Fracture Reduction and Fixation

Techniques Peter V. Giannoudis

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Fracture Reduction and

Fixation Techniques

Upper Extremities

123
Fracture Reduction and Fixation
Techniques
Peter V. Giannoudis
Editor

Fracture Reduction and

Fixation Techniques
Upper Extremities
Editor
Peter V. Giannoudis
School of Medicine
University of Leeds
Leeds
Yorkshire
United Kingdom

ISBN 978-3-319-68627-1    ISBN 978-3-319-68628-8 (eBook)

https://doi.org/10.1007/978-3-319-68628-8

Library of Congress Control Number: 2018930258

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Preface

Fracture fixation techniques have continued to evolve since their introduction

in the 1950s by the AO Group in Switzerland. Advances made in metallurgy,
implant design, targeting devices, surgical instruments, radiology and func-
tional anatomy and the better understanding of fracture healing led to the
modern practising techniques. Preoperative planning became a routine step
of every fixation case. Moreover, it was recognised that optimal fracture
reduction prior to fixation is a key element facilitating bone repair and a sat-
isfactory anatomical and functional outcome. There is plenty of scientific evi-
dence available that suboptimal fracture reduction is often associated with
complications such as implant failure, impaired healing, malunion and early
onset of osteoarthritis, amongst others.
This highly illustrated textbook is written by a panel of experts in the
upper limb, who share tips and tricks that will aid in achieving an optimal
reduction and fixation of different fracture types whilst avoiding common
pitfalls.
Each technique is clearly demonstrated using a stepwise approach with
real-time intraoperative photographs, improving the understanding and
ensuring the production of an easy-to-read, memorable textbook.
Each chapter in this book includes an outline of useful techniques for
­fracture reduction. Its objective is to provide orthopaedic surgeons and espe-
cially those still in training with a quick reference to common reduction tech-
niques becoming an essential guide to their practice. The ultimate goal is to
improve the standards of care of our patients.

Leeds, UK Peter Giannoudis

v
Contents

Part I General Considerations

1 Fracture Healing: Back to Basics and Latest Advances������������    3

Ippokratis Pountos and Peter V. Giannoudis
2 Instruments Used in Fracture Reduction������������������������������������   19
Ippokratis Pountos, K. Newman, and Peter V. Giannoudis
3 Direct and Indirect Reduction: Definitions, Indications,
and Tips and Tricks ����������������������������������������������������������������������   31
Stuart Aitken and Richard Buckley

Part II Innovations in Fracture Reduction

4 Innovations in Fracture Reduction

Computer-Assisted Surgery����������������������������������������������������������   43
Rami Mosheiff and Amal Khoury
5 Inflatable Bone Tamp (Osteoplasty)
for Reduction of Intra-articular Fractures����������������������������������   51
Peter V. Giannoudis and Theodoros Tosounidis
6 Innovations in Fracture Reduction: Poller Screws ��������������������   59
Theodoros H. Tosounidis and Peter V. Giannoudis
7 Assessment of Reduction ��������������������������������������������������������������   69
David J. Hak
8 General Principles of Preoperative Planning������������������������������   77
Charalampos G. Zalavras

Part III An Anatomical Based Approach: Upper Extremity

9 Acromioclavicular Joint Dislocation��������������������������������������������   89

Paul Cowling
10 Sternoclavicular Joint Dislocations����������������������������������������������   93
Harish Kapoor, Osman Riaz, and Adeel Aqil

vii
viii Contents

11 Clavicle Fracture����������������������������������������������������������������������������   97

Makoto Kobayashi and Takashi Matsushita
12 Scapula Fractures�������������������������������������������������������������������������� 101
David Limb
13 Humeral Head Avulsion of Greater Tuberosity�������������������������� 109
Mark Philipson
14 Fractures of Proximal Humerus Open Reduction
and Internal Fixation�������������������������������������������������������������������� 113
Harish Kapoor, Adeel Aqil, and Osman Riaz
15 Humeral Shaft Fractures
(Transverse, Oblique, Butterfly, Bifocal) ������������������������������������ 121
Anthony Howard, Theodoros Tosounidis,
and Peter V. Giannoudis
16 Distal Humerus Fracture�������������������������������������������������������������� 133
Stefaan Nijs
17 Olecranon Fractures���������������������������������������������������������������������� 143
Odysseas Paxinos, Theodoros H. Tosounidis,
and Peter V. Giannoudis
18 Coronoid Fractures������������������������������������������������������������������������ 151
Mark Philipson
19 Radial Head and Neck Fracture �������������������������������������������������� 157
Austin Hill and David Ring
20 Monteggia Fracture and Monteggia-Like Lesion – Treatment
Strategies and Intraoperative Reduction Techniques���������������� 163
Dorothee Gühring and Ulrich Stöckle
21 Forearm Fractures ������������������������������������������������������������������������ 173
Katharina Sommer and Ingo Marzi
22 Galeazzi Fracture�������������������������������������������������������������������������� 191
Theodoros H. Tosounidis and Paul J. Harwood
23 Distal Radius Fracture������������������������������������������������������������������ 201
Georg Gradl
24 Distal Ulna Fractures�������������������������������������������������������������������� 227
Tristan E. McMillan and Alan J. Johnstone
25 Scaphoid Fracture�������������������������������������������������������������������������� 237
Anica Herlyn and Alice Wichelhaus
26 Perilunate Dislocation�������������������������������������������������������������������� 247
Laurent Obert, Francois Loisel, and Daniel Lepage
Contents ix

27 Metacarpal Fractures�������������������������������������������������������������������� 255

Sam Vollans
28 Bennett Fracture and Fracture of
Trapeziometacarpal Joint of the Thumb ������������������������������������ 261
Laurent Obert, Gauthier Menu, Daniel Lepage,
and Francois Loisel
29 Hand-Phalanx Fracture-­Dislocation (PIP Joint)������������������������ 271
Laurent Obert, Margaux Delord, Gauthier Menu,
Damien Feuvrier, Isabelle Pluvy, and Francois Loisel

Index�������������������������������������������������������������������������������������������������������� 277
 Part I
General Considerations
 Fracture Healing: Back to Basics
and Latest Advances
Ippokratis Pountos and Peter V. Giannoudis
The research on bone biology and healing over
the last decades has been intense. The reason for
this high research output can be attributed to two
elements: firstly, the discovery of mesenchymal
stem cells (MSCs), a population of multipotent
stem cells found to reside in bone marrow (and in
many other tissues within the body), which
opened new avenues in tissue engineering
approaches for bone regeneration, and secondly,
the discovery and commercialization of mole-
cules that can upregulate bone repair mecha-
nisms. The aim of this chapter is to present the
key aspects of bone healing biology, factors that
can influence it adversely, and key strategies
found to enhance the healing of fractures.
Types of Bone Healing
Bone healing is a well-orchestrated complex
process that results in the reconstitution of bone
continuity without the formation of scar ­tissue.
I. Pountos, M.B., M.D., E.E.C.
Academic Department of Trauma and Orthopaedics,
School of Medicine, University of Leeds, Leeds, UK
P.V. Giannoudis, M.D., F.R.C.S. (*)
Academic Department of Trauma and Orthopaedics,
School of Medicine, University of Leeds, Leeds, UK
NIHR, Leeds, UK
Musculoskeletal Biomedical Research Center, Chapel
Allerton Hospital, Leeds, UK
e-mail: pgiannoudi@aol.com
© Springer International Publishing AG 2018
P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_1
1
It prerequisites the coordinated interplay of
­multiple cell types with local and systemic cyto-
kines, chemokines, and growth factors. This local
milieu is influenced and often regulated by the
mechanical forces exerted locally. Bone healing
can be divided into primary and secondary types
of healing.
Primary
Primary bone healing occurs when there is a
small fracture gap and absolutely no movement
at the fracture site. The discovery of this type of
healing occurred over a century ago with the
introduction of stable internal fixation [1]. It
was initially called “healing by primary inten-
tion” and subsequently “soudure autogène,” but
following histopathologic studies, the terms
“direct” and “primary” bone healing were
established [2]. Primary bone healing is the
same process as the normal bone remodeling.
Bone production and apposition to fill the frac-
ture gap occur by the osteoblasts, in the same
way that the Howship lacunae are filled after
the action of “cutting cones.” It occurs in cases
where anatomic reduction and rigid internal
fixation are achieved or in incomplete stable
cracks of the bone. Fragment end resorption
does not occur and no callus is formed. This
form of bone healing is less frequent. The
majority of fractures heal through secondary
bone healing.
3
4 I. Pountos and P.V. Giannoudis

Secondary Bone Healing
Secondary bone healing is the type of healing
that occurs in the absence of rigid fixation. It rep-
resents an organized pattern of interlinked events
that aim to activate a number of different cell
types to prepare the fracture site for its consolida-
tion, to restore the vascularity, to produce a stable
mechanical environment, and once successful to
conclude with the ossification of the area. It has
been previously proposed that this type of heal-
ing occurs in three phases: the inflammatory,
reparative, and remodeling phases. These gener-
alized phases include a number of events, which
are often overlapping. A more comprehensive
description is that of the six stages of bone heal-
ing. Based on this descriptive system, healing
starts at the time of the injury with the formation
of fracture hematoma, followed by the inflamma-
tory stage, which concludes with the formation of
granulation tissue. Then, the formation of the soft
callus occurs that eventually calcifies and remod-
els (Figs. 1.1 and 1.2).
Fracture Hematoma
The formation of fracture hematoma represents a
distinct stage of the bone healing process. It is the
first and possibly the most important determinant
of the healing outcome. Several animal studies
have shown that removing the fracture hematoma
leads to an arrest of the healing process. Equally,
when fracture hematoma is injected in ectopic
sites, osteogenesis follows.
During fracture hematoma formation, a num-
ber of changes of the local microenvironment
occur. The disruption of blood supply leads to a
significant drop of the oxygen availability. The
low local oxygen saturation changes the genetic
expression of osteoprogenitor cells, promoting
their proliferation, formation of extracellular
matrix, and differentiation toward chondrocytes
[3, 4]. This environment also induces the release
of several inflammatory molecules, collagen, as
well as angiogenic and osteogenic growth fac-
tors. In addition to the hypoxia, the CO2 exuda-
tion from the dead and dying cells, the production
of lactic acid, and the conversion of blood sugars
make the local microenvironment acidic. This
acidic environment favors osteoclast resorptive
activity, and the levels of calcium increase by ten-
fold compared to peripheral circulating levels.
Phosphorous, alkaline phosphatase, lactic acid,
and beta and gamma globulins are also elevated
in fracture hematoma [5].

Fig. 1.1 The stages of Haematoma

secondary bone healing Granulation tissue
Activation of
coagulation cascade Active proliferation
Changes of local of osteoprogenitor
cells
environment Angiogenesis
Inflammatory cells
and molecules Extracellular matrix
released production
Inflammation
Recruitment and
activation of
inflammatory and
osteoprogenitor cells
Clearance of necrotic
tissues
Callus formation Remodeling
Soft and Hard Long process
Differentiation of (years)
MSCs according to Resorption of
the mechanical remaining cartilage
environment
Restoration of
Initial stabilization Haversian system
of fracture, then No scar formed
replaced by
calcified tissue
1 Fracture Healing: Back to Basics and Latest Advances
Hours 2d 7d
Clot
Inflammation
MSC
proliferation
Angiogenesis
MSC
differentiation
Bone formation
and remodeling
Fig. 1.2 Evolution of fracture healing over time
Inflammatory Stage
An adequate inflammatory phase is a pre-
requisite for successful bone healing [6, 7].
The inflammatory stage is activated after the
hematoma formation and serves mainly two
purposes. Firstly, it prepares the site for the
upcoming healing process and secondly elicits
pain that forces the individual to immobilize the
affected limb. A large number of cells invade
the fracture site attracted by the numerous
inflammatory molecules. Polymorphonuclear
leukocytes, lymphocytes, blood monocytes,
and macrophages are present and release cyto-
kines. They exert chemotactic effect, recruiting
further inflammatory and mesenchymal cells,
and stimulate angiogenesis, enhancing extra-
cellular matrix synthesis. RUNX1 (runt-related
transcription factor 1) expression predominates
which is important for the proliferation of the
hematopoietic stem cells and osteoprogeni-
tor cells [8]. TNF-α plays an important role in
the inflammatory stage, as it is significantly
upregulated. Absence of TNF-α delays fracture
healing, while excessive amounts destroy the
bone [9, 10]. A number of cytokines are pres-
ent, but their exact role is still largely obscure.
Interleukin-17 (IL-17) has a dual effect enhanc-
ing osteogenic output but also bone resorp-
tion by the osteoclasts [11]. The levels of
many inflammatory (IL-6, IL-8, IL-12) and
5
14d 21d 6w-years
a­nti-inflammatory (IL-10) molecules are sig-
nificantly increased. Within the first week after
the fracture, the fracture site develops an osteo-
genic identity.
Granulation Tissue
Once the inflammatory stage expires, the area of
the fracture site is organized forming the granula-
tion tissue. The granulation tissue is a loose
aggregate of cells (mainly mesenchymal, endo-
thelial, and immune cells) scattered inside an
extracellular matrix. Mesenchymal stem cells
from the periosteum and adjacent tissues are seen
in the granulation tissue [12]. The fibrin deposits
are removed by macrophages and through the
actions of fibrinolytic enzymes. There is a signifi-
cant mitogenic activity at the area, which is sup-
ported by the formation of new small blood
vessels.
Soft Callus
Soft callus is closely related to the formation of
cartilage through endochondral ossification.
Endochondral ossification can be seen as an
attempt of the body to improve the stability at the
fracture site, allowing the ossification process to
commence. The soft callus extends throughout
the fracture gap connecting the ends of the bone.
This process is similar to the bone growth
observed in the growth plate. Chondrocytes start
6 I. Pountos and P.V. Giannoudis

preparing cartilage and extracellular matrix. The Remodeling

cellular density is significantly higher to that of The remodeling stage is the final stage of second-
healthy articular cartilage but its organization is ary bone healing that can last for many years. It
different [13]. In addition to chondrocytes, fibro- represents a gradual modification of the architec-
blasts start laying down stroma that helps and ture that ultimately reestablishes the typical
supports vascular ingrowth. It has been previ- osteon structure and the haversian system of the
ously shown that smoking adversely affects this bone [19]. This is done under the same mechani-
particular aspect of bone healing, i.e., vascular cal stresses involved in the normal remodeling of
ingrowth [14, 15]. the bone [20]. The end result resembles the pre-­
fracture state of the bone.
Hard Callus
Hard callus is synonymous to the formation
of woven bone. Depending on the stability of Factors Affecting Bone Healing
the fracture site, woven bone can be formed
immediately after the formation of granula- The last century was characterized by a revolu-
tion tissue through intramembranous ossifi- tion in our understanding of bone biology and
cation (stable fracture), or it can follow the fracture management. Among the pioneers are
endochondral ossification. During the intra- the members of the Arbeitsgemeinschaft für
membranous ossification, osteoprogenitor cells Osteosynthesefragen (AO) group who identified
differentiate directly to osteoblasts, without some of the key principles governing fracture
the formation of cartilage as an intermediate management, such as (1) accurate anatomical
step. In less stable fractures, the cartilage pre- reduction, (2) rigid internal fixation, (3) sound
viously formed by chondrocytes is replaced by atraumatic surgical technique, and (4) respect for
the bone. Irrespectively of the route followed, the soft tissue envelope. A number of factors
osteoblasts release vesicles that contain cal- have been found to interrupt the normal flow of
cium phosphate complexes into the matrix [16]. the bone healing process. These factors can be
They also release enzymes that degrade the pro- broadly divided in fracture or injury dependent
teoglycan-rich matrix and hydrolyze phosphate and patient dependent (Table 1.1).
esters to provide phosphate ions for precipita-
tion with calcium [17]. The transition from
cartilage formation to bone formation is not yet
Table 1.1 Factors affecting bone healing
fully elucidated. The simplest theory is based
on the property of cells of mesenchymal origin Local factors Systemic factors
to swap fates and become a different cell types. • Location • Age
• Type of the fracture • Metabolic state and
It was previously shown that fully differenti- • Fracture gap nutrition
ated osteoblasts with detectable alkaline phos- • Bone • Vitamins and mineral
phatase activity and elaboration of calcified loss—comminution deficiencies
extracellular matrix can redifferentiate to other • Degree of local • Smoking, alcohol
trauma (injury and • Systemic diseases
cell types like adipocytes and vice versa. This iatrogenic) – Diabetes
phenomenon is termed genetic reprogramming • Blood supply – Vascular disease
or transdifferentiation. Another hypothesis sug- • Method of fixation – Cancer—radiotherapy
gests that chondrocytes became engulfed in the • Level of fracture • Drug
stability • Corticosteroids
newly formed matrix, stop producing cartilage, • Presence of • NSAIDs
and eventually die [18]. Chondrocyte cell death infection, foreign • Antibiotics
seems to occur at the border of the soft callus, material, debris, • Anticoagulants
just within the newly produced matrix [18]. dead tissue • Antineoplastic
1 Fracture Healing: Back to Basics and Latest Advances 7

Patient Dependent as well as the cellular flow to the fracture site.

Nutrient and systemically released molecule
Age and Gender availability can be compromised. Literature has
shown that in such situations, i.e., compromised
Patient’s gender does not increase the risk of peripheral blood supply, inhibition of the bone
delayed healing or non-union. Males, however, healing process can occur [30]. A circulatory
have an increased risk of complications with assessment should always be performed in
healing due to the higher incidence of high-­ patients that have sustained a fracture especially
energy fractures. those with vascular disease.
Children heal faster than adults and a non-­ Increased healing times and higher risk of
union is a rare occurrence [21, 22]. Children non-union have been demonstrated in patients
have a higher regeneration potential and thick with diabetes. Growth factors like the VEGF and
periosteum and form large subperiosteal hema- TGF-β were found to be reduced in diabetes, and
toma [21]. These factors contribute to the rapid insulin availability seems to be an important fac-
formation of callus (seen in children) [21, 22]. tor during bone healing [31]. The effective man-
In adults, animal and experimental models have agement of diabetes in these patients is critical to
shown that bone healing potential declines with minimize the potential complications [32].
age [23]. Some clinical studies have shown that Hypothyroidism has been found to inhibit
age is a negative predictor for healing in specific endochondral ossification and delay bone healing
fracture types like fractures of the clavicle and [33]. As undiagnosed hypothyroidism is quite
hip [24, 25]. However, whether this increased prevalent in the general population (approxi-
risk is related to the age per se or is related to mately 5%), screening in high-risk patients
the increased number of comorbidities seen in should be performed [34].
elderly is yet to be further elucidated [26]. Anemia is associated with significant defi-
ciencies in bone healing. This has been evident
in both clinical and animal studies [35]. These
Comorbidities findings have been attributed to the availability
of oxygen at the fracture site and the impair-
Malnutrition and metabolic deficiencies repre- ment of cellular functions like the production of
sent major risk factors for unsuccessful bone collagen [36].
healing. In addition to the general health state, Other comorbidities that have been associated
the patient’s body should be able to cope with with an impairment of bone healing include renal
the increased metabolic requirements [27]. disease, rheumatoid arthritis (possibly related to
Deficiencies in calcium, phosphorus, vitamins the use of steroids), and obesity [37].
C and D, albumin, and proteins were all shown
to affect bone healing and functional recovery
following a fracture [28, 29]. These parameters Drug Administration
should be checked and corrected in all high-risk
patients. The antineoplastic drugs have strong antiprolif-
Following a fracture, the local trauma and erative and cytotoxic properties. They inhibit
swelling impair the blood supply to the fracture angiogenesis and callus formation and result in
site. In patients with peripheral vascular disease, higher non-union rates [38]. Similarly, antiangio-
blood supply is already compromised resulting in genesis agents have a detrimental effect on frac-
a critical supply to the bone and soft tissue ture healing, and the final outcome resembles
­envelope. The oxygen transport can be reduced atrophic non-union [39].
8 I. Pountos and P.V. Giannoudis
Corticosteroid administration leads to osteo-
blast apoptosis, osteocyte apoptosis, and i­ nhibition
of osteoblastogenesis. Patients on long-term ste-
roids are likely to suffer of low bone mass and
have a higher incidence of fractures [40]. During
bone healing the length of corticosteroid admin-
istration and dose are two critical parameters.
Prolonged administration and high doses seem
to be detrimental for bone healing. Smaller doses
can downregulate fracture healing as well; hence,
the clinicians should decide on risks versus the
benefits basis [41]. In addition to corticosteroids,
disease-modifying drugs like methotrexate are
widely used for the treatment of chronic diseases.
The available evidence is limited and mainly
related to methotrexate. Methotrexate seems to
have a dose-dependant effect on experimental
studies with low doses being relatively safe [42].
The clinical case series presenting bone healing
complications are related to higher doses similar
to the ones used in cancer treatment [43]. There
is limited evidence in regard to the remaining
disease-­modifying drugs [42].
Nonsteroidal anti-inflammatory drugs
(NSAIDs) are effective medications for the man-
agement of acute musculoskeletal pain. They
block the cyclooxygenase activity and inhibit the
synthesis of prostaglandins, which are potent
mediators of pain and inflammation [20]. Their
analgesic effect in patients with fractures has
been graded equal to that of stronger opiates [20].
The numerous experimental studies available are
inconclusive and present diverse and contradict-
ing results [20]. With regard to the clinical stud-
ies, there is sufficient evidence to suggest that
NSAIDs can inhibit bone healing and the forma-
tion of heterotopic bone [44, 45]. Non-union risk
was shown to double or even triple among vari-
ous studies [46]. In balance of evidence, it seems
judicious to avoid exposure to NSAIDs in patients
with fractures.
Antibiotics play an important role in trauma
care and fracture management. They are most
frequently administered systemically but also
applied locally, usually loaded onto the bone
cement. Current literature is rather insufficient to
allow a clear statement on whether they inhibit
bone healing. Fluoroquinolones at therapeutic
doses were found to interfere with the early
stages of bone healing in small animal models
[47]. Other drugs like tobramycin, rifampicin,
and gentamicin were also found to downregulate
the functions of osteoblasts [48]. Combinations
of antibiotics could be detrimental in osteopro-
genitor proliferation and differentiation, although
the same antibiotics in isolation do not exhibit
significant effects. Often underestimated are the
kinetics of antibiotics loaded on cement which
can reach concentrations 1000-fold higher that
the systemically applied ones. Such high doses
were shown to have detrimental effects on bone
cells biology.
Anticoagulants are prescribed in the majority
of hospitalized and non-weight-bearing patients
to prevent deep venous thrombosis. Studies that
evaluate their direct effect on human osteopro-
genitor cells, quite uniformly, suggest that they
reduce the proliferation and differentiation poten-
tial of osteoprogenitor cells and several osteogenic
markers like BMP-2 and IGFs [49]. With regard
to the in vivo experimental studies, contradictory
results exist; some studies suggest that anticoagu-
lants can impair bone healing, while others con-
tradict these results [50]. At present there are no
clinical studies to address this in humans [53].
Smoking and Alcohol
Smoking has several adverse effects on the
human skeleton. It decreases the proliferative
capacity of osteoblasts, reduces the overall bone
mineral density, increases the rate of hip frac-
tures, and decreases its healing capacity [51].
Currently several hypotheses exist for the mode
of action of tobacco smoking on the skeleton;
reduced blood supply, increase of oxygen inter-
mediates, interference with arteriole receptors,
and inhibition of vitamins are all potential path-
ways [52]. The vast majority of orthopedic litera-
ture highlights the importance of ceasing smoking
with clinical studies uniformly showing that
smoking delays bone healing, significantly
increases the risk of non-union and, and at least
doubles the risk of infection in patients undergo-
ing surgery [53].
1 Fracture Healing: Back to Basics and Latest Advances
Chronic alcohol consumption induces osteo-
penia and increases the risk of falls. Alcohol is
found to downregulate bone formation through a
dose-dependant adverse effect on the functions of
osteoblasts. It is of great interest that Saville have
shown that the bone density measured in the left
iliac crest of alcoholics below 45 years of age
was similar to that of nonalcoholic men and
women older than 70 years [54]. In addition,
alcohol inhibits the proliferation and differentia-
tion of MSCs as well as the production of ossified
bone matrix [55]. Clinical studies have shown
that alcoholism is associated with osteomalacia,
impaired fracture healing, and aseptic necrosis
(primarily necrosis of the femoral head) [55].
In addition to smoking and alcohol consump-
tion, the use of recreational drugs also impairs
bone mineral density and bone healing capacity.
The available literature is limited, but the available
studies clearly highlight an adverse effect [56].
Genetic Predisposition
A significant number of patients with an atrophic
non-union do not have any of the aforementioned
risk factors. These patients are most often young,
active, fit and well, and without any conditions
that are known to interfere with bone healing. The
theory of “genetic predisposition” to equation of
fracture non-union has been supported by a num-
ber of authors. Animal studies have shown that a
downregulated expression of various bone mor-
phogenetic proteins, bone morphogenetic protein
inhibitors, fibroblast growth factor signaling path-
way, and insulin-derived growth factor can result
in non-union [57]. In humans, an association
between the CCG haplotype of PDGF-A, specific
variants of the TLR4 (mutated 1/W) and TGF-β
(mutated homozygote T and heterozygote C/T),
and the occurrence of non-unions has been shown
[58]. In addition Dimitriou et al. showed that two
specific polymorphisms of two inhibitors of the
BMP pathway, the noggin (the G/G genotype of
the rs1372857 SNP) and Smad6 (the T/T geno-
type of the rs2053423 SNP), were associated with
a greater risk of fracture non-union [59].
9
Fracture Dependent
In addition to the patient-dependent factors,
local factors related to the injury are important.
Among them, the fracture personality, location,
extent of soft tissue damage, and fixation
method are critical elements for the bone heal-
ing process.
Fracture Personality and Location
The orientation of the fracture line and the
underlying bone are two factors that can influ-
ence the bone healing process. The orientation of
the fracture line influences the surface areas of
bony contact and can influence the healing. The
differences in the repair process between undis-
placed and displaced fractures are well docu-
mented. They involve retardation of the rate as
well as an increase in the amount of cartilage
formed and a decrease in the amount of primary
bone formation between the fracture ends [60].
The location of the fracture can be also an impor-
tant factor. Different healing rates are reported
between different bones. For instance, reported
non-union rates ranged from up to 18% in tibial
diaphysis but 1.7% in the femoral shaft after
reamed nailing [61].
The fracture gap can directly influence the
healing process. A gap of 2 mm or higher can
adversely affect the bone healing process [62].
Claes et al. compared three different gap sizes:
small, medium, and large [62]. Comparing the
small to the medium fracture gaps, a large callus
was noted with lower fracture stiffness in the
group with medium fracture gap. The group with
the large gap produced little callus and had low
stiffness. In addition to the amount of callus for-
mation, the fracture gap influences the revascu-
larization of the fracture site [63]. Other factors
that can influence the fracture healing process
include the amount of bone loss, the fracture
comminution, and the presence of debris or
necrotic tissue or other foreign materials [64].
Finally, the presence of infection has devastating
outcomes on the overall healing process.
10
Soft Tissue Envelope
The degree of local trauma is crucial for fracture
healing. An intact soft tissue envelope will pre-
vent the escape of fracture hematoma, provide
osteoprogenitor cells, and contribute to the angio-
genesis of the fracture site. It will also act as a
barrier against pathogen invasion. The amount of
trauma and the condition of the soft tissue enve-
lope are related to the amount of callus that is
formed. Moderate soft tissue trauma delays new
bone formation but only in the early phase of
fracture healing [65]. The latter occurs because
the surrounding soft tissues are the primary sites
to support the bone healing by acting as an impor-
tant vascular source to deliver oxygen, nutrients,
and osteoprogenitor cells to the fracture area.
Vascular damage accompanying skeletal injury
increases the rate of non-union by fourfold [66].
It requires muscle flap coverage that increases the
local bone blood flow and the rate of osteotomy
union compared to skin repair, thus supporting
the vascular role of muscle in bone regeneration
[67]. In addition to the blood flow, the surround-
ing soft tissue contributes in terms of osteogenic
growth factors, cytokines, and chemokines [67].
Reverte et al. demonstrated that tibial fractures
with associated soft tissue injury significantly
impaired fracture healing [68]. They showed that
the rate of delayed union or non-­union in tibial
fractures with associated compartment syndrome
was 55%, in comparison to 17.8% in patients
with tibial fracture without associated compart-
ment syndrome [68].
Iatrogenic damage to the bones’ soft tis-
sue envelope is a parameter often overlooked.
The surgical approach used, the manipulation to
reduce the fracture, and the preparation for the
application of the implant are all factors that can
lead to a vascular compromise of the fracture site.
Another factor often underestimate is the exces-
sive stripping of the periosteum during plating and
the pressure of the plates on the on the periosteal
surfaces. A sound surgical technique and the use
of low contact implants help to reduce the area of
contact. Today’s LC-DCP plates use a trapezoidal
cross section, which varies along the length of the
plate, to reduce the impact on the periosteum.
I. Pountos and P.V. Giannoudis
 ixation Method and Mechanical
F
Stability
The mechanical stability is closely related to the
fracture itself and the method used for fixation. It
has been previously shown that small interfrag-
mentary movement is beneficial to fracture heal-
ing but small interfragmentary movement is
critical. Claes et al. have shown that the fate and
output of osteogenic cells are related to the
mechanical environment [69]. In particular, intra-
membranous ossification found to occur with
small strain and small hydrostatic pressures,
while endochondral ossification occurred with
higher hydrostatic pressures. Large strains were
found to lead to connective tissue formation. The
proliferation and transforming growth factor beta
production of osteoblasts were increased for
strains up to 5% but decreased for larger strains.
In addition to the in vitro models, it has been
shown that excessive macroscopic movement can
arrest the fracture healing process or result in the
refracture of the hard callus [70]. On the other
hand, the absence of any strains can result in the
remodeling mechanisms to prevail over the mod-
eling drifts, and the net result would be removal
of callus with delayed or failed bone healing [70].
The fracture fixation can significantly change
the biology of bone healing. Fractures treated
with the AO principles of absolute stability heal
through primary bone healing without the forma-
tion of callus. On the other hand, if the same frac-
ture is fixed through the relative stability
principle, the fracture will heal with indirect bone
healing with callus formation (Fig. 1.3). In addi-
tion to the mode of healing, the type of fracture
fixation used can alter the outcome. It has been
shown, for example, that humeral shaft fractures
treated with an intramedullary device carry worse
outcome in comparison to those treated with
­plating [71]. Another example is the different
union rates between reamed and unreamed femo-
ral nail with regard to the delayed union and non-
union rate [72]. Even minor adaptations of the
principles can alter the outcome. In a study by
Krettek et al., for instance, 99 open tibial shaft
fractures were treated with external fixation,
which was complemented with a lag screw [73].
1 Fracture Healing: Back to Basics and Latest Advances 11

The result was a significant reduction in fracture

consolidation. In a similar study, good union
rates were documented with external fixation
alone [74].

 pproaches to Enhance Bone

A
Healing

A number of different approaches have been

described to enhance the bone repair response
(Table 1.2). Moreover, the conceptual framework
of the diamond concept has been described to
assist the clinicians to appreciate the most impor-
tant components of fracture healing that must be
present for a successful outcome (Fig. 1.4) [75].

Bone Grafting

Autologous bone grafting from the iliac crest

Fig. 1.3 Anteroposterior right tibia radiograph 14 months
after originally the fracture was fixed with an intramedul-
lary nail which was removed at 12 months following frac-
ture union. The arrow demonstrates that union occurred
with indirect/secondary bone healing (callus formation)
contains all the required elements for bone heal-
ing [76]. It has osteoinductive, osteoconductive,
and osteogenic properties. It can be harvested
with a simple technique; it has low cost and no
risk of disease transmission or immunorejection.
On the other hand, autologous bone grafting is
associated with significant donor site morbidity,
often with persistent pain at the harvest site. It
can be of limited volume, and the isolated graft,
unless tricortical, does not offer any structural
support [77].

Table 1.2 Potential Application of osteogenic materials Systemic enhancement

applications for the
upregulation of bone
healing
Autologous bone Parathyroid hormone
Autologous bone marrow Biphosphonates
Reamer-irrigation aspiration graft Anti-sclerostin antibodies
Combined grafts (Diamond concept) Anti-Dickkopf-related protein 1
antibodies

Local growth factor applications

Bone morphogenetic proteins (BMPs)
Fibroblast growth factors (FGF)
Vascular Endothelial growth factor
(VEGF)
Platelet-derived growth factors (PDGF)
Molecules involved in Wnt pathway
Biophysical Stimulation
Electromagnetic field stimulation
Low-intensity pulsed ultrasound
stimulation
Etracorporeal shock wave therapy
12 I. Pountos and P.V. Giannoudis

a­spirates exist; however, difficulties regarding

Blood Osteogenic Growth the high volume of the injectable formulation and
Supply Cells Factors
Scaffo
the technical issues resulting in inconsistencies in
ity
d Stabil the number of MSCs and the volume of the bone
Fracture marrow require further research.
Healing

Application of Growth Factors

Bone morphogenetic proteins (BMPs) are mole-

cules involved in many functions of the body
Fig. 1.4 Diamond concept of fracture healing demon-
including development, repair, and regeneration.
strating the key players that must be present for a success- BMP-2 and BMP-7 have become commercially
ful bone repair response available for clinical applications including open
tibial fractures and lumbar spine fusion or under
a humanitarian device exception [80]. However,
In addition to the autologous grafting from the their off-label application has been diverse.
iliac crest, grafts obtained with the use of the BMP-2 and BMP-7 are potent osteoinductive
reamer-irrigator-aspirator (RIA) system molecules; both upregulate the osteogenic differ-
(Synthes®, Inc. West Chester, Philadelphia) have entiation and osteogenic output. Clinical results
gained popularity over the years. A larger volume of studies investigating the bone healing have
of graft material can be harvested, capable to fill been favorable [80, 81].
large bone defects. Unfortunately, RIA grafts Platelet-rich plasma (PRP) is an increased
contain no or little osteoprogenitor cells (most concentration of autologous platelets suspended
contained in the waste water) [78] and are associ- in a small amount of plasma after centrifugation.
ated with a number of complications. Significant The activation of platelets results in the release of
intraoperative blood loss with need for transfu- several molecules involved in the clotting cas-
sion as well as thinning of the cortex and iatro- cade but also growth factors stored in the platelet
genic fractures can occur [74]. A large number of α-granules. Such molecules include the platelet-­
bone graft materials are currently commercially derived growth factor (PDGF), insulin-like
available; none, however, is found to outperform growth factor (IGF), vascular endothelial growth
the autologous bone grafts. factor (VEGF), platelet-derived angiogenic fac-
tor (PDAF), and transforming growth factor beta
(TGF-β) [82]. This technique is relatively safe
Application of Cells and of low cost. The experimental studies have
been favorable; however, in a recent meta-­
Bone marrow aspirates contain MSCs, which analysis including 23 RCTs and 10 prospective
are renowned of their osteogenic and angiogenic studies, the authors questioned its overall effec-
properties. These cells have the capacity of self-­ tiveness in fracture healing [83].
regenerating and are able to produce some of the Platelet-derived growth factor is a potent pro-
key molecules involved in bone healing (BMPs, moter of osteogenic cell proliferation, differen-
VEGF, etc.). Several authors have shown that a tiation, and osteogenic output. It also regulates
simple bone marrow injection in the fracture or chemotaxis and angiogenesis at the fracture
non-union site can result in healing in approxi- site [84]. A prospective RCT including 434
mately 90% of cases [79]. Hernigou et al. found patients undergoing hindfoot or ankle arthrod-
that there was a significant correlation between esis has shown that PDGF with beta-tricalcium
the numbers of MSCs with the clinical outcome. (Augment® Bone Graft, Wright Medical)
Techniques to concentrate the bone marrow results in comparable fusion rates as autologous
1 Fracture Healing: Back to Basics and Latest Advances
grafting but with less side effects and less com-
plaints of pain [85].
Systemic Biological Factors
Parathyroid hormone (PTH) is a naturally occur-
ring hormone that is known to increase the bone
density. Its effect seems to be directly related to
the osteogenic cell lineages and through interac-
tion with the Wnt pathway. Experimental and
clinical results have been encouraging [86]. In
elderly patients with pelvic fractures, PTH
administration resulted in a faster time to union
compared to controls [86, 87]. In a similar study,
faster healing times were also noted in patients
suffering of distal radial fractures [88].
Bisphosphonates are inhibitors of osteoclastic
activity. Experimental studies have shown how-
ever that they could also enhance fracture healing
[89]. Despite the fact that the clinical studies are
very limited, some of the data presented seem
promising [90].
Physical Stimulation
Several devices nowadays are marketed as bone
stimulators. They are appealing as they are non-
invasive and with minimal complications. These
devices can be broadly divided into three catego-
ries: electrical stimulators, low-intensity pulsed
ultrasonography, and extracorporeal shock wave
therapy.
Electrical stimulators are devices capable of
generating an electrical potential at the fracture
site. It was previously found that during fracture
compression an electronegative potential is cre-
ated which can trigger bone formation [91]. On
the contrary an electropositive potential leads to
bone loss. Therefore, applying the appropriate
electrical potential can result in bone formation
at the fracture site. Experimental studies were in
the majority in favor of this theory [91]. Clinical
studies have been inconclusive. A recent meta-­
analysis has concluded that there was no signifi-
cant impact of electromagnetic stimulation on
delayed unions or ununited long bone fractures.
13
However, some uncertainty exists due to the
methodological limitations and the high between-­
study heterogeneity [91].
The low-intensity pulsed ultrasonography
(LIPUS) principle is based on the production of
its sound waves that generate micro-stresses at
the fracture site. The cells present at the fracture
site can be stimulated by these stresses and
increase their osteogenic output. LIPUS was
found to accelerate mineralization in vitro
through the upregulation of the expression of
osteocalcin, alkaline phosphatase, VEGF, and
MMP-13 [92]. In vivo evidence also suggests
that LIPUS can accelerate all stages of the frac-
ture repair process (inflammation, soft callus for-
mation, hard callus formation). However, in a
recent meta-analysis of the available evidence, it
was suggested that LIPUS does not improve out-
comes and probably has no effect on radiographic
bone healing [93].
Extracorporeal shock wave therapy produces
a single high-amplitude sound wave that propa-
gates through the fracture site. These shock
waves stimulated cellular changes promoting
the production of several osteogenic growth
factors. Some evidence that extracorporeal
shock wave therapy is effective for hypertro-
phic non-unions than atrophic non-unions
exists, but most of the current knowledge is
based on level 4 evidence, and further studies
are needed to confirm whether any benefit
exists [94, 95].
Conflict of Interest No benefits in any form have been
received or will be received from a commercial party
related directly or indirectly to the subject of this chapter.
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 Instruments Used in Fracture
Reduction
Ippokratis Pountos, K. Newman,
and Peter V. Giannoudis
Fracture reduction can be achieved by either
direct or indirect means [1, 2]. Direct reduction
means that the forces and moments applied
when attempting to realign the bony fragments
act at the vicinity of the fracture site, while, in
indirect reduction, the forces are applied distally
to the fracture site [3]. Direct reduction is often
performed by direct visualization of the fracture
site through surgical exposure. Utilising mini-
mally invasive approaches, fractures can also be
reduced percutaneously.
Indirect reduction involves forces along the
axis of the limb, which in turn can result in frac-
ture realignment through the action of the sur-
rounding soft tissues (ligamentotaxis) [4, 5].
Indirect reduction can involve manual traction
with manipulation or can be combined with tools
like traction tables, distractors or external
fixators.
I. Pountos, M.B., M.D., E.E.C.
Academic Department of Trauma & Orthopaedics,
School of Medicine, University of Leeds, Leeds, UK
K. Newman, F.R.C.S.
St Peter’s Hospitals NHS Foundation Trust,
Chertsey, Surrey, UK
P.V. Giannoudis, M.D., F.R.C.S. (*)
Academic Department of Trauma & Orthopaedics,
School of Medicine, University of Leeds, Leeds, UK
NIHR, Leeds, UK
Musculoskeletal Biomedical Research Center,
Chapel Allerton Hospital, Leeds, UK
e-mail: pgiannoudi@aol.com
© Springer International Publishing AG 2018
P.V. Giannoudis (ed.), Fracture Reduction and Fixation Techniques,
https://doi.org/10.1007/978-3-319-68628-8_2
2
In reality, not infrequently, combination of
both direct and indirect techniques is often per-
formed. Irrespectively of the reduction technique
used, our current armamentarium in fracture
reduction aids is ever expanding. The most com-
monly used instruments are described below. In
general terms the instruments can be divided into
external devices and internal devices.
External Devices
In this category the most commonly used devices
include fracture tables, bumps and bolsters, crutches,
skeletal traction, PORD, F-tool, large distractor and
external fixator devices, amongst others.
Fracture tables with the capacity for skeletal
traction are widely used in fracture management
[6]. Fracture tables are radiolucent and designed
to achieve and maintain satisfactory reduction of
the fracture. The two most commonly used frac-
ture tables are the traction table (Fig. 2.1) and the
OSI table (Figs. 2.2 and 2.3).
Most often no further manipulation of the
fracture is required once the patient is posi-
tioned. Patient positioning on the fracture table
is often critical. A thorough preoperative plan-
ning with anticipation of potential difficulties
and easy access for fluoroscopic imaging is
essential [6]. Nowadays, fracture tables are mod-
ular, can adjust patient’s position with easiness
and can take numerous attachments to assist
19
20 I. Pountos et al.

a b

Fig. 2.1 (a) Schematic representation of traction applied right femoral fracture. Traction has been applied on the
to right lower leg using a fracture table. (b) Patient placed right hand side to reduce the femoral fracture
in the supine position on a fracture table with an open

Fig. 2.2 A polytrauma patient

with a pelvic external fixator
(sustained vertical shear fracture)
is placed supine on an OSI table
where, with the appropriate
attachment device, traction is
applied through a right distal
femoral pin to reduce the right
hemipelvic disruption

Fig. 2.3 Patient has been

positioned prone on the
OSI table with skeletal traction
(distal femoral pin) applied on
the right distal femur to reduce
acetabulum fracture
2 Instruments Used in Fracture Reduction 21

fracture reduction (Fig. 2.4). Setting up the
patient can be labour intensive, which increases
operative time, and performing multiple surger-
ies in the same setting is often challenging [7, 8].
Noteworthy, complications from patient posi-
tioning can occur and must be minimized. Such
complications can range from skin necrosis,
nerve palsy and compartment syndrome to iatro-
genic fractures [9].
Coexisting injuries and body habitus often
preclude the use of the fracture table. In such cir-
cumstances the use of the standard radiolucent
table is required. Manual traction or the use of
skeletal traction (Fig. 2.5) devices can accom-
plish the same objective with no impact on the
final outcome [10]. However, an additional assis-
tant devoted to holding and maintaining traction
is required.
A number of adjuncts can be used during
patient positioning on the operating table. Bumps
and bolsters can change patient position, main-
tain the correct orientation of the limb or assist in
muscle relaxation during fracture reduction
(Figs. 2.6 and 2.7) [11]. Alternatively, special
table attachments can be used, for example, the
posterior reduction device, (PORD™), which
can be used as a fulcrum to relax the gastrocne-
mius and soleus complexes in femoral or hip
fracture fixation (Fig. 2.8) [11, 12].

Fig. 2.6 Intraoperative picture showing a bump to con-

trol AP sag of knee

Fig. 2.4 Complementary reduction device attached on

the OSI table to assist the reduction of pelvic/acetabulum
fractures

Fig. 2.7 Bolsters to control rotation of leg

Fig. 2.5 Traction applied using a distal femoral pin

intraoperatively Fig. 2.8 Posterior reduction device (PORD)
22
Fig. 2.9 Use of a Schanz screw attached to a T-handed
chuck for fracture reduction in sagittal and coronal planes
for insertion of nails
Schanz screws can be inserted percutaneously
and can be used as joysticks for manipulation and
reduction of the most displaced fracture segment
(Fig. 2.9). The T-handed chuck attached to a
Schanz pin can be a powerful combination in
manipulation and derotating large bony frag-
ments. K-wires applied on the fracture fragments
can be used also as joysticks to achieve fracture
reduction [13]. Further interfragmentary K-wires
can be used as a temporary fixation method to
maintain intrafocal reduction. In large bone frag-
ments or when manipulation of the whole limb is
required, Schanz pins can be used. Kapandji
technique involves the insertion of a K-wire
through the fracture gap [14]. Similar to the
reduction technique with the use of a Hohmann
retractor, manipulation of the distal fragment can
occur. Definite stabilization is achieved by pass-
ing the K-wire through the distal cortex.
The femoral distractor is composed of a
threaded spindle carrying a fixed and a sliding
end piece (Fig. 2.10). Schanz screws are fixed
through the end pieces, and the distractor is
positioned parallel to the axis of the bone. An
excursion of about 27 cm is built into the device.
More excursion is possible, but angular malpo-
sition of the end of the device may occur. Once
the bony fragments are adequately reduced, the
position is maintained by the secure tightening
of the connections. The distractor allows correc-
tion of length, rotation and angulation. Also,
unlike to the skeletal traction where distraction
I. Pountos et al.
Fig. 2.10 (a) Femoral distractor. (b) Intraoperative pic-
ture of a patient in prone position demonstrating the appli-
cation of a femoral distractor to reduce a combined
acetabulum and proximal femoral fracture
forces are applied to the whole limb, the femoral
distractor applies forces directly to the bone.
This makes the distractor readily adaptable in
coping with the awkward positioning problems.
It also eliminates the risk of nerve injuries, for
example, peroneal nerve palsy or pudendal
crush syndrome.
The external fixator is a versatile device. Its
use can range from the local damage control in
cases of compromised soft tissue envelope to the
definite management of fractures or bone trans-
port [15]. Not infrequently, the external fixator is
a valuable adjunct in fracture reduction and stabi-
lization. With the use of the external fixator, the
indirect reduction of the bony fragments can be
accomplished under image intensification. Once
reduced the position can be maintained while the
internal fixation plate is slipped under the soft tis-
sues. In some situations in which the internal fixa-
tion does not provide adequate stability, the
external fixator can be left in situ for a short period
of time, to provide additional support (Fig. 2.11).
The F-tool is a simple device composed of a bar
on which different rods can be installed [16]. It
allows focused forces to be concentrated at the
apex of the deformity. Once longitudinal traction is
applied to the limb, the F-tool can be used to cor-
rect deformity and angulation along one plane
(Fig. 2.12). The F-tool is not radiolucent and should
only be used in simple fracture configurations.
2 Instruments Used in Fracture Reduction 23

a b

Fig. 2.11 (a) Application of an external fixator for a dis- allowing minimal invasive plating osteosynthesis of the
tal tibial fracture. (b) Maintaining the lateral component distal tibial fracture
of the external fixator, fracture reduction was possible

a b

Fig. 2.12 (a) F-tool prior to assemblage. (b) F-tool connected. (c) Fluoroscopic image showing use of the F-tool for
reduction of middle one third femoral shaft fracture
Another random document with
no related content on Scribd:
 Good-bye little song-bird. Some day I hope to hear you sing again. Don't
forget—"

"LAURA DAWSON."

"That's not very likely," thought the little girl, "no, indeed. What can she be going to give
me for a Christmas-box?"

"Rose, is that you?" she called out, as she heard light footsteps approaching the door.

"Oh, do come in and listen to all my news!"

Then, as Rose came in, her blue eyes fall of curiosity, she continued excitedly, "I've had
such a dear, dear letter from mother, and she's sent me a pound for my very own, to
spend as I like. You'll help me about getting Christmas presents for every one, won't you?"

"Of course I will," agreed her cousin. "How is Aunt Margaret?"

"Oh, very well; she has written so brightly. Miss Dawson is ever so much better, and I have
had a little note from her. You shall hear what she says."

And Mavis read aloud the few lines Miss Dawson had sent her.

"I am wondering what the Christmas-box will be," she remarked afterwards.

"I expect it will be a nice present, and I hope it will be something you will like," said Rose.
"By the way, I came up to tell you that Mr. Moseley has been here, and he has got mother
to consent to your singing at his concert—it's not to be till New Year's Eve. Mother was
against the idea at first, but father said he was certain Aunt Margaret would have no
objection to it, and so she gave in. Mr. Moseley is very pleased, she says, and I think she's
glad now that you're going to take part in the concert. We shall all go to hear you sing. I
expect nearly every one in the village will be there. Shall you feel nervous?"

"I am afraid so, Rosie. I only hope I shall not break down."

"Oh, I don't fancy you'll do that. I envy you your voice, Mavis—at least, I don't envy it
exactly, but I wish I had a talent of some sort. I'm so very stupid; I can't do anything to
give people pleasure."

"Oh, Rosie, I am sure that is not true. Miss Matthews said the other day that you were the
kindest girl in the school. I told Aunt Lizzie that; she was pleased, though she didn't say
much. How can you be stupid, when you always manage to find out how to make people
happier by doing little things to please them?"

"Oh, that's nothing," exclaimed Rose. The colour on her cheeks had deepened as she had
listened to her cousin's words. "It would make me very unhappy to be unkind to any one,"
she added.

"I am certain it would."

"But I wish I had just one talent," Rose sighed. "If God had given me only one, I would
have been content."

Mavis looked troubled for a minute; then her face brightened as she responded hopefully—
"I think you're sure to have one, Rosie, only you haven't found it out."

CHAPTER IX
CHRISTMAS TIME

"THERE, now I have all my presents ready," Mavis declared in a satisfied tone, one
morning a few days before Christmas, as she dropped great splashes of red sealing-wax on
the small parcel she had already secured firmly with cord. "I do hope Miss Tompkins will
like the handkerchief sachet I'm sending her."

"I should think she will be sure to like it," said Rose, who was standing looking out of the
parlour window at the birds she had been feeding with bread-crumbs. "I wonder when Miss
Dawson's Christmas-box will arrive, Mavis."

"Soon, I expect. I should not be surprised if it came at any time now, for it's getting very
near Christmas, isn't it?"

The little girls' holidays had commenced two days before, and since then, they had been
very busy preparing for Christmas. Mr. Grey had kindly driven them into Oxford, one
afternoon, to make their various purchases, and but a shilling or so remained of Mavis'
pound, the rest having been spent in presents which were hidden in the bottom of her
trunk in her bedroom, to be kept secret from every one but Rose, until Christmas Day. For
kind Miss Tompkins she had bought a pink silk handkerchief sachet with birds painted on it,
and this, with a carefully-written note, she had packed in readiness to send off that
evening.

"I wonder what mother is doing in the kitchen," remarked Rose, presently. "She said at
breakfast she would have a leisureable day, as the puddings are boiled and the mincemeat
is made, and we're to have a cold dinner. But I've heard her bustling about as though she's
very busy. Let us go and see what she's doing."

Accordingly, the little girls repaired to the kitchen, where they found Mrs. John in the midst
of packing a hamper with Christmas cheer.

"I dare say I'm very foolish to do this," she was remarking to Jane, who was watching her
with a half-smile on her countenance, "but it's your master's wish, and I won't go against
him in the matter. There'll be ten shillings' worth in this hamper, if a penny, what with that
nice plump chicken, the pudding, a jar of mincemeat, a pound of tea, a pound of butter,
and—well children?" she said inquiringly, as the little girls came forward.

"Who is that hamper for, mother?" asked Rose, her curiosity alive in a moment.

"For Richard Butt's wife," was the brief answer.

"Oh, how kind of you, Aunt Lizzie!" cried Mavis. "How pleased she will be, won't she?"

"It's to be hoped so, and I dare say she will. But the kindness is not mine, child, it's your
uncle's. 'Fill in the corners of the hamper, Lizzie,' he said, and you see I'm doing it."
"I should like to be looking on when that hamper's opened," observed Jane, as her
mistress placed down the cover and began to cord it. "It'll arrive as a blessing, I reckon.
Butt was talking to me about his wife and child yesterday, and—"

"His child, Jane? I didn't know he had one," broke in Mrs. John, greatly astonished.

"The baby's only a fortnight old, ma'am. I didn't know there was one myself till yesterday."

"Is it a girl or a boy?"

"A boy, a fine healthy little chap, so Butt's mother-in-law has written to tell him."

"How he must wish to see the baby!" exclaimed Mrs. John, with a softening countenance.

"He's hoping to, before long, ma'am, for there'll be a cottage vacant in the village at
Christmas, and he means to take it. Then, as soon as he possibly can, he's going to ask
master to allow him a couple of days' holiday to fetch his wife and baby."

"He appears to have taken you into his confidence, Jane."

Jane nodded. The hamper was corded by this time, and all that remained to be done was
to address a label.

Mrs. John glanced out of the window, then turned to Rose.

"There's Butt in the yard now; he's going into Oxford with the waggon presently, so he can
send off the hamper himself from the station. Tell him I want him."

Rose went to do her mother's bidding, and a few minutes later returned, followed by
Richard Butt, who had greatly improved in appearance since the afternoon he had begged
from Mavis, and she had impulsively sent him around to the back door. Then he had looked
ragged, cold, and dispirited; now he was comfortably clad, and held his head erect once
more.

"What is your wife's address, Butt?" inquired Mrs. John.

"My wife's address, ma'am!" the man exclaimed, in amazement.

"Yes. This hamper is to go to her; it contains a chicken, and a pudding, and a few other
things, and you're to send it off from Oxford. Here's the money to pay the carriage. Tell me
the address."

He did so, and Mrs. John wrote it on the label, which she proceeded to affix to the hamper.

"Ma'am, I can never thank you properly," the young man stammered, quite overcome with
gratitude and surprise. He looked at the shilling Mrs. John had given him, then at the
hamper. "God bless you for your goodness!" he added fervently.

"It's your master's doing. It's nothing to do with me. There, take the hamper away with
you. By-the-by, I hear you've a little son, Butt; I hope his father will be a good example to
him."

The tone in which this was said was more cordial than the words, and Butt carried off the
hamper with a radiant countenance.

"I think I never saw any one look more pleased," observed Jane. "Who comes now?" she
exclaimed, as there was a loud knock at the back door.
She went to see, and reappeared bearing a large wooden box which she deposited on the
kitchen table, saying—

"It's come by the railway van, and it's directed to you, Miss Mavis. There's nothing to pay,
but you must please sign this book, to show it's been delivered safely."

"Oh, it's Miss Dawson's Christmas-box, for certain!" cried Rose.

Whilst Mavis, feeling very important and excited, signed the delivery book under Jane's
directions.

"Oh, Mavis, open it quickly and see what's inside! Here's a knife to cut the cord."

"Not too fast, Rose," said her mother. "Better untie the knots, then the cord will come to
use again—it's a good strong piece. Here, let me help," and she effected the task herself.
"There, Mavis, now you can set to work and unpack."

Mavis lifted the lid of the box, her hands trembling with excitement, and drew out several
packages, which, upon examination, proved to contain preserved fruits and sweetmeats in
pretty boxes, such as she had often seen in the shops at Christmas-time, but had never
dreamed of possessing. Then came a beautifully bound and illustrated story-book, and
several new games, at the sight of which Rose expressed much gratification, and, last of
all, a cardboard box, which, upon being opened, revealed to sight a seal-skin cap and a
muff to match.

"Oh!" exclaimed Mavis, quite incapable of finding words in which to express her delight.

"Put on the cap, Miss Mavis," said Jane. "Let us see how you look in it."

So Mavis placed the cap on her curly head, and glanced from one to the other with the
happiest of smiles on her pretty, flushed countenance.

"Yes, it suits you capitally," declared Jane. "Doesn't it, ma'am?" she questioned, turning to
her mistress.

"Yes, indeed," agreed Mrs. John. "I think, Mavis, that you are a very fortunate little girl,"
she proceeded, as she took up and examined the muff. "It is real seal-skin, I see, and
must have cost a pretty penny."

"There's Bob!" cried Rose, catching the sound of her brother's footsteps in the passage.
"Come and see Mavis' Christmas-box," she said, as he opened the door and entered the
kitchen. "Look at her seal-skin cap and muff, and all the rest of the presents she has had
sent her."

"What will you do with them all, Mavis?" asked Bob, as he came to the table and stood
with his hands behind his back, not liking to touch anything.

"We'll share all the sweeties, Bob," said Mavis; "of course we shall do that. I only want one
box of preserved fruit for myself, to give to Mrs. Long, and the rest I should like Aunt Lizzie
to put with the nice things she has bought for Christmas."

"Very well," Mrs. John agreed, pleased at the suggestion, "I will do so. You shall have some
of the fruit on Christmas Day and the rest later on, or we shall be having all the good
things at once. By the way, what makes you wish to give a present to Mrs. Long, Mavis?"
Mrs. Long was the stout, rosy-cheeked washerwoman Mavis had first seen on the day she
had said good-bye to her mother. On subsequent occasions, the little girl had held
conversations with her, but Mrs. John did not know that.

"She has been very kind to me, Aunt Lizzie," Mavis answered.

"Oh, I don't mean that she's done anything for me, you know," she continued, as she met
her aunt's glance of surprise, "but she's spoken to me so nicely about mother that I quite
love her. She says she knows what it is to be separated from some one, one loves very
dearly, for her only daughter married and went to New Zealand, and her husband's dead,
so that now she's all alone. I should like to give her a little present for Christmas, if you do
not mind."

"Of course I do not mind, child. All these things are your own, to do as you like with."

"I want other people to enjoy them too," Mavis said earnestly. "I never had anything to
give away before this Christmas."

She selected one of the prettiest of the boxes of preserved fruits, and, later in the day, she
and her cousins called at Mrs. Long's cottage in the village and presented it to the kind-
hearted washerwoman, who, needless to say, was exceedingly pleased.

What a happy Christmas that was, and yet how Mavis had dreaded it! It brought her
nothing but joy from the moment she opened her eyes on Christmas morning till, wearied
out, she closed them at night.

Afterwards, she wrote to her mother all about it, and told her how rich she was in
presents, for, besides Miss Dawson's Christmas-box, she had received remembrances from
every member of the household at the Mill House, and from Miss Tompkins too, as well as
Christmas cards from several of her schoolfellows.

"I have so many friends now," she wrote, "and last Christmas I had so few. When we meet
I shall have such a lot to tell you, dear mother. I can't write everything. I believe Aunt
Lizzie has written and told you that I am to sing at a concert on New Year's Eve; I am to
sing your favourite psalm. Mr. Moseley says my voice is a great gift. He is a very nice man,
and has been very kind to me—I think there are a great many kind people in the world."

Mavis had never so much as hinted to her mother that she was not on such cordial terms
with her aunt as with her other relations, for she could not explain why that was the case,
and, lately, she had got on with her rather better. Mrs. John had been obliged to admit to
herself that Mavis was not selfish, that she did not try to put herself before her cousins in
any way, and that she was quick to show gratitude for a kindness, and to respond to
affection. But what she did not understand in the child, was her capability of laying aside
trouble.

"She has just the nature of a song-bird," she would think, when Mavis' voice, lilting some
simple ditty, would fall upon her ears. "She's such a light-hearted little thing."

The concert, which was held in the village schoolroom on New Year's Eve, proved a very
great success. The performers were all well-known inhabitants of the parish, in whom the
audience—composed mostly of the labouring classes—took great interest.

Mavis' part of the programme did not come till nearly the conclusion of the concert, and
when the Vicar took her by the hand and led her on the platform, she felt it would be quite
impossible for her to keep her promise, and she was inclined to run away and hide. But, a
moment later, she had overcome the impulse which had prompted her to go from her
word, and looking above the many faces which were smiling up at her encouragingly, she
summoned up her courage and commenced to sing. Her voice was rather tremulous at
first, but it gained strength as it proceeded. She forgot the people watching her, forgot her
fear of breaking down, and thought only of what she was singing, of "pastures green" and
the Good Shepherd leading His flock by streams "which run most pleasantly." As her
sweet, clear voice ceased, there was a murmur of gratification from the audience, which
swelled into rounds of applause.

"Sing us something else, do, missie!" she heard some one shout from the back of the
schoolroom, and, looking in the direction from whence the voice came, she recognized
Richard Butt.

The rest took up the cry, and from all sides came the demand, "Sing us something else!"

"What else do you know, Mavis?" the Vicar hastened to inquire, when he saw she was
willing to comply with the general request.

"I know some carols," she replied. "Shall I sing one of those?"

"Yes, do," he said, as he moved away.

She was not feeling in the least nervous now. Her heart throbbed with happiness, as she
realized her capability of giving pleasure, and a brilliant colour glowed in her cheeks, whilst
her hazel eyes shone brightly.

The carol she sang was one she had heard in the little mission church in London during the
previous Christmas season, but it was new to her audience.

"'When shepherds were abiding,

In Beth'lem's lonely field,
They heard the joyful tidings
By the heavenly host revealed.
At first they were affrighted,
But they soon forgot their fear,
While the angel sang of Christmas,
And proclaimed a bright new year.'"

That was the first verse; several others followed, concluding thus—

"'When he who came to Bethlehem

Returns to earth again,
Ten thousand thousand angels
Shall follow in His train:
Then saints shall sing in triumph,
Till heaven and earth shall hear;
The year of His redeemed shall come,
A bright immortal year.'"

The carol was as successful in pleasing as had been the psalm, and Mavis stepped from the
platform and returned to her seat with the Mill House party, hearing commendatory
remarks on all sides.
"Oh, Mavis," whispered Rose, "you sang beautifully, you did indeed!"

And she expressed the opinion of the whole room, including Mrs. John, who, for the first
time, acknowledged that really Mavis owned a very sympathetic voice, and that the words
she had sung had seemed to have come from her heart.

CHAPTER X
SICKNESS AT THE MILL HOUSE

"OH, Mavis! Oh, Bob! Mother's very ill! Oh, isn't it dreadful? The doctor's going to send a
hospital nurse to take care of her, for he says she'll be ill for weeks, if—if she recovers!"
And Rose finished her sentence with a burst of tears.

The scene was the parlour at the Mill House one afternoon during the first week of the new
year. Rose had crept quietly into the room with a scared look on her face, having
overheard a conversation between her father and the village doctor, the latter of whom
had been called in to prescribe for Mrs. John, who had been ailing since the night of the
concert, when she had taken a chill.

No one had thought her seriously ill until that morning, when she had declared herself too
unwell to rise, and had been unable to touch the breakfast which her little daughter had
carried upstairs to her. Then it was that her husband had become alarmed, and the doctor
had been sent for. The medical man's face had worn a grave expression as he had left the
sick-room, and he had immediately informed Mr. Grey that his wife was seriously ill with
pneumonia, the result of a neglected cold.

"If she recovers?" echoed Bob, questioningly. "What do you mean, Rose? It's only a cold
that mother has, isn't it?"

"No, it's something much worse than that—pneumonia. Mrs. Long's husband died from
pneumonia." And poor Rose's tears and sobs increased at the remembrance.

"Oh, don't cry so dreadfully, Rosie," implored Mavis. "People often recover from
pneumonia, indeed they do! Mother has nursed several pneumonia patients since I can
remember, and not one of them died. You mustn't think Aunt Lizzie won't recover."

"But she's very ill—the doctor said so," returned Rose, nevertheless checking her sobs, and
regarding Mavis with an expression of dawning hope in her blue eyes. "He said she would
require most careful nursing, and he couldn't tell how it would go with her."

"Doctors never can tell," said Mavis, sagely. "Mother says they can only do their best, and
leave the result to God. Poor Aunt Lizzie! How sorry I am she should be so ill!"

"The doctor says we are not to go into her room again," sighed Rose. "I heard him say to
father, 'Don't let the children into her room to worry her; she must be kept very quiet.'"

"As though we would worry her!" cried Bob, in much indignation. He felt inclined to follow
his sister's example and burst into tears. But he manfully, though with much difficulty,
retained his composure.

Before night, a trained nurse from a nursing institution at Oxford was installed at the Mill
House, and took possession of the sick-room. And during the anxious days which followed,
the miller's wife approached very near the valley of the shadow of death, so that those
who loved her went in fear and trembling, and stole about the house with noiseless
footsteps and hushed voices.

But at length, a day arrived when the patient was pronounced to have taken a turn for the
better. And after that, she continued to progress favourably until, one never-to-be-
forgotten morning, the doctor pronounced her life out of danger.

"We shall be allowed to see her soon now, father, shan't we?" Rose inquired eagerly, after
she had heard the good news from her father's lips.

"I hope so, my dear," he answered. "It will not be long before she will be asking for you, if
I'm not mistaken. But she's been too ill to notice anything or any one. You won't forget to
thank God for His goodness in sparing your mother's precious life, will you, Rosie?"

"No, indeed, father," she responded, earnestly. "We prayed—Bob, and Mavis, and I—that
God would make dear mother well again, and you see He is going to do it. I felt so—so
helpless and despairing, and there was only God who could do anything, and so—and so—"

"And so you were driven to Him for help and consolation? Ah, that's the way with many
folks! They forget Him when things go smooth, but they're glad to turn to Him when their
path in life is rough. But His love never fails. You found Him a true Friend, eh, my Rose?"

"Yes, father, I did. Mavis said I should; she said I must remember that Jesus Himself said,
'Let not your heart be troubled, neither let it be afraid,' and that I must trust in Him. And I
tried not to be afraid. I couldn't do anything but pray; and after a while I began to feel that
God really did hear my prayers, and I don't believe He'll ever seem quite so far off again."

Mr. Grey had guessed rightly in thinking his wife would soon desire to see her children, for
the day following the one on which the doctor had pronounced her life out of danger, she
asked for them, and they were allowed into the sick-room long enough for each to kiss her
and be assured, in a weak whisper from her own lips, that she was really better.

The next day, they saw her again for a longer time, but she did not inquire for Mavis, a
fact which hurt the little girl, though she did not say so, and strengthened her previous
impression that her aunt did not like her.

Before very long, Rose was allowed in and out of the sick-room as she pleased, and was
several times left in charge of the invalid. She proved herself to be so helpful and reliable
that, on one occasion, the nurse complimented her upon those points, and she
subsequently sought her cousin in unusually high spirits.

"Mavis, what do you think?" she cried, in great excitement. "Nurse says she is sure I have
a real talent for nursing! Fancy that! But for mother's illness, I should never have found it
out, should I? Oh, I'm so glad to know that I really have a talent for something, after all!"

Meanwhile, Mrs. John was gaining strength daily. Although she had not expressed a wish
to see Mavis, she thought of her a good deal, and she missed the sound of her voice about
the house.

"Where is Mavis?" she asked Rose, at length. Then, on being informed that the little girl
was downstairs in the parlour, she inquired, "How is it I never hear her singing now?"
"Oh, mother, she would not sing now you are ill," Rose replied.

"She would not disturb me—I think I should like to hear her. It must be a privation to her
not to sing."

"I don't think she has felt much like singing lately. We've all been so troubled about you—
Mavis too. Oh, I don't know how I could have borne it whilst you were so dreadfully ill, if it
had not been for Mavis!"

"What do you mean, Rose?"

"She kept up my heart about you, mother. And she's been so good to us all—helping Jane
with the housework, lending Bob her games and keeping him amused, and doing
everything she could to cheer us up. Wouldn't you like to see her?"

"Yes," assented Mrs. John, "to-morrow, perhaps."

So the following day found Mavis by her aunt's bedside, looking with sympathetic eyes at
the wan face on the pillow.

"I'm so glad you're so much better, Aunt Lizzie," she whispered softly. "You'll soon get
strong now."

"I hope so, Mavis. My illness has spoiled your holidays, I fear. You must have had a very
dull time."

"A very sad, anxious time," Mavis said gravely; "but never mind—that's past."

"And you will soon forget it," her aunt remarked, with a faint smile.

"Oh no, Aunt Lizzie, I'm not likely to do that! But I'd so much rather look forward to your
being well again. We were all so wretched when you were so terribly ill, and now God has
made us happy and glad. Why, I feel I could sing for joy!"

"I think you rarely find difficulty in doing that, Mavis; you are so light-hearted."

"Not always, Aunt Lizzie; but I do try to be."

"Why?" Mrs. John inquired, in surprise.

"Because Jesus said, 'Let not your heart be troubled, neither let it be afraid,'" Mavis
answered, seriously. "I try not to be troubled or afraid," she continued; "but it's very, very
hard not to be sometimes. I found that when mother went away; nothing seemed to
matter much when we were together, but after she'd gone—oh, then it was different. I felt
my heart would break, it ached so badly, but—are you sure I am not tiring you, Aunt
Lizzie?"

"No; I like to hear you talk. Go on—tell me all you felt when your mother went away."

Mavis complied. She would have opened her heart to her aunt before, if she had ever had
the least encouragement to make her her confidante. By-and-by, she became aware that
there were tears in the sunken eyes which were watching the varying expressions of her
countenance, and she ceased speaking abruptly.

"You must have been very lonely and sad, child," Mrs. John said. "I never realized you felt
the parting from your mother so much. I wish I had known; but I thought—"
She paused, and did not explain what she had thought. She was beginning to understand
that she had misjudged Mavis, and the knowledge that she had done so humiliated her,
whilst she was conscious that she had allowed her jealous heart to prejudice her against
the child. "I might have been kinder to you, my dear," she admitted, with a sigh.

"Oh, Aunt Lizzie, you have always been kind to me," Mavis said gratefully, unaware that
Mrs. John's conscience was reminding her not so much of actions as of thoughts.

"I don't know what I have said to make you cry," she added, as a tear ran down her aunt's
pale cheek. She wiped the tear away with her handkerchief as she spoke, and kissed the
invalid. She had never felt greatly drawn towards her before, always having been a little in
awe of her, but at that moment the barrier of misunderstanding which had stood between
them was swept aside.

"I have not heard you singing lately," Mrs. John remarked, by-and-by. "Rose tells me you
have been fearful of disturbing me. You need not be now, for I believe it will cheer me
greatly to hear you singing again. Our song-bird has been silent long enough."

Mavis smiled, and kissed her once more, and shortly after that, the nurse, who had been
absent, returned, and confidential conversation was at an end.

The young people had been back to school for several weeks before the mistress of the Mill
House was about again, and it was some time before she was well enough to undertake
her accustomed duties. But with the lengthening days, she gained strength more rapidly,
and the doctor said she needed only the spring sunshine to make her well.

In the meanwhile, Mavis continued to receive cheering news from her mother, who wrote
every mail. Miss Dawson was much better, and there was now every reason to hope that
she would return to England completely restored to health. But when that would be, Mrs.
Grey had not yet said, though in one letter she had remarked that perhaps it would be
sooner than Mavis expected. The little girl's heart had thrilled with happiness when she
had read that.

Almost the first news Mrs. John was told when she was about again after her illness, was
that Richard Butt, who had taken a cottage in the village, had been allowed a few days'
holiday, and the loan of a waggon, on which he had conveyed his household furniture and
his wife and baby from Woodstock to their new home.

"They're comfortably settled in now, ma'am," said Jane, who had explained all this to her
mistress. "I've been to see them. Mrs. Butt seems a nice, well-mannered young woman,
and the child's as fine a baby as you ever saw in your life."

"Yes," joined in Rose. "And father's very pleased with Butt, because he's so careful of the
horses, and he hasn't had the least cause of complaint against him yet. Aren't you glad to
know that, mother?"

"Butt thinks a great deal of father," Bob said, eagerly, "and no wonder! He told me he was
almost despairing when father gave him work. He said father was one of the few people
who wouldn't hit a man when he's down. I know what he means, don't you, mother?"

"Yes," was the brief assent.

"So do I," said Mavis. "I think the Good Samaritan in the parable must have been very like
Uncle John."
There was one piece of news which Rose had refrained from mentioning to her mother as
yet, and that was that she and Mavis were now in the same class at school. She dreaded
telling her this, and it was a decided relief when she learnt that it was not necessary for
her to do so, as Mavis had forestalled her.

Mavis had also told her aunt, how greatly Rose was troubled on account of her slowness in
learning, and how really painstaking she was, and this, coupled with Miss Matthews' report
that Rose was patient and industrious and always desirous of doing her best, caused Mrs.
John to reflect that she had been a little hard on her daughter.

"Although she's not quick like her cousin, she has many good qualities," she thought to
herself. "God does not endow us all with gifts alike, and I have been unwise to make
comparisons between the children."

So she spoke kindly and encouragingly upon the matter to Rose, who exclaimed, with a
ring of glad surprise in her voice—

"Oh, mother, I so feared you would be angry with me for allowing Mavis to catch up to me
in her lessons! Indeed, indeed, I have done my best. I know I'm slow and stupid in many
ways; but God has given me one talent, and, now I know that, I don't mind. Nurse said I
had a real talent for nursing, so I mean to be a nurse when I grow up. Mavis will be a
great singer, I expect, but I shall be quite content to be a nurse."

Mrs. John made no response, but she pressed a warm kiss on Rose's lips, and her little
daughter saw she was pleased, and added ingenuously—

"I asked God to make you understand I'd done my best, and He has."

CHAPTER XI
HAPPY DAYS

IT was a beautiful afternoon in May. The lilac and laburnum trees were in full bloom in the
Mill House garden. And fritillaries—snakes' heads, as some people call them—were plentiful
in the meadows surrounding W—, lifting their purple and white speckled heads above the
buttercups and daisies in the fresh-springing green grass.

"I think they are such funny flowers," said Mavis, who with Rose, had been for a walk by
the towpath towards Oxford, along which they were now returning. She looked at the big
bunch of fritillaries she had gathered, as she spoke. "And though they are really like
snakes' heads, I call them very pretty," she added.

"Yes," agreed Rose. "Look, Mavis, there's Mr. Moseley in front of us. He's been sending Max
into the water. I expect we shall catch up to him."

"And then I shall be able to tell him my news!" Mavis cried delightedly. "Oh, Rosie, I don't
think I was ever so happy in my life before as I am to-day!"
A few minutes later, the two little girls had overtaken the Vicar. And, after they had
exchanged greetings with him, Mavis told him her news, which she had only heard that
morning, that her mother and Miss Dawson were returning to England, and were expected
to arrive before midsummer.

"No wonder you look so radiant," he said, kindly.

Then, as Rose ran on ahead with Max, who was inciting her to throw something for him to
fetch out of the river, he continued: "I remember so well the day I made your
acquaintance, my dear. You were in sore trouble, and you told me you did not think you
could be happy anywhere without your mother. Do you recollect that?"

"Oh yes," Mavis replied. "And you said if there were no partings there would be no happy
meetings, and that we must trust those we love to our Father in heaven. And you asked
me my name, and, when I had told it, you said I ought to be as happy as a bird. I felt
much better after that talk with you, and I have been very happy at the Mill House—much
happier lately, too. I don't know how it is, but Aunt Lizzie and I get on much better now."

"You have grown to understand each other?" suggested the Vicar.

"Yes—since her illness," Mavis replied.

The Vicar was silent. He had visited Mrs. John during her sickness, and knew how very
near she had been to death's door. And he thought very likely her experience of weakness
and dependence upon others had softened her, and taught her much which she had failed
to learn during her years of health and strength.

"Mother says Miss Dawson is quite well now," Mavis proceeded. "I am looking forward to
meeting her again; I do wonder when that will be!"

She glanced at her companion as she spoke, and saw he was looking grave and, she
thought, a little sad.

"Is anything amiss, Mr. Moseley?" she asked, impulsively.

"No, my dear," he replied. "I was merely thinking of two delicate young girls who were
very dear to me. They died many years ago; but their lives might have been saved, if they
could have had a long sea voyage and a few months' sojourn in a warmer climate.
However, that was not to be."

"They did not go?"

"No. Their father was a poor man, with no rich friends to help him, and so—they died."

"Oh, how very sad!" exclaimed Mavis, with quick comprehension. "A trip to Australia and
back costs a lot of money, I know. Oh, Mr. Moseley, how dreadful to see any one die for
want of money, when some people have so much! How hard it must be! Didn't their poor
father almost break his heart with grief? I should think he never could have been happy
again."

"You are wrong, my dear. He is an old man now, with few earthly ties, but he is happy.
Wife and children are gone, but he knows they are safe with God, and he looks forward to
meeting them again when his life's work is over."

He changed the conversation then. But Mavis knew he had been speaking of himself, and
that the young girls he had mentioned had been his own children, and her heart was too
full of sympathy for words. Silently, she walked along by his side, till they overtook Rose.
When Max created a diversion by coming close to her and shaking the water from his
shaggy coat, thus treating her to an unexpected shower-bath.

"Oh, Max, you need not have done that!" cried Rose, laughing merrily, whilst the Vicar
admonished his favourite too.

But Max was far too excited to heed reproof. He kept Rose employed in flinging sticks and
stones for him to fetch, until the back entrance to the mill was reached, where the little
girls said good-bye to the Vicar, and the dog followed his master home.

The next few weeks dragged somewhat for Mavis. But she went about with a radiant light
in her eyes and joy in her heart. Would her mother come to her immediately on landing?
she wondered. Oh, she would come as soon as she possibly could, of that she was sure.

"I expect she wants me just as badly as I want her," she reflected, "for we have been
parted for nine months, and that's a long, long time—though, of course, it might have
been longer still."

So the May days slipped by, and it was mid-June when, one afternoon, on returning from
school, the little girls were met at the front door by Mrs. John, who looked at Mavis with
the kindest of smiles on her face.

"You have heard from mother!" cried Mavis, before her aunt had time to speak. "Has the
vessel arrived? Have you had a telegram or a letter?"

"Neither," Mrs. John answered; "but the vessel has arrived, and there's some one in the
parlour waiting for you, Mavis. Go to her, my dear."

Mavis needed no second bidding. She darted across the hall and rushed into the parlour,
where, the next moment, she found herself in her mother's arms, and clasped to her
mother's breast.

"Mother—mother, at last—at last!" was all she could say.

"Yes, at last, my darling," responded the dearly loved voice.

Then they kissed each other again and again, and Mavis saw that her mother was looking
remarkably well. And Mrs. Grey remarked that her little daughter had grown, and was the
plumper and rosier for her sojourn in the country. It was a long while before Mavis could
think of any one but themselves. But at last, she inquired for Miss Dawson, and heard that
her mother had left her in her own home in London that morning.

"I expect she's glad to be back again, isn't she, mother?" Mavis asked.

"Very glad, dear. You can imagine the joyful meeting between her and her father. I shall
never forget the thankfulness of his face when he saw how bright and well she was
looking. Poor man, I believe he had made up his mind that he would never see her again.
She does not require a nurse now, but I have promised to stay with her for a few months
longer, and during that time, Mavis, I want you to remain at the Mill House. Shall you
mind?"

"No," Mavis answered, truthfully. "But you are not going right back to London, mother, are
you?" she asked, looking somewhat dismayed.

"No, dear. I have arranged to stay a few days with you."

What a happy few days those were to Mavis! She was allowed a holiday from school, and
showed her mother her favourite walks, and spent a long afternoon with her in Oxford,
where they visited T— College and the haunts her father had loved. And oh how Mavis
talked! There seemed to be no end to all she had to tell about the household at the Mill
House, and the Vicar, and Richard Butt and his wife and baby, and kind Mrs. Long, to all of
which her mother listened with the greatest interest and attention.

"Why, how many friends you have made!" Mrs. Grey said, on one occasion when Mavis had
been mentioning some of her schoolfellows. "You will be sorry to have to say good-bye to
them; but I do not know when that will be, for I have not decided upon my future plans. I
hope we shall never be parted for such a long time again."

"Indeed I hope not," Mavis answered, fervently. "Shall we go back to live at Miss
Tompkins'?" she inquired.

"I don't know, dear," was the reply. "Perhaps we may—for a time."

Every one at the Mill House was very sorry when Mrs. Grey left and returned to town. Her
former visit had naturally been overshadowed by the prospect of separation from her little
daughter. But this had indeed been a visit of unalloyed happiness, with no cloud of
impending sorrow to mar its joy.

After her mother's departure, Mavis went back to school with a very contented heart, and
in another month came the summer holidays. Her feelings were very mixed when she
learnt that it had been arranged for her to stay at W— until the end of another term, for
Mr. Dawson had earnestly requested Mrs. Grey to remain with his daughter till Christmas,
and she had consented to do so. And she expressed her sentiments to her aunt in the
following words—

"I'm glad, and I'm sorry, Aunt Lizzie. Glad, because I can't bear the thought of saying
good-bye to you all, and sorry, because I do want mother so much sometimes. Still,
London's quite near; it isn't as though mother was at the other end of the world, and time
passes so quickly. Christmas will soon be here."

* * * * *

"I feel as though I must be dreaming," said Mavis, "but I suppose it's really, really true. I
can hardly believe it."

It was Christmas Eve, and a few days before the little girl had been brought up to town by
her uncle, who had delivered her to her mother's care. To her surprise, however, she had
not been taken to Miss Tompkins' dingy lodging-house, but to Mr. Dawson's house in
Camden Square, where she had received a hearty welcome from Mr. Dawson and his
daughter.

She was with her mother and Miss Dawson now, in the pretty sitting-room where, fifteen
months previously, she had made the latter's acquaintance. But there was nothing of the
invalid about Miss Dawson to-day; she looked in good health and spirits, and laughed
heartily at the sight of Mavis' bewildered countenance.

"What is it you can hardly believe, eh?" asked Mr. Dawson, as he entered the room.

"I have been telling her that you mean to build and endow a convalescent home in the
country for girls, as a thanks-offering to God for my recovery, father," Miss Dawson said,
answering for Mavis, "and that her mother is to be the matron, and she can scarcely credit
it. Still, I think she approves of our plan."
"Oh yes, yes!" cried Mavis. "It's just what I should wish to do if I were you," she proceeded
frankly, looking at Mr. Dawson with approval in her glance, and then turning her soft hazel
eyes meaningly upon his daughter, "and you couldn't have a better matron than mother—"

"Mavis! My dear!" interrupted Mrs. Grey.

"It's quite true," declared Miss Dawson. Then she went on to explain to Mavis that the
home was to be within easy reach of London, and it was to be a home of rest for sick
working-girls, where they would have good nursing.

"I think it's a beautiful plan," said Mavis, earnestly. She realized that it meant permanent
work for her mother, too; and turning to her she inquired, "Shall I be able to live with you,
mother?"

"Yes, dear, I hope so," Mrs. Grey answered, with a reassuring smile.

"Oh yes, of course," said Miss Dawson.

And the little girl's heart beat with joy.

She remained silent for a while after that, listening to the conversation of her elders, and
meditating on what wonderful news this would be for them all at the Mill House. Then her
mind travelled to Mr. Moseley, and her face grew grave, as she thought of those two
delicate girls so dear to him, who had faded and died. But it brightened, as she reflected
how nice it must be to be rich, like Mr. Dawson, to be able to help those not so well off as
himself.

She was aroused from her reverie by Miss Dawson, who asked her to sing a carol to them,
and she willingly complied, singing the same she had sung at the village concert at W—
nearly a year before. Afterwards, she gave them an account of the concert, and expressed
the hope that she would be a great singer some day.

"Why, Mavis, I never knew such an idea had entered your head!" exclaimed her mother,
greatly surprised.

"It never did, mother, until Mr. Moseley told me I had a great gift, and that God expected
me to use it for the benefit of others," the little girl replied, seriously.

"Surely he was right!" said Miss Dawson.

And with that Mrs. Grey agreed.

Later in the evening, when Mavis went to the window and peeped out to see what the
weather was like, she felt an arm steal around her shoulders, and Miss Dawson asked—

"What of the night? Are we going to have a fine Christmas?"

"I believe we are," Mavis answered. "The sky is clear and the stars are very bright. Look!"

Miss Dawson did so, pressing her face close to the window-pane. Then she suddenly kissed
Mavis, and whispered—

"God bless you, dear, for all you've done for me. I carried the remembrance of your sweet
voice singing, 'The Lord is only my support,' to Australia and back again, and it cheered
and strengthened me more than you will ever know. I wish you a happy Christmas, little
song-bird, and many, many more in the years to come."
 THE END

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