CHAPTER XV. FRACTURES OF THE UPPER END OF THE RADIUS. (Part 3)

fractures of the radial shaft. When the fragments of only one shaft are found to be overriding (more often the radius) our attention ma}^ be confined almost entirely to correcting the deformity of this one bone. The lateral displacement is first reduced and then the angular de- formity ; the opposite bone will follow provided it shows only angular displacement. When reduction is difficult or the patient nervous and hard to control it may be advisable to accomplish re- duction under anesthesia. It is well to remember that children are not as safe subjects for anesthesia as adults and reduction in many cases entails only an instant of pain if properly per- formed. In reducing green-stick fractures in children it may be possible to simply correct the bowing and straighten the bone but more often it will be found necessary to complete the fracture by bending the shaft in the direction of the bowing and then treat- ing the condition as a complete fracture. If the surgeon has reason to anticipate any special difficulty in effecting reduction it may be well to prepare for operation before giving the anesthetic, and then if it is found that reduction can- not be accomplished by manipulation he is ready to correct the displacement by open incision. Thus an additional anesthetic is avoided, time is saved and there are no failures to be explained. The splints employed in immobilization of fractures of the forearm are the same Avhether one or both bones are broken. Flat anterior and posterior splints will be found to meet the require- ments in the largest number of cases. They should be a little broader than the widest portion of the forearm and well padded before being applied. Light quarter-inch wood will answer the purpose well. Pliable wood such as yucca board may be em- ployed but should be used with the greatest caution and must never be bandaged in place tightly enough to force it to conform to the FRACTURES OF RADIAL AND ULNAR SHAFTS 223 Appltcatiox of Splixts to the Forearm. Fis. 307. — Fracture of both hones of the forearm prior to reduction. (See Figs. 385 and 386.) Fig-. 308. — Yentral splint appUed followino; reduction and held in position by two straps of adliesive — A. and B. Fig. 309. — Forearm turned so that thenar "cut-out" may he seen. Fig. 310. — Dorsal splint applied and held in position by two additional straps of idhesive — C. and D. Fig. 311. — Bandaging covering both splints. When the forearm is broken above the middle this dressing should be supplemented by an internal right angle splint. (See Fig. 2iaJ 224 FRACTURES AND DISLOCATIONS contour of the forearm, as otherwise constriction may result. The anterior splint should extend from the middle of the palm of the hand to a point just below the bend of the elbow when the fore- arm is semiflexed. The radial side of the lower end of the splint should be cut away to clear the thenar eminence as shown in Fig. 309. The cotton padding should be thicker just above the wrist and opposite the palm of the hand. The posterior splint should extend from the metacarpo-phalangeal knuckles to a point a short distance below the elbow. The forearm must not be bandaged before the splints are applied as the circulation may thus be in- terfered with. One splint is put in place (usually the palmar) and secured with two strips of adhesive as shown in Fig. 308 and the parts examined to see that reduction is maintained. The second splint is then applied and secured with strips of adhesive Fig. 312. — Shows same dressing opened up for inspection during the after-treat- ment. Straps C. and D. have been cut and dorsal splint turned back, thus allowing inspection and palpation of the forearm while it is still secured to the ventral splint. (See also Figs. 283 and 284.) which encircle both splints. The splints should be loosely ban- daged, especially when the dressing is first applied. Gangrene of the forearm or Yolkmann's contracture may follow too tight bandaging, and the surgeon cannot always depend on the sensa- tions of the patient to give warning that damage is being done. Gangrene is known to have occurred without attracting the pa- tient's attention. Phlegmonous inflammation is not uncommon, and pus developing within tlie tissues may cause extensive dam- age by burrowing. It must be remembered in tliis connection that a bandage may be of the proper snugness at the time of applica- tion and yet a few hours "of swelling may result in dangerous strangulation of the forearm. Any form of splint which is curved to conform to the surface of the forearm, or a rolled bandage applied to the forearm before flat splints are put in place, is more likely to produce strangulation than is the simple flat splint. Splints making pressure between the bones of the forearm to FKACTURES OF RADIAL AND ULNAR SHAFTS 225 prevent approximation of the fragments across the interosseous space are dangerous and should never be used. If the fracture or fractures are in the upper half of the forearm an internal or external right angle splint should be used in addition to the flat splints emploj'ed in immobilizing the forearm. If the break is near the elbow it will be impossible to secure proper fixation with- out immobilizing the elbow. The thumb and fingers should be left exposed in all cases so that the condition of the circulation may be known without removing the dressings. The secondary traumatic reaction is often pronounced in frac- tures of the forearm, and must be taken into consideration in the treatment of fractures in this region. If the trauma to the soft tissues is great it may be best to defer the application of splints until the swelling is decreasing and under control. It is often possible to foretell approximately the degree of swelling which will follow, by the extent of bruising of the tissues of the forearm, and when the surgeon has reason to anticipate a severe reaction the case should be treated for the first few days along the follow- ing lines. The deformity is reduced immediately and the forearm loosely bandaged on a single splint. The patient is then put to bed, the parts kept perfectly quiet and the ice cap applied at intervals to the region of fracture. Sedatives or opiates may be necessary if the pain is severe. The arm should be examined every few hours to see that the swelling is not great enough to cause constriction of the forearm within the bandages. During this time an X-ray should be taken to determine the exact nature of the fracture. When the swelling is well subsided the arm may be immobilized with splints as previously described. Operative Treatment. — The open method is indicated in recent cases when proper reduction cannot be had by manipulation and in compound cases. Simple angular deformity can, as a rule, be corrected by manipulation unless some of the soft tissues become interposed between the fractured surfaces. Overriding deformity of one or both bones and multiple fracture of one of the shafts are the conditions most often rendering operation necessary. Fracture of the radius is best exposed through a longitudinal inci- sion on the outer aspect of the forearm. The skin, fasciae and aponeuroses are divided with the scalpiel and the underlying mus- cles separated by blunt dissection. When the fracture is low in the radial shaft care should be taken not to divide the tendons of 226 ■ FRACTURES AND DISLOCATIONS the extensor muscles of the thumb which pass obliquely across the outer aspect of the lower end of the radius. The position of the radial pulse should be noted before making the incision to avoid injury to the artery when anomalously placed. With the fragments exposed reduction is accomplished by direct manipula- tion and the serrations fitted accurately together. Internal fixa- tion will usually be unnecessarj^ if the ulna has not been injured. Not infrequently one or both fragments show a disposition to slip out of place toward the ulna. When this occurs it may be possible to prevent recurrence of deformity by a single loop of wire holding the fractured surfaces opposed or it may be necessary to emplo}^ a small, light Lane plate. In operating on the ulnar shaft it is best to expose the frag- ments through a longitudinal incision a little internal to the pos- terior subcutaneous border. The fragments are reduced in a man- ner similar to that just described in operating on the radial shaft, and internal fixation used or not, according to the needs of the case in hand. When hoth hones are fractured the shafts should be exposed through two incisions as already described in operating on isolated fractures of either shaft. It is a mistake to attempt to expose both shafts through one incision since the injury to the soft tissues will be more extensive. Theoretically this would not seem to be the case, but practically it will be found to be true. Internal fixation is more frequently necessary when both bones are frac- tured than in instances of isolated fracture of either the radial or ulnar shaft. In severe compound cases where there has been considerable loss of bony tissue in one of the shafts it has often been found neces- sary to resect a portion of the opposite shaft to make the two bones of equal length. This procedure has in many instances resulted in useful arms which would otherwise have been severely crippled, but before it is employed in any given case we should consider the possibility of an autoplastic transplantation of a portion of the shaft of the patient's fibula or a section of the tibial crest into the shaft of the deficient bone. (See ''Bone Transplantation" on page 771.) Severe compound cases should be treated according to the prin- ciples laid down under the heading of "The Treatment of Com- pound Fractures and Luxations" on page 789. Severed arteries FRACTURES OF RADIAL AND ULNAR SHAFTS 227 lie fdrearm with Fig. 315. — Antero-posterior view of same case after operation and internal fixatior T«»»5»»53'^B'- Fig. 316. — Lateral view after operation. 228 FRACTURES AND DISLOCATIONS should be ligated and nerves sutured in cases where the^^ are found divided. After-Treatment. — During the first few days the bandages should be very loose and the dressings frequently inspected to see that there is no strangulation of the parts. The condition of the cir- culation beneath the nails may be easily ascertained and compared with the opposite side. There is no region in the body in which strangulation is more likely to take place than in the forearm and the results may be disastrous. Volkmann's contracture is a pos- sibility which must be kept constantly in mind during the after- treatment of fractures of the forearm. (See "Volkmann's Con- tracture," page 231.) The skin over the head' of the ulna often calls for special care to avoid irritation. Gentle massage after the subsidence of the traumatic swelling is of great value in keeping the soft tissues in good condition during the process of bone heal- ing but the greatest care should be exercised to avoid disturbing the fragments. Union may be expected in children in three weeks or even less, but the forearm should be protected by retaining the posterior splint for another ten days. The forearm should be sub- jected to only the gentlest use for two or three weeks following the removal of all splints. Active motion in all directions will be weak and limited on removal of the splints, but function will return rapidly with use and massage. The parts should be in- spected at least daily for the first ten days to properly accommo- date the dressings to the varying size of the forearm; after ten days the dressings should be removed at least twice a week to recognize and correct deformity, should it take place. If flat splints are used, as shown in Figs. 283 and 312, one splint may be removed without disturbing the other, and we are thus enabled to inspect the parts without entirely removing the support from the broken bones. Plaster splints and the plaster cast have been suc- cessfully used in the treatment of fractures of the forearm but they are dangerous appliances except in the hands of the expert. If plaster of Paris had never been employed in the treatment of fractures of the forearm Volkmann's contracture would have been much less common. If the fractures are at or above the middle of the shafts the internal or external right angle splint should be retained through- out as a necessary part of the dressing. Bowing may result from using the forearm too soon and the FRACTURES OF RADIAL AND ULNAR SHAFTS 229 patient should be warned to avoid undue strain on the bones for a period varying from one to four months following fracture. When there is doubt as to the satisfactory ossification of the callus it is advisable to base our after-treatment on X-ray findings. In adults four to five weeks will be necessary before the callus is strong enough to allow^ permanent removal of the splints. Old persons produce bone slowly and should be allowed 15 to 20 per- Fig. 317. — Slight bowing deformity following fracture of both bones of the fore- arm. The deformity here is due to overriding of the radial fragments. Note the hand which is displaced slightly to the radial side and a little backward. Operation was advised in this case but refused. Function restored but slight deformity persists. A deformity such as this will diminish with years provided the patient is young. Picture taken about four and a half weeks following fracture. cent more time than is allowed healthy adults. During the after- treatment the fingers should be manipulated daily, especially in old persons, as otherwise adhesions form about the tendons and mus- cles and between the joint surfaces, which may prove a permanent source of restricted motion. Prognosis. — The prognosis in fractures of the bones of the fore- arm varies greatly according to the conditions present. Accurate reduction of the fragments in a healthy child or adult should be 230 FRACTURES AXD DISLOCATIOXS followed by complete restoration of function. Deformity may pro- dnce loss of function. The rotary action of the forearm is most frecjuently interfered with, the most common causes being an outward bowing of the shaft of the radius or the extension of the callus from the shaft of the ulna to the radius when the fragments of these two bones are displaced toward each other. Loss of the 319 (top), Fig. 320. Figs. 318. 319 and 320. — Tliree views of a case of Volkmaun's paralysis. This case is an example of a most disastrous condition Avhieh may follow too tight bandaging of the forearm. In this case there had been no fracture. The patient sustained a lacerated wound involving one of the large arteries and an Esmarch tourniquet was applied and left in position for over twelve hours while the patient was being brought to the city for surgical treatment. ^Myositis, paralysis and contracture followed. Case first seen by author some years after the injury. power of supination may follow fracture of the radial shaft be- tween the insertions of the biceps and pronator radii teres if not treated in supination as previously mentioned. Xon-union of frac- tures of the forearm is not common but when it does take place it is usually the result of the interposition of soft tissues between the fractured ends rather than to constitutional causes or defective immobilization. When due to the interposition of muscle or fascia the prognosis will depend on whether or not operative procedures are instituted and the fractured surfaces brought into contact. A careful study of X-ray plates taken in two planes will as a rule disclose the presence of interposed tissues early in the course of the case, and if the proper surgical measures are then instituted FRACTURES OF RADIAL AND ULNAR SHAFTS 231 there will be no occasion for non-union. Slight bowing in a child will usually correct itself as j^ears go by but this fortunate condi- tion is no reason for the surgeon not insisting on the most perfect possible reduction following the accident. Yolkmann's paralysis (or contracture) is a paralysis of the fore- arm with wasting of the muscles and contracture. The first cause is said to be an ischemia which is followed by myositis and ultimate destruction of muscular tissue which is replaced by scar tissue. The function of the nerves may be subsequently destroyed by con- traction of the scar tissue as well as by disuse. The points at which nerve constriction most commonly takes place are where the median passes between the heads of the pronator radii teres, and the ulnar nerve between the heads of the flexor carpi ulnaris. Volkmann's paralysis usually follows fractures of the upper extremity in chil- dren (especially fractures of the forearm) and is the result of too tight bandaging or interference with the circulation from some other cause. Pain may be present with the onset of the condition, but is no guide whatever to the damage the forearm may be undergoing from too tight bandaging. The fingers are swollen and show passive congestion, the hand and forearm are numb and uncomfortable but seldom painful. Later on contracture develops in which the wrist is flexed, the proximal row of phalanges hyperextended and the middle and distal rows flexed. (See Figs. 318, 319 and 320.) If the condition is allowed to go uncorrected, contraction of the scar tissue replacing the muscles is likely to destroy the nerves, and all electric reaction will be lost. If the case is seen early (within a few days or a week), massage and forcible passive motion with