CHAPTER XIIL. (Part 4)

the arm at its thickest part, Lay these strips Pastipse the other, and fasten them together; and from the sheet thus formed, cut a deep scallop out of either end—at the lower end 4g to ~ 198 FRACTURES. 50cm, and at the upper end 15 to 20 cm. deep. formed, one will fit into the axilla and the other into elbow, while the intermediate portion forms an i Boek the lh fa liquid plaster and apely sat until the plaster split is fully hardened. The di secured by a few turns about the chest. Other dressings recommended are the plaster to shoulder; an internal splint with a shoulder c splints. Union requires from six to eight weeks; failure t due to the interposition of the soft parts, The musculo-spiral nerve in this connection must never’ Fracture of the Upper End of the Hs offer the very greatest difficulties in diagnosis. Such most part present themselves with swollen, painful, shoulders, perhaps deformed, and functionless. Ye is it only a severely bruised joint; is it a dislocation or & fi the surgical neck, or perhaps both; or is it an impacted fn anatomical neck; are the soft parts implicated? < Do not waste time in yague palpations but proceed : systematic examination, under chloroform, if necessary, locating the apex of the acromion; if there is no if the thumb cannot be pushed rary: concavity but Cana as it should with the humeral bead, you may conclude there is no dis- location. With the thumb still in front, close the fingers: rior aspect of the head of the humerus, and with it thus attempt rotation of the arm. The humeral head rotates with «iff. calty in dislocation; it does not rotate at all if there i fracture, and besides, there is crepitation (Figs. 124, 125). A source of error: If the lower fragment overrides much, its rota- on might be felt and mistaken for the humeral head. Abduet the sea —_— | DIAGNOSES OF FRACTURE AT SHOULDER, 199 arm; easily done in fracture, with increase of deformity and pain. Pain is also produced by pressure upward at elbow and by local pressure over the front and outer side of humerus. Fic, 124-—Bxamining the shoulder, Renating head of humerus, Examine the axillary space and all the other aspects of the shoulder, comparing the two sides; and compare the other landmarks of the arm. 200 FRACTURES, D5 mot begin any treaiment wntil the diagnosis is assured, How unfor tunate it is to attempt reduction of a supposed dislocation by the ardi- nary method when it is complicated by fracture; or to treat as a com tusion, a fracture with displacement! To Consider briefly the more common findings of such examinations: t. Fracture of the surgical neck without overriding (Fig. 126) needs Vn. 101 —Brusnining the choulter. Coceparing the relations of the comscoid srtawsem only the simplest treatment: Brace the arm on the inside with a “W"* shaped axillary pad, and with the forearm Bex at a right angle; supe port the whole extremity in a sling of the Mayor type. Additional protection may he afforded by a shoulder cap (Fig. 127), ‘Begin mas sage catly 2, Oblique Fracture of the Surgical Neck with Much Overriding — These are difficult to reduce; difficult to maintain; likely to be mistaken for dislocation FRACTURE AT SHOULDER WITH DISLOCATION, 201 Reduction —In making traction, draw downward and outward at first and then in the axis of the limb, Do not stop until the arm is the ‘correct length by measurement; until the subcoracoid projection has disappeared; the acromion, greater tuberosity and the external condyle are in the same straight line. Extension must be maintained while the dressing is applied or the displacement will certainly recur. The Henpequin apparatus described will be useful here and the plaster splints as well. Sometimes wiring is necessary. 3: Fracture of the Surgical Neck with Dislocation. —This is & very serious injury; difficult of diagnosis; of bad prognosis. Carrying out the systematic ex- amination deseribed, you find the head displaced, but the arm is not fixed in abduction as in the ordinary dislocation; it drops to the side. Again, the head does not rotate with the arm; there may be crepita- tion; from these and other confirmatory points the is made. Reduction —Anesthesia is necessary. Makea slow, gentle, but persistent traction on the arm; this com- ‘bined with manipulation cf the head cf the humerus in the axillary space may succecd in restoring the head to the glenoid fossa, for more than likely the head is still attached to the shaft by periosteum and museular fibers, “As the assistant makes the traction apply your thumbs to the head in axilla and, with (vt sP°ohiesi the Gngers braced by the shoulder, try to force the ffA,R, Pumer™ head into place. ‘Once the dislocated head is reduced, reduce and treat the fracture ‘by the ordinary means. Massage must be begun especially early. If these efforts fail, choice lies between operation and expectant treatment. Royster, of Raleigh, N. C. (Journal A. Aug. 10, 1907), re views his own experience and the literature dealing with this condition, andconcludes very logically that operative treatment in the great major- ity of cases is alone effective. ‘The preferable incision begins at the acromion process, extends = a 202 FRACTURES. vertically downward as far as necessary, and aims to reach the bone by passing between the pectoralis major and the deltoid. ‘The bead, thus exposed, Is to be reduced by manipulation, although occasionally a special hook or bone forceps may be necessary. Wiring will sekdom. be required except in the cases operated late. ‘The dressing should be applied so a8 to maintain the arm in abduction, Royster believes in immediate operation, regarding such cases as emergencies, even as strangulated hernia or’ “Even in cases of may occur as the direct or indirect C a fall upon the hand » tuberosity may he ward, and backward, bility and swelling are symptoms; crepitus may be Pain is produced by | sure. Taylor, of New’ serts (Annals of Surg 1908) that in upcomplicat with moderate diaphiceea ter covery may be practically perfect without the use of splints, massage, or special movements (Fig. 128) Fractures of the Lower End of the Humerns.—Injuries about the elbow are always to be regarded seriously. ‘They occur mach more fre« quently in chikirea and are usually due to falls upon the flexed elbow. Scudder insists that even in the apparently trivial cases the examina- tion should be made under anesthesia, for only by that means, a8 # rule, can the injury be exactly diagnosed. ‘The diagnosis itself is chiefly a matter of applied amatomy, ‘The tuppuried in Giag. (Scudder) FRACTURE AT LOWER END OF HUMERUS. 203 Jandmarks and the normal relations must be clearly in mind. Ob- serve on the sound side the relations of the internal and external con- dytes, the olecranon, the head of the radius, It is uncertain at first whether it is a contusion, or dislocation, or fracture. Even when sure Fre, 12h —Fractures through hee of humerus Patient thrown from tugey atighting, Won Sionlder, This variety of fracture is more common than formerly supposed, that the case is a fracture, yet it is to be determined whether it is supra condylar, or condytar, or some combination of the tw Scudder formulates a routine mode of procedure in making the diagnosis. Observe the character of the swelling—whethcr general or localized, Observe the carrying angle. tog WRACTURES.. Palpate the external and internal condyles, Palpate the olecranon process and head of the ulna. Rotate the head of the radius. Pid. tr9-—Enarnining the alt locating the three cantinal pormts—the tatermal ive ‘comlyle, the tip af t Teaoe ant the external coed Note the relution of the three bony points in‘extension and flexion Fig. 129). Determine the possible movements of the elbow-joint Make heasurements, Make pressure with the point of the finger to locate SUPRA-CONDYEAR FRACTURES. 205 a painful line which marks the fracture. If the X-ray is used it should show both the lateral and antero-posterior view. Certain forms of injury are found most frequently: (1) Supra- condylar fracture, (2) fracture of one of the condyles, (3) multiple fracture involving the jo’nt. (1) Supra-condylar Fracture.—The joint is not usually involved, the plane of fracture extending commonly from zbove downward and forward. The displacement of the upper fragment, therefore, is downward and forward, and if union takes place in this position the Hexion of the elbow is much abbreviated (Fig. 139). Reduction.—Often the ordinary means, that is by traction and PIG, 130.—Stapea-covsiylas [mncture of huseras Nene obliquity: (Meallim) countertraction with the forearm flexed, will not succeed. ‘Try slow and progressive traction upon the exiended forearm, aided by manipula- tion of the fragments at the site of fracture (Fig. 121). When reduction is complete, continue the traction but gently flex the elbow to an acute angle; if no displacement occurs, and if the swelling is not so great as to preclude flexion by reason of the inter ference with the brachial artery, proceed to apply the fixation dressing. ‘The molded, posterior plaster splint, or wrough, is recommended. Twelve to sixteen pieces of crinoline long enough to reach from the deltoid insertion to near the wrist, and wide enough to cover the arm, 4re quilted together and two oblique notches cut corresponding to the hend of the elbow. his piece of padding is now impregnated with liquid plaster and applied to the back of the arm and forearm, and 206 WRACTURES. well molded. The two notehes permit a ready adjustment at the bend ‘of the clhow. ‘The support of the arm is not relaxed until the plaster has hardened. The gutter thus formed may be strengthened by a loosely applied roller which passes from the wrist across to the arm near the axilla, around it and back to the wrist again, and soon. The arm is thus fixed in acute flexion. A boy of twelve years was brought in from the country with an in- * —Supre condybye| fracture ct the bameres. ra atid sos sent ees ese cme Sleep Migr eerste aa fury received the day before by being thrown from a horse, A ding- nosis of fracture about the elbow had been made, and with it the effort to fix the arm in forced flexion. The whole member was greatly swollen, edematous about the elbow with blebs in process of formation, The X-ray confirmed the diagnosis, showing epipbys- cal separation with fracture and separation of the internal condyle (Fig. 132). ‘The dressing was removed, the arm fixed in extension; daily massage was instituted to remove the tumefaction, and after four days an effort was made to reduce the fragments anil put the arm in forced flexion; but this only resulted in complete obliteration of the i . <li FRACTURE OF THE CONDYLES. 207 radial pulse, The arm was left in semiflexion and pronation, and massage was again instituted for a few days; gradually the swelling subsided, and after the end of a week more another effort was made to reduce under general anesthesia, with better results. After Pro. 132.—Bupre-condylar treeture of humerus, lower fragined displaced ga Snore soni ypward and bute = a week of fixation in the corrected position the massage was begun again and continued for some weeks. Eventually the restoration of function was almost complete. (2) Fracture of the Condyles—Ii the internal condyle is broken, 208 PRACTORIS. swelling is marked over the inner side of the elbow. The condyle can be grasped between the fingers and crepitus elicited. The inner of the three bony peints is displaced upward, which diminishes the carrying angle. The ulna is displaced upward in extension (Pig. 134). 713. 159. —Practore of external conayte of humerus tn a child “The sreall amas Tora the fount Hive in Ube epigiryaie of Ue rilitan, Hi the external condyle is broken the swelling is most noticeable externally. Although the external condyle is dislocated, its relations to the head of the radius are not changed, The fragments in either p= sats ’ ediately recurs when the pressure is removed (Fig. 133). Reduction Grasp the condyle between the finger and thumb of one band and make pressure in the bend of the elbow with the other, and while the assistant slowly brings the forearm into the position of acute Bexion, manipulate the condyle into place, Pia. s4—Pree WiC 15. = Eotercondylar fracture tot - omdlin, sen nips of fscmeron (Moniiin) Trestment,—Scudder strongly recommends fixation fn this position of ace flexion, maintaining it by passing an adhesive strip three inches wide about the wrist and upper arm, supporting the whole with a sling, He emphasizes the necessity of watching the circulation in the forearm and regulating the degree of flexion by the amount of ) The intercondylar and multiple fractures involving the joint, as they do, require a very guarded prognosis (Fig, 135). By referring 4 210 FRACTURES, ‘to the landmarks, the displacements are to be figured out and the fragments are to be manipulated until all the movements of the joint are restored. ‘The forearm is then to be acutely flexed and fixed either by the adhesive strips, or plaster splints ax before described. If the dis placements cannot be held by this means the fracture must be treated by extension for a few days and then put up im acute flexion, Massage and passive motion must be very early begun in these cases and per sisted in for a long time. FRACTURES OF THE FOREARM. Fracture of the skaf) of the ulna and radius occurs more commonly in the middle third, both bones being broken or only one. If both are broken, the radius fs likely to be broken at a higher level than the ulna. ‘There is usually not much deformity if one bane is fractured; considerable if bath are (Fig. 136). ‘The diagnosis is to be made from the pain, deformity, mobility, and crepitation; supination is particularly painful if the mdius is broken; lateral compression of the bones, even at some distance from the seat of fracture, may elicit much pain at the site of fracture, Reduction. —Flex the forearm at a right angle; direct the assistant to make countertraction from the arm; grasp the hand, place the arm in complete supination and make traction in the axis of the forearm, molding the (ragments into place; the fingers, following the Interosseous space down the front of the arm help to force the fragments apart. The preservation of the interosseous space is the essential thing. ‘The extension and supination must be maintained until the dressing is applied. Whatever its form, the fixation must have one negative quality—it must not compress the forearm laterally or else the bones may be pressed toward each other and fusion occur, Anterior ani posterior splints may be used, both wider than the forearm. ‘The anterior must extend from the bend of the elbow to the base of the Gngers; the posterior nust extend from the elbow to the wrist. They may be shaped out of boards and well padded. The palm must be well padded. ‘The splints are first secured with adhesive FRACTURE OF THE FORE-ARM. au ‘Strips and then with a roller bandage. ‘The elbow is to be immobilized ‘by suspension of forearm and hand in a sling (Pig. 137). Care must be taken not to compress the brachial artery or the bony points. Instead of the anterior and posterior splints a plasier cast may be Pio, 156:—Practare of the shalt cf wins with spas Meo the shalt of tbe rads, too high tor of the epiphyalr; tracuure Salles’ fracture ‘used, extending from the axilla to the palm of the hand, immobilizing the wrist and elbow; care must be taken not to compress the forearm Gigs. 138, 139)- Lejars recommends the plaster splint formed in this manner: twelve 212 FRACTURES. to fifteen sheets of crinoline cut in the form of an irregular quad- tilateral, Jong enough to reach from the bend of the elbow to the palmar crease, wide cnough above to encircle the arm; below, wide enough to more than encircle the wrist, are loosely quilted together. In the middle of the lower end, one inch from its border, cut an oval opening large enough to pass the thumb. "This dressing, soaked with plaster and molded to the forearm, furnishes « firm fixation. Coutes’ Feactorr,—This break at the lower end of the radius is quite common and is more often due toa fall upon the outstretched palm. ‘The lower fragment is pushed toward the dorsal surface and overrides, Feo. 157-—Anteror and pouterior aplint for Sormarm (Hes) producing the characteristic hump—the silver fork deformity. But it fs by no means seldom that fracture occurs without deformity (Fig. 140). In addition to the injury to the bowe, the inter-articular fibrocartilage may be torn loose from both its attachments, the radio- ulnar ligaments are strained or ruptured, and the head of the ulna carried forward. Sometimes the tendon sheaths are lacerated and blood extravasated into the synovial sac (Fig. 141). Diagnosis.—Determine the position of the styloid processes of the radius and ulna. If there is a fr: re the styloid of the radius is pushed up to a level with that of the ulna, the wrist is broadened. ‘The transverse lines on the flexor surface of the wrist are deepened and the axis of the limb bent toward the radial side. The pain is pronounced, mobility and crepitus are absent, Pain is elicited by point pressure across the radius. FRACTURE OP THE FORE-ARM. ats re of forearm. Phatercf-Paris splot aiited, Ribow wt right angle, (Scudder. 214 FRACTURES. ‘Tho X-ray is very useful in diagnosis of these fractures. Reduction is often difficult, but it is the chief thing and must be complete, otherwise the result will be a disappointment. Anesthesia is usually necessary. Clasp the patient's hand in your own, palm to Typéeal Cotes’ fractere: lipecwcted Iractsre of brwer eve of guia aed