more common in fractures near the articular ends of bones, where rotatory as well as angular movement occurs; the former in fractures through the shafts of bones, where angular movement only is permitted.

The Causes both of ununited fracture and false joint are local and constitutional. The local are— -1. The fragments not having been kept thoroughly at rest; 2. The fragments not having been placed in apposition in consequence of (a) muscular contraction; (b) the loss of a large piece of bone, as in compound fracture; (c) the intervention of a piece of muscle, tendon, or periosteum, or a foreign body, such as a bullet, between the fragments; and (d) the effusion of synovial fluid in the case of a fracture into a joint; 3. Necrosis of the end of one of the fragments; 4. The interference with the arterial supply of one of the fragments, as from injury of the medullary artery; 5. The poor supply of blood to one of the fragments, as in fracture of the anatomical neck of the humerus; 6. Defective nerve-influence, as sometimes occurs when the lower part of the spinal cord has been injured, with consequent disturbance of the trophic centres contained therein; 7. Malignant growths; 8. Osteomalacia.

?

FIG. 95.-False joint following fracture of the humerus. (St. Bartholomew's Hospital Museum.)

Constitutional causes.-Syphilis, tubercle, gout, Bright's disease, fevers, scurvy, anæmia, the cancerous cachexia, pregnancy, locomotor ataxy, old age, alteration of the patient's habits, alcoholism, and sudden deprivation of stimulants are all said to be causes of ununited fracture. No doubt any condition that lowers the vitality and consequent power of repair of the tissues has a tendency to delay union, but it seems doubtful if any of the above conditions except scurvy is in itself, apart from the local causes, sufficient to prevent the bone uniting. Paralysis agitans, in which there is great dificulty in keeping the patient quiet, and hence of immobolising the fragments by splints, etc., may also be regarded as a cause of non-union. The cause of the ununited fractures sometimes met with in children, in which in spite of every kind of treatment union cannot be obtained, is unknown.

Sometimes the callus, after having been formed, appears to be re-absorbed, the fracture being then spoken of as disunited. This Is common in scurvy.

Treatment.-Constitutional as well as local treatment may be

required. In recent cases, i.e., where the fracture is found ununited after having been kept in splints for the usual time-a condition sometimes called delayed union in contradistinction to ununited fracture the splints should be re-applied, and in such a manner as to insure perfect immobility of the fragments, whilst the general health should be improved by every means in our power, and any constitutional taint, as syphilis, gout, etc., that may be detected, combated by appropriate remedies. Thyroidin has been recommended. If the patient has been accustomed to stimulants, and has been deprived of them, he should be allowed a moderate quantity. In some cases it may be expedient to put the fracture in an immoveable apparatus and let the patient get about on crutches. Should union still not occur, the end of the fragments should be rubbed together to excite some amount of inflammation, and splints or other apparatus be again applied. For such purpose chloride of zine (10 per cent.) may be injected, or in compound fracture, plugs soaked in turpentine inserted. This failing, and in long-standing cases, two courses are open; either to try to unite the fragments by some operative procedure, or to apply some form of permanent apparatus to hold them in position. The choice of these methods will depend to some extent upon the situation of the fracture, and whether it is of the nature of an ununited fracture or a false joint (a point that should be ascertained by skiagraphs), and upon the patient's age, constitu tional condition, occupation, and rank of life. Thus in the case of an ununited fracture of the upper third of the femur in a patient of advanced age or of broken constitution an operation is attended with great risk to life, and for such some form of apparatus is better suited. But when the patient is young, or of good constitution, of his occupation is such that he cannot afford an apparatus and the continual expense of keeping it in good order, and especia.. where the fracture is in the shaft of the humerus, an operation should be undertaken. The older operations of subcutaneou scraping of the ends of the fragments, passing a seton betwee them, or driving in ivory pegs, which had all for their object th setting up of inflammation, and thereby inducing the formation callus and ossification, proved either unreliable, inefficient, or highl dangerous, and are no longer employed. The operations now vogue consist in cutting down on the fragments and fixing the together by wire sutures, screws, etc. (a) Where the site of th ununited fracture can be readily reached without much disturban of the soft tissues, as in the shaft of the humerus, the ends of th fragments should be cut down upon, fully exposed, fitted togethe trimming if necessary, and united with stout silver wire. Suturin as formerly done, allowed of lateral and longitudinal displaceme if the fracture was oblique or if the ends of the fragments we sawn off obliquely. Wille therefore advises that in oblique fr tures two grooves (Fig. 96) be cut with a saw in the fragmen

the direction of the grooves being at a right angle to the fractured surfaces, and the fragments tied together with wire. Further, where both the fragments can be drilled vertically, he draws with a hook, invented for the purpose (Fig. 97), the wire through the

FIG. 96.-Wille's method of wiring the fragments in oblique fractures.

drill holes, divides it, and twists each half together (Fig. 98). Walsham has tried this method and found it answer admirably. Other surgeons, to obviate the lateral and longitudinal displacement, cut

Fig 97 and FIG. 98.-Wille's method of wiring the fragments in oblique fractures. the ends of the fragments in a zigzag manner so as to dovetail them together, but this requires rather delicate manipulation and cannot always be satisfactorily performed. In some

cases the

FL 99.-Bone drill. The drill is made like a trocar and cannula. The end of the style projects beyond the cannula as a gimlet, whilst the square neck prevents it from being rotated except with the cannula. After boring through the bone the style is withdrawn, wire is passed through the cannula and the end held whilst the cannnia is drawn back.

fragments can be more securely fixed together by aseptic metal Care, however, is required in inserting them lest the bone be split. Senn advises the fixation of the fragments with bone ferrules (Fig. 100).

plate fitted to th

Watson Cheyue and others use an aluminium hy nails or screws. (6) Where the site of

the fracture is deep, or the fragments overlap considerably, and the full exposure of the fragments and sawing off their ends would

FIG. 100.--Senn's bone ferrules for fixing the fragments in
ununited fractures in situ. (After Senn.)

necessitate very extensive disturbance of the periosteum and soft parts, it is safer to merely expose the more prominent fragment,

FIG. 101. Malunited fracture. (St. Bartholomew's Hospital Museum.) bring the ends of the fragments one above the other through each ivory pegs, nails, or metal screws.

FIG. 102.--Vicious union after fracture. (St. Bartholomew's Hospital Museum.)

together, and then drill two holes fragment, and fix them in situ by The irritation of the

pegs,

nails

or screws leads to the union of the fracture by the extensive formation of ensheathing callus.

After any of the above operations the wound should be closed, and if perfect asepsis is maintained the uniting material becomes encysted, and as a rule remains permanently in situ without giving rise to any inconvenience. It occasionally, however, becomes loose and requires removal after some weeks.

In ununited fractures with loss of substance from necrosis the gap may be filled by grafting a piece of bone between the fragments. The grafts may be obtained from a young animal, or from a limb immediately after amputation. Whilst being transferred the grafts should be kept at a temperature of 100° in a capsule of boiled salt solution (3j. to Oj.). But equally good results are obtained by using dead bone chips (either decalcified bone preserved in alcohol, or calcined bone) to fill up the space between the fragments.

Malunited fracture or vicious union.-1. Fractures in consequence of having been improperly set, or not kept at rest in good position, may unite at an angle (Fig. 101), or in some other faulty direction (Fig. 103). 2. If splints have been removed too early, or if in the case of the lower extremity the patient has been allowed to walk too soon, the callus may yield, and deformity result. 3. Two adjacent bones, as the radius and ulna in the forearm, may become united to each other by callus (Fig. 102). 4. A greenstick fracture from neglect to straighten the partially-bent bone before applying splints may consolidate in its distorted condition.

Treatment. If the fracture is recent, and the fragments are not firmly united, the patient should be placed under an anæsthetic, the faulty position rectified with the hands, and splints properly applied. If fairly firm union has already occurred an attempt should still be made to re-fracture the bone, under an anæsthetic, with the hands; if this fails, and in long-standing cases, osteoclasia by means of Thomas's instrument should be undertaken, or subcutaneous or open osteotomy may be performed, or in some instances a wedge-shaped piece of bone or mass of callus removed. Some surgeons object to the osteoclast in that they affirm that it difficult to gauge the amount of injury inflicted on the soft parts. If properly used, however, very little damage is done. From personal experience, Walsham can strongly recommend its employment. It should, of course, not be used indiscriminately, but restricted to suitable cases, such as angular deformity of the bones of the leg, as shown in Fig. 101, certain forms of malunited Fett's fracture, and some varieties of fracture of the forearm where the radius and ulna are not welded together by callus. In several cases of badly-set Pott's fractures Walsham has of late years divided the fibula subcutaneously and removed a wedge-shaped pe of bone from the internal malleolus with the most excellent