The total or incomplete backward dislocation in the elbow-joint is generally seen in later childhood. In smaller children it is at least always accompanied by the separation of one or bot h condyles (Figs. 157, 138, Plate 16). The diagnosis can be made from the changed position of the olecranon in relation to the condyles and from the elastic fixation, in which the luxation is held by the contraction of the muscles.
Of the sideways dislocations, which are usually accompanied by separation of the epicondyles, the isolated dislocations of the radius outward and upward interest us most. They usually arise after the tear ing-off or at least after severe injury to the ligamentum annulare (Fig. 15S, Plate 16). Kirmisson and other French surgeons state that this last, and especially the incomplete dislocation forward, may be caused by a strong pulling on the hand. (Lifting up or pulling by one arm by the nurse-girl.) The hand is held in painful pronation (pronation dou loureuse). Kirmisson's explanation is that we do not really have a sep aration of the annular ligament, but only an abnormal stretching, which permits a partial slipping through of the head of the radius which makes a frequent recurrence of this condition possible (derangement interne).
5. The Flexion-frarture of both Bones in the Forearm This comprises about 10 per cent. of fractures in children. It is usually only a flexion "en Bois rert," and it is especially frequent in rachitic children. A fall upon the outstretched or flexed hand, a blow upon the forearm, even a propping up upon the arm, suffices to cause this fracture by increasing the natural curvature above the limit (Fig. 151a, Plate 16).
Usually both bones are fractured or infracted; rarely only one. The most frequent are the isolated fractures of the ulna with dislocation of the head of the radius. These deserve special mention and are caused by a direct force.
The diagnosis of these fractures is not difficult, especially when we remember the possibility of a suhperiosteal injury, which we can recog nize in children by the localized swelling and pain, and only rarely Nvi 11 we observe considerable dislocation (Fig. 151a, Plate 14).
6. The Fractures at the Lower End of the Radius Though these are quite frequent in adults, they occur much more rarely in children. In smaller children the flexion-fractures of both bones of the forearm will take their place, and only in older children will the neck of the radius break near the epiphyseal line (Fig. 159, Plate 16). The skiagram shows that we always have to deal with a fracture more or less near to the epiphyseal line which causes that peculiar swelling and dislocation known as silver-fork position of the hand. In small children an X-ray diagnosis is difficult owing to the wide carti laginous zone; but as the epiphyseal line itself does not ossify before the eighteenth year, it might lie t hat in later childhood, when the epiphyseal line is narrow, an epiphyseolysis would be more frequent. We know,
however, from clinical experience that the opposite happens, and we ob serve here almost always true fractures. Occasionally we may observe cases without dislocation of the fractured ends, and these we may mis take for a distortion of the hand. Dislocation of the hand is, however, so extremely rare that we have hardly any right to consider it, and in every case of swelling at the wrist of any size it will be better for both patient and doctor to institute the same treatment that WORM be used for a fracture of the radius, especially when we cannot make use of skiagraphy aml when we cannot find any abnormal motion or crepita tion owing to the thick cuff of periosteum in children. This precaution will save the patient some deformities which are very difficult to correct, and it will save the physician from reproach.
7. fi'ractures of the ildacarpus These as well as fractures of the phalanges are rare and arc caused by direct force.
[The above is meant for Germany, where baseball is not played. In the United States, where baseball is the national game and where boys begin to play almost as soon as they can walk, the direct force is given by the solid ball, which is pitched with great strength, and fractures of the end-phalanges of the fingors are of very frequent occurrence. They are still too often diagnosed as luxations, though the skiagram would readily inform us about the true nature of the injury and we would then be able to prevent the deformities which are now as much a sign of a young inan's prowess in America as the scarred faces of the German students.—THE TRANSLATOR.] S. Fractures of the Pelvis Fractures of the pelvis are caused by the action of strong forces, as a fall from great height or the falling of heavy articles upon the pelvis. In one case a fracture of the pelvis had been caused by a heavy packing box falling sideways against the pelvis of a child of four years. The bone was fractured at its thinnest place, the pubic spine, and at the junc tion of the descending ramus of the pubis with the ascending ramus of the isehium. It was quite characteristic that a piece of bone adhered to the symphysis, the same as happens in "epiphyseal fractures," and that the symphysis was not loosened (Fig. IGO, Plate 7). The acetabu hum had also been compressed by the force which had acted diagonally, so that the head of the femur seemed to be forced out. The dislocation of the bones had loosened the connection of the genito-urinary tract with the bone and the necrotic pieces of bone appeared from this suppurating cloaca. Owing to the wonderful power of regeneration of children the acetabulum was almost reformed within the year, without shortening. Except for a prominent scar in front of the urethral orifice the vulva was normal. This favorable result must be regarded as exceptional; usually these fractures are complicated by severe injuries to the intes tines, which will be a frequent cause of their fatal ending (peritonitis).