INJURIES IN THE REGION OF THE SHOULDER AND UPPER ARM
Surgical Anatomy--FRACTURES OF CLAVICLE: _Varieties_--DISLOCATION OF
CLAVICLE: _Varieties_--DISLOCATION OF SHOULDER:
_Varieties_--Sprains and contusions of shoulder--FRACTURE OF
SCAPULA: Sites--FRACTURE OF UPPER END OF HUMERUS: _Surgical neck_;
_Separation of epiphysis_; _Fracture of head, anatomical neck, or
tuberosities_--FRACTURES OF SHAFT OF HUMERUS.
The injuries met with in the region of the shoulder include fractures
and dislocations of the clavicle, fractures of the scapula,
dislocations and sprains of the shoulder-joint, and fractures of the
upper end of the humerus.
#Surgical Anatomy.#--For the examination of an injury in the region of
the shoulder the patient should be seated on a low stool or chair.
After inspecting the parts from the front, the surgeon stands behind
the patient and systematically examines by palpation the shoulder
girdle and upper end of the humerus. The uninjured side should be
examined along with the other for purposes of comparison.
Immediately lateral to the supra-sternal notch, the sterno-clavicular
articulation may be felt, the large end of the clavicle projecting to
a varying degree beyond the margins of the small and shallow articular
surface on the sternum. Any dislocation of this joint is at once
recognised. The clavicle being subcutaneous throughout its whole
length, any irregularity in its outline can be easily detected. A
small tubercle (deltoid tubercle) which frequently exists near the
acromial end is liable to suggest the presence of a fracture. The
lateral end forms with the acromion the acromio-clavicular joint,
which, however, is not always readily identified. The fingers are now
carried over the acromion, which often exhibits in the situation of
its epiphysial cartilage a prominent ridge, which must not be mistaken
for a fracture. The tip of the acromion is usually employed as a fixed
point in measuring the length of the upper arm.
The outline of the spine of the scapula can be traced back to the
vertebral border; and the body of the bone may be manipulated, and its
movements tested by moving the arm.
The coracoid process can be recognised in the upper and lateral angle
of the triangular depression bounded by the pectoralis major, the
deltoid, and the clavicle.
The head and surgical neck of the humerus may now be felt from the
axilla, if the axillary fascia is relaxed by bringing the arm to the
side. The great tuberosity can be indistinctly felt on the lateral
aspect of the shoulder through the fibres of the deltoid. It lies
vertically above the lateral epicondyle, and may be felt to rotate
with the shaft. The inter-tubercular (bicipital) groove looks forward,
and lies in a line drawn vertically through the biceps muscle.
The subclavian artery, with its vein to the median side and the cords
of the brachial plexus to the lateral side, passes under the middle of
the clavicle, and may be compressed against the first rib immediately
above this bone.
FRACTURE OF THE CLAVICLE
Fracture of the clavicle is one of the commonest injuries met with in
practice. As about one-third of the cases occur in children, the
fracture is often of the greenstick variety. The fractures are seldom
compound or complicated, unless as a result of gun-shot injuries; but
occasionally one of the fragments pierces the skin, or comes to press
upon the subclavian vessels or the cords of the brachial plexus,
arresting the pulsation in the vessels of the limb, and causing severe
pain in the arm.
[Illustration: FIG. 13.--Oblique Fracture of Right Clavicle in Middle
Third, united.]
The most common site of fracture is in the _middle third_ (Fig. 13),
and this usually results from indirect violence, such as a fall on the
outstretched hand, the elbow, or the outer aspect of the shoulder, the
force being transmitted through the glenoid cavity to the scapula, and
thence by the coraco-clavicular ligaments to the clavicle. The
violence is therefore of a twisting character, and the bone gives way
near the junction of the lateral and middle thirds, just where the two
natural curves of the bone meet, and where the supporting muscular and
ligamentous attachments are weakest.
The fracture so produced is usually oblique from above, downwards and
inwards. The sternal fragment may be slightly drawn upwards by the
clavicular fibres of the sterno-mastoid, while the acromial fragment
falls by the weight of the arm, and the fragments usually overlap to
the extent of about half an inch. The shoulder, having lost the
buttressing support of the clavicle, falls in towards the chest wall,
narrowing the axillary space, while the weight of the arm pulls it
downward, and the muscles inserted in the region of the bicipital
groove pull it forward.
Fracture of the middle third may result also from a direct stroke,
such as the recoil of a gun, or from violent muscular contraction, the
fracture as a rule being transverse, and the displacement less marked
than in fracture by indirect violence.
_Clinical Features._--The attitude of the patient is characteristic:
the elbow is flexed and is supported by the opposite hand, while the
head is inclined towards the affected shoulder to relax the muscles of
the neck. Crepitus is elicited on bracing back the shoulders, or on
attempting to raise the arm beyond the horizontal, and these movements
cause pain. Tenderness is elicited on making pressure over the seat of
fracture, and also on distal pressure. The sternal fragment almost
invariably overrides the acromial, and can usually be palpated through
the skin; on measurement, the clavicle is found to be shortened. When
the fracture is incomplete (greenstick) or transverse, the symptoms
are less marked.
[Illustration: FIG. 14.--Fracture of Acromial End of Clavicle. Shows
forward rotation of lateral fragment, and line of fracture united by
bone.]
Fracture of the _lateral_ or _acromial third_ of the clavicle is a
common form of accident at football matches, and usually results from
direct violence, the bone being driven down against the coracoid
process, and broken as one breaks a stick over the knee. The fracture
may take place through the attachment of the conoid and trapezoid
ligaments, in which case the only symptoms are pain and tenderness at
the seat of fracture, with impaired movement of the limb. Displacement
and crepitus are prevented by the splinting action of the ligaments.
When the break is lateral to the attachment of the trapezoid ligament,
the fracture is usually transverse, and is almost always due to a fall
on the back of the shoulder--the angle between the spine and the
acromion process striking the ground. The acromial fragment rotates
forward (Fig. 14), sometimes even to a right angle, causing the tip of
the shoulder to pass forwards, and so to lie slightly nearer the
middle line. The integrity of the coraco-clavicular ligaments prevents
any marked drooping of the shoulder. It is noteworthy that the
displacement is not always evident at first.
Fractures of the _medial_ or _sternal third_ are rare, are usually
oblique, and result either from an indirect force acting in the line
of the clavicle, or, less frequently, from direct violence or muscular
action. As a rule, the deformity is insignificant, except when the
costo-clavicular ligament is torn, in which case the medial end of the
distal fragment is tilted up by the weight of the arm. The shoulder
passes downwards, forwards, and medially. When close to the sternal
end, this fracture may simulate a dislocation of the sterno-clavicular
joint or a _separation of the clavicular epiphysis_. This last is a
rare accident, which may occur between the seventeenth and the
twenty-fifth years, and is usually the result of violent muscular
action. It differs from the other injuries in this region in being
more easily reduced and retained in position, the epiphysis lying
entirely within the limits of the articular capsule of the
sterno-clavicular joint.
_Simultaneous fracture of both clavicles_ usually results from a
severe transverse crush of the upper part of the thorax or from a fall
on the outstretched hands--for example, in hunting. The middle third
of the bone is implicated, and there is marked displacement and
overriding. The patient is rendered helpless, and from the extrinsic
muscles of respiration being thrown out of action and the weight of
the powerless limbs pressing on the chest, there is considerable
difficulty in breathing, and this is often increased by the fracture
being complicated by injuries of the lung or pleura.
The _prognosis_ as to union in all these injuries is good. Firm bony
union usually occurs within twenty-one days. Non-union, false-joint,
or fibrous union is but rarely met with. At the same time it is to be
borne in mind that, in spite of all precautions, some deformity and
shortening may result, without, however, interfering with the
usefulness of the limb.
_Treatment._--The displacement in complete fractures of the clavicle
is readily reduced by supporting the elbow, bracing back the
shoulders, and levering out the tip of the affected shoulder. In a few
cases the interposition of some fibres of the subclavius muscle
between the fragments has prevented perfect reduction.
In the greenstick variety the bone may be bent back into its normal
position, but no great force should be employed, as, in spite of
imperfect reduction, the clavicle usually straightens as it grows, and
although some deformity may persist, the function of the limb is not
interfered with.
_Recumbent Position._--There is little doubt that the most perfect
aesthetic results are obtained by treating the patient in the recumbent
position. In girls, therefore, in whom it is desired that the
shoulders should be perfectly symmetrical, the best results are
obtained from placing the patient on a firm mattress, with a narrow,
firm cushion between the shoulder-blades, so that the weight of the
shoulder may carry the acromial fragment laterally and backwards. A
pad is inserted in the axilla, the elbow raised, and the arm placed by
the side on a pillow and steadied with sand-bags. Massage is applied
daily. As this position must be maintained uninterruptedly for two or
three weeks, it proves too irksome for most patients. When both
clavicles are fractured, however, it is, short of operation, the only
available method of treatment.
In ordinary cases the arm should be placed in that position which
gives the best alignment of the fragments and least deformity. A thin
layer of wool is placed in the axilla to separate the skin surfaces. A
sling, supporting the _elbow_, is now applied, maintaining the arm in
position, and a body bandage fixes the arm to the side. Massage and
movement should be commenced at once.
A simple method, which yields satisfactory results, is that suggested
by Wharton Hood. The fracture having been reduced, three strips of
adhesive plaster, each an inch and a half wide, are applied from a
point immediately above the nipple to a point 2 inches below the angle
of the scapula (Fig. 15). The middle strap covers the seat of
fracture, and is applied first: the others, slightly overlapping it,
extend about half an inch on either side. The elbow is supported in a
sling. This plan has the advantage that it permits of movement of the
shoulder being carried out from the first, but the plaster rather
interferes with massage.
_The Handkerchief Method._--In cases of emergency, one of the best
methods applicable to all fractures of the clavicle is to brace back
the shoulders by means of two padded handkerchiefs, folded _en
cravate_, placed well over the tips of the shoulders and tied, or
interlaced, between the scapulae. The forearm is then supported by a
third handkerchief applied as a sling, the base of which is placed
under the elbow, the ends passing over the sound shoulder.
_Operative treatment_ may be called for in compound or comminuted
fractures when the fragments have injured, or are likely to injure,
the subclavian vessels or the cords of the brachial plexus, or when it
is otherwise impossible to reduce the fracture or to retain the
fragments in apposition. It is also indicated in some cases of
fracture of both clavicles.
These various methods of treatment are not equally applicable to all
cases. In our experience, in the circumstances indicated, the
following methods have proved the most satisfactory: (1) As a
temporary means of retention in emergency cases,--for example,
accidents occurring on the football field,--the handkerchief method.
(2) In uncomplicated fractures of average severity in any part of the
bone, the method of sling and body bandage. (3) In cases where, for
aesthetic reasons, the chief consideration is the avoidance of
deformity and the maintenance of the symmetry of the shoulders, as in
girls, the treatment by recumbency. (4) When retentive apparatus
fails, or when the fragments are exerting injurious pressure,
operative treatment.
[Illustration: FIG. 15.--Adhesive Plaster applied for Fracture of
Clavicle.]
In quite a number of cases, there is an excessive amount of pain,
preventing sleep; where this is due to cramp-like contractions of the
muscles and movements of the fragments, it is relieved by more
accurate fixation, as by strips of plaster; otherwise a hypodermic
injection of heroin or morphin is indicated.
DISLOCATION OF THE CLAVICLE
Dislocation of the #acromial end#--sometimes, and perhaps more
correctly, spoken of as dislocation of the scapula--is more frequent
than that at the sternal end, and it usually results from a blow from
behind, or from a fall on the tip of the shoulder, driving down the
scapula, so that the clavicle projects _upwards_ and overrides the
acromion process.
_Downward_ displacement of the acromial end of the clavicle is much
rarer, and may follow a fall on the elbow or a blow over the clavicle.
The end of the bone lies under the acromion process, in contact with
the capsule of the shoulder-joint, and the acromion stands out
prominently.
The _clinical features_ are so well marked that the diagnosis is
unmistakable. The head inclines towards the affected side, and the tip
of the shoulder tends to pass slightly downward, forward, and
medially. The displaced end of the bone can be seen and felt as a
prominence under the skin, or the empty socket can be palpated, while
the muscles attached to the displaced clavicle stand out in relief.
The movements at the shoulder are restricted, particularly in the
direction of abduction above the level of the shoulder. These injuries
are sometimes associated with fracture of the ribs, a complication
which adds materially to the difficulties of treatment.
_Treatment._--Reduction is easily effected by bracing back the
shoulders and replacing the bone in its socket by manipulation; but
retention is invariably difficult, and in many cases impossible; even
when the displacement is permanent, however, the usefulness of the arm
is not necessarily impaired.
Treatment is similar to that for fracture of the clavicle by sling and
body bandage. Another plan is to place a pad over the acromial end of
the clavicle, and fix it in this position by a few turns of elastic
bandage carried over the shoulder and under the elbow. The forearm is
placed in a sling with the elbow well supported, and the arm is bound
to the side by a circular bandage. When the bone cannot be kept in
position and the usefulness of the limb is impaired, the joint
surfaces may be rawed and the bones wired, with a view to obtaining
ankylosis.
#The sternal end# may be dislocated forwards, backwards, or upwards.
_Forward_ dislocation is the most common; the end of the clavicle lies
on the front of the sternum, somewhat below the level of the
sterno-clavicular joint, and its articular surface can be distinctly
palpated (Fig. 16). The inter-articular cartilage sometimes remains
attached to one bone, sometimes to the other; the rhomboid ligament is
usually intact.
In the _backward_ dislocation the end of the clavicle lies behind the
manubrium sterni and the muscles attached to it; there is a marked
hollow in the position of the joint, and the facet on the sternum can
be felt. In a comparatively small number of cases the bone exerts
pressure upon the trachea and oesophagus, producing difficulty in
breathing and swallowing. It has also been known to press upon the
subclavian artery and on other important structures at the root of the
neck.
[Illustration: FIG. 16.--Forward Dislocation of Sternal End of Right
Clavicle. From a fall on a polished floor, in a man aet. 40.]
In rare cases the rhomboid ligament is torn, and the end of the
clavicle passes _upwards_, and rests in the episternal notch behind
the sterno-mastoid muscle.
The bone may be retained in position by keeping the shoulders braced
back by a figure-of-eight bandage, or by padded handkerchiefs, and
making pressure over the displaced end of the bone with a pad. The
forearm is supported by a sling, and the arm fixed to the side.
Massage is employed from the first, and the patient is allowed to move
the arm by the end of a week. Imperfect reduction interferes so little
with the functions of the limb that operative measures are seldom
required except for aesthetic reasons.
Dislocation of #both ends# of the clavicle has occasionally occurred
from a severe crush. The ultimate result has been satisfactory, as one
or other end has always healed in normal position, and the function of
the arm has thus been maintained.
DISLOCATION OF THE SHOULDER
The shoulder is more frequently dislocated than all the other joints
in the body taken together. This is explained by its exposed position,
the wide range of movement of which it is capable, the length of the
lever afforded by the humerus, and the anatomical construction of the
joint--the large, round humeral head imperfectly fitting the small and
shallow glenoid cavity, and the ligaments being comparatively lax and
thin. The capsule of the joint is materially strengthened in its upper
and back parts by the tendons of the supra- and infra-spinatus and
teres minor muscles; while it is weakest below and in front, between
the subscapularis and teres major tendons. It is here that it most
frequently gives way and allows of the escape of the head of the bone.
The determining factor is probably that when the arm is abducted the
neck of the humerus comes in contact with the tip of the acromion, and
further abduction forces the head against the lower, weak portion of
the capsule, which gives way.
The violence is usually transmitted from the hand or elbow, less
frequently from the lateral aspect of the shoulder, the limb being
usually abducted and the muscles relaxed and taken unawares. The head
of the humerus, thus brought to bear on the weakest part of the
capsule, ruptures it and passes out through the rent. Dislocation is
readily produced in an unconscious person--as, for example, in
conducting artificial respiration in a patient suffering from opium
poisoning, the arms being hyper-abducted to exert traction on the
chest.
_Varieties._--Several varieties of dislocation are recognised,
according to the position in which the head of the humerus finally
rests (Fig. 17). The simplest of these is the _sub-glenoid_ variety,
in which the head rests on the long tendon of the triceps, where it
arises from the axillary border of the scapula just below the glenoid
cavity. In almost all dislocations of the shoulder the head of the
bone is at least momentarily in this position, but the sharp edge of
the scapula and the rounded head are ill adapted to one another, and
the position is not long maintained. The subsequent course taken by
the humerus depends upon the nature and direction of the force, the
position of the limb at the moment of injury, and the relative
strength and capacity for effective action of the different groups of
muscles acting upon the bone.
[Illustration: FIG. 17.--Diagram of most common varieties of
Dislocation of the Shoulder.]
In the great majority of cases it passes forward and medially, and
comes to lie against the anterior surface of the neck of the
scapula, under cover of the tendons of origin of the biceps and
coraco-brachialis muscles, constituting the _sub-coracoid
dislocation_. Much less frequently it passes under cover of the
pectoralis minor and against the edge of the clavicle--the
_sub-clavicular_ variety. In rare cases the head passes backward and
lies against the spine on the dorsum of the scapula, beneath the
infra-spinatus muscle--the _sub-spinous_ variety. Other varieties are
so rare that they do not call for mention.
_Clinical Features common to all Varieties._--Dislocation of the
shoulder is commonest in adult males; in advanced life the proportion
of female sufferers increases. It is usually attended with great pain,
and there is often numbness of the limb due to pressure of the head of
the bone upon the large nerve-trunks. There is sometimes considerable
shock. The patient inclines his head towards the injured side, and,
while standing, the forearm is supported by the hand of the opposite
side. The acromion process stands out prominently, the roundness of
the shoulder giving place to a flattening or depression immediately
below it, so that a straight-edge applied to the lateral aspect of the
limb touches both the acromion and the lateral epicondyle. The
vertical circumference of the shoulder is markedly increased; this
test is easily made with a piece of tape or bandage and is compared
with a similar measurement on the normal side--we lay great stress on
this simple measure, as it is a most reliable aid in diagnosis. The
head of the bone can usually be felt in its new position, and the axis
of the humerus is correspondingly altered, the elbow being carried
from the side--forward or backward according to the position of the
head. The empty glenoid may sometimes be palpated from the axilla. In
most cases, although not in all, the patient is unable at one and the
same time to bring his elbow to the side and to place his hand upon
the opposite shoulder (Dugas' symptom). Measurements of the length of
the limb from acromion to lateral epicondyle are rarely of any
diagnostic value.
The #sub-coracoid dislocation# (Fig. 18) is that most frequently met
with. It usually results from hyper-abduction of the arm while the
scapula is fixed, as in a fall on the medial side of the elbow when
the arm is abducted from the side. The surgical neck of the humerus is
then brought to bear upon the under aspect of the acromion, which
forms a fulcrum, and the head of the bone is pressed against the
medial and lower part of the capsule. In some cases muscular action
produces this dislocation; it may also result from force applied
directly to the upper end of the humerus.
[Illustration: FIG. 18.--Sub-coracoid Dislocation of Right Shoulder.]
The head leaves the capsule through the rent made in its lower part,
and, either from a continuation of the force or from contraction of
the muscles inserted into the inter-tubercular (bicipital) groove,
particularly the great pectoral, passes medially under cover of the
biceps and coraco-brachialis till it comes to rest against the
anterior surface of the neck of the scapula, just below the coracoid
process. The anatomical neck of the humerus presses against the
anterior edge of the glenoid, and there is frequently an _indentation
fracture of the head of the humerus_ where the two bones come into
contact (F. M. Caird). The subscapularis is bruised or torn, the
muscles inserted into the great tuberosity are greatly stretched, or
the tuberosity itself may be avulsed, allowing the long tendon of the
biceps to slip laterally, where it may form an impediment to
reduction. The axillary (circumflex) nerve is often bruised or torn,
and the head of the humerus is liable to press injuriously on the
nerves and vessels in the axilla.
The _clinical features_ common to all dislocations are prominent,
although Dugas' symptom is not constant.
[Illustration: FIG. 19.--Sub-coracoid Dislocation of Humerus.
(Sir H. J. Stiles' case. Radiogram by Dr. Edmund Price.)]
_Treatment._--The guiding principle in the reduction of these
dislocations is to make the head of the bone retrace the course it
took in leaving the socket. The main obstacles to reduction being
muscular contraction and the entanglement of the head with tendons,
ligaments, or bony points, appropriate means must be taken to
counteract each of these factors.
A general anaesthetic is an invaluable aid to reduction, and should be
given unless there is some reason for withholding it. It is specially
indicated in strong muscular subjects, and in nervous patients who do
not bear pain well, and particularly when the dislocation has existed
for a day or two. In quite recent cases, however, the surgeon may
succeed in replacing the bone by taking advantage of a temporary
faintness, or by engaging the patient's attention with other matters
while he carries out the appropriate manipulations.
When an anaesthetic is employed, the patient should be laid on a
mattress on the floor, or on a narrow, firm table; otherwise he should
be seated on a chair.
_Kocher's method_ is suitable for the great majority of cases of
sub-coracoid dislocation. (1) The elbow is firmly pressed against the
side, and the forearm flexed to a right angle. The surgeon grasps the
wrist and elbow and firmly _rotates the humerus away from the middle
line_ (Fig. 20) till distinct resistance is felt and the deltoid
becomes more prominent. In this way the rent in the lower part of the
capsule is made to gape, and the head of the humerus rolls away from
the middle line till it lies opposite the opening, rotation taking
place about the fixed point formed by the contact of the anatomical
neck of the humerus with the anterior lip of the glenoid cavity (D.
Waterston). (2) _The elbow is next carried forward, upward, and
towards the middle line_ (Fig. 21); the humerus acting as the long arm
of a lever on the fulcrum furnished by the muscles inserted in the
region of the surgical neck, the head, which forms the short arm of
the lever, is carried backward, downward, and laterally, and is thus
directed towards the socket. (3) The humerus is now _rotated towards
the middle line_ by carrying the hand across the chest towards the
opposite shoulder (Fig. 22). The anatomical neck of the humerus is
thus disengaged from the edge of the glenoid, and the head is pulled
into the socket by the tension of the surrounding muscles.
[Illustration: FIG. 20.--Kocher's Method of reducing Sub-coracoid
Dislocation--First Movement; Rotation of Arm away from Middle Line.]
[Illustration: FIG. 21.--Kocher's Method--Second Movement; Elbow
carried forward, upward, and towards the Middle Line.]
[Illustration: FIG. 22.--Kocher's Method--Third Movement; Rotation of
Arm towards Middle Line.]
A method of reduction has been formulated by A. G. Miller, which we
have found to be quite as successful as Kocher's method. The limb is
grasped above the wrist and elbow, the forearm flexed to a right
angle, and the upper arm abducted to the horizontal (Fig. 23). While
an assistant makes counter-extension and fixes the scapula, the
surgeon gradually draws the arm away from the body till the head of
the humerus is felt to pass laterally. The humerus is then rotated
medially by dropping the hand (Fig. 24), and the bone gradually glides
into the socket.
[Illustration: FIG. 23.--Miller's Method of reducing Sub-coracoid
Dislocation--First Movement.]
[Illustration: FIG. 24.--Miller's Method of reducing Sub-coracoid
Dislocation--Second Movement.]
In a certain number of cases reduction can be effected by
_hyper-abduction_ of the shoulder with traction. The patient is laid
upon a firm mattress, and the surgeon, seated behind him while an
assistant fixes the acromion, slowly and steadily extends the arm
until it is raised well above the head. In some cases the head of the
humerus spontaneously slips into its socket; in others it may be
manipulated into position by pressure from the axilla. This method is
restricted to recent cases, as in those of long standing the axillary
vessels are liable to be stretched or torn.
The method of reduction by traction on the arm with the heel in the
axilla is only to be used when other measures have failed, as it
depends for its success on sheer force.
_After-Treatment._--After reduction, the part is gently massaged for
ten or fifteen minutes, a layer of wool is placed in the axilla, the
forearm is supported by a sling, and the arm fixed to the side by a
circular bandage. Massage is carried out from the first, and movement
of the shoulder in every direction except that of abduction may be
commenced on the first or second day. The circular bandage may be
dispensed with at the end of a week, and abduction movements
commenced, and by the end of a month the patient should be advised to
use the arm freely.
The #sub-clavicular dislocation# (Fig. 17) is to be looked upon as an
exaggerated degree of the sub-coracoid rather than as a separate
variety. It is produced by the same mechanism, but the violence is
greater, and the damage to the soft parts more severe. The head passes
farther upwards and towards the middle line under cover of the
pectoralis minor, resting under the clavicle against the serratus
anterior and chest wall. The symptoms are usually so marked that they
leave no doubt as to the diagnosis. The outline of the head of the
humerus in its abnormal position is visible through the skin, and the
shortening of the limb is more marked than in the sub-coracoid
variety. The treatment is the same as for sub-coracoid dislocation.
#Sub-glenoid dislocation# (Fig. 17) is less frequently met with than
the sub-coracoid variety, and almost always results from forcible
abduction of the arm. The head of the humerus passes out through a
small rent in the lower and medial portion of the capsule, and rests
against the anterior edge of the triangular surface immediately below
the glenoid cavity, supported behind by the long head of the triceps,
and in front by the subscapularis muscle. It is readily felt in the
axilla. All the tendons in relation to the upper end of the humerus
are stretched or torn, and the great tuberosity is not infrequently
avulsed. There is sometimes bruising of the axillary nerve.
The projection of the acromion, the flattening of the deltoid, the
increased depth of the axillary fold, and the abduction of the elbow
are well marked; the arm is slightly lengthened, rotated out, and
carried forward. It is reduced by the hyper-abduction method (p. 60).
#Sub-spinous Dislocation.#--Backward dislocation is usually termed
sub-spinous, although in a considerable proportion of cases the head
of the humerus does not pass beyond the root of the acromion process
(_sub-acromial_) (Fig. 17). This dislocation is usually produced by a
fall on the elbow, the arm being at the moment adducted and rotated
medially, so that the head of the humerus is pressed backwards and
laterally against the capsule, which ruptures posteriorly. All the
muscles attached to the upper end of the humerus are liable to be
torn, and the tuberosities are frequently avulsed. The long tendon of
the biceps may slip from its position between the tuberosities, and
prevent reduction or favour re-dislocation, necessitating an open
operation.
In the milder cases the _clinical features_ are not always well
marked, and on account of the swelling this dislocation is apt to be
overlooked. In addition to the ordinary symptoms, the shoulder is
broadened, there is a marked hollow in front in which the coracoid
projects, and the arm is held close to the side with the elbow
directed forward. The head of the bone may be seen and felt in its
abnormal position below the spine of the scapula.
Reduction can usually be effected by making traction on the arm with
medial rotation, and pressing the head forward into position, while
counter-pressure is made upon the acromion.
_Prognosis._--The ultimate prognosis in dislocations of the shoulder
should always be guarded. The axillary nerve may be stretched or torn,
and this may lead to atrophy of the deltoid; or other branches of the
brachial plexus may be injured and the muscles they supply permanently
weakened. In a certain number of cases traumatic neuritis has resulted
in serious disability of the limb. The movements of the shoulder-joint
may be restricted by cicatricial contraction of the torn portion of
the capsule and of the damaged muscles. A marked tendency to recurrent
dislocation may follow if abduction movements are permitted before
repair of the capsule has had time to occur.
#Dislocation of the Shoulder complicated with Fracture of the Upper
End of the Humerus.#--In these injuries the dislocation is almost
always of the sub-coracoid variety, and the most common fractures by
which it is complicated are those of the surgical neck, the anatomical
neck, or the greater tuberosity. The most common cause is a fall
directly on the shoulder, and it seems probable that the head of the
bone is first dislocated, and, the force continuing to act, the upper
end of the humerus is then broken; or the two lesions may be produced
synchronously.
When seen soon after the accident, the existence of the fracture of
the humerus is liable to be overlooked, the condition being mistaken
for dislocation alone, or for a fracture through the neck of the
scapula. On careful examination under an anaesthetic, however, it is
observed that not only is the head of the humerus absent from the
glenoid cavity, but that it does not move with the rest of the bone,
abnormal mobility and crepitus are recognised at the seat of fracture,
and the upper arm is shortened. The extravasation in the axilla is
usually greater than that accompanying a simple dislocation, and the
pain and shock are more severe. A fracture through the neck of the
scapula alone is readily recognised by the ease with which the
deformity is reduced, and the way in which it at once recurs when the
support is withdrawn. In many cases it is only by the aid of a
radiogram that an accurate diagnosis can be made (Fig. 25).
[Illustration: FIG. 25.--Dislocation of Shoulder with Fracture of Neck
of Humerus.
(Sir Robert Jones' case. Radiogram by Dr. D. Morgan.)]
_Treatment._--Unless the dislocation is reduced at once, the movements
of the arm are certain to be seriously restricted, and painful
pressure effects from excess of callus are liable to ensue. An attempt
should first be made, under anaesthesia, to replace the head in its
socket, by making extension on the arm in the hyper-abducted
(vertical) position, and manipulating the upper fragment from the
axilla.
On no account should the lower fragment be employed as a lever in
attempting reduction. When reduction by manipulation fails, recourse
should be had to an open operation. The upper fragment should be
exposed by an incision over its lateral aspect, and made to return to
the socket by using Arbuthnot Lane's levers or M'Burney's hook, or a
long steel pin may be inserted into the fragment to give the necessary
leverage.
Reduction having been accomplished, the fracture is adjusted in the
usual way, advantage being taken of the open wound, if necessary, to
fix the fragments together by plates. The best position in which to
fix the limb is that of abduction at a right angle. Massage and
movement should be commenced early to prevent stiffness of the joint.
When it is found impossible to reduce the dislocation, it is usually
advisable to remove the upper fragment.
The method of allowing the fracture to unite without reducing the
dislocation, and then attempting reduction, usually results in
re-breaking the bone, or else in failure to replace the head in the
socket, and has nothing to recommend it.
#Old-standing Dislocation of the Shoulder.#--It is impossible to lay
down definite rules as to the date after which it is inadvisable to
attempt reduction by manipulation of an old-standing dislocation of
the shoulder. Experience of a hundred cases in Bruns' clinic led
Finckh to conclude that, provided there are no complications,
reduction can generally be effected within four weeks of the accident;
that within nine weeks the prospect of success is fairly good; but
that beyond that time reduction is exceptional.
The patient is anaesthetised, and all adhesions broken down by free yet
gentle movement of the limb. The appropriate manipulations for the
particular dislocation are then carried out, care being taken that no
undue force is employed, as the humerus is liable to be broken. If
these are not successful, they should be repeated at intervals of two
or three days, as it is frequently found that reduction is
successfully effected on a second or third attempt.
Should manipulative measures fail, it may be advisable to have
recourse to operation if the age of the patient and his general health
warrant it, and if the condition of the limb is interfering with his
occupation or involves serious disability. If operation is deemed
advisable, a few days should be allowed to elapse to permit of the
parts recovering from the effects of the manipulations. The joint is
freely exposed, the capsule divided, the head of the bone freed and
returned to the glenoid cavity. It is sometimes so difficult to
replace the head of the bone that it is necessary to resect it and aim
at the formation of a new joint, an operation which usually yields
satisfactory results.
#Habitual or Recurrent Dislocation.#--Cases are occasionally met with
in which the shoulder-joint shows a marked tendency to be dislocated
from causes altogether insufficient to produce displacement under
ordinary circumstances. This condition is usually met with in young
women, and, in some cases at least, appears to be due to too early and
too free movement of the joint after an ordinary dislocation, so that
the capsule is stretched and remains lax. In some cases it would
appear that the liability to dislocation is due to some structural
defect in the joint, and under these conditions both sides are
sometimes affected, and the accident is not attended with the usual
pain and disability either at the time or after reduction. The
facility and frequency with which dislocation recurs render the limb
comparatively useless, and may seriously incapacitate the patient. We
have had cases under observation in which dislocation resulted from
the hyper-abduction of the arm in swimming, from throwing the arms
above the head in dancing and in gymnastic exercises, and even in
"doing" the hair.
The _treatment_ consists in preventing the patient making the
particular movements which tend to produce the dislocation. These are
chiefly movements of hyper-abduction and overhead movements; we have
found an apparatus consisting of a belt applied around the thorax, and
fixed to another around the upper arm by a band which passes above the
axillary fold of the dress, useful in restraining these movements. If
these measures fail, it may be advisable to have recourse to
operation; this may consist in tightening up the capsule, the results
of which are said to be uncertain, or in detaching a portion of the
deltoid or subscapularis muscle and stitching it beneath the joint to
cover and strengthen the weakened portion of the capsule. It is
suggestive that in performing this operation no rent in the capsule is
discovered.
The condition is also met with in epileptics; and it is generally
found that the head of the bone is deficient, as a result either of
fracture or disease; that the muscles which naturally support the
joint are atrophied or torn; and that the capsule is unduly lax.
#Sprain# of the shoulder-joint is comparatively rare, because of the
wide range of movement of which it is capable. The region of the
shoulder becomes swollen and tender to pressure, the point of maximum
tenderness being over the front of the joint, just below the acromion
process; pain is elicited also when the ligaments or tendons are put
upon the stretch.
#Contusion# of the region of the shoulder, on the other hand, is
exceedingly common. In most cases it is merely the deltoid muscle and
the subcutaneous tissue over it that are bruised, but sometimes a
haematoma forms either in the muscle or in the sub-deltoid bursa. There
is pain on moving the limb, and the patient may be unable to abduct
the arm at the shoulder-joint. Under treatment by massage and
movement, the symptoms usually pass off completely in two or three
weeks. The affections of the _bursa_ are described elsewhere.
In other cases, the cords of the brachial plexus above the clavicle
are stretched, or the axillary nerve is bruised, and these injuries
are liable to be followed by prolonged pain, loss of abduction, and
stiffness in the arm. The deltoid frequently undergoes considerable
atrophy, and there is severe neuralgic pain in the axillary nerve,
especially marked in the region of the insertion of the deltoid.
In addition to maintaining the limb in the abducted position, it is
necessary to keep up the nutrition of the muscles by massage and
electricity.
FRACTURE OF THE SCAPULA
Fractures of the scapula may implicate the body, the surgical neck,
the acromion, or the coracoid process. They are rarely compound.
#Fracture of the Body.#--Considering its exposed position, the body of
the scapula is comparatively seldom fractured, doubtless because of
its mobility, and the support it receives from the elastic ribs and
soft muscular cushions on which it lies. Apart from gun-shot injuries,
it is most frequently broken by a severe blow or crush. The scapula
presents two natural arches--one longitudinal, the other
transverse--and when the bone is crushed or struck, the force produces
fracture by undoing its curves (E. H. Bennett). A main fissure usually
runs transversely across the infra-spinous fossa, and secondary cracks
radiate from it (Fig. 26). In other cases the line of the primary
fracture is longitudinal, passing through the spine and involving both
fossae.
[Illustration: FIG. 26.--Transverse Fracture of Scapula, with fissures
radiating into spinous process and dorsum.]
The _clinical features_ are obscured by swelling of the overlying soft
parts. Crepitus may sometimes be elicited by placing one hand firmly
over the bone, and with the other moving the arm and shoulder. When
the spine is implicated, the fragments may be grasped and made to move
one upon another. The displacement, which usually consists in
overlapping of the fragments--although sometimes they are drawn
apart--is partly due to the action of the serratus anterior and teres
major muscles, and partly depends on the direction of the force.
Movement is restricted and painful. Osseous union usually takes place
rapidly, and although displacement often persists, the function of the
limb is unimpaired.
_Treatment._--As these fractures are usually complicated by other
injuries, especially of the thorax, and are accompanied by severe
shock, it is necessary to confine the patient to bed. It is usually
sufficient to fix the arm and shoulder to the chest wall by a firm
binder, in the position which admits of the most complete apposition
of fragments. This retentive apparatus is employed for about three
weeks, after which the patient is allowed to use his arm. The bandages
are removed daily to admit of massage.
#Fracture of the surgical neck of the scapula#, although a rare
accident, is of importance, as it is liable to be mistaken for
dislocation of the shoulder. The line of fracture runs through the
scapular notch, downwards and laterally to the lower margin of the
glenoid, so that the glenoid and the coracoid process are separated
from the rest of the bone.
The coraco-acromial and coraco-clavicular ligaments are usually torn,
and the detached fragment, along with the head of the humerus, sinks
into the axilla, causing a flattening of the shoulder, and leaving a
depression below the projecting acromion. These signs may be obscured
by the general swelling of the shoulder. The arm may be lengthened
about an inch. By supporting the arm the deformity is at once reduced,
but recurs as soon as the support is withdrawn. Crepitus is usually
detected on carrying out this manipulation; and the coracoid process
is found to move with the arm and not with the scapula. By these
tests, and by the X-rays, this injury is distinguished from a
dislocation.
A partial fracture carrying away the lower part of the _glenoid
cavity_ simulates a sub-glenoid dislocation. This is, however, a rare
injury.
The _treatment_ consists in bracing back the shoulders and supporting
the elbow, and this is most satisfactorily done by a body bandage and
sling for the elbow, as for fracture of the middle third of the
clavicle. Passive movements and massage are employed from the first.
#Fracture of the acromion process# may result from a blow or fall on
the shoulder. It is often overlooked on account of the swelling
resulting from bruising of the soft parts, and the absence of marked
displacement. On palpation, crepitus and an irregularity at the seat
of fracture may sometimes be detected. The shoulder is slightly
flattened, and abduction of the arm is difficult. In rare cases the
fracture passes into the acromio-clavicular joint, and is associated
with dislocation of the clavicle.
In connection with this fracture, reference must be made to a
condition frequently met with, in which the epiphysial portion
of the acromion is found to be separate from the body of the
process--_separate acromion_. This is by some (Symington, Hamilton)
looked upon as a want of union of the epiphysis, but the weight of
evidence seems to prove that it is rather of the nature of an
un-united fracture at this level, even when, as sometimes happens, it
is bilateral (Struthers, Arbuthnot Lane).
Between the fourteenth and twenty-second years a true _separation of
the epiphysis_ may be met with, but it is seldom possible to make a
positive diagnosis of this injury. As is the case in all fractures of
the acromion, bony union seldom takes place.
The _treatment_ is the same as for fracture of the lateral end of the
clavicle.
#Fracture of the coracoid process# is rare. It may result from direct
violence, such as the recoil of a gun, but it is more often an
accompaniment of dislocation of the shoulder or of the lateral end of
the clavicle upward. As the coraco-clavicular ligaments usually remain
intact, there is no displacement; but when these are torn the coracoid
is dragged downwards and laterally by the combined action of the
pectoralis minor, biceps, and coraco-brachialis muscles. Crepitus may
be elicited on moving the fragment. _Separation of the epiphysial
portion_ of the coracoid may occur up to the seventeenth year.
The _treatment_ consists in placing the arm across the front of the
chest, to relax the muscles causing the displacement, and retaining it
in that position by a sling and roller bandage.
FRACTURE OF THE UPPER END OF THE HUMERUS
It is most convenient to study fractures of the upper end of the
humerus in the following order: (1) fracture of the surgical neck; (2)
separation of the epiphysis; (3) fracture of head, anatomical neck, or
tuberosities.
[Illustration: FIG. 27.--Fracture of Surgical Neck of Humerus, united
with Angular Displacement.]
#Fracture of the Surgical Neck.#--The surgical neck of the humerus
extends from the level of the epiphysial junction to the insertion of
the pectoralis major and teres major muscles, and it is within these
limits that most fractures of the upper end of bone occur. This
fracture is most common in adults, and usually follows direct violence
applied to the shoulder, but may result from a fall on the hand or
elbow, or from violent muscular action, as, for example, in throwing a
stone. It is usually transverse, and there is often little or no
displacement, the fragments being retained in position by the long
tendon of the biceps and the long head of the triceps. When the
fracture is oblique, the fragments are often comminuted, and sometimes
impacted. The displacement of the upper fragment seems to depend upon
the attitude of the limb at the moment of fracture. When the upper arm
is approximated to the side, the upper fragment retains its vertical
position, but is slightly rotated laterally by the muscles inserted
into the greater tuberosity, while the lower fragment is drawn upwards
and medially towards the coracoid process by the muscles inserted into
the inter-tubercular groove and the longitudinal muscles of the upper
arm, and can be felt in the axilla. The elbow points laterally and
backwards, and the upper arm is shortened. The shoulder retains its
rotundity, but there is a slight hollow some distance below the
acromion. On grasping the elbow and moving the shaft, it is found that
the head and tuberosities do not move with it, and unnatural mobility
and crepitus at the seat of fracture may be detected. When the upper
arm is abducted at the moment of fracture, the upper fragment is
retained in that position by the lateral rotator and abductor muscles
inserted into it, while the lower fragment passes upwards and
medially.
[Illustration: FIG. 28.--Impacted Fracture of Neck of Humerus, in man
aet. 75.
(Sir H. J. Stiles' case. Radiogram by Dr. Edmund Price.)]
Although there is sometimes overlapping and broadening after union,
beyond some limitation of the range of abduction the usefulness of the
limb is seldom impaired.
_Treatment._--Massage, by allaying spasm of the muscles, soon
overcomes the moderate amount of displacement which is usually met
with. Further, the skin surfaces of the axilla having been separated
by a thin layer of cotton wool, a sling is applied to support the
wrist, and the arm is bound to the side by a body bandage.
In comminuted fractures and those with marked displacement, a general
anaesthetic may be required to ensure accurate reduction; and to
maintain the fragments in apposition, and to avoid any limitation of
abduction after union, the limb may be fixed in the position of
abduction at a right angle by means of a Thomas' arm splint with
swivel ring, and extension applied, if necessary, to maintain this
attitude. After a week or ten days the patient is allowed up, wearing
an abduction frame (Fig. 29), or a splint, such as Middeldorpf's,
which consists of a double inclined plane, the base of which is fixed
to the patient's side, while the injured arm rests on the other two
sides of the triangle. Massage and movement are employed daily.
[Illustration: FIG. 29.--Ambulatory Abduction Splint for Fracture of
Humerus.]
Should these measures fail, the fracture may be exposed by an incision
carried along the anterior border of the deltoid, and the ends
mechanically fixed, after which the limb is put up in the abducted
position for three or four weeks. Massage is commenced on the second
or third day. Union is usually complete in about four weeks.
#Separation of Epiphysis.#--The upper epiphysis of the humerus
includes the head, both tuberosities, and the upper fourth of the
inter-tubercular groove. On its under aspect is a cup-like depression
into which the central pyramidal-shaped portion of the diaphysis fits.
This epiphysis unites about the twenty-first year.
[Illustration: FIG. 30.--Radiogram of Separation of Upper Epiphysis of
Humerus.]
Traumatic separation is met with chiefly between the fifth and
fifteenth years, and is most common in boys. It usually results from
forcible traction of the arm upwards and away from the side, as in
lifting a child by the upper arm, or from direct violence, but may be
caused by a fall on the lateral side of the elbow.
The epiphysis, especially in young children, may be separated without
being displaced, or the displacement may be incomplete.
When the epiphysis is completely separated from the shaft, the
clinical features closely resemble those of fracture of the surgical
neck, and the diagnosis is made by a consideration of the age of the
patient, and the muffled character of the crepitus, when it can be
elicited. The upper end of the diaphysis forms a projecting ridge
which may be felt below and in front of the acromion. The diagnosis
can usually be established by the use of the X-rays (Fig. 30).
Dislocation is rare at the age when separation of the epiphysis
occurs.
Reduction is often difficult on account of the periosteum and other
soft tissues getting between the fragments, and on account of the
small size of the upper fragment. Union almost invariably results, but
the growth of the limb may be interfered with and its shape altered,
especially when the injury occurs at an early age and its nature is
overlooked.
_Treatment._--This injury is treated on the same general lines as
fracture of the surgical neck. General anaesthesia is almost always
necessary to secure satisfactory reduction, and retention is most
easily secured if the patient is confined to bed with the upper arm
fixed in the fully abducted position. Operative treatment is called
for in exceptional cases.
#Fractures of the Head, Anatomical Neck, and Tuberosities of
Humerus.#--These fractures are met with as accompaniments of
dislocation of the shoulder, and as results of gun-shot injuries,
blows, or falls.
In sub-coracoid dislocation the _head_ of the humerus may be indented
by coming in contact with the anterior edge of the glenoid cavity (F.
M. Caird).
The _anatomical neck_ may be fractured in an old person by a direct
blow on the shoulder. In a few cases the fracture is entirely
intra-capsular, the head of the bone remaining loose in the cavity of
the joint. As a rule, however, the fracture passes laterally and
implicates the tuberosities. In some cases there is impaction, and in
others comminution of the fragments. The use of the X-rays has shown
that in many cases in which prolonged stiffness has followed a severe
blow of the shoulder, there has been a fracture of the anatomical
neck.
The _tuberosities_ may be implicated in other fractures in this region
and in dislocation of the shoulder; and either of them may be
separated by muscular contraction or by direct violence.
_Clinically_ all these injuries are difficult to diagnose with
accuracy, and, without the use of the X-rays, it is impossible in many
cases to go further than to say that a fracture exists above the level
of the surgical neck. Fracture of the anatomical neck is attended with
little deformity beyond slight flattening of the shoulder and
sometimes slight shortening of the upper arm.
When the _great tuberosity_ is torn off, considerable antero-posterior
broadening of the shoulder may be recognised by grasping the region of
the tuberosities between the fingers and thumb. Crepitus can be
elicited on rotating the humerus. At the same time it will be
recognised that the tuberosity does not move with the shaft. Firm
union, with considerable formation of callus and some broadening of
the shoulder, usually results, but the usefulness of the joint is not
necessarily impaired. There may, however, be prolonged stiffness and
impaired movement from adhesion; or pain and crackling in the joint
may result from arthritic changes like those of arthritis deformans.
_Treatment._--These fractures are treated on the same lines as
fracture of the surgical neck of the humerus.
The combination of fracture of the upper end of the humerus with
dislocation of the shoulder has already been referred to.
FRACTURE OF THE SHAFT OF THE HUMERUS
Fractures occurring in the shaft of the humerus between the surgical
neck and the base of the condyles may, for convenience of description,
be divided into those above, and those below, the level of the deltoid
insertion--the majority being in the latter situation.
Direct violence is the most common cause of these fractures, but they
may occur from a fall on the elbow or hand; and a considerable number
of cases are on record where the bone has been broken by muscular
action--as in throwing a cricket-ball. Twisting forms of violence may
produce spiral fractures.
The fracture is usually transverse in children and in cases in which
it is due to muscular action. In adults, when due to external
violence, it is usually oblique, the fragments overriding one another
and causing shortening of the limb. The displacement depends largely
on the direction of the force and the line of fracture, but to a
certain extent also on the action of muscles attached to the
fragments. Thus, in fractures above the insertion of the deltoid the
upper fragment is usually dragged towards the middle line by the
muscles inserted into the inter-tubercular groove, while the lower is
tilted laterally by the deltoid. When the break is below the deltoid
insertion the displacement of the fragments is reversed. The signs of
fracture--undue mobility, deformity, shortening, and crepitus--are at
once evident, and the patient himself usually recognises that the bone
is broken.
The nerve-trunks in the arm--the median, ulnar, and radial
(musculo-spiral)--are apt to be damaged in these injuries; in
fractures of the lower part of the shaft the radial nerve is specially
liable to be implicated. This may occur at the time of the injury, the
nerve being contused by the force causing the fracture, or pressed
upon by one or other of the fragments, or its fibres may be partly or
completely torn across. When there is evidence of nerve injury, the
practitioner should draw the attention of the patient to it then and
there, and so guard himself against actions for malpraxis should
paralysis of the muscles ensue. Later, the nerve may become involved
in callus, or be damaged by the pressure of ill-fitting splints.
Weakness or paralysis of the extensors of the wrist and hand results,
giving rise to the characteristic "wrist-drop." The actions of the
muscles should always be tested before applying splints, and each time
the apparatus is removed or readjusted, to assure that no undue
pressure is being exerted on the nerves.
Union takes place in from four to six weeks in adults, and in from
three to four weeks in children. Delayed union, or want of union and
the formation of a false joint, is more common in fractures of the
middle of the shaft of the humerus than in any other long bone--a
point to be borne in mind in treatment. Arrest of growth in the bone
from injury to the nutrient artery is also said to have occurred.
_Treatment._--To restore the alignment of the bone, extension is made
on the lower fragment and the ends are manipulated into position. This
may necessitate the use of a general anaesthetic, and care must be
taken that no soft tissue intervenes between the fragments, as is
evidenced radiographically by the persistence of a clear space between
the ends even when they appear to be in apposition.
In _transverse_ fractures the position may be maintained by a simple
ferrule of poroplastic or Gooch-splinting. The elbow is flexed at a
right angle, and the forearm supported in a sling midway between
pronation and supination. For a few days the limb may be bound to the
chest by a broad roller bandage.
[Illustration: FIG. 31.--"Cock-up" Splint, for maintaining
Dorsiflexion at Wrist.]
The splints are removed daily to admit of massage and movement being
carried out, and while the splints are off, the patient is allowed to
exercise the fingers and wrist. If at the end of four or five weeks,
osseous union has not occurred, the reparative process may be hastened
by inducing venous congestion by Bier's method.
In _oblique and spiral_ fractures it is often necessary to control the
shoulder and elbow-joints to prevent re-displacement. This can be done
by means of a plaster of Paris case enclosing the upper part of the
thorax, together with the upper arm, abducted, and the elbow, at right
angles.
[Illustration: FIG. 32.--Gooch Splints for Fracture of Shaft of
Humerus; and Rectangular Splint to secure Elbow.]
It is sometimes necessary to apply continuous extension to the lower
fragment to prevent overriding. For this purpose a Thomas' arm splint
is employed, the extension tapes being attached to its lower end, but
care must be taken that the traction is not sufficient to separate
the fragments and leave a gap between them. The elbow should not be
retained in the extended position for more than three weeks.
In rare cases it is necessary to have recourse to operative treatment.
When there is evidence that the radial nerve has been injured, and no
sign of improvement appears within three or four days of the accident,
operative interference is indicated. An incision is made on the
lateral side of the arm, and the nerve exposed and freed from
pressure, or stitched, as may be necessary; the opportunity should
also be taken of dealing with the fracture. The limb is put up in a
"cock-up" splint, with the hand in the attitude of marked dorsiflexion
(Fig. 31).
Satisfactory results have been obtained without the use of splints, by
relying upon massage to overcome the spasm of muscles, and allowing
the weight of the arm to act as an extending force (J. W. Dowden and
A. Pirie Watson).
In cases of _un-united fracture_, a vertical or semilunar incision is
made over the lateral aspect of the bone, and the muscles separated
from one another till the fracture is exposed, care being taken to
avoid injuring the radial nerve. The fibrous tissue is removed from
the ends of the bone, and the rawed surfaces fixed in apposition; the
wound is then closed, and appropriate retentive apparatus applied. As
soon as the wound has healed, massage and movement are employed.