Clinical Features.—As the fracture almost invariably implicates the articular surface, there is considerable swelling from effusion of blood into the joint. The power of extending the forearm is impaired, and other symptoms of fracture are present. The amount of displacement depends upon the level of the fracture, and the extent to which the aponeurotic expansion of the triceps is torn. As the fracture is usually near the tip, the displacement is comparatively slight, the prolongation of the fibres of insertion of the triceps on to the sides and posterior part of the process holding the small fragment in position; and the fracture may easily escape recognition. When the line of fracture is nearer the base, however, the contraction of the triceps tends to separate the fragments widely (Fig. 35), and a distinct gap, which is increased on flexing the elbow, may often be felt between them, and if the elbow is passively extended, the fragments may be brought into apposition, and crepitus elicited.



When there is little displacement, bony union may result, but in many cases the fragments are united only by fibrous tissue. The upper fragment sometimes forms attachments to the shaft of the humerus, and this leads to stretching of the fibrous band between the fragments and to marked wasting of the triceps.

Separation of the olecranon epiphysis is one of the rarest forms of epiphysial detachment (Poland). When the epiphysis is displaced upwards and unites in this position, it may interfere with complete extension of the elbow.

Treatment.—It would appear that too much stress has hitherto been laid on the necessity of bringing the fragments into perfect apposition, and too little attention paid to the importance of maintaining the functions of the triceps and the movements of the elbow-joint.

Massage and movements are carried out from the first, and the forearm is supported in a sling. Full flexion is the last movement to be attempted. In carrying out the movements, the tip of the olecranon is pressed down with the thumb, so that it is obliged to follow the movements of the ulna, and is prevented from adhering to the humerus.

It was formerly the practice to have the arm almost, but not quite, fully extended, and a Gooch splint, extending from the lower border of the axilla to the finger-tips, and cut to the shape of the extended limb, applied anteriorly and fixed in position by a bandage, the region of the elbow being covered by a convergent spica.

Operative Treatment.—Operative treatment may be had recourse to, particularly in cases in which there is wide separation of the fragments. The fracture is exposed, the joint cavity opened up and cleared of clots, and silver-wire sutures passed through the fragments without encroaching upon the articular cartilage. The limb is fixed with the elbow-joint in the position of almost complete extension. Movement may be commenced at the end of a week, the angle at which the joint is fixed being changed morning and evening. During the day the flexed position should be maintained and the arm carried in a sling; during the night the limb is fixed to a pillow in the extended position. The patient is allowed to use the joint cautiously within a fortnight.

Old-standing Fracture.—When union fails to take place, the interval between the fragments tends to increase by the contraction of the triceps gradually stretching the intermediate fibrous tissue, so that a wide gap comes to separate the fragments. It is quite common that the function of the arm is all that can be desired in spite of a gap between the fragments, but, if this is not the case, the fragments may be united by operation.

Fracture of the coronoid process is rare except as a complication of backward dislocation of the elbow. It may be produced by direct violence, as well as by muscular action. As the fracture is usually within a quarter of an inch of the tip, the fibres of insertion of the brachialis prevent displacement. The ordinary evidence of fracture is often absent, and the diagnosis is seldom completed without the aid of the X-rays. The treatment consists in flexing the elbow and supporting the forearm in a sling. In some cases associated with dislocation, however, the small fragment has been so far displaced as to become attached to the back of the humerus (Annandale).

FRACTURE OF THE UPPER END OF THE RADIUS

Intra-capsular fracture of the head of the radius may result from direct violence, from a fall on the pronated hand, or from forcible pronation or abduction—that is, deviation of the forearm to the radial side. It may accompany dislocation of the elbow or fracture of adjacent bones. The head may be completely separated, or may be split into two or more fragments. Up to the seventeenth year, the epiphysis, which is entirely intra-articular, may be separated.

The clinical features are localised pain, crepitus, interference with pronation and supination, while the elbow can be almost fully extended and flexed, and in some cases the fragment may be felt through the skin, although it usually continues to move with the shaft in pronation and supination.

Union generally takes place satisfactorily, but in some cases the fragments form new attachments resulting in impaired movement at the elbow, and necessitating operative interference.

Fracture of the neck of the radius between the capsule and the tubercle is rare.

Avulsion of the tubercle may occur from forcible contraction of the biceps, or, in children, from traction made on the forearm (A. L. Hall).

These injuries are treated with the elbow in the flexed position, and massage and movement are carried out as already described.

DISLOCATION OF THE ELBOW

Dislocations of the elbow-joint may involve one or both bones of the forearm, and may be complete or incomplete.

Dislocation of both bones backward is the most common of all dislocations of the elbow, and is the only dislocation that is frequently met with in children. It usually results from a fall on the outstretched hand, causing hyper-extension of the joint with abduction—that is, deviation towards the radial side; but it may follow a direct blow on the back of the humerus, a fall on the elbow, or a twist of the forearm.



Morbid Anatomy.—All the ligaments of the elbow, except the annular (orbicular), are torn or stretched. The radius and ulna pass backward, the coronoid process coming to rest opposite the olecranon fossa behind the humerus, and the head of the radius behind the lateral condyle. The condyles of the humerus bear their normal relations to one another. The olecranon and the triceps tendon form a marked prominence on the back of the elbow, the tip of the olecranon lying above and behind the condyles. The lower end of the humerus lies in the flexure of the joint with the biceps tendon tightly stretched over it. The coronoid process is often broken, or the tendon of the brachialis torn. The median and ulnar nerves may be stretched or torn. Not infrequently the bones of the forearm are displaced towards the medial side as well as backward.

Occasionally, as a sequel to the dislocation, processes of bone develop in relation to the insertion of the brachialis and interfere with the movements of the joint. These outgrowths are due to displacement of bone-forming elements, either at the time of the original injury or as a result of forcible efforts at reduction. According to D. M. Greig, they do not develop in the tendon of the brachialis, but under it, and are not of the nature of myositis ossificans. In from four to six weeks after reduction of the dislocation, the movements begin to be restricted, and a hard mass can be felt in the cubital fossa, which with the X-rays is seen to be a bony outgrowth springing from the quadrilateral space on the front of the elbow below the coronoid process (Fig. 37). This gradually increases in size and leads to fixation of the joint. In most cases the effects reach their maximum in about six months, and then reabsorption of the mass begins.



If the disability shows no sign of abatement within a year, or if the bony outgrowth is producing pressure effects on the median nerve, it should be removed by operation.

It is important not to mistake this condition for the effects of a fracture which has complicated the dislocation and been overlooked at the time of the accident.



Clinical features.—The elbow is held fixed at an angle of about 120 deg., pronated or midway between pronation and supination. Any attempt at movement causes great pain, and is followed by an elastic rebound to the abnormal position. The antero-posterior diameter of the joint is increased, and the forearm, as measured from the lateral epicondyle to the tip of the styloid process of the radius, is shortened to the extent of about an inch. If examined before swelling ensues, the outlines of the articular surfaces may be recognised in their abnormal positions, but swelling usually comes on rapidly, and, by obscuring the bony landmarks, renders the diagnosis difficult.

This injury has to be diagnosed from supra-condylar fracture with backward displacement of the lower fragment and from separation of the lower humeral epiphysis. A general anaesthetic is often necessary to enable an accurate diagnosis to be made. When the deformity is once reduced, there is no tendency to its reproduction unless the coronoid process is also fractured. In a considerable number of cases—according to E. H. Bennett, in the majority—this dislocation is incomplete, the coronoid process resting at the level of the trochlea, and the backward projection of the olecranon being scarcely appreciable. The head of the radius, however, is unduly prominent. In such cases the lesion is liable to be overlooked, and therefore to go untreated, leading to permanent stiffness at the elbow.

Dislocation forward is much less common than the backward variety. It is produced by severe force acting from behind on the flexed elbow, the ulna being driven forward, tearing the ligaments of the joint and the muscles attached to the condyles. The olecranon is frequently fractured at the same time (Fig. 39). When it remains intact, it may rest below the condyles (incomplete or first stage of dislocation), or may pass in front of them, especially if the triceps is ruptured (complete or second stage). The forearm is lengthened, the elbow slightly flexed, the posterior aspect of the joint flattened, and the condyles, in their abnormal relationship, can be palpated from behind.

Medial and Lateral Dislocations.—Dislocation towards the ulnar side is always incomplete, some portion of the articular surface of the bones of the forearm remaining in contact with the condyles.

The dislocation to the radial side is also incomplete as a rule, although cases have been recorded in which complete separation had taken place.

These forms of dislocation are rare, that towards the ulnar side being more frequently observed. Each form is often combined with other injuries in the vicinity.

The most common cause of these dislocations is a fall on the outstretched hand, the forearm at the moment being strongly pronated. Forced abduction favours the displacement to the ulnar side; adduction to the radial side. The limb is held flexed and pronated, and the facility with which the bony points can be palpated renders the diagnosis easy.

In a few cases diverging dislocations have been met with, the radius and ulna being separated from one another, the annular (orbicular) ligament being torn and no longer holding them together.

Treatment of Dislocations of Elbow.—The chief obstacle to reduction is the spasmodic contraction of the muscles passing over the joint, and, in the backward variety, the hitching of the coronoid process against the edge of the olecranon fossa. In recent cases, to effect reduction the patient is seated on a chair, while the surgeon grasps the humerus and wrist, and places his knee in the bend of the elbow. The limb is first fully extended, or even hyper-extended, to relax the triceps and free the coronoid process. Traction is then made in opposite directions upon the forearm and arm, the surgeon's knee meanwhile making pressure, in a backward direction, upon the lower end of the humerus. The joint is next slowly flexed, and the bones slip into position, often with a distinct snap. If the patient be anaesthetised, these manipulations must be adapted to the recumbent position.

When some days have elapsed before reduction is attempted, forcible manipulations are to be deprecated as they greatly increase the risk of ossification occurring in relation to the brachialis (D. M. Greig); and recourse should be had to open operation, and the tearing or bruising of the soft parts should be reduced to a minimum.

After reduction, the limb is flexed to rather less than a right angle and supported by a sling. Massage and movement are commenced at once.

Fracture of the coronoid process predisposes to recurrence of the dislocation; when this complication exists, therefore, the limb should be fixed at an acute angle, and movements of full extension postponed for a fortnight. Massage and limited movements, however, may be carried out from the first.

If there is a fracture of the olecranon, the treatment must be modified accordingly (p. 87).



Comminuted and compound injuries usually call for operative treatment, the fractured bones being wired after reduction of the dislocation, or the loose fragments removed.

The forward dislocation is reduced by fully flexing the elbow, and then pushing the bones of the forearm backward, while the humerus is pulled forward.

Old-standing Dislocations.—No attempt should be made to reduce by manipulation a dislocation of the elbow which has remained displaced for five or six weeks, especially when it has been complicated by a fracture. The joint surfaces become welded together by adhesions, and separated fragments often form attachments which lock the joint. Attempts to break these down are attended with considerable risk of re-fracturing the bone or of tearing the soft parts. In such cases it is best to expose the joint, and if reduction is not easily effected a sufficient amount of the lower end of the humerus should be removed to provide a movable joint.

Dislocation of the ulna alone is a rare injury, and is usually associated with fracture of one or other of its processes or of the inner condyle.

Dislocation of the radius alone, on the other hand, is comparatively common, especially as a concomitant of fracture of the upper third of the shaft of the ulna (Fig. 40).

The injury may result from a blow on the back of the upper end of the radius, a fall on the outstretched hand, or, in children, from forcible traction on the forearm while in the pronated position. The displaced head usually passes forward, and rests on the anterior edge of the capitellum, thus preventing complete flexion and supination of the limb.

The limb is held partly flexed and pronated. The displaced head of the radius can be felt to rotate with the shaft in its abnormal position, and the articular facet on the head of the radius may also be felt; there is a depression posteriorly below the lateral epicondyle where the head should be. The radial side of the forearm is slightly shortened. The superficial and deep (posterior interosseous) branches of the radial nerve are liable to be pressed upon or torn by the displaced head of the radius, especially if the ulna is fractured, leading to disturbances in the area of their distribution.



In a few cases the displacement of the head has been backwards or laterally.

Treatment.—To effect reduction, the forearm should be alternately flexed and extended, while traction is made upon it from the wrist, and the head of the radius is pressed backward with the thumb in the fold of the elbow. When reduction is prevented by the interposition of a portion of the torn ligaments between the bones, it is sometimes necessary to open the joint to ensure accurate adjustment. The joint is fixed in acute flexion to relax the biceps, to allow of union of the torn ligaments, and to prevent recurrence.

In old-standing cases, to obtain a useful joint, or to remove pressure from the branches of the radial nerve, resection of the head of the radius may be necessary.

Sub-luxation of the head of the radius, or "dislocation by elongation," is a comparatively common injury in children between the ages of two and six. It almost invariably results from the child being lifted or dragged by the hand or forearm. The traction and torsion thus put upon the radius causes the front part of its head to pass out of the annular ligament, the edge of which slips between the bones.

The person holding the child may feel a click at the moment of displacement. The child complains of pain in the region of the elbow: the arm at once becomes useless, and is held flexed, midway between pronation and supination. All movements are painful, but especially movements in the direction of supination. The deformity is slight, but the head of the radius may be unduly prominent in front. From the way in which the injury is produced the wrist also is often swollen, and in some cases the patient is brought to the surgeon on account of the condition of the wrist, and attention is not directed to the elbow.

Treatment.—Reduction frequently takes place spontaneously or during examination, the function of the arm being at once completely restored. In other cases it is necessary, under anaesthesia, to manipulate the head of the bone into position. This is usually easily done by flexing the elbow, making slight traction on the forearm, and alternately pronating and supinating it. After reduction, a few days' massage is all that is necessary, the joint in the intervals being kept at rest in a sling.

Sprain of the elbow is comparatively common as a result of a fall on the hand or a twist of the forearm. The point of maximum tenderness is usually over the radio-humeral joint, the radial collateral and annular ligaments being those most frequently damaged. Effusion takes place into the synovial cavity, and a soft, puffy swelling fills up the natural hollows about the joint. The bony points about the elbow retain their normal relationship to one another—a feature which aids in determining the diagnosis between a sprain and a dislocation or fracture. In children it is often difficult to distinguish between a sprain and the partial separation of an epiphysis. Sprains of the elbow are treated on the same lines as similar lesions elsewhere—by massage and movement.

The condition known as tennis elbow is characterised by severe pain over the attachment of one or other of the muscles about the elbow, particularly the insertion of the pronator teres during the act of pronation, and is due to stretching or tearing of the fibres of that muscle, and of the adjacent intermuscular septa. A similar injury—sculler's sprain—occurs in rowing-men from feathering the oar. The treatment consists in massage and movement, care being taken to avoid the movement which produced the sprain.

FRACTURE OF THE FOREARM

The shafts of the bones of the forearm may be broken separately, but it is much more common to find both broken together.

Fracture of both bones may result from a direct blow, from a fall on the hand, or from their being bent over a fixed object. The line of fracture is usually transverse, both bones giving way about the same level. The common situation is near the middle of the shafts. In children, greenstick fracture of both bones is a frequent result of a fall on the hand—this indeed being one of the commonest examples of greenstick fracture met with (Fig. 41).



The displacement varies widely, depending partly upon the force causing the fracture, partly on the level at which the bones break, and on the muscles which act on the respective fragments. It is common to find an angular displacement of both bones to the radial or to the ulnar side. In other cases the four broken ends impinge upon the interosseous space, and may become united to one another, preventing the movements of pronation and supination. There may be shortening from overriding of fragments.

When the radius is broken above the insertion of the pronator teres, its upper fragment may be supinated by the biceps and supinator muscles, while the lower fragment remains in the usual semi-prone position. If union takes place in this position, the power of complete supination is permanently lost.

The usual symptoms of fracture are present, and there is seldom any difficulty in diagnosis.

The prognosis must be guarded, especially with regard to the preservation of pronation and supination. These movements are interfered with if union takes place in a bad position with angular or rotatory deformity of one or both bones, or if callus is formed in excess and causes locking of the bones. In some cases the callus fuses the two bones across the interosseous space, and pronation and supination are rendered impossible.

Persistent angular deformity of the forearm is also liable to ensue, either from failure to correct the displacement primarily, or from subsequent bending due to ill-applied splints or slings. Want of union, or the formation of a false joint in one or both bones, is sometimes met with, particularly in children, and, like the corresponding fracture of the leg, is liable to prove intractable.

A considerable number of cases of gangrene of the hand after simple fracture of the forearm are on record. This is sometimes attributable to damage inflicted upon the blood vessels by the fractured bones, or to the force that caused the fracture, but is oftener due to a roller bandage applied underneath the splints strangulating the limb, to injudiciously applied pads, or to too tight bandaging over the splints. Volkmann's ischaemic contracture occasionally develops after fractures of the forearm.

In uncomplicated cases, union takes place in from three to four weeks.

Treatment.—To ensure accurate reduction and coaptation, a general anaesthetic is usually necessary. In the greenstick variety the bones must be straightened, the fracture being rendered complete, if necessary, for this purpose.

To retain the bones in position, anterior and posterior splints are then applied. These are made to overlap the forearm by about half an inch on each side, to avoid compressing the forearm from side to side, and so making the fractured ends encroach upon the interosseous space. The dorsal splint is usually made to extend from the olecranon to the knuckles, and the palmar one from the bend of the elbow to the flexure in the middle of the palm, a piece being cut out to avoid pressure on the ball of the thumb (Fig. 42). The splints are applied with the elbow flexed to a right angle, and, except when the radius is broken above the level of the insertion of the pronator teres, with the forearm midway between pronation and supination. The limb is placed in a sling, so adjusted that it supports equally the hand and elbow in order to avoid angular deformity. The use of special interosseous pads is to be avoided.



When the fracture of the radius is above the insertion of the pronator teres, the forearm should be placed in the position of complete supination, with the elbow flexed to an acute angle, and retained in this position by a moulded posterior splint, and the arm fixed to the side by a body bandage. Great care is necessary in the adjustment of the apparatus to prevent pronation.

Massage and movement should be carried out from the first. It is usually necessary to continue wearing the splints for about three weeks.

In cases of mal-union, especially when the bones are ankylosed to one another across the interosseous space, operation may be necessary, but it is neither easy in its performance nor always satisfactory in its results. The seat of fracture should be exposed by one or more incisions so placed as to enable the muscles to be separated and to give access to the callus. When the limb is straight, it is only necessary to gouge away the exuberant callus that interferes with rotatory movements; but when there is an angular deformity the bones must, in addition, be divided and re-set, and, if necessary, mechanically fixed in good position. In comparatively recent cases it is sometimes possible, without operation, to re-fracture the bones and to set them anew.

Un-united fracture of both bones of the forearm is not uncommon and is treated on the usual lines; the gap between the fragments of the radius is bridged by a portion of the fibula, that should be long enough to overlap by at least an inch at either end; it is rarely necessary to bridge the gap in the ulna, unless it alone is the seat of non-union.

Fracture of the shaft of the radius alone may be due to a direct blow; to indirect violence, such as a fall on the hand; or to forcible pronation against resistance, as in wringing clothes. It is rare in comparison with fracture of both bones. When broken above the insertion of the pronator teres, the upper fragment is flexed and supinated by the biceps and supinator, while the lower fragment remains semi-prone, and is drawn towards the ulna by the pronator quadratus.

When the fracture is below the pronator teres, the displacement depends upon the direction of the force and the obliquity of the fracture. In fractures of the lower third of the shaft, the hand may be flexed toward the radial side, and the styloid lies at a higher level, as in a Colles' fracture. From the frequency with which this fracture occurs while cranking a motor-car, it is conveniently described as Chauffeur's fracture; we have observed in doctors, who have sustained this fracture in their own persons, that they were under the impression that they had sustained a trivial sprain of the wrist.

In addition to the ordinary signs of fracture, there is partial or complete loss of pronation and supination. The head of the radius as a rule does not move with the lower part of the shaft, but may do so if the fracture is incomplete or impacted.

Fracture of the shaft of the ulna alone is also comparatively rare. It is almost always due to a direct blow sustained while protecting the head from a stroke, or to a fall on the ulnar edge of the forearm, as in going up a stair.

The upper third is most frequently broken, and this injury is often associated with dislocation of the head of the radius (Fig. 40), or some other injury implicating the elbow-joint. On account of the superficial position of the bone, this fracture is frequently compound.

The displacement depends on the direction of the force, the fragments being usually driven towards the interosseous space. There is seldom marked deformity unless the head of the radius is dislocated at the same time. The diagnosis is, as a rule, easy.

The treatment is the same as for fracture of both bones, but the splints may be discarded at the end of a fortnight.

For some unexplained reason, a fracture of the upper third of the shaft of the ulna frequently fails to unite.



CHAPTER V

INJURIES IN THE REGION OF THE WRIST AND HAND

Surgical Anatomy—FRACTURE OF LOWER END OF RADIUS: Colles' fracture; Chauffeur's fracture; Smith's fracture; Longitudinal fracture; Separation of epiphysis—FRACTURE OF LOWER END OF ULNA: Shaft; Styloid process; Separation of epiphysis—FRACTURE OF CARPAL BONES—DISLOCATION: Inferior radio-ulnar joint; Radio-carpal joint; Carpal bones; Carpo-metacarpal joint—SPRAINS—INJURIES OF FINGERS: Fractures; Dislocations; Mallet finger.

INJURIES IN THE REGION OF THE WRIST

These include fractures of the lower ends of the bones of the forearm and separation of their epiphyses; sprains and dislocations of the inferior radio-ulnar, and of the radio-carpal articulations; and fractures and dislocations of the carpus.

Surgical Anatomy.—The most important landmarks in the region of the wrist are the styloid processes of the radius and ulna. The tip of the radial styloid is palpable in the "anatomical snuff-box" between the tendons of the long and short extensors of the thumb, and it lies about half an inch lower than the ulnar styloid. The ulnar styloid is best recognised on making deep pressure a little below and in front of the head of the ulna, which forms the rounded subcutaneous prominence seen on the back of the wrist when the hand is pronated.

The tubercle of the navicular (scaphoid) and the greater multangular (trapezium) can be felt between the radial styloid and the ball of the thumb, a little below the radial styloid; and the pisiform and hook of the hamatum (unciform) are palpable, slightly below and in front of the ulnar styloid.

In examining an injured wrist, the different bony points should be located, and their relative positions to one another and to the adjacent joints noted; and the shape, position, and relations of any unnatural projection or depression observed, using the wrist on the other side as the normal standard for comparison. The power and range of movement—active and passive—at the various joints should also be tested.

FRACTURE OF THE LOWER END OF THE RADIUS

Colles' Fracture.—This injury, which was described by Colles of Dublin in 1814, is one of the commonest fractures in the body, and is especially frequent in women beyond middle age. It is almost invariably the result of a fall on the palm of the hand, in the three-quarters pronated position, the force being received on the ball of the thumb, and transmitted through the carpus to the lower end of the radius which is broken off, the lower fragment being driven backwards.

The fracture takes place through the cancellated extremity of the bone, within a half to three-quarters of an inch of its articular surface (Fig. 45). It is usually transverse, but may be slightly oblique from above downwards and from the radial to the ulnar side. In a considerable proportion of cases it is impacted, and not infrequently the lower fragment is comminuted, the fracture extending into the radio-carpal joint.



When impaction takes place, it is usually reciprocal, the dorsal edge of the proximal fragment piercing the distal fragment, and the palmar edge of the distal fragment piercing the proximal. The periosteum is usually torn and stripped from the palmar aspect of the fragments, while it remains intact on the dorsum.

In the majority of cases the styloid process of the ulna is torn off by traction exerted through the medial ulno-carpal (internal lateral) ligament, and in a considerable proportion there is also a fracture of one of the carpal bones.

The resulting displacement is of a threefold character: (1) the distal fragment is displaced backwards; (2) its carpal surface is rotated backwards on a transverse diameter of the forearm; while (3) the whole fragment is rotated so that the radial styloid comes to lie at a higher level than normal.



Clinical Features.—In a typical case there is a prominence on the dorsum of the wrist, caused by the displaced distal fragment, with a depression just above it (Fig. 43); and the wrist is broadened from side to side. The natural hollow on the palmar aspect of the radius is filled up by the projection of the proximal fragment. The carpus is carried to the radial side by the upward rotation of the distal fragment, and the radial styloid is as high, or even higher, than that of the ulna. The lower end of the ulna is rendered unduly prominent by the flexion of the hand to the radial side. The fingers are partly flexed and slightly deviated towards the ulnar side; and the patient supports the injured wrist in the palm of the opposite hand, and avoids movement of the part. Occasionally the median nerve is bruised or torn, causing motor and sensory disturbances in its area of distribution.

The general outline of the wrist and hand has been compared not inaptly to that of "an inverted spoon." Pronation and stipulation are lost, the joint is swollen, and there is tenderness on pressure, especially over the line of fracture. Tenderness over the position of the ulnar styloid may indicate fracture of that process, although it is sometimes present without fracture. No attempt should be made to elicit crepitus in a suspected case of Colles' fracture as the manipulations are painful, and are liable to increase the displacement.

Treatment.—It cannot be too strongly insisted upon that success in the treatment of Colles' fracture with displacement and impaction depends chiefly upon complete and accurate reduction, and to enable this to be effected a general anaesthetic is almost essential. The surgeon grasps the patient's hand, as if shaking hands with him, and, resting the palmar surface of the wrist on his bent knee, makes traction through the hand, and counter-extension through the forearm, with lateral movements, if necessary, to undo impaction. When the fragments are freed from one another, the wrist is flexed, and the hand carried to the ulnar side, while the lower fragment is moulded into position by the thumb of the surgeon's disengaged hand. When reduction is complete, the deformity disappears, and the two styloid processes regain their normal positions relative to one another.

As there is no tendency to re-displacement and no risk of non-union, no retentive apparatus is required, but, if it adds to the patient's sense of security, a bandage or a poroplastic wristlet may be applied. In severe cases, however, anterior and posterior splints, similar to those used for fracture of both bones of the forearm, or a dorsal splint padded so as to flex the wrist to an angle of 45 deg., but somewhat narrower, may be employed. The hand and forearm are in any case supported in a sling.

To avoid the stiffness that is liable to follow, massage and movement of the wrist and fingers should be carried out from the first, the range of movement being gradually increased until the function of the joints is perfectly restored. If splints are used, they should be discarded in a week, and the patient is then encouraged to use the wrist freely.

The various special splints recommended for the treatment of Colles' fracture, such as Carr's, Gordon's, the "pistol splint," and many others, are all designed to correct the deformity as well as to control the fragments. It has already been pointed out that if reduction is complete there is no deformity to correct, and if it is not complete the deformity cannot be corrected by any form of splint.

Unreduced Colles' Fracture.—When union has been allowed to take place without the displacement having been reduced, an unsightly deformity results. In young subjects whose occupation is likely to be interfered with, and in women for aesthetic reasons, the fracture is reproduced and the displacement of the lower fragment corrected. This is conveniently done by means of Jones' wrench, which grasps the distal fragment and affords sufficient leverage to break the bone.

Chauffeur's Fracture.—A fracture of the lower end of the radius frequently occurs from the recoil of the crank, "by back firing," in starting the engine of a motor-car. The injury may be produced either by direct violence, the handle as it recoils striking the forearm, or by indirect violence, from forcible hyper-extension of the hand while grasping the handle. The fracture may pass transversely through the lower end of the radius, as in Colles' fracture, but is more often met with two or three inches above the wrist (Fig. 46). It is treated on the same lines as Colles' fracture.



A fracture of the lower end of the radius with forward displacement of the carpal fragment, was first described by R. W. Smith of Dublin (Colles' fracture reversed, or Smith's fracture) (Fig. 47). It is nearly always due to forcible flexion, as from a fall on the back of the hand. Like Colles' fracture, it may be transverse or slightly oblique, impacted, or comminuted. The deformity is characterised by an elevation on the dorsum running obliquely upwards from the ulnar to the radial side of the wrist, and caused by the head of the ulna, which remains in position, and the distal end of the proximal fragment. Below this, over the position of the distal radial fragment, is a gradual slope downwards on to the dorsum of the hand. Anteriorly there is a prominence in the flexure of the wrist, and the distal fragment may be felt under the flexor tendons. The hand deviates to the radial side, and thereby still further increases the prominence caused by the lower end of the ulna. The radial styloid is displaced forward, upward, and to the radial side, and the ulnar styloid may be torn off.



When the deformity is not well marked, this injury may be mistaken for forward dislocation of the wrist, for fracture of both bones low down, or for sprain of the joint.

The treatment is carried out on the same lines as in Colles' fracture.

Longitudinal fractures of the lower end of the radius opening into the joint usually result from the hand being crushed by a heavy weight or in machinery. They are often compound and comminuted.

Separation of the lower epiphysis of the radius, which is on the same level as that of the ulna and lies above the level of the synovial membrane of the wrist-joint, is comparatively common between the ages of seven and eighteen, especially in boys, and is caused by the same forms of violence as produce Colles' fracture.

Although clinically the appearances in these two injuries bear a general resemblance to one another, separation of the epiphysis may usually be identified by the directly transverse line of the dorsal and palmar projections, the folding of the skin observed in the palmar depression, the absence of abduction of the hand and the ease with which muffled crepitus can be elicited (E. H. Bennett). The deformity is readily reduced, and the fragments are easily retained in position.

This injury is often complicated with fracture of the shaft or styloid process of the ulna, or with dislocation of the radio-ulnar joint, and it is not infrequently compound, the lower end of the shaft being driven through the skin on the palmar aspect immediately above the wrist. Impairment of growth in the radius seldom occurs; when it does, it results in a valgus condition of the hand (Fig. 48), calling for resection of the lower end of the ulna.



The treatment is the same as for Colles' fracture.

Fracture of the Lower End of the Ulna.—The lower end of the shaft of the ulna is seldom fractured alone. The styloid process, as has already been pointed out, is frequently broken in association with Colles' and other fractures of the lower end of the radius.

Separation of the lower epiphysis of the ulna sometimes occurs, and in rare cases results in arrest of the growth of the bone, leading to a varus condition of the hand and bending of the radius. Sometimes the separated epiphysis fails to unite, and although this gives rise to no disability, it is liable to lead to errors in the interpretation of skiagrams.

The treatment is similar to that for the corresponding injuries of the radius.

Simultaneous separation of the epiphysis of both radius and ulna sometimes occurs, and, as a result of severe violence, may be compound, the lower ends of the diaphyses projecting through the skin on the palmar aspect above the wrist.

Fracture of Carpal Bones.—The use of the Roentgen rays has shown that fracture of individual carpal bones is commoner than was previously supposed, and that many cases formerly looked upon as severe sprains are examples of this injury.

The navicular (scaphoid) and lunate (semilunar) are those most commonly fractured, usually by indirect violence, by forced dorsiflexion from a fall on the extended hand. The clinical features are: localised swelling on the radial side of the wrist, increase in the antero-posterior diameter of the carpus, marked tenderness in the anatomical snuff-box when the hand is moved laterally, especially in the direction of adduction, and, rarely, crepitus. The median nerve is sometimes over-stretched or partly torn. In many cases, however, the symptoms are so obscure that an accurate diagnosis can only be made by the use of the X-rays (Fig. 49). Codman recommends taking pictures of the navicular by placing the two wrists of the patient in adduction, and of the lunate, in abduction.



The treatment of simple fractures consists in massage and movement. Codman and Chase recommend excision of the proximal half of the fractured bone, through a dorsal incision to the lateral side of the extensor digitorum communis. When the fracture is compound, the loose fragments should be removed.

DISLOCATIONS IN THE REGION OF THE WRIST

Dislocation may occur at the inferior radio-ulnar, the radio-carpal, mid-carpal, inter-carpal, or carpo-metacarpal joints, but the strong ligaments of these articulations, the comparatively free movement at the various joints, and the relative weakness of the lower end of the radius whereby it is so frequently fractured, render dislocation a rare form of injury.

Dislocation of the inferior radio-ulnar articulation may complicate fracture of the lower end of the radius, or accompany sub-luxation of the head of the radius. The head of the ulna usually passes backward.

In children, the commonest cause is lifting the child by the hand, and the displacement is only partial. In adults, it may result from forcible efforts at pronation or supination, as in wringing clothes, or from direct violence, the separation being frequently complete, and sometimes compound.

The head of the ulna is unduly prominent, and there is a depression on the opposite aspect of the joint. The hand is generally pronated, the rotatory movements at the wrist are restricted and painful, while flexion and extension are comparatively free.

Reduction is effected by making pressure on the displaced bone and manipulating the joint, especially in the direction of supination. If the ligaments fail to unite, the head of the ulna tends to slip out of place in pronation and supination—recurrent dislocation.

Dislocation at the radio-carpal articulation, usually spoken of as dislocation of the wrist, is attended by tearing of the ligaments and displacement of tendons, and is frequently compound. The carpus may be displaced backward or forward, and the articular edge of the radius towards which it passes may be chipped off.

Backward dislocation is commonest, the injury resulting from a severe form of violence, such as a fall from a height on the palm while the hand is dorsiflexed and abducted. The clinical appearances closely simulate those of Colles' fracture, or of separation of the lower radial epiphysis, but the unnatural projections, both in front and behind, are lower down, and end more abruptly (Fig. 50). The hand is more flexed, and the palm is shortened. The styloid processes retain their normal relations to one another, and the carpal bones lie on a plane posterior to the styloids, the articular surfaces may be recognised on palpation. The forearm is not shortened.

Forward dislocation of the carpus may result from any form of forced flexion, such as a fall on the back of the hand, or from direct violence. The displaced carpus forms a marked projection on the palmar aspect of the wrist, and there is a corresponding depression on the dorsum. The attitude of the hand and fingers is usually one of flexion.

In both varieties reduction is readily effected by making traction on the hand and pushing the carpus into position. A moulded poroplastic splint, which keeps the hand slightly dorsiflexed, adds to the comfort of the patient, but this should be removed daily to admit of movement and massage being employed.



Dislocation of Carpal Bones.—The two rows of carpal bones may be separated from one another, or any one of the individual bones may be displaced. These injuries are rare, and result from severe forms of violence, usually from a fall on the extended hand. Pain, deformity, and loss of function are the ordinary symptoms. The treatment consists in making direct pressure over the displaced bone, while traction is made on the hand, which is alternately flexed and extended.

Of these injuries that most frequently observed is displacement of the head of the capitate bone (os magnum) from the navicular (scaphoid) and lunate (semilunar) bones. Frequently these bones are fractured, and fragments accompany the displaced os magnum. In full palmar flexion of the wrist the displaced head of the os magnum forms a prominence on the dorsum opposite the base of the third metacarpal, which temporarily disappears when the hand is dorsiflexed. There is an increase in the antero-posterior diameter of the wrist, situated on a lower level than that which accompanies fracture of the lower end of the radius; flexion and extension of the wrist are limited; and in some cases there are symptoms referable to pressure on the median nerve. By keeping the hand in the dorsiflexed position for a week or ten days, the bone may become fixed in its place and the function of the wrist be restored, but it is often necessary to excise the bone.

The lunate may be displaced forward by forcible dorsiflexion of the hand, and forms a projection beneath the flexor tendons; there is usually loss of sensibility in the distribution of the ulnar nerve in the hand. The most satisfactory treatment is removal of the bone.

In a few cases the navicular has been displaced (Fig. 51), and has had to be subsequently replaced by operation. Separation of any of the other bones is rare.



Carpo-metacarpal Dislocations.—Any or all of the metacarpal bones may be separated from the carpus by forced movements of flexion or extension. The commonest displacement is backward. The thumb seems to suffer oftener than the other digits. These injuries, however, are so rare, and the deformity is so characteristic, that a detailed description is unnecessary.

Sprain of the wrist is a common injury, and results from a fall on the hand, a twist of the wrist, or from the back-firing of a motor-crank dorsiflexing the hand. The marked swelling which rapidly ensues may render it difficult to distinguish a sprain from the other injuries that are liable to result from similar causes—Colles' fracture, separation of the lower radial epiphysis, dislocation of the wrist, and fractures and dislocations of the carpal bones.

In a sprain the normal relations of the styloid processes and other bony points about the wrist are unaltered, and there is no radial deviation of the hand, as in Colles' fracture. The most marked swelling is over the line of the articulation on the anterior and posterior aspects of the joint. There is usually some effusion into the sheaths of the tendons passing over the joint, and in some cases on moving the fingers a peculiar creaking, which may simulate crepitus, can be elicited. There is marked tenderness on making pressure over the line of the joint, as well as over one or other of the collateral ligaments, depending upon which ligament has been over-stretched or torn. Movements that tend to put the damaged ligaments on the stretch also cause pain. It has to be borne in mind, however, that in many cases of Colles' fracture there is extreme tenderness on pressing over the ulnar styloid and medial ulno-carpal ligament, as these structures are frequently injured as well as the radius, but the point of maximum pain and tenderness is over the seat of fracture of the radius. In all doubtful cases the X-rays should be employed to establish the diagnosis.

The treatment consists in the immediate employment of massage and movement, supplemented by alternate hot and cold douches, on the same lines as in sprains of other joints.

INJURIES OF THE FINGERS

Fracture.—Fractures of the metacarpals of the fingers are comparatively common. When they result from direct violence, such as a crush between two heavy objects, they are often multiple and compound. Indirect violence, acting in the long axis of the bone and increasing its natural curve, such as a blow on the knuckle in striking with the closed fist, usually produces an oblique fracture about the middle of the shaft, the proximal end of the distal fragment projecting towards the dorsum. Apart from this there is little deformity, as the adjacent metacarpals act as natural splints and tend to retain the fragments in position. A sudden sharp pain may be elicited at the seat of fracture on making pressure in the long axis of the finger; and unnatural mobility and crepitus may usually be detected. These fractures are readily recognised by the X-rays. Firm union usually results in three weeks.

The shaft of the metacarpal of the thumb is frequently broken by a blow with the closed fist. The fracture is usually transverse, and situated near the proximal end of the shaft; frequently it is comminuted, and in some instances there is a longitudinal split.

Treatment.—When the fracture is transverse, and especially when it implicates the middle or ring fingers, the most convenient method is to make the patient grasp a firm pad, such as a roller bandage covered with a layer of wool, and to fix the closed fist by a figure-of-eight bandage. In this way the adjoining metacarpals are utilised as side splints. Active and passive movements must be carried out from the first, and the bandage may be dispensed with at the end of a week or ten days.

In oblique fractures with a tendency to overriding of the fragments, especially in the case of the index and little fingers, it is sometimes necessary to apply extension to the distal segment of the digit, by means of adhesive plaster, to which elastic tubing is attached and fixed to the end of a bow splint, reaching well beyond the finger-tips (Fig. 52). This should be worn for a week or ten days.



Bennett's Fracture of the Base of the First Metacarpal Bone.—Bennett of Dublin described an injury of the thumb which, although comparatively common, is often mistaken for a sub-luxation backward of the carpo-metacarpal joint, or a simple "stave of the thumb." It consists in an "oblique fracture through the base of the bone, detaching the greater part of the articular facet with that piece of the bone supporting it which projects into the palm" (Fig. 53). We have frequently observed the fracture extend for a considerable distance along the palmar aspect of the shaft.



It usually results from severe force applied directly to the point of the thumb, driving the metacarpal against the greater multangular bone (trapezium), and chipping off the palmar part of the articular surface, but it may result from a blow with the closed fist. The rest of the metacarpal slips backward, forming a prominence on the dorsal aspect of the joint. The pain and swelling in the region of the fracture often prevent crepitus being elicited, and as the deformity is not at once evident, the nature of the injury is liable to be overlooked. The fracture is recognised by the use of the X-rays. Unless properly treated this injury may result in prolonged impairment of function, full abduction and fine movements requiring close apposition of the thumb being specially interfered with.

The treatment consists in reducing the fracture by extension in the attitude of full abduction and applying an accurately fitting pad over the extremity of the displaced bone, maintained in position by a light angular splint. This splint is first fixed to the extended and abducted thumb, and while extension is made by pushing it downwards the upper end is fixed to the wrist (Fig. 54 A). The apparatus is worn for three weeks, being carefully readjusted from time to time to maintain the extension and abduction. A moulded poroplastic splint added on the same principle may be employed, and is more comfortable (Fig. 54 B). Excellent results are obtained after reduction of the displacement, by massage and movement from the first, and the support merely of a figure-of-eight bandage (Pirie Watson).



Fractures of phalanges usually result from direct violence, and on account of the superficial position of the bones, are often compound, and attended with much bruising of soft parts. Force applied to the distal end of the finger may also fracture a phalanx. The proximal phalanges are broken oftener than the others. The deformity is usually angular, with the apex towards the palm, and if union takes place in this position, the power of grasping is interfered with. Unnatural mobility and crepitus can usually be recognised, but, on account of the swelling and tenderness, the fracture is apt to be overlooked. Firm union takes place in two or three weeks. In oblique and comminuted fractures, union may take place with overlapping, producing a deformity which may prevent the wearing of a glove or of rings. In compound fractures, non-union sometimes occurs, and causes persistent disability. In doubtful cases radioscopy renders valuable aid, as the parts are readily seen with the screen.

Treatment.—Early movement and massage are all-important. The contiguous fingers may be utilised as side splints, and a long palmar splint projecting beyond the fingers is applied. In oblique and comminuted fractures it may be necessary to anaesthetise the patient to effect reduction. When it is particularly desirable to avoid deformity, an open operation may be advisable.

Dislocation.—Dislocation of the Metacarpo-phalangeal Joint of the Thumb.—The commonest dislocation at this joint is a backward displacement of the proximal phalanx, which may be complete or incomplete. Its special clinical importance lies in the fact that much difficulty is often experienced in effecting reduction.

This dislocation is usually produced by extreme dorsiflexion of the thumb, whereby the volar accessory (palmar) and the collateral ligaments are torn from their metacarpal attachments, the phalanx carrying with it the volar accessory ligament and sesamoid bones. The head of the metacarpal passes forward between the two heads of the short flexor of the thumb, and the tendon of the long flexor slips to the ulnar side. The phalanx passes on to the dorsum of the metacarpal, where it is held erect by the tension of the abductor and adductor muscles.

The attitude of the thumb is characteristic. The metacarpal is adducted, its head forming a marked prominence on the front of the thenar eminence, and the phalanges are displaced backwards, the proximal being dorsiflexed and the distal flexed towards the palm.

Many explanations of the difficulty so often experienced in reducing this variety of dislocation have been offered, but the consensus of opinion seems to be that it is due to the interposition of the volar accessory ligament and the sesamoid bones between the phalanx and the metacarpal, and that this is most frequently the result of ill-advised efforts at reduction. In some cases the tension of the long flexor tendon may be a factor in preventing reduction, but the "button-holing" by the short flexor is probably of no importance.

Reduction is to be effected by flexing and abducting the metacarpal while the phalanx is hyper-extended and pushed down towards the joint and levered over the head of the metacarpal.

When this manipulation fails, the volar accessory ligament should be divided longitudinally through a puncture made with a tenotomy knife on the dorsal aspect of the joint, so as to separate the sesamoid bones and permit the passage of the head between them. An open operation is seldom necessary.

Dislocation forward is rare. It results from forced flexion of the thumb with abduction, tearing the posterior and medial collateral ligaments. The deformity is characteristic: the rounded head of the metacarpal projecting behind the level of the joint, while the base of the phalanx forms a prominence among the muscles of the thenar eminence.

Reduction is easily effected by making traction on the phalanges and carrying out movements of flexion and extension. The deformity, however, is liable to be reproduced unless a retentive apparatus is securely applied.

Dislocation of the thumb to one or other side is rare.

Dislocations of the metacarpo-phalangeal joint of the fingers may be backward or forward. They are less common than those of the thumb, but present the same general characters. In the backward variety the same difficulty in reduction occurs as is met with in the corresponding dislocation of the thumb, and is to be dealt with on the same lines.

Inter-phalangeal Dislocation.—The second and the ungual phalanges may be displaced backwards, forwards, or to the side. The clinical features are characteristic, and the diagnosis, as well as reduction, is easy. These dislocations are frequently the result of machinery accidents, and being compound and difficult to render aseptic, often necessitate amputation.

Persistent flexion of the terminal phalanx of the thumb or fingers (drop or mallet finger) may result from violence applied to the end of the digit when in the extended position—as, for example, in attempting to catch a cricket-ball. The terminal phalanx is flexed towards the palm, and the patient is unable to extend it voluntarily. A palmar splint is applied securing extension of the distal joint for three or four weeks. If the deformity has been allowed to occur it can only be corrected by an open operation, suturing or tightening the extensor tendon at its insertion into the base of the terminal phalanx.



CHAPTER VI

INJURIES IN THE REGION OF THE PELVIS, HIP-JOINT, AND THIGH

FRACTURES OF PELVIS: Varieties—INJURIES IN REGION OF HIP: Surgical anatomy; Fracture of head of femur; Fracture of neck of femur; Fracture below lesser trochanter—DISLOCATION OF HIP: Varieties—Sprains—Contusions—FRACTURE OF SHAFT OF FEMUR.

FRACTURE OF THE PELVIS

For descriptive as well as for practical purposes, it is useful to divide fractures of the pelvis into those that involve the integrity of the pelvic girdle as a whole, and those confined to individual bones.

In all, the prognosis depends upon the severity of the visceral lesions which so frequently complicate these injuries, rather than upon the fractures themselves.

Fractures implicating the pelvic girdle as a whole usually result from severe crushing forms of violence, such as the fall of a mass of coal or a pile of timber, or the passage of a heavy wheel over the pelvis. The force may act in the transverse axis of the pelvis, or in its antero-posterior axis. The pelvic viscera may be lacerated by the tearing asunder of the bones, or perforated by sharp fragments, or they may be ruptured by the same violence as that causing the fracture.

As a rule, more than one part of the pelvis is broken, the situation of the lesions varying in different cases.

Separation of the pubic symphysis may result from violence inflicted on the fork, as in coming down forcibly on the pommel of a saddle; from forcible abduction of the thighs; or it may happen during child-birth. In some cases the two pubic bones at once come into apposition again, and there is no permanent displacement, the only evidence of the injury being localised pain in the region of the symphysis elicited on making pressure over any part of the pelvis. In other cases the pubic bones overlap one another, and the membranous portion of the urethra, or the bladder wall, is liable to be torn. The displaced bones may be palpated through the skin, or by vaginal or rectal examination.

The pubic portion of the pelvic ring is the most common seat of fracture. The bone gives way at its weakest points—namely, through the superior (horizontal) ramus of the pubes just in front of the ilio-pectineal eminence, and at the lower part of the inferior (descending) ramus (Fig. 55). The intervening fragment of bone is isolated, and may be displaced. These fractures are frequently bilateral, and are often associated with separation of the sacro-iliac joint, with longitudinal fracture of the sacrum (Fig. 55), or with other fractures of the pelvic-bones.



Injuries of the membranous urethra and bladder are frequent complications, less commonly the rectum, the vagina, or the iliac blood vessels are damaged.

Localised tenderness at the seat of fracture, pain referred to that point on pressing together or separating the iliac crests, and mobility of the fragments with crepitus, are usually present. The fragments may sometimes be felt on rectal or vaginal examination. In all cases shock is a prominent feature.

The lateral and posterior aspects of the pelvic ring may be implicated either in association with pubic fractures or independently. Thus a fracture of the iliac bone may run into the greater sciatic notch; or a vertical fracture of the sacrum or separation of the sacro-iliac joint may break the continuity of the pelvic brim. In rare cases these injuries are accompanied by damage to the intestine, the rectum, the sacral nerves, or the iliac blood vessels.



Treatment.—It is of importance that the patient be moved and handled with care lest fragments become displaced and injure the viscera. He should be put to bed on a firm mattress, which may be made in three pieces, for convenience in using the bed-pan and for the prevention of bed-sores.

Before the treatment of the fracture is commenced, the surgeon must satisfy himself, by the use of the catheter and by other means, that the urethra and bladder are intact. Should these or any other of the pelvic viscera be damaged, such injuries must first receive attention.

The treatment of the fracture itself consists in adjusting the fragments, as far as possible by manipulation, applying a firm binder or many-tailed bandage round the pelvis, and fixing the knees together by a bandage (Fig. 57).



When there is displacement of fragments extension should be applied to both legs, with the limbs abducted and steadied by sand-bags.

Compound fractures, being commonly associated with extravasation of urine, are liable to infective complications. Loose fragments should be removed, as they are prone to undergo necrosis.

The patient is confined to bed for six or eight weeks, and it may be several weeks more before he is able to resume active employment.

The acetabulum may be fractured by force transmitted through the femur, usually from a fall on the great trochanter, less frequently from a fall on the feet or other form of violence. It may merely be fissured, or the head of the femur may be forcibly driven through its floor into the pelvic cavity, either by fracturing the bone or, in young subjects, by bursting asunder the cartilaginous junction of the constituent bones. When the femoral head penetrates into the pelvis—the central dislocation of the hip of German writers—the condition simulates a fracture of the neck of the femur, but the trochanteric region is more depressed and the trochanter lies nearer the middle line. The limb is shortened, and movements of the joint are painful and restricted, especially medial rotation. In some cases there is pain along the course of the obturator nerve.

On rectal or vaginal examination there is localised tenderness over the pelvic aspect of the acetabulum, and in some cases a convex projection, or even crepitating fragments can be detected. The diagnosis is completed by an X-ray picture.

When the head of the femur penetrates the acetabulum, reduction should be attempted by traction and manipulation. The pelvis is held rigid, and the thigh is flexed and forcibly adducted, while the medial side of the thigh rests against a firm sand-bag; the femoral head is thus lifted out of the pelvis. In a recent injury the amount of force required is relatively slight. The head is kept in its corrected position by extension.

Fracture of the upper and back part of the rim of the acetabulum may accompany or simulate dorsal dislocation of the hip. Crepitus may be present in addition to the symptoms of dislocation, and after reduction the displacement is easily reproduced. The treatment is by extension with the limb adducted.

Fracture of Individual Bones of the Pelvis.—Ilium.—The expanded portion of the iliac bone is often broken by direct violence, the detached fragments varying greatly in size and position (Fig. 56).

The whole or part of the crest may be separated by similar forms of violence.

When the fracture implicates the ala of the bone, it usually starts at the triangular prominence near the middle of the crest, and runs backwards or forwards, passing for a variable distance into the iliac fossa. The displaced fragment can sometimes be palpated and made to move when the muscles attached to it are relaxed. This is done by flexing the thighs and bending the body forward and towards the affected side. Pain and crepitus may be elicited on making this examination.

These fractures are treated by applying a roller bandage or broad strips of adhesive plaster over the seat of fracture, and by placing the patient in such a position as will relax the muscles attached to the displaced fragment—in the case of the iliac spine by flexing the thigh upon the pelvis; in the case of the crest or ala by raising the shoulders. Union takes place in three or four weeks.

In young persons, the anterior superior spine has been torn off and displaced downwards by powerful contraction of the sartorius muscle; and the anterior inferior spine by strong traction on the ilio-femoral or [inverted Y]-shaped ligament. These injuries are best treated by fixing the displaced fragment in position by a peg or silver wire sutures and relaxing the muscles acting on it.

Fracture of the ischium alone is rare. It results from a fall on the buttocks, the entire bone or only the tuberosity being broken. There is little or no displacement, and the diagnosis is made by external manipulation and by examination through the rectum or vagina.

A longitudinal fracture of the sacrum may implicate the posterior part of the pelvic ring, as has already been mentioned. In rare cases the lower half of the bone is broken transversely from a fall or blow, and the lower fragment is bent forward so that it projects into the pelvis and may press upon or tear the rectum, or the sacral nerves may be damaged, and partial paralysis of the lower limbs, bladder, or rectum result. These fractures are frequently comminuted and compound, and the soft parts may be so severely bruised and lacerated that sloughing follows. On rectal examination the lower segment of the bone can be felt, and on manipulating it pain and crepitus may be elicited.

Fracture of the coccyx may be due to a direct blow, or may occur during parturition. As a result of this injury the patient may have severe pain on sitting or walking, and during defecation. The loose fragment can be palpated on rectal examination. There is considerable difficulty in keeping the fragment in position, and if it projects towards the rectum it should be removed. If the lower fragment unites at an angle so as to cause pressure on the rectum, it gives rise to the symptoms of coccydynia, which may call for excision.

INJURIES IN THE REGION OF THE HIP

These include the various fractures of the upper end of the femur; dislocation and sprain of the hip-joint; and contusion of the hip.

Surgical Anatomy.—The strength of the hip-joint depends primarily on its osseous elements—the rounded head of the femur filling the deep socket of the acetabulum, to the bottom of which it is attached through the medium of the ligamentum teres. The edge of the acetabulum is specially strong above and behind, while at its lower margin there is a gap, bridged over by the labrum glenoidale (cotyloid ligament).

In relation to fractures of the upper end of the femur, it is to be borne in mind that as the antero-posterior diameter of the neck is less than that of the shaft, and as a considerable portion of the great trochanter lies behind the junction of the neck with the shaft, the greater part of any strain put upon the upper end of the femur is borne by the neck of the bone and not by the trochanter. The head and neck of the femur are nourished chiefly by the thick, vascular periosteum, and through certain strong fibrous bands reflected from the attachment of the capsule—the retinacular or cervical ligaments of Stanley. The integrity of these ligaments plays an important part in determining union in fractures of the neck of the femur, both by keeping the fragments in position and by maintaining the blood-supply to the short fragment. Whether it be true or not that an alteration in the angle of the femoral neck takes place with advancing years, it is generally recognised that this change is of no importance in relation to fractures in this region.

The articular capsule of the hip is of exceptional strength. It is attached above to the entire circumference of the acetabulum, and below to the neck of the femur in such a way that while the whole of the anterior and inferior aspects of the neck lies within its attachment, only the inner half of the posterior and superior aspects is intra-capsular. The capsule is augmented by several accessory bands, the most important of which is the ilio-femoral or [inverted Y]-shaped ligament of Bigelow, which passes from the anterior inferior iliac spine to the anterior inter-trochanteric line, its fasciculi being specially thick towards the upper and lower ends of this ridge. The medial limb of this ligament limits extension of the thigh, while the lateral limits eversion and adduction. The weakest part of the capsular ligament lies opposite the lower and back part of the joint.

The hip-joint is surrounded by muscles which contribute to its strength, the most important from the surgical point of view being the obturator internus, which plays an important part in certain dislocations, and the ilio-psoas, which influences the attitude of the limb in various lesions in this region.

Except in thin subjects, the constituent elements of the hip-joint cannot be palpated through the skin. A line drawn vertically downwards from the middle of Poupart's ligament passes over the centre of the joint, which in adults lies on the same level as the tip of the great trochanter. In children it is somewhat higher.

For purposes of clinical diagnosis it is necessary to locate certain bony prominences, the most important being—(1) The anterior superior iliac spine, which is most readily recognised by running the fingers along Poupart's ligament towards it. (2) The ischial tuberosity, which in the extended position of the limb is overlapped by the lower margin of the gluteus maximus muscle, and is therefore not easily located with precision. By flexing the limb and making pressure from below upwards in the gluteal fold, the smooth, rounded prominence can usually be detected. (3) The quadrilateral great trochanter is readily recognised on the lateral aspect of the hip. Its highest point or tip can best be felt by pressing over the gluteal muscles from above downwards.

Clinical Tests.—If a line is drawn from the anterior superior iliac spine to the most prominent part of the ischial tuberosity, it just touches the tip of the great trochanter. This is known as Nelaton's line (Fig. 58).



Bryant's test (Fig. 59) is applied with the patient lying on his back, and consists in dropping a perpendicular AB from the anterior superior iliac spine, and drawing a line CD from the tip of the great trochanter to intersect the perpendicular at right angles. This is done on both sides of the body, and the length of the lines CD compared. Shortening on one side indicates an upward displacement of the trochanter, lengthening a downward displacement. The third side AC of the triangle indicates the distance between the anterior spine and the tip of the trochanter.



Chiene's test, which is simpler than either of these, consists in applying a strip of lead or tape across the front of the body at the level of the anterior superior iliac spines, and another touching the tips of the two trochanters. Any want of parallelism in these lines indicates a change in the position of one or other trochanter.

FRACTURE OF THE UPPER END OF THE FEMUR

The fractures of the upper end of the femur that are liable to be confused with one another and with dislocations of the hip, include fractures of the head, the neck, the trochanters, and separation of the upper epiphyses, and fracture of the shaft just below the trochanters.

Fracture of the head of the femur is rare, and is usually a complication of backward dislocation of the hip. It takes the form of a split of the articular surface caused by impact against the edge of the acetabulum, and is analogous to the indentation fracture of the head of the humerus, which may accompany dislocation of the shoulder.

The epiphysis of the head, which lies entirely within the capsule of the joint (Fig. 60), is occasionally separated, and the symptoms closely simulate those of fracture of the narrow part of the neck. If the condition is overlooked or imperfectly treated, it may in course of time be followed by coxa vara.



FRACTURE OF THE NECK

It has long been customary to divide fractures of the neck of the femur into two groups—"intra-" and "extra-capsular"; but as in a considerable proportion of cases the line of fracture falls partly within and partly without the capsule, this classification is wanting in accuracy. It is more correct to divide these fractures into (1) those occurring through the narrow part of the neck, which are nearly always purely intra-capsular; and (2) those occurring through the base of the neck in which the line of fracture lies inside the capsule in front, but outside of it behind.

It is of considerable importance to distinguish between fractures in these two positions. The first group occurs almost exclusively in old persons as a result of slight forms of indirect violence, and it is liable, on account of the feeble vascular supply to the upper fragment, to be followed by absorption of the neck, which delays or may even entirely prevent union (Fig. 61). The second group usually occurs in robust adults, and results from severe forms of violence applied to the trochanter. In this group firm osseous union usually takes place.



Fracture of the Narrow Part of the Neck or Intra-capsular Fracture.—This fracture is most frequently met with in elderly persons, especially women, and is usually produced by comparatively slight forms of indirect violence—such, for example, as result from the foot catching on the edge of a carpet, a stumble in walking, or missing a step in going downstairs.

The line of fracture, which is usually transverse but may be oblique or irregular, lies for the most part within the capsule, and the posterior part of the neck is more comminuted than the anterior. The distal fragment, which includes the base of the neck, the trochanters, and the shaft, is usually displaced upward and rotated laterally. If the periosteum and the retinacular ligaments remain intact, displacement is prevented and union favoured.

Impaction is less common than in fracture through the base of the neck; it usually results from the patient falling on the trochanter, the distal fragment being driven as a wedge into the proximal (Fig. 62).



Clinical Features.—In non-impacted cases the limb is at once rendered useless, and the patient is unable to rise. There is pain and tenderness in the region of the hip on making the slightest movement; and a specially tender spot may be localised, indicating the seat of fracture.

On placing the pelvis as square as possible, and comparing the measurements of the limbs from the anterior superior spine to the medial malleolus, shortening of the injured limb to the extent of from 1 to 3 inches may be found. On applying Nelaton's, Bryant's, or Chiene's test, the tip of the great trochanter will be found elevated. It is also farther back and less prominent than normal.

The whole limb is usually everted to a greater or less degree, and is slightly abducted. In some cases, when the impaction is of the anterior portion of the neck, the limb is inverted. On comparing the ilio-tibial band of the fascia lata on the two sides, it is found to be relaxed on the side of the injury.

The violence being as a rule indirect, there is at first little or no discoloration in the vicinity of the hip, but this may appear a few days later.

Crepitus is not a constant sign, and should not be sought for, as the necessary manipulations are liable to disengage the fragments and to increase the deformity. For the same reason rotatory movements are to be avoided.

In all cases in which the diagnosis is uncertain, the patient should be put to bed, and treated as for a fracture. In the course of a few days it is nearly always possible to make an accurate diagnosis.

In examining an old person who has sustained an injury in the region of the hip, it should be borne in mind that the limb may be shortened and everted as a result of arthritis deformans, and that the symptoms of that disease may simulate those of fracture. In arthritis deformans, however, the ilio-tibial band of the fascia lata is not relaxed as it is in fracture.



In some cases, and particularly in those in which the periosteum of the neck and the retinacular ligaments remain intact, the shortening does not become apparent till a few days after the accident. As the other symptoms are correspondingly obscure, the condition is apt to be mistaken for a bruise. In all doubtful cases the part should be examined from day to day, and, if possible, the X-rays should be used.

In impacted cases the signs of fracture are often obscure, and the patient may even be able to walk after the accident. The skin over the trochanter is generally discoloured from bruising. Eversion is usually present, but there may be little shortening. Crepitus is absent. In old people it is never advisable to undo impaction, as the interlocking of the bones favours the occurrence of osseous union.

Prognosis.—A fracture of the neck of the femur in an old person is always attended with danger to life, a considerable proportion of the patients dying within a few weeks or months of the accident from causes associated with it. In some cases the mental and physical shock so far diminishes the vitality of the patient that death ensues within a few days. It is possible that fat embolism may account for death in some of the more rapidly fatal cases. In others, the continued dorsal position induces hypostatic congestion of the lungs, or, owing to the difficulties of nursing, bed-sores may form and death result from absorption of toxins. Frequently the prolonged confinement to bed, the continuous pain, and the natural impairment of appetite wear out the strength. In many cases the patient becomes peevish, irritable, or mentally weak.

Osseous union is the exception in intra-capsular fracture, especially when the periosteum and the retinacular ligaments have been completely torn, but in sub-periosteal and in impacted fractures it sometimes occurs. As a rule, however, the neck of the femur becomes absorbed and disappears, the head of the bone comes to lie in contact with the base of the trochanter, and a false joint forms (Fig. 64). Chronic changes of the nature of arthritis deformans may occur in and around such false joints.



When osseous union fails to take place, although the patient may eventually be able to get about, he can do so only with the aid of a stick or crutch, and as there is marked shortening, he walks with a decided limp. There is considerable antero-posterior thickening of the neck of the femur, and the femoral vessels may be pushed forward in Scarpa's triangle.

Treatment.—In treating a fracture through the narrow part of the neck, it is necessary to consider the age and general condition of the patient; whether the fracture is impacted or not; and the site of the fracture—whether in the narrow part of the neck or at its base. "The first indication is to save life, the second to get union, and the third to correct or diminish displacements" (Stimson).

In old and debilitated patients, bony or even firm fibrous union seldom takes place, and it is generally advisable to get them out of bed as speedily as possible. For the first few days the patient may be kept on his back, the limb massaged daily, and in the interval steadied by sand-bags; but on the first sign of respiratory or cardiac trouble he should be propped up in bed, and as soon as possible lifted into a chair. In all such cases care should be taken to avoid undoing impaction.

When the general condition of the patient permits of it, an attempt should be made to secure bony union.

Extension is applied by one or other of the methods described for fracture of the shaft (p. 149), so modified as to maintain the limb in the abducted position, which ensures the most accurate apposition of the fragments (Royal Whitman). This position may be maintained by a hinged long-splint, an adaptation of Thomas' hip splint. The fragments may be fixed to one another by a long steel peg introduced through the skin over the great trochanter, and passed so as to transfix them; or they may be exposed by operation and sutured together. Albe uses a bone peg.

Fracture of the Neck of the Femur in Children.—The use of the X-rays has shown that this fracture is comparatively common in children, as a result of a fall or a forcible twist of the leg. The fracture is most frequently of the greenstick variety; when complete, it is usually impacted. There is shortening to the extent of a half or three-quarters of an inch, a slight degree of eversion, the movements of the hip are restricted, and there is some pain. The patient is often able to move about after the accident, but walks with a limp. Unless the use of the X-rays reveals the fracture, the condition is liable to be overlooked.

When the lesion is diagnosed, the deformity should be completely corrected, any impaction that exists being undone; and the limb is put up in a wide abduction splint (p. 221) or in a plaster-of-Paris case in the position of extreme abduction.

If the condition is not recognised and treated, it is liable to be followed by the development of coxa vara (Royal Whitman) (Fig. 65).



Fracture through the Base of the Neck.—This fracture is usually produced by a fall on the great trochanter, although it is occasionally due to a fall on the feet or knees.



Although often spoken of as "extra-capsular," the line of fracture is generally partly within and partly without the capsule. The fracture usually lies close to the junction of the neck with the shaft, and in the great majority of cases is accompanied by breaking of one or both trochanters. This is due to the neck being driven as a wedge into the trochanters, splitting them up. When the fragments remain interlocked, the fracture is of the impacted variety (Fig. 67).



Clinical Features.—Although this fracture is commonly met with in strong adults, it may occur in the aged.

The lateral aspect of the hip shows marks of bruising, and there is severe pain and a considerable degree of shock. The limb lies helpless; there is generally marked eversion, with shortening, which, in non-impacted cases, may amount to 1-1/2 or 2 inches, and is evident immediately after the accident; it is due to the distal fragment being drawn up by the muscles inserted into the great trochanter and upper end of the shaft. In a limited number of cases the distal fragment lies in front of the proximal, and there is inversion of the limb.



On applying the various tests, the great trochanter is found to be displaced upwards, there is some antero-posterior broadening of the trochanteric region, and the ilio-tibial band is relaxed. On pressing the fingers into the lateral part of Scarpa's triangle, a mass consisting of the bony fragments may be felt, and is tender on pressure. Unnatural mobility with crepitus may be elicited.

In the impacted variety, the shortening seldom exceeds one inch; the eversion is less marked; there is some power of voluntary movement; and crepitus is absent. The broadening of the trochanteric region is greater, and the great trochanter is approximated to the acetabulum.

Prognosis.—The risks to life in the aged are similar to those of intra-capsular fracture. In youths and healthy adults the chief danger is that the limb may be shortened and its function thereby impaired.

As the periosteum and retinacular ligaments which transmit the blood vessels to the proximal fragments are intact, bony union is the rule. There is always, however, considerable thickening in the region of the trochanter due to displaced fragments and callus, and in a certain number of cases, even with the greatest care in treatment, there is a varying degree of shortening and eversion of the limb. In cases in which the distal fragment lies in front of the proximal there is permanent inversion.

Treatment.—As this fracture usually occurs in robust patients, there is no danger from prolonged confinement to bed; and as union without deformity can be attained in no other way, this is always advisable. When the shortening and eversion are excessive, they should be completely corrected under anaesthesia before the retentive apparatus is applied, any impaction that exists being undone. When the deformity resulting from impaction is slight, however, it is best to leave it, as it facilitates speedy and firm union.

Extension is obtained by the same appliances as are used in fracture of the shaft, and the limb should be kept in the abducted position.

Fracture of the greater trochanter occurring apart from fracture of the neck usually results from direct violence, but may be due to muscular action. The trochanter is displaced by the gluteal muscles, causing broadening of the lateral aspect of the hip. In young persons the epiphysis of the great trochanter may be separated, but this is rare. The treatment consists in retaining the fragments in position by keeping the limb abducted between sand-bags, or by pegs driven in through the skin.

Fracture immediately below the lesser trochanter may be produced by direct or by indirect violence, and the displacement depends largely on whether the line of fracture is transverse or oblique. The proximal fragment is kept tilted forward, rotated laterally, and abducted by the ilio-psoas muscle and the lateral rotators inserted in the region of the great trochanter. The lower fragment passes upward, and is rotated laterally by the weight of the limb; the displacement is aggravated by the contraction of the flexor and adductor muscles. The tilting of the proximal fragment may be increased by the displaced distal fragment pushing it forward.

On account of the difficulty of controlling the short proximal fragment, union is liable to take place with considerable shortening and deformity (Fig. 69).



Treatment.—When it is found, under an anaesthetic, that the displacement can be completely reduced, and does not tend to recur, this fracture is treated on the same lines as fracture of the shaft of the bone.

In cases in which the proximal fragment cannot be brought into line with the distal one, however, it is necessary to flex, evert, and abduct the thigh in order to get the fragments into apposition and into line. A Hodgen's splint (Fig. 77) is applied with the highest sling under the upper end of the lower fragment and with sufficient extension to correct overriding. The upper end is then strongly lifted by a counter-weight of about 15 lbs. This secures apposition of the fragments with slight forward angulation at the seat of fracture. By the end of a month sufficient callus has formed to prevent re-displacement, and if the counter-weight is gradually diminished the two fragments sag back together into a normal alignment (J. N. J. Hartley). A double-inclined plane (Fig. 70), with extension applied in the axis of the thigh, gives satisfactory results.



DISLOCATION OF THE HIP

It is unnecessary for our present purpose to attempt a comprehensive classification of the numerous varieties of dislocation that have been met with at the hip-joint. It will suffice if we divide them into those in which the head of the femur passes backward, and comes to rest on the dorsum ilii, or in the vicinity of the great sciatic notch; and those in which it passes forward and comes to rest in the obturator foramen, or on the pubes (Fig. 71).



The backward are much more common than the forward dislocations, in contrast to what obtains at the shoulder, where the forward varieties predominate.

On account of the great strength of the hip-joint, dislocation is by no means a common injury. It occurs most frequently in strong adults after the epiphyses have ossified, and before the bones have commenced to become brittle; and it is much more common in men than in women. It is invariably the result of severe violence, the limb at the moment being in such a position that the ligaments are on the stretch and the muscles taken at a disadvantage. The head of the femur usually leaves the joint at the lower and back part, where the socket is most shallow and the ligaments weakest. The ligamentum teres is almost always torn from its femoral attachment, and one or more of the muscles inserted in the region of the trochanters may be ruptured. The [inverted Y]-shaped ligament, on the other hand, is seldom torn, and so long as it remains intact the dislocation belongs to one or other of the types above named. All atypical dislocations, such as the supra-cotyloid, infra-cotyloid, ilio-pectineal, are due to rupture of some part of the [inverted Y]-ligament, and are so rare as not to call for individual description. The central dislocation of German authors, in which the head is driven through the floor of the acetabulum, is described on page 126.

Like other dislocations, those of the hip may be complicated by laceration of muscles, blood vessels, or nerves, or by fracture of one or other of the bones in the vicinity.

Dislocation on to the Dorsum Ilii.—This, the commonest form of dislocation of the hip, is usually the result of the patient falling from a height, or receiving a heavy weight on the back while stooping forward with the thigh flexed, slightly adducted, and rotated medially. It is also said to have occurred from muscular action. The shaft of the femur acts as the long limb of a lever of which the neck is the short limb, the femoral attachment of the [inverted Y]-ligament forming the fulcrum. The head, thus brought to bear upon the lower and back part of the capsule, tears it and leaves the socket, passing upwards and coming to rest on the dorsum of the ilium, above and anterior to the tendon of the obturator internus (Fig. 73). The articular surface is directed backward, while the trochanter looks forward.



Clinical Features.—The affected limb is flexed, adducted, and inverted, so that the knee crosses the lower third of the opposite thigh, and the ball of the great toe lies on the dorsum of the sound foot. There is shortening to the extent of from 1-1/2 to 2 inches, the trochanter being displaced above Nelaton's line, and lying nearer to the anterior superior iliac spine than on the normal side. The patient is unable to move the limb or to bear weight upon it; abduction and lateral rotation are specially painful; and traction fails to restore the limb to its proper length. On making these attempts a characteristic elastic resistance is felt.

The head of the femur in its new position may sometimes be felt through the fibres of the gluteus maximus, but swelling of the soft parts often obscures this sign. The normal depression behind the great trochanter is lost, the gluteal fold is raised, and there is often a degree of lordosis which compensates for the flexion. The fingers can be pressed more deeply into Scarpa's triangle on the dislocated than on the normal side—a point in which this injury differs from fracture of the base of the neck of the femur.

In a certain number of cases the lateral limb of the [inverted Y]-ligament is ruptured and the limb is everted—dorsal dislocation with eversion.



Dislocation into the Vicinity of the Great Sciatic Notch, or "dislocation below the tendon."—This variety of backward dislocation is less common than that on to the dorsum, although produced in the same way. The head of the femur passes beneath the obturator internus, and this tendon, catching on its neck, checks its upward movement (Fig. 74).

The clinical features are the same as those of the dorsal variety, but, on the whole, are less marked.

Differential Diagnosis.—Backward dislocation of the hip is usually easily recognised. When dislocation below the tendon occurs in a stout person, however, it is liable to be overlooked on account of the difficulty of feeling the displaced bone, and of the comparatively slight amount of deformity present. The nature of the accident, the absence of broadening of the trochanter, and the adduction and inversion of the limb are usually sufficient to prevent a dislocation being mistaken for an impacted extra-capsular fracture.

Dislocation into the Obturator Foramen (Fig. 71).—This dislocation is produced by great force applied from behind while the thigh is flexed and abducted, as when a weight falls on the back of a man stooping forward with the legs wide apart. It may also result from violent abduction by wide separation of the thighs.

The capsule gives way at its medial and lower part, and the head of the femur comes to rest on the surface of the external obturator muscle, its articular surface looking forward, while the trochanter looks backward.

Clinical Features.—In the standing position the thigh is slightly flexed and abducted, with the foot pointing directly forward or a little outward. The body is bent forward to relax the ilio-psoas muscle and the [inverted Y]-ligament, the foot is advanced and the heel drawn up. It is not uncommon for the patient to be able to walk after the accident, and only to seek advice some time later on account of inability to adduct and extend the limb. There is apparent lengthening of the limb due to tilting of the pelvis downward on the affected side. The hip is flattened, the trochanter less prominent than usual, and the head of the bone may sometimes be felt in its abnormal position.