It is plain, then, that the task of the masseur when asked to treat a fracture near the elbow-joint is one of great difficulty. The main laws are "go slow" and never multiply movements till the end of the second week. It has been said above that, if trouble is arising, no guide will show the gravity of the situation till it is too late. There are, however, three symptoms which, if they arise, unerringly indicate that something is wrong - good fortune may furnish one or more. These are increase in pain, decrease in mobility, tenderness near the site of fracture. Last, but by no means of least importance, the absence of local oedema may be regarded as an assurance that no great risk is being run, while its presence should fill us with suspicion. Local oedema in front of the elbow, if present, usually indicates blood-clot. If the newly-formed callus is irritated, the whole of this clot will ossify; and if, as often happens, it should run into the interstices of the muscle fibres, opened up by tearing of the sheath of the muscle by the broken fragments of bone, it will lead to a condition closely resembling myositis ossificans - usually in the brachialis anticus. If there is no local oedema there cannot be any large amount of extravasated blood, and hence ossification outside the bone, even if it does take place, is not likely to be excessive. Let us beware then of local oedema.

There is one form of fracture of the humerus near the elbow after which no fear of excessive callus formation need be entertained. This is a T-shaped fracture into the joint. The synovial fluid, it would seem, escapes from the joint between the fragments, acts thus as a foreign body, and inhibits the growth of callus. Unless mobilisation is administered with a somewhat free hand, it is no uncommon event to find non-union as a sequel to the accident. The mobilisation tends to counteract the inhibitory action of the synovial fluid. As already stated, the same applies to fractures of the head of the radius where a comparatively large fragment has been broken clean off.

One more pitfall. It is difficult to explain how an elbow can be dislocated backwards without fracture being coincident. It appears, however, that it is possible. Even without dislocation, and even if radiography can produce no evidence of fracture, any severe injury near the elbow is liable to produce an outpouring of callus from somewhere, or, if not of true callus, of a deposit which develops into new bone. Treatment of these injuries should therefore be very cautious.

When speaking of relaxed movements great stress was laid upon the necessity of paying due regard to the laws which govern their administration. If there is one condition in which this is more essential than in others, it is when we are called upon to treat any severe injury in the neighbourhood of the elbow. It is not infrequent to hear these cases cited as examples to show the great damage that can be done by "passive" movement. When the accusation is examined carefully the story is always the same. The masseur, finding movement rather limited, forces the movement in the desired direction. The result is disaster. He has been guilty of substituting "forced" movement for "passive," and the irretrievable harm done is not due to "passive" movement. Nor is it due, as is sometimes stated, to an excess of zeal. It is due to nothing more or less than gross ignorance - ignorance of the elements of the treatment of recent injury, and of the nature of passive movement.

Fractures of the olecranon may be complete or incomplete. In the latter case the untorn periosteum will form an efficient splint, strengthened as it is by fibres from the insertion of the triceps. Nothing need be feared from the bony injury, and so the only condition that calls for treatment is the arthritis of the elbow-joint. This may be treated on lines similar to those sketched out for treatment of a fracture through the lowest inch of the radius without displacement. Roughly speaking, massage for the relief of pain - superficial stroking only - is given to restore the tone of the vaso-motor system of the limb and to relieve spasm. From the outset full relaxed movements of hand, wrist, and shoulder are given, and some 30 per cent. of elbow movement. Free active movements of hand and of the shoulder below the horizontal plane are prescribed, provided that no pushing or pressing is allowed. Relaxed and active movements proceed regularly day by day, guided in extent by the amount that can be performed without pain.

If the fracture is complete, and the smaller fragment of the olecranon is drawn up by the spasm of the triceps, few surgeons can be found who would recommend massage from the outset. Lucas-Championniere, who was the first surgeon to operate on these fractures in France, gradually came to the conclusion that the results attainable by mobilisation and massage were so superior to those following operation that he abandoned the latter altogether in favour of the former. A few cases are still recommended for massage from the outset for patients who are unsuited temperamentally or physically for operation, and an excellent result may be assured provided that the masseur and the patient fully appreciate one fact. Union will not be sufficiently firm to support any serious degree of tension for four weeks. Therefore, during this period, anything that pertains to the nature of "overhand" movement must be prohibited. With this reservation the treatment may be conducted on somewhat free lines. From the outset the aim of the masseur should be to secure by gradual stages relaxed movement from 90° to 170° of extension. After ten days or so, the sole guide being the painless nature of the movement, any "under-hand" use of the hand may be encouraged, but again no pushing or pressing downward with the hand, e.g., cutting bread or meat. After this stage has been reached flexion may be increased till the movement is complete about the end of the third week. As no "over-hand" movement is to be performed for so long a time, great care must be taken to retain the suppleness of the shoulder and the strength of the deltoid by relaxed movements and static muscle contraction.