FRACTURE OF THE PATELLA 455 



as a plasterer by inability to extend the right elbow completely. The ununited 

 fracture of nine weeks' standing was oblique laterally. It was treated as in 

 the last case ; the operation presenting no difficulty. It was performed on 

 the 20th of March, 1878. The wound healed without suppuration, but the wire 

 was not completely removed ; for, the loop having broken near the twist, the 

 twisted part was alone taken away, and the loop left behind. It never caused 

 any inconvenience, and he afterwards wrote to us from his home at Bristol 

 that he was able to follow his old employment. 



The third case was that of a gentleman thirty-three years old, who had 

 consulted no fewer than eighteen surgeons on account of the weakness of his 

 left arm, caused by ununited fracture of the olecranon. I operated on the 

 28th of July, 1881, paring the broken surfaces as in the other cases, using 

 a chisel and hammer for the purpose ; and, having drilled the fragments with 

 a common bradawl, I brought them together with moderately stout silver 

 wire. In this case, however, I did not leave the ends of the wire projecting 

 from the wound ; but, having given them one complete twist (or two half 

 twists), cut the ends off short, and hammered the twisted part down flat upon 

 the bone with this small hammer. 



The advantage of this practice was strikingly exemplified by the difference 

 in the course of this case from its predecessors. Instead of keeping him under 

 treatment for several weeks until the wire could be removed, I was enabled 

 to allow him to return, fifteen days after the operation, to his home in Wales, 

 with a sound cicatrix ; and, trusting to the connecting loop of wire, permitted 

 him to use the elbow freely. I afterwards learned that he was able to drive 

 a four-in-hand as well as ever. 



The practice of cutting the ends of the wire short, and hammering down 

 the twist upon the bone, is one to which I shall have to refer again in con- 

 nexion with my later cases of fracture of the patella. It is in every respect 

 an advantage. The hammering down of the twist renders it more secure than 

 if it is left projecting, to be moved by every shifting of the dressing, and 

 perhaps broken, as in the second of the cases just referred to. We also get 

 rid of a source of disturbance, and sometimes of considerable uneasiness, in the 

 wound. The time of healing is greatly shortened, and the knowledge that 

 the loop of wire securely holds the fragments in position allows tlie use of 

 the joint to be commenced much earlier than when we have only tlie organic 

 bond of union to trust to. The practice is also of the highest value in ununited 

 fracture of the shafts of the long bones. The thickness of the wire must be 

 proportioned to the force to whicli it is to be subjected. For the olecranon, 

 that which I have here is aniplv sufficient, only about one twenty-fifth of an 



