Having now considered in detail the treatment of a concrete example of recent injury, and having examined into the rationale of the treatment, it only remains to amplify it in its application to other forms of injury.

Fractures are under the immediate care of the surgeon, and although treatment by massage and mobilisation is applicable to a very large number of fractures from the outset, it is still rarely prescribed in the earliest stages. To the author it has never seemed to be right for a medical man to pass on the responsibility of treatment till union is complete. He should at least see the patient on alternate days and examine position and splintage. He will then issue instructions to his masseur day by day.

Failing these instructions, however, it is necessary to have some guiding laws of treatment such as the following 1: -

Until union is firm no form of massage is permissible over the injured segment of the limb, save only the gentle surface stroking. Even in performing this, the area of fracture must be omitted from the stroke. It is well to begin the stroking over an area that is not sensitive, and gradually to extend the length of the stroke till the site of the fracture is approached. The stroke may then be increased to include the area beyond the fracture, only the actual site of injury being omitted.

When union is complete there are various danger-signals which must always be regarded. Any increase in tenderness at the site of the fracture is an indication for the cessation of mobilisation and should be reported immediately. It indicates irritability of the callus due to strain at the site of union. An increase in swelling means that treatment the previous day has been excessive. The same deduction may be made if movement is more restricted or if there is an increase in stiffness. Massage is to be continued; mobilisation reduced or omitted. Sudden onset of pain with swelling may be due to thrombosis; it should be reported at once, and no treatment should be administered till further orders are given. The patient's life may depend on this precaution. No one could be blamed for omitting treatment on the barest suspicion of this calamity: to overlook the symptoms is unpardonable. In addition to pain and swelling there may be a rise in temperature. The patient usually describes the pain as resembling cramp, and tenderness can be noted along a line in the long axis of the limb. If a superficial vein is implicated there will be redness, but probably there will be none if the vein lies deep.

1 The treatment of fractures by mobilisation and massage is a vast subject, and calls for wide and varied experience, if the prescription of treatment is not to be fraught with danger. Only the barest outline can here be given, and the short sketch that follows must not be taken to represent anything but a very rough guide to essentials. No attempt is here made to enter into detail; yet it is the detail that makes for success.

Fig. 72. - Position for treating a fractured clavicle with the patient supine. Note that full movement to the elbow and all joints below can be given without disturbing the site of fracture. The patient's forearm rests on that of the masseur, as shown in Fig. 25.

Great care must be taken adequately to support the ends of the broken bones. A rough idea as to how this may be effected can be given shortly; the detail requires alteration to suit the needs of each individual case.

It must be remembered that in administering a dose of mobilisation there is always one direction in which movement can be applied that will tend to displace the fragments more than movement in other directions; while it is usual to find that in one direction at least movement has no tendency to cause displacement. This movement is, of course, the first to be administered and prescribed respectively during the performance of relaxed or active movement. Similarly any movement that tends to displacement is postponed until union is firm.

Fractures of the shaft of the clavicle, if the fragments are not liable to slip, may be treated while the patient sits with the elbow supported on a cushion. If there is any danger of displacement the patient should be supine, with head low, elbow supported by the side, and hand resting on the body (see Fig. 72). Massage should deal with the neck and pectorals before the limb is touched, but the whole limb needs treatment. Movement of hand and wrist, elbow and rotation, may all be given freely from the outset. Movement of the shoulder may be commenced very slowly and gently from the start if the fragments do not tend to shift; if they are mobile it should be postponed for a week or ten days, and then it should be commenced very cautiously. Unless strapped, the patient should be allowed to move hand and wrist freely from the outset. A simple fracture of clavicle never fails to unite, but undue mobilisation causes an excessive formation of callus. A simple sling and a bandage is usually all the splinting that is required for any fracture of the clavicle, but the sling must be drawn up tightly under the elbow so as to take as much weight as possible off the site of fracture. Fig. 77 shows the usual type of sling employed. It may also be wise to hold the point of the shoulder back by means of a shoulder-brace (see Fig. 73).

Fig. 73. - To show the application of the shoulder-brace used when treating a fracture of clavicle in the middle third. The brace is not needed unless there is a strong tendency for the fragments to overlap.