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By JAMES H. STEVENS, M. D., Boston, Mass.

The subject of Colles's fracture is a tremendously interesting one. The mechanism of its production is more than an interesting study of mechanics, because it has a direct bearing upon the treatment and upon the proper understanding of exactly what has happened, and if we have no clear conception of what has happened I doubt if we shall have any idea of what we have to accomplish in order to effect a restoration which shall, at least, approximate normal.

There are thousands of cases of Colles's fracture being treated every day in this country, and as many of these cases belong in the industrial compensation class it can readily be seen that the loss of productivity reaches into an economic loss that is enormous. Many of these cases when discharged from treatment present stiffening of the motions of the wrist which is premanent, especially in flexion, and many of them present a picture in which the deformity is of such a nature as to merit the word atrocious, and especially when such a result is obtained in a woman's wrist.

Our contentions concerning these fractures as usually treated are as follows:

First. In many of the cases the posteriorly dislocated inferior fragment of the radius is never reduced.

Second. Even when the major dislocation has been reduced, the fracture is of such a nature-a crush-that this reduction of fragment is only a partial reduction, and there is always a change, especially of the antero-posterior plane of the inferior radial articulation. The fracture is, as a rule, only half reduced.

Third. That whether reduced or not the subsequent treatment of these fractures has been such as to require many weeks or months for

The Annals of Surgery for November, 1922, contains an article written by Dr. J. H. Stevens, with the title Compression fractures of the lower end of the radius," in which is outlined a treatment for Colles's fracture quite at variance with the accepted method of treatment. Impressed by the arguments which the writer put forth in support of his views concerning Colles's fracture, some of the medical officers at the United States Naval Hospital, Annapolis, Md., used the method advocated by him and obtained better results than could be expected from the methods usually employed. As Doctor Stevens's method of handling these fractures might be of interest to the medical officers of the Navy, he was invited to contribute a paper on the subject to the BULLETIN.

the recovery of motion, and that nearly always there remains a permanent loss, small or great, especially in flexion. This is the result of immobilization.

Cases of Colles's fracture in the main are now treated by restriction in plaster or splints for from three to five weeks; then they are massaged, baked, and manipulated. Even at three weeks there is restriction both in flexion and extension, the full flexion of the wrist being oftentimes overlooked because of the compensating flexion of the fingers.

In youth or young adult life most of the cases work out after a time to a fairly successful result, but in older patients the results are generally bad.

There are certain fundamentals of mechanics regarding the breaking of any substance with which one should be familiar. The less the elasticity, the nearer the bending and the breaking moments are together. The bending and the breaking moment in an absolutely inelastic substance would be together, would be simultaneous. The shorter the substance, that is, if we consider an ordinary substance like a column or a strut or a lever, the less the elasticity, and hence the nearer these two moments are together. This has a bearing in certain fractures of bone.

When we break a substance there is an elastic limit encountered at a certain point beyond which the break occurs. This term in mechanics is being supplanted to a certain extent, but it is still employed in the literature and is so often used that it is sufficient for our purposes.

The elastic limit of a breaking substance is that point beyond which there is no comeback and a permanent set occurs to the material. In other words, the substance has been irretrievably injured.

There are several kinds of stresses or strains which cause fracture or breakage when applied beyond the elastic limit. These are:

Tension, which tends to lengthen the substance under consideration; compression, tending to shorten it; transverse breaking stress, tending to bend it; sheer, tending to cause one part to slide over the adjacent part; torsion, tending to twist it.

Tension, compression, and sheer are called simple stresses. Transverse stress is a compound of tension and compression. Tortional stress is a compound of tension and sheer.

To these might be added tearing stress, which might be either tension or sheer, but in which the resistance of different portions are brought into play in detail or one after the other, instead of simultaneously as in simple stresses.

A sudden stress is more injurious than a steady or gradually applied stress.

A tension stress tends to cause rupture or separation of particles in the line of stress, but a compression stress may, depending on the material, cause it to separate into two or more wedge-shaped pieces, to bulge, to buckle, or bend, or, as in granite, to fly into pieces. Old bone will sometimes do this very thing.

If we take a material, wood for instance, and apply a transverse stress, we shall find that always will it break in tension; that is, the molecular structure of a fibrous material will always pull apart on the tension side first and there will be more or less long splintering.

In a crystalline substance the break will tend to be more transverse, and as it approaches the compression side there will be a tendency to a split out, a wedge, because a transverse stress is always a stress in tension on one side and compression on the other, and where compression and tension are equal, a break is always in tension.

Now, in order to break in compression, the compression must be greatly in excess of the tension and as this is impossible in a simple cross-breaking stress, it always breaks in tension.

A leverage fracture is always a transverse or cross-breaking stress with an element of sheer at the fulcrum.

Sheer is best illustrated by a scissors action, one or both substances being under compression, but it is an intensely localized compression or molecular compression, as it were, and there is the tendency of one portion to slide over the other.

Therefore it can be clearly seen that each particular stress has a tendency to cause an equally distinct type of break. Many times there is a combination of stresses and this must be borne in mind.

The structure broken also must be considered as having a bearing on the type of break and when we consider bone specifically, we find a vast amount of difference. Young bone and old bone are not of the same composition. Bone is a fibrous structure, containing a deposition of salts of various minerals: Calcium, potassium, iron, magnesium, and so forth. It is not a dry substance, so that it does not act the same always, depending on the difference of composition. Again, bone is hollow, and it is trabeculated, the interstices being filled with a substance of different specific gravity. There is very little bend to bone, and, in the terminology of the mechanical engineer, bone is cold short-that is, there is no diminution of structure when subjected to tensile stress in the pulling machine.

It breaks when its elastic limit has been exceeded, but there is no diminution of the area of its broken parts. Every substance that is cold short is more or less brittle. The best example of this is glass, and we do not think of glass as a particularly strong substance, but tested in the testing machine, as pure tension, one will be surprised at the tensile strength of glass.

Such a stress, however, must be uniform over the whole area, because any varient from this will bring a greater stress on some particular portion of the mass and as it is cold short, and therefore brittle, it is particularly susceptible to sheer or to impact. Comparatively small stresses will break it under these conditions, stresses which, under straight tension or static compression, it would have resisted.

All Colle's fractures, and they are all compression fractures, can be classified in three types as follows:

First. Simple transverse fracture of the bone with little or no evidence of compression.-These are more often the automobile fractures. The mechanics of the fracture are the same, but the force is not always great enough to badly damage the structure.

Second. Fracture of the lower end of the radius with evidence of great compressive force.-There is here actual loss of substance on the posterior surface of the bone, the so-called impaction. Flexion, cracks, or fissures may or may not exist on the opposite side. The planes of the articulation are always changed, much or little.

Third. Fractures of the lower end of the radius with actual dislocation of the distal fragment backward and sometimes in abduction.-There is impingement of the distal fragment on the posterior sharp surface of the proximal fragment. The same injury oftentimes breaks the styloid process of the ulna or even the ulnar shaft, but the ulnar break is always secondary to the main break and not a compression break.

The break of the ulnar styloid is simply a sheering fracture. All writers have contended that the ulna styloid is broken by the pull of the anterior annular ligament. The medical profession seem to be obsessed with the tremendous tensile strength of a ligament as against bone. The ulna styloid is really broken, as one may see by examining the articulated skeletal bones, as the result of a transverse cross-breaking strain or a sheer. The man falling goes forward on his face, and to prevent his face from striking he turns his body always away from the side injured. The hand is fixed on the ground and the radius is fixed firmly while the ulna as part of the whole arm rotates, bringing the base of the styloid of the ulna smartly against the posterior edge of the radio ulnar articulation and generally cracking it off at its base. The ulnar fracture higher up is a simple transverse tension break as the resultant of two forces, secondary to the main break.

Whether the ulnar styloid is broken or not is unimportant. If the ulna above has been broken, we have a different problem, but a different problem only as regards treatment.

Ninety-five per cent of these fractures will fall into the second and third types. Occasionally there is one which does not show the evi