The signs of fracture of the lower jaw are unnatural mobility, crepitus, displacement, pain, and loss of function. No bone in the body is more easily investigated by sight and touch, and recognition of these fractures is usually easy. Pain is provoked by attempting to move the jaw, even in talking, and depends on the extent to which the inferior dental nerve is injured. Irregularity in the line of the teeth will sometimes permit recognition. These fractures furnish excellent illustrations of the effect of muscles in producing displacement. Those of the tongue and the floor of the mouth, as well as the anterior muscles of the neck, will pull the fragments in various directions, according to the direction of the line of fracture and its location. This displacement may be trifling or serious. These fractures are often compound, internally or externally, such injuries constituting an unpleasant complication, but affording occasionally an opportunity for fastening fragments by drill or wire suture, which would otherwise require an opening to be made. In every instance antiseptic mouth-washes should be frequently used.

Treatment.

—The treatment is simplified when the dentition is good and regular so that the fragments may be fastened together with wire or waxed silk ligature around the adjoining teeth, and then fixation accomplished with a simple molded gutta-percha or plaster-of-Paris splint, by which the lower jaw is held firmly against the upper. Such a dressing is held in position by a four-tailed bandage (Fig. 283). A silk or wire loop, used for the purpose just mentioned, should include two teeth on either side of the fracture, for by constant tension the nearest tooth will soon loosen, and if this were next to the break the effect of such displacement would be injurious (Fig. 281). When the line of fracture is oblique there is often greater difficulty in adjustment.

While the simplest means by which the fragments may be kept in position are the best, there should be no hesitation in serious cases to resort to operative measures having for their purpose the insertion of wire sutures or their equivalent. These are inserted after drilling the bone at suitable points, and are introduced with a view to their subsequent removal, the ends being left projecting in order to facilitate this. In clean cases, where the incision is made in unbroken skin, the ends may be twisted short and turned in, previously to closing the wound. Such operative treatment is required when there has been a double fracture, the central fragment being badly displaced by groups of muscles which tend to pull it downward and backward.

A dentist should be consulted, as he may be able to make a mold and then construct a plate or interdental splint, by which a more perfect reposition may be effected.

Swelling, emphysema, ecchymosis, etc., may be treated in the usual way. Irritation is likely to provoke free secretion of saliva; this may be combated by small doses of belladonna. Patients should be fed by fluid or thin semifluid food, and mouth-washes should be frequently used.

FRACTURES OF THE HYOID BONE.

The hyoid may be broken by direct violence, either locally applied or by forcing the head backward. Fracture of the bone itself is not so serious as the lesions which accompany or follow it, either hemorrhage or inflammation, with edema of the larynx, which may impede respiration or cause strangulation. Fracture produces difficulty in breathing, swelling, and pain on talking. It is doubtful if bony union is attained, but fibrous union answers equally well. The treatment consists essentially of physiological rest. Edema may necessitate tracheotomy, and dysphagia feeding by an esophageal tube or by the rectum. Should the fracture be compound, or should a fragment be displaced so as to be detected, it may be removed through suitable incision.

FRACTURES OF THE LARYNX.

This may be fractured by injuries of the same character as those which fracture the hyoid, except that it is more exposed to the direct violence of a blow, as from a baseball. In elderly people in whom calcification of the laryngeal cartilages has occurred fracture is more dangerous than in the young. Injuries which produce these lesions are of a serious nature, as prompt swelling, either from hemorrhage or edema, occurs and threatens respiration. For illustration a death occurred on the baseball field within a few minutes after reception of a blow upon the front of the neck with laryngeal fracture; the cause of death was suffocation due to swelling, which might have been averted if tracheotomy could have been performed. In the milder injuries of this kind much can be done with sprays of cocaine and adrenalin, to quiet laryngeal irritation and reduce vascularity.

FRACTURES OF THE STERNUM AND RIBS.

Fracture of the sternum in childhood is exceedingly rare. In adults it may occur in connection with other injuries or as a solitary lesion. Such a fracture, of itself, would indicate in most cases excessive violence. It is usually more or less transverse, the periosteum being rarely so torn as to permit of much escape of blood. Cases are recorded in which it has been broken in straining during the act of parturition. It is most commonly injured by compressing and crushing injuries.

Sternal fractures are followed by much pain, aggravated by deep respiration and made worse by pressure. Sometimes displacement can be made out, while crepitus may be detected with the stethoscope. Occasionally there is sufficient deformity to make the injury apparent at a glance.

Displacement should be reduced and apposition then maintained by a plaster-of-Paris jacket or other suitable apparatus. It is advisable in some cases to anesthetize the patient and to make a sufficient opening that instruments may be used by which fragments may be lifted or pried into place. This should be done under aseptic precautions.

Diastases or separations of ribs or cartilages from the sternum or from each other have essentially the dignity of fractures, are recognized by the same general signs, and are treated in the same general way. A cartilage may snap in the young, and in the old, when calcified, may break as would a bone or even a pipe-stem.

The ribs are usually broken in their lateral aspects, but rarely between the head and angle. They may be fractured by muscle action or by external violence, examples of the former being violent efforts at lifting or sneezing. Violence may be applied in so many ways that it is not necessary to specify them. Fractures may pertain to one or to several ribs in proportion to the extent and violence of the exciting injury. In some crushing injuries an entire section of the chest wall may be broken loose and depressed, this corresponding to a depressed fracture of the skull. Rib fractures are usually of themselves innocent, but may be made serious by complications, as when the pleura is torn, or an intercostal artery bleeds profusely, or when a jagged fragment of bone first scratches and then perforates a lung. This will lead first to the outpour of blood and then of pleuritic fluid, by which in a short time the lung will be separated from the chest wall. Should infection occur through the injured lung, i. e., entrance of germ-ladened air, then empyema may seriously complicate matters and later necessitate operation. Even the heart has been injured, in several reported cases, by projecting fragments of bone. Gunshot fractures of the thoracic wall imply those features pertaining to every compound fracture, plus the injury possibly done to the lungs, heart, or mediastinal contents, such as hemothorax or pneumothorax.

The first and second ribs are so protected and the eleventh and twelfth so movable that by far the greater proportion of rib fractures pertain to the eight intervening ribs.

Symptoms.

—These are often vague, when but a single rib has been cracked through and not displaced, and comprise pain on pressure, as well as that provoked by deep breathing, coughing, and certain other movements. Should this pain be limited, or constant and made worse by pressure, fracture of the rib may be suspected. If auscultation crepitus can be heard, diagnosis is at once made. When abnormal mobility is unmistakable, or when by any means crepitus is elicited, the signs are positive. Sometimes the patient himself will recognize crepitus. This may be learned either by auscultation or by pressure with the flat hand over the affected area. Emphysema is an unmistakable evidence of fracture with perforation, while the signs of the presence of fluid in the chest cavity will also indicate fracture.

Treatment.

—Fracture of one or two ribs with displacement is ordinarily a matter of trivial import, the adjoining ribs acting as splints. It necessitates practically nothing but physiological rest, which may be best afforded by keeping the patient in bed, with firm compression around the chest, made either with a binder of strong cloth or a broad piece of adhesive plaster carried nearly around the body, or in more aggravated cases by a plaster-of-Paris jacket. In thin individuals the formation of callus can be recognized by the sense of touch. So soon as this is fairly formed displacement is less likely to occur and uncomfortable compression may be relaxed. Should there be external angular displacement this may be corrected by pressure. A projecting fragment which threatens to perforate should be cut away with bone forceps through a small incision, taking pains to permit as little air as possible to enter. If there be a traumatic pneumothorax the air should be removed with an aspirating needle. When it is evident that there is serious injury to the chest wall and that air has already separated the lung from it (traumatic atelectasis) the parts should be freely exposed, to permit the rounding off of bone ends, the seizure of intercostal vessels, the cleansing out of the pleural cavity, with perhaps later wiring of fragments or else their complete removal and closure of the external wound with or without drainage, as may be required. If blood or air has already escaped into the pleural cavity the blood should be speedily removed. The same plan is advisable in fractures of the cartilages. Sedatives to check cough, e. g., heroine, are also indicated.

FRACTURES OF THE CLAVICLE.

The clavicle and the radius are the two bones most frequently broken, the former more often in the young, the latter in the elderly; the clavicle yields both to direct violence, as by blows on the shoulder, and that which is transmitted through the arm from the elbow or hand. For convenience of description the bone is divided into thirds, the most common location for fracture being near the junction of the middle and outer third. Save for epiphyseal separations the extremities of the bone are seldom broken. In spite of its subcutaneous position and its proximity to large vessels, compound injuries or other complications are quite uncommon.

The clavicle is the brace which keeps the shoulder proper from falling upon and around the thorax. Consequently when it is broken the shoulder tends to drop downward, forward, and inward, except in a green-stick fracture, while even then there may be some displacement in these directions. Deformity is usually easily recognized, one or other fragment projecting beneath the skin in such a way as to be easily palpated. There is enough spasm of cervical muscles to draw the head over toward the affected side, while there is loss of function in the affected arm. Pain is made worse by pressing the shoulder inward as well as by moving it in any direction.

In young children the bone is often broken with a minimum of displacement. Fracture of both clavicles is not so very rare. Trouble may occur later in the course of the case from pressure of exuberant callus upon nerves and even vessels. This is to be prevented by foresight and by careful attention to maintenance of parts in proper position.

Treatment.

—The multiplicity of dressings which have been suggested for fractures of the clavicle attest the fact that so long as primary indications are observed the treatment can be made very simple. These indications are to keep the shoulder upward, outward, and backward, as it tends to drop in the opposite way. The action of three muscles is of great importance in considering the proper treatment of these cases, i. e., the sternomastoid and the trapezius, because they tend to pull fragments upward, and the pectoralis major because advantage can be taken of its arrangement to overcome upward displacement. It was Moore, of Rochester, who taught many years in Buffalo, who showed how this could be done. The fibers of the great pectoral which arise highest, i. e., from the clavicle, are those which are inserted lowest along the bicipital groove of the humerus, because of the semi-revolution made by the tendon of this muscle as it passes to its insertion. By putting the arm in such a position that these fibers are pulled upon the operator may counteract the upward pull of the other muscles just mentioned. This is the underlying feature of Moore’s suggestion; to force the elbow far backward, into a position which is for the time being uncomfortable, in order thus to pull down fragments which jut up beneath the skin. Any dressing which permits this position to be maintained will be equally serviceable. Moore suggests for this purpose what he calls a double figure-of-eight, which is shown in Figs. 284 and 285. It is put on as follows: A strip of cloth, sheeting, or anything of the kind, about two yards in length and folded sufficiently to make a strong strip eight inches wide, is held near its middle over the surgeon’s hand. This hand is placed beneath the elbow of the injured side, so that the strip crosses the under surface of the flexed forearm at the elbow. One end, which should be the longer, lying to the inner side, is passed upward and in front of the arm, carried over the shoulder across the back and under the opposite axilla, then over in front of the sound shoulder, meeting on the back the other end, which is carried up first over the outside of the forearm, then behind the shoulder and across the spine. This bandage should be pulled tightly, while an assistant holds the elbow as far backward and upward as the patient can tolerate it, as the more the position is exaggerated the more are the clavicular fibers of the muscle pulled upon and the better are the fragments held in place. This dressing not only meets the three primary indications laid down, but gives the added advantage just described. By it the shoulders are drawn backward and fixed to each other. The elbow should be lifted as the dressing is applied, so as to lift the shoulder. Most of the cloth materials used for such a dressing are more or less elastic, and it may need to be tightened once or twice a day during the time that it is worn. After a few days, when consolidation should have occurred, it may be changed for some other less irksome form of dressing. The hand should be supported in a sling. This dressing is useful in dislocations of the clavicle, especially of its outer end, and in every kind of injury in which the indication is to hold the shoulder upward and backward. In simple cases without much displacement the primary indications may be more simply met by a dressing of adhesive plaster, known in the East as Sayre’s and in the West as Freer’s. It consists of two strips of plaster of about the width of the arm itself. One of them is wound around the upper end of the arm, close to the shoulder, in such a way that, as it is passed around the back and brought over the chest, the arm and shoulder are pulled backward. The other strip passes from beneath the elbow of the injured side obliquely up and over the opposite shoulder. When it is applied the elbow should be firmly lifted. After the completion of either of these dressings the injured shoulder should appear at least one inch higher than the well one. Should the patient’s arm and chest be hairy they should be shaved before the application of the plaster strips. Like other material, plaster will stretch and slip, and these, like other dressings, should be readjusted every day or two, for the shoulder should be kept elevated for at least a week.

When the case is complicated by other injuries necessitating confinement in bed it is sufficient to keep the patient flat upon the back and without a pillow. In this position the shoulder falls naturally in the direction desired, and perhaps no other attention will be required. Many other methods are combined with a figure-of-eight bandage, crossing the back and forming a loop over each shoulder, so as to keep it from dropping forward.

While the results of treatment are nearly always good, if one is insistent upon a minimum of deformity, confinement upon the back on a hard bed is the surest way to obtain satisfactory results. Cases in which there is little or no tendency to deformity need only the simplest support by which rest may be ensured.

Epiphyseal separations are to be treated as fractures.

FRACTURES OF THE SCAPULA.

The most frequent fracture of the scapula is that of the acromion; this is usually the result of direct violence, such as a fall upon the tip of the shoulder. Detachment of this fragment permits a peculiar flattening of the shoulder, but without dislocation. The fragment can be easily felt, while the deltoid is displaced and its rounded contour lost. Treatment consists solely in forcing the arm upward, by dressings applied beneath the elbow, thus lifting the fragment into its place; fibrous union occurring here much more often than osseous, the latter is possible only in case a good apposition be maintained. Any form of dressing, then, by which the elbow is crowded upward and rest maintained will be appropriate.

The surgical neck is occasionally detached, sometimes with and sometimes without the coracoid process. As the humerus is attached to it by the capsular ligament the arm drops with the fragment when the patient is in the upright position, and the elbow will be found lower than that of the injured side. The arm is unduly mobile, and the fragment can usually be seized and crepitus obtained within the axilla. Here it is necessary to hold the arm up, as it controls the position of the fragment. It is usually sufficient to lift the elbow up and bind the arm firmly to the side, the scapula being immobilized by broad straps of adhesive plaster.

The coracoid process is occasionally detached, usually by muscular violence, i. e., it is pulled off by the coracobrachialis and the coracoid head of the biceps which arise from it. The injury is recognized by failure to detect the process in its proper place, and usually by discovery of the fragment at a point below its normal position, to which it has been drawn out by the muscles arising from it. Ligamentous union can be secured by relaxing these muscles, which is done by placing the hand over the opposite shoulder and dressing the arm firmly against the chest. I have seen paralysis of the arm result from excessive callus after fracture of the coracoid.

The spine, body, and the angles of the scapula are occasionally broken by severe violence. In the aged comminution may occur. Crepitus can be nearly always obtained. It may be necessary to distinguish the scapular fracture from one of the ribs beneath it. The treatment consists in simply fixing the shoulder-blade upon the chest, to which it is naturally adapted, by firm bandages, which shall immobilize not only it but the arm as well.

FRACTURES OF THE HUMERUS.

At the upper end of the humerus we deal with fracture of the processes, i. e., the tuberosities, which may be torn off by violent action of the muscles therein inserted; of the anatomical neck, which is rare and occurs most often in the aged; of the surgical neck, which is the most common; or, in the young, epiphyseal separation, which is the equivalent of the last named. Separation of the tuberosities is diagnosticated mainly by exclusion, possibly by x-rays. The anatomical neck lies within the capsule, and should the head be thus detached it might remain as a foreign body in the joint, having no means of securing nutrition. Fractures of the head of the bone are not classical and are usually the result of gunshot injuries or extreme violence. In all of these injuries there will be swelling, loss of function, while crepitus is sometimes obtained, but is very difficult to locate, even under an anesthetic. The diagnosis is to be made mostly by exclusion.

The surgical neck is the most frequently broken; the line of fracture passing below the tuberosities and above the muscles inserted along the bicipital groove. Therefore the pectoralis and the latissimus muscles will both conspire to pull the upper end of the shaft toward the thorax to such an extent that it can be felt in the axilla. This gives its axis a different direction, while all the muscles extending from the shoulder to the forearm will tend to produce shortening. Deformity is usually distinct, crepitus is easily obtained, and undue mobility is well marked. The head of the bone can be detected in its proper place beneath the deltoid, but does not rotate with the shaft. In rare instances a certain amount of impaction may make this evidence of fracture obscure. Epiphyseal separation will give the same signs and symptoms.

Treatment.

—The primary indication here is to overcome muscle pull by traction in a direction toward the crest of the pelvis of the same side. At the same time, with a certain degree of coaxing of the upper end of the shaft outward and a little forward, it may be possible to so re-apply broken surfaces to each other, and so affix the arm to the thorax, as to be effective. When serious difficulty, however, is encountered the writer advises traction, applied to the arm alone, if the patient be able to be upright, or to the arm and forearm, if he be confined in bed. It will take considerable stretching to overcome the combined action of all the muscles which tend to produce displacement. Along with such treatment a coaptation splint should be applied, the best being that which can be carefully molded to the parts and adapted to their needs. For this purpose a molded plaster-of-Paris splint is preferable to one of metal made to some standard size. In the dressing it is necessary to include not only the shoulder and arm but also the forearm, otherwise the principle of physiological rest would not be enforced. Fig. 286 illustrates the common tendency to displacement in these injuries.

Fracture of the surgical neck is occasionally combined with dislocation of the head of the humerus, by which such an injury is seriously complicated. Reduction may be attempted by manipulation. Until recently it was generally advised to wait for a week or ten days, and until consolidation had occurred, and then to make the attempt at reduction; but Porter and McBurney have shown that it is advisable to cut down upon the dislocated upper fragment, and, fixing it with forceps or with an instrument shaped like a corkscrew or hook, to force it back into place again. If this be done under the strictest precautions it lends no serious features to the case, while, in most respects, such a procedure would greatly simplify it, the wound being closed with or without drainage, and the usual fracture dressing being applied.

In cases of old fracture and dislocation the head of the bone should be exsected, the functional result thus obtained being excellent.

Epiphyseal separation has been too often mistaken for dislocation. Fig. 287, from Moore, shows how the periosteum is not necessarily entirely detached, but is stripped up to form a hinge, the fragment displaced forward, and its outer aspect often turned upward. This makes traction in an outward direction an essential feature of the replacement of the fractured surfaces, the manipulation being combined with fixation of the fragment so far as it can be seized through the axilla. If the epiphysis is properly slipped over upon the end of the humerus the case assumes ordinary features, and is to be dressed as usual.

The shaft of the bone is frequently broken, lines of fracture running in all directions and occurring at all levels. A variety of displacement may take place. The evidences of fracture are usually recognizable and diagnosis is not difficult. The brachial artery and the musculospiral nerve are occasionally involved, either in callus or by primary injury from a spicule of bone. These fractures are more liable to delay in union or even to non-union than almost any others. These occur often without evident cause, while more or less absorption of bone has been known, by which complications are produced.

In the treatment of fractures of the shaft posture is necessary to observe, the fragments not only being held in position, but the axis of the bone being maintained. An external splint, extending up to and rounded over the shoulder, and an internal splint molded to the inner side of the arm, taking in the elbow and forearm, and placed at a right angle, and then the immobilization of the entire arm by its fixation to the body will give the best result. The writer prefers to make these of plaster of Paris, by molding strips of surgeons’ lint sopped in plaster cream, and maintaining the limb in the desired position while they harden. Should comminution be extreme, or shortening difficult to overcome, a few days’ confinement in bed, with traction upon the forearm, either extended or included in the above dressing, by the usual method, with weight and pulley, will give the best result. So soon as callus has bound the ends of the bone together the patient may be released from bed and the arm left in the right-angle position, in plaster, as above. Or over such a splint as has been described, made of molded plaster, may be hung by a bandage at the elbow sufficient weight (a bag containing shot) to maintain constant traction upon the lower fragment, while the patient is in the upright position, and to influence for good any overlapping or displacement of any kind during the critical period when the bone ends are being united by callus.

The epicondyles are occasionally chipped off from the condyles, the internal being the more frequently injured. These detachments are extra-articular and are relatively unimportant, the fragments being kept from displacement by their fibrous investments. If such an injury should be compound any fragment completely loosened should be removed. It is sufficient to dress such an injured elbow with cold wet compresses in the flexed position. Supracondyloid fracture, or its equivalent in the young (an epiphyseal separation) are somewhat similar, the latter occurring nearer to the articulation than the former. In each of these injuries the arm is flexed and shortened, the fragment lying usually in front of the shaft and the olecranon protruding posteriorly. The more the arm is extended the more prominent the deformity, while by flexion it is much diminished. Hence the advantage of dressing it in the position of overflexion sometimes called Jones’ position.[39] Injury to the vessels at the bend of the elbow may occur in these fractures. If not dressed in this position the elbow should be put at a right angle, while a weight is slung over the elbow, as already mentioned above. Joint function will be greatly hampered if complete extension and reduction be not effected (Fig. 288).

In considering fractures about the elbow no greater aid can be obtained than by a study of the relations of the three prominent or salient anatomical points to each other. These are the internal and external condyles and the tip of the olecranon. They afford a key to nearly all the displacements which may be produced after fracture or even dislocation, and the only conditions under which they cannot be made available are those where there has been tremendous swelling before the case is seen by the surgeon. A fourth prominent feature, the head of the radius, is also of much assistance, but is less often available, especially in muscular or swollen forearms. When a normal arm is flexed to a right angle and viewed from behind the three points above mentioned constitute the angles of a nearly equilateral triangle. When seen from the side the point of the olecranon is just below the external condyle and in the same plane; when the arm is completely extended and viewed from behind these three points are practically in the same line. By a careful study of the variations from the above relations which are produced by injury diagnosis can be greatly facilitated.

The condyles may each be broken loose by itself, or they may be both broken at the same time. Fig. 291 illustrates what is known sometimes as a T-fracture, where the lower extremity is not only separated from the shaft but is broken into halves; such fractures imply great violence, and are particularly difficult to treat. Should the condyles be detached in such a way as to leave the lower end of the humerus in pointed wedge shape it may perforate or do much harm to the soft parts (Fig. 290). In these intercondyloid fractures the writer would advise dressing in the extended position, with a molded plaster-of-Paris anterior splint and a gentle degree of traction, the patient being confined to bed for a few days. In applying such a splint the surgeon should give extreme care to holding the fragments in proper position while the splint hardens, and in preserving the “carrying function” (Fig. 291). (See below.)

The external condyle when fractured is displaced by muscle pull; when the internal condyle is broken the tendency is to backward displacement of the fragment and widening of the joint.

Fracture of the internal condyle is often an exceedingly serious matter, because it is so often associated with more or less dislocation and with permanent deformity, as a result of inattention to the anatomical relations of the bones. The ulna sustains peculiar relations to the inner condyle; at its upper end it is wrapped around the process, holding it much as a monkey-wrench can be made to seize an ordinary object, and being held to it by the internal lateral ligament. Herein lies the secret of success or failure in treatment, for the fragment, being so fixed to the ulna, should be controlled by it, i. e., the position of the ulna is the most essential feature of the treatment of the fracture. The forearm makes an angle with the arm proper, by which a considerable degree of divergence is maintained. This has been alluded to by Allis and others as the “carrying function.” It can only be estimated in the extended position, and be accurately judged by comparison with the other arm. If the arm be flexed all possibility of estimating it is lost; therefore to dress such a fracture in the right-angle position is bad practice (Fig. 292). The only position in which the carrying function can be preserved is the extended, or one a little short of it for the purpose of comfort. If the ulna is put in the proper position the fragment will be held equally so or as nearly as possible (Fig. 294).

In the treatment of fractures of the inner condyle the patient, if a child, should be anesthetized, the upper part of the body exposed, both arms extended, and the injured arm made to correspond exactly with the other so far as concerns the angle of divergence. Upon the arm so placed an anterior plaster-of-Paris molded splint should be carefully applied, extending from axilla to wrist, and then lightly secured with bandages, the surgeon holding the arm in the proper position until the plaster is sufficiently hardened to permit no displacement. The arm should be kept in this position for at least ten days, after which the splint may be removed and gentle motion practised. It may then be reapplied for two or three days, after which we may begin to flex the arm, applying either a new plaster splint or any other that seems suitable, and in such a way that at the expiration of another week the forearm is brought to a comfortable position of right angle, where it may be maintained with a light splint or simply with a sling, according to the age and tractability of the patient. Fig. 294 illustrates the splint and the position, which is the only one in which the surgeon maintains his own security and can properly estimate the carrying function. The mistake has been in dressing this fracture, like most others at the elbow, in the right-angle position.

In fractures of the outer condyle these anatomical conditions do not prevail, and these may be dressed in whatever position best meets the indications of comfort and accurate reduction. Intercondyloid fractures are subject to the same conditions as those of the internal condyle, plus others which are added, and should therefore be dressed in the same position.

Epiphyseal separations, as well as supracondyloid fractures, should be dressed either with traction in a somewhat extended position, or in that of extreme flexion, called also Jones’ position, according as the fragments may best fall into place in one or the other.

The writer has for his own purposes discarded almost all other splint material for the upper extremity in favor of the plaster-of-Paris splints already mentioned. Figs. 294, 295 and 296, may illustrate the method and purpose of their use; many other modifications can be devised as may be demanded. It is customary, after such a splint is hard and firm, to remove it for a few moments, trim it, smooth the edges, line it with a fresh piece of soft lint or its equivalent, and then reapply it to the arm with a roller or starch bandage, the arm meantime not having been disturbed, but maintained in its proper position, and being restored to the splint and made to take its previous position. Such a splint fits accurately the individual for whom it is made. It is worthless for anyone else; nor should it ever be used again, the intent being to mold a splint for each case which shall serve its individual purpose and none other.

Too early passive motion with the intent to regain mobility is inadvisable and often dangerous. A fractured joint should be kept at rest until the bone is consolidated. If callus be thus reduced to the minimum, and consolidation be undisturbed, the patient will, in due time, recover motion, often to the extreme limit. In fractures of the humerus five or six weeks are required for the attainment of perfect union. In spite of precaution callus formation will sometimes be excessive and interfere with motion. Absorption of exuberant material then is most desirable. This can be encouraged by constant but gentle pressure. Thus when callus in front of the lower articular surface of the humerus obstructs the coronoid process of the ulna and prevents complete flexion the patient should wear for several hours at a time an elastic sling, made with a piece of Martin rubber bandage sufficiently long to make a loop around the neck, into which the hand is passed. It should be made so tight as to exert gentle but constant pressure; the result of this will be to cause rapid disappearance of the callus upon which it is made. Conditions may be reversed when necessary, and the patient may have some weight affixed to the hand by which, when the arm hangs down, reversed pressure shall be made, or when desirable these measures may be alternated. One should not, however, be tempted into resorting to them too early, since much is done, even in unfavorable cases, by purely natural processes, this being especially true of children who are growing rapidly.

FRACTURES OF THE FOREARM; THE ULNA.

At the upper end of the ulna the most frequent fracture is that of the olecranon, whose separation by direct or indirect violence corresponds to fracture of the patella. The fragment is pulled upward along the back of the arm by the triceps muscle, and the power of extension is almost lost. There is rarely any difficulty in diagnosis, except in conditions of extreme swelling, which of itself would be suspicious, as under hardly any other circumstances could a joint be so distended (Figs. 297 and 298).

Treatment.

—The difficulty here, in treatment, consists in the necessity for counteracting the pull of the triceps. The arm first of all should be dressed in the extended position. Sometimes it is possible, by partly encircling the posterior surface of the arm just above the fragment with a strong piece of adhesive plaster, to which is attached some rubber tubing, to make a constant elastic pull upon the fragment, the tubes being brought down and attached to the sides of the anterior splint below the elbow. In the absence of swelling this can often be made quite effective. So long as much fluid is present no means will be efficient. It may, therefore, be well to wait two or three days until the fluid has disappeared, aspirating the joint if necessary. In young and otherwise healthy subjects there is strong reason for advising operation, as only by absolutely approximating the fragment to the main bone and maintaining it in position can bony union be secured. In properly selected cases, and when performed with every precaution, this measure frequently gives ideal results. A short ligamentous union is represented in Fig. 299. At other times the fibrous band will stretch out to an inch or more, not completely disabling the arm but weakening it. The extended position may be relaxed within a week after operation, but not for at least two weeks after other treatment. Passive motion should not be begun too early in the latter cases.

Fracture of the coracoid process is often combined with backward dislocation of the forearm, which is no doubt an incident of the injury or may occur later by mere muscle pull. The brachialis anticus, which is inserted into it, will pull the fragment up against the anterior surface of the humerus. This fracture should be dressed in the right-angle position, in order to relax the muscle, taking care to prevent backward displacement, while ligamentous union is ordinarily all that can be hoped for.

The ulnar shaft may be broken at almost any point, usually as a result of direct violence. As it is weaker in its lower half the greater number of fractures occur here. Fracture of the shaft is easily recognized, crepitus being always obtained, unless muscle tissue has intervened, this being a condition which will occasionally prevent bony union. If it can be established by x-rays that bony surfaces are not in contact and cannot be so placed, it is advisable to cut down upon the site of the fracture, remove the obstacle, and fasten the fragments together. So long as one bone is broken in the forearm the other may be relied on to act as a more or less efficient splint. There is but one position in which any of these fractures can be dressed with safety, that is midway between pronation and supination, i. e., with the thumb pointing toward the patient’s face. Splints used for this purpose should always be wider than the forearm itself, lest by pressure the ends be forced toward the other bone. Some hold that by gentle pressure along the line between the bones, as by a narrow pad or splint, the muscles may be made to press the injured bone away from the other; nevertheless only moderate pressure can be tolerated for this uncertain purpose. It has been generally customary to use two light wooden splints, one along the palmar, the other along the dorsal surface of the forearm, padding them properly and securing them in position by strips of adhesive plaster and suitable bandages. The same plaster-molded splints mentioned above can, however, be made just as effective for this purpose, if properly applied.

When either bone is broken near the wrist, and especially when both are broken, we have to combat the tendency of the pronator quadratus, which tends to pull the lower fragments together.

The styloid process is occasionally detached, as in violent sprains, or broken off in connection with other injuries. Inasmuch as it carries the upper end of the internal lateral ligament its detachment can be quickly recognized by the abnormal freedom of motion which such an injury would permit.