CHAPTER VI. DISLOCATIONS OF THE SHOULDER. (Part 6)

apposition and the fragments in align- ment. To meet the requirements in such cases a number of splints have been devised. The Middledorf triangle maintains the arm in a position of partial abduction and inward rotation and is effec- tive in some cases in preventing recurrence of deformity. (See Fig. 141.) The Monks triangle holds the arm in a nearly horizontal position with the elbow carried forward. (See Fig. 142.) By means of a plaster cast of the upper extremity and trunk the arm may be fixed in almost any position desired. Taking every- thing into consideration it is probably the most satisfactory form 104 FRACTURES AND DISLOCATIONS of immobilization in instances in which the arm may not be treated at the side because of displacement of the upper fragment. When uncomfortable and awkward positions, such as maintained by the above splints, are necessary to keep the fragments in proper relation, the question of operation should be considered. It is the author's opinion that most cases of this kind (in Avhich reduction cannot be maintained with the arm by the side) should be operated upon, and the fragments secured in position by direct fixation. Fig. 144 Fig. 144. — Plaster cast for treatment of fracture of the upper end of the humerus in abduction. In applying the cast the humerus may be fixed in almost any position desired. Fig. 145. in abduction, tion. -Plaster cast for treatment of fractures of the upper end of the humerus This cast fixes the humerus in a position of greater outward rota- Operative Treatment. — The cases of fracture of the upper end of the humerus in which operation is indicated are numerous but the proper selection of these cases requires the most seasoned surgi- cal judgment. Fractures in which the displacement is pronounced and not reducible by ordinary methods should be operated. Recur- rence of deformity during the after-treatment is ordinarily an indi- cation for operative intervention. Cases in which the upper frag- ment is abducted, rotated, or displaced forward may be treated by some form of dressing which immobilizes the arm in a position corresponding to the deformity of the upper fragment. Such dress- ings, however, are more or less uncomfortable and insecure and in most instances it will be advisable to expose the fragments, wire or plate them together and then fix the arm hy the side with the ordinary axillary pad and shoulder cap dressing. FRACTURES OF UPPER END OF HUMERUS 105 The fragments are to be exposed througli a vertical incision on the anterior or external aspect of the shoulder. The circumflex nerve will be found winding around the surgical neck of the bone and should be avoided. It is best to expose the fragments by dull dissection in the deeper part of the wound until the nerve has been located and isolated. With the fragments exposed the needs of the case are determined and the details of the operation from this time on will vary accordingly. Reduction of deformity is performed by means of extension, counter-extension and manipulation, and is rendered easier by direct manipulation of the fragments when necessary. The fact that the fragments may be directly inspected during manipulation is of the greatest service in correcting the displacement. If a firm engagement between the fragments can be obtained by manipulation th^ wound may be closed and the opera- tion concluded; if, however, there is a tendency to redisplacement some form of internal fixation must be employed. A consideration of the illustration on page 83 will show that the structure of the bone above the surgical neck is composed of a wide-meshed cancel- lous tissue covered only by a very thin layer of compact bone, and it is in this formation that very little dependence can be placed on nails, pegs, screws, etc. Silver wire will afford the most trust- worthy fixation and should be given the preference in the region of the anatomical neck. It is frequently the case that a simple loop of wire passing through the outer side of the fracture as shown in Fig. 98 will secure a safe and accurate apposition. The Lane plate has been used in the region of the greater tuberosity though it is not reasonable to expect security from it when the screws holding it are not placed in a fairly heavy layer of compact tissue. Accordingly it is of greater value a little lower in the bone. It is sometimes necessary to excise the head of the bone because of extensive comminution, or in old cases because of non-union. It is well to remember that the head very rarely suffers necrosis follow- ing separation from the shaft. Attempts to save the head are usually successful with accurate apposition and the proper degree of fixation. Reduction and fixation of fractures of the surgical neck are not as a rule attended by great difficulty unless there is extensive comminution of the upper fragment. When the upper fragment is broken into many pieces it may be impossible to com- pletely restore the bone to its original lines. A wire encircling the surgical neck, with notches in the bone to prevent its slipping down- 106 FRACTURES AND DISLOCATIONS ward, may be of great value in lorLgitudinal splitting. It should be so placed as not to interfere with the long head of the biceps. Isolated fractures of the tuberosities are rare injuries. Little difficulty should be experienced in returning the detached tuberosity to its original position and securing it in place. In epiphyseal separations reduction of the deformity will usually be all that is required, as displacement is prevented by the projec- tion of the center of the diaphysis upward into the epiphysis. (See Figs. 110 and 111.) Suture of the periosteum on the outer side of the bone will increase the security of reduction. If a tend- ency to recurrence of deformity is present absorbable suture material may be passed through drill holes in the bone. Non- absorbable suture material should not be used across an epiphj^seal cartilage. It is well to insert a small drain of silkworm gut before the wound is closed to relieve the joint of blood and serum ; this drain should be removed in from twenty-four to forty-eight hours. After-Treatment. — In the average child or young adult union may be expected at the end of four weeks, while a middle-aged person should be allowed from five to six weeks for callous forma- tion. In the aged union may be much delayed. The acute swelling about the joint will usually have subsided at the end of ten days or two weeks. During the time the shoulder is decreasing in size the padding on the inside of the shoulder cap will require frequent changing and adjustment so that the cap may properly fit the shoulder. If the swelling has been great it may be necessary to apply a new cap when the shoulder approaches the normal in size. The case should be seen daily for the first ten days, after which every two or three days will be sufficient. The axillary pad some- times becomes loosened and is likely to slip downward or back- ward, and if not replaced may be responsible for a change in the position of the fragments. Gentle passive motion should be begun at the end of two or two and a half weeks in uncomplicated cases. Passive motion should at- all times be gentle, and the production of pain must represent the limit of motion. The splints should be removed at the end of four to six weeks, according to the age and condition of the patient, and the arm carried in a sling for another ten days. The patient should be especially cautioned not to submit the arm to any great strain for the first two months fol- lowing the removal of splints. Extreme abduction is the last mo- FRACTURES OF UPPER END OF HUMERUS 107 tion to be regained by the patient and in elderly persons it is not infrequently lost permanently. Should paralysis of any of the nerves supervene during the after-treatment (as evidenced by wrist drop or contractures) we should lose no time in exploring the nerve involved where it crosses the line of fracture. The circum- flex is the single nerve most frequently involved in fractures of the upper end of the humerus. End results following operations on the nerves cannot be expected inside of four to six months at the earliest. Atrophy of the deltoid not infrequently occurs from disuse alone without injury to the circumflex. This condition is not in itself a cause for anxiety since the muscle will regain its size and tone with use. Following reduction of an epiphyseal separation fixation should be maintained for three or four weeks. Early passive motion is of the greatest value in fractures of the upper end of the humerus. Restricted motion in the shoulder is often the result of a too prolonged immobilization. If joint ad- hesions are present after union is firm they may be forcibly broken up under anesthesia, but before this is attempted the surgeon should be positive that the callus is firm enough to stand the manipulation without re fracture. Prognosis. — The outlook in fractures of the upper end of the humerus will depend on the severity of the break and the age and condition of the patient. A fair degree of reduction will usually be followed by perfect recovery in youthful subjects. The older the patient the greater the probability of incomplete restoration of function. In the aged non-union may follow in spite of the most perfect treatment. In patients past middle life there is often slight restriction of motion and pain about the joint occurring with changes in the weather. The range of motion may be free and yet the shoulder weak. Loss of growth following epiphyseal separation is an extremely rare condition and need not be expected if anything like a fair reduction has been accomplished following the accident. IModerate deformity, if present, will decrease as the years go by. CHAPTER YIII. FRACTURES OF THE SHAFT OF THE HUMERUS. Surgical Anatomy. — To appreciate the deformities accompan^'ing fractures of the shaft of the humerus the attachments and directions of pull of the different muscles should be known. - (See Figs. 146 and 147.) AMien the line of fracture is through the insertions of the pectoralis major, latissimus dorsi and teres major the deformity is usually slight and consists of an in\Yard displacement of both fragments so that the deformit}^ is, as a rule, purely angular. When the fracture is below the insertions of these muscles, but aboA'e the deltoid eminence, the lower fragment will usuall}^ be displaced upward and outward by the deltoid, while the upper fragment is drawn inward by the pull of the pectoralis, teres, and latissimus. When the fracture is below the insertion of the deltoid the upper fragment will be displaced outward. In any fracture of the humeral shaft the serrated ends may be firmly enough engaged to prevent lateral and overriding displacement, and under such cir- cumstances the deformity is purely angular if present at all. Shortening of the arm is caused for the most part by the action of the biceps and triceps. The humerus has a wider range of motion than any other bone in the body and the varieties of strain to which it ma}' be subjected are great. Accordingly we may see any type of fracture common to long bones. The shaft of the humerus is composed of a heavy tube of compact tissue which grows larger in circumference and lighter in structure as the extremities are approached. The musculo-spiral nerve supplying the extensors and supinators descends obliquely, from a^bove, downward and outward, between the two humeral heads of the triceps. It lies in contact with the bone in the musculo-spiral groove and in this position is particu- larly exposed to injury in fractures of the humeral shaft. It may be injured by direct contusion and laceration at the time of the accident or it may be subsequently caught and compressed by the callus. lOS FRACTURES OF SHAFT OF HUMERUS 109 Figs. 146 and 147. — Views of the anterior and posterior surfaces of the right humerus. The arrows indicate the pull of the attached muscles. H., Head of the humerus; A.N., Anatomical neck; S.N., Surgical neck; L.D., At- tachment of the latissimus dorsi ; T.M., Attachment of the teres major; Cb., Coraco- brachialis; T'., Outer head of the triceps; T"., Inner head of the triceps; M.S., Musculo- spiral groove; B., Bicipital groove; P.M., Insertion of the pectoralis major; I.. Infra- spinatus; T.Min., Teres minor; D., Insertion of the deltoid; S.L., Supinator longus ; E.G.R.L., Extensor carpi radialis longior; JJ., Groove for ulnar nerve; P.R., Pronator radii teres; F.F., Flexors of the forearm; F.G.U., Flexor carpi ulnaris; Tro., Trochlear surface of humerus; C, Capitellum; E.F., Extensors of the forearm. 110 FRACTURES AND DISLOCATIONS Inward displacement of one or both of the fragments may be the cause of laceration or compression of the brachial artery which lies to the inner side of the shaft. Green-stick fractures are seldom seen and multiple breaks are uncommon. Direct violence is usually responsible for fractures of the transverse type; spiral and oblique fractures are the result of twistinpr strains. Muscular action is especially productive of frac- Fig. 148. Fig. 148. — Spiral, comminuted fracture of humeral shaft. Fig. 149. — Fracture of shaft with overriding and rotary deformity. ture of the humeral shaft, and in some cases (particularly in elderly persons) the degree of causative trauma may be disproportionately small. Impaction of the fragments is almost never seen. The most common seat of fracture is at or a little below the middle of the shaft. Symptoms. — There is pain, loss of function, crepitus, abnormal mobility and varying deformity. Swelling usually develops rapidly and ecchymosis is seen within the first day. The relative position of the fraorments varies with the level of the break and has been FRACTURES OF SHAFT OF HUMERUS 111 explained under ''Surgical Anatomy," page 108. The deformity is almost always sufficiently pronounced to be recognized by inspec- tion alone. The patient supports the injured member with the opposite hand in a manner which is characteristic. (See Diagnosis under "Dislocations of the Shoulder," page 65.) The patient is able to move the hand and fingers, and the reflexes below the site of the fracture are intact unless some of the nerves have been injured. Fig. 150. — Multiple spiral fracture of humeral shaft with pronounced deformity. Fig. 151. — Oblique fracture of humeral shaft with separation of fragments. (Taken through heavy fibre splint.) A weakening or absence of the radial pulse indicates laceration or compression of the brachial artery.^ The development of a hematoma may sometimes be recognized in the arm following tearing of the artery. Diagnosis. — Fractures of the humeral shaft are, as a rule, recognized without difficulty. The deformity is usually so pro- nounced that the diagnosis can be made by inspection alone. As soon as the arm is manipulated the point of abnormal mobility is apparent in almost all cases. Fracture of the shaft is a common fracture and is not infrequently associated with injuries to neigh- 1 A thrombosis of the brachial artery may alteration in the pulse will be delayed. be slow in forming and when it is the 112 FRACTURES AND DISLOCATIONS boring bones or joints. The surgeon should therefore be system- atic in his examination and determine the conditions of the clavicle, Fig. 152. — Oblique fracture of humerus a little below its middle Avith overriding and angular displacement of the fragments. Upper fragment anterior and external to lower fragment. Line of fracture passes below in-^ertion of deltoid, hence the outward dis- placement of upper fragment, while the biceps and triceps cause the fragments to over- ride. In this t^pe of fracture complete reduction is often impossible without operative intervention. Photograph taken within an hour of the accident. Fig. 153. — Crushing injui-y of ;u-m. This case was struck by a falling wall, the humerus fractured and the upper purtiou of arm forced through rent in skin. Skin and fascia only tissues connecting upper and lower portions of arm. Arrow points to lower end of upper fragment directly above which m.ay be seen tip of hemostat holding end of brachial artery. Amputation. Recover^-. Photograph taken while patient is under anesthetic and just prior to operation. scapula, elbow, ribs, etc., before the diagnosis can be considered complete. An X-ray plate should be made to afford further information concerning the nature of the fracture. FRACTURES OF SHAFT OF HUMERUS 113 Treatment. — The treatment will vary according to the location of the fracture and the direction and degree of displacement. It is best in most instances to reduce the deformity under anesthesia. Traction, counter-traction and manipulation will suffice in many cases to bring the fragments into proper apposition and alignment. In transverse fractures with overriding (especially when the ends are deeply serrated), reduction can best be effected by producing angular deformity and manipulating the fragments in this position until the serrated ends have been engaged. The bone is then straightened and appropriate dressings applied. In producing angular deformity for the purpose of engaging the ends, the arm should be bowed outward, to avoid stretching of the artery and nerves which lie on the inner side of the shaft. It is usually not difficult to effect reduction of a spiral or oblique fracture but it is frequently impossible to prevent recurrence of deformity in breaks of these types without resorting to internal fixation. Out- ward rotation of the upper fragment in a spiral or oblique fracture may act as a serious obstacle to reduction. Fractures of the upper third of the shaft are to be treated with dressings such as already described in the Treatment of ''Fractures of the Upper End of the Humerus" (page 101),