAR- PAL FRAGMENT. This injury is more frequent than is generally supposed. A recent investigation which I made has convinced me of the importance of the lesion. It is possible that a skiagraph of snch a fracture may interest other surgeons. A boy of about twelve years fell from a bicycle, injuring his wrist. He gave the injury no special attention, but at the end of about four weeks applied to Dr. It. Kindig for treat- ment. By Dr. Kindig he was referred to me because of the unusual deformity. It was evident from the appearance that there had been a fracture of the radius about an inch and a half above the wrist-joint and that the lower fragment was displaced anteriorly. Union was quite firm as would be ex- pected at the end of four weeks. The skiagraph taken before treatment shows the line of fracture, the forward displacement of the carpal fragment, and the callus deposited for the repair of the lesion. ■ I refractured the bone and put the fragments in proper posi- tion. There was a good deal of tendency to reproduction of the displacement, and I was obliged to resort to anterior and posterior straight splints to keep the fragments in proper posi- tion. I believe the tendency to repeated displacement was largely due to the fact that the fracture was farther from the wrist than is usual in fracture of the lower end of the radius. As a consequence, muscular action had more influence in pro- ducing displacement than is common when the fracture is nearer the joint. At the lower point the broken surfaces are 140 RADIAL FRACTURE DISPLACED FORWARDS. 141 more extensive because of the greater thickness of the bone, and therefore retain their position better when once adjusted. My ordinary treatment of fractures of the base of the radius Author's Case of Recent Fracture of the Lower End of the Radius Forward Displacement. by the metal splint of Levis or by a band of adhesive plaster around the wrist, was not sufficient to keep the fragments properly coapted. The skiagraph was taken with the radial side of the ami against the photographic plate. XVIII. FRACTURE OF THE LOWER EX.D OF THE RADIUS WITH DIS- PLACEMENT OF THE LOWER FRAGMENT FORWARDS.* This boy of fourteen years presents himself for treatment for pain in the left wrist, which followed shoveling snow. Inspection of the hand and wrist shows an unusual deformity, which consists in deviation of the hand to the radial side and the presence of an elevation on the palmar aspect above the base of the thumb. The boy says that last August a year, which is now eighteen months ago, he fell from a cherry tree and broke his left wrist. He was brought to town and taken to a hospital in the evening of the same day; there he was treated by manipulation of some sort and the application of a wooden splint to the palmar surface of the forearm. He wore the splint for about five weeks. He now has perfect use of the fingers and of the wrist-joint; but has a deformity, which makes it evident that there was a fracture of the radii;? with displacement of the lower fragment anteriorly, instead of backward as in the usual fracture at this point, and that the present deformity is the result of union with the fragments unreduced. Careful examination shows that the hand is displaced to the radial side, and thereby causes the head of the ulna to be prominent at the ulnar side of the wrist, though it does not project backward to any special degree. On the palmar sur- face at the lower end of the radius a mass of bone can be dis- tinctly felt lying beneath the flexor tendons. The edge of this bony mass, which is the cai*pal fragment, is situated about an inch above the base of the thenar eminence. The bulge * From the " International Clinics," 1897. KADIAL FRACTURE DISPLACED FORWARDS. 143 produced by tlie lower fragment is more clearly shown when the patient makes a fist, because then the flexors of the fingers are contracted and the muscular bellies at the wrist are drawn up the forearm and leave only tendons lying over the bony mass. This makes the outline of the bone more prominent. The lower end of the ulna is not involved in this mass of bone. The radius when grasped by the fingers antero-posteriorly at its lower end is much thicker than that in the normal arm, and the lateral width of the forearm just above the joint is increased. The radial styloid process is about three-eighths of an inch nearer the elbow on the injured side than in the right arm. Deep pressure gives an impression to the fingers Fracture of lower end of radius with forward and lateral displacement of lower fragment ; the lateral displacement very marked. (Cast from specimen in Dublin, Ireland.) that the fracture was oblique, the line running from the ulnar side of the radius upward and outward toward the radial side of the bone. When the palm of the hand is laid flat on a table, the front of the forearm lies closer to the table than in the normal arm. This is due, I think, to the fact that at the time of fracture the carpal fragment was rotated, so as to make the hand abnormally pronated. There is no special increase or diminution in either flexion or extension of the wrist-joint. The boy tells us that this deformity has existed without incon- venience since the time of the accident. I find, however, that he has a little pain in the wrist after using the hand for hard work, and it was this which brought him to the hospital for 144 THE MODERN TREATMENT OF FRACTURES. treatment. Here is a photograph jf a similar fracture in an adult. This injury is an unusual one and very apt to be overlooked, because the attention of surgeons has not been called to the condition as particularly as it ought to be. Fig. 32. Fracture of lower end of radius with moderate forward displacement (radial side). I showed here a couple of years ago a woman who had sustained this same fracture. It had evidently not been recog- nized, for the fragments, as in the case of this boy. had not been perfectly reduced. Here is a plaster cast (Figs. 32 and 33) of her hand and forearm, which shows a similar deform- ity to that exhibited by the boy. except that the hand is not Fig. 33. Fracture of the lower end of the radius with moderate forward displace- ment (ulnar side). deviated much to the radial side. This condition is due to the fact that the fracture was not as oblique as in the patient now before us. and that the displacement forward was very marked. This skiagraph shows the bony changes (Fig Very little study has been given to this fracture, and many men of large experience have apparently not seen it. Many KADIAL FRACTURE DISPLACED FORWARDS. 145 of the text-books refer to the possibility of the injury, but give no cases and refer to no specimens. At the meeting of the American Surgical Association a year ago I called attention to this subject, and in my paper recorded several cases of my own, together with a number collected from surgical literature. At that time I also made quite a search in museums for speci- mens of this fracture, and was surprised to find how many there were, though nearly all of them had no clinical histories attached to them. They were specimens of the fracture, united with deformity, which had been found in dissecting- rooms (Fig. 27). The illustrations now shown you give an idea of the characteristic appearance of some of these speci- Fig. 34. Dissected specimen in cabinet of New York hospital showing deformity in radius after fracture with forward displacement. mens (Fig. 34). E. W. Smith, in his book on " Fractures and Dislocations," published about fifty years ago, calls attention to this injury and gives an illustration of a plaster cast made from such a case. On account of Smith having called attention to the fracture, it is sometimes denominated " Smith's fracture of the radius." The usual fracture with backward displacement of the lower fragment was especially studied many years ago by Colles, and is often to this day called "Colles's fracture." The injury which you see in this boy is accordingly sometimes called a re- versed Colles's fracture. It is interesting to remember that the authors whose names have been attached to these injuries were both Irish surgeons living in Dublin. 146 THE MODERN" TREATMENT OF FRACTURES. There ought to be very little difficulty, I think, in recog- nizing the injury under consideration if the surgeon only re- members that it is a fracture of possible occurrence. The great frequency of the fracture with backward displacement of the lower fragment gives rise to careless diagnosis when injuries of the radius near the wrist-joint occur. The de- formity is cpiite different, and careful inspection ought to make the nature of the accident apparent (Fig. 25). The Fig. 35. Skiagraph showing bend at lower end of radius due to unreduced fracture with forward displacement. The prominence of the head of the ulna at the back of the wrist is well shown. ordinary fracture of the radial base occurs from blow- in which the force of the blow is received on the palm of the hand. It is probably that the opposite displacement is due to the application of force upon the back of the hand tend- ing to strongly flex the wrist. One of the cases of the injury which I have seen occurred in a man who fell while playing football with his hand and wrist doubled under him in a RADIAL FRACTURE DISPLACED FORWARDS. 147 position of flexion. In the other cases it was not perfectly clear in what manner the force had been applied. The late Mr. Callender of London reported a case some years ago in which fracture took place from galvanic stimula- tion of the muscles. In this instance the bone was apparently broken by forced flexion, clue to the violent contraction of the flexor muscles when the patient took hold of the handles of the galvanic machine and received the shock. Some experimental observations which I have made in the anatomical laboratory and a study of the reported cases lead me to believe that the fracture is caused in three ways. Some- times the lower end of the bone is torn oft' by a strain exerted through the posterior ligaments during extreme flexion, when the force is applied to the back of the hand. In other cases there may be a crushing of the anterior part of the base of the radius between the wrist-bones and the shaft, so that the lower fragment is forced forward; or the shaft of the bone and the base may be driven into each other by the force of the in- jury, causing a sort of mutual impaction. In a third series of cases the bony tissue of the radial base may give away at its weakest point by decomposition of the forces to which the bone is subjected. The symptoms of the lesion will depend somewhat upon the line of fracture, which may be oblique or transverse. There may be a great deal of anterior displacement, as in the woman whose plaster cast is shown you, with very little displacement to the radial side; or there may be, as in the present case, a great deal of displacement to the radial side, due to crushing of the tissue of the base of the radius, with very little anterior displacement. When the lateral displacement is great, the head of the ulna becomes markedly prominent at the ulnar border of the wrist; whereas if the displacement of the lower fragment forward is great, the head of the ulna makes a marked projection on the dorsum of the wrist. The appearance of the back and front of the wrist is very 148 THE MODERN TREATMENT OF FRACTURES. different from that which occurs in the ordinary fracture in this region, as will be seen by comparing the casts which I show yon: one is a case of an ordinary or classic fracture of the lower end of the radius, the other is the cast of the woman whom I presented at this clinic a couple of years ago. The same thing is evident if you look at this boy's wrist with care, though it is not marked as in the cast of the woman's hand, because, as I have said, the forward displacement is not so great. Here is an illustration of an experimental fracture in the cadaver which I made for the class here some years ago and Diagram of Deformity in Fracture wifh Forward Displacement Diagram of Deformity in Fracture with Backward Displacement Fig. 36. used for illustrating the deformity in the classic fracture with backward displacement. You will see in the fracture with the carpal fragment thrust forward an elevation running across the back of the forearm obliquely upward from the ulnar to the radial side. This elevation is more marked at the ulnar side of the arm, and is due to the lower end or head of the ulna, which is left behind, as it were, when the lower frag- ment of the radius with the hand attached to it is carried forward by the injury. This eminence on the back is quite different from the elevation on the radial side of the dorsum found in fracture of the lower end of the radius with back- ward displacement. In that lesion the elevation is greater on the radial half of the forearm, and you can feel with your RADIAL FRACTURE DISPLACED FORWARDS. 149 finger placed upon the back of the shaft of the radius the ele- vation corresponding to the dorsal surface of the lower frag- ment ; and the ulna has nothing to do with the prominence on the back of the forearm. In the fracture under consideration, the posterior surface of the forearm and wrist shows three planes, as it were, — the plane of the back of the forearm, followed by a second plane descending downward towards the back of the hand; and then the plane of the back of the hand, which is at a lower level than that of the forearm, but more or less parallel to it. This causes a sort of furrow below the dorsal elevation; but the dorsal elevation is not raised above the general level of the back of the forearm. It is caused by the lower fragment being thrust forward and leaving an abrupt termination to the plane of the back of the forearm. Pressure will make the hollow more evident, and show that the base of the radius is farther front than normal. In the classic fracture, however, the plane of the back of the forearm is altered by a mound or hump near the wrist-joint, and from the top of this eleva- tion there descends a plane corresponding with the back of the hand. The rude diagram which I make on the blackboard shows you the difference between the two injuries (Fig. 36). On the palmar surface of this boy's wrist you see a promi- nence which is quite different from that produced by the lower end of the upper fragment in the classic fracture. The former is nearer the wrist than the latter, and has its edge directed upward instead of downward towards the hand, as in the case when the prominence is due to the lower end of the upper fragment as it is in the usual fractiu-e. In this boy the position of the lower fragment is, as I have previously told you, well shown when the boy contracts the flexor muscles in bending his fingers, because the muscular bellies are then drawn upward and the tendons made more tense over the fragment. The normal curve of the anterior surface of the radius at 150 THE MODERN TREATMENT OF FRACTURES. its lower end disappears when the fragment attached to the carpus is thrown forward. There may, however, be made by this displacement a more marked cavity than usual in the normal bone, but it is farther away from the hand. The change in the length of the radius due to the shortening of the bone, caused by the impaction or crushing of the spongy tissue of the base or the displacement, makes the styloid proc- ess of the radius to be nearer the elbow than normal. This, of course, occurs also in fractures of the lower end of the Fig. 37. Outlines of both hands and wrists, showing on the left the elevation of the radial styloid and increased width of the wrist due to fracture. Taken with the palm laid on the paper and outlines traced with a pencil. radius with backward displacement. JSTormally, as you know, the styloid process of the radius is farther from the elbow than that of the ulna. You will notice in this boy's hand that there is an elevation — that is, a displacement to- ward the elbow — of the ulnar styloid of about three-eighths of an inch. You can estimate this quite well by placing both hands of the patient upon a. piece of paper laid upon the table, with the palmar surface next the paper (Fig. 37). If you make an outline of the hand and wrist with a pen- RADIAL FRACTURE DISPLACED FORWARDS. 151 cil and then drop a perpendicular line from the styloid processes by means of a rule laid against them, you can mark their position on the rude outline which you have drawn. I show you this in the diagrams on this paper. An increase in abduction is also permitted after fractures of the radial base, due to the change in the plane of the articular surface caused by the displacement. This occurs in fractures with forward displacement as well as in those with backward displacement. The differential diagnosis between fractures of this sort and dislocation of the wrist is to be made by a study of the deformity and the manner in which dislocations are reducible with a distinct snap. This fracture, as well as the one with displacement backward, looks somewhat like a dislocation, and requires considerable force to push the fragments into proper position. There is, however, a grating sound when the lower fragment is forced into place different from the snap elicited when the dislocation is reduced. The preternatural mobility and crepitus which are found in most fractures may be absent in this injury, because the fragments are impacted. When the fragments have been put in proper position by the application of considerable force they usually remain in place, because the broad surfaces of contact prevent recurrence of the deformity. This is due to the fact that the fracture takes place through the broad- .ened portion of the bone which constitutes the base. The treatment of a recent fracture of this sort is immediate and complete reduction of the fragments so as to restore the normal outline of the bone. To do this the surgeon should grasp the metacarpus of the patient with one hand and the lower part of the forearm with the other hand, and make strong pressure with his thumb on the carpal fragment so as to force it into proper position in relation to the shaft. It is well to have the patient's hand with the palm upward, so that the surgeon's thumb can be readily placed upon the lower fragment just above the ball of the patient's thumb. 152 THE MODERN TREATMENT OE FBACTTJBES. Traction and counter-traction with sudden extension of the hand backward at the wrist with pressure on the lower fragment will usually reduce the fracture. A light splint of wood an inch wide and six inches long applied along the back Outline of normal baud and on paper. Fig. 38. rrist in full abduction. Taken with palm of the wrist so as to prevent motion at the wrist-joint makes a very satisfactory retentive dressing. If the surgeon prefer he may apply a molded metal splint, or a splint made of plas- ter of Paris, to the palmar aspect of the forearm and hand. This splint must, of course, correspond with the normal curva- ture of the lower portion of the radius on its palmar surface. If there is not much tendency to displacement and the pa- tient can be relied upon to put no strain upon the hand and wrist, a rigid splint may be dispensed with, and the motions of the joint be restricted by a simple wristlet or band of ad- hesive plaster applied around the wrist-joint, in the manner which I have so often shown you in the treatment of the ordinary fracture of the lower end of the radius. In the present case no treatment is indicated, for the boy has perfect motion and is not particularly annoyed by the deformity due to non-reduction of the fracture at the time of the accident. Osteotomv could be done, but the result would RADIAL FRACTURE DISPLACED FORWARDS. 153 probably give Mm no better use of the hand; and the slight improvement in position would scarcely be valuable enough to justify the operation. The slight pain he feels when he uses the hand in heavy work is probably due to the disad- Outline of injured hand and wrist in full abduction. Taken with palm on paper. The great increase in abduction due to change in lower end of radius is evident when this diagram is compared with its com- panion. vantageous manner in which the muscles act on account of the abnormality in the shape of the bone. XIX. THE TREATMENT OF FRACTURES OF THE LOWER PART OF THE TIBIA AND FIBULA.* Withes the last few days there have been admitted to the hospital a considerable number of fractures of the lower extremity, and it will be interesting, perhaps, to show you some of them, as they illustrate several classes of fractures in this region. The cases presented are good illustrations of the forms of fracture of one or other bone of the leg. In two of them the lower portion of the fibula is broken with no injury to the tibia. One is an open or compound fracture of both bones due to the passage of a heavy cart across the front of the leg. The others are closed or so-called simple fractures in the ankle region, interesting because there is a marked tendency to displacement. The fifth patient is a woman whom you saw a few days ago operated upon because of the great displacement of the fragments due to contraction of the muscles of the calf. In her case the fracture involved the lower end of the fibula and the outer portion of the lower end of the tibia without involving the internal malleolus. These eases are brought before you to illustrate the vari- ous methods which are adopted to treat, successfully these common injuries. The fibular fractures unaccompanied by fractures of the tibia require very little special treatment, since the tendency to deformity is not great. I generally keep them in an ordinary fracture box or tied up in a pillow with- out a fracture box for two or three days and then apply an ambulant splint of plaster of Paris and discharge the patient on crutches. They are permitted to dispense with the * From the "International Clinics," 1897. 154 FRACTURES OF TIBIA AND FIBULA. 155 crutches and walk on the splint with the support of a cane in a very few days. One of these cases, you see, has the ambulant splint already applied, and is now a dispensary pa- tient. In applying the ambulant splint of plaster of Paris it is important to make it strong enough to bear the weight of the patient in walking. Hence you must have the upper part of the splint applied to the head of the tibia and the condyles of the femur in such a way that the patient's weight comes upon the plaster of Paris at its upper portion and is supported by the stiff splint which extends below the sole of the foot. In this manner the foot and leg hang as it were in- side the splint, which acts a good deal as does an artificial leg within which the stump is placed. In order to prevent the weight coming upon the fragments when the patient walks, an ambulant splint should be applied with a considerable amount of cotton put under the sole of the foot. This makes the splint a little longer than the patient's limb and allows the injured bones to be saved from contact with the sole of the splint during walking. Fractures of both tibia and fibula near the ankle are fre- quent and often serious injuries. Both bones may be broken without any complication or there may be a good deal of comminution, with fracture of one or both malleoli. The lower end of the tibia is seldom broken without the fibula being similarly injured, though the fracture of the smaller bone will probably be at a higher level. The woman before you had such a fracture, due to a fall which probably caused great eversion of the foot. The fibula was broken an inch or so above the malleolus, and the outer portion of the tibia split off by a line of fracture running from the interior of the ankle-joint upward and outward and obliquely backward. There was no fracture of the malleolus. The obliquity of the line of fracture and the impact of the blow which caused the injur}' drove the foot outward, causing great eversion and nearly thrust the tibial malleolus through the skin on the 156 THE MODERN TREATMENT OF FRACTURES. inner side of the ankle. \Ve have attempted to keep the fragments in place by putting the limb in a fracture-box and trying proper padding. It is impossible, however, to reduce the fracture, because of tbe obliquity of the fracture permit- ting tbe calf-muscles to cause overriding and backward dis- placement, as "well as lateral deformity. Tbe deformity can be best corrected, in my opinion, by subcutaneous section of the tendo Achillis, as in the ease operated upon a few days ago. This will relieve the muscular tension that displaces the lower fragment. Tbe woman some time ago received a similar fracture of the other leg, and I show you how greatly it is now deformed because the fragments were never properly reduced. You see how markedly the heel projects backward, and how the internal malleolus projects at the in- ner side of the leg because of tbe manner in which the foot was allowed to remain in the abnormal position caused by the fracture. This deformity makes her lame. It is curious that the woman should now have received a similar fracture of the other leg. I shall, therefore, have the tendon cut by the resident surgeon; and, now that he has done it, you see how easy it is to put the foot in the proper position and re- duce the deformity at the seat of fracture. The other woman had this operation done upon her a few days ago, and has, as you see, a perfectly symmetrical pair of feet and ankles. The tenotomy wound is closed with a little gauze held in place by collodion, and a plaster of Paris dressing is now ap- plied from the toes to a short distance above the knee. Tbis puts the parts at rest, and there is no tendency for displace- ment to occur. The tendo Achillis will soon unite and her muscular power will be as great as ever. This method of treating this fracture is a very valuable one, which is often forgotten or overlooked. Its value I have frequently prove! to my own satisfaction. It is interesting that two patients with a similar injury FRACTURES OF TIBIA AND FIBULA. 157 should be admitted within a few days of each other, and it is especially interesting that the patient just operated upon should show the result of a similar lesion of the other leg im- properly treated. This man has a fracture of both tibia and fibula, a short distance above the ankle, in which there is a great tendency for the lower fragment to project forward. He was treated for a few days in a fracture box which was suspended from a gallows erected over the bed. The fracture box is a conven- ient method of dressing fractures of the tibia and fibula, since the degree of pressure and the position of the padding can be changed in accordance with the tendency to displacement and the amount of swelling. It is always better to suspend a fracture box, because then the patient can move about in bed without displacing the fracture. The height at which the box is suspended is easily altered by having a slide of some sort upon the suspending rope. It often rests the patient very much to have the fracture box lowered or raised, since this enables him to bend his knee at a different angle, and therefore gives relief from the cramped position necessitated if the fracture box is lying upon the bed. You have seen in the wards how easy it is for a patient, with a fractured leg thus suspended in a fracture box, to move his hips about from one portion of the bed to the other, and with what ease the nurses can use the bedpan or change the sheets. After this fracture was treated by a fracture box for a few days the regular plaster of Paris splint was applied and cut down the front as soon as it was hardened. "We accomplish this by laying a long strip or tape of lead upon the front of the leg before the plaster of Paris bandage is applied. As soon as the plaster is hard a sharp knife is used to divide the plaster over the lead strip, which prevents the point of the knife cut- ting the patient. The lead is so soft that the point of the knife is not damaged. The splint was opened, as stated, and has been repeatedly removed and reapplied so that the pro- 158 THE MODERN TREATMENT OF FRACTURES. jection forward of the lower fragment could be watched and corrected. By elevating the heel, by putting cotton .into the splint at the place where the heel is to rest, the resident surgeon has been able to overcome the tendency to displacement. A per- manent plaster of Paris splint will now be applied and will not be cut, since the bones have shown a tendency to remain in proper position. Before applying a plaster of Paris bandage it is well to cover the limb with a bandage of flannel or lint, which prevents the skin being made uncomfortable by the plaster of Paris becoming entangled in the hairs or from un- due pressure. A very nice method of accomplishing this is to use a long stocking, such as is worn by women, which can be drawn over the leg, and fits more neatly and smoothly than any other bandage. A plaster of Paris splint is then made- of the stocking. I seldom use fracture boxes for more than a few days, since the plaster of Paris splints, or, indeed, any plastic splints, are much lighter, and are more convenient when the swelling has diminished and the tendency to displacement has been re- lieved. An ambulant splint is hardly proper for this patient, be- cause there has been such a marked tendency to overriding. In a few days, however, he can get out of bed and go on crutches, if he is careful not to put the foot to the ground. In other words, he can be allowed to walk about with crutches, but not with a cane. I fear that the ambulant splint would be likely to promote displacement. The advantages of having patients with fracture of the leg out of bed early are the improved circulation of the parts, which is gained by a nor- mal position of the limb, and the shortening of the period of confinement to the bed, which interferes with the occupation of the patient and his comfort. The last case is one of open fracture of the tibia and fibula, due to the passage of a wagon-wheel over the limb. Such FRACTURES OF TIBIA AND FIBULA. 159 fractures are infected, and are much more serious than closed fractures. The word " compound," which is applied to open fractures, is an unsatisfactory term, since it does not explain its own meaning. The term " simple," applied to fractures not exposed to the air by a wound, is equally unscientific and objectionable. To call one an " open " and the other a " closed " fracture at once signifies the condition present. It is difficult to get rid of the terms " simple " and " compound," however, which have been so long used by English-speaking surgeons. Surgeons of other nations do not use these terms. In order to make this open fracture aseptic I shall etherize the patient, lay open the wound freely, turn out the clots, sterilize the parts with corrosive sublimate solution, wire the fragments together after having drilled a hole through the upper and lower piece of bone. A couple of drainage tubes will be inserted and the wound dressed with sterilized gauze. Over the whole is applied a plaster of Paris splint. This will not be removed unless pain or rise of temperature indicates that the wound at the seat of fracture is not running an asep- tic course. In many fractures treated in this way the plaster of Paris splint need not be removed for several weeks. Where there is a great deal of comminution as well as an opening leading to the fracture, as in this case, it is not unlikely that the attempt at sterilization will fail, and that it may be neces- sary to open the splint, to give exit to pus and to allow thor- ough and frequent irrigation of the wound. The patient was told before etherization that it was quite possible that the leg would have to be amputated because of the severe crush- ing injury. It seems, however, that it may be saved, since both the anterior and posterior tibial arteries can be felt beat- ing at tbe ankle. INDEX. Advances, recent, 31 Advantages of exploratory incision, 4 refracture, 63 Ambulant Splints, 31, 155 Anaesthesia, 14 Anchylosis, 5, 24 Anchylosis of elbow, 78 Angle of humerus and ulna, 79, 97 Arthrotomy in dislocations, 7 B Bandage, primary, 3! Cranium, fractures of, 65 syllabus of treatment, 76 D Deformity, in fractures of radius, 148, 150 prevention of, 13 relief of, 44 Diagnosis, mistaken, 13 Dislocations, exploratory incision in, 2 Doctrine, false, in treatment, 23 Elbow, extended, in fractures of humerus, 78, 90, 101 Exploratory incision, in closed frac- tures, 2, 78, 88 advantages of, 4 in dislocations, 6 advantages of, 7 Extremities, fractures of, 13, 31, 45 False doctrine in treatment, 23 Fat embolism, 5 Fibula, fractures of, 154 Fixation by nailing, 82 Flexion, acute, in condyloid frac- tures of humerus, 91 Force in treatment of fractures of radius, 130 Fracture box, 157 Fracture nails, 11, 87 Fractures, closed, exploratory in- cision in, 2 condyloid, of humerus, 78 greenstick, 15 impacted, 16 of clavicle, 27 cranium, 65 extremities, prevention of deformity in, 13 humerus, 78, 92, 96 nose, 26 radius, 92, 96, 105, 118 forty-three cases, 121 ignorance regarding, 118 necessity of force, 130 needlessness of splints, 124 osteotomy in, 116 refracture in, 128 with forward dis- placement, 133,140, 142 tibia and fibula, 154 recent advances in treatment ment of, 31 simplicity in treatment, 34 subcutaneous nailing in, 10, 78 with displacement, 10 Greenstick fractures, 15 162 Hammer forceps, 87 Humerus, condyloid fractures of, 78, 92, 96 Ignorance regarding fracture of radius, 118 Incision, exploratory, 2, 78, 88 Impacted fractures, 16 Lead water and laudanum, harmful effect of, 93 Levis's extension plate, 53 M Motion, passive, 24, 112 N Nailing, subcutaneous, in fractures, 10, 78, 82 Nails, fracture, 87 Necessity of force in fractures of radius, 130 Needlessness of splints in fractures of radius, 124 R Radius, fractures of, 92, 96, 105, 118, 133, 140, 142 forty-three cases, 121 ignorance re- garding, 118 necessity of force 130 needlessness o f splints, 124 osteotomy in, 116 refracturein, 128 with forward dis- placement, 133, 140, 142 Recent advances, 31 Reduction of fractures, tenotomy in, 20 Refracture, 33, 44, 63, 128 results of, 62 S Simplicity in treatment, 34 Skiagraphs, 88 Skiagraphy in dislocations, 8 Splints, molded, 17, 39 needlessness of, 124 Subcutaneous nailing, 10, 78, 82 tenotomy, 20, 32 Syllabus of treatment of fractures of cranium, 76 Osteotomy, 128 Passive motion, 24, 112 Prevention of deformity in fractures, 13 Tenotomy, subcutaneous, 20 Tibia, fractures of, 154 Treatment, simplicity in, 34 Trephining, 66, 76 mortality of, 66 Vicious union, 6 OCT 28 1899