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Operative Techniques: Orthopaedic
Trauma Surgery

Second Edition

Emil H. Schemitsch, MD, FRCS(C)

Richard Ivey Professor and Chair/Chief
Department of Surgery
University of Western Ontario
London, Ontario, Canada

Michael D. McKee, MD, FRCS(C)

Professor and Chairman
Department of Orthopaedic Surgery
University of Arizona College of Medicine – Phoenix
Physician Executive Director
Orthopaedic and Spine Institute
Banner University Medical Center
Phoenix, Arizona, United States
1600 John F. Kennedy Blvd.
Ste 1600
Philadelphia, PA 19103-2899

OPERATIVE TECHNIQUES: ORTHOPAEDIC TRAUMA SURGERY,

SECOND EDITION 978-0-323-50888-9
Copyright © 2020 by Elsevier, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without per-
mission in writing from the publisher. Details on how to seek permission, further information
about the Publisher’s permissions policies and our arrangements with organizations such as the
Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website:
www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notice

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds or experiments described herein. Because of rapid advances
in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be
made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or con-
tributors for any injury and/or damage to persons or property as a matter of products liability, negligence
or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in
the material herein.

Previous edition copyrighted 2010.

Library of Congress Control Number: 2019945313

Content Strategist: Kristine Jones

Content Development Specialist: Laura Schmidt
Publishing Services Manager: Deepthi Unni
Project Manager: Srividhya Vidhyashankar
Design Direction: Amy Buxton

Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

This book is dedicated to my wife Maureen
and our four wonderful children Laura,
Geoffrey, Christine and Thomas.
Emil H. Schemitsch

I dedicate this book to the guidance

of my parents David and Nancy.
The love and support of my wife Niloofar.
My children Sacha, Tyler, Robbin, Everett,
and Darya who enrich my life every day.
And the promise of the new generation
Mickey, Felix, and Declan.
Michael David McKee

v
Preface

Fracture surgery occupies a special place in the hearts and recognized leaders in their field. In addition, through prospec-
minds of orthopaedic surgeons. This book is designed to be tive and randomized trials, they are at the forefront of develop-
a user-friendly and clinically relevant text on common frac- ing the evidence that exists for management of the patient with
ture surgery procedures. Every orthopaedic surgeon may be a fracture. Each chapter provides comprehensive technical
required to have knowledge or involvement in some aspect of descriptions supported by the best evidence in that area.
fracture care despite their subspecialty practice. The text is We believe that the production qualities of this text are the
designed for those who wish to review the surgical treatment of highest possible. The illustrations in particular are outstanding
the conditions that commonly confront them while on call. and clearly define the complex technical aspects of fracture
As fracture surgery becomes more and more sophisticated, surgery. We would like to thank all the members of COTS who
it is obvious that the technical component of operative inter- were contributors to this volume for their outstanding efforts in
vention is critical to clinical success or failure. Therefore, there making it a success. We feel this text should prove to be the
continues to be an important need to understand the techni- “resource of choice” for modern fracture care over the next
cal aspects of fracture surgery. Many pearls of wisdom are several years. It will serve those who are novices in the field
detailed by the authors in order to deal with the multiple poten- who wish to concentrate on principles, those experienced sur-
tial pitfalls seen in patients with complex fracture patterns. geons who wish to “fine–tune” their approach, and everyone in
A large number of chapters have been written by a member between.
of the Canadian Orthopaedic Trauma Society (COTS) who is
an expert in that particular area. COTS is a group of orthopae- Emil H. Schemitsch, MD, FRCS(C)
dic trauma surgeons with outstanding surgical skills who are Michael D. McKee, MD, FRCS(C)

vi
Foreword

This textbook represents the thoughts of a unique group of staff as a resource for expert opinion on the best ways to “skin
orthopaedic surgeons. It is a synopsis of current thinking in the cat.” Certainly there is more than one way to tackle the
surgery from a diverse but united group of physicians known problems than presented here; but the textbook shows a tried
as COTS. The Canadian Orthopaedic Trauma Society (COTS) and true method in the hands of each author. The method of
is active as a sub-section of the Canadian Orthopaedic Asso- approaching each area with pearls and pitfalls will be of great
ciation. COTS has been an avid leader in multi-center research benefit to everyone involved in patient care. This book should
studies for about two decades. This group has grown to over find its way into every program’s library and the bookcase of
50 members with the responsibilities of biannual research most surgeons performing trauma cases.
meetings and multiple study designs. They are a multiple I have to reiterate Dr. Leighton’s words in saying that the
award-winning group that has changed the way many simple COTS group is a great group of orthopaedic surgeons and I
and some complex problems are solved. The success of this am lucky to have been around to participate with the cohort of
group as a major force in conducting prospective multicenter surgeons and thinkers that make up this organization. Some
randomized trials has been well recognized by many including of the world’s best speakers, teachers, and researchers make
the Canadian Orthopaedic Association who awarded the group up COTS. Many surgeons from other countries wish they were
the Award of Merit for their performance. The COTS group has members of COTS and in practice many of them have become
won many awards from the world trauma organizations as a members in spirit, having adopted the basic principles and
testament to their excellence in the field of clinical randomized mechanisms of COTS. I know that COTS will continue to thrive
trials and their impact on changing the way we treat fractures for years to come. Their influence will grow and they will be a
in our day-to-day practice. The ability of this group to produce positive force in orthopaedic surgery. This text from that group
world-leading research is a testament to the Canadian norm of should be a prime resource for current orthopaedic trauma care.
friendly accommodation. Canadian demeanor is often a joke in The COTS group would like to dedicate this book to the
other countries; Canada is seen as the overly polite country. It families who continue to support us despite the long hours
certainly has been in this spirit of accommodation that the var- and many missed family events, due to the erratic nature of our
ied COTS undertakings were shuttled along to completion with specialty. Their support is essential to our continued success.
input from dozens of people in almost every phase of project We also acknowledge the tireless dedication of the research
development and completion. Ross Leighton, the current and coordinators and staff who make COTS a rich and viable
only president of the organization since COTS was founded, association.
has been instrumental in maintaining the collegiality that drives
purposeful projects. Edward J. Harvey, MDCM, MSc, FRCSC
The current group of authors, led by editors Emil H. Professor of Surgery McGill University Montreal QC Canada,
Schemitsch and Michael D. McKee, has once again been able COTS Member
to produce a literary gem that can be used by residents and

vii
Contributors

Mansour Abolghasemian, MD Rohit Bansal, MBBS, MS(ortho), D.Ortho

Orthopedic Surgery Clinical Fellow (Orthopaedic Trauma)
Bone and Joint Reconstruction Research Center, Iran Department of Orthopaedic Surgery
University of Medical Sciences Foothills Medical Centre
Tehran, Iran, Islamic Republic Of University of Calgary
Calgary, Alberta, Canada
Henry Ahn, MD, PhD, FRCSC
Department of Surgery Carl J. Basamania, MD
University of Toronto Division of Orthopaedic Surgery
Toronto, Ontario, Canada Tygerberg Academic Hospital
Division of Orthopaedic Surgery
Amro Alhoukail, MD, FRCSC Department of Surgical Sciences
Trauma and Reconstruction Fellow Stellenbosch University
Orthopedic Surgery Tygerberg, South Africa
Dalhousie University The Polyclinic and Swedish Orthopaedic Institute
Halifax, Nova Scotia, Canada Seattle, Washington, United States

Saad M. AlQahtani, MD, FRCSC Greg Berry, MDCM, FRCSC

Division of Orthopedics Assistant Professor
Sunnybrook Health Sciences Centre Faculty of Medicine
Department of Orthopedic Surgery McGill University
University of Dammam Staff Orthopaedic Surgeon
Dammam, Saudi Arabia Montreal General Hospital
McGill University
Kelly Apostle, MD, FRCSC Health Centre
Clinical Assistant Professor Montreal, Québec, Canada
Department of Orthopaedics
University of British Columbia Mohit Bhandari, MD, PhD, FRCSC
New Westminster, British Columbia, Canada Professor
McMaster University of Health Research Methods,
Diren Arsoy, MD, MSc Evidence, and Impact
Assistant Professor McMaster University Department of Surgery,
Department of Orthopaedics and Rehabilitation Division of Orthopaedics
School of Medicine Hamilton, Ontario, Canada
Yale University
New Haven, Connecticut, United States Ryan T. Bicknell, MD, MSc, FRCS(C)
Associate Professor
George Athwal, MD, FRCSC Departments of Surgery/Mechanical & Materials Engineering
Professor of Surgery Queen’s University
Roth | McFarlane Hand and Upper Limb Center Kingston, Ontario, Canada
St. Joseph’s Health Care, University of Western Ontario
London, Ontario, Canada Michael Blankstein, MSc, MD, FRCSC
Orthopaedic Surgeon
David Backstein, MD, MEd, FRCSC Orthopaedics and Rehabilitation
Division Chief University of Vermont Medical Center
Granovsky Gluskin Division of Orthopaedics Burlington, Vermont, United States
Univerity of Toronto
Toronto, Ontario, Canada

viii
PROCEDURE 1

Acromioclavicular Joint Injuries: Open Reduction

and Internal Fixation
Michael D. McKee and Alireza Naderipour

INDICATIONS PITFALLS
• Acute injury • Acute injury
• Grades IV, V, and VI in most patients unless surgery is contraindicated owing to • Skin abrasion: wait until healed
medical or psychological factors • Noncompliant patient
• Patient with substance abuse
• Grade III in selected patients, including heavy laborers (lifting, carrying) and over- • Chronic injury
head athletes/workers • Noncompliant patient
• Chronic injury
• Grade II in patients with symptomatic anterior-posterior instability
CONTROVERSIES
• Grades III, IV, and V in patients with symptomatic instability
There is no consensus on
PHYSICAL EXAMINATION • Optimum timing of surgery
• Anatomic vs. nonanatomic reconstruction
• Evaluate shoulder posture. • Best type of graft
• Determine the position of the distal clavicle relative to the acromion. • Acute repair of grade III injuries
• The deformity is more visible in standing or sitting position without support for the • Operative treatment of acute injuries is
the only treatment that will restore normal
injured arm.
anatomy, but it is associated with greater
• In grade IV dislocations, the clavicle is posterior to the acromion and stuck in the risk of complications.
trapezius. • Although often recommended, insufficient
• The distal end of the clavicle is level or superior to the acromion in other grades. evidence exists to recommend surgery for
• The distal clavicle is sitting subcutaneously, through the trapezius, in grade V injuries. heavy laborers or overhead athletes.
• Successful nonsurgical treatment of type
• In contrast to higher grades, the acromioclavicular (AC) joint is reducible in grade
III injuries in professional athletes has been
III by applying an upward force on the ipsilateral elbow. reported.
• Assess horizontal stability by grasping and moving the clavicle. • Inclusion of distal clavicle excision in
• Examine sternoclavicular (SC) joint for possible bipolar dislocation (synchronous AC management of chronic cases
and SC dislocation). • Preserving distal clavicle may add to the
stability of reduction.
• Assess active and passive shoulder motions.
• Reduction of an already arthritic distal
• AC joint pain is accentuated by abduction and cross-body adduction. clavicle may produce or aggravate pain.
• Manage glenohumeral stiffness prior to reconstruction of chronic separation. • Resection of distal 1 cm of clavicle results
• Isolated AC injury does not typically produce decreased shoulder range of motion. in a 32% increase in posterior translation.
• Evaluate deltoid and rotator cuff strength. • Resection of as little as 2.3 mm in women
and 2.6 mm in men could release the
• Consider the rare occurrence of concomitant rotator cuff pathology.
clavicular insertion of the acromioclavicular
• Perform neurovascular examination. (AC) ligaments in some patients.
• Some studies suggest improved outcomes
IMAGING STUDIES with preservation of the distal clavicle
• Plain radiographs during AC reconstruction.
• True anteroposterior view of the shoulder
• Evaluate the glenohumeral joint. TREATMENT OPTIONS
• Look for bony signs of rotator cuff pathology. • Nonoperative treatment
• Axillary view will demonstrate posterior displacement of the clavicle in grade IV • Indicated for grade I and II and most grade
injuries. III injuries
• Outlet/scapular Y view • Good short-term results
• Evaluate acromial anatomy. • 10% to 20% of patients will have
residual symptoms and may need
• The presence of a spur may warrant acromioplasty. subsequent surgery.
• Bilateral anteroposterior acromioclavicular views (Zanca view) • Nonoperative treatment of high-grade
• Evaluate the acromioclavicular joint position. injuries (IV, V) may be acceptable, but has a
• Look for possible arthritic changes. higher rate of poor outcome.
• Compare coracoclavicular distance on both sides. • A short course (1–3 weeks) of sling support
or immobilization may be used for comfort,
• Normal coracoclavicular distance is 11 to 13 mm.
Continued
1
2 PROCEDURE 1 Acromioclavicular Joint Injuries: Open Reduction and Internal Fixation

TREATMENT OPTIONS—cont’d • Stress views

• Originally described to differentiate between type II and type III injuries
but strict or prolonged immobilization should
be avoided. • Stress views are costly and uncomfortable for the patient and rarely provide
• Physical therapy new information to help diagnose an unstable injury.
• Early passive and active assisted range • Advanced imaging should be considered only if evaluation suggests rotator cuff
of motion (ROM) exercises or intraarticular glenohumeral pathology.
• When painless ROM is achieved, • Magnetic resonance imaging may be indicated to evaluate the rotator cuff in
proceed to isometric periscapular and
rotator cuff strengthening, followed by chronic injury.
isotonic exercises.
• Avoid contact sports and heavy lifting for SURGICAL ANATOMY
3 months. • Clavicle
• Operative treatment • The distal clavicle forms the medial articulation of the acromioclavicular joint.
• Components of optimal surgical technique
• Anatomic reduction of acromioclavicular • Acromion
joint •  The acromion forms the lateral aspect of the acromioclavicular joint and
• Coracoclavicular ligament repair/ typically slopes posteriorly and laterally. Newer designs of hook plates
­
reconstruction ­recognize this.
• Acromioclavicular ligament repair/ • The anterior acromion is also the site of coracoacromial ligament insertion, which
reconstruction
• Protection/augmentation of repair/ is used in the Weaver-Dunn procedure.
reconstruction • Acromioclavicular joint
• Deltoid/trapezoid fascia repair • The orientation of the joint varies from vertical to 50 degrees oblique from infero-
• Distal clavicle resection, if arthritic medial to superolateral.
• Acute injury • The intraarticular meniscus
• Coracoclavicular ligament repair and
augmentation • Made of fibrocartilage
• Multiple techniques have been described • True function unknown
to stabilize the AC joint with autograft/ • Undergoes significant degeneration over time
allograft tendon or ligament augmentation • Acromioclavicular ligaments
devices around the coracoid. • The posterior acromioclavicular ligament is an important restraint to posterior
• Transarticular acromioclavicular pin fixation
• Needs limited dissection translation of the acromioclavicular joint.
• Risk of pin migration/breakage • The superior acromioclavicular ligament contributes to a lesser extent to restraint
significant, largely abandoned of posterior translation of the acromioclavicular joint.
• Acromioclavicular hook plate • The inferior acromioclavicular ligament contributes to restraint of anterior transla-
• Mechanically very effective tion of the acromioclavicular joint.
• May result in acromial wear or fracture
• Newer hook designs that match acromial • Isolated disruption of the acromioclavicular ligament occurs in grade II injuries.
anatomy preferred • Coracoclavicular ligaments
• Avoid over-reduction • The conoid ligament is a more medial structure that attaches on the conoid tu-
• Most, but not all, patients require bercle on the underside of the distal clavicle. The conoid tubercle is located at the
eventual hook plate removal. juncture of the lateral and medial thirds of the clavicle.
• Weaver-Dunn acromioclavicular ligament
transfer • The trapezoid ligament is more lateral and attaches on the trapezoid line of the
• 40% failure rate, not used in isolation inferior clavicle.
• Provides 25% of intact coracoclavicular •  Disruption of the acromioclavicular and coracoclavicular ligaments occurs in
ligament strength grades III, IV, V, and VI injuries.
• Strength can be drastically increased by • Muscular anatomy
adding synthetic loop augmentation
• Coracoclavicular screw fixation • Trapezius, pectoralis major, and anterior deltoid muscles attach to the distal clavi-
• Has a high failure rate, not used in isolation cle and acromion.
• Acromioclavicluar ligament repair • Their combined action provides dynamic stability to the acromioclavicular joint.
• Imbrication of the torn AC ligaments • Neurologic anatomy
• Chronic injury • Brachial plexus, suprascapular, and musculocutaneous nerves are in the vicinity
• Coracoclavicular ligament reconstruction
with and could be injured in reconstruction surgeries.
• Tendon graft • AC joint is innervated by lateral pectoral, axillary, and suprascapular nerves.
• Synthetic loops • Vascular anatomy
• Weaver-Dunn procedure • Branches of the thoracoacromial artery run in the vicinity of the distal clavicle and
• Conjoined tendon transfer can bleed during the dissection and exposure of the base of the coracoid.
• Acromioclavicluar ligament reconstruction with
• Suturing of the remaining coraco-
calvicular (CC) graft around the AC joint
POSITIONING
• Intramedullary free tendon graft • The patient is placed in the beach chair position, with the surgical field draped out,
• Reverse coracoacromial ligament bony landmarks outlined, and the skin incision marked.
• Neck alignment should be in a neutral position with the head on an adjustable articu-
lating headrest or gel pad “donut.”
 PROCEDURE 1 Acromioclavicular Joint Injuries: Open Reduction and Internal Fixation 3

• If desired, an articulating arm holder is used to support and position the arm during EQUIPMENT
the procedure. Alternatively, the arm may be secured at the patient’s side.
• Articulating sterile arm holder
• A side pad is placed against the lateral chest to keep the patient from falling off the • Gel headrest
side of the table. • Side pad

PORTALS/EXPOSURES PITFALLS
• A superior surgical approach is used.
• Keep the neck aligned in neutral rotation
• An incision is made along Langer’s lines over the distal end of the clavicle. and flexion/extension position to protect the
• Begin just posterior to the clavicle and extend toward the coracoid process. cervical spine and prevent brachial plexus
injury.
PROCEDURE: HOOK PLATE FIXATION
PEARLS
Step 1: Skin Incision and Surgical Dissection
• Drape high on the neck and inferior enough on
• Surgical incision is made along Langer’s lines.
the chest to have an adequate surgical field.
• Continue dissection through the subcutaneous tissue. • If a difficult reduction is anticipated, drape the
• The skin and subcutaneous tissue are elevated to extend exposure medially and operative arm free.
laterally to expose the distal 3 to 4 cm of the clavicle and the acromion. • Position the shoulder in a way that imaging
can be used if needed.
Step 2: Acromioclavicular Joint Exposure and Mobilization
• The deltotrapezial fascia is split over the distal clavicle and acromion. PEARLS
• Typically the acromioclavicular joint capsule and ligaments are disrupted by the in- • An incision parallel to Langer’s lines will heal
jury. Be alert for this disruption and work through any defects created by the injury. with a very cosmetic scar.
• The meniscus is debrided.
• Look for arthritic changes. Distal clavicle resection should be considered in chronic PITFALLS
cases with frank arthritic changes. • An incision that is too lateral limits exposure of
• Mobilize the distal clavicle and ensure that it can be reduced. the clavicle.
• An incision that is too medial limits access to
Step 3: Hook Plate Insertion the acromion.
• A longitudinal incision in line with the clavicle,
• Anterior deltoid is elevated off the distal clavicle, subperiosteally and retracted anteriorly.
across Langer’s lines, may heal with a thick,
• Cauterize vessels imbedded in subdeltoid fatty tissue. noncosmetic scar.
• Open the subacromial space with a Cobb or periosteal elevator and insert the hook
portion of the hook plate. This typically will be posterior in the subacromial space. INSTRUMENTATION/IMPLANTATION
• Use the hook plate trials to determine the correct height of the hook plate to be in-
• Place a self-retaining retractor to hold the skin
serted; be careful not to over-reduce the joint. The clavicle should not require exces-
and subcutaneous tissue apart.
sive force to reduce (Fig. 1.1).
• Insert the chosen hook plate and then place the screws in the plate, which will bring
PEARLS
the plate down to the clavicle.
• Be careful that insertion of the screws in the shaft portion of the clavicle does not • Release enough capsule and soft tissue to
facilitate anatomic reduction of the distal
“lever” the clavicle down further.
clavicle.
• If there is any question as to reduction, use radiographic imaging to ascertain this. • Have a preoperative radiograph of the opposite
Considerable variation exists in AC joint pathology: a preoperative radiograph of the side.
opposite side can be useful to gauge proper reduction.
PITFALLS
Step 4: Optional Coraco-Acromial (CA) Ligament Transfer
• Avoid over-reduction of the AC joint: this leads
• If desired, especially in the chronic situation where an acute healing response will not to a painful, stiff shoulder with a high rate of
occur, a CA ligament transfer can be performed in addition. subsequent mechanical failure (plate pull-off,
• This Weaver-Dunn transfer can be performed by releasing the CA ligament from the acromial fracture) (Fig. 1.2)
acromion and inserting it through drill holes in the distal clavicle. • Excessive distal clavicle resection potentially
destabilizes the acromioclavicular joint by
• Alternatively, a small fragment of acromion can be resected with the CA ligament releasing the acromioclavicular ligaments.
and then secured with a lag screw to a corresponding slot cut into the distal anterior
acromion. This provides biologic healing and ligamentous stability following eventual
INSTRUMENTATION/IMPLANTATION
hook plate removal.
• Hook plate implants, including trials and
Step 5: Optional Coracoclavicular Augmentation definitive implants
• Newer hook plate designs provide a better fit
• Acute repair to the undersurface of the acromion and may
• The coracoclavicular sutures (nonabsorbable no. 5 suture or 5-mm suture tape) minimize complication and removal rates (Fig.
are passed under the coracoid. 1.3).
• The clavicle is held reduced to the acromion with direct downward push on the • Power saw, osteotome or chisel for distal
clavicle resection
distal clavicle and upward pressure on the arm through the elbow.
• Tie the sutures over the plate.
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4 PROCEDURE 1 Acromioclavicular Joint Injuries: Open Reduction and Internal Fixation

B
A

C D
FIG. 1.1 Proper alignment and positioning of the hook plate results in rapid healing in an anatomic position.

19 mm B

C D
FIG. 1.2 Over reduction of the clavicle is to be avoided as it increases pain and can lead to acromial erosion of the hook.
 PROCEDURE 1 Acromioclavicular Joint Injuries: Open Reduction and Internal Fixation 5

A B
FIG. 1.3 The angle of the hook should match the usually sloped angle of the acromion.

• Chronic reconstruction CONTROVERSIES

• Tendon ends are prepared with passing sutures.
• Distal clavicle resection is controversial.
• Tendon ends are passed under the coracoid. • Distal clavicle resection
• The tendon ends are pulled up through clavicle drill holes or over the clavicle itself • May facilitate reduction
and tied into place. Avoid making the superior aspect of the graft too bulky: it will • May prevent late acromioclavicular arthritis
interfere with the hook plate placement. • At least partial resection is required for
• Stability is then enhanced by the addition of the hook plate over top of the tendon Weaver-Dunn procedure for ligament
reattachment.
graft. Once graft healing has occurred, typically 6 to 8 months postoperatively, • Preserving the distal clavicle
the hook plate may be removed. • May facilitate acromioclavicular ligament
repair
Step 6: Deltotrapezial and Acromioclavicular Repair • May improve acromioclavicular joint stability
• The acromioclavicular ligaments and capsule are repaired over the acromiocla- • Isolated coracoclavicular ligament
reconstruction does not require distal
vicular joint, incorporating the lateral extension of the tendon graft for a chronic clavicle resection.
reconstruction.
• The deltotrapezial fascia is sutured over the clavicle with nonabsorbable suture.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES INSTRUMENTATION/IMPLANTATION

• A sling is used to support the arm for 6 weeks. • Power drill or burr to make holes in the clavicle
for suture and tendon passing
• Physiotherapy protocol
• 0–2 weeks: No shoulder motion is permitted.
• 2–6 weeks: The sling is discontinued and supine passive and active assisted ex- CONTROVERSIES
ternal rotation and scapular plane elevation is begun. • Coracoclavicular fixation can be achieved
• 6–12 weeks: Passive and active-assisted range of motion in all planes. Isometric with heavy sutures, acromioclavicular hook
deltoid and rotator cuff exercises below chest level are started. plate, coracoclavicular screw, transarticular
• >12 weeks: Progressive resisted exercises are begun. acromioclavicular screw, or pins.
• When patient compliance is a concern, early
• 16 weeks: Return to sports is allowed if range of motion is full and strength is
motion is desired, or in a revision setting, the
adequate. tendon graft is best supplemented with a hook
• Most patients attain a shoulder rating of 90+ after hook plate fixation of acute AC plate.
joint disruptions. The major complication rate is low, as long as over-reduction is • Supplementing the graft with hook plate has
avoided. been shown to result in less displacement in
biomechanical testing.
• Most, but not all, patients require hook plate removal: it is recommended that the
plate be left in place for at least 6 months prior to removal to allow adequate heal-
ing to occur to prevent re-displacement of the joint. PEARLS
• Early motion is advantageous.
6 PROCEDURE 1 Acromioclavicular Joint Injuries: Open Reduction and Internal Fixation

PITFALLS EVIDENCE
• Overly aggressive early rehabilitation can Li X, Ma R, Bedi A, Dines DM, Altchek DW, Dines JS. Management of acromioclavicular joint injuries. J
lead to attenuation or failure of the repair or Bone Joint Surg [Am]. 2014;96:73–84.
reconstruction. A comprehensive review of modern treatment methods for acromioclavicular joint injuries.
Galpin RD, Hawkins RJ, Grainger RW. A comparative analysis of operative versus nonoperative treat-
ment of grade III acromioclavicular separations. Clin Orthop. 1985;193:150–155.
This older retrospective review revealed that there was little improvement with surgical treatment
of acute acromioclavicular joint injuries and recommended nonoperative treatment in general.
Gstettner C, Tauber M, Hitzl W, Resch H. Rockwood type III acromioclavicular dislocation: surgical
versus conservative treatment. J Shoulder Elbow Surg. 2008;17:220–225.
A retrospective study (mean follow-up 34 months) of 24 patients treated surgically with a hook
plate and 17 patients treated conservatively. The mean Constant score was 80.7 in the conserva-
tive group and 90.4 in the hook plate group. The mean coracoclavicular distance was 15.9 mm in
the conservatively treated group and 12.1 mm in the surgically treated group. In this study, better
results were achieved by surgical treatment with the hook plate than by conservative treatment.
Salem KH, Schmelz A. Treatment of Tossy III acromioclavicular joint injuries using hook plates and liga-
ment suture. J Orthop Trauma. 2009;23:565–569.
A study of 25 patients revealed the hook plate was a reliable fixation tool for complete AC joint
dislocations, ensuring immediate stability and allowing early mobilization with good functional and
cosmetic results (mean Constant score 97 points).
Bannister GC, Wallace WA, Stableforth PG, Hutson MA. The management of acute acromioclavicular
dislocation. A randomized prospective controlled trial. J Bone Joint Surg. 1989;71B(5):848–850.
This study of 60 patients failed to reveal any improvement with surgery, in general. The authors
postulate that patients with severe displacement (>2 cm) may benefit from surgery.
von Heideken J, Windhamre HB, Une-larsson V, Ekelund A. Acute surgical treatment of acromioclav-
icular dislocation type V with a hook plate: superiority to late reconstruction. J Shoulder Elbow Surg.
2013;22:9–17.
Patients treated with acute surgery (22) had a more satisfactory outcome than those with late
surgery (15) after failed conservative treatment.
Pauly S, Kraus N, Greiner S, Scheibel M. Prevalence and pattern of glenohumeral injuries among acute
high-grade acromioclavicular joint instabilities. J Shoulder Elbow Surg. 2013;22:760–766.
A review of 125 patients with high grade AC joint injuries who underwent shoulder arthroscopy
revealed a high rate of intra-articular glenohumeral pathology (30%).
Canadian Orthopaedic Trauma Society. Multicenter randomized clinical trial of nonoperative versus
operative treatment of acute acromio-clavicular joint dislocation. J Orthop Trauma. 2015;29(11):479–
487.
A clinical trial of 83 patients randomized to hook plate fixation versus nonoperative treatment.
Although hook plate fixation resulted in superior radiographic alignment, it was not clinically supe-
rior to nonoperative treatment of acute complete dislocations of the acromioclavicular joint. Both
groups improved from a significant level of initial disability to a good or excellent result (mean
DASH score, 5–6; mean Constant score, 91–95 in both groups) at 2 years.
PROCEDURE 65

Sacroiliac Joint Injuries: Iliosacral Screws

Milton Lee (Chip) Routt, Jr.

INDICATIONS PITFALLS INDICATIONS

• Accurate assessment of SI joint instability is • Unstable sacroiliac (SI) joint traumatic disruptions
based on physical examination, plain pelvic • Unstable SI fracture-dislocations
radiographs, computed tomography (CT) scans, • Symptomatic sacroiliac joint arthritis
and dynamic imaging during stress examination.
• Complete and incomplete SI joint instability is • Symptomatic chronic posterior pelvic instability
commonly noted on pelvic imaging.
• SI joint instability may not be obvious if the pelvic EXAMINATION/IMAGING
imaging was performed after a circumferential • The physical examination identifies open wounds, closed degloving injuries, ecchy-
pelvic wrap was applied; the pelvic wrap often moses, prior scars, urethral meatal blood, rectal blood, vaginal-labial injuries, and
produces an accurate SI joint reduction.
neurovascular injuries.
• Manual compression toward the midline applied over each iliac crest during the
physical examination reveals instability.
INDICATIONS CONTROVERSIES • For the injured patient, anteroposterior (AP) pelvic radiograph prior to circumferential
• Controversy still exists in reliably diagnosing and pelvic wrapping
safely treating incomplete posterior pelvic injuries. • Same patient, AP pelvic radiograph after wrap application
• The role of posterior pelvic instability in chronic • The pelvic CT reveals injury sites, displacements, deformities, body habitus, hema-
symptomatic symphysis pubis instability
toma location and extent, and associated injuries.
remains controversial.
SURGICAL ANATOMY
• The SI joint is an unusual articulation composed of iliac and sacral articular pads sur-
TREATMENT OPTIONS
rounded by strong ligaments.
• Closed reduction and percutaneous fixation • The fifth lumbar nerve root is located on the sacral ala just medial to the anterior SI
(CRPF) is used whenever possible. joint.
• CRPF relies routinely on intraoperative
• For reliable and safe iliosacral screw insertions, the upper sacral osteology (in-
fluoroscopy to both assess the reduction and
direct the iliosacral screw insertion. cluding sacral dysmorphism) must be identified and quantified on the preoperative
• Usually incomplete SI joint injuries will indirectly imaging.
reduce when the anterior pelvic injury is reduced, • Hip flexion during the anterior surgical exposure for ORIF relaxes the iliopsoas mus-
or when the precisely oriented lag screw cle, eases retraction, and improves exposure of the anterior joint surface.
compresses the residual SI joint distraction.
• Aggressive medial retraction and/or clamp application along the lateral sacral ala
• Open reduction internal fixation (ORIF) of the
SI joint is selected when closed reduction during the anterior ORIF risks injury of the fifth lumbar nerve root.
techniques fail or are not possible. • Wound complications are more common when the posterior exposure is selected for
• Open reduction of the SI joint is performed ORIF.
using either an anterior exposure with the • Iliosacral screws can be safely inserted with the patient properly positioned either
patient positioned supine, or via posterior
supine or prone.
surgical exposure in the prone position.
POSITIONING
• When the supine position is selected, a folded operating room (OR) blanket is used
PEARLS
to elevate the patient and pelvis from the OR table so the iliosacral screws can be
• The folded blanket is adjusted in thickness to inserted easily.
elevate the pelvis from the OR table sufficiently • Skeletal traction is used as a reduction aid when necessary.
to allow iliosacral screw insertion.
• The surgeon must ensure that the eyes are • Positioning the patient supine allows surgical access to both the anterior pelvic ring
free of pressure, the genitals are positioned and the anterior SI joint.
appropriately, and that all bony prominences are • Prone positioning is more difficult in patients with anterior external fixation devices.
well padded when the patient is positioned prone. • The prone position denies the anesthesiologist easy access to the airway,
• Prior to draping, use the C-arm to ensure and the surgeon must ensure that there is no pressure on the eyes during the
that the patient is well positioned so that all
appropriate images can be easily obtained. surgery.
• The upper extremities are positioned so they do not obstruct either pelvic imaging or
iliosacral screw insertion.

822
 PROCEDURE 65 Sacroiliac Joint Injuries: Iliosacral Screws 823

PORTALS/EXPOSURES PITFALLS
• The anterior SI joint is accessed using the lateral surgical interval of the ilioinguinal • If the folded blanket is too thick, the pelvis will
exposure. Hip flexion relaxes the iliopsoas muscle for easier retraction and improved be overly elevated from the OR table causing
visualization. un unstable patient position.
• Once the patient is positioned and before
• Because of the SI joint’s unusual osteology, the posterior surgical exposure only re- draping, the necessary intraoperative fluoroscopy
veals the caudal articular facet, whereas the anterior articular reduction is assessed images should be obtained. Any positioning
by palpation. changes should be made prior to draping.
• The iliosacral screw’s starting point and directional aim are planned preoperatively • The surgical draping should be inclusive of all
using the pelvic CT scan and then determined intraoperatively using inlet, outlet, and necessary exposures and implants.
• Urethral meatal necrosis can result when the
true lateral sacral fluoroscopic imaging. urinary catheter is poorly positioned. Similarly,
the patient’s scrotum should not be crushed
PORTALS/EXPOSURES PEARLS between his thighs during surgery.
• A comprehensive preoperative plan includes the details of patient positioning, reduction maneuvers, clamp • Femoral vein and/or artery catheters and
application, and iliosacral screw insertion. suprapubic catheters should be prepared and
• The pelvic CT scan identifies and quantifies the parameters for the planned osseus fixation pathways. draped into the sterile field when necessary
• To optimize screw accuracy, the three-dimensional (3D) surface rendered pelvic CT models are rather than removed.
correlated with the intraoperative fluoroscopy views.
POSITIONING EQUIPMENT
PITFALLS
• The C-arm is located on the opposite side from
• SI joint malreduction decreases the area available for the iliosacral screw within the osseus fixation the surgeon.
pathway. • The C-arm unit tilts and positioning are
• Reduction clamps or the screws used to attach them to the bone should be positioned so that they do not adjusted after the patient is positioned and
obstruct the iliosacral screw insertion. prior to draping. The x-ray technician should
mark the floor and C-arm machine so the
PORTALS/EXPOSURES EQUIPMENT necessary intraoperative images remain
consistent throughout the operation.
• A poor quality C-arm unit will not produce sufficient images for safe screw insertion.
• A radiology technician who does not pay attention to the intraoperative imaging details will add
unnecessary radiation exposure, time, and cost to the operation. For numerous reasons, an attentive CONTROVERSIES
and skilled radiology technician is a critical part of the procedure.
• Some surgeons prefer prone patient positioning
for the ease of access to the posterior pelvic
ring during iliosacral screw insertion.
CONTROVERSIES • Supine positioning allows the surgeon to
access the anterior pelvic ring without
• When prone posterior ORIF is selected, the reduction clamp is applied to the anterior sacral ala through compromising surgical access to the SI joint.
the greater sciatic notch based on digital palpation of the anterior SI joint alone. This “blind” clamp • Insufficient imaging may result from
application remains quite controversial and is not advocated. poor patient positioning, morbid obesity,
• The prone posterior surgical exposure remains controversial because it has been associated with higher osteoporosis, residual bladder or bowel
wound complication rates. contrast agents, excessive flatus, among
others.

PROCEDURE PEARLS

Step 1 • Accurate reduction of the anterior pelvic

injury will often result in an excellent indirect
• In patients with an incomplete SI joint injury, accurate reduction of the anterior pelvic reduction of the SI joint.
ring injury (symphysis pubis, pubic ramus, combination injury) often will indirectly • In ORIF, the clamp must be properly located in
reduce the SI joint. In these patients, iliosacral screws are inserted to stabilize the SI order to provide uniform compression across
joint injury and support the overall fixation construct. Some evidence indicates that the SI joint during the iliosacral screw fixation.
iliosacral screw fixation of incomplete SI joint injury decreases the rate of failure of
anterior fixation. If compression is needed to complete the SI joint indirect reduction, PITFALLS
an initial iliosacral lag screw is inserted. • The reduction clamp should not obstruct the
• In patients with complete SI joint injuries, the anterior pelvic reduction may aid in optimal iliosacral screw pathway.
the SI joint reduction. In these patients with residual SI joint uniform distraction • Poor positioning of the reduction clamp usually
results in a poor reduction.
after anterior pelvic reduction, an iliosacral lag screw is used to complete the
reduction. Additional screws provide improved support for the SI joint. Multiple
INSTRUMENTATION/IMPLANTATION
iliosacral screws inserted at multiple posterior pelvic levels have lower failure
rates. • The optimal location for the iliosacral screw is
• Open reduction is selected for those injuries when closed reduction fails. The clamp best planned preoperatively using the CT scan.
• For patients with a symmetric upper sacrum and
is applied so that it does not injure the fifth lumbar nerve root and does not obstruct a unilateral SI joint injury, the uninjured side is
the iliosacral screw fixation. used for preoperative iliosacral screw planning.
Exploring the Variety of Random
Documents with Different Content
 o
I AM in my room. My watch says 1.30.
The smoke of Doctor Stein’s pipe lingers like the fume of a spent
flame that was the life of sun and stars and earth. All of my room is
the echo of a song. It is outside me, but my senses wistfully can
touch it. I touch my body, taking off my clothes. My body has the
flavor to my senses, not of the real but of the reminiscent.
I lie in bed. The white sheets fold about me like a dream. I switch off
the lamp: blackness moves dense upon me and within me: and the
light that is gone dwells in my memory like a light of fancy.
I shut my eyes. This twisted horror, life ... Philip murdered and my
parents murdered, Mildred grimacing their death with her fairness,
they with their horror swarming upon Mildred.... I cannot meet it with
my mind. I am sunk in this twisted terror. Naught is outside me for
my mind to meet, save the voice that came from the worn throat of
Mrs. Landsdowne:
“What are you doing?... But you must go on.... When to-morrow
takes its place beyond to-day, you will know. And I will help you
know.”
A flowing water, the promise of her words. I plunge in it. I lie in it, I
sleep....
 PART TWO
THE OTHER ROOM
 a
THE house stands on the height of a mountain. I am aware of the
mountain more than of the house. The room in which I am, in which
we are, has a door that opens on a narrow hall: and at the hall’s end
there is another room. That is the whole of the house. Along the
room’s length there are three French windows giving upon a roofless
porch: and the slope of the mountain starts down from the porch.
Our room is lighted by a single lamp that burns on the end wall away
from the wall with the door. (I feel that the hall is dark and that the
other room is dark and that the mountain is dark, and that the night
holding the world is dark save for our lighted room.) The walls of our
room are unpainted pine, the rafters break and cast into wild shapes
the shadow of the lamp. The long wall opposite the windows is
broken by no window, the lamp’s shadows do not fall there, its wood
is white. All about is the night, for the house stands on the very
mountain crest. Night has invaded even the hall, even the other
room. And all about is silence. The mountain sinks in silence beyond
our senses. And our senses like prisoned birds live in this shut room
where alone there is not blackness and silence.
We are I and Mildred, lovely in a gown of green that shimmers on
her body like an emerald molten by the white flame of her flesh. We
are I and Mildred and Mildred’s father, and both my parents, and
Philip LaMotte and Doctor Isaac Stein. We are seven: brightly at
ease and talking in this silent night upon a mountain top so high that
the air about us moves not toward earth but the spaces; so high that
these silences are bathed in a celestial prescience free from the
marring noises of men. And straight from our room with its solitary
lamp weaving deep shadows in the ceiling’s softness, the slope
bears down dense into a depth too vast for the penetration even of
our thoughts.
Mildred is touching a guitar, and she sings:

“As ye came from holy land

 Of Walsinghame,
Met you not with my true love
By the way as you came?

How should I know your true love

That have met many a one
As I came from the holy land,
That have come, that have gone?

She is neither white nor brown,

But as the heavens fair;
There is none hath her form divine
In the earth or the air.

I have loved her all my youth,

But now am old as you see:
Love likes not the falling fruit,
Nor the withered tree.

Know that love is a careless child,

And forgets the promise past:
He is blind, he is deaf when he list,
And in faith never fast.

His desire is a dureless content,

And a trustless joy;
He is won with a world of despair,
And is lost with a toy....”

Singing her mediæval tune, she is one with it, and one with the silver
strings that leap from her songful fingers.
I watch Mildred, and Philip LaMotte by my side watches her: Philip
LaMotte and I watch each other watching Mildred sing. We three are
closest to the other room. At the room’s end away from us, beneath
the lamp, sit my parents chatting with Doctor Stein. Close to the
central window Mildred’s father plays a game of solitaire.
Doctor Stein sits low in an easy chair with his hands clasped on his
knees and listens smiling to the comfortable converse of my mother.
My father leans back: he is enjoying his cigar, and his attention is
equal between the heavy rings of smoke that he blows high, and the
pleasant words of his wife. Mr. Fayn touches a pensive finger to his
brow between each upturn of a card. He is very serious, and
unmindful of the talk and of the music.
Mildred sings and ceases: her smile wreathes a balance between us.
She sings again. Doctor Stein’s eyes twinkle at the complacence of
my mother’s words. My father’s eyes glaze a bit as if the warm lull of
the room rocked him toward sleep. Mr. Fayn mixes his cards
noiselessly, and lays them out in silence: his feet tap in a toy
excitement as the game goes on.
We are at peace and warm: Mildred like a green fountain, sends
verdure and dance quietly down the room. Philip and I, knowing
each other, quaff her loveliness. We have enough: we are tortured
by no passion. From her fingers, from her throat, love jets a cool
source into our lives. And beyond our eager youth sits the maturity of
the others: ironic in Doctor Stein, complacent in my mother, dully
sensual in my father, childishly earnest in Mr. Fayn.
Mother sends a word, from time to time:
“Mildred, that is a pretty tune. What is it?...” and waits for no answer,
remembering some nothing to tell the Doctor. Father frowns, turned
desultorily in our direction: but a thick puff of smoke clouds out the
frown and he is once more at ease in his flat nirvana.
Mildred sings:
“The winds all silent are,
And Phœbus in his chair
Ensaffroning sea and air
Makes vanish every star:
Night like a drunkard reels
Beyond the hills to shun his flaming wheels:
The fields with flowers are deck’d in every hue,
The clouds with orient gold spangle their blue;
 Here is a pleasant place—
And nothing wanting is, save She, alas!”
“But here the place is better than your song’s. For She is here.”
Mildred laughs at my words.
“What has this place to do with the song? That is dawn. This is
night.”
“Perhaps the dawn is coming,” Philip says.
“It is less rare than she. And she is already here.”
“Yes,” he goes on. “Dawn must come where She is.”
“Dawn,” I say, “will be wonderful up here.”
“It will be perpendicular.... Shot up like a flaming arrow from below.”
“And we will watch it fly up toward us, till it kindles the house!”
Mildred claps her hands, letting her guitar lie in her lap.
“But,” Philip says, “what will become of the night?”
“The night is the black deep wine in which we have drunk.”
“Day will drink of it, and drink it up, and be drunk.” Mildred laughs at
Philip.
“Day will dance,” says Philip, “on the mountain top.”
“Mildred,” I turn to her, “you ought to know. For you are like the day
standing upon the tip of the night, and peering down on us.”
“Oh, you two, with your fanciful prose! I have to take refuge in music
... matter-of-fact music.”
She touches her guitar.
“Philip,” I say, “don’t you think we can catch the dawn soon up here?”
He is silent, not knowing.
“John, don’t be foolish,” comes my mother’s voice. “How do you
expect to see the dawn at midnight?”
“But the mountain is so high.”
“What difference does that make? Eh, Doctor Stein, what do you
think of the foolish ideas of my boy?”
“If you went high enough,” smiles Doctor Stein, “above the earth, you
could catch dawn at sunset.”
My mother tosses her head, tossing the discomfort of the thought
away.
Mildred’s laughter peals: “Oh, I shan’t be satisfied till I’ve seen that.”
“We are high up,” ponders Philip.
“I have won!” shouts Mr. Fayn. “Come, look. It’s all clear. Look!”
“But we believe you, Fayn.” My father languidly blows a ring toward
the rafters.
“And even if we aren’t so high,” says Mildred, “perhaps we are high
enough to catch the dawn at midnight.”
“We are very high,” says Philip.
“Well,” cries Mildred, “why does no one look? It’s midnight now.
Instead of arguing, instead of theorizing, why does not someone
look?”
She tosses her head up and down.
“Oh, you’re all too comfortable, here, to budge,” she taunts.
“And you, what about you?” says my mother savagely, while she
lights a cigarette.
Mildred turns toward me. I arise from my chair.
“I will look for you, Mildred.”
All of them are seated: all of them are laughing at my words, for even
as I hear them, my voice is solemn. What nonsense is this? I accept
as real and right this comfortable group of laughing persons, dear to
me, who mock from the bright assurance of their world matriced in
black, my gesture as I rise to seek the dawn at midnight.
“Look at him,” cries mother. “He’s really going to look. Doctor Stein,
what will we do with my boy?”
My father sneers in his kindliest way, and Mildred’s laughter like a
precious stone says nothing to me. But I am up from my chair.... And
I am near the window.
“Will you know,” says Philip, “how to look for it?”
I do not answer.
Mr. Fayn starts another game.
“I’m foolish,” he announces seriously. “You never win twice in one
sitting.”
“There’s a good law,” says Doctor Stein, “to break.”
Mr. Fayn shakes his head.
Mildred’s interest pierces me. Philip sits heavy at her side, a little
closer since I left my chair.
Before me is the night.—Well, why not look? Behind me, the real, the
light: my dear ones. As I move across the floor, my eyes, ere they
have looked, are heavy and are strained.
“There is nothing to see.”
The words have come ere my eyes truly saw if there was nothing to
see. It is as if my will spoke the words ... lying words?... My mother
nods, content. Mildred bends toward Philip. Father smokes and Mr.
Fayn taps his foot on the floor.
“Will you know,” the low warm voice of Philip, “how to look for the
dawn at midnight?”
“You have told us,” Mildred thrums her guitar. “It will rise
perpendicular like a flaming arrow.”
“From where?”
“From the deep.”
“From the deep below the mountain.”
“If I see,” said I, “any signs in the blackness, any stirring in the night,
will that not be the dawn?”
And as I spoke I knew that I was speaking to help my eyes from
having to look. They held back from the night as if my body had
shrunk from plunging with them down into a cold black sea.
“It might be another house, if all you saw was a light.”
“No, mother,” I spoke nervously, eager to answer every word that
came lest the silence behind me push my eyes indeed into the
blackness. “There is no other house.”
“There is one house on the mountain top,” said Mildred.
“No house could live upon the mountain side,” said Philip.
“Oh, what futile conversation,” mocked my mother. “Really, Doctor
Stein, is this all your fault?”
“No house could live,” said Philip, “on the mountain side. And no
man could hold to it.”
“He would fall back ere he had risen a single step.”
Doctor Stein soothed my mother: “Do not blame me, Mrs. Mark. And
do not blame me, either, if someone asks next how we came here ...
high up on the impassable mountain.”
Mother smiled and patted his fine hand: as much as to say “No, that
foolish you are not, dear Doctor. That foolish none of us is.”
And then, as they all smiled at the Doctor’s jest, there came from all
the room what I most dreaded: silence. No more words to pull me
back: but silence pressing against the base of my brain, as I stood
near the window.
I breathed at ease, for it was really darkness. I began to exult. I
prepared my words as if to fling at them in answer to a hostile
challenge.
“See—there is no sign of dawn at midnight.”
The words were not uttered.... I forgot the cozy room in which I
stood. I saw the night. And there was something there by which to
see it!
The black of the sky was limpid: a well of blackness, a blackness
that received my sight passively, and my sight sank in it and was
lost. This sky had no cloud, and yet no moon or star. It was a black
thing enfolding me. But the slope of the mountain was a harder
blackness: dense and wilful the mountain side struck down athwart
the mellow blackness of the sky. My eyes went immensely far, until
the vast stroke of the mountain faded, became moltenly one with the
warm night of the sky that folded all about.
Deep down where the mountain melted into space and solid and
fluid merged into a blindness, I saw a spot of light. I was silent: and
as I held my breath, the spot of light moved up.
I spoke:
“Something is down there ... and it is bright ... and it is moving up.”
But there was no answer in the room. My words seemed naked,
almost ashamed: so strange they sounded in the place I held
between the room and the night.
I turned around: they had not heard my words. They had forgotten
me. They had forgotten their own impulse, their own words which
sent me on this errand. Even Mildred. She thrummed her guitar and
her emerald body swayed, and her face, its opalescent smile,
beamed upon Philip, whose eyes she held in hers. My mother was
conversing low with Doctor Stein and my father had taken a chair
beside Mr. Fayn: they were intent together over the cards.
“Something is down there ... bright ... and it moves up.”
My words, first naked, now seemed disembodied.
—They cannot hear my words! Once more I faced the window and
the night.
The little light, as it grew larger, changed from a bright glow to a
vague gray. It became less like flame, more like some substance
through whose translucent stuff a flame ran fragilely. And as it moved
up the dense mountain slope, it seemed to limn with its march the
vastness of this world upon whose summit stood the house: and at
whose depth lay the sky.
The words behind me in the room, the tap of a foot on the floor, and
Mildred’s hands merging with the silver strings of her guitar, lay in my
ears now evanescent. The thing that was a light, yet grayly swelling,
moved up the slope of the mountain. The room with its words and its
music and its laughter became a tinkle of gilt beside this gorgeous
silence. And in the silence moved the light thing up.
I see it clear.
“Something was down there ... and is moving up ... something
convolved and gray. Some Thing....”
Now they heard me. And in the stillness of their mouths I heard their
bodies rise, and move across the floor, take place beside me. I saw
on either side of me their eyes, peering with mine into the silent
night.
The gray light Thing was flowing up the mountain. It had a simple
motion up the slope, simple and straight. Within itself it had another
motion, intricate and convolved. In its gray translucence, forms
swarmed and writhed upon themselves: contorted, funneling, in
permutation. But they were held to a unity of interaction, making
them simply one in their approach, like the bewildered parts of some
body disarrayed by magic, that writhed and twisted to fall back into
measure.
The Thing was a penetrant glow within the night, tracing the night of
the slope, tracing the night of the sky. The writhing parts of the Thing
writhed closer, moved more sluggish, densened, grew white: a white
form merged from the chaotic whirl. The Thing was almost abreast
us. It was solid. It was the form, translucent and still with a vaporous
glow about it, of a youth.
He moves up toward us. The amorphous maze from which he has
condensed is now an aura. He moves up from the right, he crosses
the front vision of our eyes. He is very near, bearing leftward toward
the house, yet slantwise so that he will not touch our room.
A youth, straight, rhythmic, with his profile sharp and his mouth a
shadow in the white of his face, and his eye an impalpable fire. His
hair is a tangle of shadows like the last embers in a hearth. Now he
is white, dazzlingly crystalline, across the black of the night, across
the gaze of our eyes!
He passes bearing toward the left. He disappears.
Mildred speaks:
“He has gone into the other room.”
And all of us, not knowing how we know, know she speaks the truth.
We turn about and see each other, and rejoice seeing ourselves so
palpable in the warm, shut room.
“He is in the other room.”
“The hall is long, and the door is shut that leads into the other room.”
My mother moves to the door. As she puts her hand on the key she
shudders. It is a terrible thing for me to see the lovely and proud
flesh of my mother broken in a shudder. But she turns the key. She
moves, as if blown by a wind, back to among us.
“Now it is locked,” she says.
We are solid and warm in the room that is locked.... Mildred is
looking at me; I feel her eyes, and do not want to meet them.
I am afraid to meet them.—Mildred, what now is in your eyes as in
your voice that sent me to spy on the night?
Sudden, from the silence, they all speak ... all save Mildred and me.
“Well, we have locked the door,” my mother says.
“What have we seen?” says father. “I have heard no one say what
we have seen. We have seen nothing.”
“Let’s get back,” says Mr. Fayn, “to our game.”
“These phenomena,” warns Doctor Stein, “are beyond our grasp.
Doubtless because they are the mere reflections of perfectly clear
phenomena. We try to grasp the reflections, and of course we fail.”
They are cool and calm, and determined.
“Well—whatever—we have locked the door.”
Philip is passionate. He has forgotten all else. He is alone with his
love.
“Mildred,” I hear him call. I turn, and I meet Mildred’s eyes at last.
Philip’s hands clasp her wrists that are tender like the stems of a
long flower. Her face is close to his, her body is close to his: but her
eyes touch mine.
“Mildred, my love—Mildred!” murmurs Philip. Her wrists lie in his
hands and her face is near his lips. But her eyes are steadfast on
me.
“In the other room?” I ask, as if corroborating.
Her eyes do not move. I nod. And I say:
“I am going to the other room, to see.”
Philip’s hands do not stir in their tender clasp. But my mother, who
was once more seated, jumps to her feet.
“No!”
“Why?” ... The others merely turn and look.
“What folly!”
“And what for?”
Mildred’s eyes are on my eyes. I am happy. Her eyes do not know
that Philip’s hands are on her hands. I want only her eyes. Her face
is white in its gold maze of curls.
I pass her. I turn the key of the door back in the lock. I face about
with my hand upon the doorknob.
—Why do they let me go so easily?
For they have not protested more. Their will is shallow: quickly they
are at the end of their will. Mother’s thoughts steal back to her easy
chair and to her cigarette and to her badinage with Doctor Stein.
Father has pulled two huge cigars from his case which he claps shut:
he offers one to Mr. Fayn who takes it. In Philip’s eyes, there is a
growing gayety of promise as he looks at the milkwarm skin of
Mildred.
The hurt of their shallow will moves me to lightness. It is as if, in
asserting for myself the inconsequence of what I am to do, their
negative permission will become less cold and cruel.
“I’ll not be long,” I say: my voice sounds high. “I’ll be back ... never
fear ... I’ll be back.”
Mildred’s eyes for the first time leave mine as if my words released
them. She looks at Philip. She is very close to him, and her face
upturns to his. Her little breasts alert in the green sheer of her gown
are very close to Philip. Her smile flowers near him. She whispers,
and they turn away from me....
I open the door. The light from the room tongues into the dark
distance and is lost. I look back. Mother and Doctor Stein are
chatting, she takes his cigarette and lights her own from it. Father
beside Mr. Fayn suggests a play of the cards. Mildred and Philip are
side by side: her guitar lies at her feet.
—They have forgotten me?
I shut the door. I am in the black hall.

There is a blacker dark than that of the starless night, there is a

blacker dark than that of the mountain. It is the black of this hall.
Those were a dark outside that my sense invaded. This is a dark that
is invading me, that will fill me, choke me, if I stay in it long. It will
drive out from the frail shell of my mind any light.
Black hall, you must be gone through! I press a finger underneath
my brow, against the lashes of my eye: I cannot see it. This dark is
immobile, so I must move. No gray tinges it, no stir of light. It is
packed density. It fights against my knowledge that it is but a hall ...
a hall to be passed through, a hall at whose other end as at the end I
have entered, is a door.
My will saves me from the sense that this invading black is infinite. I
make my hands fumble along the walls: their path is a white tracing
that all my body joyously obeys. I fumble at a door. It opens out. And
the compressed immensity of the hall blows me into a room, blows
the door shut....
There is one window, and the black of the night pours in, gray. I face
this window at the room’s far end, and my eyes drink its grayness
with an uncanny thirst. This room seems but a bellying out of the
hall. At either side of me, blank walls. The room is long, for that
single window is far away, or it is very small.
At my side I grow aware of vibrance in the dark: a vibrance near my
shoulder, and as tall as I. I force my head to turn. My eyes see
nothing. They rush back to the small window whose gray they have
drunk so greedily. The window is gone! Was it a window, then,
whose light I have drunk with my eyes? They turn again. Fear
hurries with pricking feet over my flesh. I want to go back. The
blackness of the hall would be balm now to my eyes. For there is
pillared vibrancy beside me. Fright turns my flesh into myriad
scurrying feet. I turn to bolt. The lock in the door snaps shut.
—I am alone: I am locked into this room with that which locked me
in.
The vibrance at my shoulder falls. And my eyes descry a gradual
human form picked from the blackness. It is a subtle growing, as if
individual atoms of the dark were heightened there, grew gray, grew
luminous, and made a man.
He is looking at me, as the gray of his form whitens. He is smiling at
me. He moves in the direction of the door, and I turn with him to hold
him in my eyes. He stands between myself and the door he has
locked.
His smile holds me. He is all grown, now. I can see him. He is about
as tall from the ground as I. He is entirely white. Yet he has features.
He has hair, he has hands gently clasped before him. I do not know
what power, colorless and faint, sharpens his body to my sense. But
even his smile is traced upon me, and his eyes that seem to move
with a slow swinging up and down from my brow to my feet.
And still he stands between me and the door.
My fear is gone: it is all burned away in the will to pass him, to pass
the hall, to be back in the lighted room. But even fearless, how can I
go when he stands between me and the door he has locked?
“Let me pass!”
I have spoken, as my mind blanched at the thought of a word. My
voice is throaty and real. His body grows a little dim at the words,
and tremors: he has heard. The tremor steadies back into white.
His hand is beckoning me forward. His smile grows more intense,
works now in my mind like a cold acid. But all my fear is gone. I step
forward. He has not moved. I touch him.
What happens is an instantaneous act, and has no mark upon my
sense. It is I who am next to the door: it is he, stands beyond, his
white form gray and subtly undulous.
I am all act. I have passed through the bolted door. I lance the hall
like a light. I am once more in the lighted room.

My loved ones have grown close since I left them, smiling and
saying that I would return. They are not aware that I am back.
Mildred and Philip murmur side by side. My father has drawn a chair
to the card-table and is playing with Mr. Fayn. In the far corner sit my
mother and Doctor Stein, smiling, chatting. I stand at the door and
watch them. All six faces are within my eyes obliquely, and they do
not see me.
Now instantly, these various faces turn: see me: become one in a
shrivel of horror.
I stand still. Their variance has rotted all away. They are one....
Mildred and mother and the others ... in a rigid gaze at me, in a cold
terror rising from their sight.
“Well, it is I: only I.” Their faces do not move, they have not heard
me.
But their stark death, making them one, moves. They rise to their
feet. Mildred and Philip, faces fixed on me, retreat: Mr. Fayn and my
father move aside. They huddle together in a single group. Six
various bodies crowded close and one, in a shrivel of horror.
I go forward. My hands are forward and I am near to them. They do
not stir. With my hand I touch the cheek of Mildred. With my hand I
touch the hand of my mother. My hands go forward as through an
impalpable light! I sweep with maddened arms about their bodies:
my arms, unhindered, draw in on themselves. They stand stark
huddled, their eyes fixed upon mine: and my arms thresh through
space!
Fear is full gathered in my throat. I shriek. I shriek, and thresh with
unresisted arms....

b
I AWOKE crying out.... Very warm, close-bundled, I cry as with the
toothless hollow mouth of a babe. I cry and yet there is no sound. I
stop. I am more awake. My opening eyes perceive a world that
whirls in mazing colors and threatens to break in. This delirious
dance subsides. I am quiet in my bed and the dark air lies quiet all
about me. I know my body, I know my sheets and covers, I know my
room, my open window: the city, purple and encaverned pours
through the window into my room. The room all this time has
slumbered quietly while I left it, and have come back to it. Swift fears
start still from my muscles and my nerves, like discovered
stowaways of that journey whence I am back in my room.
And then I knew my Dream, and my mind was stripped of space and
time as I tried to face it.
—There is revelation in the Dream! Of that I was convinced. Let me
explore its strangely shifting realm. But my mind could not enter.
There, stript for action, it pounded at the gate, and it could not enter.
I am inside the revealing realm of my Dream. But what good is that,
since my mind cannot enter?
I lie in this agony of confusion, holding within my hand the key to the
mystery that has distraught my world: and surely my eyes are good,
yet when I strain to see, they veer, they tangent off. I cannot see
what I hold!
From this turmoil there must be release. My body is moving. I do not
know how long I have lain in bed, breaking in vain at the gate of my
Dream. Not very long, for the night is still there murmuring like a
hollow sea outside and sending in breakers at my open window.
There have been no other thoughts, no fancies at all. The Dream is
palpable and I within it, and my mind that must rejoin me, knocking,
beating. That is all.
Then, sudden I am moving! I am getting up, and calmly with the
certainty of custom I put on my clothes: I shut the house door: I am
in the street.
Faint vestige of dawn. In sparse gray filaments dawn threads
through the night: a gradual loom of light that will thicken, that will
converge, that will become a texture.... On the street, at the door as I
step out, is a man.
He is waiting for me. He is clad in black, he stands in the black
shadow of the house: all that emerges of him is his head which is
round and white.
All of his head is white: it has a plastic and smooth pallor like the
form of certain larvæ: it is a color inhuman and yet deeply fertile. He
sees me and nods his head and I feel the black-clad body stir in the
gloom of my house. I make no sign: I begin to walk. At my rear I feel
him walk apace with me. He is behind and quiet, but he is leading
me by an invisible pressure which he holds upon the nape of my
neck, the cortex of my brain.

The city has that flaccid impenetrance which comes before dawn.
The rush of a car, the pelt of horses’ hoofs, the stride of a man, the
flutter of a woman, quiver like darts against the night and fall away.
Night is this impenetrable hide about the city.... We are outside the
city. A ferry-boat plethorically heaves us across the River. I stand at
the forward rail, and the white head man, lost in a shadow of drays
and draymen and slowly stamping horses, holds still his palpable
pressure on my brain.
—What if I turn about?
I look at the little waves ... the night is windless ... thridding and
skipping about the hull of the boat. Their cool tips carry dawn,
between the night of the sky and the night of the black waters.
—What if I leap in?
Will the waves hold me? They will part, treacherous and careless,
and let me sink at once to the night they dance against. I know in an
acceptance weary like age, that I can not leap into the River, and
that I cannot turn about. I feel: this guiding pressure upon the cortex
of my brain, if it were in my eyes, that it might blind me.
... We are walking in a field. This field is very clear to me, as if its
rugose stretch and its barren saliences had already picked their
measure in my brain. The coarse grass is dry and gray like autumn,
on this sultry April night. As my feet press through, the grass rustles.
The earth breaks into warty mounds, grass tufted, and falls to
sudden hollows slakish with caked mud. I walk, and though I have
not seen his form save for that moment at the door of my house, I
know the white head man following at my rear, and leading, keeping
pace with my feet so that the sound of his steps is lost in mine.
The field is wide and long: no light of habitation flecks its sallow
gloom. But the rathe filaments of dawn swirl in its air with more
abundance: a gray flush lies close to its black furrows, catches in the
grass and brings to it a tremorous stir as if it was a mouth feebly in
voice. I walk. The field is wide and long. The field’s horizons lip
darkly down, making this murmurous silence of the field a shut dank
thing, and I and the white head man imprisoned in it.
He still prodding me on, prodding upon the quick of my brain: he who
is behind and who is silent....
The ground looms a little ahead. And as it rises, the dead grass
ceases underneath my feet. My feet tread sterile clay: they strike on
it hard as if the clay were frozen, and yet the air of the field is wet
and sultry.... My feet stop.
I am at the top of the little loom of the ground. Straight before me an
empty shadow. The ground cuts precipitous at my feet. It wreathes
about into a semicircle. Below me in the black lies a slakish gleam: a
sort of slime within the night: far below. And beyond that, above this
bottom of the circling pit yet lower than the crest where I stand, the
field goes on over a clutter of broken rocks and stone.
I have stopped short at the edge of a limekiln! My feet have held
firm!
There is rage in me.
“So this is where you led me? to my death? to this ridiculous death?
I, after Philip LaMotte, after my mother and my father! My death was
to be at once more secret and more horrible. No trace of me was to
remain. Well: come and push me in. It’ll take more than the pressure
of your eyes.”
My feet hold firm. The pressure on my cortex fades with my rage, I
step back a little and dig a heel into the clay. Then I turn about.
The man is closer than I knew: a little below, for I am at the top of the
field’s rise.
I stare at him and my rage makes a thrust from my eyes down to his
beetling form. I challenge him, silent. He is clearer now. I can make
out in the dawn the smooth black cloth of his coat tight on his
muscular body. I can see well the blind and larval rondure of his
face.
My rage thrusts at him.
He rises from the ground.... “So this is how you dealt your tall man’s
blow at Philip LaMotte?” ... and like a bird of prey he planes low up
toward me, over my head. I whirl about and facing the kiln I see him
slowly plane into its slime.
His face remains free and his face is turned toward me.