masons, roofers, miners, and workmen on elevated railroads. It concerns either the body or the processes

of the bone.

The signs consist in ecchymosis, local pain, displacement, crepitus, and loss of function. The arch of the foot sinks down and the foot appears flat. Sometimes the swelling following the injury is so consider

Fig. 148.-Oblique fracture of first metatarsus in a rachitic girl of twelve years; healed without deformity (five weeks after the injury).

able as to prevent exact palpation; and as a consequence distortion or malleolar fracture may be erroneously supposed to exist.

The prognosis as to function is always doubtful.

The treatment consists in reposition and immobilization. The first requirement sometimes can not be

fulfilled, apposition of the fragments being possible only by bone suture or ivory pegs. Ordinarily, the displacement can be overcome by resting the leg upon a double inclined plane. In case of excessive callus formation resection of the exuberant masses is indicated. If either the calcaneum or astragalus is crushed, amputation should be performed without delay.

Fractures of the scaphoid, cuneiform, and cuboid bones fall under the same considerations as those of the metatarsal bones. In all these fractures the arch of the foot sinks down, causing talipes-position.

Fractures of the metatarsal bones (Fig. 148) and the phalanges are always produced by direct violence (falling of a heavy weight, passing of a wagon-wheel, the latter being an especially frequent cause in children). Such fractures are either isolated or simultaneous, sometimes all the bones being fractured at the same time. Usually these injuries are associated with lesions of the soft tissues. Their superficial location makes recognition of the character of these injuries easy, as a rule.

Fracture of a metatarsal bone, especially the second or third, is frequently observed in the army, as a consequence of overburdening the marching soldier. In the pre-Röntgenian era this much dreaded condition, known as "foot edema," was regarded as dependent. upon a pathologic change in the soft tissues.

The treatment consists in immobilization by a small plaster-of-Paris dressing after reposition is done. Union generally becomes perfect in three weeks.

In compound fractures the wire splint should be used in connection with antiseptic lotions. (See p. 67.)

Later on, the fenestrated plaster-of-Paris dressing is to be employed. (Fig. 5.)

If the bones are crushed, amputation should not be delayed.

FRACTURES OF THE BONES OF THE TRUNK.

Fractures of the bones of the trunk are divided into those of the thoracic wall (ribs and sternum) and those of the spinal column (body, arch, and the spinous and transverse processes).

FRACTURE OF THE RIB.

Fractures of the ribs (Fig. 149), while rare in children, are frequent in adults, and represent fifteen per cent. of all fractures. The injury may be caused by direct as well as by indirect violence. In the first event (blow against the thoracic wall, fall at the margin of the sidewalk, staircase, table, etc.) the fragments are generally driven inward. (Fig. 150.) If caused by a gunshot, the rib is splintered, the intrathoracic organs being generally also involved. A simple transverse fracture may be produced by a bullet fired from so great a distance that its force is considerably diminished when it strikes the rib.

If the fracture is caused by indirect violence (as, for instance, by compression of the thorax), it is often associated with fracture or contusion of the humerus. In rare instances the fracture is produced by muscular contraction, in which event the fragments are generally driven outward.

According to the age of the patient or to the degree of violence, an infraction (Fig. 149) or a true fracture

(Fig. 150) may result. Infractions are much more frequent than fractures. In children the thorax is so elastic that fracture is caused only by a considerable degree of violence.

The signs consist in intense local pain and in the crepitus that results if the fragment is pressed downward by the palm of the hand. Manual pressure also increases the painful sensation during the act of inspiration. Deep inspiration and stooping toward the opposite side invariably cause great pain. If the rib

is fractured only, displacement generally does not take place, but if several ribs are broken, as shown by figure 150, considerable displacement may result. It is in these cases that the intercostal artery may become injured, so that an aneurysm may develop. Fractures in the vicinity of the vertebræ impair the function of the articulatio costotransversalis and costovertebralis.

In case the lungs are injured, hemoptysis is always, and hemothorax, pneumothorax, and emphysema are sometimes, present. The last-named condition may

extend to the neck and abdomen, and in severe cases it may involve the whole body, the air escaping from the lung into the surrounding connective tissue. The left fourth, fifth, and sixth ribs at their sternal junctions endanger the pericardium and vagus, while the anterior splinter-fractures of the sixth rib may injure the

Fig. 150.-Fracture of ribs about their angles, causing kyphosis, in a woman of fifty years. On the left, the fourth rib shows slight, the fifth considerable, displacement. On the right, the fragments of the fifth rib overlap, while the sixth rib shows moderate displacement.

pleural sinus. The right seventh, eighth, and ninth ribs may cause laceration of the liver tissue.

The treatment should be mainly directed to immobilization. Taking into account the relation of the ribs to the pleura and lung, it is evident that immobili