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Chapter 8
Prenatal Development
OBJECTIVES
Upon completion of this chapter, readers should be able to:
• Identify the three classic periods of prenatal development—germinal (pre-embryonic), embryonic, and
fetal—and the postconceptional ages covered within each period;
• Describe the various classification systems used for monitoring the developmental progression of
embryos and fetuses;
• Describe the developmental changes that occur in the growing human from conception to birth across
the various body systems;
• Identify the main factors and critical, or sensitive, periods associated with atypical development,
including multiple gestation, genetic alterations, congenital anomalies, and developmental disabilities;
and
• Identify and discuss contemporary issues related to embryonic development, including the use of
reproductive technologies and stem cells.

CRITICAL THINKING TOPICS

1. We will not treat the fetus per se. What valuable information that is pertinent to practice may therapists
obtain by studying prenatal life?
• Understanding how and when developmental disabilities occur
• Understanding the medical record regarding prenatal and obstetrical history from infants referred
for therapy
• Understanding behavioral development as a continuum from intrauterine to extrauterine life, for
example, in the development of reflexes and motor behavior
• If working in a neonatal intensive care unit, being able to compare and contrast the environmental
stimulation and providing preterm neonates with as normal an environment as possible
2. Infants can be born as early as 23 to 24 weeks gestation, or about halfway through a normal term
pregnancy. Compare and contrast the uterine environment with the environment of a hospital intensive
care unit, where these infants would be cared for.
The environment of a hospital intensive care unit is significantly different from the uterus:
• Light: The uterus allows very little light; an intensive care unit often has bright lights.
• Sound: In utero, the fetus hears the sound of blood flow through the placenta and the mother’s heart
beat. Sounds from outside the uterus are muffled, as if underwater. In an intensive care unit, there
are lots of sounds, including monitors going off, voices, and maybe music.
• Touch: The only touch in utero is of self body parts or pressure exerted from the uterine wall. In the
intensive care unit, there is touch for caregiving, much of which is painful.
• Gravity: This is not a factor in the uterus, but definitely a factor outside of the uterus.
• Position: They are very flexed in the uterus; may be very extended in the extrauterine environment
unless something is done to accommodate.

© 2016 Cengage Learning®. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.
24 Chapter 8

3. Pregnancy is a time of great vulnerability for the embryo and fetus. What are some of the things a mother
can do to assure the well-being of the fetus? What are some things that are harmful? Do you think
mothers should be accountable for their actions (such as drinking), which can permanently harm a
fetus? Why or why not?
Pregnancy is a time of vulnerability because of developing systems. The greatest time of vulnerability is during
the period of organogenesis in the embryonic period. During this time, teratogens can cause damage to body
systems. Some of the things that are harmful to an embryo include drugs (prescription and street drugs),
alcohol, viruses, and smoking.
This question aims is to get students to think critically about “rights”—the right of the mother to do what she
wants versus the rights of a fetus. Could a mother be placed in jail or in a detox center to protect a fetus? The
fetus cannot protect itself in utero. Does it have rights? Is the government obligated to protect an unborn child?

ACTIVE LEARNING EXERCISE

Activity: Divide into groups. Each group will take one of the following conditions and perform Internet research
to fill out the attached worksheet.
• Cleft lip
• Amelia
• Myelomeningocoele
• Autism
• Viral infections in utero
• Club foot
• Arthrogryposis
• Intrauterine growth retardation
Report: Each group should report what they found out about the prenatal origins of these conditions.

Web Resources
The Virtual Human Embryo:
http://virtualhumanembryo.lsuhsc.edu/

The Virtual Human Embryo Project, “Carnegie Stage 18”:

http://www.ehd.org/virtual-human-embryo/stage.php?stage=18

Bartleby, “The Form of the Embryo at Different Stages of Its Growth”:

http://www.bartleby.com/107/15.html

© 2016 Cengage Learning®. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.
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gray matter of the anterior cornua of the spinal cord, involving both
the neuroglia and the cells, producing atrophy of the same and
consequent paralysis of muscles supplied by the motor nerves. It
may assume an acute febrile type, with rapid onset of paralysis, or it
may be of slower development. Usually conceded to be of infectious
origin, it still lacks the minute explanation for many of its attendant
phenomena. It may appear with acute symptoms, febrile and
convulsive, paralysis appearing more or less promptly. With the
subsidence of other serious symptoms this paralysis remains. There
may then be a period of partial improvement in the muscular
condition, with disappearance of some of the most pronounced
phenomena. Finally with the growth and development of the child
more expressions of damage remain, and produce various
distortions and deformities, varying with the muscle groups affected.
Not only do deformities result, but there is more or less arrest of
development, with disproportion in size between the limbs involved
and those which have been spared. It is the early paralytic features
which may permit diagnosis to be made in the early days of the
acute febrile attack.
Cerebral Palsies.—The cerebral palsies, so called, are the result
of hemorrhages or acute disorganization of the
brain. The former are usually unilateral and give rise to a
corresponding hemiplegia, with either paralysis or spastic rigidity,
and usually with atrophy. The paralysis may not be complete, but is
rather of the paretic type, involving the entire limb, the reflexes being
increased and the muscles stiffened rather than flaccid, with loss of
electrical reactions.
A paraplegia points rather to lesion in the spinal cord and
hemorrhage than to cerebral lesion. Transverse myelitis is rare in
children. Multiple neuritis may produce somewhat similar effects, as
may also the toxic paralyses due either to drugs (especially lead or
arsenic) or that following diphtheria, in which case it is the muscles
of the throat and neck which are likely to be involved. Figs. 274 and
275 portray extreme types which are rare, but instances of minor
degree of affection are frequent.
Fig. 275
 Anterior poliomyelitis. Duration seven years. Showing
atrophy and slight lateral curvature of the spine; two and a
quarter inches of shortening. (Whitman.)

Treatment.—As two cases of this kind are seldom alike, treatment

should be planned to meet the indications. Massage,
electricity, hot-air baths, and similar non-operative measures find
here a large field of usefulness, but, save in the milder cases, are
insufficient. In no class of cases do tendon grafting and nerve
grafting find a wider range of applicability, while tenotomy, myotomy,
aponeurotomy, and occasionally osteotomy will permit of atonement
for deformity which has not been treated. These operative measures
have been considered.
 C H A P T E R X X X I V.
FRACTURES.
The term fracture is, in surgery, applied to such injury of bone and
cartilage as effects break in continuity. This injury is effected
instantly, and it is rarely that fracture is produced by any slowly
acting cause, although this latter may so affect or disintegrate bone
as to permit fracture upon the application of a mild degree of force.
Fractures are variously classified and grouped for convenience of
description; thus we speak of traumatic and pathological fractures,
implying by the former those which occur by violence in normal
conditions of health, and by the latter those which are produced only
because of some previous disease in the bone. The difference is that
in the former case there is no preëxisting disease, whereas in the
latter it is an essential feature of the case. Fractures are also
classified as complete or incomplete, the former term implying injury
to the whole thickness of the bone, while the latter are separately
classified: (a) Fissure, in which there is a line of fracture by which
there is no complete separation of fragment, it being essentially a
crack; (b) the green-stick fracture, such as occurs in the young,
where the bone is not thoroughly calcified, but is capable of bending
to some extent, while a portion of it breaks; (c) depressed fracture,
which is generally produced by direct violence, and occurs in a flat
bone, i. e., the skull, the scapula, etc.; (d) detachment of a fragment
or separation of an epiphysis; (e) partial fractures, corresponding
much to the green-stick, but without deformity or change in shape or
position.
 Fig. 276

Impacted fracture of the shaft of the femur produced by a fall upon the knee in a
man aged eighty-three years. Illustrating impaction. (Bryant.)

Fractures are also described by means of the following adjectives,

which practically explain themselves, for instance:
A. Complete, transverse, oblique, longitudinal, dentated, etc.
Spiral fracture is also described and occasionally seen. It involves
only the long bones, and not only implies a considerable degree of
violence, but is itself regarded as exceedingly serious.
B. In number they are single, multiple, or comminuted, as when
there are a number of fragments.
C. They are often impacted, which means that one fragment is
driven into and more or less embedded in the other. This impaction
or interlocking of fragments occurs usually in the neck of the femur
and the lower end of the radius. In the former locality it is advisable
not to interfere with it; in the latter it should always be dislodged in
order to restore the fragment to its proper position (Fig. 276).
D. As to their nature and location, fractures are referred to as
pathological, gunshot, intra-articular, or extra-articular, etc., the latter
terms referring to involvement of a joint. If blood can escape from the
site of the fracture into a joint cavity, or if synovial fluid can escape
from the latter into the former, then the fracture is called intra-
articular.
Pathological fractures imply preëxisting disease. This may be
constitutional, as in the case of the fragilitas ossium, already
described in the chapter on the Bones, or it may be due to some
secondary deposit of cancer or a primary sarcoma. In adults,
especially those with a cancerous history, any spontaneous fracture,
or even one occurring with trifling violence, should lead to suspicion
of a metastatic focus in the bone at the site of its yielding. The
atrophic changes which notably occur in various bones as old age
comes on lead also to a condition which is pathological, i. e., it
permits of fracture from what would appear to be a trifling injury.
Gunshot fractures are practically always comminuted, save
perhaps some of those inflicted with the modern military weapons. A
Mauser bullet will frequently make an almost clean perforation, but
the gunshot fractures met with in civil practice are almost invariably
comminuted, especially those of the skull (Fig. 277).
E. The term compound is applied to any fracture in which there is
wound of the soft tissues and so located as to permit access of air to
the injured bone. There is a distinction between a compound and a
complicated fracture. A fracture of the femur accompanied by a gash
or extensive wound, so long as air cannot come in contact with the
broken bone, would be described as a fracture of the femur
complicated by a lacerated wound. On the other hand, if through the
slightest puncture of the skin, even at a distance from the fracture,
air can even theoretically enter and come in contact with bone
surfaces at the site of the fracture, such an injury constitutes a
compound fracture. This distinction is not a trifling one, for upon the
exclusion of air, which to a certain extent means the exclusion of
germs, depends very much the rapidity and perfection of recovery.
Compound fractures are all dangerous in proportion as they permit
of infection, and while air infection is not necessarily the most
serious of any, it nevertheless is often sufficiently so to set up sepsis
and interfere with consolidation, even if it does not prevent it.
Fractures are made compound by direct violence from the outside or
by indirect violence, as where a bone end perforates soft parts and
the skin. Even if a sharp point of bone thus protruded from within is
quickly drawn back again it is enough, since both the skin and the air
in contact with it are sources of germ activity. Thus it may happen
that a slight and apparently trivial injury of this kind is more serious
than one which is extensive.
 Fig. 277

Skiagram of compound comminuted (gunshot) fracture of elbow, inflicted with a

Dumdum bullet. Illustrating the extreme of comminution. (Lexer.)

F. Epiphyseal separations constitute a somewhat distinct form of

injury, having at the same time the importance and dignity of
fractures in the truer sense of the term. In the chapter on Diseases of
the Joints will be found a table of the ages at which epiphyses unite.
In childhood and youth a fracture near the joint is most likely to
partake of this character, and it is of importance that it should be
recognized as such when it occurs. Injuries occurring beyond the
ages mentioned in the table are not likely to be of this character
unless ossification is delayed by some morbid process.
By virtue of their occupations and habits men suffer fractures more
frequently than women. Fractures are, moreover, ten times as
frequent as are dislocations. The aged, by virtue of their atrophic
changes, are more subject to fractures than others. Fracture in the
vicinity of certain joints predisposes as well to dislocation of these
joints, and it often happens that the treatment for the dislocation is
reduction and treatment of the fracture. So far as the external causes
of fracture are concerned they are frequently referred to as (a)
fracture by external violence, and (b) fracture by muscle activity. The
former are easily explained; the latter occur from excessive muscle
action, as in violently throwing a ball, or, as in one case with which
the writer was conversant, where a colored preacher in the
vehemence of his gesticulations fractured his own humerus.
Obviously the long or large bones are more liable to fracture than
those which are short and irregular. Certain bones, especially the
clavicle, are peculiarly exposed.
Intra-uterine fractures have not as yet been mentioned. These
occur during the intra-uterine life of the fetus; this term does not
include such fractures as may be inflicted during delivery with or
without instruments. In a fetus already affected with congenital
rickets it may not require any severe contusion upon the abdomen of
the mother to inflict a fracture. Starvation (i. e., scurvy, syphilis, and
struma) in the mother may so disturb nutrition as to weaken the
osseous system of her offspring.
Such previous conditions as ensue from osteomyelitis (i. e., caries
and necrosis) may often weaken the bone. Nevertheless with distinct
necrosis there is usually so much new bone formation as to
strengthen rather than weaken the part. Bones may also become
fragile as the result of syphilis, especially when gummas develop
within them.
Fractures frequently produce certain deformities which are more or
less conspicuous and easily recognized. They are designated as
angular, lateral, or axial (i. e., when the axes of bone are
considerably displaced, even though they may be more or less
parallel), longitudinal (when ends overlap), rotary, etc.; while by the
interposition of muscles and other soft tissues more or less wide
separation may be produced, the same result occurring when the
olecranon or the upper half of the patella is widely separated from
the main bone or portion by muscle pull.

DIAGNOSIS OF FRACTURES.
 Fractures give rise to subjective symptoms and objective signs. In
diagnosis the history is also of value, especially in those cases
where it is a question of some constitutional affection and a minimum
or absolute absence of violence. The apparent immunity which the
intoxicated enjoy is in large measure due to the fact that by virtue of
their condition one of the predisposing causes of fracture is avoided.
There can be no doubt but what muscle tension, due to voluntary or
instinctive efforts to avoid harm, is a contributing factor in the
separation of many bones or their processes. A patient stupidly
drunk will not make these efforts, and will fall in a relaxed condition,
in which violence will probably be much less extensive, and the
consequences less disastrous than if he made an effort to save
himself from falling.
Pain and tenderness are evidences of injury, and will often serve
for its location; even the reference of pain is somewhat suggestive. It
is stated as a universal rule that when pressure is applied laterally or
in the long axis of a bone and evokes pain, referred to a distance
from the point where pressure is made, it will indicate fracture at the
point to which it is referred. There is always impairment, usually loss
of function, while effort to move a thus injured limb will give rise
again to localized pain and tenderness. The pain of contusion is
usually diffuse, and that of fracture is referred to a limited area. The
tenderness produced by handling or examination will vary with the
stolidity, the age, and the character of the patient, as well as the
nature of the injury.
Objective signs are crepitus, mobility, deformity, ecchymosis,
redisplacement. Crepitus means the sensation of grating or rubbing
produced when fractured bone surfaces are moved upon each other.
It is recognized by the sense of touch, sometimes by that of hearing.
Its presence is pathognomonic, but its absence is a negative sign,
and an effort should be made to obtain it. To repeat the
demonstration, especially to demonstrate it to others, means
superfluous manipulation, which is not to the best interest of the
patient. Crepitus, then, should be carefully sought for; once detected
it should be sufficient.
Abnormal mobility is explained only by fracture. It is easy to detect
it in the shaft of a long bone, but when near the joint it is confusing.
Its determination by manipulation is not seen in green-stick or
impacted fracture unless these are further broken up by
manipulation. When evident it should serve as a caution against
unnecessary or rough handling, for if it be easily recognizable
crepitus need not be sought.
Deformity is a striking and pathognomonic feature of fracture. It
may be imitated by hematoma or sudden swelling of the soft parts or
of joints. It may consist of shortening or of angular, lateral, or rotary
displacement, or perhaps of depression or indentation. Careful
inspection, then, and palpation should precede other methods of
examination, as they are often sufficient to indicate the location, the
nature, and sometimes even the character of the active causes.
Inspection of the injured part alone is not always sufficient. Careful
comparison between the two sides of the body should be made in
order that actual measurement or comparative examination may
reveal what mere inspection would not. In connection with inspection
it should be ascertained whether the individual has ever received
previous injuries. The writer recalls a case where a physician
claimed a recovery after fracture of the femur, treated by
incompetent method, yet with ideal result, inasmuch as he said there
was absolutely no shortening. A personal question, however, to the
patient revealed the fact that he had had the other thigh broken
some years previously, and that an apparently similar amount of
shortening followed in each case.
The ordinary indications of fracture are frequently followed by
ecchymosis. This will appear at a date corresponding with the depth
of the injury beneath the skin (it may occur within an hour or three or
four days). The blood will follow the fascial planes and work its way
to the surface along them. The sign is of the greatest value in the
diagnosis of basal fractures of the skull and certain fractures of the
hip and pelvis. When it occurs after an interval it is a confirmatory
rather than a promptly available sign.
Redisplacement implies that the parts when properly put into
apposition quickly fall out of it unless mechanically supported—that
is, they do not stay reduced. This sign is not universally applicable. It
applies especially to the fractures of the long bones of the
extremities, and particularly to the humerus, the femur, or double
fractures of the radius and ulna in the forearm or both bones of the
leg.
Diagnostic Aid Afforded by the Fluoroscope and the
Skiagram.
—Since Röntgen’s memorable discovery the cathode or x-rays have
been of greater and greater use in the diagnosis and portrayal of
injuries and morbid conditions in the osseous system. To such an
extent is this now true that well-equipped hospitals have ample
conveniences for fluoroscopic and photographic work, while many
medical men are doing it in their private practice. There can be no
question but that diagnosis and methods of treatment have been
made more perfect since this new method of investigation has been
made available. On one hand, however, it has led perhaps to
something of neglect of the methods previously in vogue, which
necessitated anatomical knowledge and logical reasoning. On the
other hand, the knowledge thus obtained has been sometimes a
two-edged sword, since the display of skiagrams, or x-ray pictures,
in court has too often worked harm or discredit to the surgeon or the
institution with which he was connected. Moreover, even this method
of diagnosis, with its apparent certainties, is not always reliable, and
disappointments have sometimes followed.
Intra-articular Fractures are subject to peculiar complications
which enhance the difficulty of treatment
and jeopardized the result. Among the more common of these are
the following:
1. Too wide separation of fragments by hemorrhage or distention,
with failure in resorption of fluid before fixation in bad position has
resulted.
2. Complete or partial rotary displacement, preventing proper
apposition of bone surfaces.
3. Interposition of soft or fibrous tissues between fragments by
which bony union is prevented. This is conspicuously common in
fractures of the olecranon and patella, and is of itself sufficient
reason to justify operation in otherwise suitable cases.
4. Separation of a fragment within a joint capsule, by which its
blood supply is cut off, making it essentially a foreign body. This
occurs especially at the anatomical necks of both the humerus and
femur.
5. Exuberance of callus with consequent limitation of motion.
6. Insufficient amount or absence of callus, which, when bone
ends are bathed in joint fluids, is not often thrown out.
All of these are immediate consequences. The following are
among the more undesirable remote consequences of the same
injuries:
1. Exuberant callus, which may be the result of too early attempt to
move the parts, or may result from other causes; it offers more or
less mechanical obstruction to joint movements.
2. Separation of fragments to an extent precluding the possibility
of repair, and interfering with function.
3. Pseudo-ankylosis, as a result of condensation and organization
of blood clot between joint surfaces.
4. Adhesion of tendons to surrounding callus or within their own
sheaths.
5. Displacement and distortion of bone ends with vicious union, for
which the medical attendant is sometimes responsible. Unfortunate
consequences of this kind are generally seen at the elbow after
fractures of the condyles; at the wrist, after incomplete reduction of
Colles’ fracture; at the hip, when insufficient traction has been made;
at the ankle, after the complete form of Pott’s fracture.
6. Exostoses and osteophytic outgrowths, which often complicate
fractures.
7. Absorption of bone, which is usually seen after fractures of the
neck of the femur.
8. Involvement of nerves by pressure of callus, most often seen
about the elbow.
9. Thrombosis leading to obliteration of the deeper and
enlargement of the more superficial veins.
10. Edema, also the result of venous obstruction by pressure of
callus.
11. Chronic hydrarthrosis.
12. Arthritis deformans traumatica. This is usually a remote result
of fractures, and manifests itself by slow changes in shape and
position, with deformity and disability. It occurs most often in the
aged.
13. Necrosis, which may be the result of failure in the process of
repair and will probably necessitate operation.
14. Malignant changes. These have to do with the occurrence of
sarcoma in bone callus, a complication which is known to
occasionally arise. (See Sarcoma.) It also refers to primary sarcoma,
by which bone is weakened, or secondary carcinoma, which
produces the same result.
15. Syphilis. Chronic syphilitic disease is well known to weaken
bones by atrophic processes as well as by the deposition of gumma.
It is known also to delay, or sometimes almost prevent, the process
of callus formation, ossification, and later absorption. Syphilitic
patients with fractures need to be kept under antispecific medicines.

REPAIR OF FRACTURES.
The immediate consequence of a fracture is outpour of blood both
from the broken-bone surfaces and from whatever other tissues may
have been lacerated. This produces, first, a hematoma, which is
followed by a certain degree of local edema, perhaps even of
general edema of the distal parts. The latter will subside with a
rapidity proportionate to the promptness of suitable treatment and
the nature of the injury. The blood begins to coagulate within a short
time, while with the disappearance of the more fluid portion
granulations begin to form from the periosteum, as well as bone
surfaces, externally and internally, and even from the marrow. The
clot loses its original characteristics and is permeated more or less
rapidly by granulations. With the site of the injury wrapped in a mass
of granulation tissue we speak of the so-called provisional callus,
whose amount will depend upon the severity of the injury and the
accuracy of the replacement of the parts. If laceration has been but
trifling and the bones are accurately apposed the amount of callus
will be small, otherwise it may be large; so large, in fact, as to be
easily palpated and even to cause edema and pain by pressure.
Repair of the fracture is effected by the gradual conversion of this
callus into cartilaginous tissue and then into bone. So much of it, at
least, as lies on the outer side of the bone and is known as external
callus goes through this change. The internal callus, i. e., that within
the marrow cavity, undergoes a more direct transformation, which
amounts to immediate ossification. The internal callus usually
ossifies completely, and then forms a medullary plug that serves as
an internal splint and affords support and strength. In time it
completely disappears, this time varying in different cases.
The external callus is converted into bone by passing through the
intermediary condition of cartilage. Between the broken-bone ends
granulation occurs more slowly, and repair at this point is delayed,
partly because of poor circulation and nutrition; but the internal callus
acting as a bobbin within, and the external callus acting as a solder
on the outside, give sufficient support and strength to effect a final
and absolute ossification of all the interfragmentary granulation
tissue. When the time comes when callus is no longer necessary it
begins to disappear by absorption. When everything proceeds
normally callus is absorbed in a proportion commensurate with its
loss of utility. When bone ends have badly united considerable callus
remains permanently. When apposition has been ideal it almost
completely disappears, even the medullary cavity being restored.
Fragments which are completely detached may be reunited by
practically the same primary process, but fragments of considerable
size usually become surrounded by granulation tissue, by which they
are nourished and may be finally reunited, with more or less
departure from their original shape and location. It is in this way that
a comminuted fracture may heal. Fragments that are separated
sometimes necrose and have to be removed.
 Fig. 278 Fig. 279

Compound fractures resulting from arm being caught in belting and wound
around shafting. End of radius united to ulna and lower end of ulna to the
radial fragment. Pseudarthrosis of humerus, thrice operated, the third time
in the Buffalo Clinic. (Skiagram by Dr. Plummer.) (Arch. Phys. Therap.,
May, 1905.)

The repair of the flat bones is effected by a similar process, which

is referred to as callus formation. In the skull it is brought about
chiefly through the agency of the diploë, whose powers in this
direction are somewhat limited. Cancellous bone tissue usually
throws out but little callus. Its repair occurs from within. Cartilage
heals by a very similar process, though it is not now ossific tissue but
fibrous which reunites the fractured surfaces. Instances of both kinds
can be seen when a fracture has crossed a joint surface.
 In a compound fracture much will depend upon the existence or
absence of septic complications. In a clean wound, whence blood
and fluid may have escaped, there will be little but granulation tissue.
Should this wound suppurate the exposed bone surfaces will
undergo at least a superficial necrosis, necrotic particles being
removed by the same granulation tissue which will later bind the
bone ends together. Here, too, the internal callus plays the largest
role in the process of repair. The bone tissue first formed is always
coarse and soft. Complete calcification and restoration of original
density and vascularity occur slowly. Neither cartilage nor
bloodvessels alone appear capable of forming bone; the latter is
produced only under the influence of the osteoblasts, which
penetrate from the periosteum and the bone itself along the course
of the bloodvessels.
The process is one of conversion of blood clot into provisional
callus, which then changes into granulation tissue or into cartilage,
both of these materials undergoing subsequent conversion into bone
through the medium of the osteoblasts and osteoclasts (or giant
bone cells), the neighboring bone itself undergoing a rarefying ostitis,
to change back into its original condition with the final changes of the
callus.
Repair of intra-articular fractures has already been described as
influenced by the presence of synovial fluid and cartilage. The latter
does not proliferate, and the line of fracture usually appears as a
groove on its surface. At epiphyseal junctions union is usually rapid
and satisfactory, for the changes taking place at this point are in the
direct line of what is needed for repair.

DELAYED UNION; NON-UNION.

The above description refers to the process which is supposed to
take place in normal bone repair. When, however, this is disturbed,
as it may be from a variety of causes, there may be delayed union;
when it completely fails we have non-union. General conditions have
bearing on these local failures. Whatever makes a strain upon the
system may interrupt the process, e. g., pregnancy, lactation,
exhausting hemorrhages, acute diseases, starvation. Again, failure
may result from purely local conditions, such as marked
displacement, and particularly the intervention of some of the soft
tissues, or any foreign body. Suppuration will also frequently cause
great disappointment. The humerus is the bone most often
troublesome in this direction; next the bones of the leg, the femur,
and the bones of the forearm. It is necessary to distinguish between
delayed union and absolute non-union. In the former normal
processes may be simply retarded. When thus delayed they may be
stimulated by rough handling, rubbing the bones together, or by
perforating the callus with the point of a drill, from several directions.
This method of drilling was introduced by Brainard, of Chicago. The
existence of syphilis has much to do with delay, and should be
combated by free use of antispecifics. Many patients will be found to
have phosphaturia, i. e., to be eliminating phosphates which should
go to repairing the bone. Such patients should be given phosphoric
acid, with some of the phosphates, preferably of calcium, in order to
make up for loss in this direction. Much can be done also by
massage, and by everything which stimulates nutrition and general
health (fig. 280).
 Fig. 280

Vicious union with great deformity after fracture, requiring extensive operation.
(Buffalo Clinic.)
 In non-union efforts at repair are at a standstill; the bone ends
become rounded off, the marrow cavity is plugged on either side,
while in time the surrounding granulation or connective tissue
undergoes condensation, as well as organization, and a capsule is
formed in which a certain amount of fluid resembling true synovia
collects, and thus is formed sometimes an almost perfect
pseudarthrosis or false joint, whose perfection as a joint must be
admired, although its presence is so deplored. The causes of non-
union are now better understood than formerly, and consist largely in
the interposition of fibrous and muscular tissues, that act as a barrier
and keep the granulation tissue or the callus on one side from
coalescing with that on the other.
Treatment of these cases will vary with their causes. In delayed
union patients should be encouraged to use the parts, thereby
causing greater activity, but in the presence of an actual false joint
no method is of avail except that of actual exposure, by incision, with
removal of all intervening fibrous tissue, and freshening of the bone
surfaces by saw or chisel, the endeavor being to so shape them that
they may lie in contact, and then be so maintained, by some
mechanical expedient, such as a wire nail or suture, an ivory peg, a
chromicized tendon, a bone ring, a small metal brace fastened with
screws, or by any other expedient which may suggest itself to the
ingenuity and the means of the operator. There are, however,
occasions when one deliberately endeavors to secure a
pseudarthrosis, as after ankylosis of the shoulder-joint, if in making
powerful effort to break up adhesions the neck of the humerus
should snap it would be better to prevent union rather than favor it,
as in this way something resembling the original joint, so far as
function is concerned, would be obtained. At the hip, also, after such
an accident, the same principles may be adhered to or more
deliberately secured by a subcutaneous osteotomy, as is sometimes
done for relief of deformity.
Fibrous union implies such organization of granulation tissue as
converts it into simple fibrous or ligamentous tissue, the change
stopping here and not going on to formation of cartilage or bone.
There are three localities especially where fibrous union is
sometimes the best that can be obtained and often proves sufficient
of itself; these are the olecranon, the patella, and the neck of the
femur. Even though the halves of the patella be separated by two
inches of ligamentous tissue the patient may still have reasonable
use of the limb. A separation of half an inch to one inch at the
olecranon does not materially disable the arm, while at the hip-joint
two or three inches of ligamentous tissue between the main end of
the bone and the fragment will not totally interfere with locomotion,
except so far as it permits an equivalent amount of shortening of the
leg. There are, then, occasions especially when the hip is involved in
elderly and decrepit people, when ligamentous union is the best that
can be hoped for or attained.

TREATMENT OF FRACTURES.
In principle the treatment of fractures is very simple. It consists in
putting the parts in apposition and maintaining them there for
sufficient time to permit of complete repair. That which is so simple in
theory is often very difficult and sometimes even impossible in
practice, made so by the nature of the injury or the disposition of the
patient. In the aged, who cannot lie long in one position for fear of
pulmonary stasis; also in the insane, in the epileptic, and in those
suffering from delirium tremens, will be met difficulties which are
insuperable. In such instances the first indication is to preserve the
life of the patient, the second is to get a good result, the third is to do
the best we can. Good management is not the least important
feature of such treatment. This will include suitable nutrition,
provision for elimination, prevention of bed-sores or pressure-sores,
and many other less important features.
Diagnosis having been made, the surgeon should study how he
may best carry out the fundamental principle of putting the parts in
apposition and so maintaining them.
The greatest obstacle to reduction and maintenance in position is
muscle pull. After an injury of this kind there will be more or less
muscle spasm, the more powerful groups displacing bones in the
natural direction of their pull. In the humerus and femur especially all
arm or thigh muscles will coöperate to produce shortening. As
indicated in the chapter on Joint Affections, nothing so thoroughly