he maximum tenderness is over the
injury to the bone.

The effusion of blood and synovia into the joint and into the tissues
around gives rise to swelling and discoloration, and the fluid effused
into tendon sheaths often produces a peculiar creaking sensation,
which may be mistaken for the crepitus of fracture. In sprains, the
bony points about the joint retain their normal relations to one
another, and this usually enables these injuries to be diagnosed from
dislocations. When the swelling is great, it is often necessary to
have recourse to the Roentgen rays to make certain that there is no
fracture or dislocation. The special features and complications of
sprains of the knee are discussed with other injuries of that joint.

_Repair of Sprains._--Blood and synovia are absorbed and torn
structures become reunited, but in this process adhesions may form
inside the joint and in the surrounding tendon sheaths and interfere
with the movement of the joint.

_Prognosis._--Stiffness, lasting for a longer or shorter time, follows
most sprains, but may be largely prevented by proper treatment. In old
and rheumatic persons, changes of the nature of arthritis deformans
are liable to supervene, interfering greatly with movement. While
suppuration is rare, tuberculous disease is alleged to have resulted
from a sprain.

_Treatment._--If seen immediately after the accident, firm pressure
should be applied by means of an elastic bandage over a thick layer of
cotton wool, to prevent bleeding and effusion of synovia. Later the
best treatment is by massage and movement. In the ankle, for example,
massage should be commenced at once, the part being gently stroked
upwards. If the massage is light enough there is no pain, it is
actually soothing. The rubbing is continued for from fifteen to twenty
minutes, and the patient is encouraged to move the toes and ankle; a
moderately firm elastic bandage is then applied. The massage is
repeated once or twice a day, the sittings lasting for about fifteen
minutes. The patient should be encouraged to move the joint from the
first, beginning with the movements that put least strain upon the
damaged ligaments, and gradually increasing the range. In the course
of a few days he is encouraged to walk or cycle, or otherwise to use
the joint without subjecting it to strain, or to a repetition of the
movement that caused the accident. Alternate hot and cold douching, or
hot-air baths, followed by massage