B. Separation of the Epiphysis.-The signs are similar to the above, but the patient is under twenty-one years of age.

C. T-shaped Fracture.-In this there is a transverse fracture above the condyles, combined with a vertical or oblique fracture extending between the condyles into the joint. Signs. Similar to the transverse fracture, except that the condyles move on one another as well as on the shaft, and the distance between them is increased. These signs, however, are often obscured by great effusion in and around the joint.

D. Fracture of the Condyles.-The projecting internal condyle may be broken off without implicating the joint; or the fracture may extend obliquely through either condyle and the contiguous articular surface into the joint. Cause. Generally direct violence. Signs.-Mobility and crepitus on grasping the condyles, and on flexing and extending the forearm when the internal condyle is fractured, and on pronating and supinating the hand when the external condyle is fractured.

Method of Union.-The extracapsular varieties unite by bone, the intracapsular by fibrous tissue. In the T-shaped fracture the transverse portion unites by bone, the vertical or oblique, i. e., the portion inside the joint, by fibrous tissue.

Treatment. If there is much swelling, and you cannot be quite sure that there is no dislocation, place the limb on a pillow, or better, on a Stromeyer's cushion, and apply cold in the form of lead lotion or ice, till the swelling has subsided. Subsequently reduce the fracture, and place the arm and forearm on an angular splint, or on a bent anterior splint, or in Bavarian plaster, moulded leather, or poro-plastic felt splints. Passive movements of the elbow should be begun early. Where the internal condyle only is chipped off, the angular splint should be placed on the outer side of the arm. In the other forms it is usually applied to the inner side.

THE RADIUS AND ULNA.-Cause.-Generally direct violence, when each bone breaks in the same transverse line at the spot where the force is applied; occasionally indirect violence, as a fall on the hand, when each bone generally breaks at its weakest part—the radius in its upper third, the ulna in its lower third. Nature of the Displacement.-The upper fragment of the radius is drawn by the pronator teres toward the upper fragment of the ulna, which in consequence of its hinge-shaped articulation with the humerus is not displaced. The lower fragments are drawn toward each other by the pronator quadratus. Signs.-Obvious deformity, crepitus, etc. Treatment.-Flex the elbow to relax the muscles; reduce the fracture, and place the forearm in wellpadded splints with the thumb uppermost. The splints should

reach from the elbow beyond the wrist, and should be broader than the forearm, so that the bones may not be pressed together by the bandage. If this point is attended to, interosseous pads are not necessary. The patient should be seen within twentyfour hours, as swelling may occur and the bandages require loosening. The splints must be worn for about a month, and passive movements of the fingers practiced early to prevent stiffening. Greenstick fracture of the radius and ulna is common in chil

dren.

THE RADIUS.-Fractures of the radius may involve, 1, the neck; 2, the shaft; and, 3, the lower end (Colles' fracture).

1. The neck of the radius is very occasionally fractured. It may be known by crepitus, and by the absence of movement of the head when the hand is pronated and supinated. Treatment. -Flex the forearm, and place the limb on an angular splint.

2. The shaft of the radius may be fractured by direct or indirect violence. Both fragments are drawn toward the ulna, the upper by the pronator teres, the lower by the pronator quadratus (Fig. 109). Treatment.— Similar to that of fracture of both bones.

FIG. 109.

3. Fracture of the Lower End of the Radius (Colles' Fracture).-The line of fracture generally runs transversely about three-quarters of an inch above the articular surface of the bone. Cause.-Falls on the palm of the hand; it is more frequent in the old than in the young; and is especially common in elderly

Fracture of the Radius.-(After Gray.)

women.

Nature of the Displacement.—Sometimes there may be no displacement, but generally the lower fragment with the hand is so displaced that the articular surface looks downward and slightly backward and outward, instead of downward, forward and inward. This, according to Mr. R. W. Smith, is due to the action of the supinator longus, the extensors of the thumb, and the radial extensors of the carpus. By others it is believed to be due to the impaction of the upper fragment into the lower, a condition frequently met with in specimens preserved in museums. Occasionally the lower fragment is displaced forward in consequence of falls on the back of the hand. Comminution of the lower fragment with involvement of the joint frequently occurs. Signs. Very characteristic. On the back of the wrist, just above the joint, there is a prominence caused by the back

wardly displaced lower fragment, and above this a slight depression; while on the palmer surface there is a prominence caused by the lower end of the upper fragment, corresponding to the dorsal depression, and below this a depression corresponding to the dorsal prominence. Pronation and supination are lost, the hand is deflected to the radial side,

FIG. 110.

and the lower end of the ulna is prominent. The deformity is well seen in Fig. 110. These signs are similar to those of dislocation of the carpus backward. The following points will serve to distinguish the two injuries. In fracture, 1, the styloid process of the radius is on a higher plane than that of the ulna; 2, the distance from the internal condyle to the tip of the styloid process of the radius is less than on the sound side; 3, there is crepitus; 4, the deformity, when it can be reduced, has a tendency to return if the

FIG. III.

Colles' Fracture.-(From a cast in St.
Bartholomew's Hospital Museum.)

Gordon's Splint for Colles' Fracture.-(Gordon's Fractures.)

extending force is relaxed; and, 5, it is very common in the old and occurs from slight causes. In dislocation, on the other hand, 1, the styloid process of the radius is on the same plane as that of the ulna; 2, the distance from the internal condyle to the tip of the styloid process of the radius is the same as on the sound side; 3, there is no crepitus; 4, the deformity when reduced has no tendency to return when the extending force is relaxed; and 5, it is usually the result of great violence, and more frequently occurs in the young than in the old. Treatment.Apply two ordinary forearm splints, taking care that the anterior one does not reach beyond the heads of the metacarpal bones, and place a pad beneath the wrist to restore the lost concavity of

the front of the radius. Practice passive movements from the third day, as in this form of fracture the tendons, where they cross the back of the radius, the seat of fracture, are apt to become adherent to their grooves. This is the almost invariable : method of treating Colles' fracture at St. Bartholomew's Hospital, and is attended with excellent results. If preferred, Gordon's (Fig. 111), Carr's, Hawkin's, or Bond's splints may be used. The pistol-shaped splint introduced by Nélaton, and justly condemned by Sir James Paget as so frequent a cause of stiff wrist and fingers, should on no account be used. Remove the splint in about four weeks' time, and employ shampooing, friction with stimulating liniments, etc., till any stiffness of the joint or fingers that remains has disappeared.

Separation of the lower epiphysis may occur in young subjects and resembles Colles' fracture.

THE ULNA. Fracture of the ulna may be divided into fracture of--1, the olecranon; 2, the coronoid process; and 3, the shaft.

1. The olecranon may be fractured in a transverse or oblique direction. The elbow-joint is always involved, except when the fracture is through the tip of the process only. Cause.-Direct violence, as a fall on the point of the elbow, or violent action of the triceps muscles. Nature of the Displacement (Fig. 112).The detached fragment is usually widely separated from the rest of the bone by the triceps; but when the periosteum and tendinous expansion of the triceps covering the olecranon is not torn, and the fracture is very oblique, little or no displacement occurs. Signs.--Swelling from effusion of blood, and later of serum, into the joint; inability of the patient, as a rule, to extend his arm; and generally, the presence of a gap between the fragments. Method of Union.

FIG. 112.

Fracture of the Olecranon.-(Liston's Surgery.)

Generally

fibrous; but when the separation of the fragments is slight, it may be bony. Treatment. -Place the elbow in a position of very slight flexion on 3 jointed splint, and apply evaporating lotions till the swelling has subsided. An attempt may be made to bring down the detached fragments by strapping and a bandage. Passive movements should be begun early to prevent ankylosis (seventh day, Hamilton). Many advise that the arm should be put up in full extension; but this is objectionable, as it causes the olecranon to form an angle with the shaft.

2. The coronoid process of the ulna, except in dislocation of the ulna and radius backward, is rarely fractured. It is said at times to occur from a violent contraction of the brachialis anticus muscle. Signs.--Similar to those of a dislocation of the radius and ulna backward. When fracture of the coronoid is present, the dislocation is readily reduced, but immediately returns on relaxing the extending force. When fracture of the coronoid is not present, the dislocation is more difficult to reduce; but when once reduced, has no tendency to recur. Treatment.-After reducing the dislocation, place the arm in a flexed position on an inside angular splint. Employ passive movements early.

3. The shaft of the ulna is occasionally fractured without implication of the radius. Cause.-Direct violence. Nature of the Displacement.-The upper fragment is not displaced, being held in position by its hinge-shaped articulation with the humerus. The lower fragment is drawn toward the radius by the pronator quadratus. Signs.-It is readily detected by running the finger along the prominent posterior border of the bone, when a gap or irregularity is felt, and by crepitus on movement. Treatment. Similar to that of fracture of the radius.

THE CARPUS, METACARPUS AND PHALANGES.-Fractures of these bones require no special mention. They may be diagnosed by the deformity and crepitus. Rest for a few weeks on a splint, followed by passive movements to prevent stiffening, is all that is generally necessary.

INJURIES OF THE LOWER EXTREMITY.

BRUISES OF CONTUSIONS, BURNS, SCALDS, and FROST-BITES of the lower extremity call for no special mention beyond that bruises about the hip and ankle may be mistaken for fracture, and that a contusion of the limb may be so severe at times as to terminate in gangrene.

Pain, in

SPRAINS of the ankle and knee are very common. ability to bear any weight on the limb, effusion into the joint or the sheaths of the surrounding tendons, and, later, ecchymosis of the skin, are the usual signs. A sprain of the ankle when there is much swelling, is often difficult, and sometimes impossible, to diagnose from a fracture, and should then be treated as such. For an ordinary sprain absolute rest should be enjoined, and cold or evaporating lotions or a wet bandage should be applied. When the swelling has subsided, the part may be put in a plaster-of-Paris bandage or in a poro-plastic splint for some weeks, and then shampooing and passive movements employed if any stiffness be left.