CHAPTER VI. DISLOCATIONS OF THE SHOULDER. (Part 7)

namely axillary pad, plaster shoulder cap, cravat sling, body swathe, etc. There is this to be said, however, in regard to the shoulder cap ; the lower the fracture the greater the need of extending this dressing down- ward to include the forearm. Coaptation splints are often used in fractures of the middle of the shaft though they may well be dis- pensed with, as a permanent dressing, in favor of a properly applied shoulder cap. It is a common practice to treat the condition during the onset and subsidence of swelling with the axillary pad, coapta- tion splints, body swathe and sling. Later on the coaptation splints are replaced by the plaster shoulder cap as a permanent dressing. In fractures of the lower third the elbow should be solidly immobil- ized. The axillary pad is not appropriate, and carrying the arm in a sling is entirely inadequate to secure fixation if the fracture is near the elbow. A most satisfactory method of fixation in this portion of the shaft is that shown in Fig. 215 and is described below. The following may be considered a fair example of the treatment of a fracture of the shaft of the humerus shortly following the acci- dent. The patient is placed in as comfortable a position as possible, preferably the recumbent, and an examination made of the parts, 114 FRACTURES AND DISLOCATIONS to determine as accurately as may be the exact nature and position of the fracture. The examination is more satisfactorily carried out under anesthesia. It should be remembered that the less the parts are manipulated the better it will be for the soft tissues surrounding the jagged ends of the fragments. After the fracture has been diagnosed the proper dressings should be prepared so that every- thing may be in readiness as soon as reduction has been effected. Fig. 154. — Stromeyer cushion. It is needless to add that the surgeon should, at this time, satisfy himself as to which form of dressing \Yill best meet the requirements of the case in hand. In instances in which the trauma has been great it is often best to leave the parts undisturbed and to treat the patient in the recumbent position for a week or ten days until the acute inflammatorv reaction has subsided. Durino- this time Fig. 155 Fig. 155. — Arm bandaged and axillary pad in position. Fig. 156. — Coaptation splints applied. Fig. 157. — Swathe encircling body and acting as sling, elusive.) Fig. 15' (See Figs. 132 to 14^ the arm may be supported- on a pillow and the ice cap used to control the reaction. The Stromeyer cushion, or one of its modifi- cations, may be used to advantage. If, on the other hand, it seems advisable to immobilize the arm at once the following details may be observed. The arm and side of the chest are sponged, dried and dusted with talcum powder, special attention being paid to the axilla. An axillar}^ pad is then constructed as described on page FRACTURES OF SHAFT OF HUMERUS 115 100. Coaptation splints are next made by placing thin wood on adhesive plaster (cigar-box wood is excellent) and splitting the wood with a knife. The splint should include as much of the arm, from the shoulder to the elbow, as possible without pressing into the axillary fold above, or the top of the flexed forearm below. The portion of the coaptation splint on the outer side of the arm may be longer than that on the inner side. A body swathe is next pre- pared of two or three thicknesses of heavy muslin. It should be long enough to encircle the body and injured member and broad enough to extend from the top of the shoulder to a point below tlie elbow. A cravat sling is then prepared and the necessary materials are ready. The axillary pad is placed in position and secured with adhesive plaster, after which the surgeon is ready to attempt reduction. The injured member is grasped above and below the seat of frac- ture, and the fragments gently but firmly manipulated until the senses of sight and touch pronounce the position satisfactory. The coaptation splint is then well padded, applied and secured in position with adhesive plaster. The arm is then firmly placed against the axillary pad and secured by the body swathe. The cravat sling completes the dressing, or in lieu of the sling the fore- arm may be included in the swathe, allowing the hand to emerge between the layers where they are pinned together. This form of dressing is least likely to strangulate the arm during the first week of treatment when the traumatic reaction and swelling are in progress. A very satisfactory method of fixation in fractures below the middle of the shaft is one in which internal and external plaster splints are used, as shown in Fig. 215. These splints are made of plain gauze (from fifteen to twenty ply) and should be reinforced at the elbow^ by the insertion of additional layers of gauze between the layers of the splint. The external splint extends from a point well up on the shoulder, along the back of the arm and forearm to the wrist, while the internal splint extends from just below the axillary fold to the wrist on the anterior aspect of the upper extremity. They are applied to the injured member while wet and rapidly secured in position with a roller bandage. The surgeon holds the fragments in proper reduction until the plaster has set. Specific instructions should be given to the patient and his attend- ants not to allow the splints to be covered with clothing or bed 116 FRACTURES AND DISLOCATIONS covers for at least twenty-four hours so the plaster may become thoroughly dried out. One or two folded towels should be placed between the arm and the body, and a light swathe used encircling the chest and injured member. The following day the splints should be removed one at a time, lined with a layer of sheet cotton and replaced. The splints should then be secured in position by means of strips of adhesive plaster encircling the arm. The body swathe may be used in securing the arm by the side, or strips of adhesive may be used for this purpose. Sufficient padding should be placed in the external splint in the region of the olecranon to avoid chafing and discomfort. This dressing is quite secure but requires careful watching to avoid strangulation w^hen swelling sets in. It is of particular advantage in compound fractures of the lower end of the humeral shaft since the arm may be perma- nently secured to one splint while the other is removed daily for inspection and dressing of the wound. After the arm is immobilized (whatever the type of dressing may be) an X-ray should be taken, when possible, to verify the diagnosis and to determine the accuracy of reduction. When overriding deformity cannot be corrected by solid engage- ment of the fractured ends weights may be attached to the elbow to control the action of the biceps and triceps. (Fig. 214.) The use of extension may be indicated in some cases if employed in the recumbent position, but as an ambulatory method it is, in the author's opinion, entirely too haphazard and untrustworthy to be relied upon, notwithstanding statements to the contrary. It may be stated as a rule that fractures of the shaft requiring permanent extension to maintain reduction should be submitted to operation, and the fragments wired or plated in position. If ambulatory extension is employed, and fails, w^e have a condition of deform- ity W'hich we know only too well might have been prevented by proper operative intervention. Operative Treatment. — Fractures of the humeral shaft are fre- quently of the oblique or spiral type and accurate reduction is often impossible without open incision and internal fixation. The frequency w^tli which one sees deformity following fractures of the humeral shaft treated by non-operative methods, indicates the value of open incision in the treatment of breaks in this region. It is usually best to approach the bone through an external longi- tudinal incision of sufficient length to allow free access for manipu- FRACTURES OF SHAFT OF HUMERUS 117 lation and reduction. The greatest care should be used to avoid injury to the musculo-spiral nerve in making the incision and in accomplishing reduction and fixation. Destruction of the function of this nerve will be more disastrous to the patient than non-union of the fragments or union with deformity. It should be kept in mind therefore that it is possible for the surgeon to produce an Fig. 158. Fig. 158. — Rontgenogi'am of spiral fracture of humerus after two attempts at re- duction. Rotary and lateral deformity present. Fig. 159. — Same case after operation, showing fragments held in reduction by two wires. The lower wire encircles the bone while the other, at a higher level, penetrates the shaft and secures leverage for the lower wire. injury which is far worse than the condition which he is operating to correct ; accordingly the course of the musculo-spiral nerve should be thoroughly appreciated before operation in this region is attempted. After the fragments have been exposed the nature of the fracture is accurately ascertained, reduction accomplished and the best method of fixation determined. Each case must be considered by itself, and the nature of the deformity fully appreciated before 118 FRACTURES AND DISLOCATIONS Fig. 160. — X-ray of same bone after it had been removed from soft tissues. Note the density and dis- position of the callus nine months after operation and compare this plate with the photographs of the bone shown in Figs. 161, 162 and 163. Figs. 161, 162 and 163. — Same case as shown in Figs. 158, 159 and 160. Patient had suffered from chronic chorea for past twenty-five years and sustained fracture as a result of the staggering gait which caused the fall. Fixation was particularly diffi- cult on account of the nature of the fracture and the choreoid spasms and wiring was resorted to. Nine months later patient died in the terminal dementia following Huntingdon's chorea and humerus was ob- tained at autopsy. By comparing this specimen with Figs. 158, 159 and 160 the disposition of the callus ( overing the wire will be readily appreciated. The wire A. encircling the shaft has been covered by crllus where it crosses the line of fracture. The wire B. was passed through a drill hole in both fragments and did not encircle the shaft; this wire also is cov- ered by callus where it crosses the line of fracture. Restoration of function was complete some months prior to death. The dotted outline shows where the nnihculo-spiral nerve crosses the bone in the fresh specimen; wire A. was originally passed between the nerve and the bone. 160. Fig. 162. A Fig. 163. FRACTURES OF SHAFT OF HUMERUS 119 internal fixation is employed. Lateral displacement and over- riding deformit}^ in spiral fractures can usually be prevented by a wire encircling the shaft and including both fragments. (See Figs. 158 and 159.) A second wire is then placed a short distance from the first to secure the proper leverage in preventing angular deformity. In passing the circular wire about the shaft some form of hook (such as shown in Fig. 826) should be used to avoid includ- ing the musculo-spiral nerve. The Lane plate has been used in this region with most satisfying results and has much to commend it (see page 766). After-Treatment. — The after-care of fractures of the humeral shaft is as important as reduction. The bone is deeply seated and difficult to immobilize and the dressings require daily inspection and adjustment during the first ten days. Undue constriction of the parts must be avoided and still the dressings must be tight enough to properly support and immobilize the arm. In other words, the arm is changing in size because of the swelling, and the dressings must be made to vary accordingly, so they may fulfill their proper function. When fixation is satisfactory union should be present at the end of four weeks in children, and in from five to six wrecks in adults. The older the patient the slower the bone will be in uniting. After the removal of splints the arm should be carried in a sling for another two or three weeks. Massage, early passive motion and hot applications will hasten the restoration of function. The arm should not be subjected to excessive strain for three to four months following the injury. Prognosis. — In children and healthy young adults the restora- tion of function should be rapid and complete, if proper reduction and immobilization have been carried out, and union is usually firm at the end of four weeks. In adults five to six weeks is necessary. Non-union is more common here than in any other bone in the body, and is usually due to incomplete reduction or lack of proper im- mobilization. Laceration of the musculo-spiral nerve at the time of injury will be followed by paralysis and contractures, if not exposed and repaired. Even when the ends are united recovery is tedious and often incomplete. The development of paralysis of this nerve during the after-treatment may be due to compression by the callus and unless relieved by operation gives a bad prognosis.