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Practical fracture treatment 5th Edition Ronald Mcrae
Digital Instant Download
Author(s): Ronald McRae; Max Esser, FRCS Ed ORTH FRACS
ISBN(s): 9780443068775, 0443068771
Edition: 5
File Details: PDF, 25.23 MB
Year: 2008
Language: english
Practical
Fracture
Treatment
For Elsevier:
Commissioning Editor: Alison Taylor
Development Editor: Kim Benson
Production Manager: Kerrie-Anne Jarvis
Design: George Ajayi
Practical
Fracture
Treatment
Ronald McRae FRCS (Eng) FRCS (Glas) AIMBI
Formerly Consultant Orthopaedic Surgeon, Southern General Hospital, Glasgow, UK

Max Esser FRCS Ed FRCS Ed (Orth) FRACS (Orth)

Orthopaedic Surgeon, Alfred Hospital, Melbourne; Department of Trauma Surgery, Alfred Hospital, Monash
University, Melbourne; Cabrini Hospital, Melbourne, Australia

Original drawings by Ronald McRae

FIFTH EDITION

EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO 2008
© 2008, Elsevier Limited. 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 permission in writing from
the publisher. Permissions may be sought directly from Elsevier’s Rights Department: phone: (+1) 215 239 3804 (US)
or (+44) 1865 843830 (UK); fax: (+44) 1865 853333; e-mail: [email protected]. You may also complete
your request on-line via the Elsevier website at http://www.elsevier.com/permissions.

First edition 1981

Second edition 1989
Third edition 1994
Fourth edition 2002
Reprinted 2003 (twice), 2004
Fifth edition 2008

ISBN: 978-0-443-06876-8
International Student Edition: ISBN 978-0-443-06877-5

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library.

Library of Congress Cataloging in Publication Data

A catalog record for this book is available from the Library of Congress.

Note
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our
knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers are
advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and duration of administration,
and contraindications. It is the responsibility of the practitioner, relying on their own experience and knowledge of
the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take
all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the Authors assume any
liability for any injury and/or damage to persons or property arising out or related to any use of the material contained
in this book.
The Publisher

The
Publisher's
policy is to use
paper manufactured
from sustainable forests

Printed in China
The Publisher’s Policy is to use Paper manufactured from sustainable forests.
PREFACE TO THE FIFTH EDITION

As in the previous edition more recent methods of There are also many new radiographs, CT scans
internal fixation in the treatment of many fractures and 3-D reconstructions, and in the continued
have been included, while the basics of conservative quest to improve the clarity of reproduction, digital
management and plaster cast techniques have been enhancements, judicious cropping, and the addition of
retained. This is considered to be important, particularly arrows and dotted lines have been carried out on certain
in situations where access to the wide variety of implants radiographs – or substitutions made.
and imaging equipment required for many internal In this edition a number of references, which have been
fixation procedures may be limited. considered to be of particular value have been included.
Several new fracture classifications have been We hope that these changes will add to the value of
detailed, and in many areas new thoughts on the this book.
management of some specific fractures have been
reviewed and treatment suggestions modified. An Ronald McRae, Gourock 2008
appreciable number of drawings illustrating new Max Esser, Melbourne 2008
implants and the techniques that they involve have been
added.

Acknowledgements Alfred Hospital were generous with their advice and

I wish to acknowledge the help I have had from my comments. My friend and colleague Mr Gary Nattrass,
colleagues at the Alfred Hospital: in particular Associate Royal Children’s Hospital, Melbourne, once again
Professor Alison Street, Haematologist; Associate contributed with valuable suggestions.
Professor Nina Sacharias, Radiologist; Mr Ross Snow, My wife Kym and our two children, Nick and Lauren,
Urologist; and the Audio Visual Department. who were very tolerant and supportive in this project, for
I wish to acknowledge the help I have had from my which I am grateful.
colleagues at the Alfred Hospital: in particular Associate Once again Kaye Lionello, my secretary, contributed
Professor Alison Street, Haematologist; Associate greatly to this edition with multiple e-mails and
Professor Nina Sacharias, Radiologist; Mr Ross Snow, incalculable patience.
Urologist; and the Audio Visual Department. Mr Greg
Malham, Neurosurgeon, Alfred Hospital, and Professor Max Esser, Melbourne 2008
Thomas Kossmann, Department of Trauma Surgery,
PREFACE TO THE FIRST EDITION

This book has been written primarily for the medical Secondly, fracture treatment has been given in an
student, and the introductory section assumes little uncommon amount of practical detail. As there is such
prior knowledge of the subject. The second part, a variety of accepted treatments for even the simplest of
which deals with particular fractures, is set in places fractures, this has the danger of attracting the criticism
at a more advanced level; it is hoped that the book of being controversial and didactic. This is far from
will thereby continue to prove of value to the student my intention, and I have tried to avoid this in several
when he moves to his first casualty or registrar post. ways. Firstly, as minor fractures and most children’s
In planning this volume, I have paid particular fractures (together forming the bulk of all fractures) are
attention to two points. Firstly, the details of each most frequently treated conservatively, the conservative
fracture and a good deal of the introductory section approach I have employed for these injuries should on
have been arranged in a linear sequence. The material the whole receive general approval. Secondly, in the
has been divided into small packets of text and more controversial long bone fractures in adults, and in
illustration in order to facilitate comprehension and fractures involving joints, I have on the whole pursued
learning. These packets have been set out in a logical a middle course between the extremes of conservative
sequence which in most cases is based on the relative and surgical management. The methods I have singled
importance of the initial decisions which must be out for description are those which I consider safest
made in a case, and the order in which treatment and most reliable in the hands of the comparatively
procedures should be carried out. This format is inexperienced. Where alternative methods appear to me
in a few places restrictive, with an imbalance in to be equally valid I have generally included these. To
the amount of information carried by either text or conceal my own whims I have not always placed these
illustration. This must be accepted because of spatial in the order of personal preference. In consequence, I
and subject limitations. Generally, however, text and hope that any offence given by the methods described
illustration will be found to complement one another. will be restricted to the most extreme quarters.
The text, although of necessity brief, is concise and, it
is hoped, to the point. R. M.
HOW TO USE THIS BOOK

The basic principle of fractures and their treatment 1. Where two sides are shown for comparison, the
are dealt with in the first part of this book. The AO patient’s right side is the one affected.
Classification of fractures (pp 22–24), Trauma scoring 2. As a general rule, when a procedure is being illus-
(pp 41–44) and the Mangled Extremity Severity Score trated, the patient is shown for clarification in
(pp 51–52) may be noted but do not require detailed a lighter tone of grey than the surgeon and his
study by the undergraduate. assistants.
The second part of the book is arranged on a regional 3. Where several conditions are described, and only
basis and may be used as a guide for the handling of one illustrated, the first mentioned is the one shown,
specific fractures. Detailed study is not required by unless followed by the abbreviation ‘Illus.’.
the undergraduate, but a superficial reading should 4. Most cross references within a chapter are made by
consolidate knowledge of the basic principles, and quoting the relevant frame number. Elsewhere, page
indicate how they are applied in practice. numbers are given.
The following conventions are used in the illustrations
and text:

Abbrevations
A = anterior
Illus. = illustrated
L = lateral or left
M = medial
N = normal
P = posterior
R = right
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This page intentionally left blank
 3

CHAPTER

1
Pathology and healing
of fractures

Initial definitions 4
Causes of fracture 5
Fracture patterns and their
significance 6
Describing the level of a fracture 10
Describing a fracture deformity 11
Open fractures 13
Self test 14
Answers to self test 16
Epiphyseal injuries 17
Fracture healing 20
Classification of fractures 22
AO Classification of fractures 23
Classification of open injuries 24
 4 INITIAL DEFINITIONS

1. Initial definitions: Fracture: A fracture is 2. Open fractures: All fractures are either 3. Closed fracture: In a closed fracture the
present when there is loss of continuity in the closed or open. In an open fracture there skin is either intact, or if there are any
substance of a bone. The term covers all bony is a wound in continuity with the fracture, wounds these are superficial or unrelated
disruptions, ranging from one end of the scale and the potential exists for organisms to to the fracture. So long as the skin is intact,
when (1) a bone is broken into many fragments enter the fracture site from outside. All open there is no risk of infection from outside.
(multifragmentary or comminuted fracture) to fractures therefore carry the risk of becoming (Blood-borne infection of closed fractures is
(2) hair-line and even microscopic fractures at the infected. In addition, blood loss from external extremely rare.) Any haemorrhage is internal.
other. To the layman the word ‘fracture’ implies haemorrhage may be significant. (Note: the
a more severe injury than a simple break in the term ‘compound’ is still frequently used
bone, but in the strict medical sense there is no to describe a fracture which is open; the
difference between these terms. term ‘simple’, to describe a closed fracture,
may lead to confusion, and is now largely
abandoned.)

4. Dislocation: In a dislocation there is 5. Subluxation: In a subluxation, the 6. Sprain: A sprain is an incomplete tear of a
complete loss of congruity between the articulating surfaces of a joint are no longer ligament or complex of ligaments responsible
articulating surfaces of a joint. The bones congruous, but loss of contact is incomplete. for the stability of a joint; e.g. a sprain of the
taking part in the articulation are displaced The term is often used to describe the early ankle is a partial tear of the lateral ligament
relative to one another; e.g. in a dislocated stages in a condition which may proceed to and is not associated with instability (as
shoulder the head of the humerus loses all complete dislocation (e.g. in a joint infection distinct from a complete tear). The term sprain
contact with the glenoid. In the common or in rheumatoid arthritis). is also applied to incomplete tears of muscles
anterior dislocation the head of the humerus is and tendons.
displaced anteriorly.
 CAUSES OF FRACTURES 5

7. Causes of fracture: Direct violence (a): 8. Direct violence (b): A bone may also be 9. Indirect violence: Very frequently fractures
Fractures are caused by the application of fractured if it forcibly strikes a resistant object. result from indirect violence.
stresses which exceed the limits of strength For example, a fall on the point of the elbow A twisting or bending stress is applied to a
of a bone. Violence is the commonest cause. may fracture the olecranon. bone, and this results in its fracture at some
In the case of direct violence, a bone may distance from the application of the causal
be fractured by being struck by a moving or force. For example, a rotational stress applied
falling object, e.g. a fracture of the terminal to the foot may cause a spiral fracture of the
phalanx of a finger by a hammer blow. tibia. Indirect violence is also the commonest
cause of dislocation.

10. Fatigue fractures: Stresses, repeated with 11. Pathological fractures (a): 12. Pathological fractures (b): Pathological
excessive frequency to a bone, may result in A pathological fracture is one which occurs in fractures may also occur at the site of simple
fracture. This mechanism is often compared an abnormal or diseased bone. If the osseous tumours, e.g. a fracture of the humerus (a)
with fatigue in metals which break after abnormality reduces the strength of the bone in a child with a simple bone cyst (b). The
repeated bending beyond their elastic limit. then the force required to produce fracture is commonest causes of pathological fracture are
The commonest of these fractures involves reduced, and may even become trivial. For osteoporosis and osteomalacia.
the second metatarsal – the march fracture example a secondary tumour deposit may lead
(so called because of its frequency in army to a pathological fracture of the subtrochanteric
recruits). region of the femur – a common site.
 6 FRACTURE PATTERNS AND THEIR SIGNIFICANCE

13. Fracture patterns and their significance: 14. Hair-line fractures (b): These fractures may 15. Hair-line fractures (c): Stress fractures are
Hair-line fractures (a): Hair-line fractures be difficult to detect on the radiographs, and generally hair-line in pattern, and are often
result from minimal trauma, i.e. trauma which where there are reasonable clinical grounds not diagnosed with certainty until there is
is just great enough to produce a fracture but for suspecting a fracture, the rules a wisp of subperiosteal callus formation, or
not severe enough to produce any significant are quite clear. 1. Additional oblique increased density at the fracture site some 3–6
displacement of the fragments. Such fractures radiographic projections of the area may be weeks after the onset of symptoms. Where
may be (1) incomplete or (2) complete. helpful. 2. Do not accept poor quality films. strongly suspected an MRI or bone scan may
3. Films repeated after 7–10 days may be helpful. Hair-line fractures generally heal
show the fracture quite clearly (due to rapidly requiring only symptomatic treatment:
decalcification at the fracture site). 4. A CT but the scaphoid and femoral neck are notable
scan may also help confirm the diagnosis. exceptions.

16. Hair-line fractures (d): Radiograph of 17. Greenstick fractures (a): Greenstick 18. Greenstick fractures (b): This radiograph
upper tibia of an athletic adolescent with a 7- fractures occur in children, but not all illustrates a more severe greenstick fracture of
week history of persistent leg pain. Previous children’s fractures are of this type. The less the distal radius and ulna. Note that although
radiographs were reported as normal. Note the brittle bone of the child tends to buckle on the there is about 45° of angulation at the fracture
coned view to obtain optimal detail and the side opposite the causal force. Tearing of the site, there is no loss of bony contact in either
incomplete hair-line fracture revealed by bone periosteum and of the surrounding soft tissues fracture. The clinical deformity is clearly
sclerosis and subperiosteal callus. A crepe is often minimal. suggested by the soft-tissue shadow.
bandage support only was prescribed, and the
symptoms settled in a further 6 weeks.
 FRACTURE PATTERNS AND THEIR SIGNIFICANCE 7

19. Greenstick fractures (c): Reduction of a 20. Greenstick fractures (d): In the forearm in 21. Simple transverse fractures (a): Transverse
greenstick fracture is facilitated by the absence particular, where angulation inevitably leads to fractures run either at right angles to the
of displacement and by the intact tissues on restriction of pronation and supination, some long axis of a bone (1), or with an obliquity
the concavity of the fracture. Angulation may surgeons deliberately overcorrect the initial of less than 30°. They may be caused by
be corrected by supporting the fracture and deformity (1). This tears the periosteum on the direct violence, when the bone fractures
applying pressure over the distal fragment other side of the fracture (2). This reduces the directly beneath the causal force (e.g. the ulna
(1 and 2). The elastic spring of the periosteum risks of secondary angulation (3). Healing in fracturing when warding off a blow (a)). They
may however lead to recurrence of angulation all greenstick fractures is rapid. may also result from indirect violence when
(3). Particular attention must therefore be taken the bone is subjected to bending stresses by
over plaster fixation and after care. remotely applied force (e.g. a fracture of the
forearm bones resulting from a fall on the
outstretched hand (b)).

22. Simple transverse fractures (b): The inherent 23. Simple oblique fractures (a): In an oblique 24. Simple oblique and spiral fractures (b): In
stability of this type of fracture (illustrated by the fracture (1) the fracture runs at an oblique spiral fractures, union can be rapid (1) as there
model on the right) reduces the risks of shortening angle of 30° or more (O). Such fractures may is often a large area of bone in contact. In both
and displacement. In the tibia, as a result, weight be caused by (a) direct or (b) indirect violence. oblique and spiral fractures, unopposed muscle
bearing may be permitted at a comparatively In simple spiral fractures (2) the line of the contraction or premature weight bearing
early stage. On the other hand, the area of bony fracture curves round the bone in a spiral. readily lead to shortening, displacement and
contact is small, requiring very strong union Simple spiral fractures result from indirect sometimes loss of bony contact (2). [Note: In
before any external support can be discarded. violence, applied to the bone by twisting the AO Classification of Fractures (see later)
(NB: The term ‘simple’ used to describe this and (torsional) forces (t). simple spiral, oblique and transverse fractures
the following fractures means that the fracture are classified as Type A fractures.]
runs circumferentially round the bone with the
formation of only two main fragments.)
 8 FRACTURE PATTERNS AND THEIR SIGNIFICANCE

25. In multifragmentary (comminuted) 26. In multifragmentary complex fractures 27. Multifragmentary fractures are generally
fractures there are more than two fragments. (a further division of comminuted fractures) the result of greater violence than is the case
The spiral wedge fracture (1) is produced by there is no contact between the main with most simple fractures, and consequently
torsional forces (t), and the bending wedge fragments after reduction. In complex spiral there is an increased risk of damage to
fracture (2) by direct (a) or indirect (b) fractures (1) there are two or more spiral neighbouring muscle, blood vessels and skin
violence. The fragment (B) is often called a elements; in complex segmental fractures (1). The fractures tend to be unstable, and
butterfly fragment (because of its shape). With (sometimes called double fractures) (2) there delayed union and joint stiffness are common.
greater violence a fragmented (comminuted) is at least one quite separate complete bone Segmental fractures are often difficult to
wedge fracture (3) results. [All these fractures fragment (S). In complex irregular fractures reduce by closed methods, and direct exposure
are in Type B in the AO Classification (see (3) the bone lying between the main elements may threaten the precarious blood supply to
later) and their characteristic is that after is split into many irregular fragments. [All the central segment. Non-union at one level is
reduction there is still bony contact between these fractures are classified as Type C in the not uncommon in these fractures (2).
the main fragments (4)]. AO Classification.]

28. Impacted fractures: A fracture is impacted 29. Compression (or crush) fractures: Crush 30. Avulsion fractures (a): An avulsion
when one fragment is driven into the other fractures occur in cancellous bone which is fracture may be produced by a sudden muscle
(1). Cancellous bone is usually involved and compressed beyond the limits of tolerance. contraction, the muscle pulling off the portion
union is often rapid. The stability of these Common sites are (1) the vertebral bodies of bone to which it is attached. Common
fractures varies and is more implied than (as a result of flexion injuries) and (2) the examples include:
real. Displacement will occur if the fracture heels (following falls from a height). If the (1) Base of fifth metatarsal (peroneus brevis)
is subjected to deforming forces; e.g. without deformity is accepted, union is invariably (2) Tibial tuberosity (quadriceps)
fixation, impacted femoral neck fractures rapid. In the spine, if correction is attempted, (3) Upper pole of patella (quadriceps)
frequently come adrift (2). recurrence is almost invariable. (4) Lesser trochanter (iliopsoas)
(These are all AO Type A fractures.)
 FRACTURE PATTERNS AND THEIR SIGNIFICANCE 9

31. Avulsion fractures (b): Avulsion fractures 32. Depressed fracture: Depressed fractures 33. Fractures involving the articular surfaces of
may also result from traction on a ligamentous occur when a sharply localised blow depresses a joint: In partial articular fractures (1) part of
or capsular attachment: these are often a segment of cortical bone below the level the joint surface is involved, but the remainder
witness of momentary dislocation; e.g. (1) an of the surrounding bone. Although common is intact and solidly connected to the rest of
abduction force may avulse the ulnar collateral in skull fractures, this pattern is only rarely the bone. (AO Type B fracture.) In complete
ligament attachment, with spontaneous found in the limbs. There the tibia in the upper articular fractures (2) the articular surface is
reduction. Late subluxation (2) is common third is probably most frequently affected. completely disrupted and separated from the
with this (‘gamekeeper’s thumb’) and other Healing is rapid; complications are dependent shaft. (AO Type C fracture.) When a fracture
injuries and is especially serious in the case of on the site. involves the articular surfaces, any persisting
the spine. irregularity may cause secondary osteoarthritis
(3). Stiffness is a common complication, and
this may be minimised by early mobilisation.

34. Fracture close to a joint: When a fracture 35. Fracture–dislocation: A fracture– 36. Complicated fractures: A fracture
lies close to a joint, stiffness may also be a dislocation is present when a joint has is described as complicated if there is
problem due to tethering of neighbouring dislocated and there is in addition a fracture accompanying damage to major neighbouring
muscles and tendons by spread of callus from of one of the bony components of the joint. structures. The diagram is of a complicated
the healing fracture; e.g. in fractures of the Illustrated is a fracture–dislocation of the supracondylar fracture of the humerus.
femur close to the knee, the quadriceps may shoulder, where there is an anterior dislocation (Such an injury might also be described as a
become bound down by the callus, resulting in with a fracture of the neck of the humerus. supracondylar fracture complicated by damage
difficulty with knee flexion. Injuries of this kind may be difficult to reduce to the brachial artery.)
and may be unstable. Stiffness and avascular
necrosis are two common complications.
 10 DESCRIBING THE LEVEL OF A FRACTURE

37. Describing the level of a fracture (a): The 38. Describing the level of a fracture (b): For 39. Describing the level of a fracture (c): In AO
anatomical divisions of a long bone descriptive purposes a bone may be divided terminology, long bones are divided into three
include the epiphysis (E), the epiphyseal plate arbitrarily into thirds. In this way unequal segments: a proximal segment (1), a
(EP), and the diaphysis or shaft (D). Between the (A) = fracture of the mid third of the femur; central diaphyseal segment (2), and a distal
latter two is the metaphysis (M). A fracture (B) = fracture of the femur in the distal third; segment (3). The boundaries between these
may be described as lying within these (C) = fracture of the femur at the junction of segments are obtained by erecting squares (S)
divisions, or involving a distinct anatomical the middle and distal thirds. which accommodate the widest part of the
part; e.g. (A) = fracture of the tibial diaphysis; The level of a fracture in some cases may be bone ends; in the special case of the femur the
(B) = fracture of the femoral neck; made quite clear by an eponym; e.g. a Colles diaphysis is described as commencing at the
(C) = fracture of the greater trochanter; fracture (D) involves the radius, and occurs distal border of the lesser trochanter.
(F) = supracondylar fracture of the femur. within an inch (2.5 cm) of the wrist.

40. Describing the deformity: If there is no 41. Displacement (a): Displacement (or 42. Displacement (b): Apart from the direction
deformity, i.e. if the violence which has translation) is present if the bone ends have of displacement, the degree must
produced the fracture has been insufficient to shifted relative to one another. The direction be considered. A rough estimate is usually
cause any movement of the bone ends relative of displacement is described in terms of made of the percentage of the fracture surfaces
to one another, then the fracture is said to be movement of the distal fragment. For example, in contact; e.g. (1) 50% bony apposition
in anatomical position. Similarly, if a perfect in these fractures of the femoral shaft at the (2) 25% bony apposition. Good bony
position has been achieved after manipulation junction of the middle and distal thirds there is apposition encourages stability and union.
of a fracture, it may be described as being in (1) no displacement, (2) lateral displacement,
anatomical position. (3) posterior displacement, (4) both lateral and
posterior displacement.
 DESCRIBING THE DEFORMITY OF A FRACTURE 11

43. Displacement (c): Where none of the 44. Displacement (d): (1) Displacement of 45. Angulation (a): The accepted method
fracture surfaces is in contact, the fracture a spiral or oblique fracture will result in of describing angulation is in terms of the
is described as having ‘no bony apposition’ shortening. Displacement of transverse position of the point of the angle; e.g.
or being ‘completely off-ended’. Off-ended fractures (2) will result in shortening only (1) fracture of the femur with medial
fractures are 1. potentially unstable, 2. liable after loss of bony contact. The amount angulation, (2) fracture of the tibia and fibula
to progressive shortening, 3. liable to delay of shortening may be assessed from the with posterior angulation. (Both are midshaft
or difficulty in union, 4. often hard to reduce, radiographs (if an allowance is made fractures.) This method can on occasion give
sometimes due to trapping of soft tissue for magnification). Speaking generally, rise to confusion, especially as deformity is
between the bone ends. displacement, whilst undesirable, is of much described in terms of the distal fragment.
less significance than angulation.

46. Angulation (b): Equally acceptable, and 47. Angulation (c): Significant angulation 48. Angulation (d): In the lower limb, alteration
perhaps less liable to error, would be to must always be corrected for several reasons. of the plane of movements of the hip, knee
describe these fractures in the following Deformity of the limb will be conspicuous or ankle may lead to abnormal joint stresses,
way: (1) a fracture of the middle third of the (1) and regarded (often correctly) by the leading to the rapid onset of secondary
femur with the distal fragment tilted laterally, patient as a sign of poor treatment. Deformity osteoarthritis.
(2) a fracture of the tibia and fibula in the from displacement (2) is seldom very obvious.
middle thirds, with the distal fragment tilted In the upper limb, function may be seriously
anteriorly. This is also known as a recurvatum impaired, especially in forearm fractures
deformity. where pronation/supination may be badly
affected (3).
 12 DESCRIBING THE DEFORMITY OF A FRACTURE

49. Axial rotation (a): A third type of deformity 50. Axial rotation (b): Radiographs which 51. Axial rotation (c): Axial rotation may
may be present; this is when one fragment fail to show both ends of the bone frequently also be detected in the radiographs by noting
rotates on its long axis, with or without prevent any pronouncement on the presence (1) the position of interlocking fragments
accompanying displacement or angulation. of axial rotation (1). When both ends of the (displaced fracture with 90° axial rotation
This type of deformity may be overlooked fractured bone are fully visualised on one illustrated). If a bone is not perfectly circular
unless precautions are taken and the film, rotation may be obvious (2). The moral in cross-section at the fracture site, differences
possibility of its occurrence kept in mind. is that in any fracture both the joint above in the relative diameters of the fragments
and the one below should be included in the may be suggestive of axial rotation (2). Axial
examination. rotation is of particular importance in forearm
fractures.

52. Open fractures: Open (compound) 53. Fractures open from within out: (1) The 54. Technically open fracture: Occasionally the
fractures are of two types: those which are case may be first seen with bone obviously skin damage is minimal, with a small area of
open from within out, and others which are still penetrating the skin which may be tightly early bruising, in the centre of which is a tiny
open from without in. In fractures which are stretched round it. (2) More commonly, the tell-tale bead of blood issuing from a puncture
open from within out, the skin is broached by fracture having once broken the skin promptly wound; this bead of blood reappears as soon
the sharp edge of one of the bone ends. This spontaneously reduces, so that what is seen is as it is swabbed. The risks of infection are
may occur at the time of the initial injury, or a wound at the level of the fracture. much less in open-from-within-out fractures
later from unguarded handling of a closed than those from without in. This is especially
fracture. so in the technically open fracture just
described.
 OPEN FRACTURES/SELF-TEST 13

55. Fractures open from without in (a): This 56. Open from without in (b): The risks of 57. Open from without in (c): Here the skin and
type of injury is caused by direct violence; infection are greater in this type of open soft tissue damage may be more extensive (3)
the causal force breaks the skin and fractures fracture as: (1) dirt and fragments of clothing, leading to oedema, compartment syndromes,
the underlying bone. Causes include injuries etc. may be driven into the wound, (2) the problems with wound cover, and greater
from falling objects (e.g. in the construction skin is often badly damaged; skin may even haemorrhage (4) and shock. The associated
industry, mining, rock falls in mountaineering, be lost. In either case, wound healing may fractures are more frequently comminuted,
etc.) and motor vehicle impacts. be in jeopardy. Difficulty in closure must be leading to difficulty in reduction and fixation.
anticipated. There may be vascular and/or neurological
complications. The initial assessment of any
open fracture must consider neurovascular
and significant muscle and tendon damage as
well as the fracture itself.

SELF-TEST

58. Describe the level and pattern of this 59. This is the radiograph of the tibia of a 60. This is a radiograph of the elbow of an
child’s fracture. young man who was kicked whilst playing adult injured in a fall. There is obvious clinical
rugby. What is the pattern of fracture? What deformity. What is the injury?
observations would you make regarding the
detection of such a fracture?
 14 SELF-TEST

61. This is a radiograph of the arm of a child severely crushed in a run- 62. What is the pattern of this injury?
over road traffic accident. Describe the injury.

63. Describe this fracture. What problems 64. Describe the level and any angulation or 65. Can you detect any abnormality in this AP
might you anticipate with it? displacement that you see in this fracture. radiograph of the wrist and forearm of a child?
 SELF-TEST 15

66. This is the radiograph of a patient who 67. The history in this case is of pain in the 68. This radiograph is of the hip of an elderly
complained of pain in the side of the foot back following a fall. What is the pattern of lady who complained of pain after a fall.
following a sudden inversion injury. Where is fracture? What deformity is present? Have you any
the fracture, and what is the pattern of injury? observations to make regarding any factors
contributing to the fracture?

69. What is this pattern of fracture? What is 70. What pattern of injury is illustrated in this 71. This injury was sustained in a road traffic
the importance of accurate reduction in this thumb radiograph? What is its significance? accident. Describe the pattern of injury and
case? the deformity.
 16 ANSWERS TO SELF-TEST

ANSWERS TO SELF-TEST 65. There is a greenstick fracture of the radius. Note the ridging of the
radius both medially and laterally just proximal to the epiphysis.
58. Transverse fracture of the tibia in the middle third. Simple
transverse fracture of the tibia in the middle third (or simple transverse 66. Fracture of the base of the fifth metatarsal. This is an avulsion
fracture of the tibial diaphysis). There is no significant displacement or fracture, produced by the peroneus brevis which is inserted into the fifth
angulation, and the fibula is intact. The fracture is of adult pattern and is metatarsal base.
not a greenstick fracture.
67. The radiograph shows deformity of the body of the first lumbar
59. Hair-line fracture of the tibial diaphysis (or of the tibia in the vertebra which has been reduced in height anteriorly. This is an anterior
lower mid-third). Coned-down views are often helpful; if the initial compression or crush fracture.
radiographs appear normal, they should be repeated after an interval if
there is continued suspicion that a fracture is present. CT scans of the 68. There is a simple oblique fracture of the proximal femur, running
suspect area are also often useful. between the lesser and greater trochanters, with a coxa vara deformity
(the distal femur is tilted medially). The hip is arthritic, and the
60. Dislocation of the elbow. The radius and ulna are displaced laterally disturbance in bone texture in the pelvis and femur is typical of Paget’s
in relation to the humerus (and also posteriorly, although this is not disease (i.e. this is a pathological fracture).
shown on the single radiograph).
69. There is a simple oblique fracture of the fibula, which is displaced
61. This injury cannot be anything but open as the right-angled laterally, accompanied by the talus. The distal end of the fibula is tilted
angulation of the greenstick fracture of the radius (at the junction of laterally (medial angulation). Unless accurately reduced, this fracture
its middle and lower thirds) indicates. The mottling of the soft-tissue involving a joint is liable to lead to secondary osteoarthritis.
shadows due to air is confirmatory. In addition, there is a greenstick
fracture of the ulna in its middle third (note the posterior angulation) 70. The small fragment of bone detached from the base of the proximal
and dislocation of the elbow (the ulna appears lateral and the humerus phalanx has been avulsed by the ulnar collateral ligament of the MP
AP). Both fractures are of the diaphysis. joint. It indicates that the thumb has been dislocated, and that there is
potential instability at this level.
62. Fracture dislocation of the shoulder. The head of the humerus is not
congruous with the glenoid. Lateral to it is a large fragment of bone, the 71. There is a fragmented wedge fracture of the tibial diaphysis. There
avulsed greater tuberosity of the humerus. are four fragments, and the main butterfly fragment of a bending
wedge fracture remains in contact and alignment with the main distal
63. Segmental (double) fracture of the tibia (complex segmental fragment. There is a segmental (double) fracture of the fibula. Both
fracture). The proximal fracture is virtually transverse and in the middle fractures are in the middle third. Soft tissue shadows indicate, as might
third. The distal fracture is also transverse and situated in the distal be anticipated, that this is an open fracture. There is lateral angulation
third. The fibula is fractured, and the tibia displaced medially. Bony (i.e. the distal fragment is tilted medially). During the taking of the
apposition has probably been lost in the proximal fracture. Problems AP and lateral radiographs there has been some alteration of position
with reduction, fixation and non-union at one level are to be anticipated. of the fracture: note that in the lateral projection there is considerable
axial rotation (the foot is lateral, but the upper tibia is almost in the AP
64. Fracture of the radius and ulna in the distal third. In the lateral plane). Axial rotation is not a feature of the AP projection.
projection, there is some slight anterior (volar) angulation (posterior
(or dorsal) tilting) of the ulna. In the AP view, there is lateral (or
radial) displacement of the distal fragments which are virtually off-
ended. There is some medial (ulnar) angulation (or the distal fragments
are tilted laterally). The radial fracture is oblique with a slight spiral
element. The ulnar fracture is transverse.
 EPIPHYSEAL INJURIES 17

72. Types of epiphyses: There are two types of 73. Traction epiphyses ctd: Injuries to the 74. Pressure epiphyses (a): Pressure
epiphyses: (1) pressure epiphyses (epiphyses), traction epiphyses are nearly always avulsion epiphyses are situated at the ends of the
which form part of the articulating surfaces injuries. The sites commonly affected include: long bones and take part in the articulations.
of a joint, and (2) traction epiphyses (1) the base of the fifth metatarsal, (2) the The corresponding epiphyseal plates are
(apophyses), which lie at muscle insertions, tibial tuberosity, (3) the calcaneal epiphysis. responsible for longitudinal growth of the
are non-articular and do not contribute to the Traction injuries are probably the basic cause bone. (Circumferential growth is controlled
longitudinal growth of the bone. of Osgood Schlatter’s and Sever’s disease by the periosteum.) Note: (1) epiphysis,
(2 and 3). Other sites include the lesser (2) epiphyseal plate, (3) metaphysis,
trochanter, ischium and the anterior iliac (4) diaphysis.
spines.

75. Pressure epiphyses (b): Within the 76. Pressure epiphyses (c): The metaphyseal 77. Epiphyseal plate injuries (Salter and Harris
epiphyseal plate (1) is a layer of active side of the plate is nourished by vessels from Classification):
cartilage cells (2). The newly formed cells the shaft (M). In the tibia (1) the epiphysis is Type 1: The whole epiphysis is separated from
undergo hypertrophy. Calcification and supplied by extra-articular vessels. Vessels to the shaft.
transformation to bone occur near the the femoral head (2) lie close to the joint space Type 2: The epiphysis is displaced, carrying
metaphysis (3). When there is an epiphyseal and epiphyseal plate (P). There is a variable with it a small, triangular metaphyseal
separation, it occurs at the weakest point, the (up to 25%) contribution from the ligamentum fragment (the commonest injury).
layer of cell hypertrophy (4). The active region teres. Epiphyseal displacements may lead to Type 3: Separation of part of the epiphysis.
(2) remains with the epiphysis. avascular necrosis or growth arrest. The head Type 4: Separation of part of the epiphysis,
of radius is similarly at risk. (C) = capsule, (A) with a metaphyseal fragment.
= articular cartilage. Type 5: Crushing of part or all of the
epiphysis.
 18 EPIPHYSEAL INJURIES

78. Type 1 injuries (a): The epiphysis is 79. Type 1 injuries (b): An endocrine 80. Type 2 injuries: The epiphysis displaces,
separated from the shaft without any disturbance is thought to be an important carrying with it a small triangular fragment
accompanying fracture. This may follow factor in the common forms of slipped upper of the metaphysis (illustrated here in the
trauma in childhood (illustrated is a traumatic femoral epiphysis. Avascular necrosis is not distal femur). It is caused by trauma and is
displacement of the distal femoral epiphysis) uncommon, especially if forcible reduction is the commonest of epiphyseal injuries. Its
or result from a birth injury. It may occur attempted after a delay in diagnosis. Growth highest incidence is in early adolescence.
secondary to a joint infection, rickets or arrest is seldom a problem (as it occurs in Growth disturbance is relatively uncommon.
scurvy. Reduction by manipulation is usually adolescence towards the end of growth, and as Reduction must be early – it becomes difficult
easy in traumatic lesions, and the prognosis is most femoral growth is at the distal end). after 48 hours by closed methods.
good unless the epiphysis lies wholly within
the joint.

81. Type 3 injuries: Part of the epiphysis is 82. Type 4 injuries: Separation of part of 83. Type 5 injuries: Crushing or other damage
separated. Accurate reduction is necessary in the epiphysis with a metaphyseal fragment. to the epiphyseal plate. This radiograph of a
this type of injury to restore the smoothness The lateral condyle of the humerus is most child who was dragged along the road by a
and regularity of the articular surface. The commonly affected and must be accurately car shows the medial malleolus, part of the
prognosis is generally good unless the severity reduced – open reduction is usually necessary. epiphyseal plate and the adjacent tibia have
of the initial displacement has disrupted the Failure of reduction leads to bone formation in been removed by abrasion. (The tibia is also
blood supply to the fragment. The lower and the gap and marked disturbance of growth. fractured.) The epiphyseal plate may also be
upper tibial epiphyses are most commonly crushed in severe abduction and adduction
affected (note separated portion of tibial injuries of the ankle.
epiphysis behind lateral malleolus).
 EPIPHYSEAL INJURIES 19

84. Growth disturbances (a): If growth is

arrested over part of the epiphyseal plate only,
there will be progressive angulatory deformity
affecting the axis of movement of the related
joint. There will be a little overall shortening.
This radiograph shows the tilting of the plane
of the ankle joint which occurred in the last
case, with deformity of the foot and ankle. In
the elbow, injuries of this type may lead to
cubitus varus or valgus.

85. Growth disturbances (b): If the whole epiphyseal plate is affected, growth will be arrested,
leading to greater shortening of the bone. The final result will depend on the age at which
epiphyseal arrest occurred, and the epiphysis involved; obviously the younger the child the
greater is the growth loss. Arrest of one epiphysis in paired bones will lead to joint deformity.
In the case illustrated, the radial epiphysis on the right has suffered complete growth arrest
following a displaced lower radial epiphysis. The ulna has continued to grow at its usual rate;
its distal end appears prominent on the dorsum of the wrist, and there is obvious deformity and
impairment of function in the wrist. The normal left side is shown for comparison.
 20 FRACTURE HEALING

86. Fracture healing: As a result of the injury, 87. Fracture haematoma (a): Bleeding occurs 88. Fracture haematoma (b): The fracture
(1) the periosteum may be completely or from the bone ends, marrow vessels and haematoma is rapidly vascularised by
partly torn, (2) there is disruption of the damaged soft tissues, with the formation of the ingrowth of blood vessels from the
Haversian systems with death of adjacent a fracture haematoma which clots. (A closed surrounding tissues, and for some weeks there
bone cells, (3) there may be tearing of muscle, fracture is illustrated.) is rapid cellular activity. Fibrovascular tissue
especially on the convex side of the fracture, replaces the clot, collagen fibres are laid down
and damage to neighbouring nerves and and mineral salts are deposited.
blood vessels, (4) the skin may be broached
in compound injuries, with risk of ingress of
bacteria.

89. Subperiosteal bone: New woven bone is 90. Primary callus response: This remains 91. Bridging external callus (a): If the
formed beneath the periosteum at the ends of active for a few weeks only (1). There is a periosteum is incompletely torn, and there
the bone. The cells responsible are derived much less vigorous formation of callus from is no significant loss of bony apposition,
from the periosteum, which becomes stretched the medullary cavity (2). Nevertheless, the the primary callus response may result in
over these collars of new bone. If the blood capacity of the medulla to form new bone establishing external continuity of the fracture
supply is poor, or if it is disturbed by excessive remains indefinitely throughout the healing of (‘bridging external callus’). Cells lying in the
mobility at the fracture site, cartilage may be the fracture. outer layer of the periosteum itself proliferate
formed instead and remain until a better blood to reconstitute the periosteum.
supply is established.
 FRACTURE HEALING 21

92. Bridging external callus (b): If the gap is 93. Bridging external callus (c): If the bone 94. Endosteal new bone formation (a): If there
more substantial, fibrous tissue formed from ends are offset, the primary callus from the is no gap between the bone ends, osteoclasts
the organisation of the fracture haematoma subperiosteal region may unite with medullary can tunnel across the fracture line in advance
will lie between the advancing collars of callus. The net result of the three mechanisms of ingrowing blood vessels and osteoblasts
subperiosteal new bone. This fibrous tissue just described is that the fracture becomes which form new Haversian systems. Dead
may be stimulated to form bone (‘tissue rigid, function in the limb returns and the bone is revascularised and may provide an
induction’), again resulting in bridging callus. situation is rendered favourable for endosteal invaluable scaffolding and local mineral
The mechanism may be due to a change of bone formation and remodelling. source. This process cannot occur if the
electrical potential at the fracture site or to a fracture is mobile.
(hypothetical) wound hormone.

96. Endosteal new bone formation (c): Where the bone ends are supported by rigid internal
fixation, there is no functional requirement for external bridging callus: as a result external
bridging callus may not be seen, or be minimal. Healing of the fracture occurs slowly through
the formation of new cortical bone between the bone ends. It is therefore essential that internal
fixation devices are retained until this process is complete.
Remodelling: After clinical union, new Haversian systems are laid down along the lines of stress.
In areas free from stress, bone is removed by osteoclasts. Eventually little trace of external
bridging callus will remain. The power to remodel bone in this way is great in children, but not
so marked in the adult. In a child, most or all traces of fracture displacement (including even off-
ending) will disappear. There is also some power to correct angulation, although this becomes
progressively less as the child approaches adolescence. Any axial rotation, however, is likely to
remain. In the adult, there is virtually no correction of axial rotation or angulation. It is, therefore,
important that axial rotation deformity is always corrected, and that angulation, particularly in
adults, should not be accepted.
Bone morphogenic protein (BMP): These make up a family of proteins which have osteogenic
properties. More than 16 (BMP 1–16) have been identified: they have been purified, cloned
and sequenced into human recombinant forms. They function by inducing mesenchymal cells
to transform – first into cartilage and then into bone cells. They may produce and mineralise
osteoid, influence angiogenesis, and play a part in bone remodelling. They may also have a role
to play in articular cartilage repair.

95. Endosteal new bone formation (b): The Their clinical application is being appraised. It has been found that dosage is important: too
formation of new cortical bone, with re- low, and the effect is minimal, and too high a dose may lead to osteoclastic activity. To maintain
establishment of continuity between the a suitable local concentration and prevent rapid absorption, BMPs are used with a carrier, the
Haversian systems on either side, cannot occur commonest of which are collagen based; unfortunately most carriers result in an immunogenic
if fibrous tissue remains occupying the space response which may cause problems; so there is continued research in developing more effective
between the bone ends. If this is present, it carriers. BMPs may also be delivered by gene therapy, either directly to the tissues so that the
must be removed and replaced with woven host cells are transfected, or by transfection of cultured cells which are then implanted locally.
bone. This is generally achieved by ingrowth However, the safety of viral vectors must be established before they can be used clinically.
of medullary callus which remains active
through the healing phase.
22 CLASSIFICATION OF FRACTURES

Early clinical trials have shown that in the presence of adequate environmental conditions
(biomechanical stability, soft tissue coverage and adequate vascularity) the value of BMPs in
accelerating healing in open tibial fractures, tibial non-unions, and bone defects seems clear.
97. The classification of fractures There is no fracture of any bone which has escaped an
attempt at classification. Sometimes this has been done on the basis of region and pattern,
sometimes through a concept of the stresses to which the bone has been subjected, and usually
with an eye on some understanding of the severity of the injury and its prognosis. Unfortunately
not everyone has the same ideas regarding the relative importance of the various factors
concerned, and as time progresses and knowledge expands the number of classifications that
exist has been continuing to grow.
The result is that in nearly every area there is a wealth of classifications, usually with grades,
degrees or numbers attached to the originator’s name. This bewilders the newcomer, and causes
much confusion in those who are attempting to assess the results of various treatments, as the
injuries classified by one author may not be easily compared with those described by another.
There is too the problem of how to ascribe certain fractures which have been inconsiderate
enough to adopt a pattern that does not quite fit within the classification.
No surgeon is able to master the wealth of classifications outside his own specialist area;
and for purposes of communication, as far as single injuries are concerned, a fracture is
described mainly by its site and pattern, along the lines already detailed. In such circumstances
classifications are only mentioned if they have become familiar through long usage, and in some
cases classifications of this type may be archaic.
After many years’ work the AO Group have evolved a classification which aims to encompass
all fractures, actual or theoretical, and is of particular value for research purposes.

THE AO CLASSIFICATION OF FRACTURES OF LONG BONES

The following points should be noted:
1. This is not a classification of injuries: it is a classification of fractures.
2. It does not include dislocations, unless they have an associated fracture.
3. It does not differentiate between undisplaced and displaced fractures of the
shafts of the long bones (but it does so in the case of certain fractures of
the bone ends).
4. It does not give any indication of the relative frequency of particular
fractures.
5. The sorting of fractures (beyond the area of the bone involved) depends
on the AO Group’s assessment of the severity of the fracture; this they
define as ‘the morphological complexity, the difficulty in treatment, and
the prognosis’. In areas this may reflect a preference for the use of internal
fixation rather than conservative methods of treatment.
6. The classification results in an alpha-numeric code which is suitable
for computer sorting, and which allows for research purposes (e.g.
in assessing the results of any treatment, wherever carried out) the
comparison of like with like.
7. Because of the format, it is not descriptive in a verbal sense, and is not
suitable for conveying information about the nature of an individual
fracture (e.g. over the telephone).
8. The AO Classification has been criticised as having poor interobserver
reliability, being too complex, and having little predictive value. The
classification of fractures of the distal radius and the proximal femur has
been described as being particularly poor. Nevertheless it is supported by
the Orthopaedic Trauma Association for Coding and Classification; and
besides this, one of the reasons for its inclusion in this book is because of
its great value in drawing attention to the enormous range of fractures to
which each bone is subject.
 AO CLASSIFICATION OF FRACTURES 23

98. The principles of the AO classification: 1. The AO classification for long bone fractures may be grasped by likening it to an X-ray storage slystem,
with numbered blocks of filing cabinets: one block for each bone.
Within each block, each filing cabinet (which is also numbered) represents a particular area of each bone: cabinet number 1 stores fractures of
the proximal segment, number 2 the diaphysis or shaft, and number 3 the distal segment. In the case of the tibia, there is a fourth cabinet to deal
with fractures of the malleoli. (The junction between the segments is determined in the way described on p. 10, Frame 39.) When a fracture bridges
the junction between two segments, the segment under which it is classified is determined by the site of the mid-point of the line of the fracture. In
practice therefore, a two-digit code determines the Location of a fracture: e.g. under 22- would be stored all fractures of the shafts of the radius, or
the ulna, or of both these bones.
In each cabinet all the radiographs for a single location of fracture are divided into fracture Types (represented by the three drawers); the least
severe go in drawer A (Type A), those of intermediate severity in B (Type B fractures), and the most severe in C (Type C). Some of the criteria used
to differentiate between the three types of fracture have already been indicated (Frames 25, 26, 33) but see Footnote.
Any type of fracture can be put in one of three groups (represented by folders, and numbered 1–3). The methods of selection are again described
later. Within each group fractures may be further sorted into subgroups (represented by partitions). Each of these subgroups has a numerical
representation (.1, .2, .3). [If an even more detailed classification is needed, fractures within each subgroup can have added qualifications. These
can be described by a single number (or two numbers separated by a comma) added in parentheses after the main coding. The first digit in the range
1–6 is used to amplify the description of a fracture’s location and its extent, while the second is purely descriptive. The number 7 is reserved to
describe partial amputations, 8 for total amputation, and 9 for loss of bone stock.]
As an example of the AO classification, a simple oblique fracture of the proximal part of the femoral shaft distal to the trochanters would be
coded 32–A2.1 as follows:

3 = THE BONE = the femur the location

2 = THE SEGMENT = the diaphysis of the fracture
– = separator between location and type
A = the type: A is the least severe type of fracture, with two bone fragments only
2 = the group: Group 2 includes all oblique fractures
1 = the subgroup: subgroup 1 includes fractures in the proximal part of the diaphysis where the medullary cavity is wider
than in the more central part of the bone.

Footnote: the criteria employed in sorting fractures into their appropriate types, groups and subgroups are given in a little more detail in the section
on Regional Injuries.
 24 CLASSIFICATION OF OPEN FRACTURES

99. Classification of open fractures (a): Type I: An open fracture with a wound which or (b) high energy trauma irrespective of the
The classification of Gustilo et al is well is (a) less than 1cm and (b) clean. size of the wound.
established and in common use. It is a
practical classification which relates well Type II: An open fracture with a wound which Type IIIB: An open fracture with extensive
to the common patterns of injury and their is (a) more than 1cm long and (b) which is not soft tissue loss, with periosteal stripping and
prognosis. Three types are described, with the associated with extensive soft tissue damage, exposure of bone. Massive contamination is
third being subdivided to allow a more precise avulsions, or flaps. usual.
grading.
Type IIIA: An open fracture where there is Type IIIC: An open fracture associated with
adequate soft tissue coverage of bone in spite an arterial injury which requires repair.
of (a) extensive soft tissue lacerations or flaps

100. Classification of open fractures (b): The IO3 = In excess of 5 cm of skin broken, with NV3 = Isolated vascular injury
AO Group use separate classifications for devitalised edges and local degloving NV4 = Combined neural and vascular injury
closed and open skin injuries and for injuries IO4 = Full thickness contusion, abrasion, skin NV5 = Sub-total or total amputation.
to muscle; they employ a separate fourth loss
classification for nerve and vascular injuries. IO5 = Extensive degloving. Note that for data storage purposes the above
The classification is more complex and is AO soft-tissue classifications are appended to
given here for completeness: Muscle and tendon injuries in fractures: their alpha-numeric fracture classification; e.g.
a segmental fracture of the tibia in which there
Skin lesions in closed fractures (Integuments, MT1 = No muscle injury was a small skin wound, no obvious muscle
Closed): MT2 = Local muscle injury, one muscle group damage, but an associated drop foot would be
only classified 42–C2/IO2–MT1–NV2: this is not a
IC1 = Skin undamaged MT3 = Extensive muscle injury with classification for committing to memory!
IC2 = Contusion of skin involvement of more than one group
IC3 = Local degloving MT4 = Avulsion or loss of entire muscle Note the very approximate correlations
IC4 = Extensive (but closed) degloving groups, tendon lacerations between the Gustilo and AO classifications:
IC5 = Skin necrosis resulting from contusion. MT5 = Compartment syndrome; Crush
syndrome. Gustilo Type I equivalent to IO1
Skin lesions in open fractures (Integuments, Gustilo Type II equivalent to IO2
Open): Neurovascular injuries in fractures: Gustilo Type IIIA equivalent to IO3
Gustilo Type IIIB equivalent to IO4
IO1 = Skin broken from within out NV1 = No neurovascular injury Gustilo Type IIIC equivalent to IO3–5 + NV2.
IO2 = Skin broken from without in, with NV2 = Isolated nerve injury
contused edges but less than 5cm in length
 25

CHAPTER

2
The diagnosis of fractures
and principles of treatment
HOW TO DIAGNOSE A FRACTURE
1. HISTORY
In taking the history of a patient who may have a fracture, the following
points may prove to be helpful, especially when there has been a traumatic
incident.
1. What activity was being pursued at the time of the incident (e.g. taking
part in a sport, driving a car, working at a height, etc.)?
2. What was the nature of the incident (e.g. a kick, a fall, a twisting injury,
etc.)?
3. What was the magnitude of the applied forces? For example if
a patient was injured in a fall, it is helpful to know how far he
fell, if his fall was broken, the nature of the surface on which he
landed, and how he landed; trivial violence may lead one to suspect
a pathological fracture: severe violence makes the exclusion of
multiple injuries particularly important.
4. What was the point of impact and the direction of the applied forces?
In reducing a fracture, one of the principle methods employed is to
reduplicate the causal forces in a reverse direction. If a fracture occurs
close to the point of impact, additional remotely situated fractures must
How to diagnose a fracture 25
be excluded.
History 25
Clinical examination 26 5. Is there any significance to be attached to the incident itself? For
Radiological and other visualisation example, if there was a fall, was it precipitated by some underlying
techniques 29 medical condition, such as a hypotensive attack, which requires separate
Diagnostic pitfalls 30 investigation?
Treatment of fractures 31 6. Where is the site of any pain, and what is its severity?
Resuscitation and fluid 7. Is there loss of functional activity? For example, walking is seldom
replacement 32
Complications of transfusion 36
possible after any fracture of the femur or tibia; inability to weight bear
Persisting circulatory after an accident is of great significance.
impairment 37 8. What is the patient’s age? Note that while a young person may
Head injuries 38 sustain bruising or a sprain following moderate trauma, an incident
Glasgow Coma Scale 39 of comparative magnitude in an older patient may result in a
Trauma complications 40
Trauma scoring 40
fracture.
General principles of treatment 41
Diagnosis In some cases the diagnosis of fracture is unmistakable,
Damage control orthopaedics 44
Mangled Extremity Severity e.g. when there is gross deformity of the central portion of a long bone
Score 51 or when the fracture is visible as in certain compound injuries. In the
Suspected child abuse 53 majority of other cases, a fracture is suspected from the history and clinical
examination, and confirmed by radiography of the region.
 26 FRACTURE DIAGNOSIS – CLINICAL EXAMINATION

2. Inspection (a): Begin by inspecting the limb 3. Inspection (b): Look for any persisting 4. Inspection (c): Look for local bruising of
most carefully, comparing one side with the asymmetry of posture of the limb, for example, the skin suggesting a point of impact which
other. Look for any asymmetry of contour, persisting external rotation of the leg is a may direct your attention locally or to a more
suggesting an underlying fracture which has common feature in disimpacted fractures of distant level. For example, bruising over the
displaced or angled. the femoral neck. knee from dashboard impact should direct
your attention to the underlying patella, and
also to the femoral shaft and hip.

5. Inspection (d): Look for other tell-tale skin 6. Inspection (e): Note the presence of: (C) 7. Inspection (f): If the patient is seen
damage. For example (A) grazing, with or skin stretch marks, (D) band patterning shortly after the incident, note any localised
without ingraining of dirt in the wound, or of the skin, suggestive of both stretching swelling of the limb (1). Later, swelling
friction burns, suggests an impact followed by and compression of the skin in a run-over tends to become more diffuse. Note the
rubbing of the skin against a resistant surface. injury, (E) pattern bruising, caused by severe presence of any haematoma (2). A fracture
(B) Lacerations suggest impact against a hard compression which leads the skin to be may strip the skin from its local attachments
edge, tearing by a bone end, or splitting by imprinted with the weave marks of overlying (degloving injury); the skin comes to float on
compression against a hard surface. clothing. Any of these abnormalities should an underlying collection of blood which is
lead you to suspect the integrity of the continuous with the fracture haematoma.
underlying bone.
 FRACTURE DIAGNOSIS – CLINICAL EXAMINATION 27

8. Inspection (g): Note the colour of the injured 9. Tenderness (a): Look for tenderness over 10. Tenderness (b): In eliciting tenderness,
limb, and compare it with the other. Slight the bone suspected of being fractured. once a tender area has been located the part
cyanosis is suggestive of poor peripheral Tenderness is invariably elicited over a should be palpated at the same level from
circulation; more marked cyanosis, venous fracture (1), but tenderness will also be found another direction. For example, in many
obstruction; and whiteness, disturbance of over any traumatised area, even though there sprained wrists, tenderness will be elicited in
the arterial supply. Feel the limb, and note is no underlying fracture (2). The important the anatomical snuff-box – but not over the
the temperature at different levels, again distinguishing feature is that in the case of a dorsal and palmar aspects of the scaphoid,
comparing the sides. Check the pulses, fracture tenderness will be elicited when the which are tender if a fracture is present.
and the rapidity of pinking-up after tissue bone is palpated on any aspect (3).
compression.

13. Radiographic examination: In every

case of suspected fracture, radiographic
examination of the fracture is mandatory.
Radiographs of the part will generally give a
clear indication of the presence of a fracture
and provide a sound basis for planning
treatment. In the case where there is some
clinical doubt, radiographs will reassure
patient and surgeon and avert any later
medicolegal criticism.
Radiographers in the United Kingdom
receive thorough training in the techniques for
the satisfactory visualisation of any suspect
area, but it is essential that they in turn are
given clear guidance as to the area under
suspicion. The request form must be quite
specific, otherwise mistakes may occur. At its
simplest, the request must state both the area
to be visualised and the bone suspected of
being fractured. It is desirable to include the
joints above and below the fracture. It need
hardly be stressed that a thorough clinical
11. Palpation: The sharp edge of a fracture 12. Other signs: If the fracture is mobile, examination should precede the completion of
may be palpable. Note also the presence of moving the part may produce angulation or the radiographic request if repetition and the
localised oedema. This is a particularly useful crepitus from the bone ends rubbing together. taking of unnecessary films are to be avoided.
sign over hair-line and stress fractures. The In addition, the patient will experience severe
development of oedema may, however, take pain from such movement. These signs may
some hours to reach detectable proportions. be inadvertently observed during routine
examination of the patient, but should not be
sought unless the patient is unconscious and
the diagnosis is in doubt.
 28 FRACTURE DIAGNOSIS – RADIOGRAPHY

The following table lists some of the commonest errors made in the filling in
of request forms

Area suspected Typical Error Correct request

of fracture request

Scaphoid X-ray wrist, Fractures of the scaphoid X-ray scaphoid,

? fracture are difficult to visualise: a minimum ? fracture
of 3 specialised
views is required. A fracture
may not show on the standard
wrist projections
Calcaneus X-ray ankle, A tangential projection, X-ray calcaneus,
? fracture with or without an additional ? fracture
oblique (along with the usual
lateral), is necessary for satisfactory
X-ray foot,
visualisation of the calcaneus.
? fracture
These views are not taken routinely
when an X-ray examination of the
foot or ankle is called for

Neck of femur ‘X-ray femur, Poor centring of the ‘X-ray hip, ? fracture
? fracture’ radiographs may render the neck of femur’ or
fracture invisible ‘X-ray to exclude
fracture of femoral
neck’
Tibial plateau or ‘X-ray tibia, Poor centring may render ‘X-ray upper third
tibial spines ? fracture’ the fracture invisible, or the tibia to exclude
area may not be included fracture of tibial
on the film plateau’

14. The standard projections: These are 15. Comparison films: Where there is some 16. Oblique projections: In the case of the
an anteroposterior (AP) and lateral. Ideally difficulty in interpreting the radiographs hand and foot, an oblique projection may be
the beam should be centred over the area of (e.g. in the elbow region in children where helpful when the lateral gives rise to confusion
suspected fracture, with visualisation of the the epiphyseal structures are continually due to the superimposition of many structures.
proximal and distal joints. This is especially changing, or where there is some unexplained Such oblique projections may have to be
important in the paired long bones where, for shadow, or a congenital abnormality) films specifically requested when they are not part
example, a fracture of the tibia at one level of the other side should be taken for direct of an X-ray department’s routine.
may be accompanied by a fibular fracture at comparison.
another.
 FRACTURE DIAGNOSIS – RADIOGRAPHY/OTHER IMAGING 29

17. Localised views: Where there is marked 18. Stress films (a): Stress films can be of value 19. Stress films (b): (ii) Stress films may
local tenderness, but routine films are in certain situations: (i) When a complete tear also be used where there is some doubt as
normal, coned-down localised views may of a major ligament is suspected, e.g., where to stability of a uniting fracture. They may
give sufficient gain in detail to reveal for the lateral ligament of the ankle is thought to also be employed where the possibility of
example a hair-line fracture: if such films be torn, radiographs of the joint taken with refracture arises.
are also negative, the radiographs should be the foot in forced inversion may demonstrate
repeated after an interval of 10–14 days if the instability of the talus in the ankle mortice.
symptoms are persisting (see also Hair-line (Local or general anaesthesia may be required
Fractures in Ch. 1/Frame 13). in fresh injuries.)

Other visualisation techniques

1. CT (CT) scans. These can show tissue slices in any plane, but
characteristically in median sagittal, parasagittal, coronal, and most
importantly, transverse planes. The last projection cannot be readily obtained
with plain X-rays, and can often provide useful additional information which
is not otherwise available. In addition, in the CT scan there is a greater range
of grey scale separation, allowing a greater differentiation of tissue types. It is
of particular value in:
฀ Vertebral fractures, to show the relationship between bony fragments and

the spinal canal

฀ Acetabular floor fractures, to clarify the degree of disturbance of the

articular surface
฀ Pelvic fractures, to show the number of elements involved and their

relationship. In some cases it may be possible to display and rotate

informative 3-D reconstructions
฀ In calcaneal and other fractures involving joints, to visualise the position of the

elements and the degree of joint disturbance.

2. AP and lateral tomography. In this X-ray technique the tube and film are
rotated (or slid) in opposite directions during the exposure. Their position relative
to one another and the part being examined determines the tissue slice being
clearly visualised. The results are inferior to those obtained by CT scanning, but
may be helpful if the latter is not available.
3. Technetium bone scans. Technetium tagged methylene diphosphate
(99Tcm-methylene diphosphate (MDP)) can be used 48 hours after an injury
to demonstrate bone activity at a fracture site, and confirm the presence of a
fracture when other methods of detection have failed.
30 FRACTURE DIAGNOSIS – PITFALLS

4. MRI scans. These avoid any exposure to X-radiation and produce image
cuts as in CT scans with a greater ability to distinguish between different
soft-tissues. In the trauma field they are of particular value in assessing
neurological structures within the skull and spinal canal, and meniscal and
ligamentous structures about the knee and shoulder.
5. Bone scanning with SPECT (single-photon-emission computed
tomography). This allows physiological assessment of bone by identifying
areas of increased osteoblastic activity. It is highly sensitive.
6. Ultrasound. Ultrasound imaging is of great sensitivity and of value in
assessing the presence of fluid (e.g. blood) within the abdominal cavity
in the patient with multiple injuries; it may also be helpful in elucidating
injuries to the quadriceps tendon, the patellar ligament and the Achilles tendon.

PITFALLS
A number of fractures are missed with great regularity – sometimes with
serious consequences. You should always be on the look-out for the following:
1. An elderly patient who is unable to weight bear after a fall must be
examined most carefully. The commonest cause by far is a fracture of the
femoral neck, and this must be eliminated in every case. If the femoral
neck is intact, look for a fracture of the pubic rami. Note that, on the rare
occasion, a patient with an impacted fracture of the femoral neck may be
able to weight bear, albeit with pain.
2. If a car occupant suffers a fracture of the patella or femur from a dashboard
impact, always eliminate the presence of a silent dislocation of the hip.
3. If a patient fractures the calcaneus in a fall, examine the other side most
carefully. Bilateral fractures are extremely common, and the less painful
side may be missed.
4. If a patient complains of a ‘sprained ankle’ always examine the foot as well as
the ankle. Fractures of the base of the fifth metatarsal frequently result from
inversion injuries, and are often overlooked. The mistake of not performing a
good clinical examination in these circumstances is compounded by requesting
radiographs of the ankle (which do not show the fifth metatarsal bone).
5. In the unconscious patient, injuries of the cervical spine are frequently
overlooked. It pays to have routine screening films of the neck, chest and
pelvis in the unconscious patient.
6. Impacted fractures of the neck of the humerus are often missed,
especially when one view only is taken. Conversely, in children, the
epiphyseal line is often wrongly mistaken for fracture.
7. Posterior dislocation of the shoulder may not be diagnosed when it should be
at the initial attendance. This is because the humeral head comes to lie directly
behind the glenoid, and is not detected if only a single AP projection is taken.
If there is a strong suspicion of injury, and especially if there is deformity
of the shoulder, a second projection is essential if no abnormality is noted
on the AP film. (Two views should be taken routinely in all injuries, but in
many departments the shoulder, for no good reason, is excluded from this rule.)
8. Apparently isolated fractures of either the radius or ulna should
be diagnosed with caution. The Monteggia and Galeazzi fracture–
dislocations are still frequently missed. In the same way, it is unwise to
diagnose an isolated fracture of the tibia until the whole of the fibula has
been visualised; fracture of the tibia close to the ankle is, for example,
often accompanied by fracture of the fibular neck.
 FRACTURE TREATMENT – PRIMARY AIMS 31

9. At the wrist, greenstick fractures of the radius in children are often

overlooked due to lack of care in studying the radiographs.
10. In adults, fractures of the radial styloid or Bennett’s fracture may be
missed or treated as suspected fractures of the scaphoid. Complete tears
of ulnar collateral ligament of the MP joint of the thumb are frequently
overlooked, sometimes with severe resultant functional disability.

TREATMENT OF FRACTURES
PRIMARY AIMS
The primary aims of fracture treatment are:
1. The attainment of sound bony union without deformity
2. The restoration of function, so that the patient is able to resume his former
occupation and pursue any athletic or social activity he wishes.
To this might be added ‘as quickly as possible’ and ‘without risk of any
complications, whether early or late’. These aims cannot always be achieved,
and in some situations are mutually exclusive. For example, internal fixation
of some fractures may give rapid restoration of function, but at the expense of
occasional infection. The great variations that exist in fracture treatment are
largely due to differences in interpretation of these factors and their relevance
in the case under consideration; they are in constant flux, with on the one hand
the development of more sophisticated methods of fracture fixation and new
antibiotics, and on the other the emergence of antibiotic resistant organisms.

RESUSCITATION
If a limb fracture is a patient’s sole injury, resuscitation is less frequently
required, so that it is often possible to proceed with treatment without undue
delay (although unfitness for anaesthesia may sometimes upset this ideal).
If, however, a fracture is complicated by damage to other structures, or
involvement of other systems, then treatment of the fracture usually takes
second place. Immediate action must be taken to correct any life-endangering
situation which may be present or anticipated.
Advanced trauma life support (ATLS) It is recognised that a well-organised
trauma team can give the best treatment to a severely injured patient. The core
trauma team will normally consist of ten staff: a team leader, an anaesthetist
and his assistant, a general surgeon, an orthopaedic surgeon, an emergency
department physician, two nurses, a radiographer, and a note-taker (scribe).
Each member has his own specific areas of responsibility. The team leader
should not normally touch the patient, but orchestrate the team.
Additional staff will include porters, blood bank staff including a
haematologist, and a biochemist. A neurosurgeon, thoracic surgeon, plastic
surgeon, and radiologist should also be available at short notice.
To maintain such a team with its equipment makes heavy demands, and is only
possible in a few hospitals which have the necessary workload and resources.
In most situations, especially away from large centres, smaller teams are involved
and assessment and management follow a more linear approach (as adopted below).

INITIAL MANAGEMENT
Some general principles in the initial management of cases of multiple
injuries are well established, and may be summarised with the mnemonic
ABCDE(F).
32 INITIAL MANAGEMENT – RESUSCITATION

A = Airway
1. Any blood, mucus or vomit must be removed from the upper respiratory
passages by suction or swabbing. Dentures should be looked for and extracted.
In the more minor situations, respiratory obstruction may be avoided by
support of the jaw, a simple airway, and turning the patient on his side.
2. An endotracheal tube may have to be passed:
฀ in the unconscious patient with an absent gag reflex
฀ where inhalation of mucus or vomit has already taken place (or is
suspected), for clearing of the respiratory passages under vision
฀ where there is bleeding from the upper airway
฀ for the more effective management of cases where there is respiratory
difficulty or evidence of hypoxia, e.g. in cases of flail chest. Where
there is need for intubation in a patient when a cervical spine injury is
suspected, the procedure should be carried out with great care, avoiding
excessive cervical spine extension; naso-tracheal intubation should be
used. Confirm placement by auscultation (and/or by a radiograph).
B = Breathing
1. Ventilate with 100% oxygen. Check the breath sounds. After intubation
assess the arterial blood gas levels so that if these remain impaired the
appropriate steps may be taken (e.g. reviewing the diagnosis and noting
the situations described below).
2. An open chest wound must be immediately covered to reduce the risks of
tension pneumothorax. A vaseline gauze dressing, covered with a swab,
and firmly secured to the skin with broad adhesive tape is usually quite
adequate in the emergency situation.
3. If there is evidence of a tension pneumothorax (hyper-resonance and decreased
breath sounds on the affected side, or tracheal shift to the other), or of
pneumothorax or haemothorax, the appropriate chest cavities should be drained
by intercostal catheters connected to water seal drains. A routine radiograph
of the chest will usually confirm the diagnosis, but if this remains in doubt, the
chest should be tapped in the fifth interspace in the mid-axillary line.
4. If there is evidence of paradoxical respiration due to flail rib segments, blood
gas levels should be estimated. Normal values are given below:

pO2 75–100 mmHg

pCO2 35–45 mmHg
pH 7.38–7.44
Oxygen content 15–23%
Oxygen saturation 95–100%
Bicarbonate 22–25 millequivalent/L

Slight impairment of respiratory function may be managed by giving oxygen

by inhalation and analgesics with caution. When the blood gas levels are
seriously disturbed, and especially in the presence of a concurrent head injury,
some form of assisted respiration is usually the best method of management.
C = Circulation
1. Any severe external haemorrhage must be brought under rapid control.
This can almost always be achieved with local padding or packing along
with firm bandaging. The use of a tourniquet is best avoided except in the
rarest of circumstances; then one should be used only in circumstances
where its retention for excessive periods cannot occur. A tourniquet
 INITIAL MANAGEMENT – RESUSCITATION 33

must be properly applied; too little pressure will increase the blood loss
by preventing venous return, and too great a pressure will endanger
underlying nerves. A pneumatic tourniquet should always be applied in
preference to any other type.
2. Remove blood for grouping and crossmatching, and the establishment of
base-line parameters including haemoglobin and haematocrit.
3. Set up two large bore (14–16 gauge) intravenous lines, performing if
necessary a rapid cut-down and insertion of a large bore intravenous
cannula under vision.
4. Make an assessment of the circulatory state. Initially the blood pressure
and pulse are the most useful familiar guides to the state of the circulation,
but note that tachycardia and a low blood pressure may sometimes be
absent in those suffering from hypovolaemic shock, requiring the exercise
of clinical judgement. The need for replacement depends on an assessment
of loss and the circulatory state. The amount and type of replacement is
dependent on the nature and extent of the loss. The rate of infusion is
largely determined by the response to replacement.
Classification of haemorrhage a 70 kg male has a circulatory volume of 5 L
of blood (equivalent to 25 units of packed red blood cells).
Class I: loss of up to 15% of blood volume (equivalent to 4 units of packed
red cells) normally does not cause a change in blood pressure or pulse.
Class II: loss of 15–30% of blood volume (equivalent to 4–8 units of packed
red cells) normally leads to tachycardia, but no significant disturbance of
the blood pressure.
Class III: loss of 30–40% of blood volume (about 2 L in a 70 kg man) results
in tachycardia and lowering of the blood pressure.
Class IV: loss of more than 40% of blood volume leads generally to severe
tachycardia and lowering of the blood pressure.
Estimating blood loss The following list gives a crude guidance in
anticipating potential blood loss:
฀ Closed fracture of the femoral shaft: 1 L
฀ Open book fractures of the pelvis: 2–3 L (potentially much greater where
there is a sacroiliac disruption)
฀ Intra-abdominal haemorrhage: 2–3 L
฀ Haemothorax: 1–2 L
฀ Closed head injury: blood loss is insubstantial and hypotension does not
occur unless the patient is close to death.
5. If there is blood loss accompanied by tachycardia or hypotension
rapidly run in crystalloids (such as normal saline or Ringer-lactate).
(In children, give 20 ml/kg body weight initially, and up to 60 ml/kg). Use
of warmed solutions has been shown to reduce mortality and help preserve
the haemostatic mechanisms, and should be routine. If the response is
inadequate after 2 litres, other measures will be required. These include
the administration of packed red blood cells or whole blood, and possibly
surgery (see later). Temporary splintage of limb fractures will reduce local
haemorrhage whether the fracture is open or closed.
(Note that crystalloids are poorly retained in the intravascular space. Some
prefer the use of plasma or synthetic colloids which do not suffer from this
disadvantage, but others claim that these have no advantage in the trauma
setting. Fresh frozen plasma does have the advantage of covering any
34 FRACTURE TREATMENT – FURTHER ASSESSMENT

tendency to hypofibrinogenanaemia and factor V and factor VII deficien-

cies, but takes 20–30 minutes to thaw. Two units of fresh frozen plasma
should be given where bleeding is continuing and there are coagulation
factor deficiencies present.)
D = Drugs, Allergies, Disabilities Carry out a rapid screening of the
patient, and note any information (e.g. on warning cards, bracelets or lockets,
or from relatives) of any relevant problem.
E = Eating and Exposure Obtain if possible information on the patient’s
intake of fluids and solids in case general anaesthesia is required. Where
applicable, remove clothing to allow inspection of the entire patient to avoid
overlooking any additional injuries.
F = Foley Catheter In cases of multiple injury, and where no urinary tract
damage is suspected, insert a catheter to allow monitoring of urinary output
(and hence the adequacy of the blood pressure in maintaining renal function).

FURTHER RESUSCITATION AND ASSESSMENT

Screening films: At an early stage in the assessment of a patient with
multiple injuries, screening films of the cervical spine, the chest and the
pelvis should be obtained. Where there is the possibility of an abdominal
injury with intrabdominal haemorrhage an ultrasound examination should be
carried out. If the circumstances dictate and allow, the opportunity may be
taken at this stage to arrange an X-ray examination of any limb injury, or any
injury to the skull or facial bones.
Fluid replacement: If the patient fails to be stabilised by the administration
of crystalloids, then blood will be required.
Normally blood will also be required if the haemoglobin falls below 9 gd/l;
note the following points:
฀ If the patient is exsanguinated, and will die unless blood is administered
immediately, give two units of Group O Rhesus negative blood pending
supply of cross-matched blood which ideally should become available not
more than 20 minutes after the patient’s blood sample is submitted to the
blood bank.
฀ Thereafter, or if the situation is less acute, administer cross-matched
packed red cells. If bleeding continues, then whole blood becomes more
appropriate.

The volume of the replacement required can vary enormously, and

therefore must be judged by the response: see the following flow chart
(Fig. 2.1) for a summary of replacement management.
 FRACTURE TREATMENT – FURTHER ASSESSMENT 35

Blood sampling:
1. to establish base parameters
2. for grouping and cross-matching Rapidly infuse 2 units
+ group O Rh −ve packed red cells
Establish good i.v. lines and commence Arrest any external haemorrhage
infusion with saline or Ringer-lactate Reassess and continue if necessary with
group O Rh −ve blood until
Exsanguinated Yes matched blood available

No
Administer cross-matched packed
red cell, with supplements if required
Stable, Hb > 9g No
Give whole blood if bleeding continues
Surgery if required to control bleeding
Yes
Saline or
Ringer-
Urinary output ? Post renal cause, Yes lactate
No
e.g., ruptured urethra +
Surgery
No
Yes
Hypovolaemic,
? cardiac

CVP Low
Saline or Ringer-lactate,
up to 3 L/24 h
HIGH

? Mechanical No
from thoracic trauma

Yes
Stop fluid
resuscitation
Surgery with
Start
appropriate
pharmacological
fluid replacement
treatment

Fig 2.1: Flow chart summarising fluid replacement management

Assessing the response to replacement: There is varying opinion on

the best methods of assessing the stability of the circulation and the success
of resuscitation. In all, the degree and maintenance of a positive response
to treatment is more important than the reading of isolated values. Many
methods are advocated including the following:
1. Pulse and blood pressure. In spite of some unreliability, these remain the
most valuable guides. The initial aim should be to restore the pulse rate to less
than 140, and to obtain a blood pressure in excess of 90mm systolic and rising.
2. Urinary output. Aim at 0.5 ml/kg body weight per hour in an adult (i.e.
6 mL every 10 minutes in a 70 kilo man) and 1.0 ml/kg body weight in a
child (i.e. twice the rate per kg).
3. Central Venous Pressure (CVP). This allows the monitoring of atrial
filling pressures. (Normal value = less than 10 mmHg.)
4. Haemoglobin. If the Hb level reaches 10 g/dL and remains there,
further blood is not usually required. (Below 9 g/dL, blood will
usually be required, and virtually invariably below 7 g/dL. When the
Hb lies between 7 and 10 g/dL, and there is doubt, the PvO2 and ER
(see below) may be helpful in defining transfusion requirements).
In the absence of continuing bleeding, one unit of packed red blood
cells would be expected to raise the Hb level by 1 g/dL.
Less common investigations include:
5. Pulmonary artery pressure (PAP): A pulmonary artery catheter allows
the measurement of pulmonary artery pressure and has been particularly
advocated in the elderly patient. (Normal values: systolic 15–28 mmHg;
diastolic = 5–16 mmHg.)
6. Pulmonary capillary wedge pressure (PCWP): (Normal value, mean =
6–12 mmHg.)
36 FRACTURE TREATMENT – COMPLICATIONS OF BLOOD REPLACEMENT

7. Cardiac output: (Normal value = 4–7 L/min.)

8. Cardiac index (CI): This represents the circulating blood volume per
minute. (Normal value = 2.8–4.2 L/min.)
9. Systemic vascular resistance (SVR): (Normal value = 11–18 mmHg.)
10. Arterial-alveolar oxygen difference (AaDO2)
11. Peripheral/body core temperature difference (deltaT). This gives a
useful assessment of prolonged shock.
12. Mixed venous partial pressure of oxygen (PvO2): This is a guide to the
tissue oxygen supply and is normally 6 kPa, 45 mmHg. If the patient’s
condition is stable no treatment is indicated until a critical level of 3 kPa,
23 mmHg is reached.
13. Extraction ratio (ER): This is the ratio of oxygen consumption to
oxygen delivery, and normally is around 25%. It equals
CaO2−Cv O2
CaO2,
where CaO2 = arterial oxygen and CvO2 = venous oxygen.

COMPLICATIONS OF BLOOD REPLACEMENT

1. Hypocalcaemia. Transfused blood contains citrate which binds the
patient’s ionised calcium. Usually this is not a problem as the healthy liver can
metabolise (to bicarbonate) the citrate in one unit of blood in 5 minutes. Where
transfusion rates are rapid, however, excessive calcium binding may itself lead
to hypotension, and also to tetany. To avoid citrate toxicity it has been common
practice to give 1 g of calcium chloride (or 4 g calcium gluconate) for every 4
units of blood administered. It is recommended as better practice to avoid the
administration of calcium unless there are clinical or biochemical indications
(e.g. by the assessment of the ionised calcium levels).
2. Hyperkalaemia. This is not usually a problem unless very large
amounts of blood are transfused. It is more usual to find hypokalaemia as
the metabolic activity of the red cells begins and the tissues begin to take up
potassium. Attempts at correction are only indicated if the serum electrolytes
or the ECG are disturbed.
3. Acid/base disturbances. After large transfusions any residual
disturbance is dependent on the quality of tissue perfusion, the rate of
administration, and the effectiveness of citrate metabolism in the liver. The
need for correction is determined by regular serum sampling.
4. Defects of clotting. It has been suggested that 8 units of platelet
concentrate, and 2 units of fresh frozen plasma should be transfused
routinely with every 12 units of packed red blood cells (1 unit (50 mL) of
platelet concentrate should raise the platelet count by 10 000). Nevertheless,
during the administration of large replacements it is preferable that there
should be regular monitoring of the platelet count, prothrombin time, partial
prothromboplastin time, and fibrinogen levels, and appropriate replacements
given only where clearly indicated. (Fresh frozen plasma should be given if the
prothrombin or partial prothromboplastin exceed 1.5 times the control levels.
Cryoprecipitate (1–1.5 units) is given for fibrinogen levels less than 0.8 g/L.)
5. Transmission of disease. The risks of HIV and hepatitis B transmission
are small (said to be in the order of 1 in 200 000 in the US), but are higher
Exploring the Variety of Random
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persevering effort, he became embarrassed, in consequence, it is
affirmed, of prodigal housekeeping, and retired from the adventure
no richer than he commenced it.

‘... between twa and three hours in the morning,

the queen was delivered of ane young prince, Feb. 19.
within the Castle of Stirling, in his majesty’s
chalmer there; whilk was a great comfort to the haill people, moving
them till great triumph, wantonness, and play, for banefires were set
out, and dancing and playing usit, in all parts, as gif the people had
been daft for mirth.’—Moy.
The king had scarcely seen his wife out of the perils of childbirth,
when he was obliged to come to Edinburgh to take measures
against the Earl of Bothwell, who was now breaking out into open
rebellion. Fearing to live in Holyroodhouse, which had already been
twice broken into by the turbulent lord, he took up his quarters in
‘Robert Gourlay’s lodging’ within the city.
‘... being Sunday, his majesty came to Mr Robert
Bruce’s preaching, [who] said to his majesty, that Mar. 13.
God wald stir up mae Bothwells nor ane (that was,
mae enemies to him nor Bothwell), if he revengit not his, and faucht
not God’s quarrels and battles on the papists, before he faucht or
revenged his awn particular.’—Bir.
The king ‘came to the sermon, and there, in
presence of the haill people, promised to revenge 1594. Apr. 3.
God’s cause, and to banish all the papists; and
there requested the haill people to gang with him against Bothwell,
wha was in Leith for the time. The same day, the king’s majesty
rase, and the town of Edinburgh in arms. The Earl of Bothwell,
hearing that his majesty was coming down, with the town of
Edinburgh, rase with his five hundred horse, and rode up to the
Hawk-hill, beside Lesterrick [Restalrig], and there stood till he saw
the king and the town of Edinburgh approaching near him. He drew
his company away through Duddingston. My Lord Home followed till
the Woomet, at whilk place the Earl of Bothwell turned, thinking to
have a hit at Home; but Home fled, and he followed; yet by chance
little blood. The king’s majesty stood himself, seeing the said chase’
[at a safe distance, namely, on the Burgh-moor].—Bir.
Within a few days after this affair, the earl, seeing
he could not effect his object, retired into England. 1594. May.
Soon after, much to the scandal of the preachers,
he joined the papist lords. All his plans, however, were frustrated;
and early in the next year, he left Scotland, an utterly broken man,
never again to give his royal cousin any trouble.
Kenneth Mackenzie of Kintail was rising to be a wealthy and
influential man in the west of Inverness-shire. Beginning as simple
chief of the Clan Kenzie, with a moderate estate, he ended as a peer
of the realm and the lord of great possessions. A remarkable notice
regarding him occurs at this time in the Privy Council Record, and it
is the more so, as he had been for some time a member of that
body. It is recited that he had, some time before, purchased a
commission of justiciary from the king, for a district including the
lands of certain neighbours, besides his own, and conferring the
power of proceeding against persons accused of treasonable fire-
raising. This was declared to have been given on wrong
representations, and to be contrary to the laws of the kingdom, and
Kenneth was commanded to appear by a certain day before the
Council, and meanwhile abstain from acting upon the commission.—
p. c. r.

As a specimen of how nobles possessing castles

acted towards meaner men who had fallen under July 4.
their displeasure—James, Lord Hay of Yester, was
charged before the Privy Council with having, on the ... day of June
previous, gone to the house of ... Brown of Frosthill, and taken him
forth thereof, and carried him to his ‘place of Neidpath,’ where ‘he
put him in the pit thereof, and detenes him as captive, he being his
majesty’s free subject ... having committit nae crime nor offence,
and the said lord having nae power nor commission to tak him.’ The
king had granted letters charging Lord Yester to liberate Brown, and
that they should both come before him; and this had been of none
effect. The matter being now before the Council, and a procurator
having appeared for Brown to explain that he was still a prisoner at
Neidpath, while Lord Yester made no appearance, officers were
charged to go and denounce the latter as a rebel if he should refuse
to obey the king’s command, Brown having meanwhile given surety
to the extent of two hundred pounds that he should be ready to
answer any accusation that might be brought against him.—P. C. R.

Robert Logan of Restalrig is one of the darkest

characters of this bloody and turbulent time. A few 1594. July.
years later, he was plotting with the Ruthvens of
Gowrie for an assault upon the king. So early as February 1592-3, he
was denounced for trafficking with the turbulent Bothwell. In June of
this year, he was again denounced, and for a more serious matter—
his sending out two servants, Jockie Houlden and Peter Craik, to rob
travellers on the highway, near his house of Fast Castle in
Berwickshire. They had attacked Robert Gray, burgess of Edinburgh,
as he was passing the Boundrod, near Berwick, and taken from him
nine hundred and fifty pounds, besides battering him to the peril of
his life.—P. C. R. His residence, as is well known, was a fortalice
perched on an almost inaccessible crag overhanging the waves of
the sea, with black cliffs above, below, and nearly all round—
perhaps the most romantically situated house in our ancient
kingdom. Here, it is known, Logan had Bothwell for his occasional
guest.
In July of this year, Logan entered into a contract with John Napier
of Merchiston, proceeding upon the fact of ‘diverse auld reports,
motives, and appearances, that there should be within the said
Robert’s dwelling-place of Fast Castle a sowm of money and pose,
hid and huirdit up secretly.’ John Napier undertook that he ‘sall do
his utter and exact diligence to search and seek out, and be all craft
and ingyne that he dow [can], to tempt, try, and find out the same,
and, be the grace of God, either sall find out the same, or than mak
sure that nae sic thing has been there.’ For this he was to have a
third of any money found. He was also to be convoyed back in safety
to Edinburgh, unspoiled of his gains.
As Logan was competent to make simple mechanical search for the
supposed treasure without the aid of a philosopher, there is much
reason to believe that Napier designed to use some pseudo-scientific
mode or modes of investigation, such as the divining-rod, or the so-
called magic numbers. The affair, therefore, throws a curious light on
the state of philosophy even in the minds of the ablest philosophers
of that age, the time when Tycho kept an idiot on account of his gift
of prophecy, and Kepler perplexed himself with the Harmonices
Mundi.
It is not known whether Napier did actually journey to the spray-
beaten tower of Fast Castle, and there practise his craft and ingyne.
Probably he did, and was disappointed in more ways than one, as,
two years after, he is found letting a portion of his property to a
gentleman on the strict condition that no part of it shall be sub-let to
any one of the name of Logan.200

‘This year, in the Merse, there was a great business

about sorcery and the trial of witches, and many 1594.
was there burnt, as, namely, one Roughhead, and
Cuthbert Hume’s mother of Dunse, the parson of Dunse’s wife, and
sundry of Eyemouth and Coldingham; near a dozen moe, and many
fugitives, as the old Lady A. Sundry others were delated, and the
Ladies of Butt: and Lady B.: the Laird of B.: his sister; one in
Liddesdale by virtue of [a] superstitious well, whereat was professed
great skill; one Dick’s sister, who had her mother hanged before in
Waughton. They confessed the death of the whole goods [live-stock]
of the country.’—Pa. And.

The disposition to violent and lawless acts at this

time is strikingly shewn in the proceedings against Nov.
Claud and Alexander, two sons of James Hamilton
of Livingstone, in Linlithgowshire. Having some ground of offence
against David Dundas of Priestinch, they had gone at mid-day with
an armed party to his fold, and, there barbarously mutilated and
slaughtered a number of his cattle. They and their elder brother,
Patrick, also destroyed a mill leased by the same person, and further
set fire to his barn-yard at Duddington. Two months afterwards,
when John Yellowlees, a messenger, went with two assistants to the
Peel of Livingstone, to deliver letters of citation against these young
men, the laird, with his wife and four sons, came forth to the gate,
and taking him first by the throat, proceeded to beat him
unmercifully, and then, with a bended pistol at his breast, and many
violent threats, forced him to eat and swallow his four letters, and to
promise never to attempt to bring any such documents against them
in future; besides which, they struck the two witnesses with swords
and pistols, and left them for dead. The family were denounced as
rebels.—Pit.
A great tulyie or street-combat this day took place
in Edinburgh. 1594-5. Jan. 19.

The Earl of Montrose, head of the house of

Graham, was of grave years—towards fifty: he was 1594-5.
of such a character as to be chosen, a few years
afterwards, as chancellor of the kingdom: still later, he became for a
time viceroy of Scotland, the king being then in England. Yet this
astute noble was so entirely under the sway of the feelings of the
age, as to deem it necessary and proper that he should revenge the
death of John Graham (see under February 13, 1592-3) upon its
author, under circumstances similar to those which attended that
slaughter. On its being known that the earl was coming with his son
and retinue to Edinburgh, Sandilands was strongly recommended by
some of his friends to withdraw from the town, ‘because the earl
was then over great a party against him. His mind was,
notwithstanding, sae undantonit, and unmindful of his former
misdeed, finding himself not sae weel accompanied as he wald, he
sent for friends, and convokit them to Edinburgh, upon plain purpose
rather first to invade the said earl than to be invadit by him, and
took the opportunity baith of time and place within Edinburgh, and
made a furious onset on the earl [at the Salt Tron in the High
Street], with guns and swords in great number.201 The earl, with his
eldest son, defendit manfully, till at last Sir James was dung [driven
down] on his back, shot and hurt in divers parts of his body and
head, [and] straitly invadit to have been slain out of hand, gif he had
not been fortunately succoured by the prowess of a gentleman callit
Captain Lockhart. The lord chancellor and Montrose were together at
that time; but neither reverence [n]or respect was had unto him at
this conflict, the fury was sae great on either side; sae that the
chancellor retirit himself with gladness to the College of Justice. The
magistrates of the town, with fencible weapons, separatit the parties
for that time; and the greatest skaith Sir James gat on his party, for
he himself was left for dead, and a cousin-german of his, callit
Crawford of Kerse, was slain, and mony hurt: but Sir James
convalescit again, and this recompense he obteinit for his arrogancy.
On the earl’s side was but ane slain, and mony hurt.’—H. K. J.

Hercules Stewart was hanged at the Cross in

Edinburgh, for his concern in the crimes of his Feb. 18.
brother the Earl of Bothwell. The people lamented his fate, for ‘he
was ane simple gentleman, and not ane enterpriser.’—Moy. He ‘was
suddenly cut down and carried up to the Tolbooth to be dressed; but
within a little space he began to recover and move somewhat, and
might by appearance have lived. The ministers, being advertised
hereof, went to the king to procure for his life; but they had already
given a new command to strangle him with all speed, so that no
man durst speak in the contrary.’—Pa. And.

Commenced ‘ane horrible tempest of snaw, whilk

lay upon the ground till the 14[th] of April Mar. 10. 1595.
thereafter.’—Bir. May 26.

‘John Gilchrist, Henderson, and Hutton, all three [were] hangit for
making of false writs and pressing to verify the same. Jun. 11. Ane
callit Cuming the Monk [was] hangit for making of false writs.’—Bir.

Two gentlemen of Stirlingshire, one named Bruce,

the other Forester, happened to love one woman, July.
about whom they and their respective friends
consequently quarrelled. At a meeting held by the July 12.
parties with a view to composing differences,
Bruce was hurt. Then the ‘clannit men’ of the names of Livingstone
and Bruce in the Carse of Falkirk banded themselves together for
revenge. A bailie of Stirling, named Forester, who had had no
concern in the dispute, was soon after about to journey from
Edinburgh to Stirling, when the friends of the deceased ‘belaid all
the hieways for his return.’ Before he had gone many miles, they set
upon him, and with sword and gun slew him. The most remarkable
part of the affair was what followed. Forester being a special servant
of the Earl of Mar, it was resolved that he should be buried with
solemnity in Stirling. The corpse was met at Linlithgow by the earl
and a large party of friends, with displayed banner, and in ‘effeir of
weir.’ On their journey to Stirling, they passed through the lands of
Livingstone and Bruce, exhibiting ‘a picture of the defunct on a fair
canvas, painted with the number of the shots and wounds, to
appear the more horrible to the behalders, and this way they
completed his burial.’202—H. K. J.
Another curious circumstance followed. The parties involved in the
homicide had a day of law appointed for them in Edinburgh,
December 20th, and they, in customary style, summoned their
respective friends to be present. A great attendance was expected;
but the Privy Council, knowing there was deadly feid between a
great number of them, ‘feirit that, upon the first occasion of their
meeting, some great inconvenients sall fall out, to the break of his
hieness’ peace, and troubling of the guid and quiet estate of the
country[!], beside the hindering of justice,’ forbade the coming of
such persons to Edinburgh under pain of ‘deid without favour.’—P. C.
R.

Complaint was made to the Town Council of

Edinburgh by the corporation of surgeons, against Aug. 1.
M. Awin, a French surgeon, for practising his art
within the liberties of the city. He was ordered to 1595.
desist, under a penalty, except for certain branches
of surgery—namely, cutting for the stone, curing of ruptures,
couching of cataracts, curing the pestilence, and diseases of women
consequent on childbirth.203

The violences of the age extended even to school-boys. The

‘scholars and gentlemen’s sons’ of the High School of Edinburgh had
at this time occasion to complain of some
abridgment of their wonted period of vacation, and Sep.
when they applied to the Town Council for an
extension of what they called their ‘privilege,’ only Sep. 13.
three days in addition to the restricted number of
fourteen were granted. It appears that the master was favourable to
their suit, but he was ‘borne down and abused by the Council, who
never understood well what privilege belonged to that charge. Some
of the chief gentlemen’s sons resolved to make a mutiny, and one
day, the master being on necessary business a mile or two off the
town, they came in the evening with all necessary provision, and
entered the school, manned the same, took in with them some
fencible weapons, with powder and bullet, and renforcit the doors,
refusing to let [any] man come there, either master or magistrate,
untill their privilege were fairly granted.’—Pa. And.
A night passed over. Next morning, ‘some men of the town came to
these scholars, desiring them to give over, and to come forth upon
composition; affirming that they should intercede to obtein them the
license of other eight days’ playing. But the scholars replied that
they were mocked of the first eight days’ privilege ... they wald
either have the residue of the days granted for their pastime, or else
they wald not give over. This answer was consulted upon by the
magistrates, and notified to the ministers; and the ministers gave
their counsel that they should be letten alone, and some men should
be depute to attend about the house to keep them from vivres, sae
that they should be compelled to render by extremity of hunger.’—H.
K. J.
A day having passed in this manner, the Council
lost patience, and determined to use strong 1595.
measures. Headed by Bailie John Macmoran, and
attended by a posse of officers, they came to the school, which was
a long, low building standing on the site of the ancient Blackfriars’
monastery. The bailie at first called on the boys in a peaceable
manner to open the doors. They refused, and asked for their master,
protesting they would acknowledge him at his return, but no other
person. ‘The bailies began to be angry, and called for a great jeist to
prize up the back-door. The scholars bade them beware, and wished
them to desist and leave off that violence, or else they vowed to God
they should put a pair of bullets through the best of their cheeks.
The bailies, believing they durst not shoot, continued still to prize
the door, boasting with many threatening words. The scholars
perceiving nothing but extremity, one Sinclair the chancellor of
Caithness’ son, presented a gun from a window, direct opposite to
the bailies’ faces, boasting them and calling them buttery carles. Off
goeth the charged gun. [The bullet] pierced John Macmoran through
his head, and presently killed him, so that he fell backward straight
to the ground, without speech at all.’204
‘When the scholars heard of this mischance, they were all moved to
clamour, and gave over. Certain of them escaped, and the rest were
carried to prison by the magistrates in great fury, and escaped weel
unslain at that instant. Upon the morn, the said Sinclair was brought
to the bar, and was there accused of that slaughter; but he denied
the same constantly. Divers honest friends convenit, and assisted
him.’205 The relatives of Macmoran being rich, money-offers were of
no avail in the case: life for life was what they sought for. ‘Friends
threatened death to all the people of Edinburgh(!) if they did the
child any harm, saying they were not wise that meddled with the
scholars, especially the gentlemen’s sons. They should have
committed that charge to the master, who knew best the truest
remedy without any harm at all.’
Lord Sinclair, as head of the family to which the
young culprit belonged, now came forward in his 1595.
behalf, and, by his intercession, the king wrote to
the magistrates, desiring them to delay proceedings. Afterwards, the
process was transferred to the Privy Council. Meanwhile, the other
youths, seven in number, the chief of whom were a son of Murray of
Spainyiedale and a son of Pringle of Whitebank, were kept in
confinement upwards of two months, while a debate took place
between the magistrates and the friends of the culprits as to a fair
assize; it being alleged that one composed of citizens would be
partial against the boys. The king commanded that an assize of
gentlemen should be chosen, and, in the end, they, as well as
Sinclair, got clear off.
The culprit became Sir William Sinclair of Mey. He married Catherine
Ross of Balnagowan, whom we have seen unpleasantly mixed up in
the charges against Lady Foulis, under July 22, 1590.
 Bailie Macmoran’s House.
‘Macmoran,’ says Calderwood, ‘was the richest
1595.
merchant in his time, but not gracious to the
common people, because he carried victual to Spain,
notwithstanding he was often admonished by the ministers to
refrain.’ It would appear that he had been a servant of the Regent
Morton, and afterwards was what is called a messenger, or sheriff’s
officer.206 We have also seen that, after the fall of Morton, he was
reported to have been concerned in secreting the treasures which
had been accumulated by his former master.207 His house, still
standing in Riddell’s Close in the Lawnmarket, Edinburgh, gives the
idea that the style of living of a rich Scottish merchant of that day
was far from being mean or despicable.

‘Among the constancies of the court this year, one

was remarkable, that at Glasgow, in September, Sep. 22.
the king received the Countess of Bothwell into his
favour, the 22d day, at night; and on the 3d of December, again
proscribed and exiled her, under the pain of death; yet gave her a
letter of protection, under his awn hand, within six days thereafter.’—
Bal.
This inconstancy is partly explained away in the Privy Council
Record, where it is stated that the countess abused the privilege of
the letter granted to her by going about where she pleased and
vaunting of her credit with the king, while in reality it was designed
only to serve ‘for remaining of herself and her bairns within the
place of Mostour, that her friends might sometime have resorted to
her without danger to his hieness’s laws.’

James Lord Hay of Yester, brother and successor of

the turbulent Master of Yester already introduced Oct.
to the reader, kept state in Neidpath Castle, with
his wife, but as yet unblessed with progeny.208 His presumptive heir
was his second-cousin, Hay of Smithfield, ancestor of the present Sir
Adam Hay of Haystoun. In these circumstances, occasion was given
for a curious series of proceedings, involving the fighting of a regular
passage of arms on a neighbouring plain beside the Tweed—a
simple pastoral scene, where few could now dream that any such
incident had ever taken place.
Lord Yester had for his page one George Hepburn,
brother of the parson of Oldhamstocks in East 1595.
Lothian. His master-of-the-horse—for such officers
were then retained in houses of this rank—was John Brown of
Hartree. One day, Brown, in conversation with Hepburn, remarked:
‘Your father had good knowledge of physic: I think you should have
some also.’ ‘What mean ye by that?’ said Hepburn. ‘You might have
great advantage by something,’ answered Brown. On being further
questioned, the latter stated that, seeing Lord Yester had no
children, and Hay of Smithfield came next in the entail, it was only
necessary to give the former a suitable dose in order to make the
latter Lord Yester. ‘If you,’ continued Brown, ‘could give him some
poison, you should be nobly rewarded, you and yours.’ ‘Methinks
that were no good physic,’ quoth Hepburn drily, and soon after
revealed the project to his lord. Brown, on being taxed with it, stood
stoutly on his denial. Hepburn as strongly insisted that the proposal
had been made to him. For such a case, there was no solution but
the duellium.
Due authority being obtained, a regular and public combat was
arranged to take place on Edston-haugh, near Neidpath. The two
combatants were to fight in their doublets, mounted, with spears
and swords. Some of the greatest men of the country took part in
the affair, and honoured it with their presence. The Laird of
Buccleuch appeared as judge for Brown; Hepburn had, on his part,
the Laird of Cessford. The Lords Yester and Newbottle were amongst
those officiating. When all was ready, the two combatants rode full
tilt against each other with their spears, when Brown missed
Hepburn, and was thrown from his horse with his adversary’s
weapon through his body. Having grazed his thigh in the charge,
Hepburn did not immediately follow up his advantage, but suffered
Brown to lie unharmed on the ground. ‘Fy!’ cried one of the judges,
‘alight and take amends of thy enemy!’ He then advanced on foot
with his sword in his hand to Brown, and commanded him to confess
the truth. ‘Stay,’ cried Brown, ‘till I draw the broken spear out of my
body.’ This being done, Brown suddenly drew his sword, and struck
at Hepburn, who for some time was content to ward off his strokes,
but at last dealt him a backward wipe across the face, when the
wretched man, blinded with blood, fell to the ground. The judges
then interfered to prevent him from being further punished by
Hepburn; but he resolutely refused to make any confession.209

About this time and for some time onward,

Scotland underwent the pangs of a dearth of 1595.
extraordinary severity, in consequence of the
destruction of the crops by heavy rains in autumn. Birrel speaks of it
as a famine, ‘the like whereof was never heard tell of in any age
before, nor ever read of since the world was made.’ ‘In this month of
October and November,’ he adds, ‘the wheat and malt at £10 the
boll; in March thereafter [1596], the ait meal £10 the boll, the
humble corn £7 the boll. In the month of May, the ait meal £20 the
boll in Galloway. At this time there came victual out of other parts in
sic abundance, that, betwixt the 1st of July and the 10th of August,
there came into Leith three score and six ships laden with victual;
nevertheless, the rye gave £10, 10s. and £11 the boll. The 2 of
September, the rye came down and was sold for £7 the boll, and
new ait meal for 7s. and 7s. 6d. the peck The 29 of October, the ait
meal came up again at 10s. the peck. The 15 of July, the ait meal at
13s. 4d. the peck; the pease meal at 11s. the peck.
‘In this year, Clement Orr and Robert Lumsden, his grandson, bought
before hand from the Earl Marischal, the bear meal overhead for
33s. 4d. the boll.’ ‘The ministers pronounced the curse of God
against them, as grinders of the faces of the poor; which curse too
manifestly lighted on them before their deaths.’—Bal.
As usual, the buying up and withholding of grain with the prospect
of increased prices, was viewed with indignation by all classes of
people. The king issued a proclamation in December 1595,
attributing much of the misery of his people to ‘the avaritious
greediness of a great number of persons that has bought and buys
victual afore it come off the grund, and that forestalls and keeps the
same to a dearth,’ and to ‘the shameless and indiscreet behaviour of
the owners of the same victual, wha refuses to thresh out and bring
the same to open markets.’ He threatened to put the laws in force
against these guilty persons, and have the grain escheat to his
majesty’s use.

The king professed to be at this time scandalised

at the state of the commonweal, ‘altogether Dec. 23.
disorderit and shaken louss by reason of the deidly
feids and controversies standing amangs his 1595.
subjects of all degrees.’ Seeing how murder had
consequently become a daily occurrence, he resolved upon a new
and vigorous effort to bring the hostile parties to a reconciliation ‘by
his awn pains and travel to that effect,’ so that the country might be
the better fitted to resist the common enemy, now threatening
invasion. The Privy Council, therefore, ordained letters to be sent
charging the various parties to make their appearance before the
king on certain days, wherever he might be for the time, each
accompanied by a certain number of friends who might assist with
their advice, but the whole party in each case ‘to keep their lodgings
after their coming, while [till] they be specially sent for by his
majesty.’
The groups of persons summoned were, Robert Master of Eglintoun,
and Patrick Houston of that Ilk; James Earl of Glencairn, and
Cunningham of Glengarnock; John Earl of Montrose, and French of
Thorniedykes; Hugh Campbell of Loudon, sheriff of Ayr, Sandielands
of Calder, Sir James Sandielands of Slamannan, Crawford of Kerse,
and Spottiswoode of that Ilk; David Earl of Crawford and Guthrie of
that Ilk; Sir Thomas Lyon of Auldbar, knight, and Garden of that Ilk;
Alexander Lord Livingston, Sir Alexander Bruce, elder, of Airth, and
Archibald Colquhoun of Luss; John Earl of Mar, Alexander Forester of
Garden, and Andro M‘Farlane of Arrochar; James Lord Borthwick,
Preston of Craigmiller, Mr George Lauder of Bass, and Charles Lauder
son of umwhile Andro Lauder in Wyndpark; Sir John Edmonston of
that Ilk, Maister William Cranston, younger, of that Ilk; George Earl
Marischal and Seyton of Meldrum; James Cheyne of Straloch and
William King of Barrach; James Tweedie of Drumelzier and Charles
Geddes of Rachan. The nobles in every instance were allowed to
have sixty, and the commoners twenty-four persons to accompany
them to the place of agreement, and all, while attending, to have
protection from any process of horning or excommunication which
might have been previously passed upon them. Fire and sword was
threatened against all neglecting to comply with the summons.
Earnest as the king seems now to have been, and influential as a
royal tongue proverbially is, we know for certain that several of the
parties now summoned continued afterwards at enmity.

‘The king made ane orison before the General

Assembly, with many guid promises and 1595-6. Mar.
conditions. I pray God he may keep them, be 15.
content to receive admonitions [from the clergy], 1595-6.
and be collected himself and his haill household, and to lay aside his
authority royal and be as ane brother to them, and to see all the
kirks in this country weel planted with ministers. There are in
Scotland 900 kirks, of the whilk there are 400 without ministers or
readers.’—Bir.
The admonitions which it was so desirable that the king should
receive, were embodied in a paper called Offences in the King’s
House, under the following heads: ‘1. The reading of the Word, and
thanksgiving before and after meat, oft omitted. 2. Week-sermons
oft neglected, and he would be admonished not to talk with any in
time of divine service. 3. To recommend to him private meditation
with God in spirit and in his awn conscience. 4. Banning and
swearing is too common in the king’s house and court, occasioned
by his example. 5. He would have good company about him:
Robertland, papists, murderers, profane persons, would be removed
from him. 6. The queen’s ministry would be reformed. She herself
neglects Word and sacrament, is to be admonished for night-waking,
balling, &c., also touching her company—and so of her
gentlewomen.’—Row.
On the other hand, the king demanded of this assembly sundry
concessions as to his power over the kirk, and that ministers should
not be allowed to meddle with civil affairs or ‘to name any man in
the pulpit, or so vively to describe him as it shall be equivalent to the
very naming of him, except upon the notoriety of a public crime.’
On this occasion the clergy denounced the
common corruption of all estates within this realm; 1595-6.
namely, ‘an universal coldness, want of zeal,
ignorance, contempt of the Word, ministry, and sacraments, and
where knowledge is, yet no sense nor feeling, evidenced by the
want of family exercises, prayer, and the Word, and singing of
psalms; and if they be, they are profaned and abused, by calling on
the cook, steward, or jackman to perform that religious duty ...
superstition and idolatry entertained, evidenced in keeping of
festival-days, fires, pilgrimages, singing of carols at Yule, &c. ...
swearing, banning, and cursing: profanation of the Sabbath,
especially by working in seed-time and harvest, journeying, trysting,
gaming, dancing, drinking, fishing, killing, and milling: inferiors not
doing duty to superiors, children having pleas of law against their
parents, marrying without their consent; superiors not doing duty to
inferiors, as not training up their children at schools in virtue and
godliness; great and frequent breaches of duty between married
persons: great bloodshed, deadly feuds arising thence, and assisting
of bloodshedders for eluding of the laws: fornications, adulteries,
incests, unlawful marriages and divorcements, allowed by laws and
judges ... excessive drinking and waughting, gluttony (no doubt the
cause of this dearth and famine), gorgeous and vain apparel, filthy
speeches and songs: cruel oppressions of poor tenants ... idle
persons having no lawful callings—as pipers, fiddlers, songsters,
sorners, pleasants, strong and sturdy beggars living in harlotry....
Lying, finally, is a rife and common sin.’

Sir Walter Scott of Branxholm, Laird of Buccleuch,

performed an exploit which has been celebrated 1596. Apr. 12.
both in prose and rhyme.
About the end of January, a ‘day of truce’ was held at a spot called
Dayholm of Kershope in Liddesdale, by the deputies of the English
warden, Lord Scrope, and the Laird of Buccleuch, keeper of
Liddesdale. The Scotch deputy, Scott of Goldielands, had but a small
party—not above twenty—among whom, however, was a noted
border reiver, William Armstrong of Kinmont, commonly known as
Kinmont Willie. The English deputy was attended by several hundred
followers. It happened that, before the end of the meeting, a report
came to the English deputy of some outrages at that moment in the
course of being committed by Scottish borderers within the English
line. He entered a complaint on the subject, and received assurance
that the guilty parties should be as soon as possible rendered up to
the vengeance of Lord Scrope.
The day of truce ended peaceably; but, as the English party was
retiring along their side of the Liddel, they caught sight of the
Scottish reivers, and gave chase. Kinmont Willie was now riding
quietly along the Scottish side of the Liddel. Mistaking him for one of
the guilty troop, the English pursued him for three or four miles, and
taking him prisoner, bore him off to Carlisle Castle.
Probably the Liddesdale thief had incurred more guilt in England
than ten lives would have expiated. Yet what was this to Buccleuch?
To him the case was simply that of a retainer betrayed while on his
master’s business and assurance. If the affair had a public or
national aspect, it was that of a Scottishman mistreated, to the
dishonour of his sovereign and country. Having in vain used
remonstrances with Lord Scrope, both by himself and through the
king’s representations to the English ambassador, he resolved at last,
as himself has expressed it, ‘to attempt the simple recovery of the
prisoner in sae moderate ane fashion as was possible to him.’
Buccleuch’s moderate proceeding consisted in the
assembling of two hundred armed and mounted 1596.
retainers at the tower of Morton, an hour before
sunset of the 12th of April. He had arranged that no head of any
house should be of the number, but all younger brothers, that the
consequences might be the less likely to damage his following; but,
nevertheless, three lairds had insisted on taking part in the
enterprise. Passing silently across the border, they came to Carlisle
about the middle of the night. A select party of eighty then made an
attempt to scale the walls of the castle; but their ladders proving too
short, it was found necessary to break in by force through a postern
on the west side. Two dozen men having got in, six were left to
guard the passage, while the remaining eighteen passed on to
Willie’s chamber, broke it up, and released the prisoner. All this was
done without encountering any resistance except from a few
watchmen, who were easily ‘dung on their backs.’210 As a signal of
their success, the party within the castle sounded their trumpet
‘mightily.’ Hearing this, Buccleuch raised a loud clamour amongst his
horsemen on the green. At the same time, the bell of the castle
began to sound, a beacon-fire was kindled on the top of the house,
the great bell of the cathedral was rung in correspondence, the
watch-bell of the Moot-hall joined the throng of sounds, and, to
crown all, the drum began to rattle through the streets of the city.
‘The people were perturbit from their nocturnal sleep, then
undigestit at that untimeous hour, with some cloudy weather and
saft rain, whilk are noisome to the delicate persons of England,
whaise bodies are given to quietness, rest, and delicate feeding, and
consequently desirous of more sleep and repose in bed.’ Amidst the
uproar, ‘the assaulters brought forth their countryman, and convoyit
him to the court, where the Lord Scrope’s chalmer has a prospect
unto, to whom he cried with a loud voice a familiar guid-nicht! and
another guid-nicht to his constable Mr Saughell.’ The twenty-four
men returned with Kinmont Willie to the main body, and the whole
party retired without molestation, and re-entered Scotland with the
morning light. ‘The like of sic ane vassalage,’ says the diarist Birrel,
with unwonted enthusiasm, ‘was never done since the memory of
man, no, not in Wallace’ days!’ Buccleuch himself, with true heroism,
treated the matter calmly and even reasoningly. The simple recovery
of the prisoner, he said, ‘maun necessarily be esteimit lawful, gif the
taking and deteining of him be unlawful, as without all question it
was.’
The matter was brought before the king in council
(May 25) by the English ambassador, who pleaded 1596.
that Sir Walter Scott should be given up to the
queen for punishment. It was on this occasion that the border knight
defended himself in the terms above quoted. Of course his own
countrymen sympathised with him in a deed so gallant, and
performed from such a motive, and the king could not readily act in
a contrary strain. Elizabeth never obtained any satisfaction for the
taking of Kinmont Willie.—Spot. Moy. H. K. J. C. K. S. P. C. R. Bir.211

‘... there came an Englishman to Edinburgh, with a

chestain-coloured naig, which he called Marroco ... 1596 (?) Apr.
he made him to do many rare and uncouth tricks,
such as never horse was observed to do the like before in this land.
This man would borrow from twenty or thirty of the spectators a
piece of gold or silver, put all in a purse, and shuffle them together;
thereafter he would bid the horse give every gentleman his own
piece of money again. He would cause him tell by so many pats with
his foot how many shillings the piece of money was worth. He would
cause him lie down as dead. He would say to him: “I will sell you to
a carter:” then he would seem to die. Then he would say: “Marroco,
a gentleman hath borrowed you, and you must ride with a lady of
court.” Then would he most daintily hackney, amble, and ride a
pace, and trot, and play the jade at his command when his master
pleased. He would make him take a great draught of water as oft as
he liked to command him. By a sign given him, he would beck for
the King of Scots and for Queen Elizabeth, and when ye spoke of the
King of Spain, would both bite and strike at you—and many other
wonderful things. I was a spectator myself in those days. But the
report went afterwards that he devoured his master, because he was
thought to be a spirit and nought else.’—Pa. And.
This was ‘the dancing horse’ to which Moth alludes in Shakspeare
(Love’s Labour Lost, act I., sc. 2). The actual fate of Banks, the
keeper of the animal, was not better than that which vulgar rumour
assigned to him. It is almost an incredible, yet apparently well-
authenticated fact, that horse and man, after wandering through
various countries, were burnt together as magicians at Rome.
At this time, while the country was suffering from
famine, there was a renewing of the Covenant with 1596. May.
fasting and humiliation in St Andrews presbytery.
‘After this exercise,’ says James Melville, one of those chiefly
concerned in ordering it, ‘we wanted not a remarkable effect.’ ‘God
extraordinarily provided victuals out of all other countries, in sic
store and abundance as was never seen in this land before;’ without
which ‘thousands had died for hunger,’ ‘for,’ he goes on to say,
‘notwithstanding of the infinite number of bolls of victual that cam
hame from other parts, all the harvest quarter of that year, the meal
gave aucht, nine, and ten pounds the boll, and the malt eleven and
twal, and in the south and west parts many died.’

Napier, still brooding over the dangers from

popery, devised at this time certain inventions June 7. 1596.
which he thought would be useful for defending
the country in case of invasion. One was a mirror like that of
Archimedes, which should collect the beams of the sun, and reflect
them concentratedly in one ‘mathematical point,’ for the purpose of
burning the enemy’s ships. Another was a similar mirror to reflect
artificial fire. A third was a kind of shot for artillery, not to pass
lineally through an enemy’s host, destroying only those that stand in
its way, but which should ‘range abroad within the whole appointed
place, and not departing furth of the place till it had executed his
[its] whole strength, by destroying those that be within the bounds
of the said place.’ A fourth, the last, was a closed and fortified
carriage to bring harquebussiers into the midst of an enemy—a
superfluity, one would think, if there was any hopefulness in the
third of the series. ‘These inventions, besides devices of sailing
under the water, with divers other stratagems for harming of the
enemies, by the grace of God and work of expert craftsmen, I hope
to perform.’212 So wrote Napier at the date noted in the margin. Sir
Thomas Urquhart describes the third of the devices as calculated to
clear a field of four miles’ circumference of all living things above a
foot in height: by it, he said, the inventor could destroy 30,000
Turks, without the hazard of a single Christian. He adds that proof of
its powers was given on a large plain in Scotland, to the destruction
of a great many cattle and sheep—a particular that may be doubted.
‘When he was desired by a friend in his last illness to reveal the
contrivance, his answer was that, for the ruin and overthrow of man,
there were too many devices already framed, which if he could make
to be fewer, he would, with his might, endeavour to do; and that
therefore, seeing the malice and rancour rooted in the heart of
mankind will not suffer them to diminish, the number of them, by
any concert of his, should never be increased.’213

John, Master of Orkney, was tried for the alleged

crime of attempting to destroy the life of his June 24.
brother the Earl of Orkney, first by witchcraft, and
secondly by more direct means. The case broke down, and would
not be worthy of attention in this place, but for the nature of the
means taken to inculpate the accused. It appeared that the alleged
witchcraft stood upon the evidence of a confession wrung from a
woman called Alison Balfour, residing at Ireland, a village in Orkney,
who had been executed for that imaginary crime in December 1594.
The counsel for the Master shewed that, when this poor woman
made her ‘pretended confession,’ as it might well be called, she had
been kept forty-eight hours in the cashielaws—an instrument of
torture supposed to have consisted of an iron case for the leg, to
which fire was gradually applied, till it became insupportably painful.
At the same time, her husband, a man of ninety-one years of age,
her eldest son and daughter, were kept likewise under torture, ‘the
father being in the lang irons of fifty stane wecht,’ the son fixed in
the boots with fifty-seven strokes, and the daughter in the
pilniewinks, that they, ‘being sae tormented beside her, might move
her to make any confession for their relief.’ A like confession had
been extorted from Thomas Palpla, to the effect that he had
conspired with the Master to poison his brother, ‘he being kept in the
cashielaws eleven days and eleven nights, twice in the day by the
space of fourteen days callit [driven] in the boots, he being naked in
the meantime, and scourgit with tows [ropes] in sic sort that they
left neither flesh nor hide upon him; in the extremity of whilk torture
the said pretended confession had been drawn out of him.’ Both of
these witnesses had revoked their confessions, Alison Balfour doing
so solemnly on the Heading Hill of Kirkwall, when about to submit to
death for her own alleged crime, of which she at the same time
protested herself to be innocent. These are among the most painful
examples we anywhere find of the barbarous legal procedure of our
ancestors.—Pit.

One John Dickson, an Englishman, was tried for

uttering slanderous speeches against the king, Aug. 3. 1596.
calling him ‘ane bastard king,’ and saying ‘he was
not worthy to be obeyed.’ This it appeared he had done in a drunken
anger, when asked to veer his boat out of the way of the king’s
ordnance. He was adjudged to be hanged.—Pit. It is curious on this
and some other occasions to find that, while the king got so little
practical obedience, and the laws in general were so feebly enforced,
such a severe penalty was inflicted on acts of mere disrespect
towards majesty.
The court was at this time unable to keep silence
under the pelt of pasquils which it had brought Aug. 17.
upon itself. We have now a furious edict of Privy
Council against the writers and promulgators of ‘infamous libels,
buiks, ballats, pasquils, and cantels in prose and rhyme,’ which have
lately been set out, and especially against ‘ane maist treasonable
letter in form of a cockalane,214 craftily divulgat by certain malicious,
seditious, and unquiet spirits, uttering mony shameful and
contumelious speeches, full of hatrent and dispite, not only against
God, his servants and ministers, but maist unnaturally to the
prejudice of the honour, guid fame, and reputation of the king and
queen’s majesties, not sparing the prince their dearest son, besides
their nobility, council, and guid subjects.’ The only active redress,
however, was to proclaim a reward for the discovery of the
offenders.—P. C. R.

Since November 1585, when he was driven from

the king’s councils, James Stewart of Newton Nov. 3.
(sometime Earl of Arran) had lived in obscurity in
the north.215 Now that the Chancellor Maitland was dead, he formed
a hope that possibly some use might be found for him at court; he
therefore came to Edinburgh privately, and had an interview with the
king at Holyroodhouse. He received some encouragement; but as
nothing could be done for him immediately, and there were many
enemies to reconcile, he bethought him of going to live for a while
amongst his friends in Ayrshire, trusting erelong to be sent for.
The ex-favourite was travelling by Symington, in
the upper ward of Lanarkshire, when some one 1596.
who knew him gave him warning that he was
come into a dangerous neighbourhood, for not far from the way he
was about to pass dwelt a leading man of that house of Douglas
which he had mortally offended by his prosecution of the Regent
Morton. This was Sir James Douglas of Parkhead, whose father was
a natural brother of the regent: he was now the husband of the
heiress of the house of Carlyle of Torthorald, and a man of
consideration. Stewart replied disdainfully that he was travelling
where he had a right to be, and he would not go out of his way for
Parkhead nor any other of the house of Douglas. A mean person
who overheard this speech made off and reported it to Douglas,
who, on hearing it, rose from table, where he had been dining, and
vowed he would have the life of Stewart at all hazards. He
immediately mounted, and with three servants rode after his enemy
through a valley called the Catslack. When Stewart saw himself
pursued, he asked the name of the place, and being told, desired his
people to come on with all possible speed, for he had got a response
from some soothsayer to beware of that spot. Parkhead speedily
overtook him, struck him from his horse, and then mercilessly killed
him. Cutting off the head, he caused it to be carried by a servant on
the point of a spear, thus verifying another weird saying regarding
Stewart, that he should have the highest head in Scotland. His body
was left on the spot, to become the prey of dogs and swine.216
Thus perished an ex-chancellor of Scotland, one who had been
permitted for a time to treat the world as if it had only been made
for his own aggrandisement, who had governed a king, struck down
a regent, and made the greatest of the old nobility of the country
tremble. Violence, insolence, and cruelty had been the ruling
principles of his life, and, as Spottiswoode says, ‘he was paid home
in the end.’ No decided effort was made to execute justice upon his
slayer;217 but it will be afterwards found that the Ochiltree Stewarts
did not forget his death. (See under July 1608.)

An edict of the king against what he called

unlawful convocations of the clergy, had raised a Dec. 17. 1596.
general uneasiness and excitement, many
believing that all independent action of the clergy was struck at. The
prosecution of a minister named David Black, who had slandered the
king and queen in the pulpit, and refused to submit to a secular
tribunal, added to the turmoil. James had further raised a great
distrust regarding his fidelity to the Protestant religion by his
allowing the exiled papist lords to return to their own country. It was
at this crisis that the tumult long known in French fashion as the
Seventeenth of December took place.
‘... being Friday, his majesty being in the Tolbooth sitting in session,
and ane convention of ministers being in the New Kirk [a contiguous
section of St Giles’s Church], and some noblemen being convenit
with them, as in special Blantyre and Lindsay, there came in some
devilish officious person, and said that the ministers were coming to
take his life. Upon the whilk, the Tolbooth doors were steekit, and
there arase sic ane crying, “God and the king!” other some crying,
“God and the kirk!” that the haill commons of Edinburgh raise in
arms, and knew not wherefore always. There was ane honest man,
wha was deacon of deacons; his name was John Watt, smith. This
John Watt raisit the haill crafts in arms, and came to the Tolbooth,
where the entry is to the Chequer-house, and there cried for a sight
of his majesty, or else he sould ding up the yett with fore-hammers,
sae that never ane within the Tolbooth sould come out with their life.
At length his majesty lookit ower the window, and spake to the
commons, wha offerit to die and live with him. Sae his majesty came
down after the townsmen were commandit off the gait, and was
convoyit by the craftsmen to the abbey of Holyroodhouse.’—Bir.
The king either was really exasperated or
pretended to be so. Retiring to Linlithgow next 1596.
day, he sent orders to Edinburgh, discharging the
courts of justice from sitting there, commanding one minister to be
imprisoned and others to be put to the horn, and citing the
magistrates to come and answer for the seditious conduct of their
people. Great was the consternation thus produced, insomuch that
one Sunday passed without public worship—‘the like of which had
not been seen before.’ On the last day of the year, James returned,
to all appearance charged with the most alarming intentions against
the city. A proclamation was issued, commanding certain lords and
Border chiefs of noted loyalty to occupy certain ports and streets.
There consequently arose a rumour ‘that the king’s majesty should
send in Will Kinmont, the common thief, as should spulyie the town
of Edinburgh. Upon the whilk, the haill merchants took their haill geir
out of their booths and shops, and transportit the same to the
strongest house that was in the town, and remainit in the said house
with themselves, their servants, and looking for nothing but that
they should have all been spulyit. Siclike, the haill craftsmen and
commons convenit themselves, their best goods, as it were ten or
twelve households in ane, whilk was the strongest house, and might
be best keepit from spulying and burning, with hagbut, pistolet, and
other sic armour, as might best defend themselves. Judge, gentle
reader, gif this be playing! Thir noblemen and gentlemen, keepers of
the ports and Hie Gait, being set at the places foresaid, with pike
and spear, and other armour, stood keeping the foresaid places
appointit, till his majesty came to St Giles’s Kirk, Mr David Lindsay
making the sermon. His majesty made ane oration or harangue,
concerning the sedition of the seditious ministers, as it pleased him
to term them.’—Bir.
The affair ended three months after, in a way that supports the
opinion of the Laird of Dumbiedykes, that ‘it’s sad work, but siller will
help it.’ March 22d, ‘the town of Edinburgh was relaxed frae the
horn, and received into the king’s favour again, and the session
ordained to sit down in Edinburgh the 25th of May thereafter.’ Next
day, ‘the king drank in the council-house with the bailies, council,
and deacons. The said bailies and council convoyit his majesty to the
West Port thereafter. In the meantime of this drinking in the council-
house, the bells rang for joy of their agreement; the trumpets
sounded, the drums and whistles played, with [as] many other
instruments of music as might be played on; and the town of
Edinburgh, for the tumult-raising the 17 of December before, was
ordained to pay to his majesty thretty thousand merks Scottish.’—Bir.

John Mure, of Auchindrain, in Ayrshire, was a

gentleman of good means and connections, who 1596-7.
acted at one time in a judicial capacity as bailie of
Carrick, and gave general satisfaction by his judgments. He was son-
in-law to the Laird of Bargeny, one of the three chief men of the all-
powerful Ayrshire family of Kennedy. Sir Thomas Kennedy of
Colzean, another of these great men, was on bad terms with
Bargeny. Mure, who might naturally be expected to take his father-
in-law’s side, was for a time restrained by some practical benefits, in
the shape of lands, offered to him by Sir Thomas; but the titles to
the lands not being ultimately made good, the Laird of Auchindrain
conceived only the more furious hatred against the knight of
Colzean. This happened about 1595, and it appears at the same
time that Sir Thomas had excited a deadly rage in the bosom of the
Earl of Cassillis’s next brother, usually called the Master of Cassillis.
The Master and Auchindrain, with another called the Laird of
Dunduff, easily came to an understanding with each other, and
agreed to slay Sir Thomas Kennedy the first opportunity. Such was
the manner of conducting a quarrel about land-rights and despiteful
words amongst gentlemen in Ayrshire in those days.
On the evening of the 1st of January, Sir Thomas
Kennedy supped with Sir Thomas Nisbet in the Jan. 1.
house of the latter at Maybole. The Lairds of
Auchindrain and Dunduff, with a few servants, lay in wait for him in
the yard, and when he came forth to go to his own house to bed,
they fired their pistols at him. ‘He being safe of any hurt therewith,
and perceiving them with their swords most cruelly to pursue his life,
... was forced for his safety to fly; in which chase they did approach
him so near, as he had undoubtedly been overta’en and killed, if he
had not adventured to run aside and cover himself with the ruins of
ane decayed house; whilk, in respect of the darkness of the night,
they did not perceive; but still followed to his lodging, and searched
all the corners thereof, till the confluence of the people ... forced
them to retire.’218
For this assault, Sir Thomas Kennedy pursued at law the Lairds of
Auchindrain and Dunduff, and was so far successful that Dunduff
had to retire into England, while ‘Colzean gat the house of
Auchindrain, and destroyit the ... plenishing, and wrackit all the