self for treatment. If only one or two hours have elapsed since the injury, the swelling is as yet inconsiderable, and if the fragments are accurately replaced and a tight bandage is applied, any marked degree of subsequent swelling is, as a rule, prevented. In such a case, therefore, even a primary plaster-of-Paris dressing might do no harm; but in view of the possibility of many accidents, partly owing to the stupidity of the patients themselves, a primary plaster-of-Paris dressing should be employed only when surgeon possesses technical skill and can see his patient every day.

the

Ambulatory Treatment of Fractures of the Leg (Socalled Walking Dressing).-Of recent years various procedures have at different times been recommended with a view to allowing the patient to walk about while under treatment for fracture of the leg. Splints may be used similar to Thomas' splint (see page 281), such, for instance, as those designed by Bruns; extension may be applied to the leg by means of elastic strips attached to the lower end of the splint; or the leg is allowed to hang free but at the same time fixed by specially devised splints, the patient supporting his weight on the tuberosity of the ischium when he walks. The plaster-of-Paris dressings act in a similar way, or at least reach as far as the middle of the thigh, the knee being slightly bent (Krause, Korsch). Others recommend splints or plaster-of-Paris dressings that do not quite reach to the knee, thus immobilizing only the leg and foot and permitting free movement at the knee-joint (Schmid, Dollinger, and others). The technic of these dressings includes perfect reduction, and the application of a thinly padded bandage with a maximum amount of pressure to keep the fragments in good position. The dressing must be rigid enough to prevent displacement of the fragments even when the patient is walking. The pressure is in part applied over the region of the uppermost fragment; as a precautionary measure the dressing may be renewed once or twice. With a bandage of this

kind the patient is said to be able to walk about without pain and without the aid of crutches.

For the present I adhere to my opinion that procedures of this kind and any other ambulatory dressings are not

appropriate in general practice, though they may give excellent results in the hands of a few surgeons.

After the bones have united, baths, douches, massage, and active and passive movements are required to restore

the function. If a bony prominence remains at the seat of fracture and requires correction, because it is painful or otherwise distressing, it should be removed with a chisel; I the bone should be exposed by turning back a flap of tissue.

The prognosis of fractures of the leg depends entirely on the treatment. If it is correctly carried out from the beginning, the fracture will be completely healed and function fully restored unless very special complications supervene. Experience teaches us, however, that this result is obtained in less than half the cases. Deformity and edema at the seat of fracture, rigidity of the joints, etc., often continue for a long time or permanently to interfere with the victim's power to earn a living.

[In my experience fractures of the shaft of the bones of the leg (one or both) are, of all fractures, the most appropriate for the plaster dressing. For the first week or ten days the knee-joint should be included in the dressing; after this the knee-joint may be left out, unless there is a tendency to displacement. These patients can be allowed to walk with crutches in the majority of instances after the first few days. The most important point, next to the perfect reduction and proper fixation of the fragments, is more frequent change of dressing; the plaster dressing should be changed at least once a week, and the limb bathed and rubbed.—ED.]

II. Isolated Fracture of the Shaft of the Tibia

(Plate 64, Figs. 4 and 4 a.)

It has already been remarked that fracture of both bones of the leg begins in many cases as a fracture of the tibia alone, that of the fibula occurring secondarily. Fracture of the tibia may be produced by bending, as well as by torsion. In the operation of osteoclasis for the correction of rachitic legs it is often observed that the tibia alone gives way, and that fracture of the fibula requires a second effort on the part of the operator.

Isolated fracture of the tibia may therefore be produced by indirect or by direct violence; if the latter, by a blow, a fall, the kick of a horse, etc.

The diagnosis of isolated fracture of the tibia, if it is oblique and associated with some degree of displacement, is not difficult, even though the intact fibula acts as a kind of splint. If the fracture is transverse, however, and the fragments are in good contact without displacement, the diagnosis is difficult. In the absence of other signs the surgeon must rely on a certain crackling noise elicited by forced movements, with pain on pressure and on striking the bone. If the isolated fracture of the tibia is associated with marked displacement, the fibula must also be involved. Either the bone is broken and the fragments are displaced as those of the tibia, or, as happens particularly in fractures of the upper half of the shaft of the tibia, the fibula is dislocated, the head of the bone being displaced upward (Plate 64). The mistaken diagnosis of isolated fracture of the tibia is the more easily made from the fact that the fibular fracture, instead of being at the same level with the tibial fracture, is quite frequently at some distance from it, usually at a much higher point (Plate 64, Fig. 2).

Treatment. The fragments should be replaced as perfectly as possible; in a recent case, any displacement of the fibula that may exist can at the same time be corrected. To keep the fragments in position a well-fitting plaster-ofParis or splint dressing suffices. In transverse fractures without displacement the ambulatory treatment is more easily carried out than in fractures of both bones of the leg.

III. Isolated Fracture of the Shaft of the Fibula

This is a very rare injury that can only be produced by violent direct force, as the fibula is protected by a robust layer of muscles. The injury is treated on general principles.

(C) Fracture of the Lower End of the Leg

I. Fracture of Both Bones at their Lower Ends

In this section I shall repeatedly speak of forced movements of the foot, of the foot being bent over sidewise, etc. In addition to dorsal and plantar flexion, we also speak of a lateral movement or bending of the foot toward the outside, described as abduction or pronation, and to the inside, described as adduction or supination. The movement concerns the posterior segment of the tarsus, the astragalo-tarsal articulation, and the robust lateral ligaments of the astragalo-crural articulation. The foot is rotated about a line that corresponds approximately to its long axis. Finally an injury may also be produced by rotation of the foot, which really consists in a rotation of the leg about a vertical line corresponding to the longitudinal axis of the leg, and is also known as inversion and eversion.

(a) Supramalleolar Fracture of Both Bones of the Leg Fractura cruris supramalleolaris). (Plate 65.)-This fracture merits special consideration. It may be compared to supracondylar fractures occurring at the lower end of the femur or of the humerus, and especially that occurring at the lower end of the forearm.

The fracture is produced by direct violence, or indirectly by sudden abduction or adduction of the foot; it is also frequently produced by torsion of the foot, so that the line of fracture may extend into the ankle-joint.

The diagnosis of supramalleolar fracture as such is not difficult. The displacement, which is usually quite considerable, may produce a talipes valgus (Plate 65, Fig. 3), or, as I have observed in a number of cases that healed with deformity, a varus-position or curvature of the leg in the so-called O-shape (Plate 65, Fig. 4). The lower fragment may also be displaced backward, causing the foot to drop at the heel.

Treatment. After the fragments have been replaced, a