The practice of osteopathy

Sprains

The osteopath is often called upon to treat sprains of various sections of the body as well as to relieve after effects of fractures and restore function to the part. The osteopathic treatment is very effectual; therefore, an outline of the purpose and method is given.

Sprain is defined by Dorland as “the wrenching of a joint with partial rupture or other injury of its attachments, and without luxation of bones.” From an osteopathic viewpoint the above definition is not fully explanatory, for there is in most cases a partial luxation of the bones. The most common cause of a sprain becoming chronic is the presence of partial bony displacements. Rupture of tissues may be the cause of a chronic state but is not nearly so frequent as the bony dislocation. In most sprains, the wrenching causes a displacement of the bony tissues, which may or may not return to normal position and relation. The function of the muscles is not primarily to hold the bones in place; this is left to the ligaments, so when a wrench of a joint is so severe as to cause rupture of muscles or tearing of ligaments, partial luxation of the bones is almost certain to follow; and even where such damage does not occur a change in the relation of the bones is a frequent occurrence.

Unless a sprain can be seen very early it may be difficult to detect just what has happened; whether it rests with a rupture of the areolar and connective tissues, a displaced cartilage, tendon, or bone, a torn ligament, or ruptured muscle. Hemorrhage and swelling take place so rapidly that no time should be lost in critically examining the joint. When in doubt as to the structural disturbances, particularly in acute cases if there is a possibility of a fracture, and in chronic cases any supposition that tubercular involvement is present, have a radiographic examination.

There is comparatively little to be found in medical literature relative to the pathology of sprains. Probably Moullin in his excellent monograph on Sprains has given as good an outline as can be found[41]. He says that “generally speaking, the tissues on one side of a joint are overstretched and torn; those on the other compressed and crushed together; but there is always so much twisting, and such a difference in the strength and power of resistance of various structures, that unless the part is examined with the greatest care it is almost impossible to say what actually has given way.” Hemorrhage due to torn vessels is the cause of most of the swelling within the first few hours. Later on, there is considerable lymph mixed with the blood. There is not only extravasation of blood into the surrounding tissues but also into the synovial wall and cavity. This causes considerable irritation and pain owing to the roughening of the membrane, and the joint becomes inflexible. And if the joint or any strained tissue is kept too long at rest the mass becomes organized and is the cause of much discomfort and annoyance.

Similar changes may occur in the bursæ due to the extravasated blood. Strong ligaments may be torn across, but not frequently. The tear is usually a separation from the bone. Occasionally interosseous ligaments, as for instance in the knee, may be injured.

The muscles may be severely torn, but more often they are “hurt by their own sudden and spasmodic effort at recovery than by anything else.” In a few cases the tendons and muscles will be found bruised, lacerated, and dislocated.

The veins occasionally rupture and thus results more or less effusion, so that rigidity and edema may persist for a long time. The bones are very frequently damaged. This may be a simple bruising of the tissue but more often, as osteopathic diagnosis shows, there is partial displacement of the bony structure.

A point of great importance that every experienced osteopath will agree to is the following from Moullin: “Diseases of the spine, hip, and other joints in children may be due, in great measure, to some constitutional taint, though it is open to question whether the influence of this is not overrated; but it is quite certain that the immediate starting point in nine cases out of ten is some chance sprain, often so slight as scarcely to have been noticed at the time.”

Before treating a sprain there are one or two points the osteopath should carefully note: first, that there is no complicative fracture; second, in children that there is not an epiphysial separation; and, third, note peculiarities of a constitutional character that would complicate matters. Whatever is done, always give the patient the benefit of the doubt.

If the patient can be seen early, before swelling has reached the maximum, many times a very quick cure can be secured. Do not at once put the part at rest and apply cold, but examine the sprain most carefully and thoroughly and readjust first of all any bony defects; then replace the softer tissues if displaced, and next relax contractions; follow this by light massage and passive movements to reduce and combat hemorrhage and swelling. This treatment alone in a fair percentage of cases will be all that is necessary provided frequent subsequent treatments of massage and passive movements are continued to reduce and counteract inflammation and to prevent rigidity and stiffness of the softer tissues. Where the osteopathic treatment is distinctly indicated is in the readjustive manipulation. This is the reason why the treatment is so efficacious, and the patient is cured in a fraction of the usual time, and few sprains result in complications and become chronic. In sprains that have become chronic there will be found almost invariably some osseous tissue slightly displaced. After correcting this, apply careful and thorough manipulation and massage and movements to break up adhesions, to remove effusions and extravasations, to relax muscles, and to promote normal circulation. Care should be taken that there are no displaced cartilages, ligaments, tendons, or muscles.

It is well to keep in mind that the osteopathic readjustive manipulation is not an exercise or movement, but definite, specific correction of the tissues anatomically. Do not treat the displacement by any general “pommelling,” but apply the mechanical principles indicated as in any dislocation. This will mean much to the patient in more ways than one, and especially so should the sprain be so severe and complicated as to demand anesthesia for correction.

There is no objection to the employment of cold and heat; in fact, both are beneficial. Cold to prevent extravasation and swelling, and heat to remove and relieve the same, is a sound and practical method. But do not apply a wet bandage. Pouring cold water over the sprain is the best method; even better than immersing the part. An ice bag is another good way to apply cold. When the skin begins to look blanched and dull the maximum amount of benefit has been secured. Heat at the very first may be employed instead of cold, for it has a tendency to prevent bleeding and inflammation, but the temperature of the application must be hot as can be borne or else the desired effect will not be obtained. Later on to relieve pain and rigidity, and to relax the muscles so that a better circulation will be secured, moderate heat will be beneficial. Then the application of heat and cold alternately will be of service, employed as a douche for a tonic effect, when the part is weak, inactive, and powerless after the elapse of several days. It should always be remembered that the employment of heat and cold is only of temporary benefit, so if used too long opposite effects to those desired will result.

Bandaging the sprain may be helpful, but not always. Great care should be taken as to how pressure is applied. Bandaging from periphery toward the trunk, seeing that the bandage is smooth, and padding all depressions so that the bandage does not touch bony prominences only, are necessary. Unless the bandage is applied so that an even pressure is secured, the material used not too warm, and the bandage attended to each day, the effectiveness will amount to but little.

Next, do not make the mistake of resting the injured joint too much. The function of a joint is movement, and it has been observed that prolonged rest of a healthy joint may result in rigidity, stiffness, and distension of the soft part, and even serious organic changes in the ligaments, synovial membrane, and cartilages have occurred. Consequently continued passive movements should be kept up from the inception of the injury, although it must not be carried to extremes so that inflammation, hemorrhage, or laceration will be aggravated. Moullin says: “As a rule, passive movement may be commenced from the second day with the certainty of preventing adhesions, and without the least fear.” Osteopathically, with due attention to readjustive manipulation, and care as to correct position and rest, passive motion will be allowable usually from the first day.

There is much corroborative evidence in current medical literature that bears in a general way upon part of the foregoing. The International Text Book of Surgery says: “Massage should begin early, in order to avoid, as far as possible, weakness of the muscles, and to ensure security to the position of the joints by the retention of a proper tone in them;” besides, early movement tends to reduce the effusion into the tendon sheaths around the articulation, which in some cases, particularly the ankle and wrist, may be a very prominent feature. The Reference Hand Book of the Medical Sciences voices the same opinion; and Mumford is referred to as follows: “Immobilization for more than a few days, as under the older methods, is objectionable because adhesions are apt to form, thus causing impairment of function, and because when there is a tubercular taint, proper conditions for a localized tuberculosis are established.” Among other statements Holder Sneve in the Journal of the American Medical Association of June 1, 1901, says: “Immobilization of muscles is not rest. On the contrary, in all sprains the muscles should have passive exercise the first few hours and days, and active exercise after that. In the majority of cases active exercise should be instituted from the beginning. The plaster cast should not be used at all, even in cases where we have a fracture, unless it be impossible to maintain a proper position of the joint.”[42]

Again quotation is made from Moullin. These quotations are taken from the chapters on Manipulation and Massage. It will be observed he makes a distinction between the two methods. And the osteopath should carefully keep in mind not only the difference between the two, but beyond these the more fundamental treatment, readjustment. The characteristic feature of osteopathy is anatomical readjustment, and this in sprains should be supplemented by massage (superficial work), and also manipulation (deep and more or less forcible work) in order to remove stiffness, rigidity, and fibrous ankylosis.

The following is relative to forcible manipulation: “Manipulation is much more useful than division; it can be employed for such a variety of purposes. In the early stages it prevents the occurrence of stiffness or the formation of adhesions. Later, when the swelling and heat have disappeared, it is no less successful in restoring freedom and ease of movement, and afterward, when all mechanical obstructions have been cleared away by its use, it is one of the most effectual methods known for bringing back the circulation and nutrition of the part, and giving again to the muscles and nerves the energy which has so long been wanting....

“To carry this out effectively two things are needed beyond all others. The one is a sense of touch so delicate that it can appreciate the least resistance or irregularity of movement; the other an accurate knowledge, not merely of the ordinary anatomy of the part, but of the different degrees of tension that fall on the ligaments in every position of the limb.

“Each joint requires a different kind of manipulation according to its construction....

“There should be no jerking. The movements must be vigorous and forcible, but perfectly smooth; and they must be carried out thoroughly, the joint being moved to its full extent in all directions that are natural to it. Each kind of action should be combined successively with the rest, one by one, so that the tension may fall in turn upon all the different parts of the capsule.

“Movements which are especially restricted or painful, of course require most attention, but the others, though they may not be affected to the same extent, are not to be neglected. It sometimes happens if these are dealt with first, that a considerable proportion of the main obstruction is cleared away, as it were, by side attacks, so that when its turn comes it yields more readily than it otherwise would.

“Recent slight adhesions give away at once without a sound, though the sensation is generally conveyed to the hand. When they are older the noise may be as loud and clear as when a bone is broken....

“The after treatment of these cases (cases where there has been tearing and breaking of adhesions) should be in all respects the same as that of a recent sprain, only if passive motion at an early date is advisable to prevent the occurrence of stiffness in the one, it is absolutely necessary in the other.”

The following pertains to massage of sprains: “Massage, in the strict sense of the term, is a great deal more efficacious, especially with older sprains. Its action is not limited to the skin and superficial structures. These undergo immense changes, it is true; they become softer and finer while under manipulation; their strength and elasticity increase, the extreme tenderness diminishes, and the natural appearance and texture return. The surface loses its dry, harsh character and becomes warm and moist again; the livid bluish color gives away to a brighter hue, and the deeper layers of fibrous tissue yield and stretch, so that the hide-bound, shrunken condition that is often present after long disuse gradually passes off. But the good effect is not by any means limited to, or even most conspicuously shown by, this. When properly carried out, massage exerts a simultaneous influence on muscles, nerves, and vessels; in fact, on all the tissues within its reach.

“The circulation is the first thing to feel its power. It has already been explained how, after prolonged rest, the blood, as it were, lies almost stagnant in the tissues, slowly circulating through them, and neither giving them sufficient for their nutrition, nor removing from them the waste products of their action. This is changed at once. The life of the part is quickened. The veins and absorbents are emptied first, and the fluid they contain driven out into the heart, which fills more rapidly, and contracts more vigorously and firmly. Then the pressure falls in the smaller vessels, and the tiny irregular spaces, full of lymph, which extend in all directions through the tissues. These, in their turn, are compressed and mechanically emptied, their contents being driven on into the empty vessels, from which any backward flow is prevented by the valves. The circulation becomes more rapid; nutrition is carried on with greater energy, and the actual amount of the blood in the tissues at any one time so much increased that they become full and soft to the touch and regain the even and rounded contour of active health....

“It is most essential to commence as gradually and as gently as possible, working on the deeper tissues only after the more superficial ones have become thoroughly accustomed, and have been unloaded of their surplus fluid. The skin, the soft subcutaneous tissue, the muscles, and the deeper layers, must all be worked in turn. Nor should the manipulation be confined to the injured part. In a sprain of any standing, the whole of the limb is affected more or less. It is usually better to devote attention first to the parts nearer the trunk than to deal with those around the injured area, and only afterward, when the circulation is thoroughly reestablished, to manipulate the joint itself.

“The tendency is to make the sittings last too long. Deep manipulation itself rarely requires more than five minutes; but in dealing with a recent injury it may be advisable to spend a longer time than this over the friction and other preparatory measures, so that a quarter of an hour soon passes by. When the tenderness is very great, and the amount of swelling excessive, much longer than this may be necessary, but short, frequently repeated sittings are of greater benefit than one long one. A skillful operator, too, will often effect more in a few minutes than an ordinary rubber will in as many sittings.”

A summary of the general treatments of sprains would be as follows:

1. Readjustment of parts and removal of obstructions. Osteopathy is especially adapted in these cases, for two of the primal therapeutic factors in all cases from an osteopathic viewpoint are to readjust the anatomical and to remove obstructions. One should constantly keep in mind, “a temporary displacement followed immediately by a return to place, constitutes a sprain.” The osteopath often finds that a perfect returning does not take place, and even remote lesions may affect a joint.

2. Manipulation, and massage of soft tissues, to restore circulation and to prevent and remove debris from rupture of vessels and inflammatory products.

3. The employment of cold, heat and pressure, and a certain amount of rest.

4. Anatomical readjustment and manipulation in chronic cases to break up adhesions, remove exudates, overcome the organized products of inflammation, and cure synovitis.

5. Movements both passive and active to stimulate and exercise functions of the joint.

The Spinal Column.—The osteopath is especially cognizant of the fact that many sprains occur to the spinal column. These may affect a single joint, or more or less of a section may be involved. The bones, ligaments, tendons, muscles, or spinal cord may be found injured. Even distant organs, through involvement of the circulation to the cord, or through irritation or impingement of spinal nerves and sympathetics, are frequently disordered. It is not necessary to go into detailed description, for the points bearing upon this will be found under Osteopathic Diagnosis, Etiology, and Technique, and the general description will, also, apply. Readjustment, strapping, heat, massage, manipulation, ironing, stretching of muscles, fomentation, etc., have their place. There is no doubt that sprains, strains, and blows to the spinal column are the cause of many spinal disorders and consequent visceral disturbances.

The Ribs.—Sprains of the vertebral ends frequently occur, resulting in a partial luxation, stretching of ligaments, contraction of muscles, and exudative formation in the joint structures, which often is the cause of irritation to the sympathetic nerves. The costal cartilages are frequently strained, and may so irritate the intercostal nerve as to cause considerable pain both locally and reflexly. The treatment is essentially one of replacement, and relaxation of the softer tissues. Adhesive strips to limit movement due to respiration may be helpful.

The Innominata.—Sprains of the innominata are also commonly met with. Besides being a source of discomfort to the patient they are an important cause of pelvic disorders and leg affections. Partial displacements are the rule, the correction of which gives quick relief. Where there is considerable spasm of muscles, examine carefully the lumbar alignment. In chronic cases fibrosis of muscles and adhesions may complicate matters.

The Hip Joint.—Sprains involving the hip joint may be readily corrected, and again may be the exciting cause of serious involvement. Previous tubercular disease can be aggravated in this manner, or syphilitic changes in the joint disturbed. Care should be taken that there are no complicating displacements of the innominata or irritations to the spinal nerves. Possibly the hip may be so strained as to cause a twist of the femur in the socket and thus simulate a partial dislocation; this, in fact, would probably be termed a partial dislocation. Strain of one set of muscles about the hip joint is somewhat rare, and spinal lesions may disturb the innervation to one set of muscles. In cases of intracapsular fracture considerable can be done by careful massage and manipulation after union has taken place, to secure greater freedom of movement and strength of the limb. Likewise in hip-joint disease, after the disease is healed, massage and manipulation will be very beneficial. Care must be taken if the treatment causes spasticity of the muscles; this shows the treatment is irritative and should be stopped until the spasticity has ceased. Where the limb is shortened from either hip-joint disease or intracapsular fracture apparent lengthening may be secured by careful abductive and hyperextensive stretching.

The Knee.—The knee is the most complicated joint, and sprains are apt to be very serious. The usual treatment for sprains is employed. Occasionally the semilunar cartilages are displaced and may be a source of difficulty in diagnosis; likewise injuries to the patellar tendon and lateral ligaments. Another joint frequently overlooked is the innominate. In a number of knee cases that terminate in chronic synovitis there will be found a displacement of the innominate that is preventing recovery. A villous synovitis may arise in strains from faulty posture, especially in the obese. Injury to the hip-joint, also, may cause strain or irritation at the knee. Occasionally tender points about the knee, especially at the inner side, are due to irritation at the hip, or possibly from the spine. Referred pain of the knee joint is of frequent occurrence.

The Ankle and Foot.—The ankle is often sprained. One should examine carefully for a possible fracture of the malleolus, and for fracture of the tibia. There may be a dislocation of the fibula, also a separating of the tibia and fibula at the ankle. The common bony displacement takes place between the astragalus and os calcis. Then the cuboid is frequently displaced, and occasionally the navicular. The treatment should first of all be directed to correction of the osseous lesions. The arch of the instep may be weakened from the ligamentous strain and be an immediate step in the production of flat foot. Teall is of the opinion that lumbar and innominate displacement are common predisposing causes. Faulty position of the foot in walking may be an underlying factor.

Bunions result from a malposition of the joint. Morton’s disease due to a pinching of the metatarsal nerve will often yield to osteopathic treatment alone. There is generally displacement of the metatarsal bone. A pad worn directly under the painful point will be of benefit. In many of the local neuralgias, some anatomical displacement will be found as the exciting cause. Hammer-toe if not complicated with gout, rheumatism, etc., will yield to treatment if kept at persistently, otherwise surgical interference will be necessary.

Likewise various deformities of the foot and resulting neuralgias may be traced to local sprains, ill-fitting shoes, or anatomical maladjustments higher up of such a character as to affect the pedal circulation.

Flat Foot

Flat foot or weak foot is one of the common disorders that the osteopath is constantly called upon to treat. In the first place the patient should be taught to walk correctly. The feet should be parallel in walking so that the weakened muscles may be developed and strengthened. This will be difficult at first, but recovery depends upon this important point. In addition to this, special exercises, like turning the toes under and tip toe exercises, should be persisted in for a few minutes two or three times daily. Upon the other hand, do not overdo the exercises but always carry them to a point of fatigue. These two features, walking correctly and exercising, are essential complementary measures to the adjusting treatment. In conjunction with the above, the Scotch douche at the end of the day will prove of considerable benefit.

In the technique work, first make certain that there are no innominate or spinal lesions that bear upon the circulation and innervation of the feet. Then frequently faulty walking is due to these lesions.

In recent cases, simply remolding the arches of the foot will be all that is necessary, providing correct walking and foot exercising is maintained. But in the more chronic cases considerable adjusting and remolding of the tissues, bones, ligaments, muscles and fascia, are demanded. Perfect apposition between the astragalus and navicular bones, the highest point of the longitudinal arch, should be first secured. Attention should also be given the other articulating structures down to the metatarsal bones. This reestablishes the arch and overcomes the everted tendency. Considerable repeated force is often demanded to release the fibrotic tissues, but it is the important part of this technique.

With the patient on the table, supine, place your thumb firmly at the articulation of the navicular and astragalus. Then with the other hand around the metatarsals to be used as a lever in extending, rotating and inverting the foot with the fulcrum at the thumb of the first hand, spring, thrust and adjust the arch. This requires considerable strength and exactness of application. The tissues must give freely before the result can be secured. This is often painful to the patient but should be continued and repeated to the furthest point of motion until recovery is complete. Treat as often as the condition permits. Substituting the crotch of the thumb and forefinger or the knee for the thumb will give added advantage. Follow this with thorough springing of the plantar tissues by thumb and fingers.

If this is kept up with suitable exercises and correct walking, and proper shoes (Munson last), excellent results will be obtained in the great majority of cases. Same pair of shoes should not be worn two days in succession.

Many times the anterior arch is involved, jointly or separately. Persistent adjusting and remolding of the arch tissues will secure satisfactory results unless the bones are markedly deformed and the weight of the body is relatively too great. In this disorder, aside from paying special attention to the metatarsal articulations, the great toe requires a particular technique. For this grasp the toe firmly, exert traction until the tissue gives slightly and rotate it inward, toward the median line of the body, on its longitudinal axis. Have the patient frequently turn the toes under, or attempt to do it until the exercise can be easily accomplished.

Do not employ arch supporters except in hopeless cases. They simply splint the foot and thus further weaken the foot muscles. If the above methods are persistently followed to the point of actual adjustment, accompanied by releasing of fibrous tissue and actual strengthening of muscles through exercise, a very large percentage of cases will recover. In a few cases adhesive strips will be of benefit.

The Shoulder.—Exclusive of muscular and other strains there may be a partial dislocation. In these cases the acromial end of the clavicle is frequently dislocated, and owing to a general lack of muscular tone may be very hard to keep in place. The lower and inner part of the capsule is often affected, so that freedom of function is lacking and there is considerable pain. This is due to the thinness of the capsule and the large amount of soft tissue, so that when the arm hangs at the side the tissue is thrown into folds; and being very vascular is easily injured, so that the vascular lymph readily organizes and the part becomes stiff and unyielding. It requires patient, laborious treatment to break up and absorb this fibrous tissue. Then the long tendon of the biceps in some shoulder sprains is dislocated, but rarely. In shoulder injuries, examine also, the upper ribs.

The Elbow.—The elbow is another complicated joint. One should be careful that there is no fracture, and in children that there is not epiphysial separation. Extending, flexing, pronating and supinating the arm will aid much in the diagnosis. Examine well the rotation of the radius at the elbow joint, and be positive that the olecranon process drops normally into its fossa at the end of the humerus.

The Wrist and Hand.—The wrist is another joint commonly sprained. Here, also, care should be taken that a fracture does not exist. Colle’s fracture is frequent. The bursal and tendon sheaths are usually markedly involved. The scaphoid and semilunar are apt to be displaced; also, the os magnum and the unciform.

Sprains of the fingers are often met with. Outside of strains to the muscles, ligaments, and other tissues the joint is apt to be somewhat impacted. Traction will correct the latter. Care should be taken that a fracture is not present. Dupuytren’s contraction occurs from sprains or injuries, as the result of contraction of the fascia. The ring and index fingers are members usually affected. In some cases the affection will be found in both hands (symmetrical), and a spinal lesion will be the predisposing factor. Treatment every day, by straightening the fingers and stretching the tissue will at least retard the deformity, but in a number of cases surgery will have to be resorted to.

A ganglion or “weeping sinew” is a swelling in connection with the tendon sheath. It presents a round, firm outline, usually upon the back of the wrist. There is generally found a displacement of one or more of the wrist bones. If treatment of the joint and tendon sheath does not remove the ganglion, surgery may be utilized. Trigger-finger is a rare disorder. There is usually a history of local strain, which probably resulted in some thickening of the tendon. Manipulation and passive motion if continued will generally give relief.

Fractures

Immobilization and rest have been the paramount points with most physicians in the treatment of fractures and sprains. They have claimed that a sprain should be manipulated but rarely, much less a fractured bone. Rest, quiet, and fixation of an injured joint or bone have been rules that should not be violated under any consideration. In cases of sprain the great cry has been to let the joint alone for fear of spreading a possible tubercular infection. It is well to recall Mumford’s statement that if immobilization is too long continued, should there be a tubercular taint, proper conditions for a localized tuberculosis is established. And still a word of caution here, that an osteopath should not be over zealous and should carefully weigh all possible factors, both local and constitutional, may not be amiss. In previous tubercular, syphilitic, and other diseased states discretion should be employed.

Reducing rest and immobilization to a minimum means much to the patient, not only in the loss of valuable time but in annoying and serious after effects. Many cases of sprains and fractures come to the osteopath. In sprains that have become chronic through too much rest of the part and improper treatment, almost invariably there is found displacements of bone and adhesions that should never have existed; then has followed organized exudates and chronic synovitis. In fractures and even in complete dislocations the osteopath continually observes that too much rest has been given the part, resulting in unnecessary adhesions, contractions, atrophy of muscles, and impairment of function. Treatment almost always cures the condition, or at least materially relieves. How much better if the proper treatment had been first instituted and thus a large percentage of cases prevented from becoming chronic.

Of particular interest to the osteopath is the paper prepared by Eisendrath on “Early Massage and Movements in the Treatment of Fractures and Sprains,” and the discussion that followed before the Chicago Medical Society. The Illinois Medical Journal, December, 1903, contains a report.

Eisendrath said in part: “The former routine of immobilizing all fractures and the adjacent joints for a period of four to six weeks must, I feel, be subject to slight modification in the light of recent experience, and it shall be the aim of this paper to show what these changes are. When we are called to a case of fracture, it should be one’s first duty after its reduction to consider how can I best aid the patient in recovering the usefulness of his or her limbs? Can we shorten the long convalescence with its resultant loss of valuable time and earning capacity? How can we most rapidly restore to the limb its normal joint functions and prevent an atrophy of muscles and an ankylosis which will require many months to overcome?...

“The use of massage and of active and passive movements in the treatment of fractures and of severe sprains has been gradually gaining in the number of its advocates through the writings of Lucas-Championniere of Paris. We owe him a great debt for calling the attention of the profession to the employment of these methods in order to prevent atrophy and ankylosis as well as to promote healing....

“Before taking up my subject in detail permit me to recall a few salient points in the surgical pathology of fracture. Soon after the injury the blood clot around and between the ends of the fragments is absorbed and replaced by a jelly-like mass of young connective tissue cells called the callus. It corresponds to the solder which the plumber places over the ends of two pipes he desires to join. Bone begins to form at the periphery of the callus about the tenth day and advances toward the center rapidly, forming a ring of bone around the ends of the fragments so that by the end of the third week there is but slight abnormal motion at the point of fracture (exception to this is the femur). This entirely disappears by the end of the fourth week, especially in young people, and the union is firm. In the case of the femur it requires six or eight weeks. The greater the displacement of the ends of the fragment, the larger the callus and the slower the healing of the fracture.

“During these changes (callus formation) the muscles which supply the immobilized joints atrophy and the circulation in the skin and neighboring tissues is sluggish, resulting in swelling, etc., of the limb. The enforced rest causes more or less fluid to accumulate in the tendon sheaths and joints. This becomes organized and results in fibrous ankylosis of the joints and great impediment to the free action of the tendons within their sheaths. It is this atrophy, fibrous ankylosis and tenovaginitis which interfere with the restoration of the normal functions of the limb....

“Can we decrease the amount of wasting of muscles and control the stiffness of joints and tendons after fractures?

“It is the belief of the writer, based on a large experience, that the earlier use of massage, active and passive motions, will to a great extent eliminate the above conditions, which retard convalescence and in some cases cause permanent disability.

“Massage of an injured limb increases the amount of blood supplied to it, promotes the absorption of the swelling and prevents atrophy of muscles. In the case of a joint injury the exudate rapidly disappears and the articular surfaces can be again approximated so that movement is facilitated. By the cautious use of active and passive movements, either with or without the aid of apparatus, the normal functions of a joint can be rapidly restored....

“The active and passive movements of the limbs can be carried out immediately after the massage, but should only be permitted for a period of five minutes at first and the time then gradually increased. When a severe sprain, say the elbow or ankle, is first massaged, the pain seems to be almost unbearable, but this discomfort as well as the swelling rapidly disappears, and it is surprising to those who have never applied this treatment how quickly the normal function of the joint reappears. The same applies to the synovitis which accompanies fractures in close proximity or even into joints.”

The relief given these cases by massage, movements and manipulations by the osteopath is a daily experience, and results to him are not surprising. Then in addition to what the surgeon would do, the osteopath applies his principles of careful detail readjustment.

Eisendrath continues his paper by referring to the principal varieties of fractures and giving the treatment for each. He says that if correct treatment is carried out with proper massage and movements in fractures of one or both bones of the leg, the patient will be at work in six or seven weeks instead of three or four months, that in Colle’s fracture some surgeons do not employ a splint, and that in fractures of the olecranon, massage from the first week on is of the greatest use. This part is very interesting but space forbids giving it.

He then concludes his article with citation of several very interesting cases of fractures and severe sprains. These cases are exceptionally interesting to the osteopath, but still the same good treatment and results are duplicated every day in the osteopathic school.

The doctor’s contraindications to the use of early massage in fractures or sprains are the following:

“1. Tendency to displacement of fragments in oblique fractures. Under such conditions it is best not to begin either massage or movements until the union is firm (fourth to fifth week).

“2. In compound fractures until the wound is healed.

“3. Whenever the condition of the skin is such as to permit of infection; for example, the presence of blebs, or extensive abrasions.

“4. The presence of fragments which project but do not penetrate the skin.”

His conclusions are:

“1. Massage, active and passive motions prevent atrophy of muscles, tenovaginitis and ankylosis so frequently accompanying and following fractures, especially those close to the shoulder, elbow, wrist, knee and ankle joints.

“2. They give far better results than complete immobilization in the majority of fractures.”

In the discussion that followed Henrotin said that for some time, “I have never put a restraining apparatus of any kind, nor have I used any lotions on any sprain, no matter how severe....

“It has taken many years to bring this subject before the profession. It is a method that is absolutely effective as regards sprains and some forms of fractures. I have treated several hundred such cases with the greatest success.” He also said that, “In treating an inflamed joint it is improper to use a restraining apparatus of any kind. I consider that the plaster cast is the bane of all inflamed joints unless there is a specific form of infection, a traumatic condition.” Neither does he believe that an inflamed joint should be put at rest. He says the patient is a good judge as to the amount of quiet the joint needs. He has treated Colle’s fractures and fractured clavicles without bandages or apparatus.

To sum up, the osteopathic procedure in the treatment of fractures would be as follows:

1. Immobilization in those cases especially demanding it, from the character of the fracture, until formation assures solid and firm union.

2. Manipulation and massage and movements of parts at an early period, compatible with the above, to render soft tissues pliable, to remove stiffness and adhesions, to restore a normal circulation, and to exercise and function the parts.

3. In cases of laceration of soft tissues, abrasions, etc., great care should be taken so as not to infect the parts.

4. Great care should be taken where fracture is compound, and where fragments exist.

5. In all cases, both acute and chronic, critically examine for slight anatomical deviations locally and remotely.

In dislocations the fundamentals of the above are applicable. Do not let chronic stiffness, or rigidity, adhesions, or synovitis supervene if possible to prevent.

An important consideration in all cases of sprains, fractures, and dislocations that become chronic is the probable effect upon dependent tissues by way of nerve impairment and vascular obstruction; for examples, the sprained back may readily impair organic life, the fractured elbow prevent use of the arm, the injured leg predispose to flat foot. (See J. B. Littlejohn—Osteopathic Surgery, including Treatment of Fractures, Journal of the American Osteopathic Association, Nov., 1905.)