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Orthopaedic
Examination, Evaluation,
and Intervention
Second Edition
 NOTICE
Medicine is an ever-changing science. As new research and clinical experience
broaden our knowledge, changes in treatment and drug therapy are required. The
authors and the publisher of this work have checked with sources believed to be
reliable in their efforts to provide information that is complete and generally in
accord with the standards accepted at the time of publication. However, in view of
the possibility of human error or changes in medical sciences, neither the authors
nor the publisher nor any other party who has been involved in the preparation or
publication of this work warrants that the information contained herein is in every
respect accurate or complete, and they disclaim all responsibility for any errors
or omissions or for the results obtained from use of the information contained in
this work. Readers are encouraged to confirm the information contained herein
with other sources. For example and in particular, readers are advised to check the
product information sheet included in the package of each drug they plan to admin-
ister to be certain that the information contained in this work is accurate and that
changes have not been made in the recommended dose or in the contraindications
for administration. This recommendation is of particular importance in connection
with new or infrequently used drugs.
Orthopaedic
Examination, Evaluation,
and Intervention
Second Edition
Mark Dutton, PT
Allegheny General Hospital
West Penn Allegheny Health System (WPAHS)
Adjunct Clinical Instructor, Duquesne University
School of Health Sciences
Pittsburgh, Pennsylvania

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 For my parents,
Ron and Brenda, who have always helped, guided, and inspired me
and to my two daughters, Leah and Lauren who provide me with such joy
 I have hands,
Watch me clap.
I have feet,
Watch me stamp.
I have arms,
Watch me swing.
I have legs,
They can bend and stretch.
I have a spine,
It can twist and bend.
Oh, what a miracle I am!

Oh, what a miracle,

Oh, what a miracle,
Every little part of me.
I’m something special,
So very special, there’s nobody quite like me.

Adapted from “What a Miracle’’ by Hap Palmer.

CONTENTS

Preface ix
Acknowledgments xi

䉲
Introduction xiii

SECTION I FUNDAMENTALS OF ORTHOPAEDICS 1

1. The Musculoskeletal Tissue System 3
2. The Nervous System 29
3. Kinesiology of The Musculoskeletal System 98
4. The Response of Biological Tissue to Stress 110
5. The Healing Process 126
6. Managing Impaired Muscle Performance 138
7. The Concept of Function 168
8. The Examination and Evaluation 188
9. Differential Diagnosis 252
10. Intervention Principles 346
11. Manual Techniques 385
12. Neurodynamic Mobilizations 422
13. Gait and Posture Analysis 440

䉲
SECTION II A PERIPHERAL JOINTS: THE UPPER EXTREMITIES
14. The Shoulder Complex
15. The Elbow Complex
487
489
653
16. The Forearm, Wrist, and Hand 734

䉲
SECTION II B PERIPHERAL JOINTS: THE LOWER EXTREMITIES
17. The Hip Joint
18. The Knee Joint Complex
839
841
932
19. The Ankle and Foot 1060

vii
viii CONTENTS

䉲SECTION III
20.
21.
INTRODUCTION TO THE VERTEBRAL COLUMN
The Intervertebral Disk
Vertebral Artery
1171
1197
1232
22. The Craniovertebral Junction 1246
23. The Cervical Spine 1293
24. The Temporomandibular Joint 1378
25. The Thoracic Spine and Rib Cage 1427
26. The Lumbar Spine 1492
27. The Sacroiliac Joint 1609

䉲SECTION IV POSTSURGICAL REHABILITATION

28. Postsurgical Rehabilitation of the Upper Extremity
29. Postsurgical Rehabilitation of the Lower Extremity
1659
1667
1691

䉲SECTION V PHARMACOLOGY AND MEDICAL IMAGING

30. Pharmacology For The Orthopaedic Physical Therapist
31. Imaging Studies in Orthopaedics
1729
1731
1764

Solutions for Review Questions 1789

Index 1795
PREFACE
The aim of the first edition of this book was to fill a void in the literature and to be of value to the student
and experienced clinician alike. The 2nd edition provides an update of the information provided in the
1st edition along with major revisions to almost all of the chapters and the addition of two new chapters,
Pharmacology for the Physical Therapist and Imaging Studies in Orthopaedics. My hope is that this edition
continues to build toward the objective of providing in a single volume what students and clinicians need
to provide a comprehensive examination, evaluation, and intervention of the orthopaedic patient.
In this edition, the reader will find a greater emphasis on evidence-based practice in both examination
and intervention techniques. This edition also provides updated references in all chapters, many new
photographs and line drawings, and a DVD with additional materials, including video clips of techniques
and patient exercises.
It is hoped that this book will be seen as the best available textbook, guide, review, and reference for
health-care students and practitioners involved in the care of the orthopaedic population. I would like to
thank all of you who have written or spoken to me about the book and offered comments and ideas, many
of which are included within.

Mark Dutton

Comments about this book may be sent to me at pt@mcgraw-hill.com.

ix
This page intentionally left blank
ACKNOWLEDGMENTS
From inception to completion, this book has taken almost a decade. Such an endeavor cannot be completed
without the help of many. I would like to take this opportunity to thank the following:
䉴 The faculty of the North American Institute of Manual and Manipulative Therapy (NAIOMT)—
especially, Jim Meadows, Erl Pettman, Cliff Fowler, Diane Lee, and the late Dave Lamb.
䉴 The exceptional team at McGraw-Hill, for their superb guidance throughout this object. Thank you
especially to Mike Brown for his advice and support, and to other members of the initial lineup. Special
thanks also to the crew who brought the book to its fruition: Catherine Johnson and Christie Naglieri.
䉴 The staff at Manchester United Football Club including the club doctor Dr. Mike Stone MRCP, Dip.
SportsMed., FFSEM(I) the physiotherapists Neil Hough MCSP (Deputy Head Physiotherapist), John
Davin MSc, MMACP, MCSP Physiotherapist, Richard Merron MSc, MCSP, Mandy Johnson M.Phil,
MCSP, Gail Stephenson - Orthoptist/Vision Scientist, Trevor Lea BSc, SRDm MMedSci - Dietitian
and Sports Scientist, and Steve Lyons MSc, DPodM - Podiatrist. Special thanks to Rob Swire MSc
MCSP - Head Physiotherapist for arranging the visit and acting as my guide throughout my stay.
䉴 To the production crew of Aptara, especially Sandhya Joshi.
䉴 Bob Davis for his creative eye and the excellent photography.
䉴 Phil and Sherri Vislosky for agreeing to be the photographic models.
䉴 Edward Snell, MD for his assistance with Chapter 31 and for providing the radiographic images.
䉴 The staff of Human Motion Rehabilitation, Allegheny General Hospital including Duke Rupert, Rachel
Berg, Mark Orsi, Dan Norkiewicz, Dave and Krissy Hahn, Dean Hnaras, John Karp, Marie, Lombardi,
Melissa Willis, Shawna Sutherland, Fred Lutz, Urvisha Desai, Amanda Martz, Leslie Fisher, Amy
Tretinik, Joe Witt, CJ Eberley, Randi Marshak, Bruce Jacobs, Missy Bauer, Karen Richards, Diane
Ferianc, Keith Galloway, Dan McCool, Rocco Palladini, Jodie Weiher, and Judy Hice.
䉴 Tadeusz Laska, for his friendship and advice.
䉴 To Athletic Training Solutions, LLC, which is owned and operated by Eric Cardwell MS, ATC, Craig
Castor ATC, and Todd Tomczyk MS, ATC, PES, CSCS for providing me with most of the video clips
featured on the DVD. The full range of video clips and clinical progressions can be found on their
website: www.athletictrainingsolutions.com
䉴 To the countless clinicians throughout the world who continually strive to improve their knowledge
and clinical skills.

xi
This page intentionally left blank
INTRODUCTION
“The very first step towards success in any occupation is to The goal of every clinician should be to enhance patient/
become interested in it.” Sir William Osler (1849–1919) client satisfaction and increase efficiency and decrease unwar-
ranted treatment approaches.2 The management of the patient/
Until the beginning of the last century, knowledge about the
client is a complex process involving an intricate blend of expe-
mechanism of healing and the methods to decrease pain and suf-
rience, knowledge, and interpersonal skills. Obtaining an ac-
fering were extremely limited. Although we may scoff at many
curate diagnosis requires a systematic and logical approach.
of the interventions used in the distant past, many of the interven-
Such an approach should be eclectic, because no single ap-
tions we use today, albeit less radical, have still to demonstrate
proach works all of the time. For any intervention to be
much more in the way of effectiveness. That may soon change
successful, accurate diagnosis must be followed by a care-
with the recent emphasis within many health-care professions on
fully planned and specific rehabilitation program to both the
evidence-based clinical practice. The process of evidence-based
affected area and its related structures. In this book, great
practice is presented in Table I-1. When combining clinical
emphasis is placed on the appropriate use of manual tech-
expertise with the best available external clinical evidence,
niques and therapeutic exercise based on these considerations.
clinicians can make informed decisions regarding patient man-
Electrotherapeutic and thermal/cryotherapeutic modalities
agement, including the selection and interpretation of the most
should be viewed as adjuncts to the rehabilitative process.
appropriate evaluation procedures. In addition, intervention
The accompanying DVD to this book contains numerous
strategies that are based on the best available evidence will have
video clips of manual techniques and therapeutic exercises,
a greater likelihood of success with the least associated risk.1,2
which the reader is encouraged to view. The following icon
TABLE I-1 The Process of Evidence-Based Practice is used throughout the text to indicate when such clips are
available.
1. Identify the patient problem. Derive a specific question.
2. Search the literature.
3. Appraise the literature.
4. Integrate the appraisal of literature with your clinical expertise, REFERENCES
experience, patient values, and unique circumstances. 1. Sackett DL, Rosenberg WM, Gray JA, et al.: Evidence based
5. Implement the findings. medicine: What it is and what it isn’t. BMJ 312:71, 1996.
6. Assess outcome and reappraise. 2. Schroder JA: Manual therapy and neural mobilization: Our approach
and personal observations. Orthopaedic Pract 16:23, 2004.
Data from Sackett DL, Strauss SE, Richardson WS, et al.: Evidence Based
Medicine: How to Practice and Teach EBM, 2nd edn. Edinburgh, Scotland:
Churchill Livingstone, 2000.

xiii
This page intentionally left blank
 S E C T I O N I

FUNDAMENTALS
OF ORTHOPAEDICS
This page intentionally left blank
C H A P T E R 1

THE MUSCULOSKELETAL
SYSTEM
CHAPTER OBJECTIVES
䉴 At the completion of this chapter, the reader will be able to:

1. Describe the various types of biological tissue of the musculoskeletal system.

2. Describe the types of connective tissue.

3. Outline the function of collagen and elastin.

4. Describe the structural differences and similarities between fascia, tendons, and ligaments.

5. Describe the structure and function of a bone.

6. Outline the different types of cartilage tissue.

7. Describe the constituents of a synovial joint.

8. Describe the cellular components of skeletal muscle.

9. Outline the sequence of events involved in a muscle contraction.

10. Describe the various energy-producing processes used by the body.

11. List the various muscle fiber types and their roles in muscle function.

12. Describe some of the common pathologies involving the various types of connective tissue.

䉲
OVERVIEW

A working knowledge of the musculoskeletal system forms

䉴 Nervous tissue. Nervous tissue (described in Chapter
2) helps coordinate movements via a complex motor con-
trol system of prestructured motor programs and a dis-
tributed network of reflex pathways mediated throughout
the foundation of every orthopaedic examination, evalua- the central nervous system.2
tion, and intervention. A basic tenet in the study of anatomy 䉴 Connective tissue. Connective tissue is found through-
and biomechanics is that morphology relates to function, in out the body. It is divided into subtypes according to the
that the function of a structure can often be determined by its matrix that binds the cells. Connective tissue provides
design. On the basis of morphology and function, the tissues structural and metabolic support to other tissues and or-
of the body are classified into four basic kinds: epithelial, gans of the body. It includes bone, cartilage, tendons,
nervous, connective, and muscle tissue.1 ligaments, and blood tissue. The properties of connec-
tive tissue are described in this chapter.
䉴 Epithelial tissue. Epithelial tissue is found through-
out the body in two forms: membranous and glandu- 䉴 Muscle tissue. Muscle tissue is responsible for the
lar. Membranous epithelium forms such structures as the movement of materials through the body, the movement
outer layer of the skin, the inner lining of the body cav- of one part of the body with respect to another, and loco-
ities and lumina, and the covering of visceral organs. motion. There are three types of muscle tissue: smooth,
Glandular epithelium is a specialized tissue that forms cardiac, and skeletal tissue. In this chapter, human skele-
the secretory portion of glands. tal and respiratory muscle tissues are described.

3
4 SECTION I r FUNDAMENTALS OF ORTHOPAEDICS

Together, connective tissue and skeletal muscle tissue form 3. Secretion of procollagen from the fibroblast into the matrix
the musculoskeletal system. The musculoskeletal system func- followed by assembly into collagen fibrils.
tions intimately with nervous tissue to produce coordinated
4. Organization of collagen fibrils into collagen fibers, which
movement and to provide adequate joint stabilization and feed-
have a classic one-quarter stagger arrangement. This three-
back during sustained positions and purposeful movements.
dimensional network acts both as a structural framework to
provide mechanical support to the tissue and as a binding
surface for molecules involved in mediating either matrix–
Connective Tissue
matrix or cell–matrix interactions.
The primary types of connective tissue cells are macrophages, Of the more than 20 types of collagen thus far identified,
which function as phagocytes to clean up debris; mast cells, types I to III, V, VI, IX, XI, XII, and XIV are found mainly
which release chemicals associated with inflammation (see in connective tissue proper.4 The major forms of collagen are
Chapter 5); and fibroblasts, which are the principal cells of con- outlined in Table 1-2.5
nective tissue.3 The connective tissue types are differentiated
according to the extracellular matrix (ECM) that binds the cells,
as follows1 : Elastin
Elastic fibers are composed of a protein called elastin. Elastin
1. Embryonic connective tissue is synthesized as a discrete monomeric unit and secreted from
2. Connective tissue proper several cell types, including chondroblasts, myofibroblasts, and
mesothelial and smooth muscle cells.6 As its name suggests,
a. Loose connective tissue elastin provides elastic properties to the tissues in which it is
b. Dense, regular connective tissue situated. Elastin fibers can stretch, but they normally return to
their original shape when the tension is released. Thus, elastic
c. Dense, irregular connective tissue fibers of elastin determine the patterns of distention and recoil
d. Elastic connective tissue in most organs, including the skin and lungs, blood vessels, and
connective tissue.
e. Reticular connective tissue
f. Adipose connective tissue Arrangement of Collagen and Elastin
Collagenous and elastic fibers are sparse and irregularly ar-
3. Cartilage and bone tissue
ranged in loose connective tissue but are tightly packed in dense
a. Hyaline cartilage connective tissue.7 Fascia is an example of loose connective tis-
sue (Fig. 1-1). Tendons and ligaments (Fig. 1-1) are examples
b. Fibrocartilage
of dense, regular connective tissue.8
c. Elastic cartilage
Fascia. Fascia is viewed as the connective tissue that pro-
4. Blood (vascular) tissue
vides support and protection to the joint and acts as an inter-
The anatomic and functional characteristics of the four types connection between tendons, aponeuroses, ligaments, capsules,
of connective tissue that predominate in the joints of the mus- nerves, and the intrinsic components of muscle.9,10 This type of
culoskeletal system are summarized in Table 1-1. connective tissue may be categorized as fibrous or nonfibrous,
with the fibrous components consisting mainly of collagen and
Connective Tissue Proper elastin fibers and the nonfibrous portion consisting of amor-
Connective tissue proper has a loose flexible matrix, called phous ground substance, which is a viscous gel composed of
ground substance. The most common cell within connective tis- long chains of carbohydrate molecules (GAG) bound to a pro-
sue proper is the fibroblast. Fibroblasts produce collagen, elastin, tein and water.11
and reticulin fibers. Collagen and elastin are vital constituents
of the musculoskeletal system. Tendons and Ligaments. Histologically, tendons and ligaments
are similar in composition: They are densely packed connective-
Collagen tissue structures that consist largely of directionally oriented,
The collagens are a family of ECM proteins that play a dominant high-tensile-strength collagen.12 Because of their function as
role in maintaining the structural integrity of various tissues and supporting cables in an environment of high-tensile forces, lig-
in providing tensile strength to tissues. The formation of collagen aments and tendons must be relatively inextensible to minimize
involves four steps: the transmission loss of energy.
The collagen structural organization of tendons and liga-
1. The intracellular formation of a protocollagen chain.
ments is similar—tendons consist of 86% (dry weight) colla-
2. Conversion of protocollagen to procollagen (α) chains that gen and ligaments consist of 70% (dry weight) collagen.13 . The
undergo winding into a superhelix moiety. collagen is made up of the fibers arranged in a quarter-stagger
 TABLE 1-1 Types of Connective Tissue That Form the Structure of Joints

Ground Substance
Joint Type Anatomic Location Fibers (GAGs + Water + Solutes) Cells Mechanical Specialization Clinical Correlate
Dense irregular Composes the external fibrous High type I collagen Low ground substance Sparsely located Ligament: Binds bones Rupture of the lateral collateral
connective layer of the joint capsule fiber content content cells tightly together and restrains ligament complex of the
tissue Forms ligaments, fascia, and packed between unwanted movement at ankle can lead to
tendons fibers the joints; resists tension medial–lateral instability of
in several directions the talocrural joint
Tendon: Attaches muscle to
bone
Articular Covers the ends of articulating High type II collagen High ground substance Moderate number Resists and distributes During early stage of
cartilage bones in synovial joints fiber content; fibers content of cells; compressive forces (joint osteoarthritis, GAGs are
help anchor flattened near loading) and shear forces released from deep in the
cartilage to the articular (surface sliding); very tissue, reducing the force
subchondral bone surface and low coefficient of friction distribution capability;
and restrain the rounded in adjacent bone thickens to
ground substance deeper layers of absorb the increased force,
the cartilage often causing the formation
of osteophytes (bone spurs)

Fibrocartilage Composes the intervertebral Multidirectional Moderate ground Moderate number Provides some support and Tearing of the intervertebral
disks and the disc within the bundles of type I substance of cells that are stabilization to joints; disk can allow the central
pubic symphysis collagen rounded and primary function is to nucleus pulposus to escape
Forms the intra-articular discs dwell in provide “shock (herniate) and press on a
(menisci) of the tibiofemoral, cellular lacunae absorption” by resisting spinal nerve or nerve root
stemoclavicular, and distributing
acromioclavicular, and distal compressive and shear
radioulnar joints forces
Forms the labrum of the glenoid
fossa and the acetabulum
Bone Forms the internal levers of the Specialized Low GAG content Moderate number Resists deformation; Osteoporosis of the spine
musculoskeletal system arrangement of of cells; strongest resistance is produces a loss of bony
type I collagen to flattened near applied against trabeculae and mineral
form lamellae and the articular compressive forces due to content in the vertebral body
osteons and to surface and body weight and muscle of the spine; may result in
provide a rounded in force. fractures of the vertebral
framework for hard deeper layers of Provides a rigid lever to body during walking or even
mineral salts (e.g., the cartilage transmit muscle force to coughing
calcium crystals) move and stabilize the
body

GAGs = Glycosaminoglycans.
Threlkeld AJ: Basic structure and function of the joints. In: Neumann DA, ed. Kinesiology of the Musculoskeletal System: Foundations for Physical Rehabilitation. St. Louis, MO: Mosby, 2002: 25–40. With
permission from Mosby.
5
6 SECTION I r FUNDAMENTALS OF ORTHOPAEDICS

TABLE 1-2 Major Types of Collagen which it originates. Tendons deform less than ligaments under
an applied load and are able to transmit the load from muscle to
Type Location bone.15 However, tendons transmit forces from muscle to bone
I Bone, skin, ligament, and tendon and are subject to great tensile stresses. Although tendons with-
II Cartilage, nucleus pulposus stand strong tensile forces well, they resist shear forces less well
III Blood vessels, gastrointestinal tract and provide little resistance to compression force (see Chapter
IV Basement membranes 4).
Within the fascicles of tendons, the collagen components
are unidirectionally oriented. The fascicles are held together by
loose connective tissue called endotenon. Endotenon contains
arrangement, which gives it a characteristic banding pattern and
blood vessels, lymphatics, and nerves and permits longitudinal
provides high strength and stability.14 A loose connective-tissue
movements of individual fascicles when tensile forces are ap-
matrix surrounds the bundles of collagen fibrils. Bundles of col-
plied to the structure. The connective tissue surrounding groups
lagen and elastin combine to form a matrix of connective-tissue
of fascicles or the entire structure is called the epitenon. On the
fascicles. This matrix is organized within the primary collagen
basis of the type of surrounding tissue, tendons can be classified
bundles as well as between the bundles that surround them.15
as follows:
Tendons
Tendons are cordlike structures that function to attach muscle to 䉴 Gliding tendons. These tendons are enclosed by a tendon
bone. Tendons are made up of densely packed parallel-oriented sheath with a combination of discrete parietal (inside surface
bundles of collagen, composed mainly of type I and III by dry of the sheath) and visceral (epitenon or outside layer of the
weight (86% and 5%, respectively).16 The thickness of each tendon) synovium layers. This type of tendon receives vascu-
tendon varies and is proportional to the size of the muscle from lar access only through vincula—small, loose, flexible strips
of connective tissue that connect with the mesotenon and
paratenon, the loose connective tissues around the sheath.15
Examples include the flexor tendons of the hand.
Hyaline cartilage
䉴 Vascular tendons. These tendons are surrounded by a
peritendinous connective tissue paratenon, which is con-
nected to the epitenon. If there is synovial fluid between
these two layers, the paratenon is called tenosynovium; if
not, it is termed tenovagium.15 An example is the Achilles
tendon.
As the tendon joins the muscle, it fans out into a much wider
and thinner structure. The site where the muscle and tendon
Ligament
meet is called the myotendinous junction (MTJ). Despite its vis-
coelastic mechanical characteristics, the MTJ is very vulnerable
to tensile failure.17,18 Indeed, the MTJ is the location of most
common muscle strains caused by tensile forces in a normal
muscle–tendon unit.15,19 In particular, a predilection for a tear
Tendon near the MTJ has been reported in the biceps and triceps brachii,
rotator cuff muscles, flexor pollicis longus, fibularis (peroneus)
longus, medial head of the gastrocnemius, rectus femoris, ad-
Fascia ductor longus, iliopsoas, pectoralis major, semimembranosus,
Muscle and the entire hamstring group.20−22

Tendon Injuries. Tendon injuries are among the most common

overuse injuries. Three major types are recognized:
䉴 Tendonitis. An inflammation of the tendon, which de-
spite the popularity of the diagnostic label, has rarely been
proven histologically. Common sites of tendonitis include
the rotator cuff of the shoulder (i.e., supraspinatus, bicip-
ital tendons), insertion of the wrist extensors (i.e., lateral
FIGURE 1-1 Illustration depicting the relationship between muscle, tendon, epicondylitis, tennis elbow) and flexors (i.e., medial epi-
ligament, fascia, and hyaline cartilage. (Reproduced with permission from Dutton condylitis) at the elbow, patellar and popliteal tendons and
M. Orthopaedic Examination, Evaluation, and Intervention: A Pocket Handbook. iliotibial band at the knee, insertion of the posterior tibial
New York: McGraw-Hill, 2005.) tendon in the leg (i.e., shin splints), and the Achilles tendon
CHAPTER 1 r THE MUSCULOSKELETAL SYSTEM 7

TABLE 1-3 Major Ligaments of the Upper Quadrant

Joint Ligament Function
Shoulder complex Coracoclavicular Fixes the clavicle to the coracoid process
Costoclavicular Fixes the clavicle to the costal cartilage of the first rib

Glenohumeral Coracohumeral Reinforces the upper portion of the joint capsule

Glenohumeral (“Z”) Reinforces the anterior and inferior aspect of the joint capsule
Coracoacromial Protects the superior aspect of the joint

Elbow Annular Maintains the relationship between the head of the radius and the
Ulnar (medial) collateral humerus and ulna
Radial (lateral) collateral Provides stability against valgus (medial) stress, particularly in the
range of 20◦ –130◦ of flexion and extension
Provides stability against varus (lateral) stress and functions to
maintain the ulnohumeral and radiohumeral joints in a reduced
position when the elbow is loaded in supination

Wrist Extrinsic palmar Provide the majority of the wrist stability

Intrinsic Serve as rotational restraints, binding the proximal carpal row into a
Interosseous unit of rotational stability
Bind the carpal bones together

Fingers Volar and collateral Prevent displacement of the interphalangeal joints

interphalangeal

at the heel. Tendonitis most commonly is caused by overuse. preventing excessive motion,26 acting as guides to direct mo-
Pathologic changes consistent with chronic inflammation are tion, and providing proprioceptive information for joint func-
usually observed. Tissue degeneration, characterized by cell tion (Tables 1-3 and 1-4).27,28 Inman29 feels that the ligaments
atrophy, may also be observed. Calcium can deposit along are more important as checkreins than as providers of stability
the course of the tendon (i.e., calcific tendinitis). during movement. Over an extended period of time, ligaments
respond to loading with an overall increase in mass, stiffness,
䉴 Tendinosis. A degenerative and chronic alteration of the
and load to failure (see Chapter 4).16 In addition to the struc-
tendon accompanied by pain and often associated with ten-
tural changes, the material properties show an increase in ul-
don thickening (see Chapter 4).23
timate stress and strain at failure.16 Immobilization and disuse
䉴 Paratenonitis. A term that encompasses peritendonitis, dramatically compromise the structural material properties of
tenosynovitis, and tenovaginitis to describe an inflammatory ligaments (see Chapter 4), resulting in a significant decrease in
disorder of tissues surrounding the tendon, such as the tendon the ability of scars to resist strain and a decrease in maximum
sheath. In most cases, these conditions seem to result from load to failure, energy absorbed to failure, and stiffness (increase
a repetitive friction of the tendon and its sheath.24 compliance).16

Ligaments Pathology of Ligaments. Ligament injuries are graded according

Skeletal ligaments are fibrous bands of dense connective tissue to severity (Table 1-5).
that connect bones across joints. The gross structure of the liga-
ments varies with their location (intra-articular or extra-articular,
capsular) and function.16 Ligaments are composed primarily of Bone
water, with collagen (largely type I collagen with small amounts Bone is a highly vascular form of connective tissue, composed
of type III) making up most of the dry weight. Type III collagen of collagen, calcium phosphate, water, amorphous proteins, and
is often found in injured ligaments. Collagen has a less uni- cells. It is the most rigid of the connective tissues. Despite
directional organization in ligaments than it does in tendons, its rigidity, bone is a dynamic tissue that undergoes constant
but its structural framework still provides stiffness (resistance to metabolism and remodeling. The collagen of bone is produced
deformation).13 Small amounts of elastin (1% of the dry weight) in the same manner as that of ligament and tendon, but by a
are present in ligaments, with the exception of the ligamentum different cell, the osteoblast.7 At the gross anatomical level,
flavum and the nuchal ligament of the spine. The cellular or- each bone has a distinct morphology comprising both corti-
ganization of ligaments makes them ideal for sustaining tensile cal bone and cancellous bone. Cortical bone is found in the
load.25 Ligaments contribute to the stability of joint function by outer shell. Cancellous bone is found within the epiphyseal and
8 SECTION I r FUNDAMENTALS OF ORTHOPAEDICS

TABLE 1-4 Major Ligaments of the Lower Quadrant

Joint Ligament Function
Spine Anterior longitudinal ligament Functions as a minor assistant in limiting anterior translation and
vertical separation of the vertebral body
Posterior longitudinal ligament Resists vertebral distraction of the vertebral body
Ligamentum flavum Resists posterior shearing of the vertebral body
Interspinous Acts to limit flexion over a number of segments
Iliolumbar (lower lumbar) Provides some protection against intervertebral disk protrusions
Resists separation of the lamina during flexion
Resists separation of the spinous processes during flexion
Resists flexion, extension, axial rotation, and side bending of L5 on
S1

Sacroiliac Sacrospinous Creates greater sciatic foramen

Sacrotuberous Resists forward tilting of the sacrum on the hip bone during weight
Interosseous bearing of the vertebral column
Posterior (dorsal) sacroiliac (long) Creates lesser sciatic foramen
Resists forward tilting of the sacrum on the hip bone during weight
bearing of the vertebral column
Resists anterior and inferior movement of the sacrum
Resists backward tilting of the sacrum on the hip bone during weight
bearing of the vertebral column

Hip Ligamentum teres Transports nutrient vessels to the femoral head

Iliofemoral Limits hip extension
Ischiofemoral Limits anterior displacement of the femoral head
Pubofemoral Limits hip extension

Knee Medial collateral Stabilizes medial aspect of tibiofemoral joint against valgus stress
Lateral collateral Stabilizes lateral aspect of tibiofemoral joint against varus stress
Anterior cruciate Resists anterior translation of the tibia and posterior translation of the
Posterior cruciate femur
Resists posterior translation of the tibia and anterior translation of the
femur

Ankle Medial collaterals (Deltoid) Provides stability between the medial malleolus, navicular, talus, and
Lateral collaterals calcaneus against eversion
Static stabilizers of the lateral ankle especially against inversion

Foot Long plantar Provides indirect plantar support to the calcaneocuboid joint by
Bifurcate limiting the amount of flattening of the lateral longitudinal arch of
Calcaneocuboid the foot
Supports the medial and lateral aspects of the foot when weight
bearing in a plantar flexed position
Provides plantar support to the calcaneocuboid joint and possibly
helps to limit flattening of the lateral longitudinal arch

metaphyseal regions of long bones as well as throughout the tion phase of the examination. The strength of a bone is related
interior of short bones (Table 1-6).17 directly to its density.
The function of a bone is to provide support, enhance lever- Fractures of bone may be due to direct trauma such as a
age, protect vital structures, provide attachments for both ten- blow, or indirect trauma such as a fall on the outstretched hand
dons and ligaments, and store minerals, particularly calcium. (FOOSH injury), or a twisting injury. Fractures may be closed or
Bones may also serve as useful landmarks during the palpa- open (compound), where the bony fragment punctures the skin.
CHAPTER 1 r THE MUSCULOSKELETAL SYSTEM 9

TABLE 1-5 Ligament Injuries

Grade Signs Implications
First degree Minimal loss of structural integrity Minimal functional loss
(mild) No abnormal motion Early return to training—some
Little or no swelling protection may be necessary
Localized tenderness
Minimal bruising

Second degree Significant structural weakening Tendency to recurrence

(moderate) Some abnormal motion Need protection from risk of further
Solid end-feel to stress injury
More bruising and swelling May need modified immobilization
Often associated hemarthrosis May stretch out further with time
and effusion

Third degree Loss of structural integrity Needs prolonged protection

(complete) Marked abnormal motion Surgery may be considered
Significant bruising Often permanent functional instability
Hemarthrosis

Fractures are classified as transverse, oblique, spiral, or com- or metaphyseal bone. Injuries to the physes are more likely
minuted (Fig. 1-2). Stress fractures are described in Chapter 4. to occur in an active pediatric population, in part due to the
Another type of fracture, the avulsion fracture, which is seen greater structural strength and integrity of the ligaments and
in athletes and children, occurs when a piece of bone attached joint capsules than of the growth plates (Fig. 1-3). The Salter
to a tendon or ligament is torn away. Growth plate (physeal) and Harris classification is preferred and the accepted stan-
fractures may be defined as a disruption in the cartilaginous dard in North America for diagnosing physeal fracture patterns
physis of long bones that may or may not involve epiphyseal (Table 1-7).

TABLE 1-6 General Structure of Bone17

Site Comment Conditions Result
Epiphysis Mainly develops under pressure Epiphyseal dysplasias Distorted joints
Apophysis forms under traction Joint surface trauma Degenerative changes
Forms bone ends Overuse injury Fragmented development
Supports articular surface Damaged blood supply Avascular necrosis

Physis Epiphyseal or growth plate Physeal dysplasia Short stature

Responsive to growth and sex Trauma Deformed or angulated growth or growth arrest
hormones
Vulnerable prior to growth spurt Slipped epiphysis
Mechanically weak

Metaphysis Remodeling expanded bone end Osteomyelitis Sequestrum formation

Cancellous bone heals rapidly Tumors Altered bone shape
Vulnerable to osteomyelitis Metaphyseal dysplasia Distorted growth
Affords ligament attachment

Diaphysis Forms shaft of bone Fractures Able to remodel angulation

Large surface for muscle origin Diaphyseal dysplasias Cannot remodel rotation
Significant compact cortical bone Healing slower than at metaphysis Involucrum with infection
Strong in compression Dysplasia give altered density and shape

Reid DC: Sports Injury Assessment and Rehabilitation. New York: Churchill Livingstone, 1992.
10 SECTION I r FUNDAMENTALS OF ORTHOPAEDICS

FIGURE 1-3 Salter–Harris classification of growth plate fractures. (Reproduced

with permission from Brukner P, Khan K: Clinical Sports Medicine, 3rd edn. North
Ryde, N.S.W.: McGraw-Hill, 2007.)

Possible complications of a fracture include

䉴 infection
䉴 malunion
䉴 delayed union/nonunion.
䉴 associated injury (e.g., nerve, vessel)
䉴 deep venous thrombosis/pulmonary embolism
䉴 acute compartment syndrome

Pathology of Bone
Osteoporosis. Osteoporosis is a systemic skeletal disorder char-
acterized by decreased bone mass and deterioration of bony mi-
croarchitecture. Osteoporosis results from a combination of ge-
netic and environmental factors that affect both peak bone mass
and the rate of bone loss. These factors include medications,
diet, race, sex, lifestyle, and physical activity. Osteoporosis may
be either primary or secondary.
FIGURE 1-2 Types of fractures. (A) Transverse; (B) Oblique; (C) Spiral; (D) 䉴 Primary osteoporosis is subdivided into types 1 and 2.
Comminuted; (E) Avulsion. (Reproduced with permission from Brukner P, Khan K: r Type 1, or postmenopausal, osteoporosis is thought to re-
Clinical Sports Medicine, 3rd edn. North Ryde, N.S.W.: McGraw-Hill, 2007.)
sult from gonadal (i.e., estrogen, testosterone) deficiency.
Estrogen or testosterone deficiency, regardless of age of
occurrence, results in accelerated bone loss. The exact
 Another Random Document on
Scribd Without Any Related Topics
ten thousand dollars. That will square accounts a little, and make up
for some of the things you did to me. It’s you against ten thousand
dollars, and I guess your father would rather pay up than see you
suffer. Now I’ll get down to business,” and he drew up a chair and
sat down in front of Tom.
 CHAPTER XXII
AN ANXIOUS SEARCH

George Abbot had the luck of finding the road for which he and
his chums had all vainly sought so long in the storm. It will be
remembered that the four boys had started in different directions,
corresponding to the different points of the compass, to search for a
route, either back to the hut where they had spent the night, or to
one of the three camps.
And it was George who found the road.
True he did not know which road it was at the time, but when he
had stumbled on through the drifting snow, fighting his way against
the storm for some time, he fairly tumbled down a little
embankment, rolling over and over.
“Well, what’s this?” George asked himself, rather dazed, as he rose
to his feet.
He had his answer in a moment.
“It’s a road—I hope it’s the road,” he went on, as he saw that the
little declivity down which he had fallen was where the road had
been cut through a hill, leaving a slope on either side of the
highway.
“I must signal to the others at once,” George decided. His gun had
slipped from his grasp when he fell, but he now picked up the
weapon, and fired two shots in quick succession. It was the signal
agreed upon.
The wind was blowing hard, and George was not sure that the
sound of the shots would carry to his chums. He did not know just
how far they were from him. So, after waiting a bit, he strolled down
the snow-covered road a bit, and fired again. He repeated this three
times, at intervals, before he heard an answering shot. Then he
raised his voice in a yell, and soon was relieved to be joined by Jack.
“What is it?” Jack asked.
“The road—I’ve found it,” George answered.
“Where’s Bert—and Tom?”
“Haven’t seen either of them.”
“Well, they’re probably looking yet. We’ll fire some more shots and
bring ’em up.”
George and Jack fired at intervals, the signal each time being two
rapid shots, but it was some time before they had an answer. It
finally came in the shape of another shot, followed quickly by a
shout.
“It’s Bert,” said George.
“Sounded more like Tom,” was his chum’s guess. While they
waited, they exchanged experiences. Jack told of vainly floundering
about in the drifts, while George had better news to impart.
“I fairly stumbled on the road,” he said.
“Any way at all, as long as you found it,” said Jack. “Here comes
someone now.”
It proved to be Bert, who staggered up through the storm, himself
almost a living snowball.
“Found anything?” he gasped, for he was quite “winded.”
“The road,” answered George.
“Where’s Tom?” asked Jack.
“Why, isn’t he with you?” asked Bert, in some surprise. “I haven’t
seen anything of him.”
“He’s probably off searching for a highway,” said George,
hopefully. “We’ll fire a few more shots.”
 They fired more than a few, but received no response from Tom,
and we well know the reason why, though his chums did not at the
time.
“Well, what had we better do?” asked Jack, at length. “I’m about
all in, and I guess you fellows feel about the same.”
“I would like something to eat,” admitted Bert.
“And I’m terribly cold,” confessed George, who was shivering.
“Well, let’s look about a bit on either side of this road, then go up
and down it a ways, and keep firing and shouting,” suggested Jack.
“We may find Tom. If we don’t—well, I think we’d better see where
this road goes.”
They adopted that plan, but though they shouted vigorously, and
fired many shots, there came no answer from Tom.
The exercise and the shouting, however, had one good result. It
warmed George so he was no longer in danger of coming down with
pneumonia.
“Well, it’s six of one and a half dozen of the other,” said Bert, at
length. “What shall we do, and which way shall we go on this road
to get to camp?”
“We’d better try to find one of the cabins,” said Jack. “And I think
this direction seems to be the most likely,” and he pointed to the left.
“Go ahead; I’m with you,” said Bert, and George nodded assent.
“What about Tom, though?” asked George, anxiously.
“Well, we can’t find him. He may have gone on ahead, or he may
still be searching for a road. In either case he’s too far off for us to
make him hear—that’s evident. And we may find him just as well by
trying to make our way back to camp as staying here,” said Jack.
So it was decided to do this, and off they started. The storm did
not seem quite so fierce now. In fact, there were indications that the
fall of snow was lessening. But a great deal had fallen, making
walking difficult. The cold was intense, but it was a dry cold, not like
the damp, penetrating air of New Jersey, and the boys stood it much
better.
They had not gone far before Jack uttered a cry.
“Here he comes! There’s Tom!” he shouted, pointing at a figure
advancing toward them through the mist of flakes that were still
falling, but more lazily now.
“It’s someone, but how do you know it’s Tom?” asked Bert.
“Who else would it be?” Jack wanted to know.
“It might be—Skeel,” suggested George.
“Or that—bear!” and, as he said this, Bert advanced his gun.
“Nonsense—that’s no bear!” exclaimed Jack. “It isn’t Tom though,
either,” he added, as the figure came nearer.
A moment later they all saw at once who it was.
“Sam Wilson!” exclaimed Bert. “That’s good! Now he can tell us
what to do, and where Tom is. Hello, Sam!” he called, for that was
how everyone addressed the genial guide—even those who had met
him only once or twice.
“Hello yourselves!” Sam answered in greeting. “What are you
fellows doing here?”
“We’ve been lost, and we’ve just found ourselves,” explained Jack.
“We’re on our way to Camp No. 3.”
“Oh, no, you’re not!” exclaimed Sam, smiling.
“Why not?” Bert wanted to know.
“For the simple reason that you’re on your way to Camp No. 2,”
answered Sam. “You’re going the wrong way for Camp No. 3.”
“Well, maybe we are twisted,” admitted Jack, “but as long as we’re
headed for some camp, I don’t care what it is.
 “We’ve been out all night,” he added, “or at least sheltered in only
an old cabin. We haven’t had anything to-day but some coffee, and
we’re about done out. Isn’t this storm fierce?”
“Oh, we’re used to these up here in the Adirondacks,” spoke Sam.
Then the boys told how they had been out hunting and had seen
the signpost that informed them it was seven miles to Ramsen.
“But you went the wrong way!” exclaimed Sam, when he had
heard the details. “Ramsen was in just the opposite direction.”
“Then the signboard was wrong!” declared Jack.
“That’s funny,” Sam spoke, musingly. “Signboards don’t change
themselves that way. There’s something wrong here.”
“Well, never mind that,” went on Bert. “Have you seen anything of
Tom Fairfield?”
“Tom Fairfield! Why, I thought he was with you!” exclaimed Sam,
quickly looking around.
“He was, but we separated to find the road,” explained George,
“and now we can’t locate Tom.”
“Well, this won’t do,” Sam spoke, and his voice was serious. “We
will have to hunt for him right away. He hasn’t had anything to eat,
you say?”
“None of us have,” said Jack. “That’s why we were so glad to find
some sort of road.”
“Well, I’ve got my pung back there a piece,” said the guide. “I
have some grub in it that I was taking over to your Camp No. 2. I
can give you a snack from that, and then we’ll do some searching
for the boy. I like Tom Fairfield!”
“So do I!” exclaimed Jack, and the others nodded emphatic
agreements, with a chorus of:
“That’s what!”
 Never did food taste so good as that which Sam brought up from
his pung. He explained that he had walked on ahead while his
horses were eating their dinners from nose-bags.
“And it’s lucky for you fellows I did,” he said, “though of course
you might have stumbled on the camp yourselves. But now for a
search.”
And with anxious hearts the boys took it up. Where could Tom
Fairfield be? That was a question each one asked himself.
 CHAPTER XXIII
DEFIANCE

Tom, a bound prisoner, watched the insolent professor who sat

facing him. The latter had on his face a sneer of triumph, but
mingled with it, as Tom could note, was a look that had in it not a
little fear. For the desperate man had planned a desperate game,
and he was not altogether sure how it would work out.
Tom steeled himself to meet what was coming. He did not know
what it was, but that it was something that would concern himself,
vitally, he was sure. And he was better prepared to meet what was
coming than he had been an hour or so previous.
For now, though he was a prisoner, and bound, he was warm, and
he had eaten. These things go far toward making courage in a man,
or boy either, for that matter.
“Now,” said Professor Skeel, and the sneer on his face grew more
pronounced, “we’ll talk business!”
“Oh, no, we won’t!” exclaimed Tom, quickly.
“We won’t?” and there was a sharp note in the man’s voice.
“I’ll have nothing to do with you,” went on Tom. “You brought me
here against my will, and you are liable to severe penalties for what
you did. As soon as I can get to an officer, I intend to cause your
arrest, and the arrest of those two miserable tools of yours.
“I’m not at all afraid—don’t think it. You can’t keep me here for
very long. Sooner or later I’ll get out, and then I’ll make it hot for
you! That’s just what I’ll do—I’ll make it hot for you!”
 During this little outburst on the part of Tom, Professor Skeel sat
staring at his prisoner. He did not seem at all frightened by what
Tom said, though the young man put all the force he could into his
words. But Tom was observant. He noticed that the little look of
worry did not leave the man’s face.
“I’ll make it so hot for you,” went on Tom, “that you’ll have to
leave this part of the country. You’ll have to leave if you get the
chance, and perhaps you won’t. My father and I will push this case
to the end. I don’t know what your game is, but I can guess.”
“Well, since you can guess, perhaps you can guess what I’m going
to do with you!” angrily interrupted the professor.
“No, I can’t, exactly,” spoke Tom, slowly, “but if it’s anything mean
or low-down, you’ll do it. I know you of old. I’ve had dealing with
you before.”
“Yes, and you’re going to have more!” the professor fairly shouted.
“I’m going to get even with you for what you did for me. You caused
me to lose my place at Elmwood Hall——”
“You deserved to lose it!” said Tom, cuttingly.
“And you mistreated me when we were out in that open boat——”
“Mistreated you!” fairly gasped Tom, amazed at the man’s
hardness of mind. “Mistreated you, when you tried to steal the little
water and food we had left!”
He could say no more. His mind went back vividly to the days of
the wreck of the Silver Star, when he and others had been in great
peril at sea. He had indeed prevented the professor from carrying
out his evil designs, though Tom was not more harsh than needful.
But now he was to suffer for that.
“I’ve got you where I want you,” went on Skeel, when Tom had
become silent. “I’ve laid my plans well, and you fell into the trap. I
won’t deny that the storm helped a lot, but I’ve got you now, and
you’re going to do as I say, or it will be the worse for you. You’ll do
as I say——”
 “Don’t be too sure!” interrupted Tom.
“That’s enough!” snapped the angry man. “You may not realize
that you are in my power, and that you’re up here in a lonely part of
the woods, away from your friends. They don’t know where you are,
and you don’t know where they are. They can’t help you. Those two
men of mine will do as I say, and——”
“Oh, I’ve no doubt but that you’ve trained them well in your own
class of scoundrelism,” said Tom, coolly.
“Silence!” fairly shouted the infuriated man. Tom ceased his talk
because he chose, not because he was afraid.
Professor Skeel hesitated a moment, and then drew from his
pocket some papers. Tom was at a loss to guess what they might
be. In fact, he had but a dim idea why he had been captured and
brought to the hut in the wilderness.
Some things the two men—Murker and Whalen—let fall, however,
gave him an inkling of what was to come. So he did not show any
great surprise when Professor Skeel, handing him a paper, said:
“That’s a copy of a letter I want you to write to your father. Copy
it, sign it in your natural hand, without any changes whatever, or
without making any secret signs on the paper, and give it back to
me. When I get the right kind of an answer back, I’ll let you go—not
before. Write that letter to your father!”
There was a veiled threat implied in the insolent command.
Professor Skeel held the letter out in front of Tom. The latter could
not take it, of course, for his hands were tied.
“Oh!” exclaimed the plotter, as though he had just wakened to this
fact. “Well, I’ll loosen your hands for you, but you must promise not
to fight. Not that I’m afraid of you, for I can master you, but I don’t
want to hurt you, physically, if I can help it.”
Tom did not altogether agree with the professor that he would be
the master if it came to an encounter. For our hero was a vigorous
lad, he played football and baseball, and his muscles were ready for
instant call. True, he was tired from lack of rest and the hardships he
had gone through, but he was not at all afraid of a “scrap,” as he
afterward put it.
So, then, when Professor Skeel made the remark about the bonds,
Tom was ready for what came next.
“I’ll loosen those ropes, so you can copy this letter, if you’ll
promise not to attack me,” went on Skeel.
“I’ll promise nothing!” exclaimed Tom, defiantly.
“All right. Then I’ll have to call in my helpers to stand by,” grimly
went on the former instructor. “They’ll take care of you if you cut up
rough.”
He went to the door, and called out:
“Murker—Whalen! Come in. We may need you,” he added
significantly.
Tom steeled himself for what was to come.
“Take off those ropes,” went on the professor, when his two mean
men had come in. “Then, if he starts a row—let him have it!”
The words were coarse and rough, and the man’s manner and
tone even more so.
“Are we to take off these ropes?” asked Murker.
“Yes, and then stand by. I’m going to make him write this letter.
That will bring the cash.”
“That’s what we want!” exclaimed Whalen, with an unctious smile.
“It’s the cash I’m after.”
“You’ll get none from my father!” cried Tom, beginning to
understand the course of the plot.
“We’ll see about that,” muttered the professor. “Loose his bonds,
but look out! He’s a tricky customer.”
 “Not any more so than you are,” Tom said, promptly. “And I want
to tell you here and now, when you have your witnesses present—
mean and low as they are—I want to tell you that you’ll suffer for
this when I get out. I’ll make it my business, and my father will also,
to prosecute you to the full extent of the law!”
“Words—mere words!” sneered Skeel.
“You won’t get out until you do as the boss wants,” said Whalen.
“Don’t be so rough. Better give in, it will be easier,” spoke Murker,
who seemed a little alarmed by what Tom said.
“I’ll attend to him,” said Skeel curtly. “Take off the ropes. Then you
read this letter and copy and sign it!” he ordered.
A moment later Tom’s hands were free. He did not see any chance
for making an escape then, so he waited, merely stretching his arms
so that the bound muscles were more free. True, he might have
made a rush on his captors, but the door had been locked, after the
entrance of Murker and Whalen, and Tom did not see what
opportunity he would have with three against him. He might be
seriously hurt and that would spoil his chances for a future escape.
“Read that,” ordered Skeel, thrusting the paper into Tom’s hands.
A glance showed that it was addressed to his father. It recited that
Tom was in trouble, that he had been made a prisoner by a band of
men who would release him only on payment of ten thousand
dollars. Details were given as to how the money, in cash, must be
sent, and Mr. Fairfield was urged to make no effort to trace Tom, or
it would result seriously for the prisoner.
“Sign that and we’ll send it,” ordered Skeel.
Tom dropped the letter to the floor, disdaining to hand it back.
“What’s this?” fairly roared the professor. “Do you mean you won’t
do as I say?”
“That’s just what I mean,” said Tom, coolly. “You may keep me
here as long as you like, and you can do as you please, but I’ll never
sign that letter. Go ahead! I’m not afraid of you!” and he faced his
enemies defiantly.
 CHAPTER XXIV
THE ESCAPE

Professor Skeel retained control of himself with an obvious effort.

Clearly he had expected more of a spirit of agreement on the part of
Tom, though he might have known, from his previous experiences
with our hero, that compliance would not be given. But Tom did not
even take the trouble to hand back the letter. It had fluttered to the
floor of the cabin.
“You—you——” began Whalen, angrily spluttering the words.
“Silence!” commanded Skeel. “I’m attending to this.” His face and
his tone showed his anger, but he managed to keep it under control.
He picked up the letter—something of a condescension on his part,
and said to Tom:
“Then you refuse to do as I ask?”
“I most certainly do! The idea is positively—silly!” and Tom had
the nerve to laugh in the faces of his enemies.
“We’ll make you sweat for this!” declared Whalen. “We’ll——”
“Better let the boss work the game,” suggested Murker. In spite of
his evil face, and the fact that he was just as guilty in the matter as
the others, he seemed of a more conciliatory spirit.
“Yes, you keep out of this,” commanded the professor to the
former employee of the school. “I know what I’m doing.”
Tom wondered what the next move would be. He did not have to
wait long to find out.
“Well, if you won’t sign this now, you will later,” said Skeel, as he
folded the letter and put it into his pocket. “Take him to the dark
room,” he ordered. “Maybe he’ll come to his senses there. And don’t
give him too much bread and water,” and the man laughed as he
gave this order. “A little starving will bring some results, perhaps.
Lock him up, and bring me the key.”
“All right, you’re the boss,” assented Murker. “I’m in this thing
now, and I’m going to stick it out, but I wish——”
“You’re right; you’re going to stick!” interrupted Skeel. “You’re in it
as deep as I am, and you can’t get out!”
Murker did not finish what he started to say. He shrugged his
shoulders and seemed resigned to what was to come. Tom disliked
him the least of the three, though the man’s face was not in his
favor.
“Shall we tie him up again?” asked Whalen.
“Yes, and tie him good and tight, too. Don’t mind how you draw
those cords. The more trouble we make now, the less we’ll have to
make later. Tie him up and put him away where he can cool off,” and
Professor Skeel laughed mockingly.
For an instant a desperate resolve came into Tom’s mind to make
a rush and a break for liberty. But the idea was dismissed almost as
soon as it was formed.
What chance would he stand with three full-grown men to oppose
him? The door was locked, and Tom’s feet were still bound. He had a
knife in his pocket, but to reach it, and cut the ropes on his ankles
would take time, and in that time he would easily be overpowered
by his captors. It was out of the question now.
“But I’m going to escape, if it’s at all possible,” Tom declared to
himself. “And when I do get out of here——”
But he could not finish his thought. His gun and mackinaw had
been taken away from him, and now when Whalen roughly seized
him, and put the ropes on his wrists, Skeel said:
 “Search his pockets. Take what money he has and any sort of
weapons. Then lock him up!”
Tom did have considerable money on him, and this was soon out
of his pockets, and in that of the professor. Tom’s knife and other
possessions were also removed. Then he was lifted up, carried to
another room, and roughly thrust into sort of a closet that was very
dark. Tom fell heavily to the floor. His mackinaw was tossed in to
him.
“He can use that for a blanket—we’re short of covering,” he heard
Skeel say. “We don’t want him to be too comfortable, anyhow.”
Tom was anything but at his ease just then, but he did not falter
in his determination not to give in. He shut his teeth grimly.
The door was closed and locked, and our hero was left to his not
very pleasant reflections. He managed to struggle to a sitting
position, and to edge over until he was leaning back against the
wall. He drew his heavy mackinaw to him. It would be warm during
the cold night, for that he would be kept a prisoner at least that
length of time, he could not doubt.
Tom’s thoughts were many and various. So this was why Skeel
had followed him and his chums. This was why he had reappeared
at Elmwood Hall, and had caused Whalen to ask questions about the
hunting trip.
So this was Skeel’s plan for enriching his purse and at the same
time getting revenge. So far, fate had played into the hands of the
unscrupulous man and his confederates.
“But I’ll get away!” Tom told himself. He sat there in the gloomy
darkness, trying to think of a plan.
Meanwhile his chums, with Sam Wilson, were frantically searching
for him in the storm. Sam’s idea was not to leave the neighborhood
where Tom had last been seen, until they had exhausted every effort
to locate their missing chum.
 But it was difficult to search in the storm, and the whirl of flakes
made a long view impossible. Then, too, they were in a dense part
of the wilderness. Sam Wilson’s farm was perhaps the largest
cleared part of it, though here and there were patches where trees
had been cut down.
Up and down the road, and on either side of it, the search went
on. Sam Wilson was a born woodsman, as well as a hunter and
farmer, and he brought his efficiency to the task.
“But it seems to be no go, boys,” he said, at length.
“But what has become of him?” asked George with a look of
worriment on his face.
“That’s what we can’t say except that he’s lost,” spoke Jack.
“Yes, but lost in this wilderness—in this storm,” added Bert. “It’s
dangerous.”
“Yes, that’s what it is, provided he is still lost,” Sam said.
“Still lost! What do you mean?” asked Jack.
“I mean he may have gone so far that he found his way back to
one of the camps.”
“Really?” hopefully cried Bert, who thought Sam might be saying
that simply to cheer them up.
“Why, of course it’s possible,” the caretaker went on. “He may
have gone on beyond the sound of your guns. And, unexpectedly, he
may have hit the trail to one of the camps. For there are trails that
lead through the woods. They’re not easy to find, or follow, but Tom
might have had luck.”
“Then what shall we do?” asked Jack.
“Go back to Camp No. 2,” answered Sam. “Tom may be there. If
he isn’t, we’ll go to the others in turn. Let’s go back. We’ll drive.”
So, abandoning the search for the time being, they started back
for camp in the pung, drawn by the powerful horses. They were
hoping against hope that Tom would be there, or that they would
find him at one of the other cabins.
But Tom was still a prisoner in the dark closet of the lonely shack.
What his thoughts were you can well imagine, but, above everything
else stood out the determination not to give in and sign the letter
asking for the ransom money.
Hours passed. Tom again felt the pangs of hunger. He had an idea
the men might try to starve him, but after an interval, which he
imagined brought the time to noon, Murker came in with some
bread and water.
“Boss’s orders,” he growled. “I’ll untie your hands while you eat,
and don’t try any tricks.”
Tom did not answer. The bread was welcome, but the water more
so. Murker left him a glass full after he had once emptied the
tumbler. Then the ropes were again put on his hands, and he was
left alone in the darkness.
Whether it was the same day or not, Tom could hardly tell. He
must have dozed, for he awoke with a start, and he knew at once
that some noise had caused it.
He listened intently, and heard a scratching, sniffing sound back of
him. He could feel the board side of the shack, against which he was
leaning, vibrate.
“Can it be that the boys are trying to release me?” Tom asked
himself. But in another moment he knew this could not be true. His
chums would come boldly up and not try to get him out in this
secret fashion. The scratching and sniffing increased.
“It’s some animal!” Tom decided. He edged away from the side of
the closet-room, and waited. The sound increased. Then came a
splintering, rending sound as of wood breaking. Tom fancied he
could feel a board move.
An instant later a streak of light came suddenly into his prison. It
was from the moon which was shining brightly on the snow outside,
and by the light through the crack Tom could see a big hairy paw
thrust in where the board had been torn off.
“It’s a bear!” cried the lad. “He must smell something to eat, and
he’s trying to get after it. He’s standing outside and has pulled off a
loose board, and—by Jove! I can get out that way!” he said aloud.
As he spoke the board was pulled farther loose, leaving a large
opening. A sniffing snout was thrust in. Tom had no intention of
sharing his prison with a bear, and, raising his two bound feet Tom
kicked the animal on its most tender place—the nose. With a growl
Bruin withdrew, and Tom could hear him sniffing indignantly as he
scampered over the snow. But the bear had made for Tom a way of
escape.
“If I could only get my arms and legs free, I could squeeze out
through that opening,” Tom decided. Then like a flash the plan came
to him.
The tumbler of water had been left within reach. Tom kicked it
over with sufficient force to break the glass. He had to make a noise,
but after waiting a while, he felt sure his captors had not been
aroused. They did not seem to be on guard, or they would have
heard the bear when he pulled loose the outside board.
Tom’s muscles were in good control, but he had to strain himself
unmercifully to bend over and get a piece of the broken glass
between his hands. Then he put it between his two boots, and held
it there, with a sharp edge up, by pressing his feet tightly together.
You have doubtless guessed his plan. He was going to use the
glass as a knife and saw the rope of his wrists upon it. This he
proceeded to do. The moonlight outside, streaming in, gave him
enough illumination to work by.
He cut himself several times before he succeeded in fraying the
rope enough so it could be broken. Then, rubbing his arms to
restore the interrupted circulation, Tom used the glass on the rope
that bound his ankles. This he cut through quickly enough, and, was
able to stand up. His legs were weak, and he waited a few minutes
until he could use them to better advantage. Then, forcing farther
off the dangling board, Tom crawled out in the snow, putting on his
mackinaw when he was outside.
The storm had ceased. It was night—a night with a dazzling
moon, and Tom was free. But where his chums were, or in what
direction the camp lay, he could not tell.
 CHAPTER XXV
THE SHOT

For a moment, after getting outside the cabin, Tom hardly knew
what to do. He was at a loss in which direction to start, but he
realized the necessity of getting away from that vicinity as soon as
possible.
Though his escape did not seem to have aroused his captors,
there was no telling when they would take the alarm and start after
him. Tom looked for the bear. The animal was not in sight, though
he could see by marks in the snow, where it had approached the
cabin from the woods, and where it had run off into the forest again.
“Too bad I haven’t my gun!” mused Tom. “But I don’t dare try to
get it.”
Then began for Tom a time he never forgot. He set off toward the
woods, wishing to gain their friendly shelter as soon as he could, but
once there he was at a loss how farther to proceed.
“But there’s no need to wait for morning,” he reasoned. “I can see
almost as well now, as long as the moon is up. I’ll try to find some
sort of a trail.”
He staggered on, yes, staggered, for he was weak from his
experience, and he had not had proper food in some time. It
seemed almost a week, but of course it was not as long as that.
Scarcely able to walk, but grimly determined not to give up, Tom
urged himself on. Whither he was going, he knew not, but any way
to leave that hateful shack, and the more hateful men behind, was
good enough for the time being.
 All night long Tom kept on going. He fancied he was on some sort
of trail or road, but he could not be sure. Certainly the trees seemed
cut down in a line, though it was a twisting and turning one.
Then the moon went down, leaving the scene pretty dark, but the
white snow made objects plain. Tom kept on until at last he was
fairly staggering from side to side. He was very weak.
“I—I’ve got to give up,” he panted. “I—I’ve got to—to rest.”
He looked about and saw sort of a nook under some bushes. On
top was a matting of snow, like a roof. Tom crawled into this like
some hunted animal, and sank down wearily. He pulled his
mackinaw about him, thankful that he had it with him. He must have
frozen without its protection.
Again Tom was unaware of the passage of time. He must have
dozed or fainted, perhaps, but when he opened his eyes the sun was
shining. The day was a brilliant one, and warm, for that time of year.
Tom took heart. He crawled out, and once more started on his
wearying tramp. He was very weak and exhausted, and there was a
“gone” feeling to his stomach.
“Or the place where it used to be,” Tom said, with grim humor. “I
don’t believe I have a stomach left.”
But he forced himself onward. It seemed that he had been
staggering over the snow for a week. Time had lost its meaning for
him.
“Oh, if I only had something to eat! If I only could find the camp!”
murmured poor Tom.
He reached a stump, and sat down on it to rest. He closed his
eyes but suddenly opened them again.
Was that fancy, or had he heard a shot? He leaped up, electrified,
and then hesitated. Perhaps it was Skeel and the others after him.
But a quick look across the snow showed him no one was in sight.
Tom reasoned quickly.
 “Skeel and his crowd wouldn’t shoot unless they saw me, and then
it would be to scare me. It can’t have been those men who fired. It
must be the boys. But where are they?” Tom looked eagerly about.
Again came the shot. There was no mistake this time. Then Tom
heard a shout. He tried to answer it, but his voice was too weak.
Another shot cracked on the frosty air, and then came a series of
confused calls.
“There he is!”
“We’ve found him!”
“Hurry up!”
A mist dimmed Tom’s vision. He cleared his eyes with a quick
motion of his hand, and then he saw his three chums and Sam
Wilson rushing toward him. They came out of the woods, and, a
moment later, had surrounded him.
“Where were you?”
“What happened?”
“Where’s your gun?”
“You look all in!”
Fast came the questions.
“I—I am all in,” Tom faltered. “It’s that rascal Skeel. I—I——”
He could not go on for a moment. Then he pulled himself
together.
“Here! Drink this!” exclaimed Jack, producing a small vacuum
bottle. “It’s coffee and it’s hot yet.” He poured some out into a tin
cup and Tom drank it. It revived him at once. Then, with a little
more of the beverage, and a hasty swallowing of a sandwich which
formed part of the emergency lunch the boys had brought with
them, Tom was able to tell his story.
Hot indignation was expressed by all, and then Jack related how
they had found the road, but lost Tom, and how they had met with
Sam. Their trip to Camp No. 2 had been fruitless, as we know, nor
were they any more successful when they came to Camp No. 3. Tom
was not there. Then they started for Camp No. 1, and were on their
way thither when they came upon the object of their search. On the
way they shouted and fired signal guns at intervals. The dog had
found his way to Camp No. 1, after leaving Tom, but the animal
could not lead Tom’s friends to him.
“And now to make it hot for those scoundrels!” exclaimed Sam.
“We’ll prosecute them not only for kidnapping and robbing you, for
that’s what they did when they took your gun and money, but we’ll
bring an action in trespass against them. That shack where they
kept you belongs to the hunting club.”
“And to think Tom was there all the while and we never knew it,”
said Bert.
“Oh, I intended to have a look there, if we hadn’t found him at
Cabin No. 1,” declared Sam. “But now let’s get busy! Can you walk,
Tom, or will you wait here until I can go get a horse?”
“Oh, I’ll be all right soon. I was just weak from hunger.”
Soon Tom was able to proceed. They were about half way
between Camp No. 1 and the shack where our hero had been kept a
prisoner, and it was decided to go to the latter place and make an
endeavor to capture Skeel and his cronies.
But our friends were too late. The kidnappers had fled, but Tom’s
gun and all his possessions, save his money, were found in the
cabin. Doubtless the personal belongings were too conclusive
evidence against the plotters, to risk taking, but someone had
succumbed to the temptation of the cash.
“Well, I’m glad to get this back,” Tom said, taking up his gun.
“Yes, and we’ll get those rascals yet!” declared Sam. “I’ll rouse the
whole country after them!”
They went on to Camp No. 1 and there Tom had a good rest. It
did not take long to pull himself together, and he was as eager as
the others to start out on the trail of the scoundrels. For the time
being hunting and the taking of photographs was forgotten. Sam
sent word to the authorities, and a sheriff’s posse was organized. It
was done so quickly that Skeel and the others, who had taken the
alarm and fled when they discovered Tom’s escape, were
apprehended before they could leave the neighborhood. The heavy
storms had blocked the railroad and there were no trains. The men
could not hire a sled and team and so were forced to walk, which
put them at a disadvantage. They left a trail easy for the woodsmen,
hunters and trappers to follow.
“Well, you got us, and you got us good!” said Murker, when they
were arrested and confronted by Tom and the others. “I was afraid
something like this would happen.”
“Why didn’t you say so, then, and keep me out of it?” asked
Whalen, sullenly.
Professor Skeel said nothing, but he scowled at Tom. The plotter’s
plans had fallen through, and he faced a long prison term, which, in
due course he received, as did his confederates. The letter Skeel had
tried to force Tom to write was found on the man and made
conclusive evidence against him and the others. So the scoundrel-
professor was cheated of his revenge and the money he hoped to
get from Mr. Fairfield.
It became known that Professor Skeel had various experiences
after Tom had last seen him. The man was in desperate
circumstances when he formed a plan of kidnapping Tom, and
holding him for ransom. It was a foolish and risky plan, but Skeel
talked it over with his two cronies and decided to try it. They knew
Mr. Fairfield was rich.
Then came Skeel’s trip to Elmwood Hall. The snowball was an
accident he had not counted on, and it made him more angry than
ever against Tom.
Professor Skeel’s injured ear, which looked, as Sam said, “like it
had been chawed by some critter,” was the result of a fight he had
with a man before this story opened, and with which we have
nothing to do. Sufficient to say that it served to identify the man,
and put our friends on their guard, so that justice was finally meted
out.
The trial and conviction of the men came later. After the trio were
safely locked in jail, Tom and his chums returned to the woods
where they had been lost. But they were better acquainted with the
forest now.
“And we’ll have some fine hunting!” cried Tom, now himself again.
“And get some photographs!” added Bert. “I want a view of that
hut where the bear pulled the board off so you could get out.”
“That was queer,” said Tom, smiling. “I don’t believe I’ll like to
shoot a bear now, after that one did me such a good turn.”
“You won’t have much chance,” Sam said. “I guess even the oldest
and toughest bear is ‘holed-up’ by now. Better be content with
deer!”
And the boys had to be, rather against their wills. But they were
made happy when each one got a specimen, though none was as
fine as was Tom’s antlered head. Moreover, Bert and the others
secured all the photographs they wanted.
But deer was not the only game they shot.
Rabbits, partridges and squirrels were plentiful, and the boys had
more than enough for their meals. They enjoyed to the utmost the
holiday time spent in the hunting camps, and Tom paid his first visit
to Camp No. 3.
“Well, take it all in all, how did you enjoy it, fellows?” asked Tom,
when, after a last successful hunt they were preparing to go back to
home and Elmwood Hall.
“Couldn’t have been better!” was the enthusiastic answer from all.
“But it was rather tough on you, Tom,” said Jack.
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