considered in this injury being that an adhesive plaster pad should be placed on the palm at the seat of the fracture.

Massage must be commenced early. In the exceptional case of considerable displacement wiring of the fragments may come into consideration.

Fracture of the phalanges is nearly always caused by direct violence (the fingers being caught or held in a door, etc.). Exceptionally, it is produced by indirect violence (fall on the fingers or overextension during wrestling, etc.).

The signs are typical, and, in fact, so apparent that they should hardly need description. Still, fracture is sometimes confounded with

dislocations. As to contradistinction, compare figures 96, 97, 98, and 99.

The treatment consists in keeping the fragments well immobilized by small splints of wood or pasteboard

Fig. 101.-Splint for phalangeal fracture (after Hoffa).

(Fig. 101), after thorough reduction is accomplished. The splints are to be fastened by starched gauze bandages. Union is generally perfect in two weeks.

If the fracture be comminuted or compound, extreme conservatism should prevail. It is surprising how often a shattered phalanx is entirely restored to its function under thorough aseptic precautions. The severed fragments being removed, sometimes all that is left of the phalanx is represented by a thin bony fragment; nevertheless, this may develop into a useful phalanx again, provided enough periosteum is left in its place.

FRACTURES OF THE PELVIS AND
THE LOWER EXTREMITY.

PELVIS.

Fractures of the pelvis represent less than one per cent. of all fractures, and are similar to those of the skull and thorax, inasmuch as they occur in an osseous ring, irregularly composed of several bones: namely, the os ilii, the os pubis, the os ischii, and the sacrum

Fig. 102.-Fracture of pelvis, fragments boring into ileopsoas muscle (after Hoffa).

and coccyx. They concern either one of these bones individually or the pelvic ring as a whole. (Fig. 102.)

They are generally caused by direct violence, as, for instance, by a heavy weight falling upon the pelvis, or by the patient falling from a high point, or by his being crushed between the buffers of two railroad-cars while they are being coupled, or by the passage of a wagonwheel across the lower abdomen.

In the first event-fracture of an individual pelvic

bone-palpation will always reveal separation of at least a single fractured bone-portion. Abnormal mobility, displacement, and consequently crepitus, are always present. The abdominal organs are but seldom injured.

The treatment consists in reposition as far as is possible, and immobilization by applying a long splint extending from the external malleolus to the axilla. (Compare Fig. 103.) Union in a deformed position, while, of course, undesirable, is seldom followed by any functional disturbance.

Fractures of the pelvic ring are always to be re

garded as of importance, since they are generally accompanied by simultaneous injuries either of the abdominal viscera or of the urethra, the sciatic nerve, or the femoral vessels.

The signs consist in ecchymosis, localized pain, which is severely intensified on pressure, inability to lift the lower limb, and marked displacement. In all cases of suspected pelvic fracture the rectum and urethra must be carefully explored also. In trying to press both iliac bones together an intense circumscribed pain is produced, which may direct attention to the point of fracture.

Laceration of the urethra as well as abdominal injuries are treated upon general surgical principles. In urethral injuries permanent catheterization should be employed. It is the significance and extent of these concomitant injuries that determine the course of this dreaded fracture type.

The best treatment consists in the application of a plaster-of-Paris dressing surrounding the abdomen, pelvis, and thigh (Fig. 116), or in the application of a long splint. (Fig. 103.) Extension also sometimes proves useful. (Fig. 10.)

THIGH.

Fractures of the thigh represent about six per cent. of all fractures. They are divided into those of the upper end, those of the diaphysis, and those of the lower end of the femur. In adults they generally occur in the lower, and in aged persons in the upper, end, while in children the middle third is most frequently involved. They occur, however, in any part

of the bone in children.

Fracture of the Upper End of the Femur. -Fracture of the upper part of the femur concerns either its head or neck or the trochanteric region. Anatomically, it is to be divided into epiphyseal separation of the upper end of the femur, in fracture of the neck (intra- and extracapsular), the isolated fracture of the trochanter major, and the infratrochanteric fracture.

I. Epiphyseal separation of the upper end of the femur occurs before the twentieth year, and is extremely rare. The epiphysis being intra-articularly situated, it is obvious that it is but seldom reached by an injury. As

a rule, this fracture is produced by a sudden wrench or sprain.

The signs consist mainly in abnormal mobility, intense local pain, and soft crepitus. There is also shortening and elevation of the trochanter major above Nélaton's line. It is easily confounded with dislocation, hip-disease, or infantile paralysis. It is often overlooked until the patient commences to walk. Ununited fracture may cause lameness.

The treatment is the same as that of a fracture of the femoral neck. In ununited fracture operative interference is indicated. (Compare section on Wiring the Bones, p. 70.)

II. Fracture of the neck of the femur seldom occurs before the fiftieth year of life, and may be caused by direct as well as by indirect violence (fall upon the hip, blow upon the trochanter major). The line of fracture is either in the intertrochanteric line or at the femoral head, or between these points. Its direction is either transverse or oblique to the axis of the neck. Accordingly, intra- and extracapsular fractures of the neck of the femur are distinguished, analogous to the fractures of the anatomic and surgical necks of the humerus.

(a) Intracapsular fracture (Fig. 104) is most frequent in aged persons, a prevalence that is explained by the senile changes at the angle of the thigh-bone. While in earlier life the angle of the neck to the shaft is still oblique, it becomes rectangular in elderly people. Thus the bone becomes more fragile, so that it may fracture even after trifling injuries, such as, for instance, simply falling on a carpet.

The line of fracture is transverse and is generally