Notes on military orthopaedics

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fOTES ON MILITARY
ORTHOPAEDICS

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NOTES ON
MILITARY ORTHOPEDICS

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3

By

(Colonel Sir) Robert Jones, C.B.

Inspector of Military Orthopaedics, Army Medical Service

With an Introductory Note by

Surgeon-General Sir Alfred Keogh, G.C.B.

Director-General, Army Medical Service

ILLUSTRATED

Published for the British Red Cross Society by

GASSELL AND COMPANY, LTD

London, New York, Toronto and Melbourne

1917

Deoicateo to
HIS MAJESTY KING MANUEL

In recognition of his sympathy, co-operation and

enthusiasm in the promotion of Orthopaedic Centres

for disabled soldiers, and as a small tribute of

personal gratitude and esteem.

PREFACE

THIS little work is published in the hope that it may
perhaps be of some service to surgeons engaged in
military work. It is an attempt to formulate rules for
the application of orthopaedic principles to the treatment
of injuries received in war.

The foresight of the War Office and the sympathetic
generosity of the British Red Cross Society have enabled
us to open Orthopaedic Centres in many of the principal
towns of the British Isles, and to equip them so that
the surgeon may have at his disposal every facility
likely to develop and perfect treatment.

The " curative workshops " started in each centre
owe their existence and success to the initiative and
inspiring enthusiasm of King Manuel, who has acted as
representative of the British Red Cross Society. These
workshops have already proved to be of very real
value, and are the latest but not least important advance
in the orthopaedic treatment of wounded men suffering
from physical disabilities of their limbs.

By the time a soldier has passed through various
phases of recovery from septic wounds in several different
hospitals and is finally transferred to an Orthopaedic
Centre for treatment to correct deformity and restore
the use of injured joints and muscles, his spirit is
often broken. The shock of injury, frequently in itself
severe, followed in succession by a long period of sup-
puration, and then by a wearisome convalescence, during
which he receives treatment by massage or electricity,
or by monotonous movement with mechanical appa-
ratus of the Zander type, too often leaves him dis-
contented with hospital life, its monotonous round of
routine, and its long periods of idleness.

In the Orthopaedic Centre he finds his fellow-patients
busily engaged in employments in which they are

viii PREFACE

doing something, and it is not many days before he
asks for a " job."

In the Military Orthopaedic Hospital at Shepherd's
Bush alone, out of 800 patients about 500 are employed
at some regular work, which fosters habits of diligence
and self-respect, and converts indolent and often dis-
contented patients into happy men who soon begin to
feel that they are becoming useful members of society
and not mere derelicts.

Thus, when the preliminary stages of operative and
surgical treatment are over, there is a steady gradation
through massage and exercise to productive work,
which is commenced as soon as the man can really
begin to use his limb at all. If his former trade or
employment is a suitable one, he is put to use tools
he understands, otherwise some occupation suitable
for his disability, and curative in its character, is found
for him.

Men with stiff ankles are set to drive a treadle lathe
or fretsaw. If put on a treadle-exercising machine the
monotony soon wearies the mind, but if the mind is
engaged not on the monotony of the foot work, but on
the interest of the work turned out, neither mind nor
body becomes tired.

Men with defective elbows and shoulders find exercise
and mental diversion in the carpenter's and blacksmith's
shops. If their hands and fingers are stiff, working with
a big swab to clean windows or with a paint brush is a
more interesting occupation than gripping spring dumb-
bells.

Those of us who have any imagination cannot fail to
realize the difference in atmosphere and moral in hospitals
where the patients have nothing to do but smoke, play
cards, or be entertained, from that found in those where
for part of the day they have regular, useful and pro-
ductive work.

Massage and exercise is no longer a mere routine : it
all fits in and leads up to the idea of fitness — fitness
to work and earn a living and serve the State in an
economic sense, even if not to return to the regiment and
fight once more in the ranks of the Army.

I have to thank the Hon. Arthur Stanley and Sir
Robert Hudson for their unfailing help and encourage-
ment in connection with the Orthopaedic Centres ;

PREFACE ix

Miss Perks for her drawings ; and my friends Dr.
Dawson Williams and Lt.-Col. J. Lynn Thomas, C.B.,
for help and advice in connection with the proofs.

To my friend and colleague, Mr. Aitken, who has long
been associated with me in my work, and who is con-
versant with my methods, I am much indebted for
help in this as well as in other writings.

R. J.

March, 1917.

THE several chapters of this volume appeared
as a series of articles in the British Medical
Journal during 1916, and I desire to express
my acknowledgment for permission to re-
publish them in book form.

R. J.

CONTENTS

PAGE

INTRODUCTORY NOTE. BY SURGEON-GENERAL
SIR ALFRED KEOGH .... xiii

CHAPTER

1. POSITIONS OF ELECTION FOR ANKYLOSIS FOL-

LOWING GUN-SHOT INJURIES OF JOINTS . i

2. SUTURE OF NERVES, AND ALTERNATIVE

METHODS OF TREATMENT BY TRANSPLANTA-
TION OF TENDON ..... 9

3. THE SOLDIER'S FOOT, AND THE TREATMENT

OF COMMON DEFORMITIES OF THE FOOT . 27

4. MALUNITED AND UNUNITED FRACTURES . 60

5. TRANSPLANTATION OF BONE, AND SOME USES

OF THE BONE GRAFT 81

6. DISABILITIES OF THE KNEE-JOINT . . 96

7. THE MECHANICAL TREATMENT OF FRACTURES

UNDER WAR CONDITIONS . . .no

INDEX . . . .- . / . 129

INTRODUCTORY NOTE

By SURGEON-GENERAL SIR ALFRED KEOGH,
G.C.B.

OF the many surgical problems which have needed
especial attention during the past two years, none equals
in importance those generally known as the ortho-
paedic. The term has been extended to include cases
not hitherto comprehended as belonging to this branch
of surgery, and the wider application of orthopaedic
principles has been forced upon us by their special im-
portance at the present time.

This importance rests not merely on surgical, military,
or even humanitarian considerations. The problem of
the maimed and discharged soldier has leaped into
prominence, and we are forced by grave social and
economic considerations to devote our attention not
merely to procuring a sound administrative system to
solve it, but to securing the highest professional efficiency
to ensure the best results.

The publication of such a work as this is at the moment
most opportune. The long experience and the reputa-
tion of the author will be to the profession its best com-
mendation, but I may be allowed to take advantage of
the opportunity which its appearance affords of com-
mending the subject generally to the attention of the
profession. If within the domain of Orthopaedic Sur-
gery we include the many varieties of disabilities which,
for administrative reasons, we are now bound to con-
sider as coming within the scope of this branch of sur-
gery, it follows that the general surgeon, no less than the
orthopaedist, is directly concerned with the subject. A
wider extension of surgical work becomes, therefore,
imperative. Indeed, no one who has had his attention
drawn to the after-effects of some forms of treatment

xiv INTRODUCTORY NOTE

can hesitate to recognize that unless the general surgeon
is concerned with the after-treatment of cases, the
efficacy or inefficacy of original procedures will often
be unknown to him. We are here concerned with con-
ditions necessarily entirely different from those of civil
life. The military surgeon's connection with his case
is often brief ; cases pass from one surgeon to another
with extreme rapidity ; few surgeons see their patients
from the beginning to the end. One could well wish
that there was no evil in this. But there is much of
evil, and not the least is the fact that the orthopaedic
surgeon's work is enormously increased.

But it is not merely the methods of cure which, for
many years to come, will confront the surgeon. The
relation of disabilities to earning capacity is one of the
most important problems of the day. A large part of
this subject comes within the domain of Orthopaedic
Surgery, and, indeed, the relation of physical infirmity
to industrial work has become a question of no little
moment.

If this work brings home to the surgeon the necessity
for a correlation between early and late surgical pro-
cedures, and at the same time succeeds in obtaining
for the discharged and disabled soldier the same sur-
gical interest as is displayed on his behalf in the
earlier days of his incapacity, it will prove to be a
very solid contribution to national efficiency.

ALFRED KEOGH.

NOTES ON
MILITARY ORTHOPAEDICS

CHAPTER I

POSITIONS OF ELECTION FOR ANKYLOSIS
FOLLOWING GUNSHOT INJURIES OF JOINTS

THERE are certain injuries to joints occurring after
gunshot wounds which must inevitably end in bony
ankylosis. From their very nature some of these will
not admit of excision.

When a joint has been shattered, and the muscles
governing it have been in part or wholly destroyed,
excision is not merely difficult from the point of view
of surgical technique, but often results, in a flail-articula-
tion which renders the limb quite useless. This is
especially the case when such joints as the shoulder,
elbow, and wrist are concerned. Excisions of the upper
part of the humerus are frequently practised as a con-
servative procedure in the presence of acute or persistent
sepsis, especially at the French front. This may be
very necessary, but the resulting condition will at a
later date require further surgical intervention. The
question has often been put to me : " What should be
done with these flail-joints, and, if ankylosis is to be
expected, -in what position should the joint be placed
in order to be of the greatest use to the patient ? "
The question as to flail-joints will be considered at the
end of this chapter, but in the first place it may be of
service to indicate briefly the conclusions as to the
positions for_ankylosis to which experience has ledjne. j

SHOULDER-JOINT

Position. — The arm should be abducted to about
50° (Figs, i and 2). The elbow should be slightly in
front of the coronal plane of the body (Fig. 2), so that
when it is at right angles and the forearm supinated,

B

2 NOTES ON MILITARY ORTHOPEDICS

the palm of the hand is towards the face. The arm
is placed in this position while the scapula retains its
normal position of rest.

Reasons. — If the arm be correctly placed, the hand
(Fig. 3) can be brought easily to the mouth by bending
the elbow. Further, the humerus being fixed to the
scapula at the angle indicated, the arm can be lifted
to a considerable height by scapular action (Fig. 4) ;
moreover, pockets can be reached, the hair brushed,
and the patient can pick up a plate or cup without
spilling the contents.

The arm should never be kept to the patient's side if

Figs. 1 and 2.— To illustrate

the position for ankylosis of

the shoulder in abduction.

ankylosis is feared, for in such a case the functional
result must be most unsatisfactory ; not only will it be
difficult to reach many parts of the body, but difficult
also to reach across a table or to perform many simple
movements constantly recurring in everyday life. Flail
shoulder- joints also should be ankylosed in the position
described, and joints which have been allowed to
ankylose in an adducted position (Figs. 5 A, 56) may
require osteotomy of the humerus high up to correct
this faulty position. The shoulder-joint should never
be allowed to become fixed at right angles to the side
in adults, as in that case the patient will be unable to
bring his arm down to his side.

It is to be clearly understood that I am dealing with
injuries to soldiers and sailors, and not with children, in
whom other means can be adopted owing to anatomical
considerations.

POSITIONS FOR ANKYLOSIS 3

ELBOW-JOINT

Position. — The proper course to adopt will depend
upon the patient and his calling, but by far the greater
number of men would prefer the fixation to be at just
below a right angle — that is, about 70° (Fig. 6). The
ankylosis commonly met with at 130° is not useful.
It is important to bear in mind that in cases in which
both elbows will become ankylosed it is necessary to fix
the one at an angle of 110°, and the other at 70° as
recommended for one-sided trouble (Fig. 7).

Fig»- 3 and 4. — Ankylosis of the shoulder in abduction to show (Fig. 3)
degree of abduction, (Fig. 4) the degree of power of lifting the arm.

Reasons. — This position enables the patient to move
his hand to his mouth, button his clothes, brush his
hair, and reach over a table. At an angle less than a
right angle it is certainly more easy to get the hand
to the mouth and to various parts of the head, but
limitations in other directions more than counterbalance
these advantages.

FOREARM

Position. — If the movements of pronation and supina-
tion are lost, the radius should be fixed midway between
pronation and supination.

4 NOTES ON MILITARY ORTHOPEDICS

Reasons — The hand is more useful for dressing and
eating and for manual labour in this position. A minor
advantage is that of appearance.

Fig. 5 A shows faulty adducted position of arm. and Fig. 5 B the
consequent extremely limited power of abduction.

WRIST-JOINT

Position. —All injuries of the wrist-joint should be
treated with the wrist dorsiflexed (Figs. 8, 121, and 123).

Fig. 6. — Ankylosis of elbcw-
joint at 70°.

Fig. 7.— Right elbow aot 110°. left
elbow at 70°.

This is a priceless surgical axiom, the neglect of which
is grave.

It is an urgent necessity where ankylosis is expected,
or where even limitation in movement is likely to occur.

The common deformity of palmar flexion occurs
when no splint is applied, or from the use of a straight

POSITIONS FOR ANKYLOSIS 5

splint ; in all cases in which the arm and fingers are
kept on such a splint, palmar flexion of the wrist occurs,
and this condition is a lifelong handicap to the usefulness
of the hand.

Reasons. — The grip of the fingers is diminished if
the wrist is palmar-flexed. The strong flexors over-
power the extensors of the fingers, and in consequence
proper co-ordination of the finger movements is im-
paireVl. The grasp of the hand is strongest when the
wrist is in the dorsiflexed position, the balance between
the flexors and extensors is better preserved, and the
co-ordinated movement of the fingers is secured.

The splints required are simple.

In proof of the importance I attach to the dorsiflexed

Fig.- 8. — Dorsiflexion of the wrist.

ankylosed wrist, I may state that I always restore hyper-
extension of the ankylosed joint from the position of
flexion by manipulation or incision. This invariably
improves the grip of the fingers.

Apart from the impairment of function, a flexed wrist
is unsightly.

HIP-JOINT

Position. — Ankylosis should be encouraged in a
position of very slight abduction, with thigh extended
and very slight outward rotation (Fig. 9).

Reasons. — The common deformity in ankylosis of
the hip is flexion, adduction, and internal rotation (Fig.
10), which is the characteristic position we find in an
untreated or imperfectly treated tuberculous hip-joint ;
it leads to lumbar lordosis and an ugly limp. Adduction
deformity brings the limb too near the middle line,
interferes with the normal position of the sound limb
in walking, and, by involving abduction of the sound
limb, interferes also with a free gait.

If the hip-joint is ankylosed in the fully extended
position, lordosis and the consequent trouble from back-
ache are avoided, and there is freer pelvic movement in
walking if the thigh is slightly abducted.

The limb should be very slightly rotated outwards, to
avoid the unsightly lift of the pelvis as the patient rises
on his toes when walking, due to the immobile condition

6 NOTES ON MILITARY ORTHOPEDICS

of the hip-joint. This gives an easier walk than if the
toes are pointed straight forward.

KNEE

Position. — This joint should be fixed in an extended
position.

Reasons. — Very good reasons may be given in favour
of slight flexion from the point of view of elegance in
repose and that of ease in mounting stairs. Due
weight should be given to these arguments, but in the

Figs. 9 and 10. — Ankylosis of hip. (9) Correct position, in slitht abduction

with extended thigh and slight outward rotation. (10) Faulty position of

ankylosis in flexion with adduction and internal rotation.

case of war injuries the straight position obviates many
risks. Ankylosis, as we know, is not necessarily bony ;
when it is fibrous the tendency is for the flexion angle
to increase by exercise. The incidence of the body
weight on a slightly bent knee, unless the ankylosis is
sound and bony, will increase the flexion. The position,
therefore, is mechanically a weak one for carrying body
weight. Even when new bone is forming, its complete
consolidation is sometimes a slow process, and if the
surgeon places such a knee in a slightly flexed position

POSITIONS FOR ANKYLOSIS

the degree of ultimate flexion is often much greater than
he would wish. The advantage of increased strength
and stability ensured by an extended joint will generally
outweigh all other considerations.

ANKLE

Position. — The foot should be kept at a
right angle with the leg, so that the sole
impinges on the ground in a slightly varus
rather than a valgus position (Fig. n).

'Reasons. — If the reader will recall -the
ankylosed ankles he has seen, he will re-
member that most of them were in a val-
goid position. A varoid position conduces
to a strong type of foot ; a valgoid (flat-
foot) to a weak foot, and all the disability
associated with erroneous deflection of
body weight.

\^J«7"

JOINTS OF THE TARSUS AND METATARSUS „. ,, . .

Fig. 11. — Anky-

In gunshot wounds and other injuries '^ °ffoo?nkat
of the tarsus and metatarsus, the deformi- right ansie and
ties to be feared correspond to the common ^rurpol'iti!^
static deformity of flat or pronated foot
— a subject which is dealt with at greater length in
Chap. III. — that is to say, to pronation at the mid-
tarsal joint, flattening of the longitudinal arch, and some-

Fig. 12.— Boot with bar
behind head to relieve in-
jured metatarsal joints and
phalanges from pressure.

Fig. 13. — A and », boot with straight heel

elongated and raised i in. on inner border,

with small patch to thicken inner side of

sole.

times flattening of the transverse arch associated with
pain in the metatarso-phalangeal joints. Callus exuda-
tion added to plantar malposition results in a very
crippled foot. In all gunshot injuries of tarsus and

8 NOTES. ON MILITARY ORTHOPEDICS

metatarsus the surgeon should take care during the later
stages of healing not to bandage the sole rigidly against a
flat foot-piece, for if that be done every irregularity of
bone will conduce to callosity when walking is resumed.
It is necessary, therefore, at this stage to adjust a splint
having an inside arch padded to conform to the natural
shape of the foot. Eversion of the foot should be
guarded against, and the hollow of the arch should,
when possible, be emphasized. Later, the heel of the
boot should be raised on the inner side to obviate
eversion, and, if the metatarsals are involved, in order
to allow of early walking a bar should be placed across
the sole of the boot behind the tread (Figs. 12, 13).
Light duty can then be undertaken at a much earlier
date.

FLAIL-JOINTS

In answer to the question " What should be done with
flail-joints ? " I would say, " Secure by operation an
ankylosis in the most useful position." The only
exception is in the case of the hip- joint, where by means
of simple mechanism a very useful limb may be obtained
in spite of the joint being flail.

CHAPTER II

SUTURE OF NERVES, AND ALTERNATIVE
METHODS OF TREATMENT BY TRANS-
PLANTATION OF TENDON

THERE are few problems more urgently needing solution
at the present time than those involved in the treatment
of limbs disabled by injuries involving nerves. The
conditions vary and are often very complex. The nerve
may be irretrievably injured beyond all hope of suture ;
it may be entangled in cicatricial tissue ; one or more
of the muscles it supplies may have suffered grave
lesions, varying from partial to complete destruction ;
the tendons or muscles themselves may be bound down
by adhesions, or. the joint or joints the muscles govern
may be stiff, ankylosed, or held in a deformed position
by a skin cicatrix ; or more than one of these hamper-
ing conditions may be present. The simple condition,
where the nerve or some of its fibres receive a clean
severance, is exceptional.

If once these facts are realized it will require no
argument to establish the proposition that certain
orthopaedic problems must be mastered in connection
with the suture of nerves if proper restoration of
motor function and of the normal efferent and afferent
connection between muscle and the central nervous
system is to be secured. In certain fortunate cases the
conductivity of the nerve is restored and good muscular
function may result. In other instances, although the
conductivity is restored, the function of the muscles
and joint may not be regained because certain funda-
mental principles have been neglected. There are other
cases in which the conducting power of the nerve is not
properly restored, and yet others in which, owing to
extensive destruction of the nerve, any attempt at suture
would be futile. We must, therefore, be prepared with
alternative methods in order to secure for the patient
a satisfactory limb.

LATE SUTURE OF NERVES

With regard, however, in the first place, to late suture
of the nerve, certain general principles must be borne in
mind. These are :

9

io NOTES ON MILITARY ORTHOPEDICS

1. The correction of contractures of skin or
muscle and all the anatomical constituents, from
skin to bone, on the concave aspect — that is to say,
on the side of the abnormal direction the contrac-
ture takes.

2. When possible the freeing of joints from all
adhesions and the restoration of the mobility of the
joint in all cases where ankylosis is threatened.

3. The maintenance of the paralysed muscles in
a position of relaxation throughout the period of
recovery.

4. The practice of massage during the recovery,
but without once allowing the relaxed muscles to
be stretched.

f In short, the principles and their~application coincide
with those I have so often emphasized in the treatment of
poliomyelitis.1

1. Freeing the Muscles. — If the muscles are not
freed from all mechanical obstructions to their action,
they cannot respond to stimuli sent to them through
the nerve, and therefore cannot in their turn send the
answering afferent impulse which is necessary to bring
the apparatus into proper working order. It is essential
to dwell on this point, inasmuch as many operations are
being performed while the muscles and joints are stiff.
This stiffness is not due to the nerve injury, but to the
consequences of trauma and sepsis affecting the muscles,
tendons, blood-vessels, nerves, and ligaments about the
joint. When we realize how anaemic an unused muscle
becomes, we shall not delay in giving help to prepare it
for the reception of nerve impulses.

2. Mobility of Joint. — Where the joint is threatened
with ankylosis, every effort should be made to restore
its function. Operation on the nerves is doomed to
failure if these fundamental principles be disregarded.

3. Relaxation of Muscles. — The importance of keep-
ing the partially paralysed and overstretched muscles
in relaxation during treatment has been so forcibly
brought home in ordinary civil practice in the treat-
ment of residual paralyses after poliomyelitis, lead
palsy, injuries of the brachial plexus and of isolated
nerves, that it should be scarcely necessary for me again
to call attention to it. Nevertheless, visits to wards
prove that this elementary orthopaedic measure is too
frequently entirely omitted by surgeons who have per-
formed suture of injured nerves. Thus we find men
who have had the musculo-spiral sutured allowed to

1 The Annual Oration, Medical Society, May 18th, 1914, on " Infantile
Paralysis : its Early Treatment and the Surgical Means for the Alleviation
of Deformities."

LATE SUTURE OF NERVES n

walk about with the hand dangling in palmar flexion
instead of its being kept continuously in dorsillexion !
By letting the hand hang in palmar flexion the muscles
supplied by the sutured musculo-spiral, which can only
recover if kept relaxed, are allowed to become stretched.
The result is that the fingers and hand do not regain,
can hardly be expected to regain, full normal function.
A similar grave error is often perpetrated in the case
of the external popliteal nerve, with the same dis-
appointing result in the foot. Frequently I have
noticed that the foot of a patient whose popliteal nerve
has been sutured is allowed to remain in an equinus
position ! Sometimes, indeed, the operation is even
performed while the tendo Achillis is contracted. Were
it not so frequently happening I should feel ashamed to
refer to this matter, but as it is happening I again urge
surgeons who suture nerves to insist that the affected
muscles be kept in complete relaxation until power re-
turns. The most skilful operation performed on the
most suitable case will prove a fiasco unless the affected
muscles are continuously kept relaxed until recovery
takes place.

Not only will it be found in some cases that no pro-
vision is made for the muscle to be in the most favourable
condition to respond to the earliest motor impulses
which come through the block in the nerve, but, further,
the mechanical condition of the muscle as to function
seems to be entirely neglected, and suture of the nerve
is performed when the paralysed muscle or the joint on
which it acts is immobilized by cicatricial adhesions,
If restoration of function is to follow nerve suture, the
new axis cylinders growing through a cicatrix must, of
course, be enabled to establish some sort of normal
relation as to function with the end organs in muscle.
If the muscle is mechanically disabled from making any
response, it is absurd to hope for good functional result,
even though the physiological processes of repair of the
nerve be perfect. I desire to emphasize again the funda-
mental principle of procedure — namely, that the restora-
tion of the mobility of joint and muscle must precede
the operation of nerve suture. It is useless to attempt
it otherwise.

4. Voluntary Use and Massage. — For precisely simi-
lar reasons, it is important that the patient should, as
soon as possible, exercise the limb in normal move-
ments. In the case of the lower limb this usually
means the application of some apparatus designed to
prevent strain on the recovering muscles while the
patient is permitted a moderately free physiological use
of his limb. In order to make the foregoing observa-
tions more lucid to those who have not followed my

12 NOTES ON MILITARY ORTHOPEDICS

writings, which are based on the late Mr. H. O. Thomas's
theory of " muscle lengthening," I will briefly indicate
their tenor.

It is well, in view of the enormous number of injuries
to nerves occurring in this war, to emphasize the fact
that principles applicable in poliomyelitis are applicable
here. When speaking, some years ago, of the results
of acute poliomyelitis, I pointed out that, though the
disease might permanently destroy motor cells in the

Fig. 14. — Showing action of dorsiflexing after transplantation of
tendons. Captain Mc.Vl array's case.

anterior horns of the grey matter, so rendering for
ever useless the muscles dependent upon them, unless
nerve transplantation might at some later date come to
their rescue, yet complete destruction was fortunately
the rarer condition. The clinical evidence afforded by
rapid and complete recoveries from complete paralysis
and the very many partial recoveries proved that the
motor cells concerned had suffered from temporary injury
and had not been destroyed. Something had happened
to make the muscle incapable of responding to motor
stimulus. Whether this was to be attributed to the

LATE SUTURE OF NERVES 13

absence of afferent muscle-sense stimulus, as seemed
probable, or whether it was due to some other cause, it
was clinically certain that the nerve cells became par-
tially inactive, not extinct, and that with appropriate
treatment of the muscle or group of muscles functional
activity could be reinstated. When a muscle governed
by a live cell, or rather a group of live cells, fails to act,
the disability may be spoken of as functional. Of this
disability the great outstanding cause is overstretching
of muscle fibres. A surgeon must recognize the difference
between a truly paralysed muscle and a muscle which
is overstretched, and must know how to distinguish the
one condition from the other.

The first essential of treatment is that the muscle or
muscular groups must be prevented from being over-
stretched. If the wrist is, for instance, allowed to
remain flexed, the flexor muscles undergo adaptive

Fig. 15 illustrates a similar result in another of Captain McMtirray's
cases.

shortening, and the extensors become overstretched and
consequently placed at a mechanical disadvantage.
This point is well illustrated by dropped wrist from lead
poisoning. The lesion here may be either in the cord or
in the nerve trunks ; in either case the muscles cease to
be controlled by their nerve centres, and the patient goes
about with his wrist flexed by gravity, and the extensor
muscles become disabled by continuous overstretching.
As the condition is usually bilateral, an interesting
experiment to test my contention may be made, if the
case be of some weeks' standing, by placing one of the
paralysed wrists on a splint to keep the hand dorsi-
flexed. It will be found that recovery will be much more
rapid on the side on which the extensors are relieved
from overstretching than on the other, neglected side.
When a muscle is deprived of the natural motor stimuli,
its condition from the point of view of function and
nutrition is the same whether the absence of stimuli be
due to inactivity of the central nerve cells or to interrup-
tion of the conducting paths along the peripheral nerves.

M NOTES ON MILITARY ORTHOPAEDICS

Its motor function is suspended, its nutrition suffers, it
becomes anaemic, and it may easily be overstretched by
gravity, by the unrestrained action of the opposing
muscle, or by these two forces acting in combination.
If the wrist and fingers are kept in extreme dorsiflexion,
the extensor muscles, thus relieved of strain, undergo
adaptive shortening, and soon begin to respond to the
constant stream of tonic stimuli sent to them by efferent
impulses ; later they come under the higher control of
the voluntary centres.

Another cause of persistence of functional disability
is an unequal degree of recovery in opposing muscular
groups.

Deflection of Body Weight. — A most potent factor
for evil is what I have called the erroneous deflection
of body weight, which, for physical reasons, operates
chiefly in the lower limbs. If, for example, there
be weakness in the tibial group and the patient be
allowed to walk, the valgoid deformity will constantly
increase, the tibial muscles will be more and more
stretched, adaptive contraction will affect the peronei,
and structural alteration will ensue in the tarsal bone,
terminating in a troublesome flat-foot. All these un-
toward results may be avoided by simple treatment on
sound scientific principles ; a little alteration of the boot
which, by raising the inside of the heel of the boot,
will deviate pressure from the inner to the outer side
of the foot, may suffice. When we have to deal with
a group of muscles in which the power is only slightly
impaired, the muscular balance may be restored by
over-developing the weaker group. If, for instance,
the peronei are weak, but the foot can quite easily be
placed in the everted position, then massage and exer-
cises may reasonably be expected to succeed. But if
the foot cannot be everted because of adaptive shorten-
ing of the tibial tendons, then massage and exercise of
the peronei will be perfectly useless until such time as
the deformity has been corrected and the overstretched
muscles kept relaxed for a sufficient period to permit
them to recover by interstitial shortening.

LATE RECOVERY OF MUSCLE POWER

Before any operations are performed affecting the
mobility of a joint, every use should be made of available
muscle power. No surgeon should operate on these
cases until he has fully satisfied himself whether or no
it be possible to restore the apparently paralysed muscle.
Neglect of this precaution produces such a distressing
occurrence as the unexpected recovery of muscles which
were ignored because assumed to be paralysed. For

RECOVERY OF MUSCLE POWER 15

example, a patient was brought to me once with a par-
tially ankylosed knee. The operation of arthrodesis had
been performed with a view of bringing about bony
ankylosis. As an arthrodesis the operation had failed,
for the knee had a short range of movement. As an
experiment, illustrating the principle we are discussing,
it was very successful, because the quadriceps was act-
ing with considerable strength. Prolonged fixation had
relieved the quadriceps from all strain, and restoration
of function resulted. This case exemplifies 'the mistake
of taking for granted that a muscle is paralysed without
first making quite certain that it is really paralysed.
It is only possible to make quite certain by relaxing
the muscle, and thus putting it into the position most
favourable to recovery, for a sufficient length of time.
Electrical tests cannot be relied upon to give this infor-
mation.

Treatment to Promote this. — The first stage of
treatment is the correction of existing deformity. When
deformity has been corrected the limb should be kept
immovable until the ligaments, muscles, and even bone
have become of normal length and shape. The con-
tinuity of treatment must be maintained or a relapse will
result. This point is fundamental, and neglect to ob-
serve it spells failure, as the slightest stretching of a
muscle on the point of recovery disables it again. All
the good work may be thwarted by a single indiscretion.
I cannot emphasize this point too strongly. For instance,
let us take the case of a drop-wrist which has been placed
in a splint designed to dorsiflex the hand at the wrist.
The position must be constantly maintained. The hand
must not be allowed to flex for a single moment until
recovery has occurred. Even while the patient washes,
the hand must be held dorsiflexed.

The clinical test of the recoverability of a muscle,
therefore, depends on an experiment. Let it be kept for
a prolonged period — for at least six months — in a
position of relaxation. This test should always be made
before condemning any muscle, no matter how long the
period for which it may apparently have been paralysed.
When, therefore, one reads in textbooks statements to
the effect that we are to despair of the return of power
after a certain length of time, we can quite well afford to
ignore the advice unless in addition to this time test
there has been an uninterrupted muscular relaxation
during that time.

These are views which I have without ceasing urged
upon my professional brethren as applicable to infantile
paralysis. They are equally applicable, with certain
modifications, in the case of gunshot injuries. It is
obvious that in infantile paralysis long mechanical

i6 NOTES ON MILITARY ORTHOPEDICS

treatment can do no harm. This is not so in the case of
a soldier in whom a nerve has been injured. If suture is
to give any promise of success there must be a limit to
conservative methods, and in any case an exploration
of the nerve is a harmless procedure.

TENDON TRANSPLANTATION IN GUNSHOT INJURIES
OF NERVES

In recommending tendon transplantation in gunshot
injuries, I have profited by the experience gained in
anterior poliomyelitis. I have frequently performed
tendon transplantation with success in the adult in
cases in which isolated nerves have been destroyed.

Fig. 16 A.— Showing the ten-
don which is to be trans-
planted about to be passed
through a tunnel in the acting
tendon. The tunnel is being
dilated to receive the trans-
planted tendon.

Fig. 16 B.— Trans-
plant in position.
'I he angulation is
dealt with as shown
in Fig. 16 c.

Fig. 16 c.— In order to
overcome angulation a
slit is made in the upper
part of .the receiving
tendon, which is then
wrapped r o u nd the
transplanted tendon.

Similarly, unrecorded cases have been operated upon by
my friends Mr. Thelwall Thomas and Mr. Bickersteth.
At the Military Orthopaedic Hospital, Liverpool, my
colleague, Captain McMurray, has at the moment of
writing three successful cases in which transplantation
has been done for musculo-spiral paralysis. As previously
indicated, the object of a transplantation is to improve
or restore muscular balance. It is not justified unless
it improves function. There is little satisfaction to a
patient if the transplanted muscle merely responds to
faradism, or even makes a feeble movement by the effort
of the will. It must be, or give the promise of becoming,
a substitute for the muscle it supplants, and it can only
be judged by its ultimate usefulness.

TENDON TRANSPLANTATION

A tendon may be transplanted in order to restore the
balance between opposing groups of muscles by helping
a redistribution of power, or its attachment may be
slightly altered to prevent deformity.

Recognizing that the principles involved in tendon

Fig. 17 A. — Tendons about to

be* pulled through another

before suturing.

Fig. 17 B.— The divided

ends of three tendons

passed through another

tendon in its course.

Fig. 18 A. -Showing transplanted

tendon about to be passed along

a tunnel in the receiving (active)

tendon.

Fig. 18 B.— Tendon passed along
course of active tendon.

transplantation are the same in both conditions, I will
now briefly describe certain transplantation operations
I recommend for various injuries.

As a preliminary I give here a series of diagrams,
Figs. 16, 17, 18, 19, and 20, illustrating methods of

C

i8 NOTES ON MILITARY ORTHOPEDICS

transplantation of tendon into tendon, applicable under
various anatomical conditions.

In the first part of this chapter I considered some
general principles which should guide the surgeon in
the treatment of limbs disabled by injuries involving
nerves. I pointed out the importance of giving the
muscles ample time and opportunity to recover by
keeping them in a relaxed position for a sufficiently
long period, and I began the discussion of tendon trans-
plantation as an alternative method of treatment
where nerve suture was not possible. I now propose to

Fig. 19. — Three tendons passed
through another tendon, which
has been split to receive them.

fit. 20. — Tendons inserted

into either side of active

tendon.

consider the transplantation operations my experience
leads me to recommend in various injuries.

UPPER LIMB
Irreparable Injury oj Musculo-spiral Nerve

i. In cases of musculo-spiral injury the deformity is a
dropped wrist, with loss of the power of extending the
fingers. The uncontrolled action of the flexor group
causes the fingers to curl into the palm, and the hand to
become useless.

In such a case :

(a) The flexor carpi radialis and the flexor carpi
ulnaris can be transplanted into the paralysed
extensor of thumb and fingers ; and

(6) in addition the pronator radii teres may be
affixed to the two radial extensors.

Transplantation of Pronator Radii Teres and the
Radial and Ulnar Flexors in Musculo-spiral Paralysis.

— I would recommend for this condition of musculo-

TENDON TRANSPLANTATION 19

spiral paralysis the double operation (a) and (6), and I
will briefly indicate the method of its performance.

With the forearm midway between pronation and
supination, an incision is made along the radial border
of the forearm in its middle third. Under cover of the
tendon of the supinator longus the pronator radii teres
will be found where it becomes inserted into the outer
border of the radius. From this it is detached, and is
then inserted into the tendons of the extensor carpi
radialis longus and brevis, which lie closely applied to it
on the dorsal surface.

i A horseshoe incision, with the convexity resting on
the back of the carpus, with the two straight sides ex-
tending along the radial and ulnar borders, is now made.
Through the lateral aspects of this incision the tendons
of the carpi ulnaris and radialis are identified, and are
detached from their insertion as near the carpus as
possible.

The tendons are brought round the ulna and radius
respectively in very slanting fashion, and are then
attached to the extensors of the fingers and thumb, the
carpi ulnaris being attached to the tendons of the three
inner fingers and the flexor carpi radialis to those of the
thumb and index finger. The method of fixation should
be neat and workmanlike.

Injury to Median and Ulnar Nerves

In the case of great damage to the median and ulnar
nerves, operations on tendons alternative to those on the
nerves will be very rarely required as compared with
those on the external popliteal and the musculo-spiral,
for the reason that by means of flexion of the elbow a
gap of two or three inches in the median may be closed
up ; by flexing the elbow and displacing the ulnar to the
front a similar space in this nerve can be obliterated.
End-to-end suture, therefore, is much more easily secured
in these two nerves than in the case of the musculo-
spiral and external popliteal.

In cases of complete and irreparable paralysis of the
muscles supplied by the median nerve the only active
muscles on the flexor aspect of the forearm are the flexor
carpi ulnaris and the inner half of the flexor profundus
digitorum.

Transplantation of Tendons in Median Paralysis. —
(a) The outer tendons of the flexor profundus are in-
serted into the inner tendons of the same muscle.

(6) The tendons of the flexor sublimis are inserted
into the tendon of the flexor carpi ulnaris. The ex-
tensor carpi radialis longior is attached to the flexor
longus pollicis.

20 NOTES ON MILITARY ORTHOPEDICS

Method. — A curved incision is made convex down-
wards with the apex just above the anterior annular
ligament of the wrist. After retracting the flexor
sublimis tendons, the outer two tendons of the flexor
profundus are inserted into the two active inner tendons
of the same muscle. The flexor ulnaris is then divided
close to its insertion, and between the two portions of
its split end the tendons of the flexor sublimis to the
four fingers are inserted. The tendon of the extensor
carpi radialis longior is now found at the outer border
of the incision, and after division is inserted into the
tendon of the flexor longus pollicis round the outer
border of the radius.

Fig. 21. — Tendon of peroneus

longus divided in its course,

and identified at the outer

border of the foot.

Fig. 22 — Tendon of peronens

longus drawn out through the

lower incision.

Transplantation in Complete Paralysis of the Ulnar
Nerve. — The twp inner tendons of the flexor profundus
are attached to the two outer.

The palmaris longus is inserted into the tendon of the
flexor carpi ulnaris.

After-treatment. — After operations for musculo-spiral
paralyses the hand should be kept dorsiflexed until
recovery of the mus.de is complete. When the grafted
muscles' are acting sufficiently well and strongly to lift
the hand and fingers, the time will have come for gra-
dual training in co-ordination and balanced movement.
Even after the patient has learnt to use his hand, it is
still necessary that he should continue to wear a dorsi-
flexion splint at night to prevent contractures of the
flexors during sleep.

LOWER LIMB
Paralysis of Anterior Crural Nerve

Transplant the sartorius and biceps into the patella.
An alternative measure would be the application

TENDON TRANSPLANTATION 21

of a knee cage with an extension spring to take the
place of the paralysed quadriceps. This should be worn
permanently.

Fig. 23.— Tendon of per-
oneus longus about to be
drawn through the incision
opposite the annular liga-
ment under which it has to
pass.

Fig. 24.— Tendon of per-
oneus longus about to be
drawn under the annular
ligament to be inserted
!in the tibia.

Fig. 25. — Tendon of tibialis anticus being drawn taut, the foot being kept at

right angles ; tendon is then cut and passed through a tunnel in the tibia. The

tendon of the peroneus longus is shown drawn up through the same opening.

22 NOTES ON MILITARY ORTHOPEDICS

Paralysis of Muscles supplied by External Popliteal

Nerve

The anterior group of muscles and the peronei are
paralysed. The deformity is a dropped foot with
varus due to gravity and the uncontrolled action of
the muscles attached to the tendo Achillas and of the
tibialis posticus.

Tendon Transplantation. — There is not much scope
for effective tendon transplantation in this injury, ex-

Fig. 26. — Tendon of peroneus longus about to be drawn through the hole
drilled in the tibia.

cept in cases in which only particular branches of the
nerve have been picked out. For instance, an injury
paralysing the two peronei muscles, but leaving the
anterior tibial nerve intact, would result in a deformity
consisting chiefly of inversion of the foot at the mid-
tarsal joint — that is, pes varus. In such cases, trans-
plantation of the insertion of the tibialis anticus into
the dorsum of the cuboid or into the base of the fifth
metatarsal replaces the loss of the evertors and re-
stores the balance of the foot.

Tendon Fixation. — In cases of more extensive para-
lysis there is not sufficient muscle power remaining for
it to be effectually distributed ; there is, so to say,

TENDON TRANSPLANTATION 23

not enough power to go round. Tendon fixation is then
the best operative procedure, for it establishes a firm
barrier against drop-foot, and yet allows useful mobility.
Tilanus of Holland suggested tendon fixation for certain
types of flail-foot many years ago, and I am hoping
that it will prove increasingly useful in military surgery.
The object of tendon fixation is to utilize the tendons
of completely paralysed muscles as accessory ligaments
to hold a paralysed foot in .a correct position. This can
be brought about in an endless variety of ways, and will

Fig. 27. — Tendon of peroneus
longus drawn through the tibia.

Fig. 28. — Tendon of peroneus

longus about to be stitched to

the periosteum of the tibia.

supply the ingenious surgeon with many interesting and
useful problems for reflection. Personally, after many
successful operations, I would recommend this method
of treatment to meet the disabilities of paralysis due to
injury of the external popliteal.

Tendon Fixation in Drop-foot due to Injury of the
External Popliteal Nerve. — Two small incisions are
made along the course of the peroneus longus tendon.
The first is placed over the tendon, just before it turns
round the outer border of the foot on to the sole, and the
other about three to four inches above the tip of the
external malleolus (Fig. 21).

24 NOTES ON MILITARY ORTHOPEDICS

The tendon is now divided through this upper incision,
and the lower freed portion is then pulled out of its sheath
through the lower opening while its normal attachment
to the sole remains undisturbed (Fig. 22).

An incision two to three inches above the tip of the
external malleolus is made just externally to the anterior
border of the tibia, and the divided lower portion of the
peroneus longus tendon is passed up from the lower
incision to this new one. In its new course the tendon
should pass under the anterior annular ligament (Figs.

j y

Fig. 29.^Tendons of peroneus
longus and tibialis anticus in-
serted into a groove made on the

Fig. 30. — Lower divided portions
of the tendons of the peroneus
longus and tibialis anticus inserted
into the tibia. The upper end of
the tendon of the tibialis anticus
sutured to the lower end below its
insertion in the bone.

23 and 24), but if this cannot be done it may be passed
in the deep fascial layer (Fig. 32).

The periosteum is now raised from the anterior aspect
of the tibia and a deep groove is made in the bone ; the
tightly pulled tendon, whose outer surface has previously
been roughened, is then laid in the groove and is retained
in it by a small nail or it is fixed by strong catgut into
fascia. The periosteum is then replaced over it (Figs.
29 and 30).

Another effective method of fixing the tendon is to

TENDON TRANSPLANTATION

bore a hole through the anterior border of the tibia and
pull the tendon through (Figs. 26, 27, 28). The free end
can then be stitched to periosteum on the inner side of
the tibia, or in some cases it may be more convenient to
turn the tendon over the crest of the tibia and stitch it
to the tendon before it enters the tunnel. Through this
same incision the tendon of the tibialis anticus (Fig. 25)
is divided and the upper end of the lower portion in-
serted beneath the periosteum in front of the tibia, in
a manner similar to that first de-
scribed, by nailing, or through a
hole bored in the substance of the
bone, after the second method.

When this has been done, the cut
end of the upper part of the tibialis
anticus tendon is inserted into the
lower part of the tendon distal to
its insertion into the tibia (Fig. 30).

The peroneus brevis tendon may
then be shortened and inserted into
a gutter along the anterior surface
of the external malleolus, by another
short nail.

Another simple device consists in
fixing the boot at right angles by
means of a leather tongue which is
fixed to the toe-cap, and a leather
strap round the upper part of the
boot just above the ankle (Figs. 33 B
and 33 c).

Injury to Sciatic Trunk

If the whole sciatic nerve has
been divided high up in the thigh
there is total loss of power below
the knee and in certain muscles
governing the knee-joint. In such
cases the patient can walk quite
well in a jointed calliper splint with
a filling inside the boot to keep the
foot at right angles. Another use-
ful plan is to fit a jointed knee
cage (Figs. 96 and 97) with a spring
and a right-angled support for the ankle. This really
means that we make the paralysed distal part of the
leg into a species of artificial limb, and this, in actual
practice, has proved much better than any artificial
limb that I have ever met with.

The idea of rushing to amputation of a limb merely
because the sciatic nerve is destroyed, and therefore

Fig. 31. — Diagram to
show the anatomy of the
area concerned ; the
three parts of the annu-
lar ligament are shown,
the tendon of the tibialis
anticus is hooked in-
wards, the tendon of the
peroneus longus has been
passed under the annular
ligament and brought into
contact with the tibia.

*6 NOTES ON MILITARY ORTHOPEDICS

theoretically the nutrition of the foot must go wrong, is
too horrible to be contemplated. Actual experience has
proved that, in many cases, the errors of nutrition which
ought in theory to occur do not occur, or, at worst, are
not nearly so serious as might be expected.

CONCLUSION

Surgeons will glean from what has been written that
there are many ways in which the disabilities following
nerve destruction can be met, and that hardly any case

Fit!. 32. — Alternative operation. in which the tendon of the peroneus longus it

pulled through the subcutaneous tissue without tegard to the annular ligament.

A, First stage. B, Tendon of peroneus longus drawn upwards and inwards.

is bad enough to justify a counsel of despair. Our know-
ledge of what can be done in poliomyelitis will invite
us to take a cheerful outlook in traumatic paralyses.

My intention in this chapter has been not merely to
indicate ways in which the ground can be prepared for
the operations of nerve suturing, or to point out the
value of keeping a paralysed muscle relaxed by opposing
the force of gravitation, but to indicate the great and
ever-increasing field of usefulness that is opened up by
utilizing tendon, whether that of an active or a hopelessly
paralysed muscle, for the restoration of movement or
the correction of deformity, thereby restoring to a greater
or less extent the economic efficiency of an individual
who would otherwise sink into the position of a non-pro-
ductive and dependent member of the community.

CHAPTER III

THE SOLDIER'S FOOT, AND THE TREAT-
MENT OF COMMON DEFORMITIES OF
THE FOOT

THE foot must be regarded for our present purpose as
consisting of two parts : the hinder part, behind the
mid-tarsal joint, formed by the os calcis and astragalus ;
and the fore part, in front of that joint, consisting of the
rest of the tarsus, the metatarsus, and the toes.

The Three Arches of the Foot.— The hinder part
of the foot is designed to carry the body weight when
standing. The os calcis and astragalus are strongly
bound together by ligaments, and the astragalus is
securely set between the two malleoli at the ankle-joint.

The fore part of the foot is much more mobile, and is
designed to give spring to the foot when walking. This
spring depends on the efficiency of the small muscles of
'the foot, on the integrity of the longitudinal and trans-
verse arches, and on the freedom of movement of the
toes themselves.

Regarded as a base of support, the foot is a tripod
resting on the heel, the head of the first metatarsal bone,
and the heads of the fourth and fifth metatarsal bones.
Each side of the triangle formed by these three points is
arched. The outer side, formed by the os calcis, cuboid,
and the fourth and fifth metatarsal bones, is so slightly
arched that practically the whole length of it rests on
the ground when standing. This element of the foot is
therefore not very susceptible of strain, and need con-
cern us no more.

The inner side is strongly arched ; the arch runs
from the heel upwards and forwards to the neck of
the astragalus, then downwards, forwards, and inwards
through the scaphoid, internal cuneiform, and first
metatarsal bones, to the ball of the great toe. This
arch, which varies in height in different individuals, is
composed of a number of bones, is very susceptible to
strain, and is in consequence the seat of a number of
disabilities which we shall group together as " flat-foot."

The third side of the triangle runs from the head of the
27

28 NOTES ON MILITARY ORTHOPEDICS

first metatarsal bone to the heads of the fourth and fifth
metatarsal bones, and forms the front part of the trans-
verse arch of the foot. It must be remembered that this
transverse arch extends backwards throughout the whole
of the fore part of the foot. The cuneiform bones and
cuboid bones are arranged in a transverse arch as well as
the metatarsal bones.

Deformities and Disabilities of the Foot. — In con-
sidering deformities and disabilities of the foot, due
value must be given to its various mechanical elements
— that is to say, not only to its bony structure but also
to the muscles and ligaments -which help to maintain
its shape.

Looked at in this way, we find among the deformities
and disabilities of the toes such conditions as hallux
rigidus, hallux valgus, and hammer-toe, and we note that
the two former in particular are frequently associated
with some degree of flat-foot.

Impairment of the transverse arch is specially apt to
be associated with the painful condition known as
metatarsalgia.

Impairments of the longitudinal arch are associated
with a train of symptoms which are found in the various
degrees of weak foot, everted foot, and flat-foot.

All these types of derangement of the mechanical
elements of the foot and the resulting disabilities depend
on strains about the complicated series of joints in the
fore part of the foot.

In the hind part of the foot the disabilities are fewer.
They are mainly connected with painful conditions of
t.ie heel, due to such conditions as strain of the insertion
of the tendo Achillis, or periostitis of the os calcis, due
to trauma or sepsis.

When a clear idea of these several disabilities and of
the measures suitable for the prevention and treatment of
each has been obtained, it will be more easy to grasp
and understand the various disabilities of the foot to
which the soldier is liable, always remembering that
two or more types often occur simultaneously, and that
all must be appropriately treated.

FLAT-FOOT

f The term flat-foot may be taken as a generic term to
include all degrees of strain of the longitudinal arch of
the foot. To these various conditions different names
have been given, which need not detain us here. The
point to be understood is that all degrees occur, from
slight strain of the ligaments and tendons by which the
arch is maintained, to complete descent of the arch with
osseous deformity, obvious to the most casual observer.

FLAT-FOOT 29

The essential fact in the deformity is abduction and
eversion of the fore part of the foot (Fig. 33 A). If it
commences as a sudden acute condition, it is associated
with strain of the inferior calcaneo-scaphoid ligament ;
to this is due the tenderness elicited on pressure on this
ligament just below the tubercle of the scaphoid. This
tenderness is characteristic. Pain in this situation is
often most acute in patients who have naturally a very
high arch. When such an arch begins to give way the
strain on the " spring " ligament is great and the pain
correspondingly severe, but the foot is not physically
flat, for the arch may still be higher than is normal in
most people.

As the foot becomes more strained under continued
exercise, the bones of the tarsus begin to descend and
pain is complained of across the dorsum of the foot.

Fig. 33 A.— Flatleverted foot.

Finally, when the deformity becomes still greater,
there may be pain on the outer side of the os calcis
below the tip of the external malleolus. This is probably
to be attributed to bruising of the periosteum due to the
os calcis impinging on the malleolus ; in some cases an
adventitious bursa is ultimately produced in this situa-
tion.

ACUTE FLAT-FOOT

All the above symptoms, and also actual descent of the
arch with pronounced abduction and eversion of the
foot at the mid-tarsal joint, may come on with great
rapidity, and then be associated with very severe pain,
so that the patient cannot walk, and can hardly bear to
have the foot touched. Such a condition may fairly be
described as acute flat-foot. It occurs in its typical
form in people who are in poor physical condition, as, for
instance, after an attack of influenza, and return too
soon to work which involves much standing and lifting
of weights — for example, hospital nurses. It occurs in
exactly the same way in the recruit. Take, for example,
the clerk who has taken little exercise and who has been

30 NOTES ON MILITARY ORTHOPEDICS

in the habit of wearing boots in which there is no room
for movement of the toes and bones of the fore part of
the foot : all the muscles and ligaments controlling
and supporting the arches of the foot are weak and out
of condition from want of use ; under the strain of hard
drill they give way.

Treatment of Acute Flat-foot — The treatment of
such a case falls into three stages.

First Stage. — If the foot is acutely painful the patient

Fig. 33 B. — 1. Bootlace to pass down — over " drop-foot tongue," through

eyelet holes therein, and then back into higher boot eyelet holes. 2. For

boot without toe-cap, the drop-foot tongue must go to tip of toe.

should be put to bed and the feet gently massaged for
two or three days till the acute tenderness passes off.
During this time he must never be allowed to set foot to
the ground, for the weight of the body would again
strain the ligaments.

Second Stage. — As soon as the acute tenderness has
passed off, the foot should be abducted and inverted
so as completely to restore the arch, and kept con-
tinuously in this position to allow stretched ligaments
to shorten and become adapted to the correct position.
Mere rest in bed is not enough, for then nothing is done
to restore the proper shape of the arches, adaptation

ACUTE FLAT-FOOT 31

takes place in the flat-foot position, and the patient is
left with a real flat-foot. It is often best to mould the
foot into correct position and fix it in plaster-of- Paris
for about ten days to allow the strained ligaments to
recover completely.

Third Stage. — When the plaster is removed, after, say,
ten days, the patient's foot is exercised — first of all by
massage and exercise, particularly movements of the toes
and inversion movements, never eversion movements.
These inversion movements are intended to strengthen
the muscles controlling the arch.

Boots. — The patient is allowed up in specially altered
boots. The boots should grip comfortably round the ankle

Fig. 33 c. — Side view of boot with drop- foot tongue attached.

and heel, but the whole fore part of the boot should be
roomy to allow free play of the small muscles of the foot.

Pointed toes are very harmful, as they abduct the
fore part of the foot and help to produce the condition
of flat-foot. The inner side of the boot should be straight,
so that when the two boots are placed side by side the
inner sides are parallel right forward to the great toe.
This is not the conventional boot of the shoemaker, but
it is the correct boot for a strong foot.

The present Army boot is not perfect, but it is much
better than it was some years ago.

Boots of suitable shape having seen secured, they
should be sent to the shoemaker to have the heels
" crooked " on the inner side. By this is meant that
the heel of the boot is made J in. higher on the inner
side, and tapering gradually to its outer side, so that

32 NOTES ON MILITARY ORTHOPEDICS

the inner side of the heel is J in. higher than the outer
side. In addition, the length of the heel should be
extended forwards by J in. on the inner side, and the
sole should be raised J in. by a patch on the inner side
of the sole just below the toe-joint (Fig. 133).

The patient must never put foot to the ground without
an altered boot or shoe on, otherwise he will unwittingly-
let his arch descend and so inflict a fresh strain on the
ligaments.

The man should then be instructed to walk with feet
parallel, not with the toes turned out. The altered heel
helps him to keep his toes turned in. Exercises should
be graduated till he is fit for full duty.

A bad case of acute flat-foot should be fit for light duty
in three weeks, and for full duty with the heels of his
boots raised on the inner side in six weeks to two months.

It is really a question whether the Army authorities
ought not to issue all boots with heels raised on the
inner side, as this is a great relief to the foot on a long
march and increases the man's weight-carrying and
lasting power.

Certainly all recruits with weak feet should be started
off with crooked heels on the boots until the muscles of
their feet get into training. They should also be taught
to walk with their feet parallel. If this were done the
feet would grow stronger rather than weaker, and con-
siderably fewer men would require to be taken off duty.

TRAUMATIC FLAT-FOOT

Flat-foot in every respect similar to that just described
as acute flat-foot may arise from injury — for example,
when the wheel of a trap runs over a man's foot and
strains all the ligaments.

FLAT-FOOT FROM PERIARTHRITIS

Similar mechanical conditions arise in gonorrhceal
periarthritis when all the ligaments are sodden with
exudate, become soft, and stretch. The same is true
when the infection is of an ordinary septic character, for
if the man puts weight on his foot before the arch is
restored to its strength he will get a flat foot. He can,
however, walk with safety in a boot with the heel well
crooked almost as soon as the disappearance of pain
allows him to put his foot to the ground.

RIGID FLAT-FOOT

These cases lead us naturally to the rigid form of flat-
foot which results from neglect in the acuter stages,
whether the cause of the sudden yielding of the ligaments

RIGID FLAT-FOOT

33

be overstrain due to unaccustomed exertion in walking,
to injury, or to weakening of the ligaments by the pro-
ducts of infective agents.

The foot, therefore, should be maintained in the
inverted and adducted position during recovery from
the acuter conditions, and when the patient begins to

FU. 34 A.— Flat-foot, first stage : Thomas's wrench applied to invert.

Fig. 34 B. — Flat-foot, second stage : Thomas's 'wrench applied to adduct foot
at midtarsa! joints.

walk the body weight should be deviated from the
inner to the outer side (Fig. 136). If this important
routine should be neglected the recovery of ligaments
will occur in a flat-footed position with stiffness in all
the joints. The patient in that case cannot stand on the
outer edge of the foot or turn it into an arched shape.

Treatment is very simple, but must be thorough.

The foot should be wrenched so as to break down all

adhesions and make it thoroughly pliable (Figs. 34 A,

34 B). The foot is by this means converted into an acute

D

34 NOTES ON MILITARY ORTHOPEDICS

traumatic flat-foot, and it must undergo the course of
treatment described elsewhere for that condition. It
should be moulded into the correct position, and plaster-
of-Paris applied. After two or three weeks of such rest,
to allow recovery from the trauma, graduated exercise
may be taken in boots so altered as to deviate body
weight from the inner to the outer side of tarsus. An
outside iron is often found a great assistance in main-
taining the correct position of the foot
V / during walking (Fig. 35).

OSSEOUS FLAT-FOOT

A real stiff flat-foot which has been
neglected for years becomes an " osseous
flat-foot " — that is to say, changes occur
in the shapes of the bones to adapt
them to the erroneous position. Though
something can be done to'improve such
cases, they cannot always be made fit
to be soldiers ; the surgeon must, how-
ever, be sure that he is dealing with real
osseous change and not merely with a
flat-foot which is rigid owing to liga-
mentous contractures and adhesions.

I

Fig. 35.— 9utside
iron in addition to
crooked long heel
and piece to sole.

FLAT-FOOT DUE TO SPASM OF THE
PERONEI

I described this condition (Fig. 36)
many years ago, and stated that it was
by no means uncommon. It may be
found in any out-patient department if
looked for, and I have operated upon
as many as 150 cases in one year. It
occurs usually after puberty and also in
early adolescence ; it is common among
the robust, not only among the weakly,
and is not associated with the temperament that is
known as neurotic. I will describe a typical case.
A young man of 18 limps with a springless gait into
the out-patient room. He walks with feet practically
rigid and with toes pointing out. They are both
everted, and the inner border over the region of the
scaphoid appears thickened and even angular. Both
the character of the walk and the appearance of the feet
might lead to the diagnosis that osseous changes were
advanced. On being questioned the patient may give
a history of injury such as a fall on the feet ; usually
he cannot account for the origin of his trouble. The
pain is often acute, the feet may perspire abnormally,

FLAT-FOOT

35

and the patient may not be able to walk more than a
short distance. Relief is experienced on removal of
his boots ; if he is asked to invert his foot he cannot
do so, and when .he attempts it the peronei become
rigid. The surgeon when he examines the foot manually
finds there is pain on pressure over the deltoid ligament,
over the scaphoid, and over the tip of the external
malleolus where it impinges upon the os calcis, and
tenderness over the peronei along the outer border of
the foot. If the surgeon gently attempts to invert the
ankle much pain is experienced, and the peronei, so to
speak, immediately place themselves on guard and
strongly resist his efforts. Now, while he has firm hold
of the foot, let him engage the patient in conversation,
at the same time gently pressing in the direction of in-
version. Then at the psychological moment, while the

Fig. 36.— Peroneal
spasm producing a
flat everted foot.

Fig. 37. — Exposure of ten-
dons of peronei preparatory
to exsection of about J in.

peronei are quiescent, very suddenly and very forcibly
let the foot be inverted and held there. It is a very
painful movement, but the character and contour of
the foot are completely changed. It is no longer rigid,
osseous changes are obviously absent, and the general
appearance of the foot is almost normal. The moment
the surgeon releases his hold, the old rigidity and de-
formity return.

For this condition mechanical measures are of no avail.
The patient must be anaesthetized to relax all spasm, and
about f in. of each peroneus should be removed about
i^ in. above the malleolus (Fig. 37). The foot must then
be fixed for about three weeks, well inverted and ad-
ducted at the mid-tarsal joint, and later the ordinary
treatment for flat-foot began. My old house-surgeon, Mr.
Naughten Dunn, secured equally good results by pinch-
ing with a pair of forceps the nerve as it enters to supply
the peronei. Simple tenotomy of the peronei is not
sufficiently drastic to prevent recurrence of deformity.

36 NOTES ON MILITARY ORTHOPEDICS

DIAGNOSIS

It is not an easy matter to lay down rules for a
hard and fast differential diagnosis between these
types of rigid feet, but the following considerations
will help.

An osseous flat-foot which has become adapted to its
new position is usually strong and painless.

A flat-foot rigid from adhesions and shortened liga-
ments is still susceptible to strain, and is liable to become
painful after unusual exercise.

The type due to a spasmodic contraction of the
peronei is characterized by pain, and the spasm may be
overcome in the manner I have just indicated.

In the two last varieties, after the deformity has been
over-corrected for a time, energetic massage and a
correct deviation of body weight are essential elements
in bringing about a cure. The osseous type, once the
bones have completely dropped, may not only be painless
but may be strong enough to bear the strain of long
marches. Wounded soldiers may constantly be met
with whose feet are very flat, whose mid-tarsal joints are
fixed, but who have undergone several months of hard
training without a complaint. If in addition to these
osseous changes the power of inversion of the foot is
lost or the peronei are in spasm, surgical attention is
urgently called for.

The flat-foot, for clinical purposes, may be divided
into two classes :

(a) The foot which the patient can invert.

(b) The foot which he cannot invert.

The second class will not respond to any mechanical
treatment, such as a plate or alteration of the boot. It
will not even suffer correction by means of a bandage to
an outside iron from knee to heel. An operation, or
forcible manipulation and fixation under an anaesthetic,
are essential preliminaries to the simpler mechanical
methods.

The first class will never require an operation.

This simple clinical division should be helpful to the
military surgeon.

SUBACUTE FLAT-FOOT (ORDINARY FLAT-FOOT)

The stage of flat-foot most commonly seen is neither
an acutely painful foot too tender to be handled, nor a
rigid flat-foot, but an intermediate stage, which may be
called subacute.

The patient's feet give him little trouble in ordinary
life, but a long walk makes them ache round the instep.

FLAT-FOOT 37

When he goes to bed after a hard day's exercise his feet
are apt to get stiff. Next morning they are stiff and
painful when he gets up, but as he moves about this
passes off. Later in the day, especially if he has to do
a lot of standing and walking, the feet again become
very painful.

Diagnosis. — This is made by considering the patient's
history and by finding distinct tenderness on pressure
below the tuberosity of the scaphoid ; there may or may
not be pain in other localities. Finally, the patient can
voluntarily stand on the outer edge of his foot and can
crook his foot into the arched position. This last point is
very important, for it means that he will recover if the
heels of his boots are crooked so as to deviate body
weight on to the outer side of the foot.

The patient should therefore at once be put through the
last stage of treatment described under Acute Flat-foot —
namely, graduated exercises, and he need not be taken
off duty for more than a day or two while his boots are
being altered. " Contrast baths " of hot and cold water
alternately, to stimulate the circulation of the foot, are
a great relief 'to the patient, especially at night, when
his feet may be a little sore and swollen after walking
about all day.

CONCLUSION

I have purposely avoided all mention of tiptoe exercise.
These exercises are excellent, but they will not cure a
flat-foot if the patient is allowed to come down in the
flat-footed position in the intervals.

If the principle of deviation of body weight on to the
outer edge be loyally adhered to, every ordinary case will
recover, even without special tiptoe exercise. Loyal
adhesion to the principle stated means that the patient
never sets foot to the ground except in a properly
crooked boot, shoe, or slipper. Even in his bath he
must be careful to stand on the outer edge of the foot.
The whole idea of treatment is to ensure that uninter-
rupted adaptive shortening of stretched structures shall
take place.

Massage, tiptoe exercises, electric stimulation of
muscles, all help to hasten the recovery, but a few
minutes' careless walking without boots or shoes will
undo all benefit from other treatment by again stretching
recovering structures.

Frequently the high-arched foot is the most trouble-
some type when the tendons are strained and the
ligaments begin to give. The strain upon the astragalo-
scaphoid joint in this type is, for obvious mechanical
reasons, great, and the progress of the affection is often

38 NOTES ON MILITARY ORTHOPEDICS

marked by a prominence about the scaphoid due to
pressure osteitis.

CLAW-FOOT

One of the surprises the military surgeon meets is the
number of men with claw-feet who have been passed into
the Army ; but still more surprising is the fact that many
such cases have found their way to the front after the
vigorous initial training which the recruit undergoes.
Sooner or later, however, these men gravitate to hos-
pital, and very few of them return to the ranks as
efficients. A patient with this condition of the foot is
quite unfit for military service, and should never be
accepted as a recruit. The affection usually begins in
early life, and is often not recognized until it has reached
what I have termed its second stage ; until then serious
trouble hardly ever arises.

The etiology of " claw " or " hollow " foot is still un-
certain. It is very often associated with a slight con-
traction of the Achilles tendon in childhood, and in some
cases is due to a transitory paralysis of the extensor
group of muscles. The short boot also stands in some
causal relation to it. The whole question is, however,
too vexed to be discussed here.

Clinically the condition presents five degrees or stages.
The progress of the development of the deformity from
one degree to another, though often continuous, is fre-
quently arrested in one of the early stages ; or perhaps
the facts may be better stated by saying that progress
from the first two stages to the later more severe stages is
very slow, and sometimes does not take place.

FIRST DEGREE OF CLAW-FOOT

The first degree occurs in childhood, and is easily
overlooked. There is no visible increase in the height
of the arch — in fact, the foot appears normal. The com-
plaint made is that the child is clumsy, especially
when running, and frequently stumbles or trips without
obvious cause.

It will be found in such a case that the foot cannot be
dorsiflexed beyond a right angle with the leg, and that
there is commencing contraction of the Achilles tendon
and the structures in the sole. The child's tendency to
stumble is thus explained, for the fore part of his foot
gets in his way as he tries to run.

The treatment in this stage is obviously to stretch
the Achilles tendon and the plantar structures, and so
restore the power of dorsiflexion of the foot at the ankle.
This can usually be effected by manipulation, after
which the boot in which the patient walks should have

CLAW-FOOT

39

no heel to it, but a bar £ in. thick placed transversely
under the tread. In some cases it may be necessary
to lengthen the Achilles tendon. This is best done
subcutaneously by the following procedure : The teno-
tome is entered on one side near the heel, and one half
only of the tendon is divided. The tenotome is next
entered 1^-2 in. farther up on the other side, and the
other half of the tendon is divided. Now, by forcible
dorsiflexion of the foot, the two halves of the tendon are
made to slide on one another until the required lengthen-
ing is obtained (Figs. 38 A, 38 B). A rectangular splint is
then applied so as to keep the Achilles tendon at rest in
the corrected position and to maintain tension on the

Fig. 38. — Anatomical diagram to illustrate the two stages of the operation for
the lengthening of the Achilles tendon by subcutaneous tenotomy.

sole of the foot. This method is always preferable to
that of complete division of the tendon at one level, as
the period of convalescence is shortened, and functional
power in the calf muscles is more speedily restored.

SECOND DEGREE OF CLAW-FOOT

In this degree there is definite contraction of the
plantar fascia, and the characteristic deformity of
the foot is easily observed (Fig. 39). The fore part
of the foot is dropped — that is to say, there is flexion
at the mid-tarsal joint or exaggeration of the arch of
the foot. At the same time the great toe is dorsiflexed
at the metatarso-phalangeal joint, and the tendon of
the extensor proprius hallucis stands out prominently.
Further, if the surgeon places his finger under the ball
of the great toe he easily lifts it, and the toe automatically

40 NOTES ON MILITARY ORTHOPEDICS

straightens out (Fig. 40). The other toes do not present
a similar deformity at this stage, but the Achilles tendon
is shortened. Even in this condition the patient may
not complain of pain or disability ; especially is this the
case in the very young. In older folk, such as the
recruit, complaints may begin whenever long marches
are repeated. The men have to fall out because of
pain and fatigue. They have frequently been suspected
unjustly, for even at this stage there are no very obvious
objective signs. The arch of the foot is not collapsed,
but, on the contrary, slightly exaggerated; if, however,
the surgeon makes a careful examination he will note
tenderness beneath the metatarso-phalangeal range, and
when the patient is asked to extend his toes the big toe
responds to a disproportionate extent.

Treatment at this stage must be drastic. If the
patient is to be rendered able to get about with ease

Pit. 39. — Claw-foot, Fig. 40.— Claw-foot, second degree,

second degree. The surgeon's finger easily replaces

the dropped head of the metatarsal
bone of the great toe ; a case in this
stage is suitable for tendon trans-
plantation.

and comfort, nothing less than operation will suffice. A
radical attack may save the situation, and in a few weeks
the soldier may return to duty. The operation consists
in dividing and stretching the plantar fascia and then in
making an incision over the tendon of the extensor of
the great toe (extensor proprius hallucis), and the tendon
is severed from its attachment. Two holes are drilled
close to each other behind the metatarsal head, forming
a tunnel, through which the tendon is drawn by means
of a catgut ligature (Fig. 41). The tendon is then pulled
so as to raise the dropped metatarsal head into position
(Fig. 43), and its lower end is stitched to its upper
part just above its entrance into the bone (Fig. 42).
This completes the operation, but the foot must be firmly
bandaged down to a metal sole plate with a thick roll
of wool placed transversely just behind the heads of the
metatarsals so as to flatten the arch as much as possible.
The whole foot is then fixed in a rectangular foot splint,
which is bent to rather less than a right angle. After

CLAW-FOOT 4t

the stitches are taken out, the foot is put up in plaster-
of-Paris in the fully corrected position, and the patient

fit. 41. — Claw-foot, second de'
gree. Operation by transplanta-
tion of tendon of the extensor of
the great toe. The diagram shows
how the tendon of the extensor
proprius hallucis is introduced
through the tunnel above the head
of the metatarsal bone.

Fig. 42.— Claw-foot. Operation for
second degree, showing how the
tendon of the extensor proprius
hallucii, after traversing the tunnel
in the bone, is attached to itself and
secured.

is allowed to walk in this for from three to six weeks.
He should then for a few weeks wear boots with very
low heels, and a bar across the sole beneath the heads of

Fig. 43. — Claw-foot, second degree. Operation showing the tendon of the

extensor proprius hallucis passed through the head of the metatarsal bone

of the great toe and pulled before fixing.

the metatarsal bones so as to keep the foot dorsiflexed
when walking.

42 NOTES ON MILITARY ORTHOPEDICS

THIRD DEGREE OF CLAW-FOOT

In the third degree the characteristic deformity is
more pronounced (Fig. 44) ; it is no longer possible with
the finger to lift the head of the first metatarsal into
normal line owing to the increased contraction of plantar
structures ; the operation just described for the second
degree would therefore be useless. Further, the other
toes also are now dorsiflexed, and the characteristic
deformity which at first was visible only in the great toe
is now shared by all the toes. The movements of the
toes are limited, and they are beginning to become rigid
in the position of deformity. Corns and callosities are
formed across the ball of the foot owing to the increased
pressure of body weight, for in this stage the patient can
hardly get his heel to the ground at all. The Achilles
tendon and plantar fascia are still more contracted than
in the first two stages.

Fig. 44.— Claw-foot, third degree. Fig. 45.— Claw-foot, fourth degree.

Operative treatment has now to be carried out in
two stages.

1. The first stage includes division of the plantar fascia
and severe wrenching to flatten the foot as far as possible,
but as at this stage all the metatarsal bones are very
obliquely placed it is necessary also to remove bone.
The operation consists in removing, through separate
incisions on the dorsum of the foot, a half to one inch
of the shaft of the first, second, third, and fourth
metatarsal bones toward the bases without opening the
joints. The fifth metatarsal is retained intact, as it
forms a useful splint for the rest of the bones. Re-
moval of the head of the metatarsal should be avoided.
The extensor and flexor tendons should be divided.

2. As it is impossible to correct all the cavus deformity
in this way, the Achilles tendon is divided at a later
stage by the sliding operation, and the foot wrenched
into dorsiflexion. The after-treatment and alteration in
boots follow the same lines as those already prescribed.

FOURTH DEGREE OF CLAW-FOOT

In the fourth stage, in addition to all the deformities
already described the foot acquires a well-marked varus

CLAW-FOOT

43

deformity (Fig. 45). Callosities are even more tender,
and walking is painful and difficult.

Treatment has to be still more drastic. All tense
structures must be tenotomized and stretched by wrench-
ing so as to mould the foot towards the correct position ;
it will be necessary to divide also the flexor and extensor
tendons, and then remove the astragalus. This releases
the remaining tension on the sole, and the foot can be
moulded into shape, so as eventually to carry the body
weight with comfort to the patient.

FIFTH DEGREE OF CLAW-FOOT

The last stage of claw-foot leaves the patient in a
pitiable condition. The toes are blue and contracted,

Fig. 46. — Claw-
foot, fifth degree.

Fig. 48. -Claw-foot, fifth

degree. Side view after

same operation.

Fig. 47. — Claw-foot,
fifth degree. Front
view after operation
recommended in the
text. The toes and
the heads of the meta-
tarsal bones, as well
as the astragalus, have
been removed.

the callosities exquisitely tender. The deformity is
that of equino-varus (Fig. 46). The patient longs for
amputation. This should never be done, and I would
recommend as a substitute an operation I have designed
and practised with success on many occasions.

In such a case the astragalus should first be removed,
and then a flap incision made along- the base of the toes
on the sole of the foot. A flap should also be raised
from the dorsum of the foot, and the heads of the
metatarsal bones exposed. The toes and the heads of
the metatarsal bones are removed. The result of this
operation is excellent (Figs. 47 and 48).

Although the various operative procedures I have

44

described as necessary in the treatment of the later
stages of claw-foot do not result in producing an
efficient soldier, there is every reason why they should
be known. The military surgeon has to consider the
usefulness of citizens when the war is ended, and
operations such as I have described, with appropriate
variation, will be needed for many types of contracted
feet following injuries received from the enemy.

HALLUX RIGIDUS AND HALLUX VALGUS

The conditions known as hallux rigidus, hallux valgus,
and metatarsalgia, or Morton's disease, are all frequently
associated with flat-foot ; they all have some features in
common both as regards the nature of the pain ex-
perienced, and the alterations required in the boot to
relieve mild cases, and to complete the after-treatment
in cases which have required operation.

Mobility of the Toe. — This is a convenient point at
which to make a digression to discuss the importance
of correct position and free mobility of the great toe in
marching.

The great toe is directed slightly inwards towards
the middle line of the body in young children of all
races, in line with the anterior part of the inner longi-
tudinal arch of the foot, to the structure of which atten-
tion was directed in the section on Flat-foot. (See pp.
27, 28.) Races who habitually go barefooted preserve
this position of the great toe in adult life. In civilized
races — those, at least, who wear boots — the toes are
often cramped into boots of unsuitable shape, so that
the small muscles of the foot suffer atrophy from disuse,
and the power to spread the great toe inwards in walking
is much impaired. The great toe of a strong foot,
which has not been deformed by wearing pointed
boots, is spread inwards by the action of the abductor
hallucis when balancing on one foot, when the weight of
the body is on the fore part of the foot in walking, and
still more so when carrying a pack on the shoulders.

Qualities of a Good Marching Boot. — A good march-
ing boot should, therefore, leave the foot free to adapt
itself to altering conditions of balance and strain.

1. The boot should fit comfortably and closely round
the heel and ankle so as to avoid lifting of the heel
in the boot, which results in chafing, ending in a blister
of the heel.

2. To save the arch from giving way and to avoid
flat-foot the heel of the boot should be slightly higher on
the inner side than on the outer. (Fig. 13.)

3. The inner side of the boot should be straight right
up to the tip of the big toe — that is to say, the inner

A GOOD MARCHING BOOT 45

sides of the two boots should be parallel to each other all
the way along to the great toe. There should be no trace
of pointedness, for pointedness tends to produce hallux
valgus and helps to cause flat-foot.

4. The sole of the boot inside should be as broad as
the foot with the weight of the body on it. In the case
of a soldier it should be as broad as the foot is when
carrying the weight of the soldier in full marching order
— that is to say, the weight of the man himself, his
pack, and all his accoutrements.

5. The upper of the boot should not compress the fore
part of the foot in any way. The toecap should be stiff
and deep enough to clear the toes and allow free move-
ment inside the boot. This stiffening should run back
on the inner side of the boot to a point behind the
metatarso-phalangeal joint of the great toe.

6. The boot should be long enough to allow the foot
to extend to its full length when the soldier is carrying
his pack and all his accoutrements.

These last points, dealing with freedom of movement
of the fore part of the foot, are essential to the full de-
velopment of the small muscles of the foot on which the
soldier's endurance and marching powers depend to so
large an extent.

Corns do not develop in a foot encased in a boot which
allows free play to the fore part of the foot. The regi-
mental chiropodist is a most valuable asset, but his
existence is, ipso facto, a confession that the fit of the
men's boots is not all it might and ought to be. The man
should not be allowed to judge of the tightness of his boot
when his foot is cool. On the contrary, boots should be
served out when men have come in from a long route
march, and their feet are engorged with blood, and there-
fore at their largest. If this were done, interference
with the circulation of the foot by the boot would less
often occur. When a foot swells after a march, the
swelling is practically all in the fore part, not round the
heel. To serve out boots, therefore, after a route march
would not prevent a man from choosing a pair which
fitted properly round the heel and ankle.

The present Army boot is a great improvement on the
boot served out at the time of the South African War, but
it is still lacking in two points — namely, the straight
inner side and the clear free stiffened arch in the upper
of the fore part.

HALLUX RIGIDUS

Hallux rigidus (Fig. 49) is a condition characterized
by limitation of the power to dorsiflex the great toe at
the metatarso-phalangeal joint.

If we remember that in straining on tiptoe or in

46 NOTES ON MILITARY ORTHOPAEDICS

stepping off witjj the foot in marching this joint must be
dorsiflexed, it is evident that any limitation of the move-
ment of dorsiflexion must, in the course of a long or
hard march, result in straining the joint so that it be-
comes painful and inflamed.

As hallux rigidus and hallux valgus are both disorders
of the same joint and are often intimately connected,
the rigid toe may lead on to valgus deformity and a
hallux valgus may become rigid. There is no essential
difference in the pathological condition of the joint,
but only in the direction of the deformity associated
with it.

Treatment. — The treatment of hallux rigidus must
be directed to restoring the power of dorsiflexion of the
great toe at the metatarso-phalangeal joint.

In the early stages, when the tenderness and inflam-
mation either about the joint or in the joint has not

Fig. 49.— Hallux rigidus.

resulted in osseous changes, palliative measures may
still lead to recovery.

First, the joint must be relieved of strain, so that the
inflammation may be allayed. This can be brought
about by arranging a bar like a football bar fully $ in.
thick and about i in. broad placed on the boot behind
the head of the metatarsal bone (Fig. 59). This causes
the body weight to be borne on the neck of the metatarsal
rather than on the tender joint, so assuring rest to the
joint. As soon as the inflammatory tenderness becomes
less the patient finds that the power to dorsiflex the toe
begins to return. This is the moment to begin massage,
movement, and hot and cold contrast bathing in order to
hurry up the processes of repair.

In more advanced cases, and in cases resulting directly
from trauma — as, for instance, dropping a weight on the
joint or violently " stubbing " the toe, osseous changes
due to formative periostitis occur round the joint. There
may be lipping of the base of the phalanx, and usually
there is some nodular thickening of the head of he
metatarsal, especially in its upper aspect. This osseous
outgrowth forms a mechanical block, preventing hyper-

HALLUX VALGUS

47

extension. The impact of the bones on each other
maintains the periostitis, and the condition gets pro-
gressively worse. Palliative measures may enable a
civilian to go about his business with some degree of
comfort, but he cannot do a day's shooting, and pallia-
tive measures are of no use for a man who must march.

Operation alone will remove the obstruction to move-
ment and give permanent relief.

The operation follows exactly the lines to be described
below for hallux valgus.

HALLUX VALGUS

Hallux valgus (Fig. 50) is a deformity of the first
metatarso-phalangeal joint, the essential feature of

Fig. 50.— Hallux valgus.

which is that the great toe is deflected outwards, and
in extreme cases may lie over or under the second toe.

One consequence of this position of deformity is that
the head of the metatarsal and the base of the proximal
phalanx form an undue angular prominence on the inner
border of the foot. As a result of chafing and pressure
by the boot, a bursa, or bunion, forms over the thinned

48 NOTES ON MILITARY ORTHOPEDICS

inner part of the capsule of the joint. It may com-
municate with the synovial cavity.

The continued pressure and friction cause the skin
over the bursa to become indurated and horny, and this
greatly adds to the pain and discomfort suffered by the
patient.

Frequently suppurative inflammation occurs in the
bursa (septic bursitis) ; this may be followed by septic
cellulitis with inflammatory thickening of the tissue^
round the joint, or, in cases in which the bursa communi-
cates with the joint cavity, it may lead directly to septic
arthritis.

It has been a surprise to many surgeons that soldiers
have been able to go through their training and even to
serve in France with pronounced hallux valgus de-
formity. The reason is that the disability is not due
merely to the visible deformity but to the addition of
the following three conditions :

1. Inflammation of the bursa (bunion).

2. Traumatic arthritis, of the same type as the
arthritis in cases of hallux rigidus.

3. Tenderness due to pressure on digital nerves in
every respect similar to the tenderness in a classical
case of metatarsalgia or Morton's disease. i

Bursitis is the most common of these three causes of
disability ; the dangers of septic bursitis communicating
with the joint have already been noted.

Arthritis is much more rare, and is usually of the sub-
acute type common in cases of hallux rigidus without the
valgoid deformity. It is diagnosed by tenderness and
pain on any movement of the joint, even gentle attempts
at passive rotation of the toe.

The third variety, comparable to Morton's disease, is
marked by acute pain on oblique pressure on the joint
between the finger and thumb, .and -is due to excessive
sensitiveness of the digital nerves and adjacent tissues
outside the joint. It is not, as a rule, characterized by
any objective signs other than the valgoid deformity, and
in cases of hallux rigidus of this variety there is no visible
deformity — only tenderness on pressure on the joint.

It is difficult to make a sharp division between hallux
rigidus and hallux valgus. The same types of pain and
disability occur in both. It may, however, be said that
with a distinct valgoid deformity it is comparatively rare
to find rigidity, but that in cases of painful great toe
without valgoid deformity — that is, in cases classed as
hallux rigidus — arthritis and the resulting rigidity are
much more common. Hence the difference in descrip-
tive terminology — but to understand the conditions
properly they should be taken together.

HALLUX VALGUS 49

Treatment. — Palliative measures may suffice in
mild cases. First, the weight of the body should be
taken off the joint by putting a bar — like a football bar
— across the sole of the boot behind the head of the
metatarsal (Fig. 59). If the boots are specially made,
this is worked into the thickness of the sole with a hollow
in the sole for the great toe-joint. The bar on the sole
will, however, keep a man on his feet who would other-
wise be disabled by pain in the great toe-joint. The
boot should, of course, be straight on the inner side,
and the upper should spring clear up, leaving room for
the large head of the first metatarsal — a feature unfor-
tunately absent from the Regulation boot. If the boots
are roomy enough, a piece of felt with a hole in it to
accommodate ^he bunion will afford relief.

Such measures, however, are only curative in the
milder cases, and are not applicable to the man on
service.

Operative Treatment. — Operative treatment of hallux
valgus must not aim merely at correcting the deviation,
but must also be directed to securing free dorsiflexion
of the great toe, otherwise the patient will be left with
all the disability of a hallu-x rigidus.

It follows, therefore, that, apart from the correction
of the valgoid deformity, the operative procedure is
practically the same in principle in both conditions,
and one description suffices for both,
k First, let it be stated that there are two operations
sometimes performed, which need only be mentioned to
be condemned. The first is transplantation of the
extensor proprius hallucis tendon to the inner side of
the metatarsal head in the hope that it will correct the
outward deviation. Experience has proved that this
operation is generally useless ; it is therefore a waste of
time to perform it. The second operation — excision
of the joint — cannot be too emphatically condemned,
as it is liable to end in a stiff joint, bringing with it all
the crippling disability of hallux rigidus in its worst
form.

Finally, no operation should be performed while there
is any inflammation of the bursa or of the surrounding
tissues.

A. In early cases in which there is valgoid deformity
but not much enlargement of the head of the metatarsal
by bony outgrowths, osteotomy of the neck of the first
metatarsal bone, either linear or cuneiform (Fig. 51),
associated with tenotomy of the extensor proprius
hallucis tendon, will suffice.

B. In later stages, with bony excrescences round
the joint, more free removal of bone and some form
of pseudarthrosis must be performed in order to secure

50 NOTES ON MILITARY ORTHOPAEDICS

the free movement of the toe, which is indispensable
to comfort.

1. Free exsection of the head of the first metatarsal
bone, with interposition of a flap of tissue, or of part of
the bursa, is not satisfactory in a soldier, though it has
proved satisfactory in civilians who do not have hard
walking or marching to do. The reason is that the lower
part of the head of the bone is an important part of the
weight-bearing apparatus, and must be preserved.

2. The operation to be preferred is resection of the
head of the metatarsal bone (Fig. 52), leaving as much

Fig. 51.— Hallux valgus. To illustrate osteotomy of the neck of the
metatarsal bone, showing the wedge to be removed.

as possible of the lower part, taking care to clear away
all bony excrescences which obstruct dorsiflexion or
full correction of the valgus deformity. The bursal flap
is then interposed as a covering for the raw surface of
bone. At one time I used to interpose the whole bursal
sac, but nearly twenty years ago several patients de-
veloped bursitis in the transposed bursa. The procedure
I now adopt, therefore, is to open the bursa and interpose
only one wall as a covering for the bone (Fig. 53), or to
obliterate the bursal cavity.

3. In some cases (more often in cases of hallux rigidus
than in those of hallux valgus) it is possible to preserve
the articular cartilage of the head of the metatarsal
bone. This may be done in two ways : The one method
is to remove a wedge or slice from the posterior part of

HALLUX VALGUS 5*

the head and then apply the cartilage to the raw surface
of bone. The other is to cut a wedge of bone with the
cartilage and mortise it into a cleft made in the bone
farther back, removing the intermediate bone.

Fig. 52.— Hallux valgas. To illustrate resection of head of the
metatarsal bone by oblique incision through the bone.

In every case division of the extensor proprius hallucis
is an essential part of the operation for hallux valgus,
otherwise the traction of this muscle will tend to re-
produce the deformity.

Technique of the Operation and After-treatment. — The
skin incision should be a linear incision along the inner

Fig. 53. — Hallux valgus. Showing flap to cover the end of the metatarsal
bone in the operation illustrated in Fig. 52.

side of the joint. The flap incision round the bursa
described by Mayo has not proved entirely satisfactory
in my experience.

The skin having been freed and retracted, a flap
incision is made in the underlying tissues with a second
knife. The knife used for the skin may be infected with
Staphylococcus albus from the skin ; it is therefore a wise
precaution never to use the skin knife for any deeper

52 NOTES ON MILITARY ORTHOPEDICS

dissection, especially in plastic operations where the
least infection may destroy the value of the operation.

The joint is thus opened, and the head of the meta-
tarsal freely exposed. The surgeon can then decide how
much bone he is to remove and exactly how the wedge
is to be made so that the toe will be correctly in line after
the operation. He can also decide whether he can use-
fully retain the articular cartilage, or is to dissect out a
flap of the wall of the bursa to cover the raw bone.

It should be noted that the sesamoid bones should
rarely be removed, as they seem to form an essential part
of the tread of the ball of the great toe. The pad of fat
between the sesamoid bones is, however, sometimes
thickened, red, and tender ; if so it may be clipped away.

Fig. 54. — Splint for hallux valgus after operation.

The whole operation must be carefully carried out
with the most scrupulous attention to three points :

1. Preservation of part of the lower or weight-
bearing portion of the head.

2. Restoration of free dorsiflexion, or the soldier
will not march freely.

3. Correction of the valgoid deformity in cases of
hallux valgus.

The valgoid deformity is purposely placed last, for in
a sense it is the least important from the point of view of
restoring the man's marching power.

A hallux vagus splint should be applied at the end of
the operation. The splint I use is made of thin metal,
as shown in Fig. 54. The hole in the splint fits over the
inner side of the head of the metatarsal bone and prevents
pressure from occurring at this prominent point. The
base of the splint is strapped or bandaged to the inner
side of the foot. The toe is then drawn inwards and
secured to the narrow end of the splint, care being taken
that the alignment is correct.

After-treatment in cases of hallux rigidus and hallux

HAMMER-TOE 53

valgus is quite as important as the operation if we are to
succeed in restoring function. Three weeks after the
operation the patient may walk, provided he has a proper
boot. Gradual exercise and the correct bearing of the
body weight in a properly designed boot is an essential
part of the treatment.

The boot, in the first instance, should be made of soft
material with a stiff leather sole. On the sole is put a
leather bar J in. thick and f in. to i in. wide behind
the heads of the metatarsal bones. The body weight
thus falls for the time on the necks of the metatarsals
rather than on the heads. Further, the heel should be
made J in. higher on the inner side than on the outer side,
in order to deviate body weight to the outer side of the
foot and relieve strain on the inner side and great toe
(Fig. 12). This is, of course, also the appropriate treat-
ment for the flat-foot so commonly associated both with
hallux valgus and rigidus*. The inner border of the boot
must be straight, to allow the toe to be drawn inwards
freely, so that no pressure of the boot will tend to repro-
duce the valgus deformity.

As a rule, patients shod in this way can walk at once
with comfort. Later, an ordinary boot may be altered
in the same way. The operation area is too tender to
bear the pressure of leather for two or three weeks after
operation.

It is while walking in these boots, with the body
weight carried on the outer edge of the foot, that the
real cure takes place. Under the normal physiological
stimulus of walking, repair is hastened, and the small
muscles of the foot recover strength.

To let the patient get up in a slipper is absurd, for the
weight falls then on the head of the metatarsal, and by
irritating the new bone formed at the site of operation it
sets up a fresh process of osteo-arthritis, which may leave
him worse than he was before. The patient must there-
fore be strictly kept reclining, and never allowed to set
foot to the ground till the time has come when he may
be allowed to walk in a properly altered boot.

HAMMER-TOE

Hammer-toe is a deformity which usually affects the
second toe, though it is common to find slighter degrees
of the condition in other toes. It consists of flexion of
the proximal interphalangeal joint and dorsiflexion of
the metatarso-phalangeal joint (Fig. 55). The prominent
knuckle of the proximal interphalangeal joint chafes
on the upper of the boot, while the tip of the toe is pressed
on the sole. Painful corns naturally develop at these
points of pressure, making the man unfit to march.

54 NOTES ON MILITARY ORTHOPEDICS

The causes are numerous. Sometimes the deformity is
congenital, but the commonest cause is the crowding of
the toes in ill-fitting, badly designed boots. Hence it

Fig. 55. — Hammer-toe.

Fig. 56.— The disability
produced by amputa-
tion of second toe.

;s common to find hammer-toe associated with hallux
valgus.

Treatment. — In the adult, operative procedure is
indicated if we are to produce a quick and lasting re-
covery. Neither amputation of the toe nor an attempt
at pseudo-arthrosis of the proximal interphalangeal
should ever be undertaken. Amputation should not be
done, because the absence of the second toe increases

Fig. 57. — Wedge exsection of joint for hammer-toe.

the tendency to the production of hallux valgus, and
often leads to a second disability more serious than the
original hammer-toe (Fig. 56).

Some surgeons, when operating to correct the de-
formity, leave the articular cartilage on one side of the
joint in order to obtain a new joint. My experience is
that this is followed by recurrence so frequently that the
operation should be condemned as uncertain.

DISPLACEMENT OF LITTLE TOE 55

Operation. — The operation found most uniformly
satisfactory is a wedge-shaped incision removing the
articular cartilage on both sides of the joint, so as
definitely to ankylose the joint in extension. An oval
piece of skin, including the corn, is excised over the
prominent knuckle. A wedge, base upwards, including
the joint, is then excised, of sufficient size to allow the
toe to be straightened (Fig. 57). The flexor tendon is
divided by tenotomy. The skin incision is then stitched
so as to leave a transverse linear scar. The toe is fixed
down to the toe-splint shown in Fig. 58, and the patient
walks about, still wearing the splint inside his boots for

Fig. 58 A.— Splint
for hammer-toe.

Fig- 53 B.— Splint for

hammer-toe applied.

View from sole of

foot.

Fig. 58 c.— Splint for

hammer-toe applied.

View from upper side

of foot.

some weeks, to make sure that solid ankylosis occurs
without any return of the deformity.

DISPLACEMENT OF THE LITTLE TOE
A displacement of the little toe, similar in nature to
hallux valgus, frequently occurs, usually as the result of
wearing boots which are too tight and too pointed.
Occasionally the condition is congenital. The toe is
displaced inwards either over the dorsal or under the
palmar aspect of the fourth toe. In either position it
is subjected to undue pressure in any ordinary boot,
and therefore becomes painful.

Treatment. — This condition is very troublesome, and
when it occurs in a soldier an operation is essential.
The treatment which may be applied successfully in
children has no place here, as the structures have be-
come so contracted, especially the skin, that tenotomies,
excisions, or simple splintings are wholly inefficient.
Amputation of the toe is simple and effective in most
cases, especially if no callosities have formed under the

56 NOTES ON MILITARY ORTHOPEDICS

metatarsal head. In amputating it is advisable to make
an ample flap to obviate the result of subsequent con-
tractures and to secure a lax fleshy covering for the bone.
If a callosity has formed, no pressure should be allowed
upon that area until by rest and treatment it has become
soft and normal. If the head of the bone is arthritic
and the condition is complicated by exostoses or ir-
regularities, these should be pared away. Only in very
exceptional circumstances should the head of the meta-
tarsal be removed, for, as pointed out in a previous
chapter, this forms one of the points of support on
which a soldier's marching powers depend.

METATARSALGIA

Metatarsalgia is a peculiarly painful disability of the
foot associated with flattening of the transverse arch.
The characteristic pain is usually felt in the fourth
metatarso-phalangeal joint, frequently in the third, and
less often in the second. The pain is variously described
as a sharp stab, a burning pain, or as if the patient
was " stepping on a red-hot pea." The pain may come
on suddenly as the patient is walking in the street, and
cripple him, so that he has to hobble into a shop and
get his boot off. The device adopted by most patients
to obtain relief is to grasp the metatarsals in the hands
and squeeze them so as to restore the transverse arch.
In more chronic cases the affected toe becomes glazed
and shows signs of trophic disturbance, while in some cases
there is complaint of severe pain shooting up the leg.

Morton in his original description attributed the pain
to pinching of the digital nerves between the metatarsal
heads. The fact that relief is obtained by squeezing the
metatarsal heads casts doubt on the truth of this view.
1 described the condition fully in 1897, and stated that,
as the result of the study of dissections and frozen
sections, I had come to the conclusion that descent of the
transverse arch and conseqiient pressure of the meta-
tarsal heads on the nerves when standing or walking was
the real cause of the pain.

Diagnosis is easily made by the characteristic tender-
ness elicited by pressing the offending joint between the
finger and the thumb, in addition, obvious flattening
of the transverse arch is usually present, and the fatty
pad under the heads of the metatarsals is absorbed by
the pressure of the descended arch, so that the " ball
of the foot " feels unnaturally thin, and there are corns
in the sole under the unusual points of pressure. The
condition is therefore to be regarded as directly con-
nected with overstrain of the foot, and is consequently
associated with flat-foot.

METATARSALGIA

57

Treatment. — Immediate relief can nearly always be
given by removing the pressure of the body weight off
the heads of the metatarsal bones by a bar across the
sole of the boot, behind them (Fig. 59).

The effect of this is to carry the body weight on the
necks of the metatarsals. The heeKof the boot should
also be raised £ in. on the inner side, as for ordinary
flat-foot. A band of strapping round the bases of the
metatarsals to prevent spreading also helps. These
measures, combined with exercise of all the small mus-
cles of the foot to restore the arch, and
massage to relieve the pain and improve
nutrition, will suffice to cure all early
cases in the space of a few weeks.

The patient should then be warned
against wearing narrow boots, which im-
pede the free play of the fore part of the
foot, and conduce to atrophy of the mus-
cles of the foot from disuse.

These measures do not suffice for a cure
in cases which have lasted for some time,
though they give some relief.

Operation. — More drastic measures are
required for the soldier's foot. Removal
of the head of the offending metatarsal
through a small dorsal incision completely
relieves the condition in 90 per cent, of
cases, even when the crippling effects
have lasted a long time and the patient
is suffering so much that he asks for amputation of the
foot. It gives enough relief in the remaining cases for
the patient to be made comfortable with a bar across
the sole of the boot.

After-treatment. — The bar on the sole of the boot
arid crooked heel, already described, should be employed
as an essential part of the after-treatment. The patient
may then walk during the whole period of convalescence
without injuring the site of operation, and so exciting
new inflammatory changes.

PAINFUL CONDITIONS ABOUT THE HEEL

The painful conditions about the heel most com-
monly met with may generally be traced to one of three
causes :

1. Injuries or strain about the insertion of the
tendo Achillis.

2. Spurs of bone and adventitious bursae under
the os calcis.

3. Osteitis and periostitis from direct injury of the
os calcis.

Fig. 59.— Bar on
sole of boot be-
hind the heads
of the metatarsal
bones.

58 NOTES ON MILITARY ORTHOPEDICS

i. INJURIES AND STRAINS ABOUT THE INSERTION OF
THE TENDO ACHILLIS

These are marked by pain about the back of the
heel which is aggravated by walking and relieved by
rest, but the pain recurs again if the patient is tempted
to take exercise. The condition may be divided into
three types :

(a) Tenosynovitis, in which there is swelling due to
effusion within the tendon sheath. This swelling
extends some distance up the tendon, and is both
palpable and visible.

The treatment is counter-irritation, firm bandaging
and rest. When the acute stage is past, the patient
may 'be allowed to walk limited distances with the
heel of the boot raised £ in., so as to relax the tendon
and diminish the strain. If the condition tends to
become chronic, the actual cautery may be used with
great benefit, especially in the form of the heated needle.

(b) Bursitis of the bursa under the insertion of the
tendon into the os calcis. This is diagnosed by local-
izing the tenderness at the site of the bursa and by
detecting a small area of fluctuation.

Treatment. — Relax the tendon by raising the heel
J in. Apply, a band of strapping round the leg above
the malleoli to act like the wristlet worn by workmen
who have strained a tendon at the wrist. The patient
should be instructed to walk a little every day, but should
not be allowed to do an indefinite amount of walk-
ing ; this is one of the difficulties connected with letting
soldiers out from hospital on pass.

(c) Periostitis at the site of insertion of the tendon,
due to strain of the insertion.

The diagnosis is made by localizing the tenderness
on pressure a little lower down than in the case of
bursitis, and by the absence of deep fluctuation in the
bursa beneath the tendon. Treatment by rest is the same
as for the preceding condition.

Both these last-mentioned conditions may be present
simultaneously and become chronic. The best treat-
ment then is first to puncture the bursa or the inflamed
area of periosteum several times with a hot needle.
The process is exactly that known to the farrier as
" pin-firing." The effect of this is to excite an active
vascularization of the part, after which repair takes
place more rapidly if the rest treatment is carried out.

Further, cauterizing a patient's heel deters him from
wearing a boot and going out for too long walks, and
gives the deep lesion an opportunity to recover while
the surface blister is healing.

Irregular fibrous masses are sometimes noled in the

OSTEITIS AND PERIOSTITIS 59

Achilles tendon. These are usually the result of partial
ruptures, and if large and persistently painful they
should be removed.

2. SPURS OF BONE UNDER THE Os CALCIS

Spurs of bone running forward into the plantar fascia
or short muscles of the sole are frequently seen in
skiagrams (Fig. 60). They often cause no symptoms.
On the other hand, if the patient accidentally jumps on
to a stone and bruises the periosteum over one of these
spurs, it may become enlarged, or an adventitious bursa
may develop under it. After this, the patient feels

Fig. 60. — Spur of bone under os calcis.

pain every time he puts his heel on the ground, and it
becomes acute in the course of a long march.

Treatment. — Make an incision along the side of the
foot and gouge away the spur and tissue round it to
make sure of clearing out the bursa and any chronically
inflamed periosteum. The incision should, of course,
not be made in the sole, as a scar in these regions is
often itself the cause of trouble.

3. OSTEITIS AND PERIOSTITIS

Osteitis and periostitis of the os calcis often arise from
bruising of the bone by a jump or fall from a height, or
by injury due to gunshot. There may be no gross
fracture, only some crumpling of the lamellae, which
may be seen in a good skiagram. When a fracture
occurs, the disability is often due to bony irregularities
on the under-surface of the bone.

Treatment is often unsatisfactory, and if the bony
masses are felt in the sole under the heel they should be
freely removed. Palliative measures are of no use in
the case of a soldier ; and one may state as a general
proposition that a soldier with a badly fractured
astragalus or os calcis will not again be fit for service.

CHAPTER IV

MALUNITED AND UNUNITED FRACTURES

DELAYED UNION

THE conditions to which the terms "delayed union"
and " non-union " are applied may be difficult to dis-
tinguish, becavise often we find that, even after months,
osteogenetic changes leading to consolidation will
take place in a fracture considered to
be permanently united. If we are to
avoid disagreeable experiences, we must
recognize that for various reasons, some
of which we know and some of which
are still unknown, a certain proportion
of fractures take longer to unite than
others. Some years ago I was called to
a distance to operate upon a fractured
femur. The accident had occurred three
months previously. The length and
alignment were good, but the patient
had some sugar in the urine, and we
decided, instead of operating, to place
the limb, free from circular constriction,
in a Thomas's bed splint (Figs. 61, 105,
106, 107, 109). Certain other procedures
which I advised were not carried out, but
in four weeks very firm consolidation had
occurred. This case affords an example
of a clinical type. There may be several
weeks of apparent inactivity in callus
formation, and then consolidation occurs
quite rapidly. If a practitioner takes
care to maintain a good length and ac-
curate alignment, he should look forward
cheerfully to a happy issxie even if union
is delayed. As a rule, this is exactly

g'bfspnnl"ass what he does not do- At the end of
the fifth week he begins to feel nervous,

he disturbs the bone ends, modifies his methods, and by
degree transforms into a permanent disability a con-
dition which merely demanded patience.

Delayed union is most common in the middle of the
60

DELAYED UNION 61

femur, in the humerus at the junction of the middle and
upper third, and in the tibia and fibula at their lower
third.

Causes. — In many cases there is an obvious reason
for the delayed union. Very often it is not due to mal-
position ; it is, indeed, quite remarkable how often in
delayed and ununited fractures the bones are almost
automatically opposed. I will not waste time by doing
more than mention some of the academic causes assigned
— such as tabes, syphilis, and acute diseases. I would
prefer to focus attention on the more real and prac-
tical conditions which have a direct relation to the
method of treatment.

Circular Compression. — An obvious and frequent cause
is inefficient reduction, and later on, in considering
malunion, I will refer to this in greater detail. I will,
however, deal first with another cause of delayed union — •
circular compression of the limb by splint and bandage.
A fundamental principle in the treatment of fractures
is to secure and maintain good length and good alignment,
and in attaining these ends care should be taken that
the circulation of the limb shall be in no way hampered.
The splint used should be so constructed that after the
bandage is applied the fingers can be readily introduced
between it and the lateral aspects of the limb. In look-
ing back upon the ununited fractures I have seen, I
generally recall an attenuated limb and a thick plaster
case. When the casing is removed the blanched limb
becomes red, and the blanched bone begins to take its
fill of blood. It is because plaster generally fails to
secure length and adequate blood supply that it is a
prolific source of delayed union and ununited fracture.
I would not condemn the use of plaster altogether,
much as I dislike it, but it should be used with discri-
mination. It should be fixed in such a way that the
limb remains in extension and in good alignment, and
that the circulation of the limb is in no way hampered.

Duration of Period of Consolidation. — Textbooks have
led us astray in regard to the period required for the
consolidation of bone. Fractured adult bones are never
firm after four or five weeks, as the books would lead
us to infer.

For practical purposes, ignorance of this fact may
make no difference in the case of the upper limb, but
in the case of the lower limb, where the effect of the body
weight has to be considered, to underestimate the period
of consolidation is to invite disaster. *

Treatment. — If a case of delayed union is first seen
in the seventh or eighth week we need do no more
than make quite sure of good alignment, length, and
circulation. Nature will do the rest.

62 NOTES ON MILITARY ORTHOPAEDICS

Percussion and Damming. — If a long time has elapsed
the need for action is more pressing, and we must en-
deavour to transform the indolent callus into an osteo-
genetic factory, so that bone may be generated. I
know of no better means than that suggested by H. O.
Thomas, and named by him " percussion and dam-
ming."

Femur. — As an example, I will take non-union of
the femur with shortening probably of two or three
inches. Under an anaesthetic the soft fibrous callus is
broken down and the fractured ends are turned towards
the skin and beaten with a mallet ; a pulley is then
applied to the limb, and as much length as possible
gained. A Thomas knee splint is then adjusted and
the extension maintained. Two pieces of indiarubber
tubing are tied around the limb, one three or four inches

Fig- 62. — " Damming " or congestive treatment of ununited fracture
of the humerus by Thomas's method.

above the fracture, and the other at an equal distance
below. They are kept on, to begin with, for about
twenty minutes each day until they can be borne for
several hours at a time. They should be kept tied
sufficiently tightly to produce considerable swelling and
stasis. Usually in two or three weeks callus is thrown
out, and the osteoblasts begin actively to produce bone.
Local congestion between two indiarubber tubes is much
more effective than congestion by one proximal tube. I
can recall many cases in which bones that had remained
ununited for several months became firmly consolidated
after use of this simple device (invented by Thomas
and ascribed twenty years later to Bier) for stimulating
osteogenesis. The method of applying the india-
rubber tubes to produce congestion is shown, applied
to the humerus, in Fig. 62.

Tibia and Fibula. — In old ununited fractures of the
tibia and fibula complete extension is not so easily
attained, and it may be necessary to remove bone.
If this be done, the operation should be performed under

DELAYED UNION 63

pulley extension (Fig. 63), or by turning the ends of the
bone out of the wound and engaging the fragments in
shoe-horn fashion after the method of Lane. If the
case be suitable and the surgeon possess the mechanical
skill subsequently to keep a good alignment, it is best
to avoid the introduction of plates or screws. The
bones should be kept in absolutely good apposition,
and where it can be easily accomplished they should be
wrapped in transplanted fascia, which will act as a bind-
ing membrane in the same way as periosteum.

In another type of case in which the bone is eburnated
with feeble callus production, it is well after sawing the
ends to crenate the edges with bone nibblers, and to
transplant bone from some other part of the body. The
sides of the fractured ends should be prepared to receive

Fig. 63. — Pulley used in setting and operating upon fracture of tibia and
fibula ; counter-extension shown.

the transplanted portion, which can be affixed laterally
(Fig. 64, A), or driven into each end of the medulla.
The transplanted bones and the fractured ends are held
in position with transplanted fascia wrapped around
them.

Figures 65 A and 65 B illustrate a method of sliding a
transplant to bridge over the fracture. Albee's twin
saw is used to enable the operator to detach with mathe-
matical correctness a strip of bone partly above and
partly below the line of fracture. A chisel is used at
either end to complete the detachment. The shorter
detached piece (in the figure the lower) is removed and
the larger piece is slid down (Fig. 65 B).

Autogenous transplantation of bone is far more
effective than transplantation from another patient or
from an animal. A bone graft without periosteum is
sometimes as effective as one taken with its periosteum.
This fact is important, for if bone is removed from some

64 NOTES ON MILITARY ORTHOPEDICS

other part of the body subperiosteally, the removed
bone is very rapidly replaced by new bone. Where con-
venient, however, the periosteum should be retained.
Non-union is very apt to occur where a wide gap

Fig. 64. — Bone grafting. A, Lateral bone graft for fracture. B, Lateral
bone graft for a case in which bone has been removed.

exists between the bones. In the case of fracture of the
tibia of long standing, where the growth of the fibula
has progressed, I have operated with success by remov-
ing a large lateral slice from the upper end of the fractured
tibia, and using it as a bridge to spari the gap (Fig. 64 B).

MALUNION 65

Compound Comminuted Fractures : Retention of Frag-
ments.— This leads me to speak of compound comminuted
fractures associated with loose pieces of bone. The
removal of these pieces is very frequently the cause of
non-union. If loose pieces are felt, provided the wound '
is not suppurating, they should be scrupulously saved ;
the pieces, if quite loose, should be taken out of the wound
and laid in alcohol, and then carefully replaced in
position or round the site of fracture. In such cases
I refrain from introducing any foreign bodies, such as
nails, plates, or wires. If a drain be used at all, it
should be for forty-eight hours only.

Weak Union : Exuberant Callus. — Malunion of the
femur of six or seven weeks' duration can almost always
be corrected by powerful manipulation. The same is
true of all the long bones. At my clinic every week
I am accustomed, by wrench or hand, to correct mal-
united fractures of several weeks' standing. The method
is especially applicable to a Colles's or a Pott's fracture.

Weak union can be diagnosed almost with certainty
even when ordinary manipulation fails to detect it. It
is suggested by tenderness on pressure over the site of
the old fracture, and confirmed by the additional sign of
exuberant callus exudation. A malunited fracture of
some months' duration, if accompanied by these two
signs, can usually be corrected by forcible manipulation.
This is a very important clinical fact to remember from
the point of view of immediate or gradual correction.

Exuberant callus is sometimes so abundant as to be
mistaken for malignant disease, and I have met with
many instances in which the patient has narrowly
escaped amputation. This error is more likely to occur
in the femur than in any other of the long bones, especi-
ally when the force applied to produce it has been so
slight as to suggest that the fracture was spontaneous.

MALUNION

Malunion of a fracture can always be prevented, and
should raise a strong presumption of inefficient treat-
ment. Our duty, therefore, is to examine the cause of
malunion, and to arm ourselves with a knowledge of
the weak points in our method of treatment.

The causes of malunion may be found (i) in errors
in the initial treatment or setting of the fracture,
(2) in errors in the method of maintaining the fracture
in position, or (3) in errors of after-treatment.

I. INEFFICIENT REDUCTION OF THE FRACTURE

Malunion of a fractured bone is due to this cause
more often than is commonly supposed. Sometimes it

F

66 NOTES ON MILITARY ORTHOPEDICS

is due to want of knowledge, but more often to want of
experience and confidence.

It is necessary, of course, to have a clear knowledge
of the anatomical proportions of the limb and of the
mechanics of its action ; but it is still more important
to know the nature of the impairment of function
likely to occur after any particular fracture, so as to
be ready to take means to anticipate and to prevent it.

Common causes of inefficient reduction are —

(a) Insufficient extension of the limb in fractures of
long bones — such as the femur or humerus — so that the
overriding of the fragments is not completely corrected.

(b) In Pott's fracture there is always an associated
dislocation of the ankle outwards and backwards. If the
backward dislocation is not fully corrected there is pain
over the front of the ankle when the patient walks, and,
in addition, inability to dorsiflex the ankle, which causes
a serious impairment of function.

(c) In Colles's fracture the backward displacement of
the lower fragment is very serious, and is not always
corrected by the orthodox traditional " hand-shaking "
method of reduction. The lower fragment carries
with it the articular surface for the head of the ulna,
and if this is out of line the upper and lower articulations
between the radius and ulna are thrown " out of truth "
and the radius will not rotate properly. This leads to
impairment of pronation and supination, and conse-
quent very serious interference with function.

These are merely instances of how a want of sufficient
determination in reducing the initial deformity may
play an important part in causing subsequent loss of
function. I have referred to them because they occur
in common fractures, with the treatment of which every-
body ought to be familiar, yet I see a large number of
cases of serious impairment of function really due to
these causes.

2. FIXATION AFTER SETTING OF FRACTURE

If the fixation of the limb after the fracture has been
reduced is inefficient, so that a material amount of move-
ment can take place between the fragments, then every
such movement causes pain, and produces a reflex con-
traction of the muscles. This reflex spasm may very
readily cause overriding of the fragments, and in the
case of the shafts of long bones lead to shortening.
In fracture of the neck of the femur it modifies the
angle between the neck and the shaft and so causes the
flexion of the joint, with the result that body weight is

MALUNION

67

not transmitted in the normal line. In consequence of
this, crippling changes of an osteo-arthritic character
subsequently occur in the joint. Faulty alignment of
the bones may arise from inefficient fixation, even in a
case in which the fracture was originally fully reduced
and the bones brought into correct alignment (Fig. 66).
The result is that the true line of the shaft of the bone is

Fig. 65. — End-to-end apposition of fractured femur. A, End-to-end appo-
sition and perfect alignment. B, Imperfect apposition but with good align-
<ment. c. End-to-end apposition with faulty alignment.

not maintained, and the joint at one end of the bone is
thrown out of its proper relation to the joint at the other ;
in consequence, muscles do not act in their correct line,
and the usefulness of the limb is impaired. Further, in
the lower limb the line of transmission of body weight is
altered, and this throws an improper strain on joints
and ligaments, resulting in changes in the joints, in flat-
foot, and in other disabling deformities. For instance,
in fracture of the tibia and fibula a little shortening of
the limb does not seriously impair its strength if the

68 NOTES ON MILITARY ORTHOPEDICS

alignment is good. A slight bow -leg even is not serious
(Fig. 67 A), for slight bow-leg is a harmless type. Many
muscular and powerful men are, indeed, slightly bow-
legged, but in a valgoid deformity the weight of the body
is carried too far to the inner side of the foot, and this
throws too much weight on the arch, and the result is
a flat and everted foot (Fig. 67 B).
» Any valgus deformity at the knee, in the leg, or at the

\

Fig. 67. — Diagrams to illustrate effects of malunion of tibia. A, Malonited

fracture of tibia producing bow-leg and throwing body weight on to outer

side of font. B, M alunited fracture of tibia in such a position that the weight

of the body is carried to the inner side of the foot, producing flat-foot.

ankle is a weakening deformity, and greatly reduces
the usefulness of the limb. It is a good fault, therefore,
to err on the side of producing a slight bow-leg, with
its varoid accompaniment, if there is to be any error at
all. In cases of malunion, when the callus is still tender,
it is generally not difficult to readjust the limb by
manipulation without having to perform an open
operation. In the case of the femur, this can usually be
done two, or even three, months after the original frac-
ture. As a rule, the worse the position of the bones the
longer will the callus take to consolidate.

MALUNION

69

The next point to which I would draw attention is
that callus may yield in such a way as to throw the bone
out of proper alignment. A good example of this is fre-
quently afforded by cases of Pott's fracture which have
been correctly reduced, and six weeks later are in good
position and united. A month after this, however, the
patient may complain of some pain at the site of the
fracture, and also of symptoms of flat-foot.

Here the counter-pressure of the ground on the foot
forces the astragalus against the external malleolus, and

Fig. 68. — Boot and iron for
use after Pott's fracture. A,
Showing the boot with
crooked and elongated heel
and the outside iron ; B, the
same applied.

so produces a lever action, straining the callus. To
avoid this, every case of Pott's fracture should be set to
walk with the inner side of the heel raised to keep the
foot inverted, and if the patient is a heavy subject an
outside brace also should be worn (Fig. 68 A and 68 B).
It is disconcerting and puzzling to see a perfectly good
functional result replaced by a bad one ; to avoid dis-
appointment of this kind it is advisable, particularly in
fractures of the lower limb, to apply some sort of guard
to prevent straining of the callus.

Functional Impairment associated with Various
Fractures. — Before discussing the treatment to be
adopted in particular cases, it is well to recognize the
forms of impairment of function commonly associated
with each fracture.

70 NOTES ON MILITARY ORTHOPAEDICS

Humerus. — Fractures of 'the humerus near the
shoulder-joint (that is, those of the surgical neck and
above the insertion of the deltoid) are commonly associ-
ated with inability to abduct the limb fully. The reason
is that the upper fragment is often tilted outwards,
and end-to-end union does not take place. In order to
avoid this, the surgeon's object when setting the fracture
should be to bring the fragments end to end if possible.
He should pull the arm at right angles to the trunk, or
even straight upwards, until all overriding is completely
overcome, and should then endeavour to engage the end
of the lower fragment on the broken end of the upper
fragment. By pressing the two together he can at once
tell if they are engaged or are sliding past each other.
If they are engaged, the arm can be gently brought
down to the side and secured to the trunk by bandages.

Fi<. 69. — Position for fractures about elbow in the adult. The elbow is even
more flexed in children.

Once the fragments are engaged they are not likely to
become disengaged again.

Elbow-joint. — In fractures about the elbow- joint, with
the single exception of fracture of the olecranon process,
the usual disability is limitation of flexion.

The limb should therefore be extended to push away
any fragment likely to obstruct extension afterwards.
The forearm should be supinated to make sure of clearing
a right of way in that direction, and then the elbow
should be fully flexed and bandaged (Fig. 69), care being
taken not to produce tight circular constriction of the
limb in any part. In this way we may make sure that
there shall be no callus exudate in the bend of the elbow
and at the same time the tendon of the triceps acts as
a posterior splint.

When a stiff elbow, after an injury, has to be dealt with,
the same manoeuvres are gone through so as to force the
recently formed callus out of the way until full flexion is
secured. Usually this can be done on one occasion,
but in some cases it may be necessary to flex the joint
in two or three stages.

FRACTURES: IMPAIRED FUNCTION 71

Radius and Ulna. — In fractures of the bones of the
forearm the disability most to be feared is obstruction
to supination ; pronation is usually good. Therefore,
in setting the fracture, or when breaking down callus
and resetting the fracture, the surgeon should extend
the forearm and supinate fully in order
to make sure of a clear right of way
for supination, and then set the frac-
ture, taking great care that the ulna is
perfectly straight, and that there is no
lateral pressure anywhere on the shaft
of the radius (Fig. 70). It must, how-
ever, be remembered that the radius is
a curved bone which rotates on the
ulna like the handle of a bucket ; if
the arched shape of the radius is de-
stroyed the joints at its ends will be
out of their true line, and impairment
of function will be the result.

Carpus. — Fractures of the carpus
often result in a stiff wrist in a flexed
position. Every schoolboy knows that
the grasp of the hand is weakest when
the wrist is flexed. Therefore, in every
case of fracture or injury of the carpus,
the wrist should be put up in a hyper-
extended position (Fig. 71).

If the wrist has been allowed to get
stiff in a flexed position, it should be
dorsiflexed under an anaesthetic and
fixed in that position. In rare instances
a fragment of the scaphoid is displaced
on to the dorsum and blocks extension ;
if this has occurred, it may be necessary
to remove the fragment before the wrist sary .'." fr«ctures of

radiu* and ulna.

can be hyperextended.

Ankle-joint. — When we turn to fractures near the
ankle-joint we find that many patients complain of both'
pain and stiffness which last for months or years. A
study of the causes brings to light two principal factors

70.— To show
the complete supin-
ation and extension
of the arm neces-

Fi<. 71. — DorsiBcxion of wrist for fracture of carpus.

responsible for loss of function here. Eversion of the
foot, for instance, is fairly well recognized as one of them
(Fig. 72). If the patient is allowed to recover with the
ankle in a valgus position, the body weight when he

72 NOTES ON MILITARY ORTHOPEDICS

stands will fall too far to the inner side of the foot, and
at once all the factors which make for the production of
flat-foot are produced. It is, however, not sufficiently
well recognized that these conditions may be at work
in an ankle which has every appearance of being in good
position when the patient is discharged from hospital.
Straining of young callus by body weight is very common
in fractures around the ankle-joint, owing to the patient
being allowed to walk on the unprotected joint too early.
I therefore always discharge these patients with a
" crooked " heel and often with an outside brace as
well, to ensure that the body weight shall fall on the
outer side of the foot (Figs. 68 A and 683). The natural
corollary of this is that if body weight will produce
a valgus deformity by straining the callus, it will also

Fig. 72.— Malunited Pott's fracture, showing eversion of foot.

correct it if we "crook" the boot well, and therefore
when the callus is already strained in the valgus direc-
tion, and the patient comes with a stiff painful ankle
and foot, all we need do in many of the milder cases is
to crook the boot well on the inner side, and let the
patient " walk out " his deformity. In older and more
severe cases it is from the first necessary or advisable
to wrench the foot into an inverted position under an
anaesthetic, and then let him walk with his heel well
crooked ; this is made easier by the application of an
outside brace (Fig. 68). If this after-treatment is not
persisted in for some weeks the condition will most
likely recur.

The second great disability, after injuries about the
ankle-joint, is inability to dorsiflex the ankle. The
patient, when walking, cannot get forward on to the
toes and fore part of the toes without pain across the
front of 1fhe ankle.

This is a very difficult condition to correct, once the

POTT S FRACTURE

73

deformity has been allowed to become established. The
proper thing is to prevent it when the injury is recent ;
to make sure of this the surgeon should dorsiflex the
foot and so satisfy himself that he has commanded a
complete and clear right of way for this movement in
the future.

Both these disabilities are well illustrated by cases
of Pott's fracture : this injury essentially consists of a
fracture of the fibula about three or four inches above
the external malleolus with a dislocation of the ankle
outwards and backwards (Fig. 73). There may be minor
complications, such as fracture of the tip of the internal
malleolus or the less well recognized fracture of the edge
of the articular surface of the tibia. These, however,
do not alter the general nature of the disability.

Fig. 73. — Malanited Pott's fracture, showing dislocation backwards
of the foot.

The method of reduction I adopt is the following :
The knee is flexed to relax the calf muscles. If these
muscles give trouble, tenotomy of the Achilles tendon
will put them out of action, but this is only necessary in
exceptional cases, and strength returns but slowly after
this apparently harmless operation. Grasping the foot
by the heel in one hand and the dorsum in the. other,
the foot is pulled and everted to make sure of thoroughly
disentangling the fractured ends. While still pulling,
the foot is fully inverted and the ankle dorsiflexed.
If the ankle cannot be dorsiflexed fully, it means that
there is a definite posterior dislocation or that the an-
terior edge of the tibia is fractured. It is necessary
then to push the tibia back and bring the foot well
forward until the ankle can be well dorsiflexed. The
foot is then fixed in splints in the fully inverted position
and dorsiflexed a little beyond the right angle. If the
surgeon maintains it in this position, he may wait with
confidence for a good result. If he is content with a less

74 NOTES ON MILITARY ORTHOPEDICS

thorough reposition, he is in great danger of getting
a result with some stiffness, pain, or limitation of
movement which will seriously interfere with comfort
in walking. Since the days of Percival Pott many
splints have been devised. The shape and style of the
splint does not matter a jot. The important element
is the surgeon. If he knows his work, he will fix the
foot in the position described and will be rewarded by
a good result.

As we have seen, malunion and consequent functional
disability depend on two factors : (a) eversion, (b)
diminished dorsiflexion.

(a) Eversion often calls for operation. In compara-
tively simple cases all that is needed is to pass a chisel
through the internal malleolus, and also through the site

Fig. 74. — Operation for malunited Pott's fracture ; wedge from
tibia and osteotomy of fibula.

of the old fibular fracture. The foot should then be
forcibly inverted, and treatment continued to maintain
the inversion. In the more severe type of case an open
operation is advisable. A wedge of bone is removed
from the lower end and inner side of the tibia (Fig. 74).
The wedge should only go a distance of four-fifths
through the bone. An osteotomy of the fibula is next
performed. The wounds are closed, and not dressed
for twelve or fourteen days. The stitches are then
removed, and, under gas, the limb is fractured by
forcible inversion. This two-stage operation eliminates
the anxiety which must attend the treatment of a com-
pound fracture, and this is an important matter when
powerful manipulation is necessary. For many reasons,
however, it may be advisable to complete the reduction
at the time of operation.

(b) Dorsiflexion of the ankle may be blocked by
callus exudate the result of fracture of the anterior

FRACTURES OF FEMUR

75

articular edge of the tibia. Complete dorsiflexion ot
the ankle at the time of accident would save the pa-
tient from this deformity, for the fragment of bone
would in this way be pushed to one side, but if this has
not been done, and at a later date we find that dorsi-
flexion is prevented, an incision should be made and the
offending prominence chiselled away. The space left
by the removal of bone should be packed with fat re-
moved from any convenient part. This prevents the
new callus exudate from giving rise to trouble. In all
operations where bone is removed
and pseudarthrosis is desired I find
the generous employment of fat most
helpful, and in order to reduce the
callus exudation the exposed cancel-
lous bone should be lightly hammered.

Tibia. — In fracture of the tibia
faulty alignment may be brought
about by posterior bowing ; the
weight of the body may be thrown
so far back that it passes at some
distance behind the ankle, as shown
in Fig. 75.

Femur. — Fractures of the neck of
the femur, and all fractures about the
small trochanter, should be treated
in the abducted position to prevent
deformity of the coxa vara type
(Fig. 76 A and 763). Stiffness of the
hip associated with limitation
of abduction, often accom-
panied by " osteo-arthritic "
changes in the hip-joint, is
the sequel of malunion in
this region. To prevent this it is
necessary to secure abduction and to
maintain extension in the abducted
position. If the fracture is of some
weeks' standing and the area is still tender, the callus
is certainly not consolidated ; forcible abduction and
extension in an abduction frame and rigid fixation in
this position will then be followed by adaptation of
the callus to the corrected position.

Fractures of the shaft of the femur, especially in the
middle third, are frequently followed by gross forms of
malunion, which will excellently serve to illustrate
malunion in long bones.

The faults commonly found are :

i. Shortening or overriding, due to the fact that (a) re-
duction has been incomplete, the surgeon not having
pulled until the fractured limb was at least as long as

Fig. 75. — Diagram to
illustrate position of leg
and foot in posterior
bowing of fractured
tibia.

76 NOTES ON MILITARY ORTHOPEDICS

its fellow ; (b) the method. of fixation and extension used
has been inefficient, and the muscles have caused over-
riding after the fracture was set ; (c) the body weight

Fig. 76. — Fracture of neck of femur. A, Fractured neck, showing position
in adduction. ';, Fractured neck correctly reduced in abduction.

has caused yielding of the callus after the patient has
begun to walk.

2. Angular deformity or erroneous alignment is the
result of inefficient methods of fixation, and more par-
ticularly of inefficient extension in the line of the limb.
Erroneous alignment throws all the muscles of the part

Fig. 77. — Fracture of upper third of femur. A, Adduction deformity,
n. Abduction faulty, as the upper fragment does not participate.

out of line, and, what is more important, puts the joints
above and below out of their correct relations. A com-
mon fault in fractures at the junction of the lower and
middle third is a posterior sagging (Fig. 78), which is

FRACTURES OF FEMUR

77

best seen when the patient begins to walk. The body
weight is thus thrown on the posterior part of the cap-
sule. The deformity resembles a genu recurvatum.

3. Rotation deformity is far too common, and can only
be the result of careless and inefficient treatment.

Diagnosis. — In a case of malunion of the shaft of the
femur in which one or more of these elements are present
the whole region of the fracture is tender, and is also
the seat of pain for weeks and
months after consolidation ought
to be complete. This means that
consolidation is far from complete,
and that the callus is the seat of
active change. Nature, in fact, is
struggling with the problem of
buttressing up the malunited frag-
ments so that they can meet the
forces which are acting in them :
hence the exuberant production of
callus, which is attended by pain
and tenderness.

Treatment. — In such cases it is
not difficult to break down the
callus by manipulation. Exten-
sion with block pulley and suitable
tackle will then stretch the muscles
and reduce the overriding by 2 J in.
on a single occasion (Fig. 63).
Rotation deformity is, of course,
corrected at the same time.

If open operation is employed,
the simplest form of osteotomy is
an oblique one through the callus
between the original fragments of
the shaft. Once these are cut
through, the greatest part of the
remaining difficulty is in fully re-
storing the length of the limb by
extension. The big muscles of the
thigh can only be fully over-
powered by the use of block pulley trate

and tackle (Fig. 63). When this r
has been accomplished the leg is

fixed in a Thomas's knee splint, the tuber ischii rests on
the padded ring, the extension straps are secured to the
bottom of the splint. We are then sure that, whatever
happens, the muscles cannot contract and cause further
overriding. The only thing the muscles can do is to
give up the struggle, and, as a matter of experience,
this is what always happens. The surgeon finds on his
next visit that he can get perhaps another half-inch of

Fig. 78. — Diagram to illus-
posterior sagging in

7§ NOTES ON MILITARY ORTHOPAEDICS

lengthening by further extension on the straps. Further,
in a Thomas's knee splint good general alignment of the
limb can easily be secured — in fact, is obtained almost
automatically. The only points to which the surgeon
has really to attend are the position of the foot — to see
that there is no outward rotation — and to keep up firm
extension.

Locally, splints are applied to control lateral move-
ments. In the first instance this is not difficult. When
resetting a malunited fracture it is not so easy, for the
callus already formed gets in the way.

In these malunited fractures of the femur of some
weeks' standing with considerable overlapping, after
refracturing the bone by force the pulleys should always
be applied and a great effort made to secure both length
and alignment. To render this less difficult, it may be
wise to move the fractured ends freely in all directions
to disturb and disengage the fibrous and bony exudate.
The extension by pulley should be maintained for
several minutes to lessen the resiliency of structure and
to reduce the chance of telescoping. The limb is then
maintained in extension by a Thomas's splint, and on
two or three subsequent occasions the pulleys are applied.
By these simple means overlapping of three or four inches
can be overcome, and an open operation is avoided.
The " damming " method already described is applied to
assist osteogenesis, aided when necessary by percussion.

Whatever operation may subsequently be needed, I
cannot too strongly urge the necessity of preliminary
pulley traction in order to secure a better length, and in
this way prevent the sacrifice of bone.

In cases in which union in the vicious position is so
complete and firm as to render operative procedures
necessary, the procedure to be followed is influenced by
the special type of union present. If it is a mere case of
faulty alignment, with fair apposition, a small puncture
and an osteotomy saw (Fig. 79) will do what is desired.
An X-ray photograph should be taken, and the section
made through the angle. The case is then treated as
one of simple fracture. If there is overlapping of the
fragments, with no excessive callus, the saw or chisel
(Fig. 80) is introduced between the fragments and the
lateral fixation undone. Pulley extension will then
diminish or obliterate the shortening, and the subsequent
treatment will maintain both length and alignment.
In other fractures higher up, with great thickening and
lateral deflexion, a wedge is removed from the convex
side of the bent bone, and a fracture at the point pre-
ferred may be produced some days later (Fig. 81). Ex-
tension and abduction of the limb should then be secured.
In rarer instances, when unusual deformity and over-

FRACTURES 79

lapping have occurred, it may be necessary to explore
the fracture by a free exposure, to separate the frag-
ments, to remove bone, and to plate.

CONCLUSION

It may appear that in this chapter I have dealt more
with the treatment of fractures than with the treatment

Fig. 79. — Author's osteotomy saw with protected end.

of malunited fractures, but a moment's reflection will
satisfy us that there is only one problem before us — the
restoration of function. Operation or manipulation to
free the ends of the bones when union ha§ occurred in a
faulty position is only a preliminary step. In short, a
malunited fracture cannot be cured by operation — all
the operation can do is to reconstitute the fracture or
make another fracture similar to the first.

Fig. 80.— Fracture of upper third

of femur. Diagram to illustrate

osteotomy to correct common

deformity.

Fig. 81. — Fracture of upper third of
femur- Diagram showing removal
of wedge of bone to correct ad-
duction.

If after this the subsequent treatment is not better
than the treatment adopted in the first instance, an im-
provement in the result is not to be expected. This is
probably why the statistics of late operations to correct
malunion are often disappointing. The surgeon must
not merely reduce the fracture, but must maintain the
corrected alignment until consolidation of the bone is
secured.

The fundamental principles applicable to simple frac-
tures hold good in the case of compound fractures.

8o NOTES ON MILITARY ORTHOPEDICS

The difficulties in carrying them out are obviously
materially increased. Once, however, serious compli-
cations are past, there will be ample time and oppor-
tunity to correct faulty alignment and to restore the
best possible function to the fractured limb.

The fractures met with as a result of gunshot wounds
are usually very serious, and I have witnessed with pride
the splendid efforts made by the young surgeons in
France to save these mangled limbs. Sometimes we
hear criticisms at home, not always kindly, sometimes
very unjust, because amputations are performed without
flaps, and limbs still suppurating are not in the best
position. If the whole truth were known, these mangled
limbs and napless amputations often represent surgical
triumphs where every art and device has been concen-
trated upon the salvation of life and limb.

CHAPTER V

TRANSPLANTATION OF BONE, AND SOME
USES OF THE BONE GRAFT

INJURIES inflicted by modern instruments of warfare are
so often associated with loss of considerable portions of
bone that it is necessary to bring together various
known means of replacing these defects. The present
chapter aims at giving a brief account of my experience
of the grafting of bone.

Clinical experience in recent years justifies the ex-
pectation that a bone graft will grow and fulfil the pur-
pose desired by the surgeon if the operative technique
is appropriate and scrupulous attention is paid to
asepsis. Before dealing with the practical difficulties to
be encountered, brief reference must be made to various
theories which have been advanced concerning the
growth of transplanted bone.

Three of the theories may be mentioned :

One, which has been widely held in Europe, is that,
when a bone graft is transplanted, the grafted bone
always dies and is absorbed, and that any new bone
formed in its place is laid down by the periosteum,
which is the only part of the graft which really survives.

The second is the well-known view of Macewen that
the new bone is formed by the proliferation of osteoblasts
within the bone itself, and is quite independent of the
periosteum, which is only a limiting membrane.

The third theory is that the graft is not osteogenetic,
but merely acts as a suitable and appropriate scaffolding
along and through which new capillaries and granulation
tissue can grow, taking with them osteogenetic cells
from the living bone-ends, between which the graft is
placed.

Recent investigations definitely prove that bone trans-
planted even into the abdominal wall may grow, and
that this may happen whether periosteum alone or bone
alone is transplanted.

McWilliams of New York, whose investigations are

thorough, concludes that the survival of the graft

depends on the establishment of an efficient blood

supply, and that the blood supply is more quickly and

G 81

82 NOTES ON MILITARY ORTHOPEDICS

efficiently established when periosteum is transplanted
with the grafted bone.

I advise that, whenever possible, it is best to transplant
periosteum with the bone, and, further, to be sure that
the graft should also contain part of the endosteum.

Every surgeon knows that in simple comminuted
fractures portions of bone must often be entirely, or
almost entirely, cut off from their usual blood supply,
but that necrosis of these fragments is extremely rare,
while in the presence of toxins of bacteria, as in septic
compound fractures, more or less necrosis is very prone
to occur even in portions of bone still connected with
their blood supply.

It is therefore safe to conclude that, whether the
osteogenetic cells are derived from periosteum or from
bone, scrupuloxis asepsis is essential to their welfare ;
that if they are not poisoned by septic toxins they can
survive on exuded lymph or plasma for a reasonable
period while a new blood supply is being established ;
and further, that the open cancellous medullary aspect
of the bone and the periosteum both furnish convenient
means of access for the new blood supply, and should
be retained in the graft whenever it is possible.

It is important to remember certain further facts,
which are established beyond doubt. First, that bone
taken from one of the lower animals and grafted into
man very rarely lives, even with the most careful tech-
nique. Secondly, that bone transplanted from one
individual to another only lives in exceptional cases.
These, therefore, are methods which cannot be recom-
mended. Finally, it is established that autogenous
transplantation of a portion of the patient's own bone
from one part of the body to another is fairly con-
stantly successful if the conditions are suitable and
the technique correct. The nature of the technique
and the conditions found suitable will appear in the
subsequent parts of this chapter.

Professor Tamer's experiences in relation to the trans-
plantation of ovaries are interesting and instructive.
He found that when ovaries were removed it was pos-
sible to retain the internal secretory influence of the
ovary by implanting a healthy portion of one ovary in
the abdominal wall. If the patient's own ovary was
employed it almost invariably survived and became
tender at each subsequent monthly period. In cases
in which no part of the patient's ovaries could be used,
he tried borrowing an ovary from another woman on
whom ovariotomy had to be performed. In every
case this transplantation from one individual to another
failed.

There are other facts which should be kept in mind

TRANSPLANTATION OF BONE 83

when repairing bony defects. For example, if a bridge
of periosteum can be preserved, osteogenesis, or new bone
formation, is much more likely to occur, and the gap will
be filled with greater rapidity than when no bridge is
possible. Stiles's cases of subperiosteal resection for
tubercle are evidence of this.

Since the survival of implanted bone is dependent on
the establishment of circulation within it, it follows that
necrosis is less likely to occur in small fragments than in
large pieces, when the periosteum cannot be preserved.
It is therefore a good practice to scatter small fragments
of bone along the site of the defect, for the cells in them
can live for some time on exuded plasma ; the new blood
supply will reach them in a few days.

GENERAL CONSIDERATIONS AS TO TRANSPLANTATION
OF BONE

In performing transplantation of bone to replace a
defect in the continuity of a long bone the surgeon has to
keep certain points in view, and in all must follow
Nature's rules.

i. Nutrition of the Graft. — In order to ensure the
nutrition of the graft it is essential to observe the fol-
lowing points : —

(a) Perfect hcemostasis in the bed in which the
graft is to be laid. A mass of blood clot round the
graft endangers its life, for this blood clot must first
be " organized " before the new capillaries or granu-
lations can reach or grow into the bone graft to
supply it with blood.

(b) Perfect asepsis, for toxins, if virulent, will
almost certainly cause the death of the bone cells
in the graft before a protective vascularization can
occur.

(c) Preparation of the bed in which the graft is
to lie. It should be freshened, so that rapid
adhesion and organization may take place between
the graft and surrounding tissue. Moreover, the
soft tissues should be brought round the implanted
bone.

2. Union of the Graft. — The union of the graft with
the ends of the bones between which it is placed can
be helped in a number of ways. The ends of the bone
should be opened up and prepared for the reception of
the ends of the graft. It is desirable that some part of
the graft should be in contact with the vascular medul-
lary cavity. Sometimes it is possible to push the graft
straight into the open medullary cavity (Fig. 82). As a
rule I avoid the use of plates and screws, as they tend

to delay union. Various methods of fixing grafts will
be mentioned later.

Perfect immobilization is an important factor in secur-
ing early vascularization and union. It is quite true
that a certain amount of mobility at the seat of a
fracture increases the output of callus, but this is of a
vicjous and really useless type. It is produced merely
by osteogenesis occurring in the increased exudate
caused by tearing and injuring the granulation tissue
which is being produced to unite
the fragments of bone. It is
much more reasonable to keep
the part immobile until union is
firm and has begun to ossify ;
then the next stage mentioned be-
low comes into play to strengthen
the union.

3. Growth of the Graft. — The
growth and development of the
graft so that it can perform the
function of the bone it replaces
is best promoted by a modified
or guarded exercise of the func-
tion of the bone, for then the
bone cells respond to the stresses
to which the part is subjected,
and build accordingly. This is
known as Wolff's law, which is
an essential foundation of all
surgery of bones and joints. This
law is familiar to all surgeons,
but it will not be out of place to
quote it here : " Every change in
the formation and function of the
bones, or of their function alone,
is followed by certain' definite
changes in their internal archi-
tecture, and equally definite se-
condary alterations of their ex-
ternal conformation in accordance
with mathematical laws." It follows from this that
when the graft and the bone have begun to unite firmly
the union will become stronger if a certain amount of
functional use is allowed, provided it is not violent
enough to tear up or break the union. Thus in a graft
in the leg or in the forearm the patient is encouraged to
move the tqes or fingers while the part is still in splints,
so that the slight traction of the muscles on their
origins round the site of the graft may produce a
physiological stimulus to increased growth.

In the next stage the splints adapted must allow more

Fig. 82. — Graft pushed into
open medullary cavity.

BONE GRAFTS 85

active use, while at the same time guarding against
strain which might cause a " fracture " at the seat of the
graft. Thus in the case of the lower limb an ambula-
tory splint is allowed while the part is still firmly
controlled by local splints.

USES OF BONE GRAFTS IN MILITARY SURGERY

i. To replace Bone destroyed by Infective Pro-
cesses, such as Acute Osteomyelitis. — As an instance
of bone grafting after osteomyelitis and of the extra-

Fig. 83 A. — Osteomyelitis of tibia; condition after removal of necrosed bone.
(Sketch from skiagram.)

Fig. 83 B. — Probe to hold ends of tibia apart during healing of wound.
(Sketch from skiagram.)

Fig. 83c.— Fracture of graft: marked callus exudation. (Sketch
from skiagram.)

Fig. 83 D.— The fracture of the graft united. (Sketch from skiagtam.)

ordinary vitality of the transplant, I would relate the
following facts : Several years ago I was consulted in a
the case of a youth with advanced osteomyelitis of the
tibia. I cut down along the whole length of the site of
the tibia, and found that the shaft had completely dis-

86 NOTES ON MILITARY ORTHOPAEDICS

appeared, and the periosteum also. When I had scraped
away all putrid material, there remained little except
the epiphyses and exposed muscles. A long sinus
probe was fixed lengthwise between the epiphyses in
order to maintain the distance between them, and the
wound was allowed to granulate. Several months after
the wound had healed and the probe had been removed
I transplanted a long strip of tibia from the sound
limb. This rapidly grew in thickness. The patient was
discharged from hospital, and gradually discarded all
supports. Seven months later he was knocked down one
day, receiving a blow on the leg which broke the trans-
plant, and I possess interesting radiographs of the callus
exudation and firm union at the site of the fracture.
This case was a great encouragement to me, for the
transplant was laid in an environment of firm cicatricial
tissue. The illustrations are drawn from the X-ray
photographs (Fig. 83 A, B, c, D).

2. To replace Defects of Bone where Portions of
Bone have been blown away by Gunshot Wounds. —
Treatment here follows the same lines as in the case
cited.

v To immobilize Injuries of the Spine in Cases of
Tuberculous Arthritis, or Injuries which lead to the
Development of Kyphosis. — In the present war there
have been many injuries of the spine which have been
followed by the rapid development of a kyphos, some-
times due to traumatic osteo-arthritis, sometimes to
tuberculous changes following the original injury. In
either case the treatment requires prolonged rest, during
which the patient is fixed in recumbency. The period
of recumbency can be very materially reduced by a
judicious operation.

4. As a Substitute for Plates and Screws. — Bone
grafting can be used as a substitute for plates and
screws in the treatment of certain types of fractures,
and to assist in securing union in cases of ununited
fractures.

TECHNIQUE OF BONE GRAFTING

Pieces of bone for grafts may be taken from almost any
bone in the body, but for most purposes the tibia is the
most convenient quarry in which to delve, for from it
pieces of bone can easily be cut of any length or thick-
ness likely to be needed. When a curved piece of bone is
required, as in surgery of the jaw, a portion of suitable
shape may be found in one of the ribs. I have employed
the shaft of the first metatarsal to replace a defect in
the ulna. The periosteum is left behind, the required
length of the shaft with the whole of the endosteum
being transplanted. The shaft of the metatarsal bone
is rapidly regenerated. The tibia, however, is the bone

BONE GRAFTING: TECHNIQUE 87

of choice, as periosteum can be transplanted with the
bone.

Operation. — The first stage of the- operation is to
prepare the bed for the graft, freshening the bone ends.
A pliable probe is then laid in the defect and bent to the
exact length of the graft required. The wound is packed
with gauze to stop bleeding, and covered with a sterile
towel while the surgeon removes the graft from the
selected area.

If the tibia is chosen, an incision of suitable length is
made along the outer side of the anterior border of the
tibia and the tibialis anticus is partially separated from
its insertion. The bent probe is then laid on the bone,
and the exact length of the graft required is marked off.
The periosteum is then incised on the outer and inner
surfaces of the bone, completely mapping out the portion
to be removed.

The removal of the graft is greatly expedited by the
use of a double circular saw (Fig. 84) electrically driven.
Great care must be taken to ensure that any part of the

Fig. 84. — Double circular saw for rutting bone grafts.

apparatus with which the surgeon or his assistant may
come in contact is scrupulously sterilized.

If an electric motor is not available a good hand motor
may be used. Failing both, the graft may be cut out
with drill and chisel, but this is a slower process, and
requires some care to avoid splintering the graft or
splitting the tibia. The method of procedure is to
drill a series of holes along the line of the incision in the
periosteum, and then connect these with the chisel.
The drill holes should be made into the medullary canal,
so as to ensure having some of the medullary aspects
of the bone in the graft (Fig. 85).

The transplantation should be made immediately ;
the graft should be picked up with forceps and not
touched even with the gloved fingers. It is laid directly
into the prepared bed, in which all bleeding has stopped
by this time. I am convinced that it is a mistake to
wash the graft in saline lotion or leave it in saline while
something else is being done. The best results follow
immediate closure of the deep tissues round it and suture
of the surface wound. The limb must then be securely
controlled in correct position either by splints or by a
plaster-of-Paris case.

88 NOTES ON MILITARY ORTHOPEDICS

Spinal Fixation. — Two operations are generally
described for spinal fixation — Albee's and Hibb's. The
details of the operations ought to be pretty well known,
as they have been before the profession for several years.

Albee's Operation. — This operation consists in trans-
planting a slip of the tibia into a series of spines of ver-
tebrae, bridging the weak spot in the vertebral column
(Fig. 86).

The surgeon should begin by preparing the site for
the graft. Each spine, including two above and two
below the weak or diseased vertebra or vertebras, is split
and broken outwards (Fig. 87), the junction of spine

Fig. 85, — Sliding graft marked out by drill holes preparatory to cutting out
with chisel.

and lamella being also roughened. The bed is packed
with gauze to stop bleeding.

The graft from the tibia is then cut with the circular
saw, or chisel and drill. The front of the tibia is reached
by securing the heel against the buttock with the knee in
acute flexion. This enables the surgeon to cut the graft
without turning the patient over. The whole operation
can thus be performed quietly and expeditiously.

The graft is then transferred and implanted while an
assistant stitches the wound in the leg..

No difficulty has been experienced in nursing these
cases on their backs in a Thomas's frame. This is applied
most easily after these operations by laying the frame
face downwards over the patient and turning the patient
and splint together with the aid of a sheet, thus avoiding
any strain upon the implant.

Hibb's Operation. — In this operation bony fixation of
the spines is obtained without transplanting bone from
the tibia. The spines are split, the upper and lower

SPINAL FIXATION

89

margins are broken away towards the adjacent spine, so
that the fragments split away from one spine interlock
with those split from the next. The laminae can also be
ankylosed. Superfluous chips of bone are sprinkled

Fig. £6. — Bone transplanted into cleft made in spinous processes.
(Albee's method.)

along the site of the operation, so that a line of callus
is formed locking all the spines together. I often prefer
to lay the graft upon the laminae rather than between
the spinous processes. A very suitable bed can be pre-

FU. 87. — Diagram of split spinous process with graft inserted in cleft.

pared there upon which the transplanted bone easily
lies (Fig. 88).

These operations are particularly useful in cases in
which the vertebrae affected are in the lower dorsal or
lumbar regions, for it is difficult to control these areas
completely in a support or jacket in which the patient
can go about. The alternative is prolonged recumbency

90 NOTES ON MILITARY ORTHOPEDICS

fixed in a splint or Thomas's frame. The result of one
or other of these operations is that a patient who in
former days would have been kept fixed in recumbency
for a year or more can be allowed up in a light spinal
support in three months, and can go about his ordinary
business as soon as he can walk comfortably, for with
this osseous bond between the vertebra there is prac-
tically no fear of kyphotic deformity occurring.

TECHNIQUE OF BONE GRAFTING FOR FRACTURES AND
DEFECTS IN CONTINUITY

The technique of bone grafting for fractures and for

Fig. 88.— Bone graft laid upon the laminae.

the replacing of defects in continuity of long bones,
either from loss of bone or from non-union, follows very
similar lines.

My views on the use of plates and screws in the im-
mediate treatment of fractures have been stated before
and need not be repeated at length. In most parts of ,
the limbs good alignment and good functional results
can be obtained by simple reduction and setting in
appropriate splints, and therefore the routine use of
plates seems superfluous. The art of setting fractures
is deserving of more study than has been given to it
by many members of our profession in recent years.
In the long bones correct alignment of the limbs, and
therefore of the lines of action of muscles and joints,
is more important than faultless apposition of the ends
of the fractured bone.

BONE GRAFTING 91

Excellent as plates and screws are in certain emer-
gencies, experienced surgeons know that they produce
actual delay in true and efficient osseous union of the
fracture.

In any case a metallic plate is a foreign body, and the
inevitable tendency of the tissues is to encapsule or
encyst the foreign body, while transplanted bone can be
built into the structure of the part, and therefore assists
osteogenesis.

Bone Grafting for Recent Fracture. — In my experi-
ence, spiral fracture of both bones of the leg, especially
in the lower third, is the only fracture in the limbs
which regularly presents almost insuperable difficulties
to satisfactory reduction and setting by non-operative

Fig. 89. — A, Inlay slide before being placed in position. P, Inlay
graft placed in position.

means. The difficulty is not in reducing the fracture,
but in persuading the fragments to stay in correct
alignment. The cause lies in the great tendency of the
foot and lower fragment to rotate, and then the frag-
ments override.

The Sliding Inlay Method (Albee). — In this fracture
the sliding inlay of bone, described in a previous chapter
(see p. 63), is a very fascinating and simple way of
locking the two fragments so that they do not easily
disengage when they undergo slight rotatory move-
ments. All that is required is the parallel circular saw
shown in Fig. 84.

The fracture is reduced and held or clamped in position
while the cuts are made as in the diagram (Fig. 89 A and
B). The shorter piece is lifted out, and then the longer
piece with the medulla is slipped down to lock the two
fragments of the broken bone. The smaller fragment is

92 NOTES ON MILITARY ORTHOPEDICS

then laid into the gap above the longer fragment which
has been slid down. Muscles, periosteum, or any other
of the deep tissue belonging to the part are stitched
over the graft, the wound is closed and the fracture put
up in sheet-iron splints or plaster, taking care that no
displacement occurs. In a few days organization has
occurred sufficient to prevent any further danger of dis-
placement unless there is carelessness or some unusual
disturbance of the part. It is seldom necessary to peg
or screw the fragments, and the introduction of a foreign
body is to be avoided.

This spiral fracture of the tibia in the lower third of the
leg is practically the only ordinary fracture for which, in
my opinion, operation should be considered at once as an
immediate procedure, and then fixation by bone to pre-
vent rotation is preferable to plating if it can be done.
Failing facilities for a proper fixation by bone, plating
comes next.

Neither plating nor bony fixation seems necessary in
any other ordinary fracture of the limbs. In the case
of unusual fractures exceptions occur. Further, each
surgeon must, of course, use his own judgment in every
case that comes under his notice, and employ those
methods which he best understands and in which he
feels most confidence. These will differ according tto the
surgeon's training. My contention is, however, that a
surgeon skilled in the use of splints can get good results
so generally that operation is rarely needed.

Ununited Fractures. — It may be admitted that in
dealing with ununited fractures when firm fixation is
required, plates and screws afford a most secure and
rapid means of fixing the fragments. This method re-
quires less surgical skill than when bone grafts are used,
both in the operative procedure and the after-treatment.
There is, however, always the point to be considered
that in these cases the patient has already shown defec-
tive osteogenetic power at the seat of fracture, and the
plate is, after all, a foreign body, which will be likely
to impede osteogenesis, while a bone graft is a direct
assistance to osteogenesis.

For many years I used to cut down on the ununited
fracture, crush and drill the ends of the bones to open
up new routes for fresh blood-vessels, and turn a strip
of periosteum off one fragment down to the other.

At a later period I employed in addition animal bone
as a graft, with results which were not very encouraging.
The use of a strip of the fractured bone as a bridge
between the two fragments was followed by much better
results (Figs. 90 A and 90 B).

It is assumed in the methods now to be described that
autogenous grafts are always used. The three methods

BONE GRAFTING

93

of employing a graft have been referred to in a previous
chapter.

i. The Lateral Graft. — This consists of laying a strip
of bone along the side of the bone to be repaired, taking

Fig. 90 A. — Fashioning of bed and freshening of ends for a slide graft in an
ununited fracture.

Fig. 90 B. — The slide in position ; portion removed from bed distributed
between ends of bone,

care to make a fresh bed for the graft along its whole
length, so that raw bone is in contact with raw bone
(Fig. 91).

It is the simplest method, and often the only one which
can be used — for example, when the ends of the broken
bone are tapering and wasted (Figs. 92 A, B, c).

Fig. 91.— Lateral graft.

2. The Intramedullary Plug (Fig. 82). — This can only
be employed when a good open medullary canal is avail-
able and the transplanted bone can be inserted into the
medulla above and below the fracture. This is often
difficult. It is advisable, when possible, to use it in
combination with the sliding or the lateral grafts.

3. The Sliding Inlay. — The inlay method described
above can be employed when bridging a gap ; the bits

94 NOTES ON MILITARY ORTHOPEDICS

of bone cut from the end of the slide must not be wasted,
but should be broken up and sewn along the site of the
defect to form additional foci of osteogenesis.

A combination of the sliding inlay (Figs. 90 A and B)

Fig. 92. — A, Preparing bed for transplanted lateral graft. B, Transplanted

lateral graft held in position by catgut. ' , Transplanted lateral graft held in

position by jails.

and medullary plug is a strong and satisfactory method
when available (Fig. 93).

CONCLUSION

Recapitulating in brief, it may be said that, whatever
particular theory of osteogenesis may be the true one,
the following points have proved valuable in practice :

The area of the graft must be kept scrupulously

Fig. 93. — The intramedullary plug used in combination with the sliding
or lateral graft.

aseptic, and free from unnecessary blood clot. Adequate
blood supply is necessary to the growth of the graft.

The graft must be placed in close apposition to raw
surfaces of the bone with which it is to unite.

The whole region must be kept fixed for a long period
for undisturbed organization to take place.

The bone graft should be autogenous, and it is better
that it should include « both periosteum and medulla
wherever this is possible, for both these aspects of the
bone afford facilities for the growth of new blood-vessels.

UNION IN FRACTURES 95

Surgeons should have patience, for union is often
delayed, and hasty conclusions that union is not going to
take place, and consequent relaxation of strict fixation
of the part, may convert a case of delayed union into
one of non-union.

After any of these procedures it is essential to fix the
limb absolutely to let new vessels grow undisturbed
by chance movements, for the idea of the operation is
that all the transplanted bits of bone shall become
vascularized.

As a general rule, the limb should be kept fixed and
undisturbed for at least twice the time necessary for
union of the same bone in an ordinary simple fracture.

I often see cases which have been operated on, and
in many instances plated, by some other surgeon, in
which splints have been removed at the end of a few
weeks, and the case has been regarded as a failure because
union has not taken place.

There is no definite time within which a fracture will
unite. The times given in textbooks are understated
as applied to the majority of cases. For example, I
may quote the case of a patient, seen in 1908, with an
ununited fracture of the humerus of twelve months'
duration, which was treated by the " hammer and dam "
method, but had to be kept still for nearly six months
before the bones united. The ultimate union was abso-
lutely satisfactory. Operative procedures had pre-
viously failed. This question of the consolidation of
fractures has been discussed in Chapter IV. The wounds
received in this war have brought the surgery of septic
bones very much into the foreground, and bone grafting
will have to be very extensively practised. We must
be careful to allow a sufficient time to elapse before pro-
ceeding to this operation. It is difficult to formulate
an exact rule as to when the operation should be per-
formed, for we seem never to be quite free from the
danger of recrudescent sepsis. My habit is to wait for
at least six months after a sinus is closed, during which
time and for a variable period afterwards efforts can be
made to improve the general nutrition of the limb.
It frequently happens that during this delay union of
the fragments takes place, and no transplantation is
needed. Early operation is to be discouraged from
every point of view, and failure to observe this rule has
resulted in many a tragedy. It is very exceptional,
unless there has been a great loss of bone, for non-union
to persist in fractures which are the seat of the type of
suppuration met with at this time.

CHAPTER VI
DISABILITIES OF THE KNEE-JOINT

EVERY kind of disability of the knee-joint may occur in
military practice, from a simple sprain to the results of
a severe wound.

An attempt will be made in this chapter to give a broad
classification of these derangements and disabilities, with
their diagnostic signs, and to indicate appropriate lines
of treatment.

There are three common conditions which are not
always as clearly distinguished by practitioners as they
might be. They are (i) simple sprain of the lateral
ligament, usually the internal ; (2) slipping of the semi-
lunar cartilage ; and (3) nipping of the infrapatellar pad
of fat. All these injuries may be produced by a twist
or fall which at first does not seem serious ; all are
associated with effusion of fluid in the joint, and in all
the patient complains of more or less recurring disability
after the lesion, unless it has been recognized and treated
in the first instance.

SPRAIN OF INTERNAL LATERAL LIGAMENT

Sprain of the internal lateral ligament is distin-
guished by definite pain and tenderness on pressure over
the attachments of the internal lateral ligament ; the
patient himself localizes the pain of which he com-
plains to the inner side of the knee ; definite pain and
tenderness are not found anywhere else about the knee,
and the movement of eversion and external rotation
of the leg stretches the injured ligament and retards
recovery.

The treatment indicated, therefore, is firm strapping
round the knee in order to steady it, and a raising of the
inner side of the heel to divert body weight to the outer
side of the foot, and thus relieve the ligament from ten-
sion. It is hardly necessary to say that this treatment is
preceded by rest in bed, usually with the aid of a straight
posterior splint. This is the initial treatment, but
neglect of the after-treatment just mentioned renders
the patient liable to recurring injuries of the ligament.

96

DISABILITIES OF KNEE-JOINT 97

• INTERNAL DERANGEMENTS OF THE KNEE

A regular gradation of injuries is met with, from a
slight strain of the attachments of the internal semilunar
cartilage of varying degrees of gravity to fractures of
the spine of the tibia with rupture of the crucial liga-
ments. The former is a condition scarcely distinguish-
able at first sight from a simple sprain ; the latter is at
once obvious as a grave disability. It has become very
important in military surgery to be able to distinguish
these conditions clearly by signs which can be deter-
mined by the surgeon rather than by symptoms described
by the patient ; as, in my experience, a considerable
number of men who wish to avoid service have found that
they can puzzle the medical officer by complaining of
obscure pain and disability in the knee.

There are very many cases in which military surgeons
have been led to operate upon a normal joint, expecting
to find some abnormality of the semilunar cartilage.
The cartilage is very frequently torn in its posterior
portion, and before deciding at operation that it is not
damaged it is necessary to dislodge it outwards. Hence
the necessity for careful consideration of symptoms
before deciding to operate ; it must be realized that
exploration, in the case of a cartilage, really involves
its removal, otherwise a damage at the posterior part
of the cartilage may be overlooked.

Mechanism of Certain Injuries. — Probably the best
way in which to get a clear idea of the injuries which
lead to error is to consider the mechanism of the various
injuries, beginning with simple sprain and going on to
real rupture or tear of the semilunar cartilage, and to
compare them with bruising of the infrapatellar pad of
fat, which is a lesion not always recognized or under-
stood.

All these conditions may lead to a recurring chronic
synovitis. Every case of recurring synovitis has a cause,
and practically each is curable if the cause is recognized
and receives appropriate treatment.

It has already been stated that simple sprain of the
internal lateral ligament is marked by a specially tender
spot over the attachments of the ligament and nowhere
else.

Rupture of Internal Ligament and Damage to the
Semilunar Cartilage. — If we remember the anatomical
fact that the internal semilunar cartilage is closely
connected round its convex margin with the deepest
layers of the internal ligament and with the capsule
of the knee-joint, we shall understand why a severe
twist of the knee, with the leg abducted, may rupture
the ligament and drag the semilunar cartilage with it,

98 NOTES ON MILITARY ORTHOPEDICS

straining or tearing the attachments of the anterior
horn. At this stage the inner side of the knee-joint is,
so to speak, opened out, and everything depends upon
what happens when it closes again as soon as the dis-
torting force ceases to act.

If the cartilage is caught in displacement between the
bones the knee " locks " in the manner familiar to us
all. The cartilage may be split, fractured transversely,
rolled up, or completely torn from its attachments. A
perusal of the literature of the subject, indeed, shows
that every conceivable injury to the semilunar cartilage
may take place, and such cases have often been fully
described. Sometimes the cartilage slips back into
position without being crushed or caught between the
bones ; there is then no locking of the joint, but, in
every respect, the etiology of the lesion is the same with
the exception of the actual injury to the cartilage, and
the patient generally states that he felt something
" slip " or " click " in the knee, but could quite easily
straighten it immediately after the accident.

The history suggests the usual cartilage injury of text-
books but without locking ; the knee becomes distended
with fluid, and the patient refers his pain to the inner
side. The physical signs are tenderness on pressure
over the internal lateral ligament, and a specially tender
spot to the inner side of the ligamentum patellae just
over the border of the tibia, a symptom always strongly
suggestive of an injury about the attachment of the
anterior end of the internal semilunar cartilage.

The treatment of the condition when the knee cannot
be fully extended without causing pain will be discussed
later. If the knee can be fully extended without causing
pain, the aim should be to ensure complete rest until
the torn attachments have united. The knee should be
kept absolutely straight on a back splint for at least
ten days, the bandage being firmly applied over cotton-
wool. After this the patient may begin to walk, and
when he does so he should have a firm bandage over the
knee to prevent effusion into it. Movements of the
joint should be very limited the first day, and should
gradually increase in range.

A common fault in treatment is to allow the patient
up without a proper protective bandage on the knee, the
result of which is effusion into the joint, and, what is
more harmful, into the newly formed cicatrix about the
anterior horn of the semilunar cartilage, thus stretching
the newly formed scar and letting the end of the cartilage
shift about. When this happens the patient is often
put to bed for a week until the effusion has disappeared,
but when he gets up again the effusion recurs, and so
he goes on week after week, until finally the attach-

DISABILITIES OF KNEE-JOINT 99

merits of the anterior end of the cartilage become
elongated and slack. The patient then complains that
occasionally he feels a " give " in the knee, but it does not
" lock." Some day a slight unusual twist may result
in a real locking of the joint.

A joint such as this which has been the seat of a
definite injury will generally fill up with synovial fluid
when first used. Therefore the application of a pressure
bandage should never be omitted. If the knee is care-
fully brought into use by graduated exercise, there should
never be much effusion, and each day it should be less
in amount ; that is to say, there is no effusion in the
morning, although by the end of the day it may have
appeared, and each evening the amount is less than on
the preceding one.

Thickened Cicatrix about the Semilunar Cartilage.
— If the effusion does not become progressively less,
either the patient is using the knee too much and mov-
ing it too roughly, or some injudicious masseur is
moving it too roughly for him, or the surgeon has made
a mistake in his diagnosis and there is some condition
in the joint which requires further attention, and he
should make a careful examination and reconsider his
opinion of the case. When these cases have been the
victims of defective after-treatment, repeated stretching
and effusion about the anterior end cf the semilunar
cartilage gives rise to a thickened cicatrix, which is
tender, and can sometimes even be felt by the surgeon
moving under his finger as the knee is flexed and ex-
tended. This painful spot is situated at the diagnostic
point, already described, on the front of the knee, well
to the inner side of the ligamentum patellae. Some-
times this cicatricial thickening is so great that it is
pinched between the bones when the knee is fully
extended, and this causes sharp, well-localized pain and
tenderness.

Treatment in such cases depends upon the exact
condition, and two types must be distinguished :

1. In cases in which the cicatrix is not pinched,
but merely gives rise to a sense of insecurity as if
something is moving or " clicking " inside the
joint, a rigorous course of strict rest, followed by
massage and carefully graduated exercises, may
cure the condition in a month.

2. In cases in which the cicatricial mass gets
definitely nipped, the condition has become similar
to the type of displaced semilunar cartilage usually
described, and if rest and careful exercise fail, an
operation to remove the whole mass is indicated —
the opportunity being taken to inspect the cartilage
at the same time.

ioo NOTES ON MILITARY ORTHOPEDICS

Displaced Cartilage with " Locking." — It has long
been recognized that definite locking of the knee-joint
is a characteristic sign of displacement of the internal
semilunar cartilage, as described in textbooks. This
condition is a more severe variety of the injury just
described ; it differs from it in the fact that some portion
of the cartilage is, for a time at least, caught between the
bones and prevents full extension.

The treatment of this condition aims at the restora-
tion of the power of extending the knee fully without
pain.

If the displaced cartilage is fully reduced the knee can
be fully extended, both actively and passively, without
pain. If this cannot be done, the cartilage is not re-
duced. When the cartilage becomes disengaged the
patient is aware of it — in fact, he is the most competent
judge of the success or failure of the manipulation.

Treatment of the Initial Injury. — First, complete re-
duction is necessary. This can usually be effected by
manipulation without the use of force, and the routine
I prefer involves the active assistance of the patient.
The patient should lie on his back with the thigh flexed
on the body and the leg on the thigh. When in this
position the surgeon can manipulate the leg, and can
sometimes feel a fullness over the site of the displaced
cartilage.

The patient is then told that he will be given the word
" One, two, three — kick ! " On the word " kick," the
patient extends the limb as suddenly as he can. At the
same time the surgeon rotates the foot inwards and pulls,
while pressure is placed upon the thigh. If the dislocated
cartilage is reduced, the patient is almost certain to
announce the fact, and the objective sign is that the
knee can be completely extended without impediment.
The knee, surrounded by wool, should be bandaged
firmly, and fixed on a posterior knee splint. If the
patient is not of a temperament likely to be helpful, an
anaesthetic is advisable.

Our next effort is to secure the healing of the lesions
in and about the cartilage, so that it may have a chance
of adhering in its proper position. The patient should,
therefore, wear the splint for about ten days, but can
usually be allowed up in his room at the end of five days.
After ten days he may walk with the knee bandaged,
taking care not to bend the knee suddenly. Active
flexion of the joint should be practised very gradually,
and the quadriceps muscle should be massaged and
exercised gently. If the progression is carefully made
from gentle to stronger movements, the full range should
be recovered without the recurrence of any effusion in
the joint in about three weeks. The majority of these

DISABILITIES OF KNEE-JOINT 101

cases, carefully and efficiently treated in the first in-
stance, do not give any further trouble.

Where a successful reduction is not accomplished, and,
in consequence, the patient is not able to extend the knee
fully, an operation will probably be required.

Cases of Imperfect Reduction. — I see many cases two
or three weeks or more after the accident, in which
it is obvious that attempts at reduction have either
not been made or have failed. The surgeon in charge
of the case may have thought that he had got the knee
fully extended, but passive extension still caused pain,
localized over the anterior end of the cartilage ; the
knee filled with fluid when the patient walked, and,
though comparatively free from pain after rest, it became
tender after exercise. It is often possible, even after
weeks of displacement, to reduce the cartilage in these
cases by manipulation similar in kind but more forcible
than that necessary in dealing with the oiiginal injury.
This manipulation forces the displaced cartilage from
its abnormal to its normal position, where it may become
firmly and accurately fixed. This late reduction so
often succeeds that it is always worth trying. If,
after an attempt at reduction under anaesthesia, the
cartilage still remains in a position in which it gives
trouble, or if it remains loose and frequently gets nipped,
operation is the only sure treatment ; for the case now
has become one of recurring dislocation of the semilunar
cartilage with locking of the joint.

A word of warning may here be given about cases in
which reduction is apparently complete, and the patient
can get about with tolerable comfort, but complains that
the knee-joint does not feel quite secure, although there
is no evidence of the intrusion of any structure between
the bones. These symptoms are often due to some
minute adhesion within the joint which does not pro-
duce sufficient limitation of movement to be detected
by the surgeon, but leaves the patient with the sense
that he cannot use the joint without a feeling of restraint.
Full movement of the joint, particularly in rotation,
under gas anaesthesia, will often remove these symptoms,
although the surgeon cannot always feel any definite
adhesion give way during the manipulation.

Operation on the Internal Semilunar Cartilage. —
It is needless to say that the knee should never be
opened except under the most scrupulously aseptic con-
ditions, and never in a hospital in which there are a
large number of septic cases. Operations on cartilages,
even at base hospitals at the front, should be dis-
couraged. It is not a practice which can be recom-
mended, as the environment is a source of danger, no
matter how experienced the surgeon.

loa NOTES ON MILITARY ORTHOPEDICS

The procedure which I prefer is the following : The
leg is placed to hang over the end of a table at right
angles to the thigh ; the knee is wrapped in sterile
gauze, soaked in biniodide solution ; the incision is
made through the gauze, and the edges of the gauze
clipped over the skin edges to the superficial fascia.
As the knife with which the skin is cut may become
infected by Staphylococcus albus, a second clean knife
should be used for all the deeper dissections. The
incision need not be more than an inch or an inch and a
half in length ; it is made over the anterior end of the

Fig. 94. — Showing position of incision.

cartilage, sloping very slightly downwards and inwards
— that is, nearly, but not quite, parallel to the upper
edge of the tibia (Fig. 94). Great care should be taken
never to allow the incision to extend far enough to the
inner side to cut any fibres of the internal lateral liga-
ment ; this is a fault which leads to weakness of the
knee lasting for months or years, and is, unfortunately,
still frequently to be met with in cases which have been
operated on by the old large J -shaped incision described
in textbooks. The joint being opened,, a blunt hook
can be slipped under the free margin of the cartilage,
and by picking it up it can easily be seen whether the
front part is intact, or torn, or has tags or projections
producing disability. In removing the whole cartilage

DISABILITIES OF KNEE JOINT 103

great care should be taken that no tags of cartilage are
left projecting from the attachment to the coronary
ligament, as these frequently give rise to continued symp-
toms, due to nipping or adhesions, and may necessitate
a second operation. The condition of the fringes
should be examined before closing the knee, and by
retracting the patella the opposite front part of the
cartilage can be inspected, if this be deemed necessary.
No movement of the knee must be allowed after the in-
cision has been made, as this may favour the entrance of
air — a minute risk, but an avoidable one, and therefore
one which the surgeon has no right to take. It is not
until the stitching is complete and pads are placed over
the wound that the knee is straightened. Dressings are
then applied, elastic pressure is put on by bandaging
over large pads of wool, and a simple posterior knee
splint affixed to keep the knee straight. If the operation
is performed with a tourniquet around the thigh — and
this is advisable — no vessels need be tied ; and if the
elastic pressure is applied before the tourniquet is re-
moved there need be no fear of bleeding into the joint.
My experience of these operations now extends to
over two thousand cases, and I feel that I can speak
with some authority.

After-treatment. — In a straightforward case there
is no reason why the patient should not get out of bed
on to a couch on the third or fourth day. He should
not, however, put his foot to the ground for the first
week. The stitches are removed as usual about the tenth
day and massage may be commenced, the patient being
allowed gradually to bend his knee. Each day he exer-
cises, bending and extending the knee more and more,
until in about three weeks he should reach the full
range of movement and walk with freedom. In my
practice several professional footballers have resumed
their game in six or eight weeks after the operation.
There is no reason why in suitable cases men should
not return to light duty about five weeks after the
operation, and, if properly exercised, be fit for full duty
three weeks from that date. This, however, depends
upon the patient being put through a course of carefully
graduated movements and exercises during the whole
period of his convalescence.

Surgeons who have been operating upon soldiers com-
plain of the weakness in the knee which so often follows
operation. This experience is common, but if the
operation has been properly performed and the after-
treatment by massage and exercise has been thorough,
these disappointments will not occur. The surgeon
should be assured that the thigh muscles are restored
to their normal condition, and a patient should not be

io4 NOTES ON MILITARY ORTHOPEDICS

discharged from hospital until the thigh has attained
its normal girth. We must also retain a critical attitude
of mind, for some soldiers are keen to remain off duty,
and the knee is often only an excuse.

RECURRENT EFFUSION INTO THE KNEE-JOINT

Recurrent effusions into the knee-joint are often very
puzzling. It is possible, however, to lay down a few
rules for guidance.

1. After injury of the knee, effusion of fluid into the
joint is very liable to occur, and if the patient is kept
resting and not using the limb, the effusion will probably
recur the first time he uses it. The patient is again put
to bed, but when he gets up effusion reappears. The
rational treatment in such cases is to bandage the knee
firmly and let him walk, and in the evening there will be
some effusion which will disappear by morning. The
knee should again be bandaged and the patient allowed
to walk. In the evening there will still be effusion,
but not so much as before. By following this routine
the joint will gradually become accustomed to the in-
creasing exefcise, with a diminishing amount of effusion
on each day. This is the real test that a joint which
has been injured is really recovering and is fit for
gradually increasing exercise.

2. The second point is that recurring effusion which
increases instead of diminishes under the above careful
treatment is a sure indication that the joint is not
fit for use, and localizing symptoms and signs should
be searched for to find what is the precise cause of the
disability.

3. Recurring effusion which is associated on each
occasion with some slight mishap — a trifling strain,
such as a twist of the knee, a feeling that something has
slipped in the joint, or definitely localized pain — is
rather an indication that there is some definite body
loose in the joint which is occasionally getting nipped,
though not retained long enough in one position to
produce " locking." The surgeon should then decide
whether it is an enlarged pad of fat, a loosened cartilage,
or a loose " body," or a portion of the cartilage left after
operation.

DISLOCATIONS OF THE EXTERNAL SEMILUNAR
CARTILAGE

The symptoms associated with accidents to the ex-
ternal semilunar cartilage are much less clearly defined
than those associated with injury of the internal
cartilage. One reason for this is that the external
cartilage is not attached to the external lateral ligament

DISABILITIES OF KNEE JOINT 105

of the joint, and there is no definite mechanism by
which it is pulled out of place. " Locking " may occur,
the pain being referred to the front or back portion of
the outer part of the knee according as the anterior
or posterior end of the cartilage is torn from its attach-
ment or crumpled up. Cases occur in which both car-
tilages are displaced by one injury, suggesting that
it is only a rather more severe accident than that
usually associated with the displacement of the internal
cartilage which damages the external one also, the
mechanism probably being a lateral sliding of the con-
dyle on the top of the tibia, squeezing the cartilage out
of place and tearing its attachment.

RUPTURE OF CRUCIAL LIGAMENTS

In more severe accidents to the knee the displacement
of the tibia on the femur may be sufficiently great to
cause rupture, not only of lateral ligaments, but of the
intrinsic ligaments of the joint. This may or may not
amount to what may be described as complete disloca-
tion. Experience of cases of dislocation of the knee-
joint, in which of necessity all the ligaments have been
torn, proves that with appropriate rest in a correct
position an astonishingly good result can be obtained.
When called on to treat a serious accident such as this,
the practitioner's instinct is to get the limb straight
and to keep it fixed for a long time. It is when the
accident has been less than a complete dislocation that
one is liable to think that less strict treatment may
suffice. Consequently, cases are met with in which
the patient suffers from abnormal mobility of the knee-
joint, clearly indicating that one or both of the crucial
ligaments have been ruptured or stretched. Bearing in
mind the mechanism of the crucial ligaments, it is not
difficult to make a diagnosis.

1. The anterior crucial ligament is tense when the
knee is fully extended, and prevents the tibia from being
displaced forwards on the femur.

2. The posterior crucial ligament is tense in com-
plete flexion, and prevents the tibia from being dis-
placed backwards on the femur.

3. Both ligaments check inward rotation of the tibia.
Hence, if the tibia cannot be- displaced forwards in the
extended position, it may be assumed that the anterior
crucial ligament is not completely torn ; and if the
tibia cannot be displaced backwards in full flexion, the
posterior crucial ligament is presumably not ruptured.
Abnormal mobility indicates elongation or rupture of
the corresponding ligament. The history of an injury
helps the surgeon to exclude cases in which prolonged

106 NOTES ON MILITARY ORTHOPEDICS

distension of the joint with fluid has caused elongation
of all the ligaments, as well as the conditions associated
with diseases such as Charcot's disease or locomotor
ataxia.

The treatment, when any such condition is diagnosed,
is prolonged rest with the knee in extension, or fixed
in plaster, or a Thomas calliper splint, in which the
patient can walk, the object being to keep the joint
immobilized for a time long enough to allow union of
the torn ligaments or adaptive shortening of stretched
tissue. The operation of stitching the ligaments is
absolutely futile as a mechanical procedure. Natural
cicatricial tissue, allowed to mature without being
stretched, is the only reliable means of repair.

FRACTURE OF THE SPINE OF THE TIBIA

The mechanism of this accident appears to be the
following : The knee is subjected to violent torsion
such as might produce a dislocation or rupture of the
crucial ligaments ; at the time when the force is applied
the condyle of the femur grinds across the surface of
the tibia, and the sharp intercondylar margin shears
off the spine. In some cases avulsion of the spine
occurs instead of rupture of the crucial ligaments.
The displaced fragment of bone may be lodged in the
front part of the knee-joint, and so prevent its full
extension. Diagnosis is verified by X-ray examination.

Symptoms. — The most constant symptom is a some-
what rigid block to full extension, usually accom-
panied by pain behind the patella.

Treatment. — If the knee can be fully extended the
displaced fragment of bone being presumably pushed
back somewhere between the condyles, the knee should
be fixed in this position for a long period to allow the
torn structures to reunite. On the other hand, if the
displaced fragment blocks extension, and the surgeon
cannot manipulate it back into a harmless position, or
extend the knee even by moderate force, it is best to
remove the obstructing fragment of bone, fixing the
knee afterwards in a straight position, and leaving
Nature to effect her own repair. The surgeon must
use his own judgment as to the route he adopts ; the
freest access is obtained by splitting the patella longitu-
dinally (Fig. 95), but if the X-rays show that the offend-
ing fragment of bone could be reached by an incision
at the side of the patella, this is a less severe method of
procedure. As I am largely responsible for the split -
patella route in dealing with unusual derangements,
I am anxious to emphasize that it is only needed in
exceptional cases.

DISABILITIES OF KNEE-JOINT 107

THICKENED RETROPATELLAR PADS OF FAT

Almost any injury of the knee which is associated
with increased vascularity or bruising may give rise to
swelling of the pad of fat situated behind the patellar
ligament. Consequently this fat is liable to be nipped
in full extension of the knee. In ordinary civil life, this
forms one of the varieties of the initial stage of a local
monarticular rheumatoid arthritis. The condition, how-
ever, is in no sense rheumatic. The patient complains
of pain and tenderness in the knee after walking, and
especially when going up and down stairs, or when getting
up suddenly from a chair after sitting for any length of

Fig. 95. — Showing patella split. A, Femur: l!, Tibia: c. Transverse ligament:

i>. Anterior crucial ligament; E, Posterior crucial ligament; F, Cut halves of

patella.

time. The condition is maintained by the repeated
small injuries which occur every time the knee is fully
extended. The treatment, therefore, is obviously to
prevent the patient from inflicting small bruises on
the tender fat and its covering of synovial membrane.
This can easily be done by putting a cork pad, half an
inch thick, inside the boot under the heel, to prevent
the complete extension of the knee during walking, and
by fitting the knee with a cage support (Figs. 96 and 97),
which allows full flexion but limits extension by about
30 degrees. When wearing this boot and cage splint the
patient cannot fully extend the joint and in this way
bruise the post-patellar fat. The swelling gradually
disappears, and .after a few weeks full extension can
be performed without pain. The diagnosis of this

condition is easy. The patient complains of pain in the
knee, or, more often, in the front of the knee, not at
the inner side. Passive extension of the knee by the
surgeon produces the pain, which is definitely localized
just below and behind the patella. On palpation the
thickening of the pad of fat may be felt ; it is enlarged
and tender, but there is no sensitiveness over the in-
ternal cartilage or the internal lateral ligament. In
some instances the retropatellar pad of fat may be bruised
in common with injury to the semilunar cartilage.

Fig. 96. — Cage support for
knee.

Fig. 97. — Cage support for
knee applied.

The full tender point of the internal lateral ligament,
cartilage, and fatty pad will be found in such a case..

In all the injuries of the knee which I have been dis-
cussing, wasting and weakening of the quadriceps
muscle is a characteristic feature, and no treatment can
be regarded as sufficient which does not provide for the
restoration of the efficiency of this muscle during the
stage of convalescence. This is particularly to be noted
in the condition which is now under discussion, for some
of the deep short fibres of the subcrureus muscle are
inserted into the synovial membrane of the. joint, and
when they contract they draw up the synovial mem-
brane and help to pull the pad of fat out of danger
when the knee is extended. Neglect, therefore, of the

DISABILITIES OF KNEE-JOINT 109

quadriceps muscle will leave the patient peculiarly
liable to a recurrence of the injury.

If the reader has appreciated the regular gradation
of disorders of the knee already described, he should have
little difficulty in applying and adapting the method of
diagnosis and treatment to unusual types which occur
as a result of injuries in military service. Even bullet
wounds through the joint, which sometimes chip off
fragments of bone, can be dealt with on lines similar to
those indicated for fractures of the spine of the tibia.
The whole question of septic arthritis in and about the
joints, with resulting ankylosis, is a larger subject,
which cannot be dealt with in these pages.

CHAPTER VII

THE MECHANICAL TREATMENT OF FRAC-
TURES UNDER WAR CONDITIONS

THE methods employed must be both efficient and
simple ; they must allow easy and painless access to
the wound, and ensure immobilization of the limb
during transport. The following notes are a contribu-
tion towards the attainment of these needs, but it must
be understood that modifications of them may be
rendered necessary by the severity of the wounds, or
by the necessity of providing for the transport of the
patient, should early evacuation be necessary.

Plaster-of-Paris, so often used in the treatment of
simple fractures, becomes a filthy method where sup-
puration has occurred. Despite every precaution for
the exposure of the wound the plaster mops up dis-
charges, and becomes horribly offensive, adding to the
infection of the wound. I would urge my young col-
leagues at the front to discard it altogether.

FRACTURES THROUGH THE LOWER SPINE
AND PELVIS

Fractures through the lower spine and pelvis are, in
my opinion, best treated on the double Thomas frame.
(Figs. 98, 99, 100). All that is needed is to place the
patient on the frame, bandage the limbs, and press the
body and leg wings into position to prevent side move-
ment. If there is any wound on the posterior surface
that requires dressing, the pad can be shaped accordingly
to allow of access.

THOMAS'S DOUBLE FRAME

Measurements required : Nipple to external malleolus.
Splint Measurement : 4 in. less than above measure-
ment.

Application. — Place the patient -on the splint with
the buttocks on either side of the horseshoe-shaped
gap in the back pad, which has been left for nursing pur-
poses. The wings of the splint should then be moulded

FRACTURES: WAR CONDITIONS m

round the patient's chest and ribs, care being taken to
turn them up acutely enough from the back pad to pre-
vent side movements of the body. A 5-in. -thick pad
is placed under each
knee to prevent genu
recurvatum, and the
ankle grips, which reach
just above the malleoli,
must be well padded.
The knees are now ban-
daged firmly to the
splint, and constant
pressure of bed-clothes
on the feet avoided
during treatment.

Double Frame too
Short. — Place the pa-
tient as high up. on the
splint as the lesion will
allow. Posterior knee

Fig. 98.— Thomas's double
frame.

Fig. 99. — Thomas's doable frame
applied.

splints firmly bandaged to the knees will be found to

supply the deficiency at the foot of the splint quite well.

Double Frame. too Long — Place the patient on

the splint with chest band at the nipple line as usual.

ii2 NOTES ON MILITARY ORTHOPEDICS

Readjust the back pad sufficiently high up the splint to
allow for nursing purposes. The pads under the knees
will require to be larger, and the heels must be protected
with rectangular foot splints or plaster-of-Paris, as
they will be lying on the leg bars of the splint — other-
wise, proceed as usual.

Hints for Nursing a Patient on Double Frame. —
The patient should never be turned for nursing purposes,
or the spine and limbs will sag laterally. Place a
block underneath the bar between the ankles to avoid
pressure on the heels, increasing the height of the block
when necessary to insert a flat bedpan beneath the
splint. In this raised position all necessary washing of
the buttocks can be done. The patient is never taken
from the splint, nor are the bandages removed for

Fig. 100. — Method of lifting patient on Thomas's double frame.

any purpose, but only the exposed skin washed. The
feet should be supported at right angles, and protected
from the weight of the bed-clothes.

HIP AND UPPER THIGH

Fractures through the hip- joint and those just below
the trochanter are best treated by a modification of
the Thomas splint, which I have described as an " ab-
duction frame " (Fig. 101). It is a splint upon which
the patient lies and can be carried (Figs. 101 and 102) ;
extension is easily applied, maintained, and need not
be relaxed for any purpose. The patient is placed upon
this splint, and any displacement should be overcome
by immediate extension in the abducted plane. The
limb should be rotated inwards slightly until the foot
is at right angles to the table and be fixed in this position

FRACTURES: WAR CONDITIONS 113

on the frame. It will be seen by the illustration that
)th limbs are controlled and that extension is secured
by strapping on the injured limb with counter ex-
tension by means of a smooth leather groin strap on
the opposite side of the pelvis. This groin strap should
not be slackened by the nurse under any pretext, but
in order to avoid pressure sores she should be instructed
to alter the area of skin subjected to it over the ad-
ductor muscles by moving it to and fro. This method
of " fixed extension " in abduction secures the lower

Fi{. 101. — Left abduction frame.

limb in relation to the pelvis in a manner which can
never be satisfactorily achieved by weight and pulley,
where reliance is placed on the weight of the body for
counter-extension. It is by reflex nervous impulses,
induced by changes of tension in the muscle, that
muscular spasm is produced. A patient lying in bed
with a fractured femur — high up or lower in the shaft — •
cannot avoid constantly changing the state of tension
of the muscles of his thigh if a weight and pulley are
attached to his limb. The counterpoise is the weight
of his body. Every time he tries to shift the position
of his shoulders by digging his elbows into the bed
he alters the tension of his muscles, calling forth a

H4 NOTES ON MILITARY ORTHOPEDICS

reflex spasm. When he falls asleep and his muscles
relax ; when he moves in his sleep ; when he is lifted
xipon a bedpan or moved slightly by the nurses to
have his bed put straight, there is apt to recur this
reflex contraction due to sudden change in tension.

The long Listen splint, which is much in use, is quite
unsuitable for fractures of the upper thigh. It does not
permit abduction, but maintains the limb in line with

Fig. 102. — Left abduction frame applied. Fig. 103. — Left abduction frame:

limbs parallel for transport.

the trunk — a position which must result in angular
union, and in a sagging which proves one of the very
common and troublesome deformities. Furthermore,
as the splint extends to the axilla, any movement of
the trunk involves movement of the limb, and attention
to the secretion disturbs the fracture. Both the Listen
and the ordinary weight and pulley are ill suited for
any form of fracture with suppuration, where good
alignment, comfort and ease of transport are desired.
One of the objections to the old abduction frame was
the difficulty of transport. The abducted limb proved

FRACTURES : WAR CONDITIONS 115

difficult both on the boat and in the train. To obviate
this, the splint is now made so that the patient may be
put up for transport with both limbs parallel. As soon
as the patient arrives at hospital the limb is abducted
without disturbing him in any other way (Fig. 103).

The patient who lies on an " abduction frame " can
be lifted and moved without pain, without disturbing
the fracture or relaxing the extension, and the dressing
can be changed without interfering with the mechanism
of fixation. If the wound is through the buttock and
the discharge takes place there, the splint can be modified

Fig. 104. — Modified abduction frame for pelvic wound ; only to be used
while wound discharges.

as shown in the illustration (Fig. 104). The abduction
frame can be applied in a few minutes.

ABDUCTION FRAME

Measurements required : Nipple to external malleolus.
Splint Measurement : From chest band to ankle grip,
4 in. short of above measurement.

Application. — A strip of adhesive plaster, to which a
strong loop has been sewn at one end, is applied to each
side of each leg. The adhesive plasters should reach
from as near the lesion as possible to the malleoli — the
loops lying at each side of the heel. Bandage these

n6 NOTES ON MILITARY ORTHOPEDICS

on firmly. The patient now lies on the splint (see
" Double Frame," p. no), but before bandaging down the
knees lay the body of the groin strap along the gluteal
fold of the sound limb, securing it by means of its per-
forated ends to the pegs on the splint wing. Next apply
the traction required to the injured limb, maintaining it
by tying the external loops to the end of the splint by
means of bandage which has previously been passed
through the loops. The groin strap remains stationary.
Further traction of the limb is obtained by means of
this extension. The sound limb should have very slight
traction applied to avoid pelvic tilting.

If Abduction Frame too Short. — Place patient on
abduction frame allowing only about 6 in. of space
between the heels and the extension loops of the splint.
Move the back pad higher up the splint fitting the gap
between the patient's buttocks for nursing purposes.
Having fitted the groin strap to the patient's gluteal
fold, tie the perforated ends over the chest band of the
splint at the axilla and proceed as usual.

If Abduction Frame too Long. — Place patient on
abduction frame, fixing the groin strap in the usual
manner. If the chest band will not mould down suffi-
ciently to lie comfortably in each axilla, it may be
turned back flat with the bed and ignored. Heels that
do not reach beyond the leg piece of the splint must be
protected from pressure with a rectangular foot splint or
plaster-of- Paris, and proportionately thicker pads placed
under the knees (see " Double Frame").

Nursing Hints for Patient on Abduction Frame.
— The patient should never be turned for nursing pur-
poses, or the spine and limbs will sag laterally. Place
a block underneath the bar between the ankles to avoid
pressure to heels, increasing height of block when neces-
sary to insert a flat bedpan beneath the splint. Also in
this raised position all necessary washing of the buttocks
can be done. The patient is never taken from the
splint nor are the bandages removed for this purpose,
but only the exposed skin washed. The feet should
be supported at right angles, and protected from the
weight of the bed-clothes. Remove the groin strap
for five minutes four-hourly during the first twenty-
four hours ; twice daily is usually sufficient afterwards.
Rub area with spirit and powder during these intervals,
replacing strap in same hole as before, but as much as
possible over a different adductor skin surface.

UPPER MIDDLE AND LOWER THIGH

For all other fractures of the thigh the Thomas bed
splint is incomparably the simplest and best (Fig. 61).

FRACTURES: WAR CONDITIONS 117

I have often fixed a fractured thigh in this splint and
sent the patient home in a cab. By reason of its con-
struction, it automatically secures a correct alignment,
as any surgeon with a mechanical mind can see if he
examines the illustration. I am in the habit of using
this splint for the treatment of all fractures of the
middle and lower third of the thigh, fractures through

Fig. 105. — Strapping extensions applied to leg. Suspension slings
to splint to support limb.

the knee-joint, and fractures through the upper and
upper middle portion of the leg.

The application of the Thomas bed splint is quite
easy. Strapping of adhesive plaster is applied in the
usual way to the sides of the limb. At the lower end
of the extension strapping there is a loop of webbing to
which is attached a length of strong bandage (Fig. 105) .
The ring of the splint is passed over the foot (Fig. 106)
and up to the groin till it is firmly against the tuber

ri8 NOTES ON MILITARY ORTHOPEDICS

ischii. The extensions are then pulled tight, the ends
turned round each side bar (Fig. 107) and tied together
over the bottom end of the splint, which should project

6 or 8 in. beyond the foot.
Care must be taken to avoid
internal or external rotation
of the limb, the foot being
kept at right angles. Local
splints can then be em-
ployed, and are made of block
tin or sheet iron. They can
be moulded by the hand to
fit the limb, and yet, being
gutter-shaped, they are rigid

Fig. 106. — Introducing limb through
ring of Thomas's knee splint.

Fig. 107.— Knee splint

in position, traction

applied.

longitudinally (Fig. 108). They can be disinfected by
fire or water. A couple of transverse bandage slings
suspend the limb from the side bars of the knee splint.
A straight splint is placed behind the suspensory band

FRACTURES: WAR CONDITIONS 119

ages of the thigh and knee. On the front of the thigh
another sheet-iron splint is applied, and the femur is
thus kept rigid. The alignment from the hip-joint to
the ankle is perfect, being dependent on a straight
pull (Fig. 109).

One may prefer to use a screw extension instead of
bandage in some cases, when there is difficulty in main-
taining the full length of the limb (Fig. no). This splint
allows the patient to raise his shoulders, or even sit
in bed. His other leg can be moved freely without
altering the tension on his thigh muscles, and there is
no reflex spasm. Even if the muscles try to contract
they cannot, for the ring of the splint is firm against
the tuber ischii. The muscles therefore do not remain

Fig. 103. — Sheet-iron splints moulded by hand for various uses.

on the alert but become quiescent, and starting pains
do not occur. Such is the difference between " fixed "
and " intermittent " extension.

In using this splint a little attention is necessary to
prevent soreness of the perineum. The ring of the
splint, being covered with smooth basil leather, can
easily be kept clean ; so can the skin-. The dressings
can be applied without in any way interfering with the
action of the splint. When the fracture has occurred
through the knee or upper tibia the splint is applied
in the same way.

It has often been a matter of astonishment to me
that so simple and effective a splint has not been
universally employed. It can be applied in a few
minutes, usually without an anaesthetic, and one is
always sure of good length and good alignment. The

120 NOTES ON MILITARY ORTHOPEDICS

fractured limb can be moved in any direction without
giving pain, so that transport is easy and safe. I have
never yet had to plate or wire a femur in a recent case,
and this I ascribe to using the Thomas splint.

THOMAS'S BED KNEE-SPLINT

Measurements required : Horizontal circumference of
thigh at groin, length of leg from fork to base of heel.

Fig. 109. — Thomas's

bed knee-splint with

local splints applied.

Fig. 110.— Screw ex-
tension which may be
used with Thomas s
knee 'splint or abduc-
tion frame.

Splint Measurement : Add 1 1 in. to circumference
measurement to allow for obliquity of ring. Add 6 in.
to 8 in. to length of leg measurement to allow for ex-
tension pull.

Application. — Apply a strip of adhesive plaster, to
which a loop has been sewn at one end, to each side of
the leg with the loop lying at the heel. These should
be firmly bandaged on and reach from the heel to as
near the lesion as possible. Slide the ring of the splint
over the foot and up the leg, pushing the ring well into

FRACTURES: WAR CONDITIONS 121

the groin, and apply the necessary counter-extension on
the limb. This counter-extension is maintained by
tying the extension loops to the end of the splint by
means of bandage which has been previously passed
through the loops.

A posterior knee-splint, short enough just to avoid the
gluteal fold at the upper end and the heel at the lower
end, is then slung between the side bars of the bed splint
to support the limb. Local splints can be applied if
required, and the whole bandaged compactly together.
Sling or support the foot of the splint to prevent pressure
of the heel on the bed.

If the Splint is too Large in the Ring. — Fix a suffi-
ciently large soft pad in the ring at its junction with
the outer bar to prevent the inner portion of the ring
slipping from the groin across the perineum.

If the Splint is too Small in the Ring, — Saw through
the ring just in front of its junction with the outer
bar ; open as necessary.

Fig. 111. — Skeleton splint for injuries near the ankle-joint.

Nursing Hints for Patient with Thomas Bed Knee=
Splint. — This is usually applied when extension of the
limb is required ; therefore pressure over the ischium
may be great, but this can be relieved by raising, lower-
ing, or abducting the limb from time to time. The
skin surface lying under the ring should frequently be
changed and kept dry and well powdered. The foot
end of the splint must be either slung or supported
to prevent pressure under the heel, and if the foot has
been left free it should be supported at right angles by
a pillow or otherwise.

LEG

Fractures of the lower portion of the tibia or fibula,,
and fractures through the ankle-joint, I treat in a
skeleton splint, such as I have illustrated (Fig. in).
It allows of easy access to the wound, and can without
difficulty be modified to suit a special case. Fortunately,
in gunshot wounds the spiral fracture is rare, and,
generally speaking, one bone remains unbroken. The
treatment, therefore, of fractures of the leg does not
present so much difficulty as does that of fractures of
I*

122 NOTES ON MILITARY ORTHOPEDICS

the thigh. For transport, however, and for general com-
fort, the splint should immobilize the knee (Fig. 112).

SKELETON OR RECTANGULAR FOOT SPLINT

Measurements required for Skeleton Splint : Tread of
great toe to heel.

Measurements required for Rectangular Foot Splint :
Tip of great toe to heel.

Splint Measurements : The same, but any adult size
is easily adapted.

These splints are usually applied to feet which are,
or are required to be, held at right angles. When this
is not the case, it is advisable to alter the splint's angle,
or a pressure sore may result to the heel which is not
lying in its appointed place.

Rectangular Foot Splint too Large. — Of no conse-
quence unless marked, when a pad will be required

Fig. 112. — Skeleton splint applied.

above insertion of the tendo Achillis to prevent pressure
on the heel ; and a skeleton splint will require a local
splint or its substitute to the sole of the foot.

Skeleton Splint too Short. — The foot-piece of the
splint can be lengthened by a local flat splint or its
substitute.

Nursing Hint for Patient with Skeleton Foot Splint.
— This splint should be supported on a graduated pillow
which is thicker under the knee.

FRACTURES OF THE UPPER LIMB
ARM

Fractures through the shoulder-joint and through the
surgical neck of the humerus require no splints. The
elbow should be slung at right angles, and fixed by a
broad bandage to the side. The dressings would prob-
ably replace the usual pad in the axilla, which should
never be bulky. Shoulder shields are unnecessary and
cumbrous. The patient, when practicable, should be
treated in the upright position, and should have his
liead and shoulders well propped at night.

FRACTURES: WAR CONDITIONS 123

When ankylosis is to be expected after a bad smash
and suppuration of the shoulder, and opportunity is
afforded for continuous treatment, the arm should be
kept abducted slightly forwards and rotated slightly
inwards (Figs. 113 and 114). This assures a much

Fig. 113. — Splint to keep the arm abducted slightly forwards and
rotated slightly inwards.

1

Fig. 114. — Splint applied to keep the arm abducted slightly forwards
and rotated slightly inwards.

-extended range of movement at a more useful radius,
such range of movement being brought about by the
action of the scapula. This position need not be
adopted if the patient has to be transported, as it
can be established after the arrival home. Fractures
through the elbow or immediately above the condyles

124 NOTES ON MILITARY ORTHOPEDICS

are best treated without splints. If possible, the arm
should be kept flexed well above a right angle. Sup-
purating cases in the adult will not admit of the very
acute flexion which we insist upon in the case of chil-
dren. If, for a rare reason, a splint has to be applied,

Fig, 115. — Splint immobilizing the elbow-joint but allowing access to it.

the internal wooden angular splint must be avoided,,
because it is always clumsy and often causes deformity,
and a splint as illustrated used (Figs. 115 and 116).

Fractures of the middle and lower middle portions
of the shaft of the humerus, where dressings have to-

Fig. 116.— Elbow splint applied.

be frequently changed, require very gentle handling,,
and I illustrate two splints which may be found very
useful. One is a modified Thomas knee splint used to
maintain extension in the abducted position, the patient

FRACTURES : WAR CONDITIONS 125

being recumbent (Figs. 117 and 118). The other is a
modified Thomas humerus-extension splint (Figs. 119
and 120), to be used when the patient can walk about
or sit up in bed. Either splint permits of easy dressing,

Fig. 117. — Thomas's knee splint, modified, used to maintain extension of
the humerus in the abducted position.

Fig. 118. — Extension arm splint applied.

and maintains adequate fixation. As so much destruction
of bone may be produced by modern'shrapnel, and even
by rifle bullet, great care must be taken to prevent
over-extension, otherwise non-union will ensue.

Fig. 119. — Modified Thomas's humerus-extension splint.

FOREARM

The chief disability to be feared in fractures of the
shafts of the bones of the forearm is inability to supinate
the forearm completely. The trouble usually arises
then both bones are broken, but it may occur when
we radius alone is involved. We must remember that the

126 NOTES ON MILITARY ORTHOPEDICS

whole length of the posterior border of the ulna is sub-
cutaneous and is practically straight. On this straight
ulna the curved radius rotates, like the handle of a
bucket. We must therefore attend to two points. First,
we must keep the ulna straight ; second, we must not
interfere with the natural curve of the radius. That is
to say, there must be no lateral pressure of bandage
or splint on the middle of the shaft of the radius. In
dealing, therefore, with these fractures, whether one

Fig. 120. — Modified Thomas's humerus-extension splint applied.

or both bones be broken, the position of supination
should invariably be maintained. This is even more
important in septic compound fractures than where no
complication exists. Neglect of this important point
will often result in a locking of the bones in pronation.
We must remember that in nearly all neglected fractures
of the forearm, supination and not pronation is defective,
the arm being usually fixed in the pronated position.

WRIST AND HAND

Gunshot wounds through the wrist are very common
and far too many have been treated with the hand in
line with the forearm — that is, midway between palmar
and dorsiflexion. This is fatal to good function. All
injuries of the wrist-joint should be treated in the
dorsiflexed position, as shown in the illustration, in

FRACTURES: WAR CONDITIONS 127

order that the fingers may maintain their grasping
power (Figs. 121, 122, 123, 124, and 125). Fractures

Fig. 121. — Hyperextension hand splint.

Fig. 122. — Hyperextension hand splint applied.

of the hand may be immobilized as shown (Figs. 126
127, and 128).

Care must be taken to fit the wrist flexion accurately

Fig. 123.— Skeleton hyperextension hand splint.

Fig. 124. — Skeleton hyperextension hand splint applied.

to the splint flexion, thus avoiding any possible strain
of the carpal joints.

RETENTION OF LOOSE PIECES OF BONE
I do not intend to deal with the surgical considerations
involved in the treatment of the suppurating wound.

128 NOTES ON MILITARY ORTHOPEDICS

Many distinguished surgeons are devoting themselves
to this problem. It may be well, however, to offer a

Fig. 125. — Skeleton hyperextension hand splint applied.

Fig. 126.— Long hand splint.

Fig. 127.— Long hand splint, with
thumb-piece.

word of warning against the destruction of loose pieces
of bone removed from the wound. If quite loose they
can be taken out, cleaned, and replaced. Suppurative

Fig. 128. — Long hand splint applied.

compound fractures unite well if time be given them ; a
common source of failure is due to the removal of bone.

INDEX

ABDUCTION frame, 115

modified. 115

— nursing patient on, 116
Albee's operation, 88

sliding inlay method, 91, 93

Alignment, erroneous, in fractures of

femur, 77
Angular deformity in fractures of

femur, 76

Ankle-joint, functional impairment in
fractures about, 71

position of election for anky-

losis of, after gunshot wounds,
7
Ankylosis, positions of election for, r

• in ankle, 7

— • in elbow, 3
in flail-joint, 8

in forearm, 3

in hip, 5

• in knee, 6

• in shoulder, i

— in tarsus and meta-
tarsus, 7

in wrist, 4

Anterior crural paralysis, tendon

transplantation in, 20
Arm, fractured, treatment of, under
war conditions, 122

BICKERSTETH, Mr., and tendon trans-
plantation, 16

Body weight, deflection of, 14
Bone grafting, 63

conclusions as to, 94

for recent fractures, 91

for ununited fractures, 92

technique of, for fractures

and defects in con-
tinuity, 90

• "general, 86

— grafts, autogenous, superiority

of, 82

— means to promote growth
of, 84

. — nutrition of, 83

theories of growth of, 8t

— . union of, 83

Bone grafts, use of, in acute osteo-
myelitis, 85

uses of, in military s-.ir-

gery. 85

loose pieces of, retention of, 127

Boot and iron for Pott's fracture,

69

• Army, imperfections in, 45

proper time to serve out,

45

for acute flat-foot, 31

for deformities from injuries of

tarsus and metatarsus, 8

for metatarsalgia, 57

good marching, qualities of, 44

with bar across sole, 8, 53

• with heel raised on inner side,

8, 31, 37, 44, 53

CARPUS, fractures of, functional im-
pairment in, 71
Claw-foot, 38

fifth degree of, 43

first degree of, 38

fourth degree of, 42

second degree of, 39

third degree of, 42

Colles's fracture, inefficient reduction
in, 66

Compound comminuted fractures, re-
tention of fragments in, 65

DAMMING and percussion, 62
Deflection of body weight, how to

avoid, 14
Delayed union, 60

causes of, 61

in femur, 62

in tibia and fibula, 62

most common sites of, 60

in compound comminuted

fractures, 65

treatment of, 61

. • by percussion and

damming, 62

Displacement of little toe, 55
Dorsiflexion of ankle, loss of, in frac-
tures about joint, 73

129

130

INDEX

Dorsiflexion of wrist, importance of,

in ankylosis, 4
Double circular saw for tutting bone

grafts, 87
Drop-foot, tendon fixation in, 23

ELBOW splint, 124

Elbow-joint, fractures about, func-
tional impairment in, 70

— ankylosis of, position of elec-

tion for, 3
E version of foot in fractures about

ankle-joint, 71

External popliteal paralysis, tendon
fixation in, 22

transplantation

in, 22
Exuberant callus, 65

FAULTY alignment of bones from in-
efficient fixation,
67

from yielding of

callus, 69

Femur, delayed union in, 62

fractured, treatment of, under

war conditions, 112
— : fractures of, functional im-
pairment in, 75

malunited, treatment of, 77

Fibula and tibia, delayed union in, 62

fractured, treatment of,

under war conditions,

121

Fixation, spinal. (See Spinal fixation)
Flail-joints, ankylosis of, 8
Flat-foot, 28

acute, 29

boots for, 31

treatment of, 30

clinical division of forms of, 36

diagnosis between different

forms of, 36

— from periarthritis, 32

— from peroneal spasm 34

— ordinary, 36

— osseous, 34
— — rigid, 32

— subacute, 36

— traumatic, 32
Foot, arches of, 27

— deformities and disabilities of,

28
Forearm, fractured, treatment of,

under war conditions, 125
Fractures, bone grafting for, tech-
nique of, 90

— functional impairment in. (See

Functional impairment)

malunited and ununited. (See

Delayed union ; Malunion)

Fractures, recent, bone grafting for, 91
— time required for consolidation

of. 95

treatment of; under war condi-
tions, no

— — arm, 122

forearm, 125

hip and upper

thigh, i i z

— leg, 121

— lower spine and

pelvis, no

— upper middle

and lower
thigh, 116

wrist and hand,

126

Functional impairment in fractures,
69

about ankle-joint, 71

• about elbow-joint, 70

— of carpus, 71

of femur, 75

of humerus, 70

— of radius and ulna,

7i

— of tibia, 75

GUNSHOT wounds of joints, position
of election for ankylosis after.
(See Ankylosis, positions of elec-
tion for)

HALLUX rigidus, 45

after-treatment of, 52

boot for, 53

— treatment of, 46

— valgus, 47

and hallux rigidus, rela-
tion between, 46, 48
post-operative splint for

52

treatment of, 49

Hammer-toe, 53

— splint for, 55

treatment and after-treatment

of, 54
Hand and wrist, injured, treatment

of, under war conditions, 126

— splints, 127

Heel, painful conditions of, 57
Hibb's operation for spinal fixation,

88

Hip and upper thigh, fractured,
treatment of, under war condi-
tions, 112
Hip-joint, ankylosis of, position of

election for, 5

" Hollow " foot. (Sie Claw-fooO
Humerus, fractured, treatment of
under war conditions, 122

INDEX

Hummis, fractures of, functional im-
pairment in, 70

INEFFICIENT fixation after setting of
fracture, 66

— reduction, 65

common causes of, 66

Intramedullary plug, 93

JOINTS, gunshot injuries of, positions
of election for ankylosis after.
(See Ankylosis, positions of
election for)

mobility of, and late suture of

nerves, 10

KNEE, cage support for, 107 ,
Knee-joint, ankylosis, position of
election for, 6

— dislocations of external semi-

lunar cartilage, 104

— fracture of spine of tibia, 106

— internal derangement of, 97

— - displaced cartilage

with "locking,"
100

• — • rupture of internaj

ligament and dam-
age to semilunar
cartilage, 97

• thickened cicatrix

about semilunar
cartilage, 99

— operation on internal semilunar

cartilage,
101

after - treat-
ment, 103

— recurrent effusion into, 104

• rupture of crucial ligaments of,

105

— sprain of internal lateral liga-

ment of, 96

— thickened retropatellar pads of

fat, 107

(See also Functional impair-

ment)
Kyphosis after injuries to spine, 85

LATE suture of nerves, principles of,

9

Lateral graft, 93

Leg, fractured, treatment of, under
war conditions, 121

Limbs, voluntary use and massage
of, and late suture of nerves,
ii

Little toe, displacement of, 55

Lower spine and pelvis, fractured,
treatment of, under war condi-
tions, no

McMuRKAY, Capt., aud tendon trans-
plantation, 1 6

McVViUiains on bone grafts, 81
Malunion, 65

causes of, 65

Median paralysis, tendon transplant-
ation in, 19

Metatarsal joints, ankylosis of, posi-
tion of election for, 7

Metatarsalgia, 56

boot for, 57

— treatment and after-treatment

of, 57
Morton's disease, 56

— treatment and after-treat-

ment of, 57

Muscle fibres, overstretching of, 13
— : — power, recovery of, late, 14

• how to secure, 15

Muscles, freeing of, from obstruction
and late suture of nerves, 10

— relaxation of, and late suture of

nerves, 10

Musculo-spiral paralysis, tendon trans-
plantation in, 1 8

NERVES, injuries to, causing dis-
ablement of limbs, 9

— late suture of, principles of, 9
Nursing of patient on abduction

frame, 116

with skeleton foot splint,

122

— on Thomas's double frame ,

112

. with Thomas's bed knee-
splint, 121

OPERATION, immediate, for fracture,

92

Os calcis, spurs of bone under, 59
Osteitis and periostitis of os calcis, 59
Osteomyelitis, acute, use of bone

grafts in, 85
Osteotomy in claw-foot, third degree,

42

— in hallux valgus, 49

in hammer- toe, 55

in malunited femur, 77

in metatarsalgia, 57

— in Pott's fracture, 74

in ununited fractures of tibia

and fibula, 62

— saw, author's, 79

PATELLA, splitting of, in operation

for fractured tibial spine, 106
Paralysis. (See various nerves)
Pelvis and lower spine, fractured,
treatment of, under war condi-
tions, no

132

INDEX

Percussion and damming, 62
Periostitis and osteitis of os calcis, 59
Plates and screws, bone grafts as
substitutes for, 85

drawbacks to, 91, 92

— use of, in spiral fracture of

tibia, 92
Poliomyelitis, treatment of, applicable

to injuries to nerves, 12, 1 6
Pott's fracture, reduction of, 73

— inefficient, 66

Pulley extension in ununited frac-
tures of tibia and fibula, 62

RADIUS and ulna, fractures of, func-
tional impairment in, 71

Rectangular foot splint, 122

Retropatellar pads of fat, thickened,
107

Rotation deformity in fractures of
femur, 77

SCIATIC trunk, injury to, treatment
for, 25

Screw extension splint, 119

Shortening or overriding in frac-
tures of femur, 75

Shoulder-joint, ankylosis of, position
of election for, i

Skeleton foot splint, 122

nursing patient withi

122

Sliding inlay method, 93

Spinal fixation, 88

Albee's operation, 88

Hibb's operation, 88

Spine, lower, and pelvis, fractured,
treatment of, under war condi-
tions, no

Spurs of bone under os calcis, 59

Suture of nerves, late, principles of, 10

TAFFIER, Prof., and transplantation

of ovaries, 82
Tarsal and me tatarsal joints, ankylosis

of, position of election for, 7
Tendo Achillis, injuries and strains

about insertion of, 58
Tendon fixation in drop-foot, 23

in external popliteal para-
lysis, 22

— transplantation, 16
— for claw-foot, 40

in anterior crucial para-

lysis, 20

in external popliteal para-
lysis, 22

Tendon transplantation in median
paralysis, 19

• in musculo-spiral para-

lysis, 1 8

- in ulnar paralysis, 20

Thigh, upper, fractured, treatment of>

under war conditions,
112

middle and lower, frac-
tured, treatment of
under war conditions,
116

Thomas, Mr. Thelwall, and tendon
transplantation, 16

Thomas's knee-splint, 117, 120
modified, 124

— - nursing patient with, 121

double frame, no

— nursing patient with,
112

humerus-ex tension splint, modi-

fied 125

theory of " muscle lengthening,"

12

wrench, 33

Tibia and fibula, delayed union inf
62

fracture of spine of, 106

fractures of, impai ment of

function in 75
Tiptoe exercises, 37
Toe, great, importance of, in march-
ing, 44
Transplantation of bone. (See Bone

grafts)

of tendon. (See Tendon trans-

plantation)

Tuberculous arthritis after injuries to
spine, 85

ULNAR paralysis tendon transplanta-
tion in, 20
Union, delayed. (See Delayed union)

weak, 65

Ununited fractures, bone grafting for,
90, 92

(See also Delayed union)

Upper middle and lower thigh, frac.
tured, treatment of, under war
conditions, 116

WEAK union, 65

Wrist and hand, fractured, treatment
of, under war conditions, 129

ankylosis of, importance of

dorsiflexion in, 4
position of election for, 4

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