1 The range of movement possible in every direction at the shoulder-joint varies greatly. It is most important, therefore, to compare the mobility of the two shoulders before the manipulation.

2 It is a common event during the manipulations to feel adhesions within the sheath of the tendon give way. To ensure that the tendon is free, the elbow should be fully extended and the forearm supinated while the shoulder is also in full extension.

3 This refers to a fracture which has not entailed wide separation of fragments, e.g., a star-shaped fracture. If there has been wide separation, or if an operation has been performed to unite the fragments, great caution is called for.

Manipulation of the radio-ulnar joints requires attention to the fact that the movement at the lower joint differs from that at the upper in so far as it is not a pure rotation. As the lower end revolves from supination to pronation round the head of the ulna, it simultaneously glides forward. It is always well, therefore, to free the antero-posterior movement which is possible at this joint before forcing rotation. This should then be performed with firm backward pressure over the lower end of the radius for supination, and with forward pressure during pronation.1 The hand on the front of the wrist in this case exerts its pressure over the region of the lower end of the ulna. Unless this antero-posterior movement is secured, the posterior ligament of the inferior radio-ulnar joint is liable to suffer severe damage during forcible pronation, and the anterior ligament during supination. If the obstruction is at the upper end of the radius care must be taken lest we inflict injury which will excite callus formation.

The wrist is a difficult joint to deal with, as there is so much, as a rule, that requires to be done. The amount of flexion and extension that is possible varies in each individual. It is essential, therefore, to examine the mobility of the sound wrist. Pure ulnar and radial deviation are well marked and often of wide range, but (and this point is often missed) there is a very considerable amount of true rotation possible independent of the radio-ulnar joints. Finally, there is not only the radio-carpal joint to consider, but, even more important very often, there are the joints between the inter-articular fibro-cartilage and the head of the ulna above and the carpus below. In full pronation these joints are, to all intents and purposes, locked; but in supination there should be very considerable antero-posterior mobility. The loosening of these joints is often all that is necessary in order to restore perfect function to a practically useless limb. Unless they are freed no amount of manipulation of the wrist will ever restore freedom of movement or function.

Manipulation of the hand is a somewhat lengthy process, but it should be possible to do all that is necessary under gas. Yet time is sure to press, and it is well to have a regular routine in mind so that nothing may be missed. The first carpo-meta-carpal joint is freed by grasping the thumb and exerting full tension in the long axis of the metacarpal. The digit is then carried into full abduction posteriorly and is swung round into full opposition. Great care is necessary to avoid torsion at the metacarpo-phalangeal joint during the movement. The joints between the bases of the remaining metacarpals are next freed by exerting a posterior pressure on the head of one metacarpal and anterior on the next adjacent, and then reversing the movement. Each pair is dealt with in turn.1 Having done this, we ensure that our objective has been secured by forming the posterior convex arch which the heads of the metacarpals can assume and flattening it out again.

1 For this manipulation the grip shown in Fig. 80, p. 157, is useful.

Manipulation of the digits is frequently mismanaged. It cannot be emphasised too often or too strongly that the metacarpo-phalangeal and inter-phalangeal joints are not pure hinge joints. A marked gliding element is present, and, unless this is regarded, the posterior ligament and probably both lateral ligaments will be torn during forced flexion. Considering the metacarpo-phalangeal joint as a type, in full extension the base of the proximal phalanx rests upon the extreme distal extremity of the articular surface of the metacarpal. If hyper-extension is possible it rests towards the posterior aspect. In full flexion, on the other hand, the situation of the base of the phalanx has shifted very considerably, and it now rests well down on the anterior surface of the bone. The nature of the manipulation required is now manifest. Little or no attempt is made to bend the joint. The digit is grasped firmly, and longitudinal tension is applied. Abduction and adduction of the phalanx on the metacarpal are first given in each direction, then rotation is performed with the joint very slightly flexed. The lateralisation is given in full extension, but rotation is very limited in this position and only becomes free when a minute amount of flexion has been added. Then pressure is exerted anteriorly on the head of the metacarpal and posteriorly over the base of the phalanx. Instantly flexion begins.

1 See Fig. 37, p. 78. 221

The direction of the pressure over the back of the base of the phalanx alters and tends to follow the base of the bone round the head of the metacarpal until it is exerted directly in the long axis of the metacarpal when full flexion is reached. The movement should partake far more of the nature of movement of the head of the metacarpal on the phalanx than vice versa. The wrist, of course, should be kept in dorsi-flexion throughout. Extension is performed by reversing the process. In this way only can the ligaments be saved from tearing. At the proximal inter-phalangeal joints the tendons of the inter-ossei are thus saved from damage - an accident which I have seen lead to almost irretrievable injury. Each joint in each digit is treated in similar manner. It is fatal to force full movement if rigidity has been serious or of long standing, or if it is in part the outcome of sepsis. In these cases movement should be performed in each direction just past the "dead point" and no more. Even though the amount of movement gained is minute, still it is enough; and it paves the way for greater gain at a subsequent manipulation. If too much is attempted the last condition of the patient is sure to be worse than before the manipulation. It is hard to avoid doing too much.