If the fragments are freely mobile splintage is arranged on somewhat different lines. The patient is anaesthetised, and the gutter splint is moulded as before, and is then fixed in situ by a circular bandage. The advantage of this method is that the bones can be moulded into position in the gutter splint while we are still able to check their position by sight and touch. Only when the fragments are adjusted to our satisfaction do we finally enclose the limb. After a few days the circular plaster can be cut off without disturbing the original gutter.

After fracture in the region of the ankle-joint treatment by mobilisation and massage is often of the greatest possible service. After fracture of the lower end of the fibula, assuming that there is no displacement and that immediate treatment is called for, the first point is to see that kneading is performed over the external lateral ligament with sufficient firmness to arrest haemorrhage if this is obviously progressing, and to remove any effusion that may have already taken place. A thick pad of wool is then applied, and the whole is tightly bandaged. If, however, treatment commences at a later date, surface stroking massage should be commenced from about the middle of the calf to the hip, and the region of the ankle is gradually approached. Presently the stroke begins on the dorsum of the foot, it skips the ankle region, and then is continued up the limb. Any area of local swelling over the external lateral ligament is next subjected to firm kneading to try to dissipate local effusion. Care must be taken to avoid the site of fracture. In any case local treatment is called for over the ligament, unless there is some definite contra-indication. All movements, minute in amplitude at first, are administered to all joints of the foot, with the exception of eversion, and to the ankle. The second day deep stroking and compression massage of the thigh, and perhaps of the calf, may be added; and the third day the patient may hang the foot down and begin to move it about gently at the end of treatment. As soon as all swelling has disappeared - usually about the eighth day - exercises without weight and general re-education may be begun.

Treatment for fracture of the internal malleolus should follow similar lines. The fracture is one which is commonly stated to fail to unite. This is probably due to the escape of synovial fluid between the fragments, and mobilisation affords us a potent weapon wherewith to counteract this tendency. Eversion and inversion should not be prescribed at first, but ail the other co-ordination exercises without weight (see Chapter XX (Re-Education In Walking).) should be hurried on apace. After fracture of either malleolus without displacement it is usually unwise for the patient to bear weight on the injured limb for three weeks, when he may begin to do so gradually, though another week or more may be required before he is able to walk. Sometimes freedom cannot be allowed for six weeks. The only way to judge how rapidly treatment may advance is to go by very gradual stages and watch for increase of pain or swelling or decrease in mobility. If any of these occur we must retard treatment; if they are absent we can continue our advance.

If both bones are broken, or if there has been dislocation of the foot combined with fracture of one or both of the bones, treatment is much more difficult. The surgeon must reduce the deformity and arrange some fixation apparatus. Massage of the thigh can, none the less, aid repair by acting on the circulation and the nervous mechanism. When the splints are removed, care must be taken always to maintain inversion of the foot until union is quite sound, i.e., for a fortnight at least.

If a patient is found in a box-splint without a vertical foot-piece, then let the masseur beware. There is no more potent cause of thrombosis in the posterior tibial vein than the omission of the foot-piece. A glance at Fig. I will show that, if the foot is allowed to drop, the calf muscles flatten out, and the vein must accordingly be obliterated (see p. 15).

Fractures of the tarsal bones are serious injuries, and are often the prelude to osteo-arthritis in the joints. The patient is then in a parlous state. Treatment by mobilisation and massage tends to avert this evil; but the administration of movement is often impracticable during the early stages.

Fractures of the metatarsals, accidental or operative - as, for instance, after operation for hallux rigidus or valgus, when the bone has been completely divided - always provide a certain anxiety for the masseur. The severity of the injury varies, fracture of the first metatarsal being the most injurious, that of the fifth being least so. Mobilisation after massage must be given with all possible freedom to all the joints where movement does not involve any danger of displacing the fragments (see Fig. 90). When these are united, in about three weeks, all that remains is re-education in walking, which is preceded by free movement of all the joints of the limb. The patient, as a rule, is not able to walk freely for about six weeks.

Fractures of the patella are of two varieties - the stellate and the transverse. In the former the periosteum, with its strengthening fibres derived from the quadriceps and patellar ligament, is not ruptured and acts as a most efficient splint. Treatment should therefore be on the lines of a recent sprain to the knee-joint. If the fracture is complete and the fragments are widely separated, treatment by mobilisation and massage cannot quickly ensure any excellent result. Lucas-Cham-pionniere advised that, in all these fractures, the fragments should be united by suture. Plates are not so satisfactory, as they do not permit of any moulding or subsequent adaptation of the fragments. Then, if the shape of the bone is not perfect, refracture is almost a certainty. Robert Jones in his Injuries to Joints records that admirable results follow the use of the walking calliper for this accident. Massage could assist to maintain the nutrition of the limb and thus hasten repair, while mobilisation could be administered without fear of stretching the fibrous union, at least from a point half-way through the period that the instrument must be worn, which is about two months. The manner in which reduction of splintage should be adjusted is indicated in Chapter XXXII (The Combination Of Massage And Splintage In Orthopaedic Surgery).

Fig. 90.   To show a useful grip for mobilisation of the tarsal and tarso metatarsal joints. Kneading the foot without allowing the hands to slip over the surface of the skin may be performed in the same position

Fig. 90. - To show a useful grip for mobilisation of the tarsal and tarso-metatarsal joints. Kneading the foot without allowing the hands to slip over the surface of the skin may be performed in the same position.

Efficient re-education in walking is a very special art, and is invariably required to a greater or less extent after all fractures of the lower limb (see Chapter XX (Re-Education In Walking).).

Before leaving the subject of fractures it is necessary to utter a word of warning. Not every masseur is a fit person to be entrusted with the responsibility of treating a recent injury. If fracture is present, only those who have received special teaching and training in the art should be asked to deal with it, and, even then, great care and discrimination are called for in selecting a masseur for a difficult case. Experience alone is inadequate in the absence of the necessary skill and temperament. To hand over a case of recent fracture to a masseur merely because he happens to be proficient in other branches of his work is to court disaster. The responsibility for failure belongs to the medical man who selected the masseur, so it is his duty to be sure that the latter is qualified - by training, experience, skill, and temperament - for his highly specialised and very responsible duty. For the treatment of recent injury is an art apart. Under no circumstances can the medical man shift his responsibility for the position in which the fragments unite. If the result in this respect is faulty, he alone is to blame, as it was his duty to watch the position and correct errors while there was yet opportunity.