i--* > T--'--^- CX' prances CS. $Bm, 1^. §♦ "■^^P^, ,-.,,-. ;^ PAY LABORATORY '■::iLZR BLDG. w1L:3 BLDG. aLIFORNIA ^j Byo^j5yn:jgyiujgygygynynj:cyr Presented hij Frances Leex, D. 0. COLLEGE OF OSTEOPATHIC PHYSICIANS AND SURGEONS • LOS ANGELES, CALIFORNIA ___t . EXCLL ^ ..,..i..ATORy sum. .7/lLEBBLDG. LOS AKuii.Lii.o, CALIFORNIA $vancm m. gem, pi. §, EXCLUSiVJ ^^ Iv AY LABORATORY SUITE 620 DA^.i-D^rV/ILER BLDG. LOS ANGELES, CALIFORNIA INJURIES 6P DISEASES OF THE BONES AND JOINTS INJURIES 6? DISEASES OF THE BONES AND JOINTS THEIR DIFFERENTIAL DIAGNOSIS BY MEANS OF THE ROENTGEN RAYS BY FREDERICK H. BAETJER, M.D. Associate Professor of Roentgenology, Johns Hopkins University; Roentgenologist, Johns Hopkins Hospital AND CHARLES A. WATERS, M.D. Instructor in Roentgenology, Johns Hopkins University; Assistant Roentgenologist, Johns Hopkins Hospital ILLUSTRATED WITH 332 ROENTGENOGRAMS AND ONE LINE DRAWING NEW YORK PAUL B. HOEBER 192 1 Copyright, 192 i By PAUL B. HOEBER All Rights Reserved Published, March 1921 Printed in the United States of America To William Stewart Halsted Dear Dr. Halsted, Tour l^nd consent to accept the dedication of this hoo\ has brought to a happy conclusion our labors of the past year. Tour sympathy and encouragement have been a constant stimulus in the study of the many problems which have confronted us. We offer to you this, our first boo\, as a to\en of the esteem and gratitude in which we hold you as one who has ever represented, not only to us but to the profession at large, the best ideals in surgery. Ver}' sincerely yours, F. H. Baetjer C. A. Waters February 28, 1921. PREFACE THE TECHNICAL side of roentgenology has been so ably described by various authors that mention of it is mere repetition, therefore, we have in this book, confined ourselves to the study of the finished product — the plate. Our object then, is to show that roentgenology is not a picture process, but a medical procedure based upon careful analysis and logical deductions from the shadows observed upon a plate and the translation of these shadows into pathological terms. The constituent parts of the normal bones and their functions have been discussed; and with these as a basis, the lesions have been studied and correlated with the gross pathological findings of the operating and autopsy rooms. Age and sex play such an important role in the production, character and situation of the lesion that we have linked them up with the .\-ray plate in arriving at a diagnostic conckision. Inasmuch as the pathological findings and classifications in certain types of bone and joint lesions are not yet thoroughly established, we may state that in the same way our interpreta- tions of the -V-ray shadows of these lesions also may be subject to revision in the light of further pathological investigations. No attempt has been made to give a bibliography, as this book is the result of our observations in theclinicof the Johns Hopkins Hospital. In this connection we wish to express our appreciation for the assistance given us by the x-ray Staff of the Johns Hopkins Hospital. vii 22837 VIII PREFACE In conclusion our thanks are also due to Mr. Paul B. Hoeber and his editorial staff for their painstaking care and efficient cooperation in the preparation of this volume. F. H. B. C. A. W. Februan,' 28, 1921. CONTENTS Chapter Page I Introduction ^ II. Normal Bones 13 The Periosteum, The Cortex, The Medullary Canal, The Nutrient Foramen, Cartilage, Joints, Growth, Joint Lesions, Eflect of Sex. III. Epiphyses 33 Scapula, Clavicle, Humerus, Radius, Olecranon, Carpal Bones, Pha- langes, Pubis and Ischium, Femur, Patella, Tibia and Fibula, Vertebrae. IV. Fractures of the Upper Extremities 47 Elements Affecting Fractures— Muscular Tension, Age and Sex, Occu- pation, Condition of Soft Tissues, Bone Atrophy, Formation of Callus. Fractures from Pathological Causes, Fractures Classified According to Age— The Skull, Facial Bones, Mandible, Clavicle, Scapula, Humerus, Forearm, Wrist, Hand, Ribs, Sternum, Pelvis. V. Fractures of the Lower Extremities 99 Femur, Patella, Tibia and Fibula, Bones of the Foot, Astragalus, Os Calcis, Scaphoid, Cuboid and Cuneiforms, Metatarsal Bones, Phalanges, Sesamoids, Bone Splints. VI. Congenital Dislocations 133 Congenital Dislocations of tiie Hip, Dislocations of the Shoulder Joint, Abnormalities in the Development of Epiphyses. VII. Acquired Dislocations 145 Shoulder, Elbow, Ulna and Radius, Wrist, Hand, Pelvic Bones, Hip, Patella, Knee, Tibia, Fibuhu VIII. Bone Infections 1^9 Osteomyelitis — ^Tuberculosis, Lues. Typhoid, Actinomycosis, Raynaud's Disease, Leprosy, Coccidoidal Granuloma, Mineral Poisoning, Special Infections. IX. Joint Lesions in Children 183 Rickets, Congenital Lues, Scurvy, Tuberculosis, Acute Epiphysitis — Non-tuberculous, Perthes's Disease or Juvenile Deforming Osteochond- ritis. X. Joint Lesions in Adults 205 Changes Indicating an Arthritic Condition, Acute Polyarticular Rheumatism, Chronic Arthritis — ^Tuberculosis, Caries Sicca, Luetic Arthritis, Atrophic, Hypertrophic Arthritis. Gonorrheal Arthritis, Arthritic Changes due to Age, Arthritis in the Spine, Villous Arthritis, Non-arthritic Joint Lesions — Gout, Charcot Joint, Syringo- myelia. Hemophilia, Arthritic Changes in Ligaments. IX X CONTENTS Chapter Page XI. Bone Tumors 241 -Method of Analyzing Bone Tumors, Carcinoma, Hypernephroma, Round-cell Sarcoma, Spindle-cell Sarcoma, Periosteal and Osteo- sarcoma, Myeloma, Giant-cell Sarcoma, Enchondroma or Osteochon- droma, Cyst, Osteoma, Fibroma, Myxoma, Hemangiomata, Ossifying Hematoma, Osteitis Fibrosa Cystica, Brain Tumors. XII. The Spine 289 Conformation, Divisions, Classification of Lesions, Diagnostic Aids, Arthritis, Infectious Arthritis, Acute Spondylitis Deformans, Charcot Spine and Syringomyelia, Tumors, Application of Classification Aids, Functional Conditions. XIII. Abnormalities 3^1 Extra Ribs, Non-union — Rudimentary Vertebrae, Abnormalities in the Lumbosacral Region, Clavicle, Scapula, Shoulder, Forearm, Hand, Femur, Tibia and Fibula, Ankle and Foot. XIV. Dystrophies 323 Acromegaly, Osteomalacia, Chondrodystrophies, Pulmonary Osteo- arthropathy, Osteogenesis Imperfecta, Dyschondroplasia. LIST OF ILLUSTRATIONS Figure Page 1. Section of normal radius and ulna with periosteum invisible. ... 14 2. Deposition of calcium salts in the periosteum of tiie tibia 15 3. Bony cortex of the tibia 16 4. Finely reticulated bony structure at the end of the bones 17 5. Medullary canal in the long bones 18 6. Joint cartilage IQ 7. Cartilage present in costal cartilage IQ 8. Tibia and fibula showing cortex, medullary canal, and cancellous bone 20 9. Flat bone with grooves for blood vessels visible 20 10. Carpal bone 20 1 1. Normal joint space filled with cartilage 22 12. Destruction of cartilage in joint space 22 13. Abnormally wide joint space at the knee in early childhood 23 14. Wide epiphyseal lines in the wrist of a child of seven • • 23 15. Narrowing of epiphyseal line of the first metacarpal in a child of eleven 24 16. Head of humerus of a new-born child 25 17. Atrophy in shoulder joint of a man of fifty 26 18. Position of the sacrum in the female pelvis 28 19. Position of the sacrum in the male pelvis 29 20. Ossification of epiphyseal centers in a child ot eigiiteen months. . 34 21. Ossification of epiphyseal centers in a child of three years 34 2:1. Delayed ossification of carpal bones in a child of ten years 34 23. Ossification of the epiphysis of the acromion in a child of fifteen years 34 24. Ossification of the head of the humerus in a child of four years. 35 25. Epiphysis at the elbow joint in the fourteenth year 3" 26. Lower epiphysis of the radius 37 27. Epiphysis of the olecranon at the fifteenth year }P 28. Centers of ossification of the carpal bones at four years 38 29. Centers of ossification of the carpal bones at seven years 38 30. Centers of ossification of the carpal bones at eleven years 38 31. Pubis and ischium at five years 39 32. Epiphysis of the greater trochanter at nine years 4^^ 33. Epiphysis of the lower end of the femur in child under six months 4 1 34. Epiphyseal center of the patella at four years 42 35. Well-developed head of the tibia at eight years 42 36. Epiphyseal centers of the ankle joint present at birth 43 xi xii LIST OF ILLUSTRATIONS Figure Page 37. Three centers of ossification in the vertebrae 43 38. Location of the epiphyses of the hrst and other metacarpals .... 44 39. Swelhng from fracture of the lower third of the radius 50 40. Old Colles's fracture showing marked atrophj- 50 41. Callus formation six weeks after fracture $2 42. Backward displacement of the lower end of the humerus §2 43. V-shapcd skull fracture with depression in the frontal region. . . ^^ 44. Linear skull fracture in the occipital region 56 45. Fracture of the malar bone with hemorrhage into the sinus 57 46. Fracture of the mandible followed by osteomyelitis 58 47. Fracture of the condyle of the mandible with displacement 58 48. Fracture of the coronoid process of the mandible 60 49. Oblique fracture of the mandible, not complete 60 50. Green-stick fracture of the outer third of the clavicle in a child.. 61 51. Fracture of the outer third of the clavicle with slight displacement 62 ^2. Fracture of the extreme tip of the clavicle 63 53. Fracture of the body of the scapula 63 54. Fracture at the base of the spine of the scapula 64 55. Fracture and displacement beneath the glenoid fossa 65 §6. Linear fracture of the coracoid process 65 57. Fracture of the tip of the acromial process 66 58. Epiphyseal separation of the upper end of the humerus 66 59. Fracture of the surgical neck of the humerus 6v 60. Fracture of the head of the humerus with outward displacement. . 68 61. Fracture of tuberosity and surgical neck of the humerus with atrophy 69 62. Fracture of the surgical neck of the humerus 70 63. Old fracture of the greater tuberosity of the humerus 71 64. Epiphyseal separation of the lower end of the humerus 72 65. Green-stick fracture of the humerus 72 66. Spiral fracture of the humerus 72 67. Attempted reduction of supracondylar fracture of lower end of the humerus 73 68. Fracture of the external condyle of the lower end of the humerus 74 69. Fracture of the olecranon process 75 70. Fracture of the olecranon process 75 71. Fracture of the coronoid process 76 72. Fragment of the head of the radius 76 73. Fracture of the head of the radius 77 74. Fracture of the neck of the radius 77 75. Fracture of the upper third of the ulna — lateral view 78 76. Fracture of the upper third of the ulna — anteroposterior view.. . 78 77. Old fracture of the upper third of the ulna 79 78. Green-stick fracture of the radius and ulna 79 79. Fracture and displacement of the radius and ulna 80 LIST OF ILLUSTRATIONS xiii Figure Page 80. Backward dislocation of the epiphysis of the radius 80 81. Epiphyseal separation of the lower end of the radius 81 82. Fracture of both bones of the forearm at site of Colles's fracture 82 83. Fracture of the forearm at site of Colles's fracture 82 84. Colles's fracture of the forearm with marked displacement 83 85. Colles's fracture with anterior displacement of the lower fragment 83 86. Old Colles's fracture with backward displacement 84 87. Impacted Colles's fracture without displacement 84 88. Old Colles's fracture with angulation. No displacement 85 89. Barton's fracture 86 90. Old fracture of the styloid of the radius 86 91. Fracture of the scaphoid of the wrist without displacement 88 92. Colles's fracture associated with the scaphoid. No displacement 88 93. Fracture of the first metacarpal bone with displacement 89 94. Oblique fracture of a metacarpal bone without displacement .... 89 95. Fracture of the first metacarpal bone with angulation 89 96. Longitudinal fracture of the terminal phalanx of the thumb .... 90 97. Crushing fracture of the terminal phalanx with osteomyelitis. . . 90 98. Base-ball Finger 90 99. Fracture of several ribs with slight displacement 91 99a. Fracture of the sternum showing lateral displacement 92 GO. Fracture of the upper third of the femur, ilium and pubis 93 01. Fracture of ischium and pubis 94 02. Fracture of the ilium bj^ a crushing injury 95 03. Fracture of the acetabulum with head of femur in pelvic canal.. 96 04. The epiphyseal separation of the head of the femur 100 05. Fracture of the neck of the femur just behind the head loi 06. Old fracture of the mid portion of the neck of the femur 102 07. Intertrochanteric fracture 103 08. Absorption of the neck of the femur in old ununited fracture. . . . 104 09. Healed fracture of the neck of the femur without callus 105 10. Intertrochanteric fracture with coxa vara 106 1 1. Position of a fracture of the upper third of the femur 107 12. Green-stick fracture of the femur 108 13. Transverse fracture of the femur 108 14. Epiphyseal separation of the lower end of the femur no 15. Old epiphyseal separation of the lower end of the femur 1 1 1 16. Oblique fracture of the lower end of the femur 112 17. Lateral view of Fig. 1 16 with line of fracture visible 113 18. Fracture of the patella 114 19. Fracture of the patella 114 20. Fracture of the tibial tubercle 114 21. Fracture of the tuberosity of the tibia 115 22. Fracture of the upper end of the fibula 1 16 23. Fracture of the external tibial spine 1 1- xiv LIST OF ILLUSTRATIONS Figure Page 124. Green-Stick fracture of the tibia in the first age period 118 125. Oblique fracture of tiie tibia in the first age period 118 126. Spiral fracture of the tibia in the first age period 118 127. Comminuted fracture of tibia and fibula 118 128. Epiphyseal separation of the lower end of the tibia 1 19 129. Fracture of the lower end of the tibia 119 130. Typical Pott's fracture, anteroposterior view 120 131. Lateral view of a Pott's fracture 120 132. Clear triangle in the soft parts at the normal ankle joint 121 133. Triangle obscured by swelling from injury or disease 121 134. Fracture of the astragalus 122 135. Fracture of the end of the astragalus 122 136. Fracture of the os calcis due to a crushing injury 123 13". Fracture of the tip of the scaphoid 123 138. Old fracture of the cuboid, with callus formation 124 139. Fractures of metatarsals and phalanges 124 140. Fracture of the base of the fifth metatarsal 125 141. Old fracture of the tibia with bone graft 126 142. Bone transplant of the upper end of the humerus 128 143. Pressure atrophy around the ends of the bone graft 128 144. Old fracture of the humerus with bone graft 129 145. Metal plate acting as an irritant 129 146. Tibia after a bone graft has been removed 130 14-^. Straight sides of the pelvis before walking 134 148. Beginning concavity of the sides of the pelvis 135 149. Congenital dislocation of the hip with shallow acetabulum 135 150. Destruction of the head of the femur with dislocation 136 151. Bony ankylosis seen in non-tuberculous infection 137 152. Undeveloped femur in congenital dislocation 138 153. Congenital dislocation of both hips with shallow acetabula 138 154. Partial subluxation of the ankle joint from injury 139 ijj. Club foot 139 156. Club hands 139 15-". Abnormality of the femur due to anterior poliomyelitis 140 158. Subcoracoid dislocation of the humerus 146 159. Subglenoid dislocation with unusual position of the humerus. . . . 147 160. Subglenoid dislocation with usual position of the humerus 147 161. Subglenoid dislocation of the humerus associated with fracture. . 148 162. Dislocation of both bones of the forearm backward 149 163. Another view of Fig. 162 showing lateral displacement 149 164. Dislocation of the elbow 149 165. Lateral view of Fig. 164 149 166. Dislocation of the elbow reduced 150 167. Dislocation of the wrist joint 150 168. Anterior dislocation with rotation of the semilunar 150 LIST OF ILLUSTRATIONS xv Figure Page 169. Backward dislocation of the thumb plialanx 151 170. Backward dislocation of the hip 152 171. Obturator dislocation of the hip 153 172. Lateral dislocation of the patella 154 173. Subluxation of the tibia 154 174. Posterior dislocation of the foot 155 175. Dislocation of the hrst metatarsal 156 176. Osteomyelitis with invoKement of medullary canal and cortical bone 160 177. Osteitis with an extensive periostitis 160 178. Acute infection in the joint involving the femur 161 179. Compound fracture with osteomyelitis 162 180. Osteomyelitis with sequestrum 162 181. X-ray of an acute osteomyelitis one week after onset 164 182. Chronic osteomyelitis with new bone formation 165 183. New bone formation showing boundaries of infection 166 184. Exterior deposition of bone simulating expanded shaft 169 185. Chronic osteomyelitis with sequestrum 168 186. Brody's abscess in the head of the radius 168 187. Typical tuberculosis of the shaft of the radius 169 188. Tuberculosis of one side of the epiphysis of the tibia i~i 189. Tuberculosis of the first metacarpal with periostitis i~2 190. Tuberculous osteomyelitis in an infant with sequestrum 172 191. Luetic periostitis of the forearm 173 192. Luetic periostitis of the ulna (lace work type) I73 193. Luetic osteomyelitis without swelling of the soft tissue i"4 194. Involucrum with the entire shaft becoming a sequestrum i"^4 195. Acute osteomyelitis with no involucrum 175 196. A typhoid periostitis with a cavity in the cortex 176 197. Raynaud's disease showing appearance of terminal phalanges. . . 17'^ 198. Leprosy 178 1 99. Leprosy i "8 200. Coccidoidal granuloma 179 201. Coccidoidal granuloma I79 202. Coccidoidal granuloma 179 203. Saucer-shaped expansion of the epiphyses in rickets 184 204. Saucer-shaped expansion of the epiphyses in rickets 184 205. Saucer-shaped epiphyses of tibia and fibula with atrophy 185 206. Atypical rachitic changes 185 207. Atrophy in rickets as the cause of multiple fractures 186 208. Atalectatic strips of consolidation in the chest from rickets 187 209. Rachitic condition shown by faulty calcification in epiphyses. . . . 189 210. Congenital lues in tibia and fibula 189 211. Periostitis present in congenital lues 190 212. Triimmer zone of destruction in scurvy 191 xvi LIST OF ILLUSTRATIONS Figure Page 213. Elevation of periosteum and organized hemorrhage in scurvy. . . 191 214. Beginning organization of hemorrhage under torn-up periosteum 192 215. Ossifying hematoma in scurvy 193 216. Cod-iiver oil feeding in rickets differentiated from scurvy 196 217. Rickets after cod-hver oil feeding 196 218. Healed rickets after cod-hver oil feeding 197 219. Tuberculosis of the knee with marked hazing and atrophy 198 220. Non-tuberculous infection with bone production 199 221. Juvenile deforming osteochondritis (Perthes' s disease) 200 222. Juvenile deforming osteochondritis (Perthes' s disease) 201 223. Graphic illustration of the stages of bone infection 206 224. Acute polyarticular arthritis 208 22§. Infectious arthritis in the first stage 208 226. Second stage of infectious arthritis 210 227. Third stage of infectious arthritis 212 228. Tuberculous arthritis of the wrist 214 229. Tuberculous arthritis of the knee, almost healed 215 230. Caries sicca of the shoulder joint with atrophy 216 231. Gonorrheal arthritis of patella, tibia and femur 217 232. Luetic arthritis with periosteal changes 218 233. Atrophic arthritis with atrophy 219 234. Hypertrophic arthritis with exostoses and joint mice 220 235. Joint mice in hypertrophic arthritis 221 236. Synovial thickening in villous arthritis 224 237. Punched-out areas characteristic of gout in joints 226 238. Early case of gout with punched-out areas missing 227 239. Charcot joint with complete destruction. No atrophy 228 240. Anteroposterior view of Fig. 239 229 241. Charcot joint of the ankle with marked periostitis 230 242. Hemorrhage cysts beneath the cartilage of the joint 231 243. Hemophiliac joint with surfaces destroyed by hemorrhage 232 244. Organization of hemorrhage in elbow joint 232 245. Bone formation in the tendo Achillis from arthritic condition. . . 234 246. Deposition of salts in the subdeltoid bursa 235 247. Deposition of salts in the subdeltoid bursa 235 248. Non-gonorrheal type of exostosis of the os calcis 236 249. Gonorrheal exostosis 236 250. Tumor arising within the medullary canal. (Giant-cell sarcoma.) . 244 251. Tumor arising from the cortex. (Fibromyxoma.) 245 252. Bone production within a tumor. (Osteoma.) 246 253. Benign tumor with slight expansion of the bone. (Cyst.) 248 254. Benign tumor of the fibula. (Cyst.) 249 255. Complete destruction of the head. (Round-cell sarcoma.) 250 2^6. Expansion of cortex from medullary tumor. (Giant-cell sar- coma.) 25 1 LIST OF ILLUSTRATIONS xvli Figure Page 257. Metastatic carcinoma showing invasion 252 258. Metastatic carcinoma with pathological fracture 256 259. Carcinomatous metastases of the skull 257 260. Carcinoma of the mandible 258 261. Metastasis from a prostatic carcinoma 259 262. Mihary prostatic metastases of the lumbar vertebrae 260 263. Round-cell sarcoma of the humerus 261 264. Spindle-cell sarcoma of the tibia 262 265. Advanced case of periosteal sarcoma 264 266. Periosteal sarcoma with bone striae perpendicular to the shaft. . . 264 267. Periosteal sarcoma wath bone striae in the soft tissues 265 268. Osteosarcoma with dense bone production 265 269. Giant-cell sarcoma with cortex intact 266 270. Giant-cell sarcoma with spontaneous healing 267 271. Lateral view of Fig. 270 267 272. Multiple enchondromata of medullary and cortical origin 268 273. Osteochondroma of the head of the fibula 269 274. Large osteochondroma of the femur 270 275. Bone cyst of the humerus, which is multilocular 2^2 276. Pathological fracture of the humerus through a bone cyst 2"2 277. Osteoma showing typical cauliflower growth 273 278. Osteoma 273 279. Table-top type of exostosis 274 280. Pencil type of exostosis pointing away from the nearest epiphy- sis 2''4 281. Exostosis terminating in osteochondroma 2~5 282. Fibroma of the phalanx 275 283. Hemangioma with calcified bodies in the soft tissue 276 284. Hemangioma of the hand 277 285. Ossifying hematoma of the femur 278 286. Myositis ossificans 278 287. Osteosarcoma with bone destruction 279 288. Osteitis fibrosa cystica with lengthening of the tibia 281 289. Pressure atrophy of the cranial bones from internal pressure. . . 282 290. Destruction of the sella turcica from hypophyseal tumor 283 29 1. Centers of ossification of the vertebrae 290 292. Fracture and subluxation of the second cervical vertebra 292 293. Fracture of the transverse process of the lumbar spine 293 294. Scoliosis showing primary and secondary curves 294 295. Lateral angulation of the spine 295 296. A fractured spine with new bone production 296 297. Arthritis with edges of the vertebrae sharpened 298 298. Exostoses along the vertebrae and lateral ligaments 298 299. Destruction and fusion of two vertebrae with angulation 299 300. Marie Striimpell type of arthritis deformans 300 xviii LIST OF ILLUSTRATIONS Figure Pa^-e 301. Charcot joint of the fourth lumbar vertebra 301 302. Carcinoma of the lumbar vertebra with joint spaces intact 303 303. Pressure destruction of a lumbar vertebra from a tumor 308 304. Rudimentary vertebra arising from the seventh cervical vertebra 312 305. Cervical rib arising from one side only 313 306. Rudimentary spina bifida of the seventh cervical vertebra 314 307. Rudimentary vertebra in the dorsal region 314 308. Synostosis of the bodies of two ribs 315 309. Congenital non-union of the laminae of the sacrum 315 310. A pair of lumbar ribs 316 311. Sacrolization of the fifth lumbar vertebra 316 312. An attempt at sacrolization on one side 317 313. Aberrant articulation between clavicle and coracoid 317 314. Absence of the ulna due to a faulty epiphysis 318 315. Extra digit arising from the little finger 318 316. Fourth and fifth fingers with common metacarpal 319 317. Extra digit on the toe 3^9 318. Congenital absence of the fibula 319 319. Osteitis deformans 324 320. Osteitis deformans 324 321. Changes in cranial bones in osteitis deformans 325 322. Acromegalic skull 326 323. Changes in the bones of the hand in acromegaly 3^7 324. Osteomalacia 328 325. Osteomalacia 328 326. Achondroplasia 329 327. Achondroplasia with deformity of the radius 330 328. Pulmonary osteoarthropathy 331 329. Osteogenesis imperfecta with multiple fractures 332 330. Osteogenesis imperfecta with multiple fractures 333 331. Osteogenesis imperfecta with multiple fractures 333 CHAPTER I INTRODUCTION INJURIES AND DISEASES OF THE BONES AND JOINTS CHAPTER I Introduction ROENTGENOLOGY Is of comparatively recent ori- gin; only within the last decade and a half has it made its greatest progress. Before that period our b^ entire energies were devoted to the purely mechan- ical side of developing a technique so that examinations could be properly made. Today one hears less and less of technique and more and more of diagnostic principles. Unfortunately the term "picture" has been introduced, not in the sense that an internist would use it when he speaks of a chnical picture, but as one would speak of a photograph. There is no such thing as an .v-ray picture. A roentgenogram is a projection upon a photographic plate of a series of shadows of varying density representing the various structures through which the rays have passed. The correctness of the diagnosis depends entirely upon the skill with which these various shadows are separated and interpreted. To interpret these shadows correctly one must know not only the appearance of the normal structure, but also the alterations that take place when there is a pathological process present. It therefore follows that the abihty of the roentgenologist depends not so much upon his technical skill as upon his famiharity with the general problems of medicine and surgery. When there is a variation from the normal he must know whether it is a devek^pmental process or the result of disease. The bone of a child differs materially from that of an adult. In the former case it is in the growing stage, and too often a diagnosis of fracture has been made when the supposed crack 3 4 INJURIES AND DISEASES OF BONES AND JOINTS was the normal epiphyseal line. A thorough knowledge of the anatomy and development of the bone would have obviated this mistake. The reverse of this has occurred where a linear crack was present just below the head of a bone in an adult and was interpreted as the epiphyseal line. The thinning out of the cortex on the internal sides of the radius and ulna for the attachment of the interosseus membrane has often been mis- taken for a periostitis. So it may be said that the first requisite of a good roentgenologist is a thorough knowledge of the normal anatomj', not only its appearance but also its normal development. The roentgenologist should also be so thoroughly ac- quainted with every phase of the development of the bone that he can tell the approximate age of the individual by its appearance. If the epiphysis of the lower end of the radius has united at fourteen years, or is still present at twenty-five, it may possibly give the clue which will solve a very obscure case. Going a step further, the roentgenologist must know the constituent parts of the bones, their make-up and what role they play in the normal. He must be thoroughly familiar with the blood and lymph supply, as that shows how metastatic infection or malignancy reaches certain portions of the bone, and why other portions are omitted. In the same way he applies his knowledge to the joints, knows their constituent parts and what role each part plays. If he knows the blood and lymph supply of the cartilage he will know w hy in cartilaginous lesions the infection always starts from the periphery and never from the center of the cartilaginous mass. After becoming thoroughly acquainted with the histology of the normal bone and the functions of its various parts, the roentgenologist must turn to the pathological side and know the changes that take place. He must know not only the inti- mate structure of the lesion, but also its method of progres- sion. This does not occur at random, but follows well-defined laws based on the character of the lesion and on the roads of transportation. Having learned the normal and pathological INTRODUCTION 5 conditions of bone, how is he to translate them into what may be termed A-ra}' gross histology and pathology, for after all if he cannot connect the lesion with the x-ray plate, his knowl- edge is of no avail. It is in bridging the gap between these lesions and their shadows cast upon the plate that the expert knowledge of the roentgenologist comes into play. Only two pathological processes are registered upon the plate; bone destruction and bone reproduction. The con- sideration of how^ and when these processes occur, where they are situated, and their relation to each other, enables one to make a diagnosis. Bone destruction may arise from some infection, or from a malignant growth. In either case what may be termed an irritant substance is introduced into the bone. This acts as an exciting agent, and, if it is an infection, more or less destruction of bone ensues, depending upon its virulence. If the irritant is of a benign nature it stimulates, and there is new bone formation around the substance, as this is nature's way of taking care of a pathological condition. The question will present itself as to why in one case there is destruction and in the other bone production. The point of contact between the lesion and the bone is the point of stimulation, and it takes nature some little time to lay down bone; so if the infection or tumor is virulent the point of contact is swept away and a new one formed before there has been time for new bone formation, hence the process is entirely destructive. On the other hand, if the point of contact remains stationary for a short period then nature has time to lay down new bone. So there are two well- defined changes taking place in bone, namely, destruction, indicating an advancing lesion, and production, indicating a lesion that is retrograding and probably under control. In some processes there is continued destruction and no bone production, indicating that the lesion is a rapidly advanc- ing one and out of control. This is seen in malignant tumors, such as carcinoma, round and spindle-cell sarcoma and virulent infections. The nature of the lesion determines the character of the destruction. An osteomyelitic infection spreads by 6 INJURIES AND DISEASES OF BONES AND JOINTS means of the Haversian canals and their intersecting rami- fications, and thus may break out in a point distant from the original focus, leaving normal bone between. On the other hand growths advance by direct extension, and so fresh foci are not found separated from the parent growth with normal bone between. The character of the destruction, therefore, makes it possible to establish one point of differential diagnosis. The production of bone at the junction of the lesion and the normal bone has already been mentioned. When new bone, then, is laid down at the edge of the destroyed area it is in- dicative either of an infection or of a benign growth. On the other hand new bone is sometmes seen within the lesion itself where there is normally no tissue that will produce bone. Such a condition probably indicates a bone tumor such as an osteoma or an osteosarcoma. Thus a second point of differential diagnosis is established. When the lesion is in the medullary canal there is no bone production, but vacuolated areas appear in benign growths and infections, and the path of least resistance is taken, namely, up and down the canal, while malignant tumors grow in a spherical manner and tend to destroy the cortex by pressure. So a third point of differentiation is established — pressure effects, and the manner in which the lesion extends. The above points may be termed direct evidence. Then the remote effects must be considered, whereby changes occur in the bones, not directl}^ due to the lesion, but rather to mechanical causes. When some process, especially an infection, involves the bone, there is generally pain with consequent inability or lack of desire to use the particular part affected on account of discomfort. This disuse brings about a condition known as atrophy, which is not due to disease, but is entirely a disuse process. It is seen even in a normal bone if the part is put at rest. The calcium salts are absorbed and a very porous bone results. Each constituent part is present, but in much dimin- INTRODUCTION 7 ished quantity. This process is entirely functional, and the bone will quickly return to normal upon use. It is never a pathological condition. At times there is a local atrophy following a pathological process. In fractures, where the blood vessels are destroyed, there is sometimes actual necrosis of the bone due to lack of nourishment. Atrophy, then, is an indication of disuse of the part, and thus calls attention to the fact that some cause must be found for its presence. As an example of this, an examination of the hip was requested in a certain case. The plate showed no lesion in the joint, but that portion of the femur shown upon the plate disclosed marked atrophy. There was no lesion present that would account for this condition. In discussing the case with the surgeon attention was called to this point, and the statement was made that for some cause unknown to the roentgenologist the femur must have been at complete rest for a long period of time. This elicited the information that there had been fracture of the lower third of the femur, and that both femur and pelvis had been in a cast for nearly twelve weeks. Atrophy, therefore, is a functional disuse process, and its presence must be accounted for, as it always means non-function frequently due to disease. On the other hand a knowledge that atrophy is absent is often of the greatest importance. In a Charcot joint the plate shows swelling and extensive destruction. In any other condition the joint would be painful and the part could not be used; but the lack of atrophy indicates that the joint was used, and hence there could have been no pain. Thus, by simple logic the absence of pain is deduced in a badly disorganized joint by the fact of the absence of atroph\', and a diagnosis is established. So far the changes seen upon an .v-ray plate have been discussed, and they may be termed direct evidence. Are there any other factors that may be obtained which will aid in a diagnosis? There are two such factors, and even these if nec- essary may be deduced from the plate by a skilled roentgen- 8 INJURIES AND DISEASES OF BONES AND JOINTS ologist. However, these factors, namely, sex and age, will be considered as indirect evidence. Certain lesions peculiar to the female are seen but infre- quently in the males. As an example, separation of the symphy- sis pubis which is common in the female after childbirth, is but rarely seen in the male except following severe trauma. Certain fractures are much more common in the male. Certain metastatic malignancies have a different l^one distribution in the female than in the male. Again aneurysms are relativeh^ uncommon in the female. Consequently destruction of the vertebrae due to pressure from beneath is not often seen; destruction of the thoracic vertebrae in a female, therefore, is apt to be malignant, while in the male in the same region it may be a pressure result. Age has a very important bearing. The bones differ some- what at different ages, and the resulting injuries from trauma will vary according to age. As an example, take the same degree of injury to a hip and see what follows at different age periods. In the young an epiphyseal separation of the head of the femur results; between twenty and forty years a dislocation is produced; and after forty a fracture of the neck is sustained. In the same way, if there is a malignant growth in the bone of a child it is certain that it is not a carcinoma, as that is an old-age disease. A joint infection in early youth cannot be a hypertrophic arthritis, as that, too, is an old-age lesion. Rickets and scurvy are seen only in the first few years of life. So laws of probabilities as to sex and age can be estab- lished. A law of probability also may be determined from the portion of the bone in which the lesion is situated, thus car- cinoma is generally found in the middle of the shaft and sarcoma at the ends. These probabilities will be dealt with in the succeeding chapters. When all the data that can be determined from the plate are obtained, it is well to write down everj^ pathological INTRODUCTION 9 condition that can allcct the part in question. Many can be eliminated immediately, but some few will still remain. In each of these there will be some factor that does not fit in with the plate, and finally, by exclusion, the fist of pathological conditions will be narrowed down to one. Then the process must be reversed, and every shadow upon the plate must coincide with the lesion; if it docs not, there has been an error which must he sought out. It is only when they agree that we may feel reasonably sure of the correctness of the diagnosis. As has been stated, roentgenology is not a picture process, but a medical procedure based upon careful analysis and logical deductions from the shadows observed upon an .v-ray plate and translated into pathological terms. This means — and it cannot be too strongly emphasized— that the skill of a roentgenologist will vary directly with his medical knowledge; and the value of the roentgenologist to the medical profession will be based upon this fact and not upon his technical ability. It must also be borne in mind that roentgenology is but one of many diagnostic methods, and that it has not as yet reached a stage of such precision that it may be considered infallible. It is only by close cooperation with his colleagues, in conjunction with his medical knowledge, that the roentgenol- ogist can advance his specialty. He has four friends who are only too willing to cooperate with him, and the more intimately he associates himself with them the better will be his progress. These four friends, the anatomist, the patholo- gist, the internist and the surgeon, the roentgenologist should most zealously cherish and esteem. CHAPTER II NORMAL BONES CHAPTER II Normal Bones A NORMAL bone is composed of several highl}' organ- ized structures having different functions. Some of these are plainly seen upon an .v-ray plate, and others are demonstrable only when they are in what might be termed a pathological state. This is particularly true of such a struc- ture as the periosteum. The constituent parts of the bone vary according to its particular type and also according to its function; for example, some bones have a shaft and car- tilaginous articulating surfaces, as the femur or tibia; others, such as a carpal bone, have no shaft or periosteum, but are irregular in shape and are covered entirely by cartilage. \\ hile bones may vary in shape, yet they are composed of practically the same constituents modified according to the use to which nature intends them to be put. The normal constituents are as follows: The Periosteum. This is a fibrous sheath, rich in blood vessels, covering that portion of the bone not entering into an articulation. This structure has a ver}^ important function, as it is one of the bone producing elements, and its finely divided blood vessels penetrate the cortex, thus helping to nourish the bone. If the periosteum is torn from a bone we shall find the cortex studded with small bleeding points. In the young this sheath is quite thick and very vascular, but is loosely attached to the shaft and firmly adherent at the epiphyses, while in adults it is firmly attached to the shaft. This is important because when hemorrhage takes place beneath the periosteum in children it generally surrounds the entire shaft, as the periosteum is so loosely connected, while on account of the firm attachment in adults the Iiemor- rhage is generally localized to one j^art. 13 14 INJURIES AND DISEASES OF BONES AND JOINTS In its normal state the periosteum casts no shadow upon the plate (Fig. i), but in its pathological state there is invari- ably deposition of calcium salts (Fig. 2); consequently it can be easily demonstrated. Whenever the periosteum is visible upon a plate it indicates an abnormal condition. Fig. I. — A section of a normal radius and ulna. The periosteum cannot be seen as the calcium salts are not present in its normal state. The Cortex. Beneath the periosteum we come to dense, hard bone, called the cortex. Fig. 3. This is composed of bone cells imbedded m masses of inorganic salts known as the matrix. This dense bone is pierced by numerous small Haver- sian canals ^^ hich run parallel to tlic long axis of the bone and NORMAL BONES 15 are united by numerous intersecting canals. The canals play a very important role in certain diseases, as they may be termed the roads of transportation for the infections. At the ends of the bone the cortex expands into fmely reticulated bone, rich in blood and lymph vessels, which is spoken of as Fig. 2. — The deposition of calcium salts in the periosteum on the internal aspect of the tibia clue to an inflammatory process of the periosteum. cancellous bone, Fig. 4. These two types are simply variations in the amount of matrix present, there being more in compact bone and less in cancellous bone. The cortex and the cancellous bone are nourished partly by minute vessels from the peri- osteum and partly from the medullary artery. i6 INJURIES AND DISEASES OF BONES AND JOINTS The Medullary Canal. Within a long bone there is a long narrow cylindrical channel known as the medullary canal (Fig. 5) containing the marrow fat, nerves, blood and lumph vessels. From an .v-ray standpoint the medullary canal appears as a hollow channel, as its contained elements Fig. 3.— Note the dense bony cortex of the tibia. In this area we have the bone cells, inorganic salts and the Haversian canals. do not cast shadows. This canal does not traverse the entire bone, but merges at its ends into the cancellous heads. The Nutrient Foramen. At approximately the middle point of the shaft is the nutrient foramen, an aperture which allows the big vessels to enter the medullary canal. In some bones, such as the femur, there may be two such foramina. While this foramen cannot be demonstrated by the A-ray, yet it is of great importance, as it is the entrance by which metas- NORMAL BONES 17 tatic infections and malignancy gain admittance to the medullary canal. Cartilage. The ends of the bones are covered by a hyaline material called cartilage. This is a dense, hard structure free from vessels. It varies in thickness, being thicker at its Fig. 4. — There is no cortex present at the end of the bones; it and tlie medullary canal fuse and form a linely reticulated bony structure rich in blood vessels. weight-bearing points, that is, its convex portion, and thinner at its concave portion. The hgaments of the joints are imbedded in it. When there is infection, the thinnest portion is destroyed hrst, therefore bone changes must be sought in those areas. Joint cartilage does not undergo cak^ificatiou, Fig. 6. It has poor recuperative power, and when cak'ilication is present it means that the cartikige has been destroyed and replaced i8 INJURIES AND DISEASES OF BONES AND JOINTS by bone tissue. In other types of cartilage, such as the costal cartilage (Fig. "), calcification is a normal change due to age but this never takes place in a joint. As cartilage does not contain blood or lymph vessels, metastatic infections and malignancv are not found in this tissue. Fig. 5. — \\ithin the center of the bone there is the medullary canal con- taining the ner\-es, blood and lymph vessels, and the marrow fat. This canal appears as a hght channel upon the print. Variations in bone architecture are due to differences in combinations of compact and cancellous tissues and the mechanical distribution of cartilage. We can, therefore, classify the bones as follows : I. Long bones. NORMAL BONES 19 Fig. 6. — The space between the bones is tilled with cartihige whicli casts no shadow. This type of cartilage does not undergo calcification with age. Fig. 7. — Tins shows a diflerent t>pe of cartilage present in the costal cartilages which normally undergo calcihcation with acKancing age. 20 INJURIES AND DISEASES OF BONES AND JOINTS 2. Flat bones. 3. Irregular bones. The long hones (Fig. 8) are made up of all the structures just Fig. 9. — A flat bone showing its cancellous structure, and, incidentally, the grooves for the blood vessels. Fig. 8. — Tibia and fibula, showing cortex, medul- lary canal and cancel- lous bone. Fig. 10. — Carpal bone composed entirely of cancellous tissue with a very thin cortex. This bone comes under the head of what might be termed the irregular bones. described, and may be the seat of fractures and disease not only of the shaft, but also of the joints, so both bone and joint lesions may be present. NORMAL BONES 21 The flat hones (Fig. 9) have slightly diflercnt architecture. There is no medullary canal, but the bone is made up of cancel- lous tissue lying between two thick plates of compact bone. There may or may not be joint cartilage present. Examples of this type are the innominate bones, scapulae, ribs, and the cranial bones. The first two, having articular cartilage, may be the seat of either bone or joint lesions, while the latter two are only subject to bone lesions. The irregular hones (Fig. 10) such as the carpals and tarsals, are entirely cancellous and have a cortex of a very thin compact layer of bone; some of them are entirel}^ covered with cartilage, as the carpal bones, or are partially covered, as the os calcis. So with some of the bones, those covered entirely with cartil- age, only those lesions occur which may be termed joint diseases, while others, as the os calcis, are subject to both bone and joint diseases. The vertebra may also be looked upon as an irregular bone; the upper and lower borders are covered with cartilage, and the sides with periosteum; so here also both bone and joint lesions may be present. Joints. In a joint, which may be defined as the junction of two bones, a totally different condition prevails. No periosteum is present, but there are more or less large articulating cartil- aginous surfaces and a capsular covering enclosing the joint known as the synovial membrane. The synovial membrane is a fibrous tissue sheath, but, unlike the periosteum, is incapable of producing bone. In a joint there are no normal elements which will produce bone. Therefore whenever bone is formed in a joint it is the result of destruction of cartilage and exposure of raw bone which then proliferates. Nearly all the elements of a normal bone are directly demonstrable, while the elements of the normal joint cannot be seen. In bone there is direct evidence of destruction, while in joints only indirect evidence is obtained, and the destruction must go on until the bone beneath is involved before direct evidence appears. As has been stated, cartilage casts no shadow; howe\er, the space 22 INJURIES AND DISEASES OF BONES AND JOINTS between two joint surfaees is filled with cartilage (Fig. ii) and when this space is narrowed (Fig. 12) it shows that cartil- age has been partially destroyed; thus we have w^hat is termed indirect evidence of cartilage destruction. When cartilage is involved it is bj^ direct contact either from the joint space or from the bone beneath. The lesion can never start from within the cartilage mass, as there are no vessels to carry in the infection. Fig. II, Fig. 12. Fig. II. — Normal space between the bones filled with cartilage. Fig. 12. — Partial destruction of cartilage, indicated by narrowing of the joint space. Growth. Thus far the discussion has been limited to a bone that has reached its full growth. Up to the age of epi- physeal union the bones differ very materially. Since bones have to grow, as does other tissue, and as they are rigid, fixed structures, some mechanism must be present that will allow them not only to lengthen, but also to expand. The expansion is very simple, being due largely to bone being laid down by the periosteum. This is done so insidiously that it cannot be dem- NORMAL BONES 23 onstrated. It may be likened to the constant replacement of skin epithelium. To allow bones to lengthen nature has placed at each end of nearly all of them a very highly organized mechanism known as the epiphysis. When the bones first appear in fetal life they are composed entirely of cartilage, but soon centers of ossifica- tion appear and the cartilage is gradually transformed into bone. At birth all the long bones are fully developed, except as Fig. 13. Fig. 14. Fig. 13. — A knee joint at a very early age, showing center of ossification for the lower end of the femur. The upper end of the tibia is composed entirely of cartilage, the ossified center not having appeared. Note the enormous width of joint space, composed entirely ol cartilage, which casts no shadow. Fig. 14. — The wrist of a child of seven showing the wide epiphyseal hnes. Note particuLirlv the epiphyseal hnc of the hrst metacarpal and com- pare with Fig. 15. to size, with the exception of each end, and there the heads are composed entirely of cartilage, Fig. 13. At various ages, centers of ossification in the l)one heads appear (Fig. 14) and increase in size, but do not unite until full growth has finally been attained. There is consequently a point where the 24 INJURIES AND DISEASES OF BONES AND JOINTS bone and ossified heads are united, but it is by a cartilaginous band which is wide in the young and becomes narrower with age, Fig. 15. It finally disappears bj' union with the shaft when full growth is attained, and under normal conditions the growth then ceases. This band of cartilage lays down new bone which causes the shaft to lengthen, and at the same time reproduces its own tissue. W hen it ceases to reproduce its own tissue then union takes place. This band is known as the epi- FiG. 15. — A child of eleven years. The epiphyseal line of the first meta- carpal has become quite narrow as this epiphysis unites at fourteen. The epiphyseal Une of the radius is still quite distinct as it does not unite until eighteen. phj-seal line, and is easily demonstrable by the .v-ray. Any interference at this epiphyseal line, either by disease or injury, is attended with serious consequences to the particular bone involved. There are certain diseases in which the epiphyses are subject to either excess or retarded growth, and profound changes are invariably the result of these conditions. Joint Lesions. While the bone is growing it always retains its mechanical shape, and thus lesions up to puberty are similar to those of adults. The joint lesions, however, are more NORMAL BONES 25 difficult to discern, as the heads are composed largely of car- tilage which does not cast a shadow and consequently there may be various lesions which cannot be recognized by direct x-ray evidence. In an adult a fracture of the head of the humerus can be readily demonstrated, while in a newborn child, the head, being composed of cartilage (Fig. 16), may be broken or pulled off completely and yet not be recognized. It is the writers' belief that many of the so-called congenital abnor- FiG, 16. — The head of the humerus of a newborn ehild. The entire head is composed of cartilage and may be injured and yet not be recognized by means of an x-ray examination. malities are in reality injuries to the cartilage after birth, and that the resulting deformity is due to faulty growth or mal- position of the cartilaginous fragment. Complete displacement of an epiphysis results in non-growth of that portion of the bone. These epiphyseal injuries are so often unrecognizable both clinically and roentgenologically at the time of injury that when later in life such a condition is seen it may be considered as congenital in origin. It may be stated almost as an axiom that l^cforc joint lesions in children can be demon- 26 INJURIES AND DISEASES OF BONES AND JOINTS strated by means of the .v-ray they must always be more advanced than in adults. Thus far it has been shown that in normal bones and joints there are definite variations between those of children and of adults, and that these variations may materially influence and aid in bringing about pathological conditions. The question \ Fig. 17. — The shoulder joint in a man of fifty, showing atrophy from age. In this condition the bones are quite brittle, and fracture easily. naturally arises \\hether there are any variations after the bones and joints have attained their full growth. The varia- tions in youth can be classed as developmental. In adults there are no such changes; the bones have ceased growing. However, in adults there are alterations in some of the constituent parts. It may be roughly stated that the bones reach their full growth at twenty, and that from this age up to forty no change of anv character can be noted. This is our most vio;orous NORMAL BONES 27 period of life and our bones should be at their best. After forty we begin to slow up somewhat and this can be noted in our bones. Certain changes begin to take place, which may be termed retrograde, very shght at forty, but increasing with age. Up to forty our bones are dense, due to the inorganic salts, flexible and more resistent to stress and strain. After forty they gradually lose their nexibihty and become some- what brittle. Fig. 17. In children green-stick fractures are common owing to the flexibility of the bones; but in old age the fractures are always complete and sometimes comminuted as the flexibihty has disappeared, leaving a more brittle bone. This is due to a gradual absorption of hme salts, so that the bone becomes more atrophic and ofl"ers less resistance to injuries and diseases. This atrophic condition is readily recog- nized upon an .v-ray plate. There are certain types of fractures occurring after the age of forty which are extremely rare below that age. Thus the hfe of the bone may be regarded as having three distinct phases: 1. Up to the age of twenty; the stage of progressive de\el- opment. 2. From twenty to forty; the stage of greatest de\cIopmcnt and strength. 3. From forty on; the stage of retrogression and weakening of the bone structures. Effect of Sex. The second question to be considered is whether there are any changes in the structure of the bones in the male that make them difler from those of the female. The bones of both sexes are identical as far as structure is concerned, except that as a rule those of the female arc shorter and narrower; but in proportion to their size, they are as strong as those of the male. The arrangement of the bones may be slightly modifled in the female to accommodate them to functions peculiar to that sex. The pelvis (Fig. 18) wiH dem- onstrate this point. In the female the sacrum occupies a high position, so that its top plane is on a level or just sHghtly below a plane passed through the crests of the iha. This causes a 28 INJURIES AND DISEASES OF BONES AND JOINTS Fig. 1 8. — The pelvis of a female. Note the high position of the sacrum with the corresponding position of the fifth hmibar in relation to the crest of the iha. NORMAL BONES 29 Fig. 19. — The deep-set sacrum of a male. Again note tlie position of the fifth hmihar in relation to the liia. 30 INJURIES AND DISEASES OF BONES AND JOINTS Ilaring out of the iliac bones and gives a wider and deeper pelvic canal, which in turn slightly alters the angle that the femur makes with the pelvis. In the male (Fig. 19) the plane of the iliac crests passes through the middle or top of the fifth lumbar vertebra, resulting in a narrow pelvis. It is reasonable then to conclude that age and sex have a definite relationship to normal bones, and that they also have an effect upon the bone lesions when they occur. In the following chapters injuries and diseases will be studied from the standpoint of sex and of the three age periods that have been enumerated. CHAPTER III EPIPHYSES CHAPTER III Epiphyses IN roentgenological diagnosis it is very important to have a thorough knowledge of the epiphyses of the bones. This portion of the bone plays such an important part in the growth and is so easily affected by injur}- and disease, that all the normal changes which occur up to the time of its union with the shaft should be thoroughly understood. It must be known therefore, at what time the center of ossifica- tion appears, the appearance of the epiphysis at various ages, and finally, the period when it unites and becomes an integral part of the bone. The age of a child of average development can be approximately determined by the absence of the centers of ossification or by the size of the ossified centers when present. This is very important diagnostically as some injuries and diseases are limited to certain ages. It must be remembered, however, that the development of the epiphysis is somewhat variable, being influenced b}" a number of conditions. Nutrition is probably one of the greatest factors. It has been the general experience that in undeveloped and poorly nourished children, the growth of the centers of ossification is very materiall}' retarded. It must also be borne in mind that the epiphyses in the newborn are, for the most part, composed entirely of cartilage, and since cartikige does not cast a shadow it cannot be demonstrated by an .v-ray exami- nation. Fig. 20. It is only when the center of ossification appears that information can be obtained. Fig. 21. \\c then judge of its size, position and contour to determine whether it is normal, pathok)gicaI, or has been the seat of an injur\ . It has been noted that mahiutrition retards the develop- ment of the epiphysis, and that in the normal indi\"idual, there is a wide variation in the time of appearance of the centers of 3 33 34 INJURIES AND DISEASES OF BONES AND JOINTS y. Fig. 20. Fig. 21. Fig. 22. Fig. 20. — A child of eighteen months with only two centers of the carpal bones showing. Fig. 21. — A child of three years showing three centers of ossification of the carpal bones. Fig. 22. — A child of ten years with delayed ossification. None of the carpal bones are developed as fully as they should be at this age. I Fig. 23. — A child of fifteen years with the center of ossification of the epiphysis of the acromion just appearing. Sometimes mistaken for a fracture. EPIPHYSES 35 ossification (Fig. 22) and the time of fusion. For practical pur- poses only those centers of ossifications which appear after birlh need be considered. Scapula. The scapula has seven centers of ossification of which but three need be mentioned here. They are the center for the coracoid process, the center for the outer end of the acromial process, and that for the inferior angle of the body of the scapula. The coracoid center appears at the end of the Fig. 24. — A child of four years, showing separate centers of ossification for tlie head of the humerus. Tliese fuse into one solid head at about the sixth year. first year and unites at about the fifteenth year. The outer end of the acromion (Fig. 23) has one and sometimes two centers appearing about the fifteenth year and fusing about the eighteenth. The center for the inferior angle appears at the age of fifteen and fuses at about eighteen. These epiphyses are sometimes mistake?! for Jraclures. Clavicle. The sternal end of the clavicle has a separate center which appears from the fifteenth to the se\cnteeiith 36 INJURIES AND DISEASES OF BONES AND JOINTS year and fuses at the twenty-third to the twenty-iifth. This epiphysis is seldom of pathological interest, but is a good index in determining the age of a patient. Humerus. The upper end of the humerus has three centers: the head, appearing at the sixth or eighth month; and the greater and lesser tuberosities, appearing from the third to the fourth year, Fig. 24. These unite at about the Fig. 25. — The epiphyses around the elbow joint at the fourteenth year. sixth year into one big epiphysis. This epiphysis is of great importance, as it is a common seat of injury and disease. The lower end of the humerus has four centers (Fig. 25) ; (i) the capitelkim, appearing at one year; (2) the internal condj'le, at five; (3) the trochlea, at ten to eleven; and (4) the external condyle, at twelve to fourteen. They remain as separate centers until the age of sixteen to seventeen, and then unite as a mass and fuse at the eighteenth or nineteenth year. The lower epiphysis figures very largely in injuries at the elbow joint in the first ten years of life. EPIPHYSES 37 Fig. 26. — The lower epiphysis of the radius. This epiphysis is a very important one as it is so frequently torn off and displaced backward. Fig. 27. — The epiphysis of the olecranon at the fifteenth year. This is important as it is occasionally torn off. 38 INJURIES AND DISEASES OF BONES AND JOINTS Radius. The center for the head of the radius appears about the fifth and unites at the sixteenth to seventeenth year. This epiphj'^sis is seldom injured. The lower epiphysis appears about the second year and unites at the seventeenth Fig. 28. Fig. 29. Fig. 30. Fig. 28. — A child of four years with four centers of ossification of the carpal bones. Fig. 29. — A child of seven years with seven centers of ossification of the carpal bones. Fig. 30 — A child of eleven years. The center of ossification of the pisiform is now present, appearing between the eighth and eleventh year. or eighteenth. This is also a very important epiphysis, as it is so frequent!}' dislocated, Fig. 26. Olecranon. The olecranon center appears at eight or nine and fuses at seventeen. It is subject to frequent injuries. Fig. 27. The lower epiphysis appears at the fourth and fuses at the eighteenth year and is seldom injured. Carpal Bones. The carpal bone centers appear in the fol- lowing order: os magnum, unciform, cuneiform, semilunar, trapezium, scaphoid and trapezoid; and a good working rule is that they appear one for each year in the order named above (Figs. 28 and 29), the center for the pisiform appearing between the eighth and eleventh year. Fig. 30. The metacarpal centers appear about the third and fuse at the seventeenth to eigh- teenth year. Phalanges. The phalangeal centers also appear about the third year and fuse at the sixteenth or seventeenth. Pubis and Ischium. The pubis and ischium unite at EPIPHYSES 39 from seven to nine (Fig. 31) and the acetabulum fuses at fifteen to sixteen. The center for the crest of the ihum appears at from fifteen to eighteen years and fuses at twenty-three to twenty-five. Fig. 31. — The pubis and ischium unite at from seven to nine >ears. Tliis plate of a child of five shows that complete ossification has not taken place. The centers for the ischial tuberosity, the iliac spine and tubercle of the pubes, appear at fifteen and unite at twenty and are of little pathological importance. Femur. The center for the head of the femur (Fig. 32) appears at the first year and fuses at seventeen to eighteen. The epiphysis is of great importance, as it is frequently dis- located. The greater trochanter appears at the fourth and unites at 40 INJURIES AND DISEASES OF BONES AND JOINTS the eighteenth year. The lesser trochanter appears at the eleventh to thirteenth year and unites at seventeen. The center for the lower epiphysis of the femur appears at birth (Fig. 33) and unites at eighteen to twenty years. This epiphysis is important, as it is sometimes dislocated. Patella. The patella center appears at the third to fourth year, Fig. 34. Fig. 32. — A child of nine jxars showing the epiphysis of the greater tro- chanter. The lesser trochanter is not present as the ossified center does not appear until the eleventh year. TiBLA. AND Fibula. The center for the upper epiphysis of the tibia (Fig. 35) appears in the latter half of the first year and unites at eighteen or twenty and is but rarely separated. The lower center appears at about two and unites at seventeen or eighteen years and is subject to injuries. The upper center for the fibula appears at three to four and unites at eighteen to EPIPHYSES 41 twenty-five j^ears. The lower epiphysis appears at two and unites at seventeen to eighteen. The centers for the os calcis, astragalus and cuboid appear before birth (Fig. 36); the external cuneiform at one year; internal cuneiform at the third year; the middle cuneiform and scaphoid at the fourth year. The separate center of the pos- terior extremity of the os calcis appears at the tenth and unites ^ Fig. 33. — A child under six months, showing the center of the epiphysis of the lower end of the femur which is present at birth. The center for the upper end of the tibia is not present as it does not appear until the last six months of the first year. at the eighteenth year. The centers for the metacarpals and phalanges vary in their appearance from three to seven years and unite at about seventeen. For practical purposes, it may be accepted that with the exception of the head of the fibula, which fuses after twenty years, union of the epiph3'ses of the long bones takes place approximately at eighteen years. Vertebrae. Vertebrae (Fig. 37) arise from three centers, one for the body and one for each lamina. These are almost fully developed at birth; in the first jxar the laminae unite and at the third year the body and the arch join. At the sixteenth year secondary centers appear, one for the tip of each transverse process and one for the spinous process. At twenty-one a 42 INJURIES AND DISEASES OF BONES AND JOINTS thin circular plate of epiphyseal bone forms in the cartilage between the vertebrae, one above and one below each vertebra and unites between the twenty-fifth and thirtieth year. These epiphyses seldom play any part in injuries, but by variations in ossification they produce al3normantics, as in sacrahzation of the fifth himbar \ertebra, where there has been over- FiG. 34. Fig. 35. Fig. 34. — The center for the patella appears at the fourth jear. The age of this patient is about nine years and the patella has not reached its full size. Fig. 35. — The well-developed head of the tibia at eight years. development of one of the lateral masses. The reverse of this is seen where the lateral mass on one side of the fifth lumbar vertebra is under-developed and a scoliosis results. These variations in the normal process of development and union of the epiphyses are important factors in the production of deformities. Certain diseases of infancy, notably rickets, lues and scurvy, affect the epiphyses, retarding growth and producing deformities. Then again, in cretinism and infantil- ism there is marked delay in the union of the epiphyses. EPIPHYSES 43 In cases of the latter condition all the epiphyses have been seen as late as the age of thirty. In the various types of chon- drodystrophies the reverse takes place; the epiphyses unite at a much earlier age than normal, and consequently the bones are much shorter, but the periosteal growth continues until the bones reach their normal width. Fig. 36. Fig. 37. Fig. 36. — Showing the centers of the ankle joint present at birth. Tlie space between the leg bones and metatarsals is filled with cartilage. Fig. 37. — Note the three centers present in the vertebrae, one for each lateral mass and one for the body. There are certain variations as to the position ot the epiphyses that must be borne in mind. The thumb metacarpal has its epiph3'sis at the proximal end, while the remaining four have their epiphyses at the distal end. This, taken into consideration with the fact that all the phalanges have their epiphyses at the proximal end and that the thumb has only two phalanges, suggests that the thumb metacarpal is in reality a phalanx. Fig. 38. This condition exists afso in the big toe. 44 INJURIES AND DISEASES OF BONES AND JOINTS In a small percentage of cases the second metacarpal and the metatarsal, besides having epiphyses at the distal end, have additional ones at the proximal ends. Fig. 38. — Showing the epiphysis of the first metacarpal at the base while the other metacarpals have their epiphyses at the distal end. As has been noted, the epiphyses play an important part in injuries. The junction of the epiphysis and shaft is relatively weak and in injuries of that region epiphyseal separations are common. We seldom have dislocation, as the joint capsule is stronger than the epiphyseal union. CHAPTER IV FRACTURES OF THE UPPER EXTREMITIES CHAPTER IV Fractures of the Upper Extremities A FRACTURE may be defined as a break in the bone texture or a solution of continuity. When such a condition takes place we have a pathological process in one or more of the component parts of the bone, directly dependent upon the severity of the trauma. The diflerent types of bone have already been described. The character of fractures will vary with the type of bone involved, as trans- verse, obhque and spiral fractures of the long Idoucs, or stellate fractures of the flat bones. The gravity of a fracture also varies not only as to displacement, but also as to its position. A fracture of a cranial bone is always serious whether displaced or not. The shaft of a long bone msiy not be perfectly reduced, yet the function and cosmetic results will be good. A perfect reduction of a fracture that extends into the joint may end in hmitation of motion on account of calkis protruding into the joint. elements affecting fractures Muscular Tension. Two distinct elements enter into every fracture, trauma and muscular pull. Given a certain degree of trauma with the muscles relaxed, and no fracture may ensue, while with the same degree of trauma with the muscles in tension a fracture will occur. This is of importance, as in the latter condition a fracture may ensue from a very slight injury. In one case a condjde of the femur was broken off by suddenly attempting to cross the legs. Never rule out fracture because there is no history of trauma or only a shght one. Every bone has a certain amount of flexibility, but when the muscles are under tension it becomes more or less rigidly 47 48 INJURIES AND DISEASES OF BONES AND JOINTS fixed, and a sharp blow will cause it to shatter, because it is held so rigidh" that elasticit}^ is lacking to take up the shock of the trauma. Age and Sex. Besides the two main conditions mentioned above, another factor that enters into the production and type of fracture is age. Up to the time of puberty the growing portions of the bones, the epiphj^ses, are but looseh^ united by bands of cartilage, which arrangement weakens the bone at those points. When the force of an injury centers at the epiphysis there is more apt to be an epiphyseal separation than a fracture. As an example of this it may be stated that an epiphyseal separa- tion of the lower end of the radius is extremely common, while a fracture, such as a CoIIes's, is quite rare before puberty. It must be understood that we are referring only to ordinary trauma and not to fractures produced by crushing injuries or direct heavy bIo^^'S. \\'hile the bony structure before the age of puberty is most flexible, 3-et the presence of the epiphysis, as just mention- ed, renders the bone as a whole relativeh' weak. After the epiphyses have united and up to forty years of age bones are probabfy at their strongest, and while in this period fractures are frequent, many sprains and dislocations are also seen which do not occur nearly so frequently in the age before puberty or in old age. After fort}' bones begin to lose their flexibility, and there is a certain absorption of calcium salts, causing them to become brittle and fracture much more easily. In this period disloca- tions are- not simple but are generally associated with fracture. Certain fractures are met with in the old age period which are rarely seen in the first two periods. A fracture of the neck of the femur is an example of this. From a simple injury, such as a fall, it is extremely rare to see such a fracture result before fortj^ years of age. We also see many more fractures in the male than in the female. This is not due to structural weakness of the bones FRACTURES OF THE UPPER EXTREMITIES 49 but is the result of habits and customs. As a general rule a child is under the care of the nurse or mother up to live or six years, and accidents resulting in fracture may occur to either sex in that period. After that age and up to forty the male is engaged in more active sports and hazardous occupations which cause a great frequency of fractures. After forty years both sexes generally revert to the safe way of living and the occurrence of fractures is again distributed approximately equally between the two sexes. Age and sex bear a definite relationship to fractures. Occupation. There are certain fractures which we ma\^ term occupational. Before the day of self-starters on auto- mobiles, chauffeur's fracture of the radius due to cranking was not uncommon. This was a definite type of fracture and could generally be recognized as such. It was interesting to note as motors became more powerful how the fracture changed from a subperiosteal one without displacement to the displaced and comminuted type. Condition of Soft Tissues. In addition to determining the presence of a fracture and the position of the fragments, the condition of the soft tissues must also be noted, and the presence or absence of atrophy and callus determined. A care- ful study of the plates will give this information. Just after a fracture has occurred the soft parts surrounding the fracture will swell (Fig. 39) and this swelling will persist for about one week after the fracture has been immobilized. After that period the soft parts become normal in size, but as the immobilization continues atrophy of the soft parts also will begin to ensue, due to disuse. This is most marked in ununited fractures. Just as in bones this is a functional rather than a pathological process. Bone Atrophy. When a fracture is present the affected part is held immobilized either by the application of splints, or if not treated the patient will hold the part immobile on ac- count of pain. When a bone is immobilized disuse of that part results, and after a lapse of about three weeks the roent- 50 INJURIES AND DISEASES OF BONES AND JOINTS genogram will show a beginning porosity of the bone, Fig. 40. This gradually increases according to the length of time of immobilization. The condition is known as atroph}^ and is entirely a disuse process and not due to injurj'^ or disease, per se, so it also must be regarded as a functional rather than a }• \ ^ }f Fig. 39. Fig. 40. Fig. 39. — Showing swelling of soft parts from a recent iniur\', resulting from a fracture of tlie lower third of the radius. Fig. 40. — Old Colles's fracture where there has been marked limitation of motion with resulting atrophy of the bones. This marked degree of atrophy is never seen except with injury or disease of long standing. pathological process. This can be readily demonstrated in a forearm where the radius has been fractured but the ulna is intact. At the end of five or six weeks the ulna will have be- come as atrophic as the broken radius. Care must be taken not to confuse this general atrophy with the localized atrophy present at the ends of broken bones. FRACTURES OF THE UPPER EXTREMITIES 51 This localized atrophy is a true bone absorption and is the result of the tearing of the blood vessels with a resulting death of the bone nourished by the particular vessel injured. With increasing age there is a gradual absorption of lime salts, producing a certain degree of atrophy of all the bones. This can be readily recognized, as all the bones will be equally affected, and the atrophy will not be confined to the injured bone. Some ^^ riters use the phrase ''atrophy of quality" when there is absorption ol lime salts and the bone is more porous, and "atrophy of quantity" when the bone is smaller in size than normal. Atrophy of quantity, is a very misleading term, since it implies that an actual reduction in the size of the bone has taken place, whereas the difference in size is due to non-development and not to shrinkage. The undeveloped femur in a congenital dislocation illustrates this point. When a bone is immobilized, atrophy begins to show in about three weeks and increases with the time of immobiliza- tion. In an old ununited fracture the atrophy may be so exces- sive that it is often difficult to get a roentgenogram which will properly demonstrate the bone. Formation of Callus. It has already been mentioned that the periosteal covering of the bone in its normal state cannot be demonstrated upon a roentgenogram. When a trauma occurs to it, and especially if it is torn, the resulting reaction will be the gradual deposition of hme salts and the formation of new bone. This, taken in connection with the new bone thrown out at the end of the fragments, wc speak of as callus, Fig. 41. In adults this lime deposition cannot I)e recognized as such until nearly four weeks have elapsed, but in children it may take place as early as the end of one week. Up to that period the bone may be firmly united, yet the .v-ray will not show any calcium salts. During this prc-lime salt period we speak of the bone and periosteal reaction as soft callus. Cahus is then first seen in about four weeks, and under ordinary conditions reaches its maximum in six weeks, after ^2 INJURIES AND DISEASES OF BONES AND JOINTS which period it will be gradually reabsorbed. The amount of callus depends upon the severity of the injury to the parts and upon the amount of the displacement of the fragments. In the subperiosteal fracture with no displacement no excess callus will form — in fact, sometimes no callus is seen at all, while in a fracture with marked displacement there will be a Fig. 41. Fig. 42. Fig. 41. — Callus formation at the end of six weeks. Callus as a rule does not show much before the fourth week in adults. Fig. 42. — Backward displacement of the lower end of the humerus. The periosteum was torn loose for a distance of two inches from the posterior aspect of the humerus. At the end of eight weeks the space between the torn periosteum and humerus has become completely filled with new bone. great amount of callus. The greater the injury and the more the periosteum is torn the greater will be the new bone formation. New bone formation does not take place at random, but is the direct result of stimulation. In all cases of fractures the stimulation is the injury, and consequently the new bone will be produced as far as the injury extends. This is the reason FRACTURES OF THE UPPER EXTREMITIES 53 that in some fractures, particularly' in supracondyloid frac- tures of the lower end of the humerus, subperiosteal bone will be seen extending upwards a third or a half of the shaft, as in such a fracture the periosteum will be torn loose that far, Fig. 42. If we take into consideration soft tissue swelhng, atrophy and calkis and their relation to each other we can relatively tell the age of the fracture. This is sometimes of great impor- tance, as the following case will illustrate. A man of forty-five entered suit for $50,000 against a construction company for a fracture of the neck of the femur alleged to have been sustained while in the employ of the defendants. An .\-ray examination made two days after the injury showed a fracture of the neck of the femur. At the trial the defendants called a roentgenologist who after seeing the roentgenograms of the broken bone was able to state that the fracture was at least six months or a year old. This opinion was rendered upon the following data ob- tained from the plate: There was an extreme degree of atrophy present, no calhis formation but partial absorption of the neck of the femur. A temporary postponement of the case was granted. Further testimony obtained showed that the patient had fractured his hip several months previously while in the employ of some concern in the West and the defendants won the case. To summarize briefly the points in determining the age of the fracture: In a fresh fracture there is soft tissue swelling, no atrophy, no calhis. In a fracture of two weeks duration there is no swelling, no atrophy, no callus. In a fracture of four weeks duration there is slight atrophy of the soit tissues, atrophy of bone and beginning callus formation. In an old ununited fracture there is excessive atrophy of both soft tissues and bone, no callus formation and the edges of the fracture have become smooth and slightly eburnatcd. Fractures from Pathological Causes. The above description applies only to traumatic Injuries. In a certain class of cases fractures occur not as the result of trauma, but from 54 INJURIES AND DISEASES OF BONES AND JOINTS destruction of bone following some pathological process. This is particularly true in osteomyelitis and in malignant tumors of the bone and in benign conditons where the bone undergoes a rarifying process either local, as in bone cysts, or general, as in osteomalacia and osteitis deformans. In these conditions the fracture, position of fragments and method of repair will be influenced by the pathological process antedating the fracture. In all fractures it is well to bear in mind that the older the patient the more slowly repair takes place and the greater the chance of non-union. The duty of a roentgenologist is not only to determine the presence or absence of a fracture but, if a fracture exists, whether there is displacement or not. By data obtained from the plate he should be able to determine the approximate age of the fracture, so that il no callus is present he can state whether it is too early for callus, or that there is delayed callus formation or the condition of non-union exists. FRACTURES CLASSIFIED ACCORDING TO AGE The foregoing description applies to fractures in general. An attempt will now be made to describe briefly the more common fractures that the roentgenologist encounters. These fractures will also be discussed from the standpoint of age periods, as follows: 1. Up to twenty, or the first age period. 2. From twenty to forty, or the second age period. 3. Over forty, or the third age period. Fractures of the Head The Skull. Being a semi-hollow sphere, the skull has a certain elasticity, and this in combination with the close fit- ting integuments, such as skin, muscle and periosteum on the outside, and the intracranial contents, gives rise to variations in its fractures. In other words, displaced fractures are not, as a rule, encountered, but cracks in the cranial bones; though, FRACTURES OF THE UPPER EXTREMITIES 55 of course, when there is a very severe blow, as from a rock or hammer, or from a fall on some blunt object, there will be depressed fractures (Fig. 43), which are easy to recognize. The linear fractures (Fig. 44) arc often \ery difficult to detect and may be mistaken for the grooves in the bones which carry the blood vessels. The importance of detecting these linear fractures is not in locating the fracture itself, but because Fig. 43. — V shaped fracture with dei^ressioii in the frontal reiJ!;u)n. its presence indicates a probable hemorrhage beneath it; and for this reason, on account of the delicate brain structure, it is very necessary to determine the location of such a fracture. Fractures of the skull may be divided into those ot the vertex and those of the base. Both types may come Irom direct violence or may be the result of transmitted force, so that in such injuries a careful study of all parts ot the head 56 INJURIES AND DISEASES OF BONES AND JOINTS should be made irrespective of where the actual trauma occurred. Since these fractures are due to violence thej^ may occur at any age, but are most common in both sexes in the first age period and in males in the second age period. As linear fractures of the vertex may be present without a brain lesion and mav be overlooked, manv cases of con- FiG. 44. — Linear fracture in the occipital region. This was only differ- entiated from the groove for a blood vessel by stereoscopic examination. cussion are probably fractures of the vertex. Fractures of the base are always accompanied by grave symptoms and consequently are x-rayed, hence fracture in this location is not so often overlooked. Every injury of the head should be examined; if this were systematically done the recorded percentage of fractures would be materially increased. The important thing to remember is that the majority of FRACTURES OF THE UPPER EXTREMITIES 57 fractures of the skull arc not important in themselves, but are merely indicative of hemorrhage, pressure or injury to the delicate brain structure lying beneath. Facial Bones. These fractures are due to direct violence, such as severe blows or a fall upon some blunt object. On account of the complexity of the x-ray shadows in this Fig. 45. — Fracture of tlie malar bone with hemorrhage into the sinus. region it is frequently difllcult to make the diagnosis from the plate. Fig. 45. Fracture of the nasal bone when dis- placed may be easily recognized. The zygoma is next in frequency and may also be recognized. Fractures of the malar bone and superior maxilki, unless badly crushed, may be overlooked. These fractures are frequently associated with hemorrhage into the sinuses. Mandible. Fractures of this bone are very rare in early childhood, but do occur in the hitter part of the first age 58 INJURIES AND DISEASES OF BONES AND JOINTS Fig. 46. — Fracture of the mandible through one ol the molar sockets followed bv osteomvehtis. Fig. 47. — Fracture of the condyle of the mandible with displacement. FRACTURES OF THE UPPER EXTREMITIES 59 period. It is by far the most eommon of all fractures of the facial bones in the second age period. In the white race at least eighty per cent occur in the male. In the colored race only about sixty per cent occur in the male and this is not due to structural weakness, but to social conditions. The common site of the fracture is in the ramus near the angle of the jaw, and the line of fracture is transverse or shghtly oblique, Fig. 49. The nearer the fracture is to the angle the greater the chance of displacement. Since the frac- ture generally extends through one of the tooth sockets infection is common, and these fractures are frequently associated with osteomyelitis. Fig. 46. Pathological fractures are quite common in this region as the result of infection, cysts or growths. Fractures of the condyle and coronoid process are rare, Figs. 47 and 48. Fractures of the spine will be discussed separately in the chapter on the spine. (See Chapter XII.) Fractures 0/ the Upper Extremities Clavicle. Fractures of the clavicle may be di\ided into: 1. Fractures of the inner third. 2. Fractures of the middle third. 3. Fractures of the outer third. Fractures of the inner third are relati\ely infrequent and seem to occur by direct trauma, such as a severe blow. Fractures of the middle third, especially at the junction with the outer third, are the most common of all. Fractures of the outer third, especially near the acromial end, are also quite frequent. In fracture of the inner third the few cases observed by the writers were all in the second age period. Fractures of the middle third are most common in childhood and decrease in frequency with the approach of old age. This is prol^ably due not to structural weakness, but to the fact that the dan- ger of trauma decreases w^ith age. In the first age period 6o INJURIES AND DISEASES OF BONES AND JOINTS Fig. 48. — Fracture of the coronoid process of the mandible. The frag- ment extends down to the third molar. Fig. 49. — Obhque fracture of the mandible, not complete. FRACTURES OF THE UPPER EXTREMITIES 6i these fractures of the middle third may be of the green-stick variety (Fig. 50) with marked bowing or angulation, or com- plete fractures with displacement. They may be either trans- verse or obhque. In the transverse type in children reduction seems to be more difficult than in the adult and the fragments frequently have to be wired. These fractures may result from very slight trauma and may be unrecognized. In one case of a child of two years a diagnosis of sarcoma was made. The A'-ray examination showed a fracture, and the hard mass present was callus formation. In the second age period the middle third is frequently broken and is generally oblique Fig. 50. — Green-stick fracture ol the outer third of the clavicle in a child. with the outer fragment displaced downward. In the third age period the middle third is less frequently broken than the outer third. In the young fracture of the outer third is common, and the fragment is generally displaced downwards, Fig. 51. In the second and third age periods there is one fracture of the outer third that deserves especial attention, since the clinical diagnosis of this is often wrong. In these periods, dislocation upward of the clavicle at its acromial end is quite common. In a number of cases, however, instead of a true dislocation taking place, the tip of the clavicle is fractured. Fig. 52. It remains in situ, but the clavicle rides up and the prominent end that is uppermost is often mistaken for the 62 INJURIES AND DISEASES OF BONES AND JOINTS end of the clavicle when in reahty it is the fractured end of the shaft. Scapula. Fractures ot the scapula, excepting theacromion, are relatively uncommon and many of them, especially ot the body, are not recognized. They may be divided into fractures of the body, spine, glenoid fossa, coracoid lower angle, and acromion. Fractures of the bod}' (Fig- 53) generally occur in the subspinous fossa starting just below the glenoid fossa, and are Fig. 5 1 . — Fracture of the outer third of the clavicle with shght displacement. often incomplete. Fractures of the spine ( Fig. 54) are uncom- mon unless associated with fractures of the body. Fractures of the glenoid (Fig. 55) are quite rare, and generall}' the lower third is involved, though the writers have seen one case where the glenoid was separated irom the body. Fractures of the coracoid (Fig. 56) are also uncommon; the tip is sometimes pulled off by muscular violence. The lower angle is occasionally broken off and may be displaced. Care must be taken not to confuse the epiphysis of the angle for a fracture. Fracture of FRACTURES OF THE UPPER EXTREMITIES 63 Fig. 52. — Fracture of the extreme tip of the clavicle, tlie small fragment remaining in situ while the shaft of the clavicle has ridden up, simulat- ing a dislocation. ^yg Fig. 53. — Fracture of the body of the scapula with the glenoid dis- placed inward. 64 INJURIES AND DISEASES OF BONES AND JOINTS the acromion (Fig. 57) is most common and the outer tip is frequently pulled off instead of an acromio-clavicular dis- location. Scapular fractures are uncommon in the first age period and most frequent in the second age period. Hu-MERUS. In the first age period we have the epiphysis present, and this relatively weakens that portion of the arm, 3'et separation is very uncommon, Fig. 58. The writers have .S0^ Fig. 54. — Fracture at the base of the spine of the scapula. had only two such cases. In these cases the head remained in the glenoid fossa but rotated slightly allowing the shaft to slip shghtly upward and outward. In young infants this injury may occur more often than is supposed, but since no ossification centers are present it cannot be demonstrated, as cartilage does not cast a shadow upon the x-ray plate. Upper End. The most common fracture in this age period is in the upper third of the shaft or in the surgical ^P ^ ^ ^^jf^l ^B Vi ^I^^B ''>'-i ^ J ■■A '-5 '^ :^ 'o U-, 66 INJURIES AND DISEASES OF BONES AND JOINTS Fig. 57. — Fracture of the tip of the acromial process with displacement. Fig. 58. — Epiphyseal separation of the upper end of the humerus. Note the rotation of the head with ridmo; up of the shaft. FRACTURES OF THE UPPER EXTREMITIES 67 neck, Fig. 59. These are generally transverse, and the upper fragment is displaced outward. Fracture of the greater tuberosity is uncommon. In the second and third age periods fractures of the ana- tomical neck may occur. In the experience of the writers this is a very rare fracture; while the clinical diagnosis of this fracture Fig. 59. — Fracture of the surgical neck of the humerus in a patient over fifty, associated with a fracture of the greater tuberosity. is made, the diagnosis is seldom borne out by the .v-ray findings. Only two such cases have come under our observation. Fracture of the surgical neck of the humerus is the most common, most frequent after the age of twenty. This fracture may be transverse, slightly oblique or impacted. Displacement varies according to the nature and severity of the trauma. It 68 INJURIES AND DISEASES OF BONES AND JOINTS may be associated with fracture of the greater tuberosity or with dislocation of the head of the humerus. In the second age period the fracture is confined to the surgical neck, and is seldom associated with fracture of the greater tuberosity or dislocation of the head. The shaft, when displaced, as is also the case in the first age period, is generally pushed to the inner side, Fig. 60. In the third age period this is by far the most com- mon of all fractures of the humerus, and is frequently associated with fractures of the greater tuberosity (Fig. 61) or dislocation of the head. The capsule is often badly torn, so that the end of the shaft rides up into the glenoid fossa and displaces the head outward. Fig. 62. Where the head is not dis- located it rotates slightly outward, so that the frac- tured surface points out- w^ard. When the fracture unites in this position the arm can only be raised to a right angle. This is due to the fact that at the time of union the head is in a position of partial rotation and when the arm is raised to a right angle the head, on account of its abnormal position, is in complete rotation. Occasionally frac- ture of the surgical neck is accompanied by a "T" fracture through the head, and then the internal portion of the head is dislocated, lying generally beneath the coracoid or in the axilla. Fracture of the tuberosity alone is quite common and is Fig. 60. — Showing the outward dis- placement of the head of the humerus in a fracture near the surgical neck. FRACTURES OF THE UPPER EXTREMITIES 69 often unrecognized, as there may be no displacement of the fragment, Fig. 63. It is only after there is marked limitation of motion that something more serious than a bruise is suspected. Occasionally the attachments of the scapular muscles will be torn loose with a small bony fragment. This small fragment will be just external to the greater tuberosity. Care must be Fig. 61. — Old fracture of the greater tuberosity and surgical neck of the humerus with atrophy from disuse. exercised not to confuse this condition with subdeltoid bursitis with a calcium deposit in the wall of the bursa. Sometimes it is impossible to differentiate the two conditions. The follow- ing case will ilkistrate this point. A man, aged forty, fell striking his left shoulder. Two hours after the injury swelling became pronounced and was accom- panied by severe pain and limitation of motion. The .v-ray disclosed what was taken to be a small fragment of bone torn 70 INJURIES AND DISEASES OF BONES AND JOINTS loose from the tuberosity. The arm was immobihzed but there was no relief from pain. There had been no past history of any discomfort in or injury to that shoulder. It was finally decided that the apparent frag- ment of bone was in reality a deposit of calcium in the bursa. Operation confirmed this and with removal of the bursa the patient made a complete recovery. W hile every injury, es- peciallv in elderly indi- \iduals, should be viewed with suspicion as to frac- ture, it must be borne in mind that there is always present a quiescent low- grade arthritic condition. This may never have troubled the patient, yet an injury to the part may cause this arthritis to flare up and produce such acute pain in the joint that a fracture will be sus- pected. Shaft. Fractures of the shaft are common and may occur anywhere between the surgical neck and the supracondyloid ridge, though fracture of the middle portion is most frequent. There is no definite displacement, as this varies according to the nature and severity of the trauma. In the first age period (Fig. 65) green-stick and oblique fractures are more frequent, while in the second and third age periods, transverse and comminuted fractures are more common. Fig. 66. The one interesting thing in fractures of the shaft is that non-union is quite frequent, due partly to the displacement of the frag- FiG. 62. — Fracture ut the surgical neck of the humerus with the end of the shaft in the glenoid fossa and the head displaced outward. FRACTURES OF THE UPPER EXTRExMITIES -i ments and partly to muscle or fasciae lying between the fragments. Lower End. Fractures of the lower end of the humerus Fig. 63. — Old fracture of the greater tuberosity of the humerus, not recog- nized at the tune of iniury. below the supracondyloid ridges are the most common of all. They may be divided into: 1. Supracondyloid fractures (epiphyseal in the young). 2. Fracture of the external condyle. 3. Fractures of the internal condyle. 4. Fractures of the internal epicondyle. 5. Fractures of the external epicondyle. 6. Fractures of the capitelhim and trochlea. The supracondyloid fractures may be transverse or oblique, and when close to the condyles may extend through the olecranon -2 INJURIES AND DISEASES OF BONES AND JOINTS fossa, and there is often present a "T" fracture ex- tending into the joint. The lower fragment may be dis- placed laterally or posteriorly according to the line of the fracture. In the first age period the supracondyloid fracture generally involves the epiphyseal line, and in the very young the fragment is usually displaced back- wards and slightly to the Fig, 64. — Epiphyseal separation of the inner sides, Fig. 64. It is a lowerendofthe humerus. The joint yerv difficult fracture to re- is carried back with the fragment. ^j^^^^^_ j^^ internal displace- Fig. 65. — Green-stick fracture of Fig. 66. — Spiral fracture of the the humerus in an infant with humerus. Such fractures are no displacement. Just dis- more commonly seen in the first cernible. age period. FRACTURES OF THE UPPER EXTREMITIES 73 ment of the lower fragment can be corrected and held. The posterior displacement can be corrected, but generally can- not be held, Fig. 67. When this fracture occurs the periosteum on the posterior surface is torn loose for some distance along the shaft. In such cases where reduction cannot be obtained the fragment may be left in this position and the displaced periosteum will throw down a strong bony bridge. When this has taken place the lower end of the shaft will be anterior and will prevent flexion. An open operation in chisel- FiG. 67. — An attempted reduction of a supracondylar fracture of the lower end of the humerus. This was reduced under fluoroscope, but the fragment could not be held in the plaster cast and reverted to the original displacement. ing off this fragment will give a perfectly functioning elbow. This fracture is often diagnosed as dislocation of the elbow. Fractures of the cpicondyles in children often cannot be demonstrated on account of their being entirely cartilag- inous. The internal epicondyle is most frequently fractured. The writers have never seen a fracture of the external epi- condyle. Fractures of the condyle are most common in this age period, and fracture of the external condyle is the more common 74 INJURIES AND DISEASES OF BONES AND JOINTS of the two. They may or may not be displaced, varying accord- ing to the nature and severity of the trauma. In the second and third age periods the supracondyloid fracture generally takes place just where the shaft expands to form the condylar portion of the lower end. These fractures are oblique, and the fragment may be displaced forward or backward according to the nature of the injury. Fractures of the condyles (Fig. 68) are more common in the second age period than in the third. The supracondyloid fracture in the second age may be accom- FiG. 68. — Fracture of the external condyle of the lower end of the humerus. The fracture almost extends into the fossa. panied by a "T" fracture into the joint. The fragments may be more or less displaced. Fractures of the capitellum and trochlea are quite rare except where there is a crushing injury of the joint. In injuries of the lower end of the humerus in young children care must be exercised in making a diagnosis of " no fracture." We must bear in mind that a great portion of the joint is cartilaginous and that a fragment of cartilage may be broken off and yet not be demonstrable by the x-ray. In such cases it has always been- the custom of the writers to return a diagnosis stating that no fracture can be demonstrated. Forearm. Upper End. Fractures of the olecranon may occur at any age, but seem to be most common in early adult FRACTURES OF THE UPPER EXTREMITIES -5 and middle life, though occasionally in the young the epiphyses may be torn loose. Besides trauma, muscular pull plays an important part in this fracture, the writers having seen such an instance from throwing a base ball. The fracture may take place in any portion of the coronoid fossa and is very seldom comminuted. The position of the frag- ment depends entirely on whether the triceps attachments are torn loose. If attachments are intact there will be no separation (Fig. 69), but if torn, the fragments may be widely Fig. 69. Fig. -o. Fig. 69. — Fracture of the olecranon process. There is no displacement as the fascia has not been torn. Fig. 70. — Fracture of the olecranon process where the fascia has been torn which has allowed the fragment to separate and rotate. separated, Fig. 70. It is interesting to note that the chance of fibrous instead of bony union increases with the nearness of the fracture to the tip of the olecranon; and, conversely, as the fracture approaches the shaft, bony union generally takes place. A fracture of the coronoid process (Fig. ^i) is generally associated with backward dislocation of the ulna. It is very uncommon as a simple fracture. The line of fracture is roughly parallel or slightly oblique to the long axis of the shaft. \\ hile -6 INJURIES AND DISEASES OF BONES AND JOINTS the writers have seen such cases they are extremely uncommon, and in none of the cases observed was there any displacement of the fragment. Fractures of the head of the radius are frequent and may var}^ from cracks to comminuted fractures with displacement Fig. 71. Fig. 72. Fig. 71. — Fracture of the coronoid process and the head of the radius with dislocation of the joint not completely reduced. Fig. 72. — A small fragment of the head of the radius broken off. The small calcified areas above this fragment are in the Hgaments and are probably due to calcification of small hemorrhages. Fracture is six months old. of the fragments. This fracture is common in early adult life and old age. It is very uncommon in the young and the writers have never seen a case of epiphyseal separation. Fractures of the radial head, unless displaced, are often overlooked. It is the wTiters' experience that careful examina- tion of the radial head in injuries of the elbow w ill show frac- tures without displacement to be much more frequent than is commonly supposed, and that these fissure fractures are FRACTURES OF THE UPPER EXTREMITIES //' seldom recognized at first. In fact the patient does not consult a surgeon at first, thinking he has only a bruise; but with no amelioration of discomfort, at the end of a week or ten days, he seeks professional advice and x-ray examination shows the fracture. The writers saw four such cases in one afternoon, and m Fig. 73- E'G. 74. Fig. 73. — Fracture of the Iicad of the radius with part of the head displaced. Fig. 74.- — Fracture of the neck of the radius with marked anterior dis- placement. all had sustained their injuries a week or ten da\ s previously. The fracture may be confined to just a part ol the outer edge of the head (Fig. 72); it may extend into the shaft; or it may be comminuted (Fig. 73), and divide the head into several fragments. When there is no displacement and the fracture is healed, a large percentage of the cases do not get complete extension of the arm. In the comminuted type, where one or more fragments are displaced, non-union will sometimes take place, and in that case the fragment acts as a foreign body and ^8 INJURIES AND DISEASES OF BONES AND JOINTS has to be removed. Sometimes when displaced they will unite with excess callus and interfere with rotation. Fractures of the neck of the radius (Fig. 74) are much less frequent than those of the head. The line of fracture is '# Fig. 7S- Fig. -6. Fig. 75. — Lateral view showing fracture of the upper third of the uhia with anterior dislocation of the head of the radius. Fig. 76. — Same condition as that shown in Fig. 75 from an antero- posterior position. generally oblique, and there is usually displacement. It is often very difficult to reduce and hold these fragments in place. Displacement with non-union is fairly frequent. Fracture of the ulna (Figs. 75 and 76) alone is generally seen in the upper third just behind the coronoid fossa and FRACTURES OF THE UPPER EXTREMITIES is frequently associated with dislocation of the head of the radius forward, Fig. 77. Shaft. Fractures of the shaft of both bones of the forearm are probably next in frequency to Colles's fracture, and may m Fig. 77. Fig. 78. Fig. 77. — Old fracture of the upper third of the ulna with forward dislo- cation of the radius. The radius has shpped well up on the head of the humerus, due to the shortening of the ulna from absorption. Fig. 78. — Green-stick fracture of radius and ulna showing angulation but no displacement. occur at any age period. Fractures of the middle and lower third are the common situations, and are relatively infrequent in the upper third. Unless the fractures are of the green- stick (Fig. 78) or subperiosteal variet}'^ invariably there is dis- placement with more or less over-riding of the fragments, Fig. 79. This displacement may be so excessive that union will not take place, or if it takes place the excess callus may actually 8o INJURIES AND DISEASES OF BONES AND JOINTS produce a bony synostosis and rotation will be lost. In children this fracture is often incomplete and of the greenstick variety. Lower End. Fractures in this region may be ad\antage- ously studied according to the three age periods. In the first period the most important part of the lower Fig. -^g. Fig. 8o. Fig. 79. — Fracture and displacement of radius and uhia. Fig. 80. — Backward dislocation of the epiphysis of the lower end of the radius. The joint is carried back with the epiphysis. end of the radius is the epiphysis. Its union with the shaft is relatively weak when compared with the shaft of the bone, and trauma localized at that point will frequently displace it (Fig. 80) instead of breaking the bone. When this takes place the condition is much more serious than that obtaining with an ordinary fracture. In a fracture ^^•ith faulty reduction FRACTURES OF THE UPPER EXTREMITIES the end result is a deformity; with a displaced epiphysis not only the deformity results but, what is infinitely more impor- tant, the growing portion of the bone is destroyed. If the epiphyseal separation is not reduced, the deformity steadily increases as the ulna continues to grow, while the end of the radius remains stationary. This will result in a marked deflection of the hand to the radial side, continuing to increase until the ulna has reached its full growth. This epiphyseal separation of the radius is sometimes accom- panied by a chipping off of a small fragment of bone from the ulnar side of the diaphysis of the radius. Fig. 8i. Fracture of the styloid of the ulna, as in CoIIes's fracture, is also occasionally as- sociated with this separation ; but the writers have never seen the ulnar epiphysis torn off. Occa- sionally after a trauma one will find a swollen wrist and limita- tion of motion; the x-ray exami- nation, however, will disclose no separation, but the epiphyseal line seems to be a trifle wider and more irregular than is normally seen. This swelling and tenderness may persist for several weeks; and in one case under the writers' observation, without any additional injury the epiphysis became slightly displaced, though it was in normal position just after the injury. This gives rise to the belief that following trauma the epiphysis may partially slip off and then snap back into position again. When such a condition is suspected the arm should be placed in splints and treated as an ordinary fracture. Fig. 8i. — Epiphyseal separation of the lower end of the radius with a small fragment torn off from the radius. 82 INJURIES AND DISEASES OF BONES AND JOINTS \\'hen the patient falls upon the palm of the hand the epiphysis is dislocated posteriorly; if the hand is flexed and the patient falls upon the dorsum then the dislocation is anterior, but this is extremely rare. If the trauma is sufiicient to produce fracture and the epiphysis does not yield, then the radius Fig. 82. Fig. 83. Fig. 82.— Fracture of both bones of the forearm, just below the point where a CoIIes's fracture would occur in the third age period. Fig. 83. — Fracture in the second age period where both bones of the fore- arm are broken, resulting from a fall which would have produced a CoIIes's fracture if the patient had been older. fractures an inch to an inch and a half below the epiphj^sis (Fig. 82) and is frequently associated with a fracture of the idna at the same point. \\ hen this condition takes place the fragments generally override, and on accmmt of the pronator muscles it is often impossible to reduce them without an open operation. Occasionalh' the ulna alone will be fractured in this same region. In this age period green-stick and subperiosteal frac- tures are frequent. On account of the flexibility' of the bones in FRACTURES OF THE UPPER EXTREMITIES 83 this period it is unusual to see comminuted fractures resulting from simple injuries. In the next age period the epiphyses of the bones have united, and trauma in this region will cause a fracture of the radius or ulna or both about an inch and a half below the joint, Fig. 84. Fig. Fig. 84. — CoIIes's fracture with marked displacement backward of the lower fragment carrying the joint with it. Fig. 85. — CoIIes's fracture with anterior displacement of the lower fragment due to falling on the dorsal instead of the anterior surface of the hand. and as in the first age period we maj^ ha\e the same deformities. Fig. 83. During this period CoIIes's fracture is unusual. In repeated series of consecutive CoIIes's fractures resulting from falls we have found that only from i to 2 per cent occur in this age 84 INJURIES AND DISEASES OF BONES AND JOINTS period. From direct blows, such as cranking a car, we see CoIIes's fractures; but this type we may term occupational. In the last age period the CoIIes's fracture predominates. A CoIIes's fracture is essentially a fracture of the middle-aged and old. Repeated series of this fracture show that from 98 to 99 per cent are above the age of forty. This is no doubt due to what may be termed senile changes in the bone, i.e., loss of Fig. 86. Fig. 8' Fig. 86. — An old CoIIes's fracture with backward displacement, the usual position of the fragment. Fig. 87. — Impacted CoIIes's fracture with no displacement. This t\-pe of fracture is frequently mistaken for a sprain. flexibility and absorption of calcium salts, thus causing the bone to become brittle. This fracture is through the cancellous portion of the end of the radius; it extends across the bone about three quarters of an inch below the joint, and is generally associated with a fracture of the styloid of the ulna. In the writers' series of cases the sty- FRACTURES OF THE UPPER EXTREMITIES 85 loid of the ulna was broken in from This fracture may vary from simple to comminuted, and, as in epiphyseal separations, the lower fragment may be displaced posteriorly (Fig. 84) or anteriorly according to whether the fall was on the palmar or dorsal surface of the hand (Fig. 85), the former being by far the most common. The roentgenologist probably sees more old CoIIes's fractiu-es than any other type of fracture, and this is because such a fracture if improperly set will give more trouble than any other. In cases w^here bad end results are ob- tained it is due to one of the following three causes: I. Posterior dislocations, W'here the fragment has not been reduced. Fig. 86. 2. Impaction, where the shaft is driven into the fragment with- out any displacement at all. In such cases on account of the good alignment of the bone and lack of displacement the fracture is fre- quently dressed Nxithoiit rechic- tion. Fig. 87. 3. Angulation, where the fragment has not been dislocated but has turned upon its axis, so that while there is no displace- ment, yet the long axis of the w correspond to the long axis of the 60 to 70 per cent of the cases. Fig. 88.— Old CoHcs's fracture where there is angulation without displacement. Note the divergence of the axes of the shaft and fragment. rist and fragment does not radius. Fig. 88. 86 INJURIES AND DISEASES OF BONES AND JOINTS The vast majority of impacted fractures result in painful and partially stiff wrists. If such a fracture is examined three weeks after reduction there will be found absorption of the ends of the fragments, and with the muscular tension these fragments are pulled together and shortening is produced. If, however, the impaction is broken up, then the fragments are separated and the consequent hemorrhage taking place between them keeps the fragments apart, so that when union takes place Fig. 89. Fig. 90. Fig. 89. — A Barton's fracture which follows approximately the epiphyseal line if that were present. A very rare fracture. Fig. 90. — An old fracture of the styloid of the radius. Note the marked atrophy from disuse. there is no shortening. It is a safe rule to follow that where the condition of the patient permits, every impacted CoIIes's fracture should be broken up. If this is done the end results will be infinitely better. The important point to remember is that it is the anterior or posterior dislocations which produce the more or less painful and partial limitations of movements, while lateral FRACTURES OF THE UPPER EXTREMITIES 8- displacement gives an enlarged wrist, but it is not painful nor does it limit motion. In middle and old age every injury to the wrist must be looked upon as a probable fracture, as the so-called sprains in the third age period are very rare. This is particularly true of those with impaction, as there is no displacement and on account of lack of deformity they are frequently overlooked unless A-rayed. Besides the fractures already mentioned there are two others of the low^er end of the radius, Barton's fracture and fracture of the styloid of the radius. Barton's fracture (Fig. 89) seen only in the adult, is a transverse fracture of the radius just below the joint, that is, between the site of a CoIIes's fracture and the articulating surface of the radius. This fracture takes place at the site of what would be the epiphyseal line if it were present. There is seldom any displacement. Barton describes this as a common fracture, but in the writers' experience in over ten thousand fractures around the wrist joint, it was found to be very rare. Fractures of the styloid of the radius (Fig. 90) are quite common and vary in position from the tip of the styloid to an oblique fracture through the joint surface, involving a third of the radial end. If the fracture is simple it is seldom displaced. It is frequently associated with a CoIIes's fracture, and then it is often displaced. Ununited fractures in this region do not occur. Wrist. Fracture of the scaphoid (Fig. 91) is the most common of all carpal fractures. It may occur alone, but is frequently associated with fractures of the lower end of the radius. It was formerly believed to be quite rare, but careful examination of x-ray plates has shown that it is relatively common. Fracture of this bone is infrequent in the young. Between the ages of twenty and forty it is generally unassoci- ated with fracture of the radius. After forty it is seldom simple, but is generally associated with CoIIes's fracture. Fig. 92. One of the fragments may or msiy not be displaced. The union is 88 INJURIES AND DISEASES OF BONES AND JOINTS generally fibrous, so that it is impossible to determine by the A-ray whether it has united or not, as no callus is ever thrown out. W hen union does not occur the fragments may remain in apposition for years and then some slight twist of the wrist dislocates one of the fragments. The writers have seen one case where the fragment was dislocated eight years after the original injury. Fracture of the semilunar is next in frequency but is relatively rare, dislocation being more common. Fig. 91. Fig. 92. Fig. 91. — Fracture of the scaphoid of the wrist without displacement. Fig. 92. — CoIIes's fracture associated with fracture of the scaphoid; one, of the fragments is displaced. The remainder of the carpal bones are but infrequently fractured. Hand. Fractures of the metacarpal bones are common accidents but not so frequent in the young unless there has been a crushing injury. Epiphyseal separation is most un- common. By far the greater majority of metacarpal fractures occur after the union of the epiphysis, and they are much more common in the male than in the female. The second, fourth FRACTURES OF THE UPPER EXTREMITIES 89 and fifth metacarpals are more frequently broken. The third is seldom fractured. The fractures are of two varieties; the most common is just below the head of the bone with the head displaced toward the palmar side of the hand, Fig. 93. The oblique fracture (Fig. 94) generally invokes the shaft and may extend almost the entire length of the bone; there is seldom much, if any, displacement. The shaft of the first metacarpal is seldom broken. \\ hen a fracture occurs in this bone it is a short oblique one just Fig. 93. FiG. 94. Fig. 95. Fig. 93. — Fracture of the distal head of tlie first metacarpal I)one, with chsplacenicnt. Fig. 94. — Oblique fracture of a metacarpal bone without disi^Iacemeiit. Fig. 95. — Fracture of the base of tlie first metacarpal with anguhition. above the base, starting at the inner side and extending downward to the outer side of the bone. Fig. 95. This tri- angular fragment remains in situ, but the shaft is displaced outward, simulating a dislocation. It is difficult to reduce. When union takes place, function is not impaired, but there may be deformity. 90 INJURIES AND DISEASES OF BONES AND JOINTS , Fractures of the phalanges (Fig. 96) are generally the re- sult of direct violence and are frequenth^ multiple; some, there- fore, maj' be unrecognized. The fragments are often displaced. These fractures are relatively rare in the young, but are most common in men between the ages of twenty and forty, as that period may be termed the period of hazardous employ- ment. These fractures alwaj^s unite, but, since they are due to crushing injuries, they are either compound or are attended Fig. 96. Fig. g-^. Fig. 98. Fig. 96. — Longitudinal fracture of the terminal phalanx of the thumb. Fig. 97. — Crushing fracture of the terminal phalanx with osteomyehtis. Fig. 98. — A small fragment of bone broken off from the articulating surface of the terminal phalanx, producing the "base-ball finger." with lacerations, so that osteomyelitis is a common sequela, with the joint eventually becoming involved, in which event an ankylosis (Fig. 97) may ensue. The first and second pha- langes are the ones most commonly broken. Besides these fractures from crushing injuries there is also the "baseball finger," Fig. 98. When such a finger is examined by means of the .v-ray a small fragment of bone is usually found broken from the articulating surface of one FRACTURES OF THE UPPER EXTREMITIES 91 of the phalangeal joints. The fragment is generalh' pulled away and union does not take place. It frequently acts as a foreign body, and a fibrous ankylosis of the joint may take place. Fractures of the Trunk Ribs. Fracture of the ribs is probably the most frequent of all injuries. It may occur at any age, but is most common Fig. 99. — Fracture ol sc\"cral ribs witli slight displacement. in the second and third age periods. Such fractures are gener- ally the result of falls, and while any rib may be involved it is very unusual to see the hrst rib broken. From the third to the ninth rib is the seat of the usual fracture; above and below that area fractures are less frequent. They generally Q2 INJURIES AND DISEASES OE BONES AND JOINTS EiG. 990. — Fracture of the sternum showing lateral displacement FRACTURES OF THE UPPER EXTREMITIES 93 Fig. 100. — Fracture ol the upper third of the fenuir, ihuin, ischium and pubis, ckie to tlie passage of a heavy wagon wheel over the peKis. occur on the anterior and axillary side of the chest, though occasionally the fracture may be posterior, close to the spinal articulation. They are generally subperiosteal in character when one rib is broken, Fig. 99. If several ribs are broken they may be displaced and one of the fragments may even tear or puncture the pleura. In one case under the writers' observation resulting from a fall from a horse, the third, fourth and fifth ribs were broken at about one and one-half inches from the spinal articulation. The short fragments pierced the muscles and could be felt lying under the skin. Fractures of the costal cartilage are quite common, but unless ossification has taken place this condition cannot be 94 INJURIES AND DISEASES OF BONES AND JOINTS demonstrated by means of the .v-ray. Fracture of the ribs may occur and the position be such that it cannot be demon- strated by the .v-ray. \\ hen no fracture can be demonstrated it is not wise to make a positive diagnosis that a fracture is not present. In such cases it has always been the writers' habit Fig. ioi. — ^Fracture of ischium and pubis, ^^'ith this type of fracture there is seldom displacement. to return a diagnosis of "no fracture can be demonstrated." Sternum. Fractures of the sternum are relatively rare and very difficult to demonstrate, as it is hard to get a clear view of the sternum. The manubrium is most common^ broken and the fracture is of the depressed variety. Lateral displacement rarely if ever occurs, Fig. 99a. Pelvis. In the first age period fractures of the pelvis from simple injuries are most uncommon. In severe trauma, such as crushing injuries or passage of heavy vehicles over FRACTURES OF THE UPPER EXTREMITIES 95 the body, while almost any type of fracture may occur, separation along the epiphyseal lines is most frequent, Fig. 100. It is in the second age period that we find the greatest percentage of fractures. Fracture of the pubis is probably the most common and generally takes place in its mid portion Fig. 102. — Fracture of the iiium by a crushing injury, with but fittle displacement. The fracture of the ischium is next in frequency. The fracture is generally near the pubis and may he accompanied b}^ displacement. Fig. loi. Fractures of the iliac bone are next in frequency, occurring usually along the long axis of the bone. Fig. 102. In severe crushing acci- dents the line of fracture is through the acetabulum and the lower half of the acetabulum is displaced. In one instance in a 96 INJURIES AND DISEASES OF BONES AND JOINTS fall from a height where the patient landed on his feet, the head of the femur was driven completely through the ace- tabulum, Fig. 103. In the third age period fractures of the pelvis are not so common and when they do occur the pubis and ischium are most frequently involved. Since most of these fractures occur Fig. 103. — Fracture of the acetabulum where the head of the temur has been driven through and is resting in the pelvic canal. in the hazardous occupations it follows of necessity that the vast majority of such injuries are sustained by males. There is one type of injury, however, that is quite common in the female, especially in the second age period and that is separa- tion of the symphysis due to child birth. These separations may vary from one quarter of an inch up to one inch. CHAPTER V FRACTURES OF THE LOWER EXTREMITIES CHAPTER V Fractures of the Lower Extremities FEMUR. Upper End. In dealing with injuries of this portion of the femur, the age is such an important factor that attention is again called to the three age periods: 1. Up to the union of the epiphyses. 2. From union of the epiphyses up to fortj" years of age. 3. Beyond the age of forty. In considering injuries of the first age period, as has been so frequently pointed out, we have the ununited epiphysis, and this epiphyseal line constitutes the weakest portion of the bone at that point. It is a well-known dictum that a chain is only as strong as its weakest link, and the weak hnk in the neck of the femur is its epiphyseal line. Consequently, when an injury occurs in this region, an epiphyseal separation is ex- pected and not a fracture of the neck, and in the experience of the writers this is what happens. The epiphyseal head is torn off and remains in the acetabuhim. Fig. 104. It has rotated shghtly and the shaft has ridden up. The separation is seldom complete, so that if untreated union will always take place; but on account of the rotation of the head and the riding up of the shaft there will be a shortened leg and limitation of abduction. The capsule and neck are much stronger than the epiphyseal line, so that dislocation or fracture of the neck is extremely rare. While various authorities state that the neck of the femur in the young is fractured more frequently than is commonly supposed, yet in the writers' experience it is most uncommon. Only one such case has come under our observation. We are excluding crushing injuries, such as those caused by the weight a heavy vehicle or by falls from heights. In the second age period fracture of the neck is also uncom- 99 100 INJURIES AND DISEASES OF BONES AND JOINTS Fig. 104. — The epiphyseal separation of the head of the femur. FRACTURES OF THE LOWER EXTREMITIES loi M. Fig. 105. — Fracture of the neck of the femur just behind the head. mon, though fracture of the head has been observed. The capsule in this period seems to be the weakest link and dis- location is seen oftener than fracture. It is in the last age period that most of the fractures of the neck occur, and they are more common in the female than in the male. In one winter month the writers saw fifteen such fractures, of which thirteen were in the female. This percentage is abnormally high, but indicates the larger proportion in the female. The neck may be fractured where it joins the head (Fig. 105), in its mid portion (Fig. 106), or at its base, Fig. 107. The fragments may be impacted or lying free; when free the x-ray will show the riding up of the shaft and the trochanter 102 INJURIES AND DISEASES OF BONES AND JOINTS Fig. io6. — Old fracture of the mid portion of the neck of the femur with absorption. rotated posteriorly indicating the outward rotation of the leg. Non-union is a frequent occurrence, and the frequency of non-union increases as the location of the fracture nears the head. When the fracture remains ununited there is a fairfy rapid absorption of the neck. At the end of six months such fractures have been observed where the neck has been com- pletely absorbed, Fig. io8. When the fracture is just behind the head or in the middle of the neck, impaction is relatively rare. Fracture at the base is generally impacted, and there may be more or less coxa vara. Impacted fractures without coxa vara -are sometimes extremely difficult to recognize. If a second x-ray FRACTURES OF THE LOWER EXTREMITIES 103 "^r FiG. 107. — Fracture through the trochanter, involving also the lesser trochanter (intertrochanteric fracture). 104 INJURIES AND DISEASES OF BONES AND JOINTS Fig. io8. — Old, ununited fracture of the neck of the femur with complete absorption of the neck. FRACTURES OF THE LOWER EXTREMITIES 105 Fig. 109. — Healed fracture of the neck of the femur. No cahus could be demonstrated. io6 INJURIES AND DISEASES OF BONES AND JOINTS examination is made at the end of two weeks, the absorption at the ends of the fragments appears, and then the condition is easil}" recognized. Another difficult problem for the roentgenologist to de- s Fig. 1 10. — Intertrochanteric fracture with coxa vara. termine is whether union has taken place and whether it is safe to place weight upon the leg. As the union in these fractures is sometimes fibrous it is impossible to determine that point in such cases. Even when bony union takes place there may be no FRACTURES OF THE LOWER EXTREMITIES 107 visible callus thrown down, and again the roentgenologist is placed in a quandary, Fig. 109. It has been the writers' practice never to return an aOirmative opinion unless bonj' callus can be demonstrated. Fig. III. — Characteristic position ot" a fracture of the upper third of the femur. Tliis was a compound fracture into which Dakm tubes had been introduced. In considering these fractures of the neck of the femur according to the age periods the following approximate 'Taw of probabilities" can be deduced. In the first age period, trauma generally produces an epiphyseal separation and rarely a fracture of the neck or a dislocation. In the second age period dislocation is themostcommoninjuryand fracture is uncommon. In the third age period fracture is very common and disloca- tion is uncommon. Fractures iiuoKIno- the trochanters are frencralK seen in io8 INJURIES AND DISEASES OF BONES AND JOINTS the third age period. The fracture is generally oblique, starting through the greater trochanter or at its junction with the neck and extending downward and inward to a point just below the lesser trochanter, the lesser trochanter frecjuently forming a fragment by itself, Fig. i lo. There is generally no displacement, but a riding up of the shaft and a resulting coxa vara. Union Fig. 112. Fig. 113. Fig. 112. — Green-stick fracture of the femur which in reduction was made complete. Note the callus formation. Fig. 113. — Transverse fracture of the femur with characteristic dis- placement. always takes place and is bon}" in character. Fracture ot the trochanters alone is unusual. Shaft. Fracture of the upper third of the femur is quite common (Fig. in), and the fragments assume a character- istic appearance, that is, the upper fragment is displaced anteriorly and outward while the lower fragment is posterior and inward. The separation and angukition may be so marked FRACTURES OF THE LOWER EXTREMITIES 109 that untreated fractures may result in non-union. The fractures in this region are generally oblique and may occur in any of the age periods. The only difference observed is that transverse fractures occur more frequently in the first age period. Fractures of the middle third of the shaft are common in all age periods. They are generally oblique or green-stick (Fig. 1 12) in the first age period. In the second and third age periods the fracture is frequently transverse and there is generally more or less displacement, Fig. 113. Non-union is frequently due to faulty position arising from muscle and periosteum lying between the fragments. Lower End. In the first age period the lower epiphysis is sometimes displaced. When this happens the epiphysis is generally displaced anteriorly (Fig. 114), occasionally posteriorly and the periosteum is frequently torn away from the shaft for a distance of several inches, Fig. 115. The shaft is displaced posteriorly due to the pull of the gastroc- nemius. This epiphyseal separation is uncommon and seems to be associated with great violence. It is interesting to note that in the writers' series of cases three resulted from the leg being engaged between the spokes of a revoking wagon wheel. Oblique fractures are occasionally seen occurring just behind the condyles, the fracture extending from the front backwards. In the second and third age periods as in the first age period oblique fracture occurs just behind the condyles. If the fracture is above the attachment of the gastrocnemius the lower fragment will be posterior. Occasionally this fracture is associated with a fracture through the condyles into the joints, Figs. 116 and 117. The condyles may be separated with the shaft lying between. Occasionally there may be a fracture of one condyle alone. In severe sprains, occasionally the ligamentous attachment will be pulled off, carrying with it a smafi fragment of bone. Patella. Fractures of the patella are rarely seen in the first age period, and while occurring in the second age period no INJURIES AND DISEASES OF BONES AND JOINTS Fig. 1 14. — Epiphyseal separation of the lower end of the femur with the epiphysis displaced anteriorly. FRACTURES OF THE LOWER EXTREMITIES in Fig. 115. — Old epiphyseal separation of tiic lower end of tlic femur with the epiphysis displaced posteriorly. Note stripping up of the periosteum with new bone formation. 112 INJURIES AND DISEASES OF BONES AND JOINTS are most common after forty. They are much more frequent in the male than in the female. They generally result from a fall upon the knee; but the writers have seen such fractures resulting from violent contractions of the quadriceps. Fig. 1 1 6. — Oblique fracture of the lower end of the femur associated with a fracture through the condyles and into the joint. In those resulting from falls the fracture may be simple or comminuted, depending upon the severity of the injury. The fractures are generally anteroposterior, and the anterior third is the most frequently fractured. If the quadriceps fascia over the patella is intact there FRACTURES OF THE LOWER EXTREMITIES 1 1 is seldom displacement, Fig. ii8. When it is torn the frag- ments may be widely separated (Fig. 119), the lower frag- ment sometimes resting over the articulating surface of the tibia and rotated. When the fragments are approximated the Fig. 1 17. — Lateral view of Fig. 1 16 showing the hne of fracture. union is generally fibrous and less frequently bon\'. There again it is difficult for the roentgenologist to determine whether proper union has taken place. Tibia and Fibula. Upper End. In the first age period, although the epiphyses are present, dislocation of them is most unusual. The writers have never had such a case under 8 114 INJURIES AND DISEASES OF BONES AND JOINTS observation. The tibial tubercle, however, has a separate center of ossification, and this may be pulled loose by muscular Fig. ii8. Fig. 119. Fig. 118. — Fracture of the patella without displacement as the fibrous sheath of the patella is intact. Fig. 119. — Fracture of the patella with wide separation of the fragments due to a torn sheath. Fig. 120. — Fracture of the tibial tubercle. violence or broken by direct violence. The writers have seen several instances where the tubercle was broken by falling on a sharp edge, as the edge of a curb stone. Fig. 120. FRACTURES OF THE LOWER EXTREMITIES 115 Fractures through the heads of the tibia and fibula are unusual in this age period. In the second and third age periods fracture of the heads of these bones is quite common, and with the tibia there is generally a fracture of one of the tuber- osities, Fig. 121. The tuberosity is, as a rule, forced outwards and frequently is displaced slightly posteriorly. Sometimes we have the tuberosity broken off without a transverse fracture Fig. 121. — Fracture of the tuberosity of tibia. of the tibia. Fractures of the head of the fibula may occur without a fracture of the tibia, but they are more frequently associated with fracture of the middle third of the shaft of the tibia, Fig. 122, In injuries around the knee joint the tibial spines should always be carefully inspected, as one or both may be broken. This injury is much more frequent than has been suspected (Fig. 123), and a routine .v-ray examination should always ii6 INJURIES AND DISEASES OF BONES AND JOINTS be made in slight injuries or sprains of the knee. This fracture is frequently associated with dislocations of the semilunar cartilages. Shaft. Fractures of the shaft are common in both bones, and are generally associated. Fracture of the tibia alone is quite common, while fracture of the shaft of the fibula alone Fig. 122. — Fracture of the upper end of the tibula associated with frac- ture of the middle third of the tibia. (Mottled effect due to an unusu- ally dense plaster cast.) is rare. When the libula is fractured alone the injury is either at the upper or lower end. There is no one definite fracture of the shaft of the tibia. It assumes a variety of forms. In the first age period it ma}' be of the green-stick variety or oblique, Fig. 124. At the end of the first age period and the beginning of the second age period the fractures are oblique (Fig. 125) or spiral (Fig. 126) and occasionally transverse (Fig. 127), FRACTURES OF THE LOWER EXTREMITIES ii" while in the third age period they are generally transverse and frequently comminuted. In the first two age periods non-union is uncommon, while in the third age period non- union occurs quite frequently. Lower End. In the hrst age period separation of the epiphyses of the tibia with or without displacement is Fig. 123.- — Fracture of the external tibial spine, frequently mistaken for a simple sprain. quite common, Fig. 128. Separation of the epiphj^ses of the fibula is quite uncommon. When the epiphyses of the tibia is dislocated it is generally associated with a fracture of the lower end of the fibula. In this period linear fractures of the tibia are also seen extending from the joint upwards into the shaft, but with no displacement. In the second and third age periods fractures around the ankle joint are extremely common. The lower three inches of the fibula (Fig. I2q) is the site of more fractures than an\' other portion of the bones of the leg. The fracture is generally oblique, and may or may not be displaced. When displaced the lower frag- ment is usually posterior. ii8 INJURIES AND DISEASES OF BONES AND JOINTS Fig. 124. Fig. 125. Fig. 124. — Green-stick fracture of the tibia in the first age period. Fig. 125. — Obhque fracture of the tibia in the first age period. Fig. 126. Fig. 127. Fig. 126. — Spiral fracture of the tibia in the first age period. Fig. 1 2-. — Comminuted fracture of tibia and fibula in the third age period. FRACTURES OF THE LOWER EXTREMITIES 119 When both bones are broken Pott's fraeture is the most common, Fig. 130. This is a fracture of one or both malleoli of the tibia and of the lower end of the fibula. With this fracture there is extensive tearing of the ligaments and there will often Fig. 128. Fig. 129. Fig. 128. — Slight epiphyseal separation of the lower end of the tibia with a fragment of bone torn from the tibia. Fig. 129. — Fracture of the lower end of the tibia. be a dislocation of the foot, Fig. 131. These fractures are gener- ally associated w ith more or less deformity. In examinations of the ankle joint special attention should be given to the shadows of the soft tissues in the lateral view, as they will frequently aid in determining the presence or absence of injury or disease. In the lateral view a black triangle 120 INJURIES AND DISEASES OF BONES AND JOINTS (Fig. 132) is formed by the os calcis, the tendo Achillis and the posterior tibial muscles. The os calcis forms the base of the triangle, and the apex is about three inches above where the belly of the muscle begins. This triangle is normally filled with fat, and ofl'ers very little resistance to the x-ray, so that it appears black upon the plate. Any injury or disease will Fig. 130. Fig. 131. Fig. 130. — Typical Pott's fracture, anteroposterior view. Fig. 131. — Lateral view of a Pott's fracture associated with a posterior dislocation of the foot. cause it to become filled with blood or inflammatory tissue, and the triangle becomes obliterated. Fig. 133. When the triangle is absent the plates should be carefully examined, as this is an indication of injury or disease. Bones of the Foot — Astragalus. Fracture of the astrag- alus is generally the result of a fall from a height, followed by a landing on the feet, Fig. 134. The fracture is generally transverse, and displacement depends upon the degree of violence. It occurs usually in the second and third age periods. 122 INJURIES AND DISEASES OF BONES AND JOINTS Following injuries of the ankle joint one frequently sees a small fragment of bone lying close to the posterior border of the Fig. 134. — Fracture of the astragalus with separation of the fragments Fig. 135. — Fracture of the end of the astragahis simulating an os trigonum. astragalus. Many writers claim this fragment to be a small independent bone, namely the os trigonum. In a number of cases in our series the writers were fortunate enough to have by chance plates of the ankle before injury showing no os trigonum, FRACTURES OF THE LOWER EXTREMITIES 123 and a later plate following an injury showing this fragment, indicating that this was the result of the injury, Fig. 135. Fig. 136. Fig. 137. Fig. 136. — Fracture of the os calcis due to a crushing injury. Fig. 137. — Fracture of the tip of the scaphoid. .Most frequently seen in toe dancers. Os Calcis. Like the astragalus this bone is broken in falls from heights, Fig. 136. In the writers' series of cases ft was found that the niajorit}- of such fractures were sustained by carpenters, bricklayers, riveters, etc., whose occupations necessitating work upon scaffolds. This also indicates that these fractures occur in the second and third age periods. These fractures may be simple or comminuted according to the severity of the trauma. In several instances violent muscular tension has caused the tendo Achillis to pull off a fragment of bone at the attachment. Scaphoid. Fracture of the scaphoid is seen frequently in crushing injuries. Two cases have been observed where the internal portion was pulled off in dancers performing the ballet. Fig. 137. Cuboid and Cuneiforms. The only fractures observed in these bones were due to crushing injuries, caused by great 124 INJURIES AND DISEASES OF BONES AND JOINTS Fig. 138. — Old fracture of the cuboid, with some callus formation. A Fig. 139. — Fractures of all the metatarsals and some of the phalanges due to a crushing injury. FRACTURES OF THE LOW ER EXTREMITIES 125 weights falling on the foot, or the passage of a hea\ y wagon wheel, Fig. 138. Phalanges. These fractures are due to direct violence and like those in the hand may be compound and associated with infection, Fig. 139. Metatarsal Bones. The metatarsal bones are frequent fractured as the result of falls and crushing injuries, Fig. 139. The base of the fifth metatarsal is so often fractured as to warrant especial mention. It is generally due to muscular violence. Fig. 140. Fig. 140. — Fracture of the base of the lifth metatarsal. Sesamoids. Fractures of one of the sesamoids is a rare injury. The other foot should always be examined, as some- times three sesamoids are present and one of these might be mistaken for a fragment in the injured foot. NON-UNION In the beginning of the previous chapter we outlined in a general way the conditions that lead up to the production of fractures, and how age, sex and occupation play an important 126 INJURIES AND DISEASES OF BONES AND JOINTS role. There is one other condition to which attention must be called and that is non-union. This is frequently encountered, and certain bones are more sub- ject to it than others. How can an old ununited fracture be differentiated from a fresh one where sufficient time has not elapsed for callus to form? In an old ununited frac- ture extreme atrophy of bone and soft tissues are found and the broken ends are smooth, having lost the irregular serrated edge of the fresh fracture. Fig. 141. In a recent fracture there is but little atrophy of the bone and soft tissues. By the time atrophy begins in a fresh frac- ture callus should be visible, and a mistake in diagnosis should not be made. Changes are seen upon a plate that will aid in the recogni- tion of some of the causes of non- union. The most obvious one is where the fragments are so widelj'' separated that union can- not take place. In other frac- tures, there will be actual necro- sis of the ends of the bone, due to the rupture of a blood vessel, thus bringing about non-union. In certain lesions, such as sar- coma and carcinoma, the destruction of the bone will pro- duce a fracture, and it will of necessity not unite. In the virulent stage of an acute osteomyelitis a fracture, if present, Fig. 141. — Old fracture of tibia with bone graft showing atrophy and smooth edges in an ununited fracture. Fragments of fibula re- moved. (Taken through a heavy plaster cast.) FRACTURES OF THE LOWER EXTREMITIES 127 will not unite until the lesion is halted. When the bones are in good alignment but separated by a space, shown upon the plate, that generally means that muscle or fascia is in between the fragments, and again there will be no union. There are, however, a certain percentage of cases where none of the above causes exist, but in which union will not take place. We do not know the cause, but it must be due to some alteration in metabolism probably secondary to faulty blood supply. While non-union may occur at any age if the fragments are widely separated, it is in the second and third age periods that it is most frequently met with. Probably the changes due to old age are an added factor to other unknown causes. The humerus and femur are the two bones in which this condition occurs most frequently, and the ununited fractures of the neck of the femur are the most common. Probably one of the causes in fracture of the neck of the femur is the non- approximation of the fragments; but even when operated upon and the fragments pegged, a large percentage of cases fail to unite. The blood supply in this area is not particularly good, and this may be one of the factors. Bone Splints. Since the roentgenologist has to deal with non-union, the operative procedures to relieve this condition must of necessity be examined also, so he must be thoroughly familiar with the various bone splints. Special attention is called to the intermedullary bone graft. This graft, generally taken from the tibia, is introduced into the medullary canal, and at first is a tight fitting bone splint (Fig. 142) ; but as time goes on a vacuolated area from pressure atrophy forms around the splint, especially at each end. The writers have seen this mistaken for an osteomyelitis when in reality it is merely a pressure absorption, Fig. 143. Do not look for union of the intermedullary graft and bone, as this does not take place; the graft only acts as a mechanical splint, and is eventually absorbed. The graft at times may be broken while in situ and this should always be looked for and reported if present. Fig. 144. 128 INJURIES AND DISEASES OF BONES AND JOINTS Fig. 142. -Bone transplant of the upper end of the humerus. The transplant employed is the upper end of the fibula. Fig. 143. -Pressure atrophy around the ends of the bone graft. (Taken through a heavy plaster cast.) FRACTURES OF THE LOWER EXTREMITIES 129 Fig. 144. Fig. 145. Fig. 144. — Old fracture of the humerus with bone graft \\hich is broken and partially absorbed. Fig. 145. — Metal plate which has worked loose and is now acting as an irritant. Other splints, such as Lane plates, wires, etc., should be carefully examined to see whether the plate is firmly attached. The splint may work loose and act as an irritant, Fig. 145. The roentgenologist should also be familiar with the appearance of the tibia after a piece of bone has been removed for grafting purposes, Fig. 146. The area from which the bone has been removed may be mistaken for some pathological condition. Where there has been surgical interference in a fracture it has been the experience of the writers that repair takes place more slowly and consequently caHus does not appear 130 INJURIES AND DISEASES OE BONES AND JOINTS as early as one would expect. In cases of non-union after surgical interference, if union takes place repair is a very- slow process. The writers have seen a year elapse before any Fig. 146. — Tibia after a bone graft has been removed. callus could be demonstrated. The roentgenologist should be very guarded in his expression as to whether union will eventu- alh' take place or not. CHAPTER VI CONGENITAL DISLOCATIONS CHAPTER VI Congenital Dislocations WHILE congenital dislocations have been noted in many of the joints, yet with the exception of the hip they are uncommon. The etiological factor has not been dehnitely estabhshed, but some malposition of the parts in fetal hfe may be the causal factor. In the newborn the heads of the bone are entirely cartilaginous and cannot be demonstrated by the x-ray, so in some cases injuries at birth may deform or displace the head, and later on these disloca- tions be termed congenital. Congenital dislocations of the hip cannot, however, be attributed entirely to birth injuries, as under such conditions the percentage of cases should be equally distributed between the male and female, whereas the lesion occurs much more frequently in the female. Congenital Dislocation of the Hip. This condition is seldom recognized at birth. The abnormal condition of the hip is only noted some time after the child has started to walk. The waddling gait at first is thought to be simply awkward efforts in learning to walk. When this does not clear up medical advice is sought. The fact that the child is seen after it has learned to walk has an important bearing upon the .v-ray findings. In studying the plate of such a case, there are several points which should be carefully noted — the shape of the pelvis, the position and shape of the head and neck of the fe- mur, and the size of the atlected bone in comparison with the normal one. In a newly born child and until walking takes place, the pelvis, roughly speaking, is triangular in shape, with the base above and the apex at the pubis. The two sides of the triangle are approximately straight (Fig. 147); but when the child walks, the upward thrust of the femur localized at the ace- 133 134 INJURIES AND DISEASES OF BONES AND JOINTS tabulum, which is the point of articulation, gradually causes the acetabulum to be pushed in slightly, and at this age, the bones being soft, this is easily accomplished. At the same time the body weight exerting a downward pressure causes the ilia to flare out. These two mechanical factors change the shape of the pelvis, so that where it was triangular with straight sides before walking, it has now become a triangle with the base slightly widened and the sides slightly curved, the convexity be- ing inward. Fig. 148. This naturally gives a stronger joint and one in which dislocation is less apt to occur. When one hip is dis- FiG. I4~. — Straight ^icle- of a pelvis in a child who has not walked. located that side of the triangle will be found straight and the other slightly bent in. The acetabulum will also be shallow, as there will have been no pressure from the femur to deepen it, Fig. 149. The dislocation is generally upward, so the trochanter will be high. The neck is also frequently bent, and this may throw the head anteriorly and, from its appearance upon the plate, suggest that it may have been destroyed by disease. Congenital dislocations are found at the age when acute epiphysitis, tuberculous and non-tuberculous, is prevalent. In these two conditions, however, not only will the head be partially or wholly destroyed, but the acetabulum will also CONGENITAL DISLOCATIONS 135 Fig. 148. — Beginning concavity of the sides of the pelvis ckie to the upward thrust of the femora in walking. Fig. 149. — Congenital dislocation of the hip. The acetabulum is shallow and there is no concavity of the pelvis on the aOected side. Note the distance of the dislocated head of the femur from the acetabulum. 136 INJURIES AND DISEASES OF BONES AND JOINTS be more or less involved, Fig. 150. In congenital dislocation the acetabulum will be shallow and the outhnes clean-cut, but there will be no destruction. If the disease takes place after the child has walked there will also be the bent side of the tri- FiG. 150. — Destruction of the head of the femur with pathological disloca- tion. The acetabulum is also involved. The destruction allows the neck and shaft to lie close to the pelvic wall with no intervening space. Compare this with the space seen in congenital dislocation, Fig. 149. angle, while in dislocation it will be straight. Then, too, in the non-tuberculous epiphysitis there will be new bone formation in the late stages and this is never present in dislocation, Fig. 151. Occasionally one will find a new small acetabulum on CONGENITAL DISLOCATIONS 137 the posterior surface of the ilium in dislocation. In diseased processes, as a rule, the trochanter, besides being high, is closer to the bone on account of destruction, while in disloca- tion a wide space generally separates the femur from the Fig. 151. — Bony ankylosis seen in non-tuberculous infections. pelvis. In congenital dislocation the femur on the aflected side will be smaller than the normal one, due to retarded develop- ment probably from lack of bone stimulation. This, however, is also seen when the head has been destroyed by disease, Fig. 152. Congenital dislocation of the hip is much more common in the female, being in the proportion of six or seven to one in the male. Either hip may be involved; in the writers' series of cases the distribution w^as about equal. Dislocation of both hips 138 INJURIES AND DISEASES OF BONES AND JOINTS Fk;. 152. — The small undeveloped femur in congenital dislocation. This is not "atrophy of quantity" but non-development. Fig. 153. — Congenital dislocation of both hips. Note the shallow acetabula and straight sides of the pelvis. CONGENITAL DISLOCATIONS 139 Fig. 154. — Injury of the lower epiphysis with consequent retardation of growth causing a partial subluxation of the ankle joint. Fig. 155. — Club foot. Fig. 156. — Club hands. 140 INJURIES AND DISEASES OF BONES AND JOINTS Fig. iy~. — Abnormal position of femur due to anterior poliomyelitis. Tiiis hip could be dislocated with but shght manipulation. CONGENITAL DISLOCATIONS 141 occurred in about 30 per cent of the total number of cases, Fig- 153- Dislocations of the Shoulder Joint. In dislocations of other joints birth injuries play a most important part, and this is particularly true of the shoulder joint. As has already been stated, injuries to the humeral head may occur without being recognized and only be discovered later in life. Obstet- rical paralysis may cause subluxations and these later may be called congenital. Abnormalities in the Development of Epiphyses. Any abnormality in the development of the epiphysis, cither over-development or retardation, may bring about mechanical dislocation. The writers have seen several cases where the epiphyseal head of one of the bones of the leg or forearm failed to develop. This, of course, retarded the growth of the bone, and with the normal increase in the length of the adjacent bone mechanically brought about a dislocation, Fig. 154. In club foot (Fig. 155) and club hand (Fig. 156) partial or complete dislocations may occur, just as in obstetrical paralysis we may find a dislocation of the hip due to anterior poliomyelitis, Fig. 157. CHAPTER VII ACQUIRED DISLOCATIONS CHAPTER VII Acquired Dislocations DISLOCATIONS arc not often seen by the roentgen- ologist before being reduced. The majority are re- duced and then sent for .v-ray examination to see if the reduction is proper or to rule out a possible fracture. In the writers' series of cases the percentage of shoulder disloca- tions is very small, due to the above fact. In hospital and out-patient departments, practically every fracture is seen before and after reduction, while dislocations are generally seen only after reduction. Shoulder. In the first age period dislocations of the shoulder are rare, though occasionally one ma}' result from instrumental delivery. The second age period shows the great- est number of dislocations, and they are largely confined to the male. This period covers the age of hazardous occupa- tions, and since the female does not engage in such pursuits dislocations are relatively rare. The various text books of surgery give percentages covering the different types of dis- locations. From personal observation the subcoracoid (Fig. 158) has been found to be by far the most common, and the variations of the subglenoid type (Figs. 159 and 160) are pro- bably next in frequenc}'. Dislocations in the third age period are generally the result of falls and occur with the same relative frequency in both sexes. In this age period, however, we find that these dislocations are often associated with fractures of the greater tuberosity or of the surgical neck. It is common to see a fracture of the surgical neck with the end of the shaft in the glenoid fossa and the head dislocated outward, Fig. 161. In these cases one wonders whether the dislocation is the result of the fracture or vice versa. Occasionally one will see the head split longitudinally with a portion of it in the axilla. 10 145 146 INJURIES AND DISEASES OF BOXES AND JOINTS Elbow. Dislocations of this joint appear \\ ith the same relative frequency as to age and sex as those of the shoulder. They are much more common in the male, and occur most often between the ages of twenty and forty. In the first age period dislocations of the elbow are relatively rare. In some of the older works it is stated that the great majority of the dislocations of the elbow occur under twenty and that half of them occur under the age of ten. The writers have Fig. 158. — Subcoracoid dislocation ut the humerus. seen many cases in young children diagnosed as dislocations, in which the .v-ray examination has shown that the condition was one of epiphyseal separation or a supracondyloid fracture. It is reasonable to suppose that the epiphyseal line is weaker than the capsule, and consequently we have separation instead of dislocation. Most of these dislocations are encountered in the latter portion of the first age period and the first half of the second age period. Dislocation of both bones backward is b}' far the most common, with its \'ariations of outward and ACQUIRED DISLOCATIONS 147 Fig. 159. — Subglenoid dislocation with unusual position of the humerus. (Courtesy oj Dr. Henry J. Walton.) Fig. 160. — Subglenoid dislocation. The usual po^iiujn of the humerus. (Courtesy of Dr. Henry J. Walton.) 148 INJURIES AND DISEASES OF BONES AND JOINTS inward, Fig. 162 and 163. Dislocation forward is apparently a very rare condition. These dislocations are frequently associ- ated with fractures of the coronoid, olecranon and head of the radius. Ulna and Radius. The ulna is sometimes dislocated backwards v>ith an accompanying fracture of the radius. The radius may be dislocated forward (Fig. 164 and 165) Fig. 161. — -Subglenoid dislocation of the humerus associated with fracture, the shaft resting in the glenoid fossa. (Courtesy oj Dr. John Evans.) without fracture, but when dislocated forward and upward it is invariably associated with a fracture of the upper third of the ulna. In the extensive tearing of the ligamentous attachments in dislocations there sometimes follows a partial or complete ossification of the capsule with a resulting stiff joint. Fig. 166. In the third age period dislocations are uncommon. Injuries ACQUIRED DISLOCATIONS 149 Fig. 162. Fig. 163. Fig. 162. — Dislocation of both bones of the forearm backward, associated with fracture. {Courtesy of Dr. Henry J. \Valto7i.) Fig. 163. — Another view of the condition indicated in Fig. 162, showing the lateral clisi)lacfnient. (Courtesy of Dr. Henry J. Walton.) Fig. 164. Fig. 165. Fig. 164. — Dislocation of the elbow associated with fracture of tlie neck of the radius. (Courtesy oj Dr. Henry J. Walton.) Fig. 165. — Same as Fig. 164, showing lateral view. (Courtesy oj Dr. Henry J. Walton.) 150 INJURIES AND DISEASES OF BONES AND JOINTS Fig. 1 66. — Dislocation of the elbow reduced, followed by deposition of bone in the torn hgaments producing ankylosis. Fig. 167. Fig. 168, Fig. 167. — Dislocation of the wrist joint. Fig. 168. — Anterior dislocation with rotation of the scmihinar. ACQUIRED DISLOCATIONS ItI producing dislocations in the second age period produce fractures in the third age period. Wrist. Just as in other joints, dislocations of the wrist are rare in the first age period. Since the advent of the x-ray many so-called dislocations are found to be fractures, and the one most often mistaken in this age period is the epiphyseal separation of the radius. The comparatively few dislocations that do occur are in the second age period, Fig. 167. Dislocation of the uhia back- ward is sometimes seen. Dislocations of the carpal bones at the radial articulation or at midcarpal arti- culation are seen very rarely, and when they do occur are generally associated with fracture. While any carpal bone may be dislocated, the semilunar is the one by far most frequently involved. It is dis- located anteriorly and is generally rotated, so that the radial articulation is pointing backward, Fig. 168. Hand. Dislocation of the thumb metacarpal at the carpal articulation is by far the most common of the metacarpal dislocations, and is generally back\\ard. While the other metacarpals may be dis- located, fractures occur much more fre- quently. Dislocations of the phalanges (Fig. 169) are quite common, and backward dislocations of the first phalanges, especially of the thumb, are the most fre- quent of all. Pelvic Bones. Dislocations oi the pelvic bones are quite rare, though the writers have seen one case where a blow upon the sacrum caused a complete forward dislocation. The so-called sacro-iliac subluxations, in the writers' opinion, do not exist. The joint is of the saw-tooth variety and before a slipping could take place these saw-tooth edges would have to Fig. 169. — Backward dislocation of the thumb phalanx. ■a INJURIES AND DISEASES OF BONES AND JOINTS Fig. 170. — Backward dislocation of the hip. ACQUIRED DISLOCATIONS 153 Fig. 171. — Obturator dislocation of the hip. 154 INJURIES AND DISEASES OF BONES AND JOINTS be broken. These conditions must be ligamentous sprains. Hip. Dislocations of the hip are much more common in the male than in the female. In the first age period, except in pathological conditions, dislocations are very rare. The epiphyseal line being present, injury to this joint causes a separation instead of the tearing of the capsule followed by a dislocation. It is in the second age period that most of the hip dislocations occur as the neck of the femur is much stronger than the K Fig. 172. Fig. 173. Fig. 172. — Lateral dislocation of the patella. Fig. 173. — Subluxation of the tibia, due to an old tuberculous process. capsule, and consequently trauma causes the capsule to tear, allowing the head to slip out, instead of producing a fracture of the neck. Backward dislocations are the most common (Fig. 170), and probably dislocations into the region of the obturator foramen are next in frequency, Fig. 171. Besides these two groups there are variations of each one. In the third age period, on account of the absorption of ACQUIRED DISLOCATIONS :>j the lime salts with a resulting brittleness of the neck, trauma will cause a fracture of the neck instead of a dislocation, though occasionally dislocations are seen in very old people. Patella. Dislocations of the patella are uncommon, though w^hen they do occur they are cither internal or external. Fig. 172. ^ Knee. Dislocation of the knee is more common in the male than in the female. This is due not to any structural difference in the knee, but to the fact that the male engages in more violent pursuits and hazardous occupations. Dis- locations of the knee in any case, however, are very un- common. They seldom occur in the first age period, due to the presence of the epiphyses. The cartilaginous union of the epi- physis is weaker than the cap- sule of the joint; consequently in injury it yields instead of the capsule. Tibia. In the second age period the tibia may be dis- located backward, forward or laterall}^ The backward dislocation is probably the most common. Complete lateral dislocations are quite rare without fracture, though slight lateral subluxation is frequently seen as the result of bad tearing of the ligaments, or one condyle may be displaced laterally in a longitudinal fracture through the joint. In old pathological processes, such as tuberculosis, the contractions of the muscles combined with the destruction of the articulating surfaces frequently bring about a posterior dislocation of the tibia. Fig. 173. Fig. 174. — Posterior dislocation of the foot with fracture. 156 INJURIES AND DISEASES OF BONES AND JOINTS Dislocation of the semilunar cartilage is quite a common occurrence, but since cartilage does not cast a shadow upon the plate it cannot be demonstrated. This condition is often asso- ciated with fractures of the tibial spines, and when this is noted one should also be suspicious of a dislocated cartilage. Fibula. Dislocations of the upper end of the fibula from injuries and from muscular violence have been reported, but they are extremely uncommon. The writers have never seen such a case. Pathological dislocations, such as crushing in- juries with frac- ture of the head of the tibia, or non- growth of one of the bones, are oc- casionally found. Foot. Dis- locations of the foot are quite common (Fig. 174), but rarely occur in the first age period, as in that period the epiphysis yields instead of the joint. In the second age period this injury is most frequent. The foot may be dislocated backward or laterally. It is often associated with a Pott's fracture. Any of the tarsal bones may be dislocated, but dislocation of the astragalus is most com- mon. Dislocation of the metatarsals is uncommon without frac- ture. The first is the one most commonly involved. Fig. 175. Dislocation of the phalanges of the feet does not occur as frequently as dislocation of these bones of the hands. They are generally associated with fracture, and, as they usually result from crushing injuries, they are frequently compound. Fig. 175. — Dislocation of the first metatarsal. {Courtesy of Dr. Henry J. Walton.) CHAPTER yill BONE INFECTIONS CHAPTER VIII Bone Infections THIS chapter will be devoted to the discussion of those infections that primarily involve the bone, though they may simultaneously or later involve the joint. Osteo- myelitis is the most important and frecjuent of these infections. Osteomyelitis. In Chapter II on Normal Bone attention was called to the constituent parts of a bone: the periosteum, cortex, medullary canal, the cancellous heads and the cartilaginous articulations. Any one or all of these structures may be involved in an inflammatory process. When the periosteum is involved w^e have a periostitis; when the infection is confined to the cortex we have an osteitis, and when the medullary canal is attacked alone we speak of a myelitis. The combination of a diseased cortex and medullary canal is known as osteomyelitis. While the pyogenic factors may vary in bone infection, the process is the same, varying only as to the severity and duration of the infection. Before taking up the changes that occur it is well to bear in mind just how the infection reaches the bone, as the picture varies according to the point at which the infection starts. In a general way we may speak of four portals of entry. 1. Infection, hematogenous or lymphoid in origin, carried directly to the medullary canal by means of the nutrient canal. 2. Infection lodging beneath the periosteum. 3. Infection arising within the joint. 4. Infection b}' direct inoculation, as in wounds and com- pound fractures. In the first group, the blood or lymph suj^ply carries the infection through the nutrient canal into the medullary canal; and since this is filled with soft marrow fat the infection 159 i6o INJURIES AND DISEASES OF BONES AND JOINTS Fig. 1-6. Fig. 177. Fig. 176. — Osteomyelitis showing in\oIvement of the medullary canal and cortical bone. Fig. 177. — Osteitis with an extensive periostitis. may spread easily and rapidly up and down the canal, and by means of the Haversian canals will finally involve the dense compact cortical bone. Fig. 176. In this condition the changes take place within the bone, and the infection works its way toward the periphery. In the earlier stages the cortex and periosteum are not involved. When the infection lodges beneath the periosteum we have both it and the bonv cortex involved. Since the cortex is BONE INFECTIONS i6i Fig. 178. — Here is an acute infection starting in the joint and inxolving the femur. i62 INJURIES AND DISEASES OF BONES AND JOINTS quite dense the infection spreads more easily into the per- iosteum and along the outside of the shaft. The cortex becomes infected more slowly on account of its density, and the spread of the disease is more or less limited. Consequently the medul- FiG. i~9. Fig. i8o. Fig. I "9- — Compound fracture with osteomyelitis. Fig. i8o. — Osteomyelitis with sequestrum l\ing in a cavitj*. lary canal is not often in\c)Kcd, but with the localized osteitis we may have an extensive periostitis, Fig. 177. \\ hen the infection starts in the joint we have extensive destruction of both articulating surfaces, and fmall}* the disease breaks through one of the cartilaginous surfaces and BONE INFECTIONS 163 destroys to a more or less degree the head of the bone where the cancellous bone is present; and again the infection ex- tends but slowly into the medullary canal proper. Cartilage is quite resistent to infection, and it is only the more virulent organisms, such as streptococcus, etc., that produce such conditions, Fig. 178. In compound fractures (Fig. 179) the infection is carried directly to the medullary cavity and raw, exposed bone sur- faces, so that periosteum, cortex and medullary canal may be involved simultaneously. The question naturally arises: "Does osteomyelitis give us a constant roentgenological picture?" The answer must be, "No," but this answer may be qualified by stating that the pathologic process is the same, varying only as to the in- tensity and duration of the infection. Hence, if we understand the fundamental principles of bone infection, while the picture may vary, yet the condition may be recognized. Only two changes may be seen upon a plate upon which to base a diag- nosis — bone destruction and bone production. The variation in these two processes constitutes the basis of a diagnosis. Attention has been called to the fact that the dense, compact bone is pierced by numerous small Haversian canals, and that these are in direct connection with the medullary canal. Now an infection that starts in the medullary canal not only extends up and down, but also enters the Haversian canals; and since these canals extend through the compact bone and have numerous intersections the roads for the transporta- tion of infection are already prepared. Between these canals w^e have dense masses of calcium salts which, relatively, are but slowly absorbed by infection. Thus these canals make it possible for the infection to spread and break out in other portions of the bone, frequently leaving normal bone between the primary focus and the secondary lesion, as the infection may have failed to enter all the canals in the affected area. Often by means of the intersecting canals the infection i64 INJURIES AND DISEASES OF BONES AND JOINTS may completely surround an area of bone and thus dcxitalize it and form what is known as a sequestrum, Fig. i8o. Since the infection is at first confined to the medullary canal and within the Haversian canals, there is a short period of time when the canals are filled but no destruction has taken place. This is important to remember, because, as has already been pointed out, the only changes visible upon a plate are bone destruction and bone production; so there is a period in beginning osteom^-e- litis when the .v-ray examina- tion will show a perfectly nor- mal bone. Frequently cases of acute osteomyelitis have been seen in the first ten days of the infection, where there were ex- tensive swelling and inflamma- tion of the soft tissues surround- ing the bone, with intense pain and high temperature, yet the Fig. i8i. — A -ray of an acute osteomyelitis one week atter onset. Operation showed the Haversian canals to be full of pus, but since breaking down of the bone tissue had not oc- curred, the A-ray examination was negative. A"-ray examniation was nega- tive, Fig. i8i. Such cases at operation will show an inflamed, infected periosteum and the canals full of pus, but no destruc- tion. Care must be taken in such cases not to mislead the surgeon by reporting no infection present. When the infection is very virulent we have extensive destruction and but little new bone production, while in the chronic type we have but little destruction and extensive bone production, Fig. 182. In an acute osteomyelitis we get the following picture upon a plate: The infection, having lodged in the medullar}' cavity, takes the path of least resistance and extends along the medul- BONE INFECTIONS 165 lary canal, and we get vacuolated spaces represented by areas of lessened density. The infection now spreads to the bony cortex and travels irregularly by means of the Haversian canals, so that there are areas of bone destruction with normal bone in between, and eventu- ally these normal areas will be cut off and become sequestra. This is an important point of differential diagnosis, because every pathological process in bone must be viewed as a pos- sible malignancy until proven otherwise. Malignancy in long bones starts from one central point and radiates equally in all directions, absorbing the bone as the growth advances, but never appears as separated areas with normal bone in be- tween and never produces sequestra. The osteomyelitic infection will finally pierce the cortex in one or more places, leaving areas of normal cortex between. Here again we have another important point of differential diagnosis, as in malignancy. Fig. 182.— Chronic osteomyelitis when the growth reaches the showing marked new bone cortex, it destroys it completely formation but with little T T J ^ • M. destruction. as a whole and not m parts as osteomyelitis does. Thus far we have been discussing the acute destructive process; but, when the cortex is pierced and drainage estab- lished, nature, with the acquired resistance of the tissues, [66 INJURIES AND DISEASES OF BONES AND JOINTS Fig. 183. Fig. 184. Fig. 183. — The new bone formation defines the boundaries of infection. Fig. 184. — Tlie periosteal new bone gives the appearance of a shaft actually expanded, but the apparent expansion is due to deposition of bone on the outside. BONE INFECTIONS 167 now attempts to limit the destructive process. This is done by building up a new bone wall at the edge of the infection. To produce bone reaction there must be stimulation, and the point of stimulation has to be at the point where the infection stops and the normal bone begins; so we must look for our new bone production at the edges of the infection and not in the middle of it. The result of this will be that the new bone laid down will follow the edge of the infection. This gives us a varied picture, as the boundaries of the destructive process will determine where the new bone will be laid down, Fig. 183. At the same time, since the infection has reached the periosteum, we shall find extensive periosteal bone following the course of the periosteum. This deposit of periosteal bone w^ill frequently be sufficiently great to give the appearance of expansion of the bone, Fig. 184. Close inspection, however, will reveal that the apparent expansion is in reality due to deposition of bone on the outside. This, too, is an important point, as benign growths of the bone, such as cysts and osteochondromata, invariabh' expand the cortex while osteomyelitis does not. The predominating feature in acute osteomj-elitis is bone destruction with but little new bone formation. The acute types are seen most frequently in the young and in early adult life. In chronic osteomyelitis the conditions are just reversed. We have excessive bone production with but few small areas of destruction. The entire bone is thickened, frequently to such an extent that the medullary cavity seems to be obliterated. The bone is often irregular in shape and much thickened, due to extensive deposition of periosteal bone upon the cortex. In the bone there may be small areas of absorption due to focal spots of infection. When sequestra are present they are usually very small, and, on account of the surrounding dense bone, frequently cannot be demonstrated by the .v-ray. Fig. 185. This type of osteomyelitis is seen more frequently in middle and old age. When the infection starts beneath the periosteum the lesion will be confined to the cortex. When it starts in i68 INJURIES AND DISEASES OF BONES AND JOINTS the joint it spreads slowly into the cancellous head, and if untreated will reach the medullary canal and then spread rapidly. In compound fractures the infection is confined to the ends of the bone and seldom spreads, as bone drainage from the infection exists through the open wound. Fig. 185. Fig. 186. Fig. 185. — Chronic osteomyelitis with a small cavity containing a sequestrum. Fig. 186. — Vacuolated area in the head of the radius, known as Brody's abscess. In a certain number of cases we shall find a single punched- out area, definitely circumscribed, situated in the cancellous head of a bone about a half inch from the joint. Such a locahzed osteomyelitis we speak of as Brody's abscess. Fig. 186. The upper ends of the tibia and humerus seem to be the favorite locations for such conditions. From this description it wilt be readily seen that there is no BONE INFECTIONS 169 Fig. 187. — A most atypical tuberculosis ol the shaft of the radius in a patient of forty-five years. The condition was not diagnosed until a microscopic examination was made after operation. i-o INJURIES AND DISEASES OF BONES AND JOINTS one definite .v-ray picture, but that the changes will depend entirely upon the virulence of the infection, the stage of the disease and the resistance of the patient. The six points which follow should always be carefully noted upon the plate: 1. The place where the infection starts. 2. The character of the destructive process. 3. The path of extension, that is, spreading in all directions or following the path of least resistance. 4. The character and situation of the new bone production. 5. The condition of the cortex, whether it is intact, de- stroyed as a whole or pierced by sinuses, expanded or unex- panded. 6. The type of periosteal reaction, whether it is parallel or perpendicular to the shaft. Thus far we have discussed only those infections arising from pyogenic organisms. Tuberculosis. The question of tuberculosis as an osteo- myelitic infection has been much discussed, and some authori- ties state that it is much more frequent than is commonly supposed. In the writers' experience it was found to be ex- tremely rare in adults, onl}^ two cases having been encountered in which diagnosis was made only by the microscopical exami- nation following operation. In one case there was extensive destruction of the shaft of the ulna, no new bone formation, no sequestrum, and the cortex was expanded just as in a benign growth. Fig. 1 87. It is true that in extensive tuberculosis of the joint, the disease penetrates the cartilage of one of the articulating surfaces and involves the head of the bone, but the infection is generally limited to the bone beneath the cartilage and does not extend down into the cancellous bone as does an ordinary osteomyelitis. Fig. 188. There is no new bone production, no sequestrum and the joint is always involved. In children, however, it is common to see a tuberculous dactylitis which may involve one or more bones accompanied BONE INFECTIONS 171 by a marked periostitis. Occasionally one of the metacarpals or phalanges will show punched out areas in the shaft of bone similar to cysts. Lues and osteomyelitis will frequently give the same appearance upon the plate, so that often it is impos- sible to differentiate these three conditions b}' .\-ray examina- tion, Fig. 189. Fig. 188. — Tuberculosis of one side of the epiphysis of the tibia. The disease does not extend do^\•n into the cancellous portion of the bone beneath the epiphysis. Besides the tuberculous dactjditis in children we occa- sionally see tubercuh:)sis of the shaft, and this is probably more frequent than has hitherto been supposed. The writers have seen five such cases in the last year. These lesions generally start at or just behind the epiphyses in the cancellous bone or medullary canal. The bone is destroyed just as in ordinary osteomyelitis, and there may be a marked periosteal bone production but seldom new bone in the shaft. The lesion is 172 INJURIES AND DISEASES OF BONES AND JOINTS frequently multiple. So far, from the few cases observed, it has seemed impossible to differentiate it from an acute or luetic osteomyelitis. In the tuberculous types, however, the Fig. 189. Fig. 190. Fig. 189. — Tuberculosis of the first metacarpal with marked periostitis. Fig. 190. — Tuberculous osteomyehtis in an infant with sequestrum. This cannot be differentiated from the inflammatory type of osteomyehtis. joint is frequently involved and the lesion is near the epiph3^sis. Fig. 190. Lues. Lues, while attacking practically all the structures of the body, seems to have a peculiar afTinity for the bones, and the congenital and acquired forms manifest themselves in a variety of ways. The congenital type will be discussed in the chapter on "Joint Lesions of Children." The acquired form varies from a slight periostitis to an advanced osteomyelitis. Luetic periostitis is probably the most common of all lesions, and is seen most often in the last half of the second and all of the third age period. It may involve one or several bones. The periostitis is generally marked, and the calcium salts are laid do\Mi more or less parallel to the long bone and are frequently raised a little from the shaft. This type cannot be differen- tiated from the inflammatory type. If two or more bones, however, are involved, the lesion is generallj' luetic in origin, and this is especially true if it is accompanied by an osteitis BONE INFECTIONS 1-3 without a cavity, Fig. 191. Occasionally the calcium salts may be laid down perpendicular to and extending out from the shaft about one quarter of an inch. For want of a better name Fig. 191. FiG. 192. Fig. 191. — Luetic periostitis, showing in\oKement of both bones ol tlie forearm. Fig. 192. — Luetic periostitis (lace-work type) of the ulna. we speak of this as the "lace work type" of periostitis, and when this is present it is invariably luetic in origin. Unfortu- nately this type is the exception rather than the rule, Fig. 192. Luetic osteomyelitis produces the same bone changes as the inflammatory type and frequently cannot be differentiated. 1-4 INJURIES AND DISEASES OF BONES AND JOINTS ' which may go on to actual organization and deposition of cal- cium salts. Fig. 244. The joint is hazy and indistinct and may simulate tuber- culosis, but the differential points to be noted are the gouged- out areas behind the joint surfaces or the organized blood clots which do not occur in tuberculosis. When such a con- dition is present it is invariably the result of hemophilia. Arthritic Changes in Ligaments. Besides these joint conditions certain changes take place in the ligaments and bursae, \\ hich, while not involving joints, should be looked upon as arthritic in origin. In the chronic arthritic group there is alw ays more or less calcification of the ligaments at their bony attachments, suggesting that these deposits are exostoses; but the deposits are entirely in the ligaments, Fig. 245. This is particularly true in the tendo Achillis and the quadriceps, attachment to the patella. The entire crests of the ilia may be roughened from the same condition. These changes may frequently precede the joint changes and should always be looked upon as infectious in origin. There are two bursae which seem to be the favorite site for arthritic changes, (i) the subdeltoid, and (2) the bursa situated at the attach- ment of the plantar fascia to the os calcis. The latter condition is known as exostoses of the os calcis or painful heels. 234 INJURIES AND DISEASES OF BONES AND JOINTS Subdeltoid Bursitis. The subdeltoid bursa is situated just at the external side of the greater tuberosity of the hu- merous and about five mm. from the cortex. Calcium deposits Fig. 245. — Trauma following upon an arthritic condition, producing marked new bone formation in the tendo Achilhs. Of course, this is an exaggerated case. take place in the walls of the bursa and not in the bursa itself. This usually brings about a very painful condition with limitation of motion. The x-rav examination will show JOINT LESIONS IN ADULTS 235 Fig. 246. — Showing deposition of salts in the subdeltoid bursa. Fig. 247. — Deposition of caleiuni salts in the subdeltoid bursa. 236 INJURIES AND DISEASES OF BONES AND JOINTS Fig. 248. — The non-gonorrheal type of exostosis of the os calcls. It has the same structure as the bone itself. Fig. 249. — Gonorrheal exostosis. The calcification takes place at the attachment of the-planta fascia where there is a small bursa and finally unites with the os calcis. JOINT LESIONS IN ADULTS 23- a deposit of calcium salts just to the outer side of the greater tuberosity JDut not attached to it. With no history of injury the diagnosis is easy to make, Figs. 246 and 247. In a certain number of cases, however, this deposition may take place without the production of any symptoms at all. In such conditions a trauma of the shoulder will produce an acutely painful joint with limitation of motion. The .v-ray will show these calcium deposits; but with apparently a normal joint before injury and symptoms following the trauma, it is fre- quently impossible to determine whether this is a subdeltoid bursitis or a small fragment of bone torn off by the attach- ments of the suprascapular muscles. The diagnosis some- times can only be made by observing the course of the disease; if the symptoms do not subside with fixation of the arm the condition is probably a bursitis and not a hgamentous tearing. This condition is not seen in the young, but is most common in the third age period. Exostosis of the Os Calcis. Two types of deposit arc noted in exostosis of the os calcis, both infectious in origin. The condition is generally known as painful heels. In one type there is an exostosis springing from the os calcis at the point of the plantar fascia attachment, Fig. 248. It starts from the bone, grows outward like a stalactite, has the same structure as the bone and is a true exostosis. It is most frequent in the latter part of the second and all of the third age period. The second type is of gonorrheal origin (Fig. 249), and the calcium salts are deposited first in the bursa at a short dis- tance from the cortex. Then fresh deposits arc subsequently placed until it becomes attached to the cortex. The deposits seem to be laid down in layers, and the mass does not have normal bone structure. It cannot be looked upon as a true exostosis. This type is seen most frequently in the second age period. CHAPTER XI BONE TUMORS CHAPTER XI Bone Tumors BEFORE discussing bone tumors, reference must again be had to the normal bone, as a correct diagnosis depends upon variations of its constituent parts from the normal. A long bone is composed of an outside fibrous sheath called periosteum, not demonstrable by the A-ray in its normal condition. Beneath it is a dense compact bone known as cortex, composed of bone cells and masses of inorganic salts traversed by numerous small canals. Within is the medullary canal con- taining the marrow, fat, nerves, bloodvessels and lymph channels. At the ends of the bone the cortex and medullary canal merge into fmely reticulated bone forming the cancellous ends, and these, in turn, are covered by cartilage forming the joint. The bone is pierced halfway between the ends by a small canal perpendicular to the shaft. The canal is the point of entrance for the nerves, blood and lymph vessels. Since the malignant cells are carried by either the blood or lymph, this nutrient canal plays a very important part in metastatic maHgnancy. In the diagnosis of bone tumors the essential thing is to determine whether the growth is mahgnant or not. If that point can be established the surgeon will be given the informa- tion that is necessary for him to determine the character of the operation to be performed. It is, however, still better if the roentgenologist can go further and determine the exact nature of the lesions. With the exception of the cartilage any one or all of the constituent parts of the bone may be involved by neoplastic growths. In the chapter on joint lesions it was pointed out that cartilage is quite easily attacked by an infection, but is quite resistent to tumors, and is seldom if ever involved by them. 1^ 241 242 INJURIES AND DISEASES OF BONES AND JOINTS Attention has been repeatedly called to the fact that the only direct changes that can be seen upon an x-ray plate are bone destruction and bone production, and that it is the variation in these two processes that yields certain data upon which to formulate a diagnostic hypothesis. In addition, as we have mentioned, there are two accessory aids of great value — age and sex. One does not expect to find carcinoma in the young. If a malignant tumor is found in the bone of a child it is known that it must be sarcomatous in origin. In the same way a malignant growth of the pelvis of a female over fifty years is probably a carcinomatous metastasis from the breast, as that tumor predominates in the female, while in a male pelvis of the same age the growth is apt to be a metastasis from the prostate, as that tumor is the most frequent in the male. Method of Analyzing Bone Tumors. By studying the point of origin and the character of the bone changes the writers have been led to formulate a rough outline for the analysis of these various bone tumors. Four points have been taken as the basis for classification. They are: 1. Origin of the tumor. 2. Presence or absence of bone production. 3. The condition of the cortex. 4. Invasion. At first glance it is often impossible to determine all four of these points, but if one or two of them can be established they frequently lead to the correct diagnosis. It must be borne in mind that these points, which have been named the cardinal points, are merely methods of approach to a diagnosis. If one such point can be established it automatically rules in or out certain tumors, and will generally aid in estab- lishing a second point; thus eventually all four will be estab- lished, and as each point eliminates certain tumors, a diagnosis by exclusion is obtained. As an example of this method, if by the first point it can be absolutely shown that the tumor arises from the periosteum, that automatically excludes a carcinoma, as there are no primary epithelial cells in bone, and conse- BONE TUMORS 243 quently if an epithelial growth develops there, it must be carried in by the lymph or blood. Since these vessels enter the medul- lary canal by means of nutrient channels, carcinoma must of necessity have its origin in the medullary canal. Again, if it can be estabhshed that there is new bone in the tumor, that would also automatically rule out round and spindle-celled sarcomata and carcinomata. In no lesions of the bones is it more important to have a knowledge of pathology than in bone tumors. The .v-ray plate must not be regarded as a photograph in the ordinary sense. Medical knowledge must be brought to bear upon it. The roentgenologist must I)e familiar with the growth of tumors; he must know how they involve the bone and how and why they metastasize. Never make a diagnosis oj a tumor because it looks like something that has been seeyi before. The diagnosis must be made upon the fundamental facts of pathology which have been translated into shadows and registered upon the plate. After the diagnosis is made, the reasoning must then be reversed, and each pathok)gicaI point of the tumor in question apphed to the plate, and they must fit in. If they do not the diagnosis is probably incorrect. This point cannot be em- phasized too strongly. These four cardinal points may now be examined, bearing in mind, however, that they are merely methods of approach, and that while they will help in the vast majority of cases, yet like all other methods of medical classifications they are not infallible. Point of Origin. By point of origin is meant the position where the growth arises whether in the medullary canal (Fig. 250) or whether it springs from the cortex or periosteum. Fig. 251. The cartilaginous articulating surfaces, are not included, as tumors do not arise from them. If this can be determined one point of differential diagnosis is established. All tumors in bone must be either primary or metastatic. It has already been mentioned that there is no primary epithelial tissue in bone, and that if carcinoma is present it must, by means of the vessels 244 INJURIES AND DISEASES OF BONES AND JOINTS Fig. 250. — A tumor arising within the medullary canal. (Giant-cell sarcoma.) BONE TUMORS 245 Fig. 251. — A tumor arising from the cortex. (Fibromyxonia.) 246 INJURIES AND DISEASES OF BONES AND JOINTS through the nutrient canal, have lodged in the medullary canal and grown there. So carcinoma must always be metastatic in origin, and must arise in the medullary canal. Since sarcoma is of connective tissue origin, it may be either primary in the medullary canal or metastatic in origin. It is also known that enchondromata may be either cortical Fig. 252.— Bone production within a tumor. (Osteoma.) or [medullary in origin, while bone cysts are nearly always medullary in origin and very rarely cortical. Periosteal and osteosarcomata are cortical in origin, as well as osteomata. Ossifying hematomata are not bone growths, yet clinically may simulate them and so they have been classed among tumors and they may be looked upon as periostial in origin. Sometimes when the growths have become very extensive it is impossible to determine their origin. BONE TUMORS 247 While this cardinal point hmits the numfDcr of tumors, some having been cxchided by their points of origin, one is still tar from a diagnosis. The second cardinal point, therefore, is brought to bear upon the problem. Boiie Production. Bone production docs not take place in cither carcinoma or in round-cell, spindlc-cell, or giant-cell sarcomata. Consequently if it can be cstabHshcd definitely that there is bone production within the tumor the above mentioned growths can be ruled out, Fig. 2^2. That in turn w^ill again limit the tumors to osteoma, osteochondroma, periosteal, and osteosarcoma, and ossifying hematoma. Bone cysts are not bone producers, but since they are so frequently accompanied by fracture, bone production hiid down as the repair of the fracture may be at times confusing. After determining that the tumor contains new bone procUiction it must then be considered what is the character of the new bone; is it laid down in any definite way? All the bone pro- ducing tumors are either cortical or periosteal in origin and in their growth extend out into the soft tissues. In this region bone production is best studied, as here it has free growth, not being confined or hampered by the bone nor can the new l3one growth be confused with the bone itself, as might be done if the JDone production in that portion of the tumor lying within the bone were considered. Close inspection of this new bone gives the rather starthng information that in malignant growths, JDone is laid down in long striae practically perpen- dicular to the shaft, while in benign grow^ths (with the ex- ception of an osteoma) the growth of new bone is more or less parallel to the shaft. This second cardinal point helps materially in diagnosis by the process of elimination. But there still remain a number of tumors which must be diagnosed, particularly those of medullar}^ origin, so the third cardinal point is involved. Cortex. It must be determined whether the cortex is present or absent, and if present whether it is expanded in a spherical or longitudunal manner. W hen considering the diag- 248 INJURIES AND DISEASES OF BONES AND JOINTS nosis of tumors based upon the first two cardinal points the tumors have been spoken of as arising from the cortex and per- iosteum, and the production of bone in them has been mention- ed; but it is well to check them up again with this third point. The condition of the cortex is also a verj' important factor. Experience has shown that benign tumors arising in the medullary canal are slow growing and always take the path of least resistance; that is, while they grow slowly toward the Fig. 253. — Benign tumor extending up and down the medullary canal with shght expansion of the bone. (Cyst.) cortex they progress more easily up and down the shaft. The pressure from the growth, however, causes an expansion of the cortex, but the expansion is always spindle-shaped (Figs. 253 and 254), or cylindrical, and the cortex is intact unless the growth is unusuallj' large. On the other hand in malignant conditions, the growth is spherical in nature and extends equally in all directions. On account of the rapid growth of the BONE TUMORS 249 Fig. 254. — Benign tumor of the fibula. Note the extension within the medullary canal and expansion of the cortex. (Cyst.) 250 INJURIES AND DISEASES OF BONES AND JOINTS tumor, the cortex docs not expand, but the growth involves and destroys it, so that in this lesion the cortex is absent. Fig. 255. In the early stages of such a tumor the growth has not reached the cortex and it is intact; however, since at this time there will be no symptoms, the lesion will not be seen in this stage. It is only after pressure symptoms begin that the patient Fig. 255. — Complete destruction of the head. The cortex destroyed. (Round-cell sarcoma.) presents himself for examination. Then these cortical changes are discovered. There is only one exception to this and that is the giant-cell sarcoma, Fig. 256. As the name implies it belongs to the sarcomatous group, but on account of the character of its cells, metastasis is almost impossible, so that practically a benign condition is dealt with. BONE TUMORS 2.; I The fourth cardinal point, invasion, is still to be considered. Invasion. This point, frequently the hardest to determine, is the most important of all. If it can be definitely established that the growth is invasive, by that meaning that it infiltrates into bone and soft tissue, everything is in reality determined, because maligiiamy depends upon invasion, Fig. 257. Fig. 256. — Marked expansion of the cortex from a medullary tumor. Cortex thinned out, but still visible. (Giant-cell sarcoma.) After determining these four cardinal points it is then well to take up what might be termed the three laws of probabilities. By these laws is meant what is most frequently found when the age and the sex of the patient are taken into consideration with the particular bone involved. Law as to Age. It is known that certain tumors arc most 252 INJURIES AND DISEASES OF BONES AND JOINTS Fig. 25-. — Metastatic carcinoma showing invasion. Primary gro\\'th in the urinary bladder. BONE TUMORS 253 common at some age periods and arc very rare at others. Carcinoma is quite common over forty years, that is in the third age period, w hile it is cxtremels rare in children, that is in the first age period, and is seen only occasionally between twenty and forty years, the second age period. Sarcoma, however, may occur at any age, but it is most common in the first and second age periods. A malignant liimor of the first age period would then be by this law a sarcoma rather than a carcinoma. Laic as lo Sex. The (irsl law demonstrates thai carcinoma is a lesion found most Irequentlx in the third age j^eriod; it is also known that of all growths in the female at that period, carcinoma of the breast is by far the most common. So in an elderly female, by this law, any grow th in a bone is most apt to be carcinomatous in origin. Law as to Bone Involvement. It has already been stated that carcinoma is a metastatic growth, while sarcoma may be either metastatic or primary in origin. Since carcinoma enters the bones by means of the nutrient canal it generally metas- tasizes close to the entrance of this canal, w hile in sarcoma the favorite site for the grow th is at the ends of the bcjne; so again by this law a medullary growth near the middle of the bone will probably be a carcinoma. Again a growth in an elderly female in the thoracic spine is aj^t to be carcinomatous, lirst on account of sex, then on account of age, and finally because ol all thoracic spine growths carcinomatous metastases (^f that region are by far the most frequent. Before attempting to describe the si^ecilic h-sions of the more common growths, it is of interest to dwell brielly upon how malignant and benign tumors grow and their relation to normal bone. \\ hen a malignant grow th starts in the medullary canal it grows l)\ cell division. Starting from a central point it grows equally in all directions; conseciuently such a growth is spherical in shape. It grows as a mass so rapidly that the surrounding bone is killed by pressure and absorbed; the cortex does not have time to expand, but is destroyed. \\ hile it is true 254 INJURIES AND DISEASES OF BONES AND JOINTS that it does extend down the medullary canal, still as a whole it is spherical in shape. It does not penetrate the Haversian canals and does not pierce the cortex but destroys it. Since it grows as a mass it is limited as a mass to one section of the bone, and does not break out in the same bone at another point leaving normal bone in between. Immediately one sees the fundamental differences between it and an inflammatory lesion such as osteomyelitis. In the latter condition the infec- tion spreads by means of the Haversian canals, and conse- quently destruction of bone may occur at various places with normal bone between. \\ hen the infection reaches the cortex it breaks through in one or two places, leaving normal cortex between. This breaking through the cortex relieves the pressure, and the cortex will not be destroyed en masse as in growths. In all malignant tumors except periosteal and osteo- sarcoma there is no new bone production within the tumor or in the bone adjacent to it. In osteomyelitis when the in- fection subsides there is new bone production at the edges of the infected area, this being nature's way of limiting the in- fection. This reaction does not take place with malignant growths. The question naturally arises: Why is bone produc- tion not seen under such conditions? It must be remembered that to produce bone there must be a source of stimulation, and that any foreign element intro- duced into normal bone will produce such a reaction provided sufficient time elapses for the new bone to form. In osteo- myelitis the infection is a foreign element, but in the acute stages new bone is not encountered. The infection travels too rapidly, and sufficient time does not elapse to allow the new bone to form, because the point of stimulation is just where the infection stops and normal bone begins. In a virulent infection, on account of its rapid spread, its point of contact with normal bone is constantly changing its position, and nature docs not have sufficient time to lay down new bone because the infection passes over that point and a new contact point is established. It is like attempting to BONE TUMORS iss build a dam by throw! ng in earth in a rapidly moving stream. The moment the infeetion subsides, however, its point of con- tact with normal bone remains practically stationary, and nature then has sudicient time to lay down her dam of new bone and limit the spread of infection. In maHgnancy there is the rapid growth similar to the acute infection; but the great difference is that at no stage does the rapid growth of the tumor cease as in an infection, for that reason in no j^eriod ot the grow'th of the tumor has nature sufficient time at her disposal to lay down a protective dam of new bone. Just as in an infec- tion, the point of stimulation is the point of contact between the tumor and the normal bone. In benign growths occurring within the medullary canal a totally different condition arises. While the growth starts at a central point as a spherical mass, it grows but slowly, and when it comes in contact with the walls of the bone it expands very slowly in a lateral direction but extends up and down the medullary canal. Its pressure, however, extended laterally, slowly expands and thins out the cortex but does not destroy it as in malignant growths. With the expansion of the cortex go- ing on very slowly there is probably at the point ol contact some new bone laid down, just a sufficient amount to counter- act the slow pressure destruction from the tumor. \\'ith the growth of the tumor the point of contact is slowly pushed out. The result is an expanded but thinned cortex. Since the growth extends down the canal the expansion will not be spherical but cylindrical in shape. The point of contact at the edge of the tumor in the medullary canal will also show a thin line of bone definitely limiting the growth; but, as in the gradual spreading of the cortex, this thin lineot bone will also slowly change its position. The following are the chief characteristics of the more important bone tumors: Carcinoma. This is essentially an old age tumor. It is always metastatic in origin, and since it enters by means of the nutrient canal it is most frequently seen at the middle point 256 INJURIES AND DISEASES OF BONES AND JOINTS Fig. 258. — Metastatic carcinoma showing invasion. Primary growth in the breast. Note the pathological fracture. Impossible to differentiate the points where the tumor ends and the normal bone begins. BONE TUMORS 257 Fig. 259. — Small carcinomatous metastases of the skull from a breast tumor. of the bone, Fig. 258. Since it is epithelial in origin there is no bone production within the tumor, and on account of its rapid growth there is no new bone reaction external to it. It grows equally in all directions as a solid mass, does not expand the cortex but destroys it completely, and shows dis- tinct signs of invasion in the medullary canal and soft tissues. In the female, carcinoma of the breast is the most common, and its metastases are seen in the order of tluir I requency in the ribs, thoracic spine, lumbar spine, ilia, femur, especially the greater trochanter, skull (Fig. 259) and humerus. It is almost an axiom that carcinoma of the breast never metastasizes below the elbow and knee. Carcinoma 0/ the ovaries and uterus seldom metastasizes to bones, but in our series of cases the writers have had two 258 INJURIES AND DISEASES OF BONES AND JOINTS metastases of the tibia from careinoma of the urinary bladder. Whether the tibiae are the favorite sites for such lesions it is impossible to say, as two cases are too few upon w^hich to base conclusions. In the male, carcinoma 0/ the tongue and lip are Fig. 260. — Carcinoma of the mandible, secondary to carcinoma of the tongue. most common and frequently involve the mandible by direct extension, Fig. 260. Carcinoma of the prostate is also very common and the bones are very frequently involved. Fig. 261 and 262. The bone changes differ slightly from those in other types of carcinoma, but when once seen will always be recognized, as the changes are quite typical. Since this type of tumor grows very slowly, production of new bone is not found within the growth but just at the edge of the growth in the normal bone, in other words at the point of stimulation. Consequently, these meta- stases seem to be more or less encapsulated in a calcium wall, as nature attempts to limit the growth. There are also irregu- lar areas of increased density of calcium salts throughout the bone where no gross malignancy can be demonstrated. This may be due to malignant infiltration too small to be recognized upon the plate and yet sufTicient to produce bone reaction. When a pelvis is so involved it sometimes appears as if the +-> 26o INJURIES AND DISEASES OF BONES AND JOINTS Fig. 262. — The marked density of the lumbar vertebrae with mihary pro- static metastases. This density is due to growth of new bone around the small metastases. The fourth hmibar vertebra has also been shghtly compressed. The individual metastases are too small to be seen. BONE TUMORS 261 lesion were that of Pagct's disease. The l)ones most commonly affected are the pelvic bones, sacrum, lower lumbar vertebrae, femur and occasionally the scapula and clavicle. Just as in carcinoma of the breast, when the long bones are involved, pathological fractures are frequent. This growth is essentially a lesion of the third age period. I Fig. 263. — Round-cell sarcoma of tlu- humerus. Tlie condition cannot be differentiated from carcinoma except by the i)osition of the tumor in the bone and the absence of a primary carcinomatous growth. Note the destruction of the cortex with no expansion of bone. Hypernephroma. This is also of medullary origin and gives the same x-ray appearance as carcinoma. In fact it is im- possible to differentiate it from any medullary non-bone- producing growth. It does not metastasize to bone with great frequency, but when it does the bones of the upper part of the body are involved, particularly the humerus. It is a lesion 262 INJURIES AND DISEASES OF BONES AND JOINTS of the latter part of the second and the first half of the third age period. Round-cell SARCO^L\. Like carcinoma this lesion (Fio;. 263) is also very malignant. It is medullary- in origin, expanding equally in all directions, contains no bone within the growth, does not expand the cortex but destroys it and is invasive. As far as the growth is con- cerned it cannot be differenti- ated from carcinoma upon an A-ray plate. It may occur at any age period, but is especially common in the first and second age periods. To make a differ- ential diagnosis between such a lesion and carcinoma, indirect evidence must be relied upon, namely, the laws of probability. By the law relating to age, if the tumor is in the first age period and the first half of the second period the lesion will be sarcomatous in origin. In the third age period the law does not help us materially, as both types of gro\\"th occur. Fig. 264.— Spindle-cell sarcoma . ^y ^he law relating to sex it of the tibia with marked is known that carcinoma of the periosteal reaction. breast is by far the most com- mon, and consequently the growth is more apt to be carcinomatous. \\ hile prostatic car- cinoma is also quite common, yet its bone lesions are typical and it has an identity of its own. B}' the law relating to bone involvement, since carcinoma is metastatic entirely, the lesion is more apt to be near the entrance of the nutrient canal. \\ hile sarcoma may occur in any portion of the bone, as the primary elements are through- BONE TUMORS 263 out the bone, yet the great majority of the lesions are at the ends. Then too eareinoma is but rarely seen below the elbow and knee, and lesions of bones below these two joints are con- sequently more apt to be sarcomatous in origin. Spindle-cell Sarcoala. While spindle-cell sarcoma is malignant it does not seem to be as invasive when seen upon an x-ray plate. It destroys equally in all directions is generally medullary in origin, does not expand the cortex but destroys it. The growth, however, does not show the same degree of invasion and may be mistaken for osteomyelitis. Fig. 264. It gives the appearance of being slightly limited in its extension through the medullary canaL Periosteal and Osteosarcoma. These growths have probably the same origin but they give such a different picture upon the plate that they will be described separately. Periosteal sarcoma (Figs. 265, 266 and 267), as its name implies, arises from the periosteum. It is a bone-producing tumor, but the major portion of the bone is laid down in the soft tissues. The shaft and periosteum show but little destruc- tion; occasionally the cortex may look a trifle irregular and worm eaten. It is probably the most characteristic of all tumor growths, and when the peculiar way in which the new bone is laid down is once recognized, a mistake in diagnosis will seldom be made. Small striae of calcium salts are laid down approximately perpendicular to the shaft, but not quite reaching the cortex. In other words the lines of bone are laid down in the tumor and apparently are not connected with the periosteum. They resemble, roughly, the picture of the rays of a sunset. In this tumor the greatest growth is in the soft tissues, and the bone changes are entirely outside of the bone proper. This lesion is seen most frequently in the first age period and the first half of the second age period. Osteosarcoma (Fig. 268) arises from the cortex, and extends out into the soft tissues as well as involving the bone. It is frequently impossiJDle to determine where it arises, as both cortex and apparently the medullary canal are involved. It is a 264 INJURIES AND DISEASES OF BONES AND JOINTS Fig. 26^. — Periosteal sarcoma. An advanced case where the shaft is involved. Fig. 266. — Periosteal sarcoma showing the faint bone striae in the soft tissue perpendicular to the shaft. BONE TUMORS 265 Fig. 267. — Periosteal sarcoma showing perpendicular bone striae in the soft tissues. Fig. 268. — Osteosarcoma showing the dense bone production. Note the perpendicular arrangement of the bone at the edges of the growth. 266 INJURIES AND DISEASES OF BONES AND JOINTS bone-produciiig tumor, and the amount of bone produced depends upon the mahgnancy of the individual tumor. In the more malignant type there is but little new bone, while in the slow growing type there is marked bone production. Like periosteal sarcoma the growth extends out into the soft tissues, but unlike periosteal sarcoma there is extensive destruction of the shaft. The new bone is laid do\^ n in perpendicular striae and is connected with the shaft. When it is laid down massiveh'. Fig. 269. — Giant-cell sarcoma. Note the expanded but intact cortex and sharp demarcation of the tumor in the medullary canal. stalagmites of new bone arise from the bone mass hke church spires piercing a city's sky line. Of all the malignant growths these are the only two tumors that produce bone within themselves. This lesion is most frequent in the first age period and the first half of the second. Myeloma. Alyeloma is a malignant tumor which is seen only occasionally. It is slow growing and consequently does not belong to the more mahgnant class. Its favorite site is the flat BONE TUMORS 267 bones, though the long ones may be in\'oIvcd. The cardinal points cannot be applied as a whole in the diagnosis of this tumor. It is a multiple lesion, and the bones are pierced by small focal spots of destruction. It does not expand or destroy the cortex. There is marked rarefaction of the bones; the cortex may be thinned out; pathological fractures are common. It is very difficult to make a diagnosis from the roentgenogram alone; but the chnical history and the presence of Bence- FiG. 270. Fig. 2-1. Fig. 270. — A giant-cell sarcoma which underwent spontaneous healing. The growth became calcified. Fig. 271. — Lateral view of the same condition. Jones's bodies in the urine with this atypical .v-ray picture generally lead to a correct diagnosis. Those tumors will now be considered which arc looked upon as benign. Giant-cell Sarcoma. Giant-cell sarcoma (Fig. 269) has a malignant name but is entirely benign in character. This tumor is composed of very irregular cells w hich in growing are 268 INJURIES AND DISEASES OF BONES AND JOINTS so locked together that it is impossible for one to break off and be swept away in the circulation and lodge elsewhere and grow. Occasionally they may heal spontaneously, Figs. 270 and 2-1. After all, malignancy depends upon two factors — first, the ease with which a cell may break loose from the parent growth, and second, the presence of roads of transporta- tion, ready to carry this cell away and deposit it in some other portion of the body where it grows. The giant-cell .sarcoma Fig. 272. — Multiple enchondromata. These growths are both medullary and cortical in origin. Note how sharply each gro\nh is dehmited. starts in the medullary canal, hence the roads of transportation are there; but the type of cell is such that it cannot become detached from the parent body. Like a malignant tumor it grows equally in all directions; but unlike a malignant tumor it does not destroy the cortex but on account of its slow growth expands it. There is no new bone formation, but the growth BONE TUMORS 269 seems reticulated. It is generally limited in the medullary canal by a thin bony wall and does not show any sign of inva- sion. Its favorite site of location is at the ends of the bone. The lower end of the femur, the upper end of the tibia the lower end of the radius and mandible are most frequently involved, though any long bone may be attacked. It is seen most frequently in the last half of the second age period and at the beginning of the third. Fig. 273. — Osteochondroma of the head of the fibula. En CHONDROMA OR OSTEOCHONDROMA. Enchoudroma (Fig. 272) or osteochondroma (Figs. 273 and 274), as its name implies, is cartilaginous in origin and is generally seen before the epiphyses unite. Its early recognition is probably- due to the fact that pathological fractures are quite common and the patient comes in for fracture and the .v-ray then shows the tumor. In this connection it ma\- l)e mentioned that a fracture 270 INJURIES AND DISEASES OF BONES AND JOINTS Fig. 274. — Large osteochondroma of the femur. BONE TUMORS 271 through such a growth will readily unite, but since the growth is still present the fracture will occur again. Repeated fractures in the same area should always be viewed with suspicion as being pathological from some growth. The lesion is seen near the ends of the bone close to the epiphysis but not involving it. When it is medullary in origin it expands and thins out the cortex but does not destroy it, and since the growth takes the path of least resistance, along the medullary canal, it is oblong in shape and the cortex is expanded in a cylindrical manner. There is no new bone formation unless there has been a fracture. The growth is cystic in character and frequently is locu- lated. These tumors are supposed to arise from misplaced bits of cartilage, that is, during the growth of the bone a bit of cartilage at the epiphysis may be surrounded completely by bone but does not itself undergo transformation. This condition probably takes place in everyone, but for unknown reasons the bit of cartilage will proliferate in some. As has just been mentioned these misplaced bits of cartilage are common in many bones, and the stimulation, whatever it may be, causes all these bits to proliferate; consecjuently enchondromata are almost invariably multiple in origin. They may also arise from the cortex, and in that case form blistcrlike lesions in that area. Their growth is always sharply limited, having a definite border, and they are not invasive. Any of the long bones may be involved, but the bones of the hand are most frequently affected. It may be mentioned in passing that malignancy in the bones of the wrist, hand, ankle and foot are so extremely rare that they need not be considered. All growths in these parts may be looked upon as benign. These tumors are prac- tically limited to the first age period and are seen most fre- quently between the ages of five and fifteen j^ears. Cyst. Cyst (Fig. 275) is most commonl}^ seen at the same ages as the enchondroma, and like it occurs at the end of the bone in the region of the epiphyseal line. It is medullary in origin and extends up and down the shaft; the cortex is intact, but is expanded in a cylindrical manner. It is sharply limited. 2-2 INJURIES AND DISEASES OF BONES AND JOINTS has a definite contour and may be loculatcd, but is generally one large cyst. Cysts are supposed to be multiple, but in the writers' series of cases only one cyst was present in each case though all the bones were examined. It is often impossible to differentiate a cyst from a single lesion of an enchondroma. Fig. 2j^. Fig. 276. Fig. 275. — Bone cyst of the humerus. Note the expansion of the bone and the sharp limitation of the growth. This cyst is multilocular. Fig. 276. — Fracture of the humerus. The x-ray examination through a plaster cast sliowed, however, that this was a pathological fracture through a bone cyst. The differential point is that cysts are single lesions, while enchondromata are multiple. Fractures in cysts are quite fre- quent. Fig. 276. Osteoma. Osteoma (Fig. 277) arises from the cortex and is almost a solid bone tumor with small areas of cartilage. It extends out into the soft tissues entirely and does not involve BONE TUMORS 273 Fig. 277. — Osteoma showing typical cauliflower growth. Fig. 2-8. — Osteoma. 18 2-4 INJURIES AND DISEASES OF BONES AND JOINTS the bone, though attached to the cortex by a more or less wide bony pedicle. The bone is laid down symmetrically, radiating from the point of attachment. The growth is lobulated and has a cauliflowerlike appearance. The ends of the lobulation are clean cut and sharp and no invasive changes are present. The growths are generally multiple at the point of origin and arise perpendicularly from the shaft. They are usually seen in Fig. 2t Fig. 279. Fig. 280. Fig. 279. — Table-top type of exostosis. -The pencil type of exostosis. These always point aA\ay from the nearest epiphysis. the first age period, and while they may arise from any bone the favorite sites are the upper end of the humerus, lower end of the femur, and the upper end of the tibia. They are not painful, and the patient comes for examination because the mass of bone mechanically interferes with flexion or on ac- count of cosmetic reasons. BONE TUMORS 275 Exostoses are overgrowths of bone arising from the cortex, having the same structure as the bone, limited by sharp, straight borders, and generally enping in a more or less blunt point. They are of two kinds, the table-top type (Fig. 279) similar to a broad-angled triangle, the base being attached to the cortex; and the long-pencil type, arising from the cortex at an Fig. 281. — Exostosis terminating in a small osteochondroma. hiG. 282. —Fibroma of the phahinx. angle and pointing away from the nearest epiphysis, Figs. 280 and 281. Occasionally the end is capped by a small osteoma. They are benign in character and occur most frequently in the first and second age periods. Fibroma. Fibroma (Fig, 282) is a rather rare tumor. It is cystic in character, has a definite border, is oval in shape extending up and down the medullary canal, thins the cortex, contains no new bone and is not invasive. From an x-ray stand- point it cannot be dincrcntiated from a cyst or cnchondroma. 276 INJURIES AND DISEASES OF BONES AND JOINTS It occurs as a single tumor and is not multiple as enchon- dromata. In the only case observed the tumor was in the phalanx of a patient in the first half of the second age period. Myxoma. Myxoma is also an unusual tumor. The .V-raj^ appearance is similar to that of a cyst. It sometimes Fig. 283. — Hemangioma. Note the circular calcified bodies in the soft tissues. Bones are not involved. undergoes malignant degeneration. This tumor occurs in the first age period. HexMangiomata (Figs. 283 and 284) are lluctuating tumors, cystic in character ^^•hich involve most frequently the hands, feet and forearms. They are not primarily bone BONE TUMORS 277 tumors, but since there is deposition of calcium salts in them, it was thought well to describe them. The .v-ray examination shows them as large soft tissue swellings. Lying within* the tumor are a series of round calcified bodies having concentric rings within them. This appearance is characteristic, and Fig. 284. — Hemangioma of the hand. when once observed cannot be mistaken. These tumors are benign in character. Ossifying Hematoma. This growth does not belong to the tumor group, as it is inflammatory in origin ; but on account of the frequency with which it is clinically diagnosed as sar- coma, it seems well to consider it under bone tumors. \\ c have already discussed this lesion in connection with scur\y. Since 278 INJURIES AND DISEASES OF BONES AND JOINTS Fig. 285. — Ossifying hematoma of the femur. Fig. 286. — Myositis ossificans. in children the periosteum is but loosely attached to the shaft of the bone, hemorrhage beneath it easily separates it from the bone and the hemorrhage will surround the entire bone, from epiphysis to epiphysis. In adults the periosteum is much more firmly attached, consequently, the lesion will be more or less localized. This condition is the result of trauma to the peri- osteum, generally following a violent blow. In the writers' seventeen cases in adults sixteen were from injuries received in football, and the seventeenth from the kick of a mule. They all occurred on the anterior surface of the femur. The patients were all males in the latter part of the first age period and first BONE TUMORS 279 4 i Fig. 287. — Osteosarcoma, showing destruction of tlie bone whicli Is one of the differential points in distinguishing it from an ossifying hema- toma. 28o INJURIES AND DISEASES OF BONES AND JOINTS half of the second age period. In nearly half of the cases a clinical diagnosis was made of sarcoma. Apparently what happens is as follows : The violent trauma evidently ruptures a blood vessel in the periosteum; the hemorrhage gradually raises the periosteum until the resulting pressure becomes greater than the blood pressure, and the hemorrhage ceases. A roentgen examination made shortly after the injur}' has been sustained reveals nothing, since the perios- teum is not demonstrable in its normal condition and the cortex of the bone is never involved. At the end of about three weeks calcium salts will be laid down in the periosteum and the hemorrhage beneath it will undergo organization with deposition of calcium salts. Fig. 285. The lesion on account of the periosteum will have a definite border which will be at- tached to the bone, and the calcium deposits in the hemorrhage will be laid down more or less parallel to the shaft. This con- dition must be differentiated from myositis ossificans (Fig. 286) and from the two malignant bone tumors, periosteal and osteosarcoma, Fig. 287. The following points will aid in the diagnosis. In hematoma, since the hemorrhage is limited by the periosteum, there is a definite, sharp calcium border. The shaft of the bone is never involved and the calcium salts in the hemorrhage are more or less parallel to the shaft. In the malignant bone tumors there are no sharp borders, the calcium deposits are laid down perpen- dicular to the shaft and the shaft is more or less involved. The tumor from hemorrhage follows the shaft and is generally ob- long. The malignant tumors are generally circular in character. Osteitis Fibrosa Cystica. Although osteitis fibrosa cystica is generally classed with tumors, it is also probably of in- flammatory origin. It is practically a disease of the first age period. The femur and tibia are the bones most frequently in- volved. Fig. 288. The striking feature is the deformity pro- duced by the softening of the bones, which frequently results in pathological fractures. When this condition occurs the lesion is extensive, involving the greater portion or even all of the BONE TUMORS 281 bone. As in osteomyelitis the length of the bone may be ae- tually increased. When the femur is involved, particularly the upper portion, the neck may be bent almost to a right angle; the trochanter may be so high as to impinge upon the Fig. 288. — Osteitis fijjrosa cystica, showing the lengthening of the tibia. The bowing is due to the softening and lengthening of the bone. The striae of new bone with cvsts are characteristic features. ihum, and abduction be completely limited. The shaft of the femur and tibia are markedly bowed as in rickets. Besides these deformities the .v-ray shows other marked changes. The cortex is expanded and thinned, but intact. There 282 INJURIES AND DISEASES OF BONES AND JOINTS are large cystlike areas in the medullary cavity. The normal bone structure becomes ver^^ irregular. Long striae of lessened and increased density- occur, enclosing these cystlike formations. Occasionally these cysts may be very small and numerous and the striated bone be the striking feature. The condition is Fig. 289. — Pressure atrophy ul tiie cranial bones due to internal pres- sure. This case was one of marked internal hydrocephalus. always definitely limited and the cysts have sharp borders. It is sometimes mistaken for osteomyelitis or sarcoma. Brain Tumors. In discussing the bone lesions of tumors it is advisable to draw attention to the changes in the cranial bones in brain tumors. Unfortunately the .v-ray evidence regarding brain tumors is unreliable, but there are certain bone changes occurring in advanced cases which must be noted — those occurring from BONE TUMORS 283 internal pressure, whether from growth or Uuid, Fig. 289. The cranial bones become so much thinned out in certain areas, i.e., over the convolutions, that in extreme cases the plate suggests that the roentgenologist has actually succeeded in .v-raying the brain itself. In hypophyseal tumors the sella Fig. 290. — Complete destruction of the sella turcica from pressure ol an hypophyseal tumor. turcica may be expanded and partiali\' destroyed, also due to pressure, Fig. 290. Brain tumors do not metastasize to bones. In conclusion it must be remembered that these growths and metastases do not give the same appearance in the flat bones, such as the cranial bones or scapula, and so the four cardinal points cannot be applied to pathological conditions in these regions. In fact one cardinal point, invasion, is com- pletely reversed. In metastatic tumors of the cranial bones there will be a sharp punched-out area with an abrupt and 284 INJURIES AND DISEASES OF BONES AND JOINTS definite border, while in inllammatory lesions the edges of the infected area will be irregular and \\'orm-eaten, suggesting invasion. Just as in other bone lesions, and particularly in malignant growths, the roentgenologist depends upon bone destruction and production for diagnostic signs and anj^ surgical inter- ference may so completely change them that he will be com- pletely misled. In such cases one should be extremely guarded in making a diagnosis, as the bone destruction may be the result of surgical interference, and bone production the repair of surgical trauma. Below is a summary of the bone tumors grouped ac- cording to the four cardinal points which aid in diagnosis: 1. Origin — Medullary or Cortical a. Medullary Sarcoma Carcinoma Hypernephroma Myeloma Fibroma Bone cysts Enchondroma Giant-cell sarcoma b. Cortical Periosteal sarcoma Osteosarcoma Osteoma Enchondroma Ossifying hematoma Bone cysts (rare) 2. Bone Production Periosteal sarcoma Osteosarcoma Osteoma BONE TUMORS 285 2. BoxE Production Ossifying hematoma Enchondroma and bone cyst (where there has been trauma) 3. Cortex — Expanded or Destroyed a. Destroyed Sarcoma Carcinoma Osteosarcoma Hypernephroma Myeloma (advanced stage) Periosteal sarcoma b. Expanded, hut Intact Enchondroma Bone cysts Giant-ccII sarcoma Fibroma 4. Invasion All malignant tumors show invasion. CHAPTER XII THE SPINE CHAPTER \1I The Spine WHILE the spine is subjeet to the same injuiies and diseases as other bones, yet for the sake of bringing out more clearly the differential diag- nosis between the various lesions it was thought wise to devote a special chapter to it as a whole. Conformation. The conformation of the spine is some- what different from other bones, as it acts as a housing for some of the most important structures of the body — the cord and its attendant nerve trunks. Each individual vertebra arises from three big centers, one for the body and one for each lateral mass, Fig. 291. These unite to form one solid structure. Between each vertebra is a cartilaginous disc giving a clear joint space as with the long bones. On each side of the body are interlocking articulations preventing any lateral slipping, and the entire spine is bound together by a number of very strong ligaments and muscles. It is probably one of the strongest structures in the body, as it not only carries the weight of the body but protects the spinal cord. The vertebral i)ody is composed entirely of can- cellous bone, and rehitively there is but little periosteum present. The nerve trunks emerge from between the vertebrae. Divisions. The spine is divided into the cervical, thoracic, lumbar and sacrococcygeal portions. The bodies of the verte- brae increase in size downward until the sacrum is reached. This is mechanically correct, as the lumbar \ crtebrae have more weight to sustain than the cervical ones. While the spine functions as a whole, yet the \arious parts have slightly different action and are slightl>- modified by other anatomical relations. The same lesions, therefore, in different parts will be somewhat modified. 19 289 290 INJURIES AND DISEASES OF BONES AND JOINTS The cervical portion, especially the upper vertebrae, is the most flexible, has the greatest mobility and sustains less weight, consequently any lesion in that portion gives early clinical S3^mptoms by limitation of motion, just as an ordinary joint would; but there is less compression destruction. The thoracic vertebrae articulate with the ribs, and these in turn are fixed to the sternum, so in this region there is relatively little movement; and while these vertebrae carry more weight Fig. 291. — Showing the three centers from which each individual vertebra arises — one for the bodv and one for each lateral mass. than those in the cervical region, yet the ribs and sternum act as supporting walls, so that in the thoracic region a lesion is actually subjected to less compression. In this region clinical symptoms arc not noticeable so early, and compression changes appear more slowly. The lumbar vertebrae have great flexibility, but no supporting walls, and, while they are the largest and strongest, yet a lesion in them gives early clinical signs and shows marked compression changes. THE SPINE 291 Fifth Lumbar Vertebra. The fifth lumbar vertebra is a very important one and differs from all others as to function, in that it is the end hnk of a flexible chain and absorbs the shock of the entire spine. It may be likened to a train of cars stopped by a bumper. The first car hits its neighbor and it in turn moves forward and hits the next one, each one absori^ing a certain portion of the shock; but the last car is against the I^umper, a fixed and immovable object, and so it stands all of the shock which has not been absorbed JDy the other cars. In the case of the spine the sacrum and pelvis are the immovable bumper, and so the fifth lumbar vertebra has to take all the remaining sliock. Classification' of Lesions. The lesions of the spine ma}' be divided into age periods just as with other bones and joints; but the diagnostic points are somewhat complicated, because in a measure ever}- lesion has to be considered as more or less affecting both })one and joint and must therefore be considered together and not separately, as a l^one lesion or a joint lesion. From this standpoint our lesions are divided into: 1. Those affecting the intervertebral space and articulating surfaces. 2. Those affecting both the intervertebral space and f^ody. 3. Those affecting the body alone. Before appfying these cfassifications it will be wefl to de- scribe the separate fesions first and then see how this cfassifica- tion can Idc appfied so as to bring about points of differential diagnosis. Fractures. These are but rarely seen in children. They occur most frequently between the ages of twenty and forty, that is, the second age period, fess frequentfy in the third age period. They are most common in the male and relatively in- frequent in the female. This is due not to structural weakness of the spine but to the more active and hazardous pursuits of the male. The body of the vertebra is most frequentfy broken the break occurring most often between the fifth cervical vertebra, and the second lumbar, increasing in fVequency 292 INJURIES AND DISEASES OF BONES AND JOINTS from above downward. In the cervical and upper thoracic region one or two vertebrae may be affected, while in the lumbothoracic region generally only one is involved. Frac- tures of the body are invariably accompanied by more or less subluxation, consequently, dislocation is one of the x-ray signs to be looked for when a fracture is suspected. Fractures of the cervical region (Fig. 292) are more grave than those in the himbothoracic region, as in the writers' Fig. 292. — Fracture with subhixation of the second cervical vertebra. series of cases the mortality was higher; fracture of the laminae are seen most frequently in the cervical region. This is pro- bably due to the fact that the arch formed by them is large and also because from an x-ray standpoint they are easier to demonstrate. Fractures of the Spinous Processes. These fractures are seen in the cervical region. The processes there are longer and more THE SPINE 293 slender, and for that reason are more easily broken. Fractures of the spinous processes of the thoracic and himbar vertebrae are either uncommon or the .v-ray fails to show them. Various textbooks state that fractures of the transverse processes are infrequent, but in the writers' series they are quite common, especially in the lumbar region. A fall upon the flat of the back may fracture all of them on one side, or a severe twist may fracture one or more processes, Fig. 293. Fig. 293. — Fracture of tlic transverse process of tlie lumbar spine. Upon two occasions the writers have seen a fracture of the process of the fifth lumbar vertebra following an attempt to make an extra long drive while playing golf. However, it is probably not correct to draw conclusions as to the relative frequency of fractures of various parts of a vertebra since per- centages are based upon only such cases as are .v-rayed, and then too there may be slight cracks which can not be demon- strated. On numerous occasions an .v-ray examination of the kidneys has resulted in the accidental iindiiig of one or more 294 INJURIES AND DISEASES OF BONES AND JOINTS Fig. 294. — Scoliosis showing the primary and secondar\- curves. Note that there are curves but no angulations. THE SPINE 295 fractured transverse processes. Upon questioning, the patient may remember an injury, but it was apparently so trivial as not to necessitate medical attention. There is no question but that many ol these fractures are overlooked, and that if percentages were based upon the num- ber of fractures that actually occur a totally different condition might be discovered as to the relative frequency of fractures of the body, laminae and transverse and spinous processes. Besides exammmg the sus- pected area for fracture the spine must be viewed as to the curves. There is normally a curve in the lumbar region with concavity outward and one in the thoracic region with con- vexity outward. There are no lateral curves except in scoliosis (Fig. 294); consequentlx , while curves are functional, angula- tions are due either to injuries or to disease. Angulations always mean some pathological process, and a knowledge of whether they point posteriorly or laterally will aid in diagnosis. Fig. 295. When the body of the cervical vertebra is broken the articulating pedicles are broken also, and allow a dislocation, generally backward, producing an angulation. The joint space disappears, and, if the iVacture is old, there w^ill be new bone formation. Fractures of the Bodies of the Thoracic and Lumbar Vertebrae. On account of the wide intervertebral space in the normal, the changes resulting from these fractures can be more easily demonstrated. The body is more or less compressed iG. 295. — Lateral angulation in- dicating a pathological condi- tion. This case was a fracture. 296 INJURIES AND DISEASES OF BONES AND JOINTS and widened laterally, the intervertebral space is obliterated, and there is a generally lateral angulation, seldom posterior as in tuberculosis. If the fracture is an old one there will be new bone production, again different from tuberculosis (Fig. 296), as in that lesion there is no bone production. Fig. 296. — A fractured spine with new bone production. Diagnostic Aids. There are, then, five important points upon which to base a diagnosis. 1. Angulation. 2. Lateral deformity. 3. Bone production. THE SPINE 297 4. Involvement of the intervertebral space and body. 5. Laws of probability as to age. By angulation is meant a sharp angular deviation; in the cervical region this may be lateral or posterior, but in the tho- racic and lumbar regions it is generally lateral. Lateral deformit}^ is due to the fact that with fracture the body is compressed and spreads laterally. In an old fracture there is bone production. The intervertebral space is always obliterated by crushing. The law as to age establishes the observation that fractures are most frequent in the second age period. Arthritis. This condition has already been discussed in the chapters on joint lesions, and while the same bone changes occur in the spine as in other joints there are certain modi- fications which must be noted. On account of the thickness of the muscles and the rigidity of the ligaments it is not possible to demonstrate periarticular swelling, and there is no fluid present. Atrophy, except in ex- treme cases, is also hard to demonstrate. There are then only two processes to fall back upon, destruction and bone pro- duction, and of these two, bone destruction is hard to demon- strate in many of the cases. In the ordinary joint the destruction of the cartilaginous spaces was indicated by joint narrowing. The vertebrae, however, articulate by small pedicles, and the bodies are separated by the intervertebral discs. \\ hile the cartilage of the articulations is destroyed yet the interverte- bral space will not be narrowed, as the discs hold them apart. Consequently the condition is not recognized in the early stages but only in the stage where there is bone production. One frequently sees the stiff, rigid, painful, poker back which in the early stages of the lesion is shown by the .v-ray as a normal spine. Months later bone production will finally appear. The first A-ray change to be noted w ill be a llattening of the edges of the vertebrae (Fig. 297) where the lateral ligaments are attached. Later at those points exostoses will form, always 298 INJURIES AND DISEASES OF BONES AND JOINTS pointing towards the adjacent bodies. This process will go on until they actuall}' engage, Fig. 298. Infectious Arthritis — Tuberculosis. Just as in the other joints infectious arthritis in the spine occurs at any age, and the hypertrophic type in the third age period, the latter type throwing down more bone than the former. These changes are all confined to the intervertebral space, and, as has been Fig. 297. Fig. 298. Fig. 297. — The edges of the vertebrae are becoming sharpened. This is the first change noted in an arthritis. Fig. 298. — The formation of exostoses taking place along the edges of the vertebrae and lateral ligaments. explained, there is no narrowing of the joint space as with other joints. Tuberculosis, however, is a notable exception. In the first stage of the disease there is destruction of the articulating surfaces alone. This stage is but seldom recognized. It is only when there begins to be destruction of the body with obliteration of the space that this lesion is recognized. In the advanced cases there are obliteration of the space and THE SPINE 299 destruction of the body. There is no new bone formation, and in the thoracic and lumbar regions there is posterior angulation. This is due to the fact that the anterior border of the body becomes softened and then is crushed by the body weight, Fig. 299. The posterior portion of the body and the laminae are practically never involved, so that a lateral .v-ray examination will show that the vertebra has become triangular in shape, the apex being anterior and the base posterior. This gives the characteristic angulation or knuckle, the true tuberculous kyphosis. Therefore in the noti- tuberculous cases there is found : 1. No angulation. 2. No lateral deformity. 3. Bone production. 4. No obhteration of joint spaces, no body involvement. 5. The condition occurring at any age according to the type of infection. While in the tuberculous cases are found: 1. Angulation. 2. Posterior and not lateral deformity as a rule, according to where the lesion is situated. 3. No bone production. 4. Oi^Iiteration of joint space and involvement of body. 5. The condition occurring most frequently in children and young adults. It must be borne in mind that, as in other joints, when the tuberculous lesion in the spine becomes a mixed in lection then we have bone production. Marie-Slrumpell Type. Besides the arthritic types de- scribed there are two arthritic lesions which differ markedly and must be looked upon as separate entities. The Marie- Striimpell type of spondylitis deformans occurs generally be- FiG. 299. — Dcstructiiin Jilt I I using of two vertebrae witli posterior angulation, result of a tuber- culous infection. 300 INJURIES AND DISEASES OF BONES AND JOINTS twecn the ages of twenty and forty, that is, the second age period. It involves the entire spine, frequently the hips and shoulders. It does not attack an\ of the other joints. It starts Fig. 300. — Marie-Striimpell type ol arthritis deformans. Note the complete bony ankylosis of the ligaments. in the liinibar region and in\()hx\s progressively the entire spine, occasionally omitting the axis and atlas. The shoulders and hips are the last joints to become affected. It is a slowly THE SPINE 301 progressing infection the action of which extends over Ncars, Fig. 300. It is probably infectious in origin, though this has not been definitely established. In the early stages the .v-ray shows Fig. 301. — Charcot joint of the fourtli lunibar \crtcbra. Note lateral deviation. only involvement of the lumbar region, calcification of the ligaments being so complete as to result in actual ankylosis, with the vertebrae very atrophic. The entire spine becomes 302 INJURIES AND DISEASES OF BONES AND JOINTS involved, accompanied by a marked anterior bowing which, in extreme cases, is so pronounced that the upper portion of the spine is at right angles to a line drawn perpendicularly through the sacrum. W hen this state is reached practically all the ligaments have become calcified, particularly those situated anteriorly. In fact the entire spine appears as if molten bone had been poured over it. On account of the extreme anterior flexion the anteroposterior .v-ray examination shows an apparent ob- literation of the joint spaces. This, however, is due to the marked bowing which causes the .v-ray shadows of the verte- brae to overlap. If a lateral examination is made each joint space will be seen to be intact, the bone change having taken place entirely in the ligaments. In the early stage this disease looks like the ordinary infectious arthritis. Acute Spondylitis Deformans. This lesion gives an acute clinical history. From an .v-ray standpoint it presents the same picture as the Marie-Striimpeli type except that progress is more rapid and that the joint infection is not confined to the spine, hips and shoulders. Any joint may be involved. This condition is probably an atypical form of infectious arthritis. Charcot Spine and Syringomyelia. Charcot spine (Fig. 301) and syringomyelia occurring in the third age period show practically the same changes on the .v-ray plate and cannot be distinguished except with the aid of the clinical history. These lesions are characterized by the obliteration of the intervertebral space, destruction of the body, lateral angulation, deformity, and bony detritus lying around the destroyed vertebrae. Tumors. Tumors in the spinal column give the same .v-ray appearance as when located in other bones. Secondary carci- noma is the most common of all. The lesions of tumors are all confined to the body alone, and as has been so frequently pointed out do not involve the cartilage. Consequently^ the joint space is intact and there is no angulation or deformity un- THE SPINE 303 til the lesion is in an advanced state. Sarcomatous and earei- nomatous tissue is relatively dense, and so the body weight compresses it slowly. The characteristic picture shows the body of the vertebra much narrowed, sometimes to less than half the width of the other vertebral bodies; the joint space on each side is intact, Fig. 302. Carcinoma is the most common lesion, round and spindle-cell sarcoma next, then osteosarcoma Fig. 302.— Carcinoma of the lumbar \ertcbra, showino; the joint spaces intact and the vertebra not compressed at tliis stage. and finally osteoma and giant-cell sarcoma. Cyst and enchon- droma have never been observed in our scries of cases. A brief description of these lesions has only been given to refresh the memory, as they have been described in more detail under their respective heads. Application of Classification Aids. An attempt will now be made to show how diagnosis may be very materially 304 INJURIES AND DISEASES OF BONES AND JOINTS helped by the use of the classification given in the beginning of this chapter. These lesions may be divided into three groups : 1 . Those affecting the intervertebral space, but not obliterating it. In these lesions the body of the vertebra is intact, and all the changes take place in and around the Joint space. In this class will fall the various types of arthritis and the first stage of tuberculosis. 2. Those affecting both the intervertebral space and body. Here are grouped what might be termed transitional lesions, as they are passing over from the pure intervertebral space lesion to the pure body lesion. These lesions are relatively few in number and arc noted in the destructive stage of tubercu- losis, fracture dislocation, and the neuropathic conditions such as Charcot spine and syringomyelia. Osteomyelitis should be placed in this group, but it affects the vertebra so infrequently that it can be disregarded. 3. Those affecting the body alone. This group is composed entirely of tumors. The characteristic changes of the first group are bone pro- duction at the edges of the vertebrae and in the ligaments, no narrowing of the joint space, no angulation or deformity, and occurring at different ages according to the type of infec- tion. There is no change in the body of the vertebrae or ob- literation of the joint space. There may be mechanical ankylosis from the interlocking of opposing exostoses, as in hypertrophic arthritis, or one or two bodies may actually unite by means of deposits in the lateral ligaments, or there may be complete ankylosis as in acute spondylitis deformans or the Marie-Striimpell type. The first stage of tuberculosis falls in this class since only the cartilage is involved at this period. The important point to bear in mind is that this group consists solely of joint lesions. The second group differs from the first by obliteration of the joint space and involvement of the body. The four principal THE SPINE 305 lesions arc the destructive stage of tuberculosis, Charcot spine, syringomyelia, and fracture dislocation. Tuberculosis occurs most frequently in the first and second age periods. If this disease is present there is angulation, anteroposterior deformity, and no new bone production; but fibrous or bony ankjdosis may be present. In the neuropathic lesions, Charcot spine and syringomyelia, angulation and lat- eral deformity are present; new bone formation is seldom seen, but bony detritus is generally present. These lesions are seldom seen before the third age period. In fracture dislocation, angulation, lateral deformity, new bone production and bony ankylosis are present. It is most common in the second age period. The changes in fracture dislocation apply only to the thoracic and lumbar regions, as in the cervical region the dis- placement is generally posterior instead of lateral. The third group is differentiated from the first and second by the fact that the body alone is involved. This group is com- posed of the tumors. These generally occur in the third age period. The chief points are: no angulation until the late stage is reached, seldom displacement, but narrowing of the body with or ^^'ithout bone production according to the type of lesion. This classification must not be looked upon as one would a rule in mathematics, as it is only approximate in its exactness. It does help, how^ever, very materially, as each point, if established, limits the number of possibilities. The arthritic group of spinal lesions, just as in other joints lesions, is pro- bably the one that offers the greatest difilculty. The etiological factor is unknown in many of the cases, in others the factors are in dispute, and finally the types seem to overlap clinically. The same perplexities that confront the clinician are equally applicable to the roentgenologist. In studying these joint lesions, the trite phrase that Osier used to force home the diffi- culties encountered in the treatment of arthritis upon us as students, seems more and more applicable: "Gentlemen, 20 3o6 INJURIES AND DISEASES OF BONES AND JOINTS when a case of chronic rheumatism comes in your front door, climb the back fence, as you will get more credit than if you treated the case." Functional Conditions. Besides fractures, arthritis and growths, there are other conditions affecting the spine which may be termed functional. Scoliosis. This is not a disease but a deformity, and maj' be the result of some abnormality either of the spine or of the structures connected directly or indirectly with it. It some- times is the result of overdevelopment of certain muscles, but in the vast majority of cases the cause remains undetermined. The process is entirely a functional one, and whenever there is a primary curve there is a secondary one, either above or below, curving in the opposite direction so as to maintain the spinal balance. Some of the causes that have been demonstrated by A'-ray examinations are as follows: It has already been mentioned that a vertebra develops from three principle centers, one for the body and one for each lateral mass. There are several secondary centers which appear later, but they are not perti- nent in this condition. Any overgrowth or faulty development of any one of the principle centers, but especially those for the lateral masses, will produce an asymmetrical vertebra and thus a scoliosis. Occasionalh' in the thoracic region a rudimentary triangu- lar vertebra ma}' be inserted on one side between the adjacent vertebrae, and thus produce a scoliosis. A single cervical rib as well as the sacrolization of one side of the fifth lumbar verte- bra has also produced this condition. \\ here an arm or leg has been amputated or over or under- growth of these parts has occurred, a scoliosis will result. In certain trades, such as hod carrying, where one side of the hod carrier's body has been used more than the other, scoliosis will occur. Spinal curves are always functional, while angula- tions are pathological. Another spinal lesion about which there is much dis- THE SPINE 30- cussion is the so-called sacroiliac subluxation. This condition is not believed to be a real subluxation, but a ligamentous in- volvement. It is perfectly true that one frequently sees one side of the sacrum higher than the other, suggesting slipping, accompanied at the same time by marked clinical symptoms. Manipulation under anesthesia and fixation by a plaster cast will result in complete recovery, yet a second .v-ray examination will fail to show any change at all in the position of the sacrum. The sacroiliac articulation is one of the strongest in the body, and its anatomical structure is such that only the most severe trauma could cause it to slip. While many cases of indefinite pain and discomfort in this region may be due to ligamentous rather than bony changes yet it must be borne in mind that there is at times a lorward slipping of the fifth lumbar vertebra. A lateral view of the fifth lumbar and the top of the sacrum in such cases will show the body of the fifth lumbar projecting, anterior to the top of the sacrum. As an example of this condition, a patient was referred for possible kidney stone on account of pain and albuminuria. When the patient was lying extended upon her back there was such an extreme lordosis that after the kidney examination a lateral examination of the lumbosacral region was made. No stone was found, but there was anterior slipping of the lilth lumbar vertebra. The patient was placed in a plaster cast, and within three days the albuminuria and pain had disappeared. The cast was worn a year and complete recover^'^ ensued. Of course the subluxation was not reduced; the cast simply prevented further slipping and allowed nature to tighten up her ligaments and adapt herself to the altered state of affairs. Pressure destruction of the vertebrae is occasionally ob- served, not due to any disease but to direct pressure from tumors lying adjacent to the spine. This is notably true in aneurysms of the thoracic aorta, particularly those arising from the descending portion. This aneuiysm lies well poste- riorl}'. It may come into direct contact with the spine, and by 3o8 INJURIES AND DISEASES OF BONES AND JOINTS its continued expansion so press upon one or more vertebrae as to bring about an actual pressure necrosis. The same condition Fig. 303. — Pressure destruction of the lumbar vertebrae from a tumor lying adjacent to it. When the tumor \\'as removed there was com- plete regeneration of the vertebra. has been observed in large tumors of the neck and in tumors of the spinal muscles, Fig. 303. CHAPTER XIII ABNORMALITIES CHAPTER XIU Abnormalities THE spine is probably the scat of more abnormalities than any other part of the bony structure, and atten- tion has already been called to the fact that while these abnormalities are not pathological in the sense ol disease, yet they may produce symptoms most annoying to the patient. For convenience it is well to consider them according to their locations, namely, cervical, thoracic and lumbosacral. Extra Ribs. In the cervical region the most common abnormahty is the presence of extra ribs. Fig. 304. They usu- ally spring from the seventh cervical, and may be cither unilateral or bilateral. The former is the most common. It is present from birth although the symptoms — pain and numbness in the arm — usually do not appear until the second age period. The symptoms usually lead to a diagnosis of neuritis, and if the condition be due to pressure from one of these ribs it will not yield to medical treatment; removal of the rib isthe only cure. Cer\Tcal ribs, ho^^•ever, may be present without pro- ducing any symptoms at all, and in those cases they should not be disturbed. When the abnormality is unilateral the diagnosis is esisy (Fig. 30,5), since the corresponding rib on the opposite side will be absent. The difficulties arise when ccr\ ical ribs are present on both sides. They may be mistaken tor the first pair of thoracic ribs. This can be determined only by the examination of the entire thoracic spine to ascertain whether there are twelve or thirteen pairs of ribs present. II there are thirteen it is certain that an extra pair of cervical ribs are under consideration. The seventh cervical vertebra is similar in .v-ray appearance to the first thoracic, hence no conclusions can be drawn as to whether the ribs arise from the sc\enth 311 312 INJURIES AND DISEASES OF BONES AND JOINTS cervical or first thoracic vertebra. It might seem more simple to take the entire cervical portion of the spine and upon examination see if there are six or seven cervical vertebrae present. Unfortunately this would not help, even if only six cervicals were found, because the attachments of the ribs are Fig. 304. — Rudimentary ribs arising from the seventh cervical vertebra. variable. They may be attached to the vertebrae one too high or one too low. In other words, the first pair of ribs may be attached to the seventh cervical and stop with the eleventh thoracic, or the first pair may arise from the second thoracic and stop with the first kimbar. In this way there may ABNORMALITIES 313 be six cervical, twelve thoracic and six lumbar \ ertebrae, or eight cervical, twelve thoracic and four lumbar vertebrae. While these cervical ribs practically always spring from the seventh cervical, the writers have seen one case where a pair arose from the second ccr\ ical; the ends being imbedded in the •1 £ft^ l^^dttl ■^ m gr»"..-. Fig. 305. — Ccr\ ical ril) arising from one side only. tonsils. The tonsils were remo\cd on account of their patho- logical condition, and at operation a small bit of bone had to be removed from each tonsil. An .\-ray examination after opera- tion disclosed this curious anomaly — a pair of cervical ribs. Non-union — Rudimentary Vertebrae. Congenital non- union of the laminae that form the spinous process is quite common in the seventh cer\ ical and occasionally present in the sixth, Fig. 306. Its importance lies only in the fact that it is sometimes mistaken for a fracture. 314 INJURIES AND DISEASES OF BONES AND JOINTS The abnormalities of the thoracic vertebrae are relatively uncommon, the most frequent being the congenital non-union of the laminae of the first two thoracic vertebrae. This abnor- mality is also of importance for the same reason — that it may be mistaken for fracture. Occasionally one sees a rudimentarj- vertebra, triangular in shape, inserted on one side. This con- dition invariabh" results m scoliosis, Fig. 307. It generalh- occurs in the upper thoracic region and is important in that the resulting scoliosis will not yield to the ordinary corrective Fig. 306. Fig. 30-. Fig. 306. — Rudimentary spina bifida of the seventh cervical. Fig. 307. — Rudimentary vertebra in the dorsal region, producing scoliosis. exercises. Occasionally such a vertebra may have a rudimen- tary rib attached. Synostosis of the bodies of two ribs is quite a frequent finding. These are found independent at the spinal attachment; the bodies then become united, but iDifurcate again at the costochondral junction. Fig. 308. Abnormalities ix the Lumbosacral Region. In the lumbosacral region nearl}- all abnormalities are confined to the fifth lumbar and first sacral vertebrae. Cong-enital non-union ABNORMALITIES 315 Fig. 308. — Synostosis of the l)()clics of two ril )S. Fig. 309. — Congenital non-union of the laminae of the sacrum. 3i6 INJURIES AND DISEASES OF BONES AND JOINTS Fig. 310. — A pair of lumbar ribs. Fig. 311. — Sacrolization of the fifth kimbar vertebra. (Fig. 309) is b}- far the most common abnormality. In a series of 1,000 cases of the lumbosacral region this non-union occurred in over 15 per cent. These were not selected cases with symp- toms, but were found in examinations made for kidne}- and uretral stones, pcKic fractures, etc. In fact every plate upon \\hich this region occurred was inchided in the series. It ABNORMALITIES 317 Fig. 312. — An attempt at sacrollzation on one side. Fig. 313. — An aberrant articulation ix-tween the clavicle and coraculd. In our series of cases this condition was seen most frequently in the colored race. 3i8 INJURIES AND DISEASES OF BONES AND JOINTS should not be mistaken for a fracture. Occasionally a pair of extra ribs will be seen arising from the fifth kimbar \ertebra, Fig. 310. Another abnormality is frequent — the fifth lumbar takes on characteristics of the sacrum. The transverse processes on one or both sides fuse with the sacrum and the fifth lumbar be- comes an integral part of the sacrum. This is known as sacro- lization of the fifth lumbar vertebrae, Fig. 311. Sometimes the Fig. 314. Fig. 315. Fig. 314. — The ulna is not seen due to retarded growth from a faulty epiphysis. Also note the multiple chondroma. Fig. 315. — An extra digit arising from the Httle finger. processes become bulbous and have the shape of the top of the sacrum, but do not unite. Fig. 312. This may be spoken of a pseudo-sacrolization. This abnormality generally gives symp- toms. Rudimentary spina bifida of the sacrum is quite common. Clavicle. Occasionally only the sternal portion of the clavicle is present, the acromial end having failed to form. Another interesting abnormality which has been occasionally observed is an articulating facet upon the clavicle forming a joint with the coracoid process of the scapula, Fig. 313. In ABNORMALITIES 319 Fig. 316. — Fourth and fifth fingers arising from a common metacarpal. '*. - \ 5 , L » Fig. 317. — Extra digit on the toe, a con- genital deformity. Fig. 3 1 S. —Congenital absence of the fibula. 320 INJURIES AND DISEASES OF BONES AND JOINTS the writers' series of cases this was most frequentl}^ found in the colored race. This articulation is normally present in birds. Scapula. The scapula is fairly constant in structure, but occasionally what is known as congenital elevation is seen. In this case the scapula is rotated and elevated. The etiology is unknown, but is probably due to some fetal pressure. Shoulder. iMost of the deformities of this joint are prob- ably secondary to birth injuries; dislocation and nongrowth of the humerus are also probabi}' secondary to such injuries. The lower epiphysis of the humerus may be affected in a similar manner. FoREARAL Absence or partial growth of either bone of the forearm (Fig. 314) is quite common and occasionally synostosis of the upper third of the forearm is seen. Hand. Extra digits (Fig. 315), fusion of the phalangeal joints (Fig. 316), and synostosis of the metacarpals are the most common deformities of the bones, causing club hand. Femur. Congenital absence of this bone is occasionally encountered. Subluxation of the head is sometimes seen following an unrecognized poliomyelitis in infancy. The patella may be either absent or dislocated. Ankle and Foot. Extra digits (Fig. 317), fusion of phalangeal joints, synostosis of the metatarsus and club foot are the most common abnormalities in this region. No attempt is made to enumerate every deformity, only the more common ones that are occasionally met with in A-ray examination. TiBL\ OR Fibula. Either tibia or fibula or both may be absent or only partially present, Fig. 318. CHAPTER! XIV DYSTROPHIES CHAPTER XIV Dystrophies OSTEITIS deformans was first described by Paget and is more commonly known by his name. It seems to be a chronic inllammatory process, though the etio- logical factor is unknown, and it occurs ahnost entirely in the third age period. A pathological examination shows the bone to be increased in size, sometimes in length, due to a combination of rarefying and proliferative osteitis. The weight-bearing bones, especially the pcKis, lemur and tibia, are most frequently involved; the spine is less frequently affected. The skull when affected is the most typical of all. The x-ray changes are as follows: There are longitudinal striae of porosity and increased density, Figs. 319 and 320. This is due to rarefying and proliferative osteitis. There is proliferation of periosteal bone, causing the bone to become wider. When the rarefying changes are most predominant the bones are weakened and bowing and fractures ensue. In one case under obscr\ation for over ten years, where only the tibia was involved, the bone was fractured four times while walking with no additional trauma. Union took place very slowly, about fifteen weeks elapsing each time before there was good union. During the entire process of healing theie was but little callus formation. In the leg the overgrowth of the tibia, with fibula unaffected, generally causes a marked bowing. When the spine is affected the softening of the body of the vertebra with the arches unaffected causes an anterior bowing. The skull changes are the most characteristic, Fig. 321. The plate will show round, knobbylike masses of bone lying between the inner and outer tables of the bone; sometimes these will be on the outer table, and thus the head will have a knobby irregular feeling when palpated. The best description 323 324 INJURIES AND DISEASES OF BONES AND JOINTS Fig. 319. — Osteitis deformans. Fig. 320. — Osteitis deformans of the tibia. Note the marked bowing of the tibia, due to actual overgrowth of bone. There is a markedly thick- ened cortex. Striae of bone absorp- tion and bone production are also present. DYSTROPHIES 325 of this condition is to imagine the curled kinky hair of the negro to have undergone calcification. The head also increases in size l^ut the enlargement is uniform and does not show any deformity as in acromegaly. This disease is more common in the male than in the female. Acromegaly. This lesion is never seen in the first age period and but rarefy in the second. The third age period, or in middfe and ofd age, is the time when it appears or is recog- FiG. 321. — Clianges seen in the cranial bones in osteitis deformans. nized, Fig. 122. Disease of the hypophysis, cspeciaffy in derange- ment of its secretions, seems to Idc the etiological factor. The roentgenogram shows a general overgrowth of the cranial and, in fact, all the bones. The increased size of the hands and feet is especially noticeable, and there is generafly increased tufting of the terminal phalanges giving a clubbed finger effect, Fig. 323. The changes in the head are as foflows: There is an overgrowtli of the frontal l^onc, gi\ing what might be 326 INJURIES AND DISEASES OF BONES AND JOINTS Fig. 322. — Acromegalic skull. Note the overgrowth of bone, prominent frontal sinuses, and the protruding mandible. DYSTROPHIES 32- termed a beeiled brow eflect; the frontal sinuses are often markedly enlarged, and the mandible will be lengthened and will protrude so that there will be no ocehision of the front teeth; the sella turcica is frequently much enlarged and very Fig. 323. — Changes in the bones of the hand in acromegaly. There is increased tufting of the terminal plialanges and increased size of all the bones of the hand. deep, suggesting an hypophyseal tumor. In gigantism the same picture will frequently be seen. Osteomalacia. This disease is one of the third age period, and while its etiology is unknown it is supposed to be of an inflammatory nature. It is characterized by an absorption of the calcium salts in an irregular manner; the bones become 328 INJURIES AND DISEASES OF BONES AND JOINTS softened and often deformed. It is much more common in the female and is frequently associated with pregnancy. The x-ray plate will show the bones to have long striated areas, parallel to the shaft, of diminished density due to ab- sorption of the lime salts. There is no overgrowth of bone. The long weight-bearing bones are bent, and while there are no joint changes yet the altered shape of the bones may change Fig. 324. — Osteomalacia. (Courtesy Fig. 325. — Osteomalacia. [Courtesy of Dr. G. \V. Holmes.) ^ 0/ Dr. G. W. Holmes.) the angle of the weight-bearing joint surfaces, which circum- stance causes secondary- alterations. Figs. 324 and 325. Fractures are frequent on account of the absorption^of lime salts, and they unite slowly and with but little callus. The condition is sometimes mistaken for Paget's disease. These points differentiate: In osteomalacia more bones are involved, the skull remains unaffected, and there is no new bone formation; in Paget's disease the bones of thejlower DYSTROPHIES 329 extremity are most frequently involved; there is bone proclue- tion, and there are typical changes in the cranial bones. Chondrodystrophies. This disease is of congenital origin and is probably due to some interference or defect in the cartilaginous structure, especially of the epiphyseal cartilages. This results in slow growth of epiphyseal bone, and sometimes complete arrest of growth in certain I:)ones. The periosteum is Fig. 326. — Acliondroplasia. intact, consequently the changes noted on the .v-ra\ phite are limited to the epiphyses. The bones are short, ckie to poor epiphyseal growth; but since the periosteum is intact it lays down bone in the normal manner, and so the bones are of normal width. The epiphyses also undergo fusion early resulting in abnormally short bones of normal \\ idth. At the epiphysis there may be overgrowth of i^one, which gi\es a broadened end to the bone. The ends are often much deformed from aberrant calcification. Practicallx all the bones are involved, and there is more or less deforniity. Figs. 326 and ^2~. 330 INJURIES AND DISEASES OF B0NL3 AND JOINTS In cretinism there is a similar change in the bone. In fact, the two conditions are frecjuenti}' associated. Pulmonary Osteoarthropathy. This is an inliamma- tory disease associated with any chronic infection, especially when the lungs are involved. In the writers' series of cases Fig. 327. — Achondroplasia with deformity of the epiphysis of the radius from fauhj^ epiph^'seal development. all were associated with pulmonary tuberculosis with the exception of two, one, a primary- sarcoma of the pleura, the other a bronchiectasis. The periosteum becomes slightly raised, and there is a deposition of calcium salts in it, but not attached to the bone, Fig. 328. The A-ray plate shows a generalized periostitis particu- larly of the metacarpals, metatarsals, and the phalanges of the hand and foot. The calcified periosteum is raised, with a clear space between it and the bone, but there is no change in the DYSTROPHIES 331 bone. The joints frequently show swelhng and fluid, but the cartilage is intact. The flesh shadows of the hand show the typ- ical ckibbed fingers. In marl^ed cases practically all of the long bones will show this periosteal change. The disease is one of early life and in our series all were in the first age period. Fig. 328. — Puhnonary osteoarthropathy. Note the periosteal changes. iOsTEOGEXESis IMPERFECTA. This is a childhood infection and is apparently congenital in origin. All the bones may be invoKcd, but especially those of the lower extrcniitx . It is characterized by absorption of the linie salts. The bones on account of the absence of lime salts become so atrophic that it is often dillicult to get a satisfactory plate. The joints are never involved. The bones become soft and in part cartilaginous. 332 INJURIES AND DISEASES OF BONES AND JOINTS Fig. 329. — Osteogenesis imperfecta with multiple fractures. The bones of the lower extremity also suggest achondroplasia. DYSTROPHIES 333 In such cases there may be distortions at birth, and, on account of the weakness of the bones, multiple fractures are common, Figs. 329, 330 and 331. A somewhat similar appearance is given by the lesions ol rickets and lues, but the differential point is that in the latter disease there are epiphyseal changes, while in the foniur the epiphyses are intact. Fig. 330. — Osteogenesis imperfecta, Fig. 331. — Osteogenesis imperfecta, showing multiple fractures. showing multiple Iractures. When the lesion is seen after the child has walked there will be deformities due to softened bone, and the \ertebrae will be very narrow due to flattening iroiii j^rcssurc. W hen the bones are fractured they unite very slowly with but little callus formation. DvsCHO.XDROPLASiA. This is also a disease of the car- tilaginous structures in utcro, and as in chondrodystrophia the 334 INJURIES AND DISEASES OF BONES AND JOINTS epiphyses are involved, so that the bones are shortened and deformed. But there is one feature which does not occur in chondrodystrophia, namely, the formation of multiple exosto- ses arising from the cortex. It is often limited to one side of the body. It is more com- mon in the male and frequently successive generations of the same family will show this involvement. INDEX INDEX Abnormalities of the bones, 311 ankle and foot, 320 cervical region, 312, 313 clavicle, 318 extra ribs, 31 1 femur, 320 fibula, 320 hand, 320 lumbosacral region, 314 rudimentary vertebra', 313 scapula, 320 shoulder, 320 thoracic region, 314 tibia, 320 Acetabulum, fracture through the, 95, 96 mechanical alteration of, in Perthes's disease, 202 shape of, in congenital dislocaticjn, 135, 137, 138 Achondroplasia, 330, 332 Acromegaly, 325 cause, 325 .v-ray appearance, 325 Acromial process, centers of ossification of. 35 Acromion, fractures of, 62, 64 Actinomycosis, 176 Acute polyarticular rheumatism, 207 x-ray appearance of, 208 Acute spondylitis deformans, 302, 304 Age, as factor in, bone development, 27 diagnosing bone tumors, 242, 251 joint lesions of children, 183 production of fracture, 48 .v-ray diagnosis, 4 laws of probability regarding, 29" of fracture, estimate of, 53 relation of, to fractures, 54 Anatomy, normal, necessity for knowledge of, 4 Aneurysms, 8 of the thoracic aorta in spine in\'oIvc- ment, 307, 308 22 Angulation, in Colles's fracture, 85 in fractures of the spine, 296, 297 Ankle, abnormalities of, 320 Ankle joint, fractures around, 117 subluxation of, 139 Ankylosis, as repair process of infectious arthritis, 212 between patella and femur, gonorrheal origin of, 216 fibrous, in tuberculosis of the joint, 197 in fracture of jihalanges, 90 in non-tuberculous hij} infections, 137 in spinal conditions, 304 in typhoid osteomyelitis of the spine ,175 Arthritic changes due to old age, 222 in ligaments and bursae, 233 calcification at bony attachments, 233, 234, 235. 236, 23^ Arthritic condition present in eldcrl}' indi- viduals, 70 Arthritic lesions of the spine, 305 Arthritis, 206 indirect evidence of, 206, 207 infectious, Guldtliwaite's classification of, 209 resemblance of appearance of hemo- philia to, 233 spinal, 223, 297 See also Chronic arthritis and Joint lesions. Arthritis deformans, 206, 207 atrophy in, 207 indirect evidence of, 207 Astragalus, centers of ossification of, 41 dislocation of, 156 fracture of, 120 Atelectatic strip of lung in rickets, 188 Atrophic arthritis, 219 conditions present, 219 .v-ray appearance, 2i() Atrophy, ditlcrentiation of local and gen- lormed with bone splints, i 2~, 128 337 338 INDEX Atrophy, in arthritis deformans, 207 in infectious arthritis, 211 in non-union of fracture, 126 in rickets, 186 of age, 5 1 of quantity, 51, 138 of quality, 51 presence of as diagnostic aid, in frac- tures, 49 in gout, 225 usual absence of, in scurvy, 193 Barton's fracture, 86, 87 "Baseball finger," 90 Bence Jones's bodies in urine as diagnos- tic of myeloma, 266 Benign tumors, brief outline of growth of, 255 direction of growth of, 248 presence of bone production noted in, 6 Blood-vessels, 13, 15, 18 Bone cysts as related to fractures, 54 Bone destruction, diagnosis determined by, 5. 6 causes of, 5 Bone graft in non-union of fracture, 126 Bone infections, see Infections, bone. Bone involvement as factor in diagnosing bone tumors, 253 position of, as diagnostic point in bone tumors, 253 Bone, normal ^ee Normal bone Bone production, absence of, in Paget's disease, 328 in tuberculosis of the joint, 197 in malignant growths, 254 as a diagnostic point in fractures of the spine, 296, 297 character of, as diagnostic point, 247 causes of, 5 diagnosis determined by, 5, 6 in arthritis of the spine, 297 in epiphsitis, 200 in mixed tuberculous joint infection, 214 in osteoma, 274 in osteosarcoma, 266 in Paget's disease, 328 in periosteal sarcoma, 263 Bone production in tuberculosis of joint if sinus formation is involved, 198 origin of tumors causing, 247 Bone tumors, 241 Bones, flat, description of, 21 irregular, description of, 21 long, description of, 20 Brain tumors, 282 3c-ray appearance of, due to internal pres- sure, 283 Brody's abscess, 168 Bronchiectasis associated with pulmonary osteoarthropathy, 330 Bursae, arthritic changes in, 233 Bursitis, subdeltoid, 233, 234, 235, 237 Callus, formation of, in fracture, 51, 52 lack of, in osteitis deformans, 323 Cancellous bone, 15 description of, 15 Capitellum, fracture of, 74 Carcinoma, 8, 262 bone destruction in, 5 chief characteristics of, 255 frequency of, in age periods, 253 lack of bone production in, 247 location of bone involvement in, 253 non-union of fracture in, 126 of the spine, 302 origin of, in bone tumors, 242, 246 Caries sicca, 214 x-ray appearance, 215 gouged-out areas, 215 atrophy, 215 Carpal bones, centers of ossification of, 34, 38 dislocation of, 151 Cartilage, 17 description, 17 joint, 17 costal, 18 involvement of, in dyschondroplasia, 333 in chondrodystrophia, 329 in joint injuries, 205 resistance of, to tumors, 241 Centers of ossification, 23, 35 Cervical ribs, extra, neuritis due to pres- sure of, 311 Cervical vertebra, 290 INDEX 339 Charcot joint, 225, 226, 227, 228, 229 neuropathic origin, 225 x-ray appearance, 225-230, 302 periostitis, 231 atrophy, absence of, 23 [ similarity of gout to, 225 Charcot spine, 302, 304, 305 x-ray appearance, 302 Chauffeur's fracture, 49 Chondrodystrophy, 329 effect of, on epiphyses, 43 cause, 329 x-ray appearance, 329 Chronic arthritis, 209 infectious arthritis, 209 diversified x-ray appearance of, 209 first stage, 21 1 second stage, 21 1 atrophy, 2 1 1 narrowed joint space, 21 1 third stage, 21 1 replacement of destroyed area, 21 1 tuberculosis, 213 x-ray appearance, 213 caries sicca, 214 gonorrheal, 21 5 luetic, 217 atrophic, 219 conditions present, 219 x-ray appearance, 219 hypertrophic arthritis, 220 x-ray appearance, 221 Clavicle, absence of acromial end of, 318 centers of ossification of, 35 metastasis of, from prostate, 260 spurious facet attached to, 318 Club foot, x-ray of, 139 Club hand, due to synostosis of the meta- carpals, 320 x-ray of, 139 Clubbed fingers, in pulmonary osteoar- thropathy, 331 Coccidoidal granuloma, 177 Cod-liver oil treatment in rickets, meta- bolic changes from, 195 Colles's fracture, 50, 79, 84, 87 angulation in, 85 dislocation in, 85 impaction in, 85 Colles's fracture, relation of age to, 48 Condyle, fractures through, 59, 79, 109, 1 12 Congenital abnormalities due to injury of cartilage, 25 Congenital dislocations, i 33 Connective tissue origin of sarcoma, 246 Coracoid, fractures of, 62, 148 Coracoid process, centers of ossification of, 35 Coronoid fossa, fracture of, 75 Coronoid process, fracture of, 59, 60, 76 Cortex, 13, 14 description, 14 as point of origin in bone tumors, 243, 245. 247 infection of, known as osteitis, 159 nature of expansion of, in bone tumors, 247 Costal cartilage, 18 Coxa vara, intertrochanteric fracture with, 106, 108 presence of, in Perthes's disease, 202 Cranial bones, changes in, in Paget's dis- ease, 329 Cretinism, association of, with chondro- dystrophies, 330 effect of, on epiphyses, 42 Cuboid, centers of ossification of, 41 fracture of, 123, 124 Cuneiform, 38 external and internal, centers of ossifi- cation of, 41 fracture of, 123 Cyst, 271 origin, 271 differentiation from cnchondroma, 2~2 example of growth of, 248 Cysts, action of, in expanding cortex, 167 bone, origin of, 246 lack of bone production In, unless ac- companied by fracture, 247 relation of, to fracture of mandible, 59 Dakin tubes in compound fracture, 107 Deformity, lateral, as diagnostic point In fractures of the spine, 296, 297 Density, increased, in osteitis deformans, 323 340 INDEX Diagnosis, differential, 6 direct evidences for, bone destruction, 6 bone production, 6 pressure effects, 6 extension of lesion, 6 atrophy, 6, 7 absence of pain, 7 indirect evidence for, age, 8 sex, 8 in bone tumors, 241, 284 in dyschondroplasia, 334 in osteomalacia, 328 in osteomyelitis, 170 in rachitic joint infection, 188 in scur\y, 194 See also under specific injuries and diseases. Diagnosis, x-ray, elements involved in, 3, 4 See also under specific injuries and diseases. Diaphyseal side of epiphyseal line involved in lues, 189 Digits, extra, in the toe, 319, 320 Dislocation, from hip injury, 8 in Colles's fracture, 87 of the spine, 304, 305 Dislocations, acquired, 145 shoulder, 145 elbow, 146, 149, 150 ulna and radius, 148, 149 wrist, 151 hand, 151 pelvic bones, 151 hip, 154 patella, 155 knee, 155 fibula, 156 foot, 156 congenital, 133 hip, 133 .V- ray differentiation, 134, 136, 137 frequency, 137 shoulder joint, 141 epiphyses, 141 posterior, in Colles's fractures, 85 relation of, to age, 48 Displacement, in subperiosteal fracture, 79 necessity of reporting, 54 of ulna, 76 Dyschondroplasia, 333 Dystrophies, 323 osteitis deformans, 323 acromegaly, 325 osteomalacia, 327 chondrodystrophies, 329 pulmonary osteoarthropathy, 330 osteogenesis imperfecta, 331 dyschondroplasia, 333 Enchondroma, 269 fracture an accompanying feature, 271 nature of growth, 271 differentiation from cyst, 272 origin of, 246 Elbow, fracture of, 76, 77, 146 Endarteritis obliterans involved in Ray- naud's disease, 177 Epicondyles, fracture of, 73 Epiphyseal cartilages, defect of, as cause of chondrodystrophies, 329 Epiphyseal centers of the vertebrae, 289, 290 Epiphyseal changes in osteogenesis imper- fecta, 333 Epiphyseal flattening in Perthes's disease, 202 Epiphyseal line, changes in, in scurvy, 191 erroneous diagnosis of, 4 expanded in rickets, 184 fractures along, of femur, 99 .v-ray appearance of, 24 Epiphyseal separation, erroneous diagnosis of as dislocation, 146 in hip injun*% 8 in metacarpals, 88 likelihood of, 48 of pelvis in crushing injuries, 95 of radius as erroneously- diagnosed, dis- location, 1 5 1 Epiphyses, 13, 23, 33 abnormalities of, 42, 141 value in estimating age, 33 appearance of centers of ossification, 33 variation due to malnutrition, 34, 35 scapula, 35 clavicle, 35 humerus, 36 radius, 38 fracture of, 81 INDEX 341 Epiphyses, carpa! and metacarpals, 34, 38,41 phalanges, 38, 41 pubis and ischium, 39 lemur, 39 displaced in fracture, 109 patella, 40, 42 tibia, 40, 42 tuberculosis in, 171 fibula, 40 OS calcis, 41 astragalus, 41 cuboid, 41 cuneiform, 41 scaphoid, 41 vertebrae, 41, 43 Epiphysitis, acute, 134, 136 in joints of children, 183, 199 x-ray appearance, 199 sharp outlines, 199 focal spots of disease, 199 ankylosis, bony, 200 bone production, presence of, 200 summary of diagnostic points, 200 Etiology in Perthes's disease, unknown character of, 202 Exostoses, 275 in arthritis of the spine, 297 in early stages of gout, 225 in spinal lesions, 304 multiple, in dyschondroplasia, 334 of OS calcis, 233, 237 gonorrheal and non-gonorrheal types, 23<), 237 presence of, in infectious artliritis, 211 Facial bones, fracture of, 57 Femur, abnormalities of, 320 centers of ossification of, 39 fracture of, 93, 96, 99 neck of, legal case relating to, 53 neck of, prevalent in old age, 48 involvement of, in osteoma, 274 in osteitis deformans, 323 metastasis of, from prostate, 260 non-union in fracture of, 127 site for giant-cell sarcoma, 269 site lor ossif\ ing hematoma in adults, 278 Fibroma, 275 Fibroma, similarity in appearance to cyst or enchondroma, 276 Fibula, abn, 60 clavicle, 59 scapula, 62, 63, 6';, 66 humerus, 64, 67, 68, 71 forearm, 74 wrist, 87 hand, 88 ribs, 91 sternum, 94 jjelvis, 94 342 INDEX Fractures, of the lower extremities classified according to age, 99 femur, 99 patella, 109 tibia, 113 fibula, 1 1 3 bones of the foot, 1 20 non-union, 127 bone splints, 128 in osteitis deformans, 323 in osteomalacia, 328 multiple, in osteogenesis imperfecta, 333 of the spine, 291 Frontal bone, overgrowth of, in acromeg- aly, 325 Functional conditions of the spine, 306 Gastrocnemius muscle, displacement due to, 109 Gigantism, resemblance of x-ray appear- . ance of, to acromegaly, 327 Glenoid fossa, fractures of, 62 Goldthwaite, classification of, for arthritic conditions, 209 Gonorrheal arthritis, 215 ankylosis between patella and femur as diagnostic of, 216 Gout, 225 .v-ray appearance, 225 swelling, 225 atrophy, 225 punched-out areas, 225, 226 exostosis in early stages, 225 Green-stick fracture, 16, 70, 72, 79, 80 of clavicle, 61 of femur, 108 Grafting of bone in fracture, 126 Growth of tumors, brief outline of, 253 Growths, spread of infection in, 6 Hand, abnormalities of the bones of, 320 bones of, involved in enchondroma, 271 fractures of the, 88 Haversian canals, 6, 160, 165, 254 in cortex, 14 Head, fractures of, 54 Hemangiomata, 276 ! presence of calcified bodies in, 277 Hematomata, 246 in scurvy, 193 Hematomata, ossifying, 277 inflammatory in origin, 277 connection with scurvy in children, 278 association with severe trauma in adults, 278 difi"erentiation, 278, 280 Hemophilia, 233 clinical appearance simulates infectious arthritis, 233 AT-ray appearance, 233 gouged-out areas, 232, 233 hazy, 233 organised blood clots, 233 Hemorrhage, 13 in scurvy, 191, 194 subperiosteal, absence of, in rickets, 188 Hereditary character of dystroplasia, 334 Hip, dislocation of, 133, 152, 153, 154 fracture of, diagnosis of, in different age periods, 8 Hip joint involved in Perthes's disease, 201 Histology, knowledge of, as aid to x-ray diagnosis, 4, 5 Howland, 195 Humerus, centers of ossification of, 36 fractures of, 64 injuries of, as cause of dislocations, 141 involvement of, in bone cyst, 272 in osteoma, 274 metastasis of, from hypernephroma, 262 Hypernephroma, 260 origin, 260 Hypertrophic arthritis, 8, 220 x-ray appearance, 221 atrophy, presence of, 221 bony exostoses, 222 new bone formation, 222 mechanical ankylosis, 222 in spinal lesions, 298, 304 Hypophyseal tumors, expansion of sella turcica in, 283 Hypophysis, irregularity in secretion of, as cause of acromegaly, 325 Iliac crests roughened by calcification in arthritis, 233 Ilium, fracture of, 93, 95 Impaction, in Colles's fracture, 85, 86, 87 in fracture of femur, 102 INDEX 343 Infantilism, effect of, on epiphyses, 42 Infection, presence of bone production noted in, 6 relation of, to fracture of mandible, 59 spread of, through medullary canal, 17 stages of, in joint lesions, 205 Infections, bone, 159 osteomyelitis, 159 channels of infection, 159 AT-ray appearance during various periods, 164-167 acute, 167 chronic, 167 diagnostic points, 170 tuberculous, 170 luetic, 172 typhoid, 175 actinomycosis, 176 Raynaud's disease, 176 leprosy, 177 coccidoidal granuloma, 177 mineral poisoning, 180 special infections, 180 virulent, bone destruction in, 5 Infectious arthritis in the spine, 298 tuberculous, 298 non-tuberculous, 299 See also Chronic arthritis and Joint lesions. Inflammatory nature of osteitis defor- mans, 323 Intervertebral space, involvement of, in fractures of the spine, 297 Invasion, as diagnostic point in bone tumors, 251, 252 change of aspect of, in brain tumors, 284 lack of, in osteoma, 272 Involucrum, diagnostic value of, in osteo- myelitis, 174, 17$ Ischium, centers of ossification of, 3() fracture of, 93, 95 Joint cartilage, 17 susceptibility of, to infection, 241 Joint infection of osteomyelitis, 159 Joint, 21 constituents, 21 synovial membrane, 21 invisibility to .v-ray, 21 indirect evidence of pathology, 21 Joint lesions, 24, 25 in adults, 205 parts involved 205 .v-ray appearance, factors governing, 205 stages of infection, 205 arthritis, differentiation of, 206 acute polyarticular rheum'atism, 207 infectious, 209 chronic arthritis, 209 summary of differential points, 222 changes due to old age, 222 in the spine, 223 villous, 223 non-arthritic, 224 gout, 225 Charcot joint, 225 syringomyelia, 232 hemophilia, 233 arthritic changes in ligaments, 233 in children, 183 relation of age to, 183 rickets, 183 congenital lues, 188 scurvy, 191 tuberculosis, 195 epiphysitis (non-tuberculous), 199 Pcrthes's disease or juvenile deform- ing osteochondritis, 201 Joint mice in hypertrophic arthritis, 222 Joint space, narrowed, in infectious artii- ritis, 21 1 in tuberculosis, 196, 214 Knee, dislocations of, 155 Kyphosis, tuberculous, 299 Laminae of the spine, non-union of, 313 Lane plates, use of, in fractures, 129 Lateral deformity as a diagnostic point in fractures of the spine, 296, 297 Legg of Boston, 20 1 Leprosy, 177' Ligaments, arthritic changes in, 233 imbedded in cartilage, 17 Lues, 172 lace work type of periostitis, 173 as joint infection in childrn, 183 congenital, in relation to joint lesions in children, iSS 344 INDEX Lues, congenital, .v-ray appearance, i88 multiple involvement, i88 changes in the epiphyseal line, 189 presence of punched-out areas, 190 atrophy, usual absence of, 190 periostitis, 190 summan.- of diagnostic points, 190 effect of, on epiphysis, 42 similarity- of, to osteogenesis imperlecta, 333 to osteomyelitis, i~i Luetic arthritis, 2i~ conditions present, 2 1 - .v-ray appearance, 21- Lumbar vertebrae, abnormalities of, 314 Lumbosacral region, abnormalities in, 314 Lymph vessels, 13, 18 Lymphoid origin of osteomyelitis, 159 Malar bone, fracture of. 57 Malignancy of tumors dependent upon invasion, 251 Malignant tumors, bone destruction in, 5 character of growth of, 248, 253 -NLindible, fracture of, j~, 58, 59, 60 involvement of, in typhoid osteomyeli- tis, 175 lengthening of, in acromegaly, 327 Manubrium, fracture of, 94 Marie-Striimpel type of spondylitis, 223, 299, 304 Medullars- artery, 15 Medullar\- canal, 16 as point of origin in bone tumors, 243, 244 as road for osteomyelitic infection, 165 Medullary- infection, kno\^n as myelitis, 159 Metabolic changes in rickets resulting from cod-liver oil feeding, 195 Metabolism, faulty, as cause of non-union in fracture, 127 Metacarpal, periostitis of, in pulmonary osteoarthropathy, 330 thumb, a vestigial phalanx, 43 tuberculosis in, i~2 Metacarpal bones, centers of ossification of, 38, 41 dislocation of, 151 fractures of, 88 Metastasizing to bone, absence of, in brain tumors, 283 Metastatic infection through the medul- lary^ canal, 17 Metatarsals, dislocation of, 156 fracture of, 124, 125 periostitis of, in pulmonarv' osteoarthro- pathy, 330 Metatarsus, synostosis of the, 320 Mineral poisoning as cause of bone infec- tion, 180 Muscular tension, 47 Myelitis, definition of, 159 Myeloma, 266 diagnostic points, 266, 267 Myositis ossificans, differentiation of, from ossifying hematoma, 280 Myxoma, 276 Nasal bone, fracture of, 57 Necrosis, evidence of, in fracture, 126 Negro race, presence of articulating facet on the clavicle in, 320 Neuritis due to pressure from extra cer- vical ribs, 31 1 Neuropathic conditions of the spine, 304 Neuropathic origin of Charcot joint, 225 Non-tuberculous arthritis of the spine, 299 Non-tuberculous joint infections in chil- dren, 183 Non-union, congenital, in the lumbosacral region, 316 frequency of, in fracture of the femur, 102 of fractures, 126 causes, 126, 127 bone splints, 127, 128 of laminae of the spine, 313 Normal bone, 13 constituents, 13 periosteum, 13 cortex, 14 medullary canal, 16 nutrient foramen, 16 cartilage, 17 classification, 18 long bones, 20 flat bones, 2 1 irregular bones, 21 joints, 21 INDEX 345 Normal bone, growth, 22 function of cpiph\ scs, 23 centers of (ossification, 23 epiphyseal line, 24 joint lesions in children, 24 developmental variations in various age periods, 26, 27 variations due to sex, 27, 28, 29 Nutrient canal, importance of", in meta- static malignancy, 241 Nutrient foramen, 16 description, 16 entrance for infections, 17 Occupation, as factor in shoulder disltjca- tion of males, 145 relation of, to fracture, 49 Olecranon, centers of ossification of, 37, 38 fracture of, 75 associated with dislocation of the elbow, 148 Os calcis, centers of ossification of, 41 fracture of, 123 Os magnum, 38 Osteitis, definition of, 150 Osteitis deformans, as related to fractures, 54 occurrence, 323 x-ray changes, 323 Osteitis fibrosa cystica, 280 probable inflammatory origin, 280 softening of bones and elongation, 280 A'-ray appearance, 281 expansion of cortex, 282 cystlike areas, 282 differential diagnosis of, 282 Osteoarthropathy, pulmonary, 330 inflammatory character, 330 .v-ray appearance, 330 Osteochondromata, action of, in e\|:)and- ing cortex, 167 Osteogenesis imperfecta, 186, 331 atrophic condition of bones in, 331 Osteoma, 272, 273 bone production as indicati\e of, 6 origin, 2^6, 272 .v-ray appearance, 2-4 multiple character of, 274 in the spine, 303 Osteomalacia, 327 Osteomalacia, as related to fractures, 54 inflammatory character of, 327 .v-ray appearance of, 328 differential diagnosis of, 328 Osteomyelitis, acute, 127, 167 association of mandible fracture with, 59 as related to fracture, 54 as sequela in fractured phalanges, 90 channels of infection of, 159 chronic, 167 difTerentiation between, and malignant tumors, 254 erroneous diagnosis of, for osteitis fibrosa cystica, 282 tuberculous, 170 luetic, 172 spread of infection in, 5 .v-ray appearance during various peri- ods, 164-167 Osteosarcoma, 263 origin, 246, 263 bone production in, 6, 26.\. destruction of the shaft, 264 differentiation of, from ossifying hematoma, 279, 280 in the spine, 303 Os trigonum, presence of, in fracture of the ankle, 122 Ovaries and uterus, carcinoma of, 258 Paget, 31 1 Paget's disease, erroneous diagnosis of, for osteomalacia, 328 Pain, absence of, in Charcot joint, 231 Painful heels, exostoses (if os calcis or, 233, 234, 237 gonorrheal and non-gonorrheal types, 236 Park, 195 Patella, abnormalities of, 320 center of ossification of, 40, 42 fracture of, 109, 155 Pathological causes of fractures, 53 Pathology, value of, in .v-ray diagnosis, 3, 4. 243 Pelvic bones, dislocation of, i ■; i metastasis of, from prostate, 260 Pelvis, fracture of, 94 involved in osteitis deformans, 323 of female compared with the male, 29, 30 346 INDEX Pelvis, shape of, influenced by walking, 134 in hip dislocation, 135 Periosteal infection, known as periostitis, 159 of osteomyelitis, 159 Periosteal sarcoma, 263 bone production in soft tissues. 263 bone striae perpendicular to shaft, diag- nostic point of, 263 origin of, 246 Periosteum, 13 description, 13 function, 13 .v-ray appearance, 14 as point of origin in bone tumors, 243 effect of tearing of, on callus formation, 52 Periostitis, definition of, 159 in rickets, 184 mistakes in diagnosis of, 4 of metacarpals, metatarsals and pha- langes in pulmonan.' osteoarthro- pathy, 330 presence of, in scurvy of the joints, 193 Perthes, 201 Perthes's disease, 183, 200, 201 description of, 201 x-raj" appearance of, 202 clear bone detail, 202 epiphyseal flattening, 202 mechanical changes in acetabulum, 202 etiological factor in, 202 Phalangeal enlargement in acromegaly, 325 Phalangeal joints, fusion of, 320 Phalanges, dislocations of, 151 fractures of, 90, 125 involvement of, in Raynaud's disease, 176 of the feet, dislocation of, 156 periostitis of, in pulmonary osteoarthro- pathy, 330 Phalanx, presence of fibroma in, 2~6 "Pigeon breast" of rickets, i8~ Pisiform, 38 Poliomyehtis, abnormal hip due to, 140 as cause of subluxation of the head of the femur, 320 Porosity in osteitis deformans, 323 Pott's fracture, 119, 120 associated with dislocation, 156 Pressure destruction, as cause of spinal lesions, 307, 308 Pressure effects, and extension of lesion in differential diagnosis, 6 Proliferation of periosteal bones m osteitis deformans, 323 Pronator muscles, prevention of reduction of ulnar fracture because of, 82 Prostate, carcinoma of, 258 Pubis, centers of ossification of, 39 fracture of, 93, 95 Pulmonars' osteoarthropathy, 330 Pulmonary tuberculosis, association of, with osteoarthropathy, 330 Quadriceps attachment to patella, calcifi- cation of, 233 Radius, centers of ossification of, 37, 38 chaiiff^eur's fracture of, 49 dislocation of, 148 fracture of, 75, 77, 78, 84, 87, 148 Raynaud's disease, 176 Ribs, abnormalities of the, 311 fracture of, 91 Rickets, 8 as joint infection in children, 183 .v-ray appearance, 184 atrophy, 186 chest appearance, 186 multiple involvement, 184 periostitis, usual absence of, 184 saucer-shaped expansion of epiphy- seal line, 185, 188 summary- of diagnostic points, 188 effect of, on epiphyses, 42 metabolic changes caused by cod-liver oil feeding in, 195 similarity of, to osteogenesis imperfecta, 333 Roentgenogram, definition of, 3 See under specific injuries and diseases for x-ray appearance. Rudimentary vertebrae, 313 "Saber chin" in rickets, 188 Sacral vertebrae, abnormalities of, 314 INDEX Sacralization of the fifth lumbar vertebra, 42, 318 Sacroiliac subluxation, 307 non-existence of, 151 Sacrum, metastasis of, from prostate, 260 Sarcoma, 8 absence of bone production in, 247 associated with osteoarthropathy, 330 bone destruction in, 5 confusion of ossifying hematoma with, 280 connective tissue origin of, 246 erroneous diagnosis of, for fracture, 61 for hematoma in scurvj', 193 for osteitis fibrosa cystica, 282 example of destroyed cortex in, 250 frequency of, in age periods, 253 giant-cell, 267, 303 benign character of, 250 nature of growth, 267, 268 origin, 268 hypothetical exclusion of, in bone tumors, 243 non-union of fracture in, 126 round-cell, 262 origin, 262 similarity in .v-ray appearance to carcinoma, 262 spindle-ccil, 263 -v-ray appearance, 263 Scaphoid, 38 fracture of, 87, 88, 123 Scapula, abnormalities of, 320 centers of ossification of, 35, 41 fractures of, 62, 63 metastasis of, from prostate, 260 Scoliosis, 42, 306 causes, 306 curves in, 294, 295 due to rudimentary vertebra, 314 Scurvy, 8 as joint infection in children, 183 connection of, with ossifying hematoma, 278 effect of, on epiphyses, 42 joint involvement in, 191 .v-ray appearance, 191 multiple lesions, 191 changes in epiphyseal line, 191 Triinimer zone, 192 Scurv}-, joint involvement in, atrophy, usual absence of, 193 periostitis, presence of, 193 hemorrhage, 192, 193, 194 summary of diagnostic points in, 194 Sella turcica, enlargement of, in acrome- galy. 327 expansion of, in hvpophyseal tumors, 283 Semilunar, 38 dislocation of, 151, 155 fracture of, 88 Sequestrum, presence of, in osteomyelitis, 162, 164, 165, 172, 175 Sesamoids, fracture of, 125 Sex, as factor, in diagnosing bone tumors, 242. 253 in bone development, 27 in incidence of fracture, 48, 49 relation of, to acromegaly, 325 to dyschondroplasia, 324 to osteomalacia, 328 Shoulder, abnormalities of, 320 Shoulder joint, dislocation of, 141 Sinus formation in tuberculosis of joint, result of, 198 Sinuses, frontal, enlargement of, in acro- megaly, 327 in tuberculous joints producing infec- tion, 214 Skull, fractures of, 54 displaced, $^ linear, 55 of the base, $y of the vertex, 56 involvement of, in osteitis deformans, 323 lack of involvement of, in osteomalacia, 328 Skull changes in osteitis deformans, 323, 325 Soft tissues, condition of, in cases of frac- ture, 219 shadows in, diagnostic value of, 1 19 Spina bifida, 314, 318 Spine, abnormalities of, 42 arthritis in, 223 conformation of, 289 peculiarities of specific divisions, 289 cervical, 290 348 INDEX Spine, peculiarities of specific divisions, thoracic, 290 lumbar, 290 fifth, 291 classification of lesions, 291 fractures, 291 diagnostic points, 296 arthritis, 297 .v-ray changes, 297 infectious arthritis, 298 acute spondylitis deformans, 302 Charcot spine, 302 syringomyelia, 302 tumors, 302 application of classification aids, 303, 304 functional conditions, 306 scoliosis, 307 sacroiliac subluxation, 30" ligamentous changes, 30" pressure destruction, 30", 308 involvement of, in osteitis deformans 323 in typhoid, i~5 of the scapula, fractures of, 62 Spinous processes, fractures of, 292 Spondylitis, Marie-Strumpel type of, 223 Spondylitis deformans, 299 .v-ray appearance, 302 acute, 223, 302 Sprain, fracture diagnosed as, ii~ Sprains and dislocations, relation of, to age, 48 ligamentous, mistaken for subluxations, 152 Sternum, fracture of, 92, 94 Styloid, of the radius, fracture of, 87 of ulna, fracture of, 81 Subcoracoid fracture of shoulder, 145 Subdeltoid bursa, calcification at, in ar- thritis, 233, 234, 235, 23- Subdeltoid bursitis confused with fracture of tuberosity of humerus, 69 Subglenoid fracture of shoulder, 145 Subluxation, of the head of the femur, 320 in the sacroiliac region, 307 Subperiosteal fracture, 79 absence of callus and displacement in, 52 Superior maxilla, fracture of, 57 Supracondyloid fracture, 72, 73 erroneously diagnosed as dislocation, 146 of humerus, deposit of callus in, 53 Surgical interference, in fracture, 129 necessity for knowledge of, in bone tumors, 284 necessity for recognition of, 180 Symphysis, fracture of, 96 Symphysis pubis, separation of, in females, 8 ' in males, 8 Synostosis, of rib bodies, 314 of the metacarpals, 320 Synovial membrane, 21 in joint injuries, 205 swelling of, in acute polyarticular rheu- matism, 207 thickening of, in villous arthritis, 223 Syringomyelia, 232, 302 neuropathic origin, 232 A-ray appearance resembles Charcot joint, 232, 302 in the spine, 304, 305 Tendo Achillis, calcification at, in arthritis, 233 tension of, as cause of fracture, 123 Thoracic vertebrae, abnormalities of, 314 differential diagnosis concerning, 8 Tibia, abnormalities of, 320 as site for giant-cell sarcoma, 269 centers of ossification of, 40, 42 dislocation of, 155 fracture of, 113, 126 involvement of, in osteitis deformans, 323 in osteoma, 274 -V-ray appearance of Charcot joint in, 230 Tongue and lip, carcinoma of, 258 Trapezium, 38 Trapezoid, 38 Trochanter, fracture through, 103 greater, 39 lesser, 40 position of, in hip dislocation, 134 fractures involving the, 107 Trochlea, fracture of, 74 Triimmer zone in scurvy, 191, 195 INDEX 349 Tubercle, tibial, injury to, 114 Tuberculosis, a factor in dislocation of tibia, 155 as osteomyelitic infection, 170 adult cases, 170 children's cases, 170 in infectious arthritis, 213 x-ray appearance, 2 1 3 haziness, 213 narrowed joint space, 213 atrophy, 213 in joint lesions of children, '83, 195 .v-ray appearance, 196 hazy and indistinct, 196 narrowing of joint space, 196 bone involvement, 196 atrophy, presence of, 196 new bone production, absence of, 197 joint, presence of atrophy in, 211 of the shaft of the radius, 169 of the spine, 298, 304, 305 resemblance of appearance of hemo- philia to, 233 Tuberculous dactylitis in children, 171 Tuberosity, of humerus, fracture of, 68, 71 tibial, fracture of, 115 Tumors, as causes of pressure destruction in spinal involvement, 308 bone, 241 constituents involved in neoplastic growths, 241 analysis of, 242 origin, 243 bone production, 247 condition of cortex, 247 invasion, 251 law of age, 25 1 law of sex, 253 law of bone involvement, 253 growth of, 253 carcinoma, 255 cyst, 271 hypernephroma, 2O0 Tumors, bone, round-cell sarcoma, 262 spindle-cell sarcoma, 263 periosteal sarcoma, 263 osteosarcoma, 263 myeloma, 266 giant-cell sarcoma, 267 enchondroma or osteochondroma, 269 osteoma, 272 fibroma, 275 myxoma, 276 hemangioma, 276 ossifying hematoma, 277 osteitis fibrosa cystica, 280 brain, 282 malignant and benign, as related to fractures, 54 of the spine, 302 classification of, 305 Typhoid infection of the bone, 175 Ulna, backward displacement of, 76 dislocation of, 148 fracture of, 78-83 fracture of styloid of, 81 Unciform, 38 Vertebrae, centers of ossification of, 41 cervical, 290 tlioracic, 290 lumbar, 290 fifth, 291 lower, metastasis of, from prostate, 260 rudimentary, 313 Villous arthritis, 223 Wrist, dislocation of, 150, 151 fractures of, 87 X-ray appearance, see under specific in- juries and diseases. Zygoma, fracture of, 57 Paul B. Hoeber 67-69 East 59TH Street New \'ork r rtB ; >8 1^7^ ■s PRINTED N o.s . CA T NO 24 161 DW WE lUl Blii2i 1921 Baetjer, Frederick H Injuries & diseases of the bones and joints. MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664 University of California SOUTHERN REGIONAL LIBRARY FACILITY 305 De Neve Drive - Parking Lot 17 • Box 951388 LOS ANGELES. CALIFORNIA 90095-1388 Return this material to the library from which it was borrowed. T! FED IN U.S * CAT NO 24 161 D 000 298 345 WE lUl Bll+2i 1921 Baetjer, Frederick H Injuries & diseases of the bones and joints. MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664