CHAPTER IX. FRACTURES OF THE LOWER END OF THE HUMERUS. (Part 2)

in fracture of the external condyle. Fracture of the epitrocMea (a vertical fracture separating the internal epicondyle from the remainder of the bone without entering the joint or involving the trochlea) is not an uncommon injury, and since neither the joint cavity nor the articular surfaces are involved the symptoms are usually slight. There is some local tenderness and pain on the inner side of the elbow, and ecchymosis is usually seen within the first day. Flexion and extension of the elbow^ are not painful except in as much as they disturb the detached fragment. Extreme extension or acute flexion may be attended by pain. Local swelling is usually present. The symptoms are often so slight that the condition is not infrequently mistaken for a sprain and treated as such. Supracondylar and diacondylar fractures are similar conditions and the symptoms so resemble each other that they wdll be de- scribed together. Swelling, pain, tenderness, loss of function, crepitus, and mobility are present as in vertical fractures involving the articular surfaces. Loss of carrying angle and even gunstock deformity are usually prominent symptoms. The deformity is often characteristic, the bones of the forearm and humeral frag- ment being displaced backward in such a w^ay as to produce a strong 132 FRACTURES AND DISLOCATIONS Fig. 138. — Transverse fracture of the lower end of the humerus. Note the back- ward displacement of the elhow. Palpation reveals the three bony prominences all dis- placed backAvarcl without disturbance in their relative positions. Sigmoid cavity of ulna not empty, as in Fig. 229. Picture taken about twenty-four hours following accident. Note sv'elling and slight ecchvmosis. Fig. 189. — Same case in sitting position. Note that the defonnitv persists with change of position. The elbow is flail-like yet the action of the biceps and triceps pro- duce and maintain the deformitv. FRACTURES OF LOWER END OF HUMERUS 133 Fio-. 190 Figs. 190 and 191. — X-ray plates of case shown in Figs. 188 and 189 after incom- plete rednctiou. :\i Fig-. 193. Figs. 192 and 19o. — L'oiupound comminuted fracture of lower end of humerus. Note the backward and inward displacement which is characteristic, Forearm is cov- ered with blood which accounts for its darkened condition in the photograph. Arrow points to the wound just above and behind the elbow. Picture taken about one hour after injury. 134 FRACTURES AND DISLOCATIONS resemblance to backward dislocations of the elbow (see page 159). The character of the deformity is well shown in Figs. 188 and 189. On palpation the two condyles are found to be no longer continuous with the shaft of the humerus though they are continuous with each other and move together. If the upper end of the ulna is palpated Fig. 194. Figs. 194 and 195. — Compound comminuted fracture of the lower end of the humerus. Note the deformity and flail-like condition. the greater sigmoid cavity will be found occupied by the lower end of the humerus and not empty as in backward luxation. The lateral stability of the elbow is destroyed. The characteristic deformity of a supra- or dia-condylar fracture is first the backward displacement of the elbow and second the '^gunstock" deformity. (See Figs. 192 and 193.) In iJie T- or Y -fracture of the loiver end of the humerus or in FRACTURES OF LOWER END OF HUMERUS 135 cases in which the lower end of the hone is extensively comminuted practically all the symptoms of the above described transverse and vertical fractures are present in exaggerated form. The lateral Figs. 196 and 197. — Old case of gunstock deformity and almost complete loss of function of elbow due to fractures above and below the joint. X-ray examination shows supracondylar fracture in lower end of humerus and fracture of ulna below coronoid process. stability of the elbow is more completely destroyed in these types than in other forms of fracture in the lower end of the humerus. The traumatic reaction is usually severe and the fracture is not 136 FRACTURES AND DISLOCATIONS infrequently compound. On palpation crepitus is readily recog- nized, and when the comminution is extensive the region of the elbow may give one the sensation of a sack of marbles. When the condition is compound the wound is not infrequently located just above the olecranon on the posterior aspect of the arm. Fracture limited to the capitellum is extremely rare and presents no characteristic symptoms. Local tenderness and pain with use of the elbow are present, but the condition is seldom recognized without the aid of the X-ray. Fig. 199. Figs. 198 and 199. — Old case of dia^ondylar fracture with the usual backward dis- placement of elbow. Deformity closely resembles backward luxation of the eibow. The characteristic depressions at the back 'of the elbow are absent and palpation of the sig- moid determines that it is not empty. (Compare with Figs. 225 to 230.) Diagnosis. — The diagnosis of fractures of the lower end of the humerus is based on the symptoms just enumerated. Swelling about the elbow is usually rapid in onset and pronounced following fractures in this region, and the earlier the surgeon sees the case after the accident the less difficulty there will be in establishing a diagnosis. Firm, local, gentle and continued pressure in a given FRACTURES OF LOWER END OP HUMERUS 137 spot will iu many cases so displace the fluids within the swollen tissues as to render recognition of the underlying bone possible. If there is difficulty in determining the nature of the fracture the examination should be systematically conducted so that all the data possible may be gathered before the surgeon forms an opinion of the condition. If the traumatic reaction is pronounced it will usually be advisable to anesthetize the patient before examining the parts. The expense of repeated Rontgenographic examinations is frequently objected to by the patient, and under these circumstances it may be advisable to learn all that is possible from a physical Fig. 200. Fig. 201. Fig. 200. — Examination of three bony prominences with elbows acutely flexed. Note the slight backward and upward displacement of the patient's right internal condyle. Fig. 201. — With full extension it will he noted that there is a loss of carrying angle in the patient's right arm. The left arm is normal. Old fracture of lower end of right humerus. examination under anesthesia, reduce the fracture and then have an X-ray plate taken to verify the diagnosis and the completeness of reduction at the same time. A careful inspection of the parts is of the greatest value and should be done before the arm is sub- jected to any manipulation whatever. The character of the deform- ity and the attitude of the patient will often be sufficient to indicate the nature of the injury so that the diagnosis is confirmed by the least possible manipulation and palpation. The less the parts are disturbed and the more gentle the manipulation the better. If inspection indicates the nature of the injury the surgeon should examine the part suspected first. Otherwise the lower end of the 138 FRACTURES AND DISLOCATIONS bone should be covered systematically. The external condyle should be palpated and note made of whether or not the process is continuous with the shaft of the humerus and the opposite con- dyle. The same examination should then be made of the inner condyle. The lateral stability of the elbow should next be tested with the forearm fully extended. In determining this point the Fig. 203. Figs. 202 and 203. — Old fracture of lower end of liumerus with union in deformity. Pronounced gun-stock deformity and shortening of arm. The positions of the three bony prominences have been marked and the displacement is apparent. A line drawn through the two condyles is not at right angles to the shaft of the humerus. By examining the elbow in this position one can tell the position which the forearm Avill occupy when extended. (See accompanying text.) Function good considering the deformity. Case first seen six years after the injury at which time these photogi'aphs were taken. lower end of the arm is • grasped above the elbow to steady the humerus while the opposite hand grasps the wrist and an attempt is made to adduct and then abduct the forearm. The wrist nor- mally moves inward in passing from the position of supination to pronation, and the distance traversed is nearly equal to the breadth of the wrist. This motion, however, is accomplished entirelj^ by the lower end of the radius encircling the head of the ulna and in FRACTURES OF LOWER END OF HUMERUS 139 110 wise means lateral motion at the elbow. Lateral motion does not exist in the normal elbow. The relation of the three bony prominences of the elbow should be carefully noted, and if the normal relation is disturbed the surgeon should determine which of the prominences is displaced. The olecranon should be carefully palpated and its continuity with Fig. 204. — Another view of case shown in Figs. 202 and 203, showing the striking deformity. the ulnar shaft determined. The head of the radius should be palpated and note made of whether or not the head rotates with the radial shaft during pronation and supination of the forearm. The forearm should be carried through its normal range of motion and any restriction of action or pain should be noted. The backward displacement accompanying transverse fractures 140 FRACTURES AND DISLOCATIONS of the lower end of the humerus closel}^ resembles the deformity seen in backward luxations of the elbow. In luxations, however, the deformity is usually more pronounced and the sigmoid cavity is found empty on palpation (compare the appearances of the cases shown in Figs. 199 and 229). In fractures mobility is increased, while in luxations it is usually restricted. Fig. 205. — Fracture about two inches above the condyles Ihree years after the accident. Note the inAvard angular displacement of the lower fragment and resultant gun-stock deformity. Paralysis result of injury to musculo-spiral nerve at the level of the fracture. Nerve injury not recognized at the time of the inju.ry and nothing done subsequently to repair the damage. Patient has practically no use of the member. Cage first seen by author at time of taking this photograph. Fractures of the lower end of the humerus must be differentiated from Dislocations of the elbow. Dislocations of the ulna alone. Dislocations of the radial head. Fractures of the olecranon, Fractures of the coronoid and ulna below the elbow, Fractures of the radial head, neck, or shaft, Simple sprain of the elbow. FRACTURES OF LOWER END OF HUMERUS 141 Fig. 206. — Another view of case shown in Fig. 205. Patient cannot extend arm beyond position shown here. Note waist-drop, contracture and atrophy. Fig. 207. — Another view of case shown in Figs. 205 and 206. 142 FRACTURES AND DISLOCATIONS Fig. 208. — A rare case whicli demonstrates two deformities in the same patient. Both, arms were broken some years ago just above the elbow and both elbow joints were involved. After union had taken place the deformities were recognized. Valgus in one elbow and varus in the opposite. The left arm shows exaggerated carrying angle while the right arm shows "gun-stock" deformity. Case first seen by author 'at the time this picture was taken. Function in both arms fair considering the deformities. Fig. 209. — Picture taken to show how pronounced the normal carrying angle may be and the necessity of always examining the opposite elbovi'. (Left elbow has been painted with iodine following sprain.) FRACTURES OP LOWER END OF HUMERUS 143 The reflexes and condition of the circulation below the level of the fracture should be tested both before and after reduction. The ulnar nerve is the structure most commonly injured, especially in fractures of the internal condyle, and its function should be most carefully tested. The value of the X-ray cannot be overestimated in the diagnosis of fractures of the lower end of the humerus and should be made use of whenever possible. The plates taken should be at right angles to each other or else made stereoscopically. Treatment. — An accurate appreciation of the nature of the fracture is essential to the intelligent treatment of fractures of the lower end of the humerus. As a rule anesthesia should be employed in reducing the displacement and in fixing the arm. Reduction is easily accomplished in many cases, yet it is not uncommon to encounter a condition in which reduction and fixation can be had only with open treatment. Transverse fractures can usually be reduced by grasping the lower end of the arm above the elbow to steady the humerus, and then making traction in the axis of the semiflexed forearm. This pulls the bones of the forearm forward and with them the lower fragment seated in the sigmoid cavity of the ulna. When the fragment has been brought back into position the elbow is flexed and immobilized in this position. Treatment of these fractures in acute flexion will give the best results in the greatest number of cases, yet the value of this position should not be overestimated nor should it be employed blindly. The best position in which to treat fractures of this region is the position w^hich will most accurately and securely maintain reduction, and just which position this is must be determined in each and every case to the satisfaction of the surgeon. Much has been said and written of the value of the three bony prominences in the diagnosis of fractures about the elbow, yet their chief value lies in the treat- ment of these conditions and seems to have been overlooked. A careful consideration of these three points with the elbow flexed will enable the surgeon to determine the position the forearm will occupy when extended. This determination is made in much the same manner as one would foretell the position a door would occupy when open, by a study of the position of the hinges when closed. This point is well illustrated in Figs. 202 and 203. In reducing a fracture in this region the surgeon should have the two condyles directly under his touch, so that he may follow the effect 144 FRACTURES AND DISLOCATIONS on the fragments as the forearm is slowly carried through flexion and extension. The degree of flexion in which the fragments seem to occupy a position nearest to normal should be maintained, and dressings then applied which will immobilize the elbow. The two condyles should be in a line at right angles to the axis of the shaft of the humerus, and neither should occupj^ a position anterior to the other (taking the posterior surface of the humerus as a base). The tip of the olecranon should be at about the same level as the condAdes if extension is complete, at the apex of an equilateral triangle in acute flexion and j)roportionately situated between these two points in the various degrees of flexion. It will usuallj^ be found that posterior displacement of the lower fragment is cor- rected, more or less completely, by acute flexion, and we therefore seldom find the extended position available in the treatment of these cases. An arm may appear well reduced in the flexed position, and the surgeon may be pleased with the outlook of the case, and yet after union has taken place, the splints removed and the arm extended, a condition such as shown in Fig. 203 may become evident, to the chagrin of the surgeon and the dissatisfaction of the patient. Such results might be avoided by a careful examination of the three bony prominences following reduction as described above. In the treatment of vertical fractures involving the articular surfaces similar principles are to be followed out. Acute flexion, however, is not nearly as efficient in preventing recurrence of de- formity in these vertical fractures as it is when the break is trans- verse. During reduction lateral pressure should be made on the fragments in order that they may be forced closer together. Meas- urements of the distance between the two condyles should be made following reduction and compared with the opposite elbow. In some instances a detached condyle may follow the movements of the forearm during flexion and extension, and when this occurs the elbow should be fixed in the degree of flexion in which the fragment occupies a position nearest. to normal. If the fragment is rotated it may be necessary to operate to effect reduction. It should be remembered that the displacing action of the muscles of the fore- arm attached to the condyles varies with the degree of flexion of the elbow. In acute flexion the pull is upward and forward, in semiflexion it is forward, while in complete extension it is down- ward. FRACTURES OF LOWER END OF HUMERUS 145 The principles involved in the treatment of epiphyseal separa- tions are the same as those given in the treatment of fractures of the corresponding parts. Special padding of the splint may be of aid in retaining the frag- ments though it is not so satisfactory a method as might be desired. Displacement depends somewhat on the extent to which the intermuscular septa and fasciag have been torn, and accordingly we experience less difficulty in those cases in which the damage sustained bv these tissues has been sli^'ht. Fig. 210. — Method of fixing the arm iu a position short of acute flexion for the treatment of certain fractures at the elbow. This method is far better than passing adhesive about the wrist and upper part of the arm as is commonly done. Fractures entering the articular surfaces demand the most accu- rate reduction. Perfect apposition means a small callus and is essential to restoration of joint function. The dressings employed to fix the part vary with the degree of flexion in which the elbow is immobilized. In cases in which the traumatic reaction is pronounced