anti ComtelVs MANAGEMENT OF FRACTURES, DISLOCATIONS, AND SPRAINS Ke) and Comt ell's MANAGEMENT OF FRACTURES, DISLOCATIONS, AND SPRAINS Key and Conwell’s MANAGEMENT OF FRACTURES, DISLOCATIONS, AND SPRAINS H. EARLE CONWELL, M.D., E.A.C.S Attociale Profener of OrlbopeJic Surgery, Vniterstty of Ahhams School of MeJieine, Birmingham, Ala, Attending Ortbopejie Surgeon, IJnitersily llospml St Vinctnl’s Hospiul, Children's Hospital Baptist llospitals Lati Lnd Hospital and South Highljndi Infirmary, Birmiaghim, Ala Consulting Orthopedic Surgeon Velerans Hoip/faJi, Tusealoota, Ala, and hXonigomery, Ala Member Trauma Committee American College of Surgeons, Member, frae/ure Commtuee American Academy of Ortbopaedie Surgeons Member, Orlhopedie Adutorj Board Alabama 5/aie Crippled Children t Serure Chief, Conwetl Orthopedic Clinit Birmingham Ala ERED C. REYNOLDS, M.D. Profeisor of Orthopedic Surgery, Washington Unitersiiy School of Medicine, St Louts, Mo SEVENTH EDITION Wnh 1227 lUustratiotis THE C. V. MOSBY COMPANY 1961 ST. LOUIS SnVFNTH tomov OOPYRJGHT © 196i BY TUCC V MOSJrt CO\tPAN\ /til righn teicrteJ Pretiaui editions copyng^hted 1954, 1937, 1942, 1940 1931, 1936 Libnrj of Congress Cnlslog OsrJ Humber 6! S2o4 Distributed in Great Drilnii by Hear} Ktntpton Lon ion Dedicated to MARY LOU PERRY CONWELL and PHYLLtS M REYNOLDS J ALBERT KEY, M D PREFACE TO SEVENTH EDITION In this revision of the Management of Fractures, Dislocations, and Sprains Dr Fred C Reynolds, who was associated with Dr J Albert Key and who is now his successor as Professor of Orthopedic Surgery at Washington University School of Mediane, is partiapating as co-author Although raethodologj is constantly changing, we have found little reason to depart from the basic concepts of consenatism Since true ad\ances in the management of trauma ate those that increase our understanding of the pathologic phj-siologic processes occurring not only in the local area of impact but also in the organism as a whole, we have continued to stress the importance of looting upon the injured individual a^ a whole being It JS not the purpose of this book to present an encyxlopedia of injuries and their treatment. Rather, emphasis is placed on selective injuries, and sound methods used in their treatment h3\€ been described This edition has been thoroughly revised Much that was repetitious has been deleted and methods of treatment which have become obsolete ha\e been eliminated More detailed discussions of deceleration injuries and spinal disc in\oI\ement have been included A discussion of treatment with the medullary nail has been presented and indications for its use, based on thorough investigation have been included Also, the use of the hip prosthesis has been discussed The text and illustratnc material have been presented in such a way that the book will be of great use to the general practitioner, the medical student the general surgeon, the orthop^ist, medical personnel in the military forces, and even members of the legal profession Since the general practitioner is frequently called upon to car/) out the early manage ment of facial injuries, the chapter on Fractures of the Jaw and Related Bones of the School of Medicine, has again been included in the book In addition, a discussion on anesth«ia in patients with extremity injuries has been prepared by Dr Robert B Dodd, Professor of Anesthesiology, Washington University Siiool of Mediane The chapter on Injuries of the Hand has been revised by Dr Ariut H Stem, ]r, Assistant Professor of Orthopedic Surgery Washington University School of Medicine 11 12 PREFACE TO SEVENTH ECmON As SO aptly stated m the preface of the first edition, little claim is made for origi nalit) nie experiences of other surgeons hase been freely drawn upon We especially thank those who allowed us to use tbcir ideas and illustrative material We also wish to thank Mr Q D Schenk for his fine photography H E C F CR CONTENTS PART 1 PRINCIPLES AND GENERAL ASPJ CTS CHAPTER 1 GENERAL CONSIDERATIONS 23 Tractures 23 First Aid 38 Dislocations H Diagnosis of Fractures and Dis locations 51 X ray Examination in Diagnosis and Treatment of Fractures and Dislocations of Extremit es 51 Plaster of Pans Cast Techn c 55 CHAPTER 2 REPAIR OE rRACTURES 39 Factors Tend ng to Cause Nonun on 65 Clinical Delayed Union and Nonunion 68 CHAPTER 3 PRINCIPLES OP FRACTURE TREATMENT 82 Anatomic and Functional Reduction S'* Emergency Treatment of Fractures 83 Time Element in Ireatment 83 Anesthesia 83 Anesthetic Considerations (Robert B Dodd MD) 83 Methods of Obtaining Reducl on, 97 Physical Therapy m Treatment of Injuries of Bones and Joints 113 CHAPTER 4 COMPLICATIONS OF FRACTURES Up Injuries to Overlying Soft Parts 119 Infection 120 Injures to Muscles 120 Injur es of Important Blood Vessels 124 Brain Injury 126 Visceral Injury 127 Injuries to Nerves 128 Injury to Neighboring Joint 130 Traumatic Arthr tis 131 Acute Traumatic Bone Atrophy (Sudeefc) 132 Fat Embolism 133 Pulmonary 13 14 CONTENTS Complications 1}1 Dehnura, 155 Malumun lj5 Nonunion 157, Pccssure Sof« and Bed Sores 139 CHAPTER 5 PATHOLOGIC IRACTURES 141 Pathologic Fmtufcs Due to Local Bone Changes Ul Pathologic Prictures Due to General Conditions 155 Diagnosis Pff^osis and Treatment of Pathologic Fractures I }C CHAPTER f> OPLN FRACTURES AND WAR WOUNDS 158 Open Fractuces 158 Infected Open rraciures With Gas Gangrene 17H Infected Open Fraciufes VC ithout Gas Gangrene 174 Old Infected Open Fractures 175 Gunshot Fraeturea 178 Open FractuiTS and Wounds in VC ar or Afajor Disaster 180 PART 2 DIAGNOSIS AND TREATMENT OF SPECIFIC INJURIES CHAPTER 7 FRACTURES Of JAWS AND RELATED BONES OI lACI (James Barrcit Brotin, D . and Minot P Tijcf, M D ) 185 Fractures of Loner Jaw 185 i raclures of Teeth and Almlar Processes 211 Iractures of I pper Jaw 212 Internal Wire Fixation for Fractures of Jaw 222 Fracture of Nasal Bones 225 Dislocation of Loser Jaw 230 Anlcylosit 234 Chemcilherap) in Compound Facial Injuries and Jaw FrKturcs 23f CHAPTER H rRACTURES AND DISLOCATIONS OI HVOID AND rRACTURC or LARYNX AND TRACHFAL CARTILAGES 257 Iractures of Hyoid 237 Dislocalioft of Hyoid 257 Fracture of Ijrynx and Tracheal Cariilages 239 CHAPTER 9 INJURIES OI THORAX 240 Surgical Anatcinrr, 240 Fracture* irf Rib* 24l Dtslocation of Rih* at Vertebrae 236, Fractures and Dislocations of C«tjl Onilages 355 Fractures of Sternum, 256 CONTENTS CHAPTER 10 INJURIES or SPINE 260 Surgcal Anatomy 260 General Considerations 265 Compression Traclures of Spine 266 Fracture Dislocations Without Paralysis 291 Poster or Disfocition of Lumbar Vertebrae 295 Isolated Fractures of Transverse Processes 295 Isolated Fractures of Spinous Processes and Laminae 298 hi latcd Fractures of Articular Facets 299 Schmorl s Nodes 500 Injuries of Cervical Vertebrae 300 Dislocations of Cervical Vertebrae 305 Fraailre-D slocation of Cervical Vertebrae In juries of Spinal Cord and Nerve Roots Associated W ith Injuries of Spine ^20 Spondylol sthesis 32R lean ns « f Inlervcrtebral Discs in It w Back CHAPTER 11 INJURIES IN REGION OF SHOULDI R GIRDLE AND SHOULDER 348 Surgical Anatomy 343 Differential D agnosis of Injuries to Shoulder and SI oulder Girdle 351 Examination of Shoulder Girdle and Shoulder 355 Fractures of ClavicJr 355 Sfernoclaviculaf Dislocation. >68 Am m wJavjfular Dislocation, 371 Fractures of Scapula 379 Dslocaton of Scapula 388 Dislocation at Shoulder 389 Fractures of Upper End of Humerus 411 Bursitis and Periarthritis of Shoulder 128 Rupture of Rotator CulT 430 CHAPTER 12 FRACTURES OF SHAFT OF HUMERUS 432 Surgical Anatomy 43'’ Fractures of Shaft of Humerus 432 CHAPTER 13 FRACTURES IN REGION OF ELBOW 446 Surgical Anatomy 446 DiHerential Diagnosis of Fractures and Dislocations at Elbow 450 Examitution of Elbow 454 Complete Fractures of Lower End of Humerus 45 1 Fractures of Single Condyles and Epicondyles of Lower End of Humerus 481 Fractures of Capitellum 490 Mult pie Fractures in Reg on of Elbow 491 Complications of Fractures and Dislocations at Elbow 192 Fractures of Upper End of Ulna 498 Fractures of H«d and Neck of Rid us 510 Dis locatons at Elbow 516 Repair of Old Malun ted Fractures and Unreduced Dis locations at Elbow 536 Fractuies of Upper “Iljifd of Shaft of Ulna With or With Out Dislocal on of Head of Radius 539 Tennis Elbow 541 16 CONTENTS CHAPTER U FRACTURES OF FOREARM . . 545 Surgical Anatomy, 545, Examinaiioft of Fonarm 548 Fracturrt of Shaft of L/ina Alone, 550 Fractures of Shaft of Radius Alone 555 Fractures of Both Radius and Ulna SfiO CHAPTER 15 INJURIES IN REGION OF WRtST 580 Surgical Anatomy 580 Extension and Compression Trarturts of Lower End of Radius (Colin rracturn) 58} riexion and Cotnpresston Icactuces of Lower End of Radius (Smiths Fracture) 60S Tlexion rractures of Anterior Articular ^fafsm of Radius 6o8 Isolated Fracturn of Styloid Process of Lina 608 Dislocations at Wrist 609 Complications of Fractures of Lower End of Radius 6I4 sprains at Wrist Joint (\1 CHAPTER 16 INJURIES 01 HAND (Arthur H Stcjo, Jt MD> 618 Inttoduction 618 Anstomy 6(6 Examination and Evaluattixi of Hind, f}! Methods of Splinting 635 Erarturts of Carpus 6(1 Dislocations of Carpus 657 Fractures of Metacatpals, 666 Fractures of Phalanges 677 D slocation at Finger Joints 681 Open Iniuries to Hand 691 Thom Injuries to Digits F9S Injuries Caused by Wringer 699 Hand Infections 700 Ihinciples of Reconstruction of Severely Inisred Hand 705 CHAPTER 17 FRACTURES AND DISLOCATIONS OF PELVIS 715 Anatomic Considerations 715 Examioatson of Petsis, 717 Fractures 718 Fractures of Individual Bones Without BreaV >n Pelvic Ring. '*24 Single Fractures of Ring of Pelvis, 733, Separations and Fractures Near Symphysis Pubis 757 Double Fnclures Through Pelvic Ring (MaJgaigne) 744 CHAPTER 18 INJURIES IN REGION OI HIP 747 Anatomic Comidcritions 747 Eaamination of Hip 750 Dislocations at Hip 753 fracture of Acetabulum and Central Dislocation at Hip 775. Friaures of UpFf ith Ifi;ory of Ankle Joint 982 FmeJurrs of Both Tibia and Fibula, 982 Delayed Union in Fractures of Leg 1012 CHAPTER 22 INJURIES IN REGION OF ANKLE 1014 Surgical Anatomy 1014 Sprains of Ankle 1016 Fractures and Fracture Dis locat ons 1020 Dislocat ons at Ankle Without Major Fracture 1057 Open Frac tures and Fracture Dislocations at Ankle 1064 CHAPTER 23 INJURIES OF FOOT 1068 Surgical Anatomy 1068 Foot Strain Flatfoot or Pronated Foot, 1072 Fractures of Talus 1074 Fractures of Os OIcis 1081 Total Dislocation of Talus 1104 Subtalar Dislocation 1I04 D slocation at Rfidtarsal Jo nt 1107 Fractures of IS CONTENTS Anterior Tarsal Bones, llIO, Dislocations at Tarsometatarsal Joints, 1113. Trac tures of Metatarsals, 1 m 6, Tractuces of Toes, 1125, Dislocation at Metatarso- filialangeal Joints, U2r>, Fractum of Sesamotjs of Great Toe, 1129 Key and Connell’s MANAGEMENT OF FRACTURES, DISLOCATIONS, AND SPRAINS PART 1 PRINCIPLES AND GENERAL ASPECTS CHAPTER 1 GENERAL CONSIDERATIONS FRACTURtS T.^uipment One of the pfmcipjl reasons for the poor results so fre! immtJ' I rat on n plaster cast to forrann and «rst Tig " /I and B Anleroposierior and lateral mc«.$ of x ray films faiiing t > show occult fracture of tibia C and D, Similar films 1 oionth later sitowing f'criosteal new bone formation on lateral film indicating occult fracture (Trom Reich R S, and Rosenberg N J A M A 16G 6 1958 1 yO PROsOPLES AV.D CtNERAL ASPECTS signs of Its presence yet whidi sMth excellent rotnti’en rjy technic nU) not be demon strated before reparative cliangcs have taken place A wirfi6 frjcturc is a subperiosteal fracture which results from excessive use and is not caused by a specific injury (Ham mood and O Connor) DEPENDENT UPON DIRECTION AND CHARACTER OF ttNE OF FRACTURE TractUrCS arc class fied as long tudmal transverse oblique $p ral (Fig 9) and V T stcllati^ or Y shaped Comminuted jnetures are those in Rhich there is not onl) a break in the con t nu ty of the bone but tlic bone is broken into three or more fragments (Tig 10) An nnpicted jraefure is one in wh eh one fraemcot has been driven into the other fragment and rcraa ns embedded there Impacted fractures ten I to occur at points where the ends Fip 9 Sp nl /raclufc of tower and m JJte Ih rd» of fern r IrealeJ hy sxdctal Inct on w I £00(1 result F £ t( Open CO nn nuted fraauic of i JJle orJ upper (h rJi of t K a due lo d ret v olen e Treated by debr dement and skeletal Irart on Ih ourH tba and taler by ornilar plasler cast w th £Ood result of the b o frigments are of dilTerctil dene 1) wl ere tl c dense cortical bone of t! e shaft merges into the cancellous bone of Uic metapliysii as at tl c lower end of the rad 0 * the upper end of the femur and the upper cnl of the } umcnis In such fractures the dense cortex is driven into tl e carKellous structure Interlocking of fragments may occur witliout true impact on Compress on fracture is one n which the fracture fragments have been driven together so Uiat the trabeculae arc interlocked Tli s us ally occurs in cancellous bone DEIESorNT UPON PORTION Of BONE INVOLVED In dcscf pt ons pf frattutcs the Site of tlic fracture is usually stated as fracture of Uic shaft or lower end of the humcros or fneture through the neck, or infcrtrochintcric or supracondylar fracture nf tl c femur GFNERAL CONSIDERATIONS 31 If the fracture line lies entirely within a joint cavity, it is called an intra articular frac ture, whereas if it imoKes both intra articular and extra articular portions of the bone. It IS called a true articular fracture A fracture should gcncrallj be described anatomially and not designated by a surgeons name such as Colles, Potts, etc Tlie anatomic description is more speafic and correct Epiphyseal Separations Epiphyseal separations arc fracturc-s in which tlie fracture line lies wholly' or partly witJiin tlie epiphyseal line and the epiphysis may be wholly or partly separated from the shaft In an epiphyseal separation a portion of the cortex of the shaft is split off with the epiphysis Traumatic epipliyseal separations are most frequently in the lower end of the radius, tlie upper end of the humerus, the lower end of the tibia, and the upper end of the femur Because of the fact that all of the epiphyses hase united by Uie twenty fifth year m the normal individual and that most of them Ime united before the age of 20 years epiphyseal separations practically do not O'^cur after 20 years of age and are %ery rare after 15 years of age Most of the cases occur between the ages of 6 and 12 at a time when the epiphyses are rather large and the epiphyseal cartilage is relatively soft this being the period of aclne growth Fifc U Usual displacement in epiphyseal separation of lower end of radius Reduced by nan pula tion and immobilized m plaster cost The diJTerential diagnosis between an epiphyseal separation and a fracture can m many instances be made only by x ray examination, but in a young person in a fracture neat a joint in which the line of acute point tenderness lies at about the level of the epiphyseal line of the invoKcd bone, an epiphyseal separation sliould be suspected In the treatment of an epiphyseal separation an attempt should be made to obtain an anatomic reduction Howe\er, manipulation must be gentle to prevent further damage to the epiphyseal cartilage Open reduction is seldom indicated Growth disturbance will occur m the epiphyseal plate when it has been sc%erely damaged It is important that the surgeon warn the parents of the patient to the effect that e\en with perfect reposi bon of the epiphysis there may occasionally be dtstuibancc in bone growth with asso ciated deformity Synipioms The symptoms of fractures may be divided into objectne and sub- jective Subjective symptoms are those which are felt by the patient the knowledge of which the surgeon obtains from the patient Objective symptoms are those w-hich can be seen or felt by the surgeon himself 32 PROxaPLCS AND GENERAL ASPECTS SUBJECTIVE SYMPTOMS The subjcctnc S)*mptonis are those included m the histor) of the accident loss of funaion pain and tenderness History Tlie hislof) should include a history of the acadent and a lustorj of any previous fractures or deformities which the patient may have suffered and which may ime altered the form of the Jimb or whiA might lead the surgeon to suspect the presence of a pathologic fracture In obtaining the htvtory of the acciden*- the surgeon should endeavor to ascertain as accurately as possible the degree of the traumatizing force and the manner and d rcction in wh eh it was applied < n of it iUl f«rt n ( f ulna w ih cinv deraWc iin arc wre it* icry I uhl ni; ■*.] en itirj d occur Pant Pan at the tim“ of the in|tiry ami aftcrwird both spontaneous and upon movement of the fractured limb is a constant accimipaniincnt of fracture but the de* grc' of pain vanes cmsidcrably in different fractures and m different persons with similar fractures Not only should the surgeon Itam as accurately as possible the character and local on of the pain which the patient suffers while the extremity is at rest but during the physical ctamitulioni he should also endeavor to cl cit p-iin at the site of the lesion by certain manipulations since th $ pJn may be of considerable aid in the diag nosis of obscure fractures In certssn fractures without obvious dispUccmcnt localized pain at the s tc of Uve fracture may be ehciteil by making axiaJ pressure on the distal fragment or by making cross strain sucli as wlien the bones of the leg or forearm arc squeezed together or by slight bending or twisting of the lower fragment while the upper is immohilized lor the purpose of diagnosis such localized pain need not be severe Init merely enough to indicate that when strain is put upon the given bone the pain occurs at a certain point TtfJeniess Tlic amount of tenderness vanes greatly in different persons an! also GENERAL CONSIDERATIONS 33 Fg 13 Part al efphseal arrest Mth salgus deform ty C 5 years folio ng separat on of d slal end of fern r and fl desp te good reduet on Treated by osteotomy of femur 3^ PRD^OPLES AND GENERAL ASPECTS Vines directly the aroount of iojii*y to the ^ft parts and v.iih the tune eUpmg after the injury Some patients compUm of tenden3“ss at any point along the limb, in r^hich case it is more a question of apprdi-nsiOQ than of true tenderness If fractures are co^ seen until some hours after injury and if there is considerable ssvelling and damage to the «oft parts, there may be tend tress me'- a n ide area An important feature m the diagnosis of a fracture is n-hat is called fracture tender ness or point tenderness "niis is a runo« Im- of acute tenderness directly oser site of injury Point tenderness is difficult to thol m bones vfhich are covered by thick layers of soft tissue, as lo the femur, but it is compaiatirdy easy to chat m superficial bones. To eliat point tenderness th“ surgeon most handle the hmb 'cry genti) and begin at some point distal to the site of tiv* suspected fracture and v.-|lh the tip of the finger genllf press on the sfcinj graduall} apprradung th“ site of the fracture When pressure IS made directly oier lh» site of the fracture, the palien»^ will complain of acu'e fender ness The surgeon should then begin at the other end of the limb and approach the frac ture from the other direction If true point tenderness has been located the points of acut' tenderness mil tend to coincide Loss ej runction Loss of funaion also lanes in different fractures and m different persons rvith the same fracture The surgeon should first obtain a rough idea of the de- gree of loss of function from the history and he should then corroborate the patient s statOT^nts by having the patient a^empl to carry out certain moiements These should first be earned out without resistance and if this can be done they should be earned out against tesistance In incomplete or impacted fractures the loss of function may be relatiiely slight We have seen a fen patients who ha\e walked on an unpacted fractore of the upper end of the femur OBjECil\E SYMPTOMS The cfcjeclue symptoms aie surgiol shock, deformity swelling ecchjmosis atpitus abnormal mobility, and v ray findings Constsls/twfjl Symptoms of Fraefures All fractures are accompanied by more or less shodk to the patient; and the degree of this aaries with the person and with the severity of the injury In th* ivencc closed fracture shod is not present to any mitked degree, but in a patient who has had a severe open fracture of a large bone with eitcn sive damage to soft tissues and s-vere hemorrhace surgical shock maj be the dominant feature and may demand immediate lieatment before it is possible to attempt treatment of the fracture In a patient widi a dosed fracture who exhibits symptoms of severe surgical shock and in wdiom the fracture does not seem of sufnaent gtav ity to account for the shod^, a careful se-aixh should be made for visceral injuries as otherwise these might be over looked The constitutional symptoms after an injury arc apt to be more serious in older patients than n younger ones Dunng the first few days after the fracture other dosed or open many patients tend to run a temperature and a mild leukocytosis This is apparently due to the resorption of the cMravisaled blood but at times the temperattire may reach 103’ 1^ or even more and lead the surgeon to suspect infection Hemafog enous infection in closed fractures is unusual, but occasionally it occurs and necessitates drainage and appropriate systemic tbenpy Persistent elevation of the icmp-rature of 103® F or more following open fracture almost always indicates that the primary treat ment, which is treatment of the wound has failed In such instances the decision is a very delicate one as to whether or not an open fracture which has been defariJed and sutured should be reopened Deformity Deformity signifi”s a change in the shape or position of the limb which IS not due to swelling in th" soft tissues is due to alterations in the bony stni-lures This deformity may ^ a shortenmj^ alterahon of the normal alignment abnormal rota tion, or angulation of the extremity It is dcp'vulent upon displacement of the fraements and cannot be present unless the fragtoerts are displaced (Figs 14 18) GEVERAL CONSroERATlONS 35 Fig lA ^^arked radial druat on in rtcent fracture of lower third of both bones of forearm Fig 15 Marked siUer fork deformity Tig 16 Usual deformity in fractore of lower third of femur Thu is an open fracture (puncture wound) 56 PRINCIPLES AND GENERAL ASPECTS FolfoTving a general simey of the patient and an assessment of the extent of in jury search for deformit) should be the fint step So that deformit) cm be detected the injured limb and its fellow on the opposite side should be placed m the same refa tive positions and should then be compared by inspection palpation and measurements In many instances in complete fractures with considerable displacement deformity is obvious at a glance In others 'aith very slight displacement deformity is very difficult to determine and the limb must be not only carefully inspected but also measured and palpated In interpreting the results obtained by inspection measurement and palpation one must take into consideration any deformity which may base existed in the limb previous to the given injury and must also take into consideration the fact that slight as)mmetr} IS not infrequently present in normal persons This as)mirctry is particular!) common in / Tr is Xiay film of sane patient as in F 5 s \( and 17 Deform t> ho ever u seldom this marked Treativl by Jtbtidemeni and skeletal tract cm regard to the length of the lower extremi^, and in many normal persons one lower txtremil) as measured from the antcrroc supenoe spine to the tip of the internal malleolus is from one fourth to one half inch shorter than its fellow on the opposite side In incoinpiete and in impacted fractures the defrrmit) if present is persistent and annot be corrected without cither breaking up the impaction or in the case of an in complete fracture, bending the intact portion of the bone Su tiling The presence of considerable swelling or of a large amount of sub cutaneous fat maj obscure deformities which would be obvious in a normal slender hmb, or such swelling may cause a dcforroity to appear more marked than it rcall) is GENERAL CONSIDFRATIONS 37 Swelling in the vianity of a fracture is the result of extra%asation of blood and serum into the tissues The degree of swelling saries v,ith the extent of soft tissue and vascular injur) and the length of time since injur) Extensive spelling not onl) interferes with fracture management but at times produces grave circulator) embarrassment In cases with extensive swelling large blebs filled with a )c!lowish brown serum may appear on the skin surface a day or two after the injury In fractures which communicate with joints the synovial avit) becomes filled with blood and the joint presents the picture of an acute traumatic sjnovitis In open fractures the swelling is not a prominent feature, as the blood escapes through the wound Ecchymosis Ecchymosis is the presence of blood m the subcutaneous tissues and leads to discoloration in these bssues It is almost always present after a fracture but it is not to be regarded as an important symptom in an acute fracture because the ecchymosis may not appear until 2 or 3 days after the injury In fractures in deep seated bones the ecchymosis may not appear for several days and it may appear at some site far removed from the site of the fracture As extravasated blood always settles to the most dependent portion the ecdiymosis is most marked in this region Abnormal Mobility Abnormal mobility is motion in a limb at a point or in a direc tion in which it does not normally occur and next to deformity is probably the most important single sign m the diagnosis of fractures When it can be demonstrated in a bone, it is a pathognomonic sign of a fracture which is located at a point approxi mately at the center of the abnormal motion In the case of a joint it may be the sign of ruptured ligaments or of a fracture In seeking to demonstrate abnormal mobility in a limb manipulation should be slowly and gently performed and the movement should be carried no farther than is necessary to make the diagnosis definite In most instances this can be done without ausing further damage to the soft tissues and without inflicting much pain on tiie patient In fractures through the shaft of a long bone of cither the leg or the arm all that IS necessary is to grasp the upper fragment and gently raise the distal portion of the limb or gently move it from side to side In fractures near the ends of the bones the abnormal mobility is, of course, more difficult to detect and m many instances cannot be Satisfactorily demonstrated In certain fractures where there is overriding of the fragments the limb can be telescoped b;i aJow ^enjJe s/arlioo and then pushicig ipwaxd very gently on the limb and carefully noting any change hi its lengtli Jn other instances abnormal mobility m the direction of rotation may be detected by grasping the trochanter of the femur and rotating the thigh or by palpating the head of the radius while the forearm is being rotated In the forearm and leg abnormal mobility of one bone when the other is intact can be demonstrated by placing the fingers over the seat of the fracture and either squ^zing the bones together or grasping one fragment of the suspected bone and moving It from side to side Where an apophysis has been lorn off, as in a fracture of the tuberosity of the humerus or of the femur, it is often possible to gmsp the separated fragment and move It in an abnormal manner The norma! elastiaty of the ribs and of the fibula may give one the impression of abnormal mobility when this does not really exist Crepitus In fractures crepitus is th'^ grating sound or sensation produced by the friction of one fragment moving on the other When true bone crepitus is obtained, it is pathognomonic of fracture and for this reason is usually considered a most important diagnostic point, but crepitus is not as frequently sought for at the present time and is not considered of as great importance as it was before the day of the use of the xray The ends of the fragments must be placed in amtact and must be moved upon one another to produce crepitus As a result many patients have been subjected to violent 38 PRINOPLES AND GENERAL ASPECTS and useless manipulations m an attempt to eliat crepitus when the fracture could liave been diagnosed without it However, if the ends of the fragments are m contact, crepitus may be felt or even heard when the surgeon moves the limb in endeavoring to demonstrate false motion FIRST AID A large percentage of fractures occur at points some distance from a hospital This IS especially true of those injuries caused by automobile acadents, which are ever be- coming more frequent As a result ph)siaans who do not ordinanlj treat traumatic in juries are frequentl) called upon to render first aid to injured individuals where little or no equipment is available Since World War I the usefulness of the TTiomas arm and leg splints for emergencj treatment and transportation of fractures of the cxtr«nities has been stressed, but it is most unusual to find such a splint when one is called upon to render first aid because in civil life fractures are not expected If such splints arc available, they should be used where indicated, as is noted in the chapters on specific injuries (Fig 19 ) Ordinarily the only materials available are boards, bandages, cloth and padding TTiese cm be procured almost everywhere, and with them the resourceful phjsician can immobilize the average fracture sufficiently to enable the patient to be transported to a hospital with out danger of adding to the grav itj of his injuries fi/; 19 Immobiliracion of fracture of lemur for iran»j>onation (Courtesy Major GcrcmI N T Kirk United Sut«4 Army (Reiiredj ) Cxampiaiwii at Site of Actideitt A rapid general physical examination is neces sary, the purpose of which is not to arrive at an exact and complete diagnosis but to determine whether the patient is seriousi) and perhaps fatally injured or whether the in juries are trivial As a rule this will not necessitate removal of all of the patients clothes Major fractures of the extremities which will require immobilization for trans portation arc usually obvious, and detcrmioatcon of the details of the fracture can be deferred until the patient is so situated that definite treatment can be begun Emergency Treatment If the patient is severely and dangerously injured, the emergency treatment has for its object the conservation of life If he is unconscious, he has a brain injury If in shock, the patient should be given enough sedation to relieve the pain and should be kept warm and be moved as little as possible If open wounds are present, the) should be covercvl with sterile dressings, but no attempt should be made to cleanse than (See section on open fractures ) If die patient is bleeding the hemorrhage should be stopped with either a tourniquet or a tight compress, dc pending upon the location and the seven!) of the hemorrhage If a tourniquet is used and It IS neccssar) to leave it on more than 1 hour, the tourniquet should be loosened for a few minutes at intervals, and after the first hour at intervals of from 20 to 30 minutes Tins is done to avoid gangrene GENERAL CONSIDERATIONS S9 Severely injured patients should be covered with blankets and allowed to lie on the ground until they can be splinted and moved in an ambulance to the nearest hospital The tendency is to put them in the first available automobile and to rush them to the nearest doctors office or drugstore, where the superficial wounds are carefully cleansed and dressed while the patient is dying of shock If important bleeding is arrested and major fractures are properly splinted, a journey of a hundred miles or more m an ambulance will rarely increase the danger to the life of a patient Such a journey will usually get him to a hospital where he can receive proper treatment emergency Splmting Major fractures in which there is a tendency for the frag ments to move should be splinted before the patient is transported because the move- ment of the fragments causes great pain, damages the neighboring soft tissues, increases the hemorrhage and shock, and may even result in the death of the patient It was for this reason that the practice of splinting the wounded on the field was adopted by the 2o Correct application of Ducks exiension and pillow splint the latter for emergency treal m«it for fractures of leg and ankle (Courtesy Dr J W Tourney ) various armies during World War I It has been said that the routine application of the Thomas splint on the field reduced (he mortality from 80 to 20 per cent m gunshot fractures of the femur Since a Thomas splint is rarely available, we shall describe methods of immobilizing major fractures hy means of simple board splints Tliese splints afford suffiaent immobilization for emergency transport but are not suitable for the definitive treatment of fractures In the illustrations padding is omitted, but all of them should be padded with blankets, quilts sheets, clothing cotton, or whatever is available It is to be noted that the splints immobilize the joints above and below the fracture SEVERE FRACTURES OF SPINE OR PELVIS Thc ladder Splint IS efficient and the materials for its construction can usually be procured It consists of two Jong boards which are fastened together by three crosspieces If hammer and nails are not available, the crosspieces can be tied on The splint is padded if material is available, and the patient is bound to it It also serves as a litter and is useful for patients with visceral in* 40 VRISaPLES AND GENERAL ASPECTS Fig 21 Ertiffsency drMs nu ( t severe injuries in region of st oulder Po nter ind cale$ pjJ in axilla Fig 22 Board spl nls js used m emergency immohil rat on of frafiures of shaft of humerus elbow fractures and fnetures of upper Ih rd of forearm rg 2i F* 21 Fig 2J Same as Fig 21 '»ilh arm bound to side Fig 24 Board splint as used la emergcixf immobiliwt on of fractures of fotcarm utist elbow when forearm at elbow is m fJneJ pos tion CENERAL CONSIDERATIONS 4l Junes lacking such a splint the patient should be transported and lifted with the head, shoulders, trunk, pehis, and limbs supported m a horizontal plane to avoid further flexion of the spine and possible damage to the spinal cord If tlie patient is very un comfortable in this position, he may jie on his side or back, but the site of the /racture should be supported sihen he is lifted, or he may be rolled like a log Transporting such a patient on a litter with a large pad under the fractured vertebrae is verj uncom fortable A small pad below or above the fracture may be grateful!) received FRACTURES OF UPPER EXTREMITY In Simple fficturcs of the clavicle and minor injuries in the region of the shoulder, all that ts necessary is to place the arm m a snug triangular sling as illustrated in Fig 26 In more severe injuries in the region of the shoulder the dressing illustrated in Fig 21 is useful It consists of (1) a pad in the axilla (indicated by the pointer), (2) a scarf or band binding the elbow to the shoulder (3) a band binding the arm to the chest (this should not be too tight as it may com press the brachial vessels), and (4) a sling to support the forearm and hand Fig 25 Same as Figs 22 21 with tiunsular sling being applied Fig 2C Sling IS folded and ready CO be lied at back of neck 1 ractufcs of the lower half of the shaft of the humerus elbow fractures and frac tures of the bones m the upper third of the forearm can be immobilized m board splints as illustrated m Figs 22 and 23 Tither a single long or two overlapping short boards can be used Further immobilization can be secured by binding the arm to the side The splint on the mesial surface should not extrad too high m the axilla Fractures of the forearm m the lower two thirds and fractures at the wrist can be immobilized in dorsal and volar board splints as illustrated in Fig 24, and the fore arm supported in a triangular sling (Figs 25 and 26) The splints should extend beyond the elbow in order to prevent rotation of the forearm FRACTURES OF LOWER EXTREMITY In fracturcs of the hip, shaft of the femur, and knee it is necessarj to immobilize the lower extremity and the trunk, and m fractures of tlie leg It IS necessarj to immobilize the tliigh and foot A certain amount of im mobilization can be secured by binding the two lower extremities together but in frac tures of the hip, thigh, and knee it is advisable to apply boards as illustrated in Figs 42 PRINCIPLES AND GENERAL ASPECTS Fig 27 Pillow splint for temponify dressing of fractures of lower leg and ankle Pillow can be reinforced by straight boards under and on sides of leg Fig 28 Lateral board splints for temporary dress ng of fractures of leg Note that both knee and ankle are fixed Fig 29 Long board spl nts for cmergenc) imn ob luation of fractures of h p shaft of femur and knee joint Fig 30 ^mc as Tig 29 seen fn m inner side Note tlut foot is bound to spt nt to proent rotation GENERAL CONSIDERATIONS 45 29 and 30 Note that the board on the outer sede extends to the axilla and that rotation IS prevented by tying the foot to the splint In fractures below the knee it is not necessary to include the trunk, but it is desirable to include the thigh and the shorter boards can be applied as shown in Hg 31 If a pillow IS ava lable a very cfliaent and comfortable pillow splint can be applied (Fig 27) Straight board splints nuy be fixed on either side and on the bottom of the pillow after it is pinned around the leg and foot or a roller bandage may be used Fg 31 Lateral board splints as used m emergency treatment of fractures below knee Vote that Icftce IS immob hzeO r S 52 Use of w ire Udder spl nt as emergency immob i zat on for fractures of ankle (Courtesy Ma)or General N T K ik Uo ted Slates Army [Ret redl ) The order of urgency m rendering first aid at the site of the injury is (1) to estab- lish an airway (2) to control hemorrhage and (3) to comtttt shock as much as pos 5 ble by immob lizing the fractures making the injured person as comfortable as possible while waiting for a suitable vehicle for transportation Once these things have been accompl shed there is no need to rush pell mell to the nearest hospital Rarely w-ill a patients life be saved by such a course of action but travel ng at high speed over busy highways or streets endangers life not only to the injured person who is being 44 pRiNaPLrs and gfneral aspects transported to the hospital but also to all those encountered en route As a rule the in jurcd person will be taken to the nearest hospital Upon arrival it is again of the utmost importance that he be seen immediately b) a phjsioan who must be sure that there is an adetjuate airway and that hemorrhage is controlled If a tourniquet has been applied at the Site of injury it should be removed and the major bleeding vessels should be clamped Otherwise bleeding should be controlled with a large pressure dressing If a dressing has been placed over an open fracture it should not be disturbed unless it is necessarj to do so to control hemorrhage If a traction splint has been applied it must be closely inspected to be sure that there js no embarrassment of circulation In cases of fracture of the femur if a traction splint has not been applied at the site of injury it will probably be advisable to do so at this time provided this can be accomplished without undue pain to the patient If the patient has had a head injury or if there is a history of unconsciousness he should not receive opiates and must have a very careful survey Sucking wounds of the diest must be closed by appropriate dressing an unstdile chest must be stabilized by traction and signs of intra abdominal hemorrhage must be sought for Once the patient has been adequately resuscitated and immediate danger to life has been removed the physician must decide whether he and the hospital in which he works is adequately prepared to carry out definitive treatment to the injured person If so these treatments may then be undertaken m th- order of their urgency as desenb-'d elsewhere in this book If however the physician or the institution is not prepared by training experience and equipment to manage th* entire extent of the trauma the patient should be immediately transported to the nearest hospital that is properly equipped and staffed If the patient is to be transported to another institution under no circumstances should wounds be closed nor other treatments rendered beyond resuscitation and adequate immobilization DISLOCATIONS Compared to fractures disloations are relatively rare injuries Tliey occur only about one tenth as frequently as do fractures It is also of interest to note that about 8$ per cent of all dislocations occur m the upper extremity and about 50 per cent occur at the shoulder joint Causes Tlie predisposing causes are instability of the joint and exposure of the joint to injury This is particularly illuslrateil in the shoulder in which the large head of the humerus fits into the small glenoid fossa and is held in place by ligaments tendons and surrounding muscles This joint also occupies an exposed position in which it is frequently subjected to trauma both directly on the shoulder and indirectly by means of leverage of the upper extremity Occasionally abnormal development of the joint may predispose It to dislocation '' The determining cause is usually external violence which is in most instances applied in an indirect manner that is Ihrouqh leverage exerted on the distal portion of the extrettuty In addition to primary dislocations we occasionally see recurrent or habitual dislocations Most of these cases occur at the shoulder joint and the subject is treated in Chapter 1 1 Pathology of Recent Dislocations In a traumatic dislocation the articular surface of one of the bones entering into a joint is violently pushed or pulled away from its fellow and forced through the joint capsule and into the surrounding tissues where if comes to test and is fixed by muscle spasm It is obvious that not only must tlie capsule of the joint he ruptuted to permit the passage of the articular surface of the dislocated bone but also the ligaments of the joint must be ruptured to a variable degree, and many of the muscles which control the joint are cidier stretched or tom The degree of displacement and tlie extent of damage to the soft tissues vary directly with the scvcrtiy of the dislocating force and w ith the size of the joint GENERAL CONSIDERATIONS 45 In addition to the damage to the capsule, ligaments, and muscles, fractures of the articular surfaces or of the bones in the MCini^ maj occur, and blood \essels and nenes m the vianity may be torn, stretched, or contused The damage to the soft tissues and the extravasated blood cause swelling just as in fractures The progress of the displaced bone is cscntuall) arrested by the untorn ligaments or muscles nhich are attached to it and b) the soft parts which he m its path In cases of \er) sesere Molence the end of the bone may be forced through the shin and an open dislocation results The primary displarcment, as in fractures, is caused by the dislocating force, and eventual displacement is the result of tension of untorn ligaments and muscles, of gra^ ity , and of the fracturing force Complications. In addition to the possible fracture of the imohed bone or bones, complications of dislocations are practically the same as are those of fractures and are considered in Qiaptcr 4 It is important to mention old unreduced dislocations which are considered In Chapter 11 Repair. If the dislocation is reduced without excessive trauma and if the joint is immobilized, the extravasated blood will be absorbed and the tear m the capsule will heal by the formation of granulation tissue and a scar as docs any other fibrous tissue E%cntually this scar will be co\eted by a layer of cells corresponding to those lining the rest of the joint The ligaments and tendans also tend to heal by scar tissue, but, if the immobilization is continued o\ee too long a period, tJie ligaments and apsuJe tend to become shortened and considerable difficulty may be experienced in restoring norma! motion in the joint Tears m the muscles will heal, and muscles which ire torn off from their insertions also tend to heal by scar tissue Any fractures incident to the dislocation heal in the normal manner if the fragments ate approximated In ases m which there has been extensile stripping up of the periosteum at the time of the dislocation, considerable new bone formation may occur during the process of healing, and this may be so extensive as to interfere with movements of the joint This is especially to be feared after severe dislocations it the elbow and the hip Signs and Symptoms The signs and symptoms of dislocations are similar to those of fractures There is a history of an injury If an accurate description of just how the injury occurred can be obtained, one is frequently able to predict the type of lesion which IS to be found on physical examination Particularly should one ask whether this is the first dislocation or whether there have been others at the same joint SUBJECTIVE SYMPTOMS With the dislocation there is severe pain which may be described as sickening or nauseating in character It may subside gradually after the injury but tends to persist for an indefinite lime until the dislocation is reduced There may be paralysis or a tingling of the nerves Loss of function may be present, and, as in a fracture, it may vary greatly in degree in different persons even with the same lesion, and one occasionally sees a dislocation which has been present for some time in which considerable power and movement are present in the affected limb OBJECTIVE SYMPTOMS The main objective symptom of dislocation is deformity The pathognomonic signs of a dislocation arc the identification of the articular end of the displaced bone in an abnormal position and the demonstrabon of its absence from Its normal position This can usually be acromplishcd by inspection and palpa tion (Figs 33 36 ) In addition to the deformity due to the displacement of the articular end of the bone, there is also a deformity of tlie limb as a whole which is characteristic of the given dislocation This fixation of the limb m an abnormal attitude IS one of the most important points m the differential diagnosis between a dislocation and a fracture Whereas in a fracture the limb can be moved freely and even false motion may be obtained, in a dislocation it will be found that the limb is fixed in some abnormal posture There may be shortening or apparent lengthening of the limb, and Fe 33 Fg 3^ 1 33 SubcoracQ cl d slocat on of $ho Idcr Note typ cal f7 VX iBiamJ K \X ilk nv Co fRloadi,J F and Kai Avkai \r Influence on f omul on of Callus in Cspcfimctital Fratlurr ’^urjttiy It J? 19 1’ I Kef I A OJell R T anj Tayl r L. VC Fa lure of C rtivone lo Delay of to Prevent Ileal I f Fractures in Rati J Hone & Jo »t SufB MA (6^ 1952 f^tincl field r r Sankaran, B and Sam fsorn R Effert of Ant coa£uljriC Therapy C'n P ne Repa f J B«ie A Jo nt Surg 5S-A 2 0 IStW REPAIR OF FRACTURES 67 granulation tissue in this area is completely blocked, and union fails to occur Howe\ef, most cases of nonunion may be traced cither to extensive damage to local tissues or to incomplete reduction and immobilization Injection Infection by pjogemc orgamsim produces a local hyperemia, v\hich if neither severe nor of too long duration maj actually stimulate bone formation How e\-er, if the hyperemia is se\ere or if it continues it presents proper organization of the sascular granulation tissue and interferes with the formation of callus In addition to the hyperemia there is destruction of local soft tissue as a result of liberation of toxin from the infectious agent, as ^\ell as autolysis of the fibrin dot due to the digestue action of the leukocytes Infection for the most part tends to retard healing and if not promptly eradicated usually produces nonunion follosved by eburnahon of the ends of the fracture fragments which are walled off in dense scar Fig 6l I\onunion of second and third mttacarpals poss bly due to too early motion or strenuous manipulat on Successfully treated by bone graft Poor Blood Supply and Presence of Synoiial riiiid Certain fractures are noto- riously liable to result in nonunion This is cspeoally true of fractures through the neck of the femur and fractures througli the carpal scaphoid Next m order come fractures through the junction of the middle and lower thirds of the humerus or tibia The im portance of the presence of synosial fluid in the first two types is debatable, since other intra articular fractures m which reduction and immobilization are carried out can be healed in the normal manner On the other hand, there is no question but that if teduc tion IS Unsatisfactory and if immobilization is not obtained the synovial fluid will tend to cause the fractured surfaces to become cohered by a layer of fibrin and e^entually by a layer of connecti\e tissue and nonunion will result In cither instance, however if the fragments are jammed togetlier, tiie presence of synovial fluid is excluded and cannot be a factor Also there is the question of blood supply The blood supply to the proximal frag ment in fractures through the neck of the femur, or through the carpal scaphoid is 08 PRINaPLES A*JD GCNCRAL ASPECTS unusuall)' poor Fractures belou the nutrient vessel m Jong bones may also ha\c im pairment of arculation, and fractures of the dutal tibu and distal humerus arc rather prone to develop nonunion Houever, the distal fragment almost insariably develops osteoporosis and one would not antiapate such a diangc if the blood supplj were in adei^uate Ve may saj in general houc\tr that for a fracture to heal rapidlj there must be sufficient uell nourished soft tissue sunoundmg the fracture to proside the proper climate for new bone formation Unkiwivn VaciOTS Most physiaans viho have treated and seen large numbers of fractures will admit that serj rare!) do they erKOunter t fracture rihich is properly re- duced and properly immobilized which in an otherwise normal person either docs not unite in the usual time or goes on to csentuat nonunion This is most marked m the case of so-called congenital or birth fractures m which even with a beautiful!) executed autogenous grafting followed by adequate immobilization union often fails to occur It is true that these cases will be a very small proportion of the fractures which one sees nevertheless the) should be mentioned CLINICAL DELAYID UNION AND NONUNION The term dela)ed union is applied to fractures which have not united after the lapse of the usual amount of time for the given fracture and the term nonunion is applied to those fractures m which not only has union not occurred after the usual lapse of time but also there is no probability that union will occur at an) time without surgical intervention Many aulhonties reserve the tenn nonunion for those fractures which after a )ear from the tune of the injury have not united We wish to stress that there IS no accurate timetable for fracture union There are too many variables, and to find two identical situations for comparison vs difficult if not impossible Treatment must be continued in etch case until solid consolidation has occurred and an be demonstrated by both clinial and roentgenographic examinations Too many failures in the management of fcactutcs ace still seen because immohilizition was dis continued at (he end of a prescribed number of weeks rather than upon the stage of healing of the fracture The term delayed union implies reversibility and is used to designate slower than expected progress of union In like manner a fracture is nut labeled a nonunion on the basis of elapsed time hut upon the stage of healing and nonunion mdiatcs that the healing responses initiated by the trauma have spent themselves Tlie periosteal callus has failed to bridge the defect and although often exuberant has become hard rounded and covered with mature connective tissue The cndostnl callus has hkcvuse become dense and fills the medullar) canal with bone The ends of (he fracture fragments are eburnated and fibroid degeneration is evident in the connective tissue binding the fragments together and so union is impossible regardless of time (Iti. 65) In a consideration of dela)ed union it is to !« remembered that the larger the bone the longer the time retired for union while fairly firm union may be expected in a finger within 3 or 4 weeks the shaft of the femur will reejuire from 2 to 3 months for the same degree of union to take place The bones of cluldren unite more tjuickl) than do those of adults It is often stated that the bones of tlie aged do not unite as rapull) or as certainl) as do those of joungtr adults but our experience has been that once the bones have obtained their normal growth age has rclativel) hllle effect if the general condition of live patient is gvxxl A jxwsible exetpuon is fractures through the neck of the femur Cancellous bone unites more rapidly than does compact bone Syphilis IS often regarded as a cause of nonunion and many surgeins bel eve that llic first thing to d \ when confronted with a case of delayed or nonunion iv to nuke a serologic test and give antis)] hilitic treatment regardless of the results of the test Per sonally we believe that syphilis rircly tauses nonunion Wc have seen fractures heal in Fir 62 Delayed union of femur due lo distraeion Successfully treated by open reduction and fixation uitli metal plate and plaster last 70 mwaiLr^ anu S ft Dttiycd union of (loseii fraanic of both bonea of winch wxs veronJary t > comn inuiHO anti decreasol bone contict Another type of nonunion is one in whKii tlierc is no connection between the frag ments (rig 66) This occurs in instances m which the ends of the fragments are widely separated and in intra arucular fnctutes such as those of the neck of the femur m winch there may be no fibrous connection between the fragmerts Treatment In considering the treatment of delayed union and nonunion it is im portant to determine as nearly as possible the {robabihty as to whether or not union will occur under conservative treatment and to determine the cause of nonunion If delayed union is due to madecjualc inunohilieation inadequate reduction or infection (Tt I ett ~t ) Fig €3 Nonunion due eo tnsde<]uite reduct on and immobiJ zat on. ^£.66 Nonun on in open fracture due to loss of substance and infect on secondary to fa lure of eatfy wouad treatinrat 72 mlNtlPlIS AND tiLNERAL ASPCCTS 74 JRINaULS AND CENrRAL Asprcrs r D 1 1^ 70 A anj B Nonun on of tibu dur (a tnicrfcrcncr uttli circulation by racluni band With nrcriKis T rojini first h) a »J line bone C uuhoot luiiMs and lalcr by « nlay ^.raftmc »ith union D c Tig 71 A Fracture of both bones of leg IrcateJ by opai reOuction and internal fxation with a plate Hie fracture was held in some distraction B Fracture of plate and failure of union 9 months fater C Appearance 2 months following remosal of plate and screws followed by reduc t on mtraenedullary fixation and autogenous bone grafts 76 pRrNapLCS and general asi ccts Tig 73 Tracture of femur with angufation and nonon on due to nc/Sc ent n ob liraf on Treated by removal of metal drill ng of fragments realignment and mmob Iization in plaster cast with good result after about 10 months In certa n cases such as this one in which some un or IS taking place drill ng at the fraaure site tn early convalescence v. II result in union lig 73 Nonanion of i bia poss hfy airyutmon at )«» of age afttr rrpcatrJ lime enft Rg bad failrd and fibula Tltis vili sometimes result in escntuil union We believe tlut where facilities for good bone surger) arc available it is belief to rperate earl) in eases m which union IS not progressing nomul!) ralhcf than to ctntinue inimobilizatii.n over a Jong pcntHl witli the hope thu cvcntoillj the fragments will unite Bj early operation a relatively simple procedure such as multiple drilling with or without a graft of cancellous or cortical bone across the fracture site may result in prompt union Since the batard to REPAIR OF FRACTURES 70 A a C ri^. 77. A, Nonunion of fractuie throui;li Io«er one fourth of tibia and fibula, fnltotMng Internal fixation with bene plate D and C, Results foI1o^^■np removal of internal fixation and bone Sraft on tibia, with perfeet union Note that the fibula has united without anj' additional surgery rig 78 A, So-called coogcnltai or birth fractures with nonunion in girl 11 years old. B, "nifee years later with inlay graft in place. A graft 3 years previously had united and then was absorbed a year later. C, Sis months later. Union apparently obtained. 80 PRlSaPLfS AKD GENERAL ASPECTS F g 79 Nooun on of clav do to a is to immobilize the fractutc until unit n has occurred ANATOMIC AND lUNCTlONAL RFOUCTION Reduction IS said to be anatomic when the displaced fragmaits arc replaced in theif normal position and is said to be functional when the displaced fragments arc placed in a position in which if union occurs the function of the hmb will not be impaired regardless of whether or not the fragments are in ihcir normal position Tor instance, m a transverse fracture of the shaft of the femur, if the bone ends are placed in contact so that as much as one fourth of their surfaces is end on wc arc assured of full length and if tlie nornul alignment of the shaft of the bone is maintained wc arc assured of function when and if union occurs In the case of joint fractures, and this is especially true m fractures mvoliing weight I'caring joints the terms fuiuliunol an I anatomic reductions are sj-nonymous that is if normal function is to be resiored to the part, an anatomic reduction must be secured and displaced fragments must be replaced in approximately their original positions in order tlut the contour of tt» joint surfaces be restored Tins nuj require open operation However, operative procedures may not be successful in cwtim cases because of severe comminution of the bone or severely traumatized soft (issues 82 PRINOPLES or FRACTURE TREATMENT S3 EMERGENCY TREATMENT OF FRACTURES All pahents who suffer fractures, ocn those who happen to fall m a hospital or physiaan s office, require some form of transportation before the fracture can be treated The nonambulatorj fracture pitient that comes from a great distance, of course, presents a much more difficult problem than do those who arc close to the treatment center Splinting of the injured parts is always advisable Transportation of the patient without splinting not only leads to great pain, but also to increase of surgical shock and may even be a cause of death For this reason the principles of splinting the wounded on the field of battle was adopted in the sarious armies during World War I Howeaer, in avil practice this is rarely practiable since the Thomas splints for the arm and leg, which arc probabl) the most satisfactory and efficient transportation splints yet devised, are rarely available Consequently the emer gcncy treatment must be adapted to the arcumstances as well as to the injury This is discussed m Chapter l The emergency attention required by open fractures is discussed in Chapter 6 time ELEMENT IN TREATMENT When the patient arrives at a treatment center with a fresh fracture, he should have an immediate assessment of the extent of injury by competent personnel, an ainvay established, hemorrhage controlled and shock treatment instigated When these measures have been earned out, or if they arc not indicated by the extent of injury a carefully taken history and physical examination will establish a provisional diagnosis of the fracture or fractures The injured extremities are splinted and (he clinical diagnosis is checked by xray examination Every hour that elapses after the injury usually adds to the swelling and in the case of overriding adds to the shortening and to the muscle spasm which must be overcome if reduction is to be obtained Those patients with closed fractures who are seen early before muscle spasm and swelling have become extensive may have the fracture reduced under local or regional block anesthesia How e>er, those who are seen after the swelling has become extensive should be immobilized m a plaster cast and reduction should be delayed for a few days until the swelling has subsided and the patient can be adequately prepared for anesthesia In out opinion there IS rarely a place for the injection of substances such as hyaluromjase into the hematoma m an effort to disperse the hematoma and edema rapidly so that reduction may be carried out during tlie day of injury All open fractures of course require emergency management, as described m Chapter 6 anesthesia When the patient arrives at the hospital and the surgeon takes charge, one of the first things for him to deadc is whether or not Uie patient should have an anesthetic It has been our experience that the surgeon is likely to err on the side of leniency in this phase of treatment, and, in order to spare the patient a general or local anesthetic. Will often be content with a mediocre result We believe that where any manipulation or change in position of the fragmente is indicated it is advisable to administer an anesthetic in order that relaxation may be secured and the surgeon may be free to do what he sets out to do anesthetic CONSIDERATIONS (Robert B Dodd, MD) In this section we ate concerned with conditions present m the patient whidi might alter the choice or conduct of the anesthesia There are some general remarks concerning ffie philosophy of preanesthetic medication and a few suggestions as to the agents to be used An effort has been made to place the choice of the anesthetic agent or technic in 84 PRINDPLES AND GENERAL ASl LOTS Its proper perspective Hnally since nrthoptclic surj^ry lends itself so well to mesthesu produced b) local anesthetic a^-ents (ic conduction anesthesia) i brief descriptun of the maiugemcnt of reactions to local anesthetic e made to vomit by first inducing anesthesia with open drop Vindhene or ether to the point tint they arc begin ning to lose consciousness but arc still swallowing act vcly and then by turning the patient head down and aspirating the pharynx with a suction catheter or tip Tlie patient will usually retch violently and emp^ his stomach Thereafter the pilicnts are usually tractable and easy to anesthetize If a patient is comatose one must be as alert to the dangers of aspiration as if the patient were in a drug induad anesthetic state Suction apparatus should be immediately available The question arises as to whether an emergency patient whose stomach cannot be considered empty can be operated upon safely under light sedation and some type of conduction anesthesia. The answer is a qualified yes Surgery on the lower extremities can be pcfformetl under a conduction te^nique such as spinal epidural nerve block or infiltration ancstlicsia Excluding sptcul and epidural anesthesia the same holds tnic for operations on Uie upper extremity Two po nts must be kept m mind how-cver The surgeon must plan to do his surgery m its entirety under a con luction techniC IHittmg PRINOPLCS or fRACTURC TREAT^^L^^T 83 the patient to sleep during the middle of the procedure because of discomfort will cn hance the chances of regurgitation and aspirahon The other point is that an untoward reaction to the local anesthetic drug used mi^l produce loss of consciousness, regurgita tion and aspiration EXTRACELLULAR FLUID DEFICITS SHOULD BE CORRECTED Marked electrolyte im balance is not commonly encountered in orthopedic patients It is not uncommon, how e\er, to encounter patients, particularly in the older age groups, who show extracellular fluid depletion through long established dietary habits plus a lack of intake since the time of injury These patients should rccei\e intravenous fluids preoperatively, dextrose in water and/or lactated Ringers solution A patient with a contracted extracellular fluid volume does not tolerate general anesthesia well, and spinal or epidural anesthesia might bring on a rapid deterioration HEMCXILOBIN LEVEL SHOULD BE ADEQUATE The minimum adequate preoperative hemoglobin level necessary for anesthesia and surgery has never been determined The following remarks pertain to patients whose low hemoglobin levels cannot be accounted for on the basis of such relative rarities as blood dyscrasias long standing inanition, etc If the contemplated operation is one in which a blood loss of 250 to 500 ml is to be expected, the patients hemoglobin level should be within SO to 100 per cent of normal according to the standards of Uie laboratory used Such a hemoglobin level should probably be no lower than 115 gram per cent A patient who has a normal ardiovascular system and a near normal amount of circulating hemoglobin should be able to tolerate a blood loss of at least 750 ml without the need of replacement trans fusion Whenever possible, transfusions should be given preoperativcly rather than during surgery, either to build up an anemic patient or to replace blood lost incidental to the trauma for which surgery is to be performed If overloading of the heart from givif\g blood is /eared, packed red cells which gne the same amount o! cjimlating hemo globin m half the volume of a whole blood transfusion may be used General anesthesia masks reactions to blood transfusions Although the hazard of unrecognized reaction to blood transfusion during anesthesia exists, the risk of not giving blood when indicated by excessive blood loss or signs of impending shock during surgery is undoubtedly much greater The lowest acceptable hemoglobin level for general anesthesia for such procedures as changing of casts and manipulations is a matter of much controversy It should be assumed that the anesthetic risk increases greatly m proportion to tlie extent that the hemoglobin level falls below 10 gram per cent SYSTEMIC DISEASE SHOULD BE CONSIDERED IN PREPARATION OF PATIENT FOR SURGERY All types of systemic disease winch might affect the preparation of the patient for surgery or Ae choice or conduct of anesthesia cannot be discussed The following re- marks are intended to be helpful m the management of the more common problems It IS assumed that expert consultation will be sought, when av'atlable, in handling the more difficult cases Diabetes Melhtus Diabetic patients should be under control, if possible, before submitting them to anesthesia and surgery Exceptions to this rule are patients who have severe infection or pain, eg, fractures either of which prevent their diabetes from being brought under control Insulin management during the operative and immediate postoperative period should be such that the patient spills a little sugar m the urine Insulin shock occurring during surgery can be a very confusing complication The ideal way to handle diabetic patients is to disturb their eating habits as little as possible If the patient is to have surgery performed upon one of his extremities a light breakfast may be allowed and the surgery performed under a conduction technic with minimal sedation If the surgery is completed before midmoming the patient should feel well enough by noon to take his regular diet and continue on it thereafter 86 PRlNOPLtS AND GENERAL ASPECTS Cardiac Disease The recognized cardiac patient, if he is not rruAedl) decom pensatcd, usually tolerates anesthesia and surgery remarkably well Tlie kc) to the preceding statement is recognizing cardiac disability and making pros isions for it m the anesthetic and surgical management of the case Preoperatise electrocardiograms should be taken on all patients oscr 50 and on patients who hase a history of cardiac disease The tracings may reseal unsuspected heart damage and ate s-aluable as a reference if cardiovascubr complications should develop during the operative or postoperative period In assessing the cardiac p^ents ability to withstand the stress of anesthesia and surgery, however the hndings of the physical examination and a history of the amount of activity that the patient can tolerate without fatigue of pain are of far greater importance than laboratory determinations If, for example, a patient were able to do her own housekeeping before her injury or illness she should be able to tolerate the operation unless she is not compensated at the time of surgery Tins leads to the question of which patients should receive digitalis preoperativciy TIic cardiac patient who IS not on digitalis therapy should be given digitalis preoperativciy if he shows signs of frank or impending ardiac failure or has had cardiac failure in the past for which digitalis therapy was necessary In the case of frank failure, the patient should receive digitalis until the signs of failure have either disappeared completely or have receded to the point where he can tolerate the transportation and positioning necessary for the Surgical procedure Less than complete recovery from cardiac decompensation is accept able when surgery will allow the patient to be mobilized to dimmish the risk of pul monary complications The amount of digitalis used when given ptephylactically should be one half to two thirds of the estimated full digitalizing dose in either a single dose or divided doses Tins reduces the risk of dieitalis mtoxiation which may be precipitated by surgery, starts the patient toward digitalization m case decompensa tion ensues during the immediate postoperative period, and appears to protect die patient against arrhythmias particularly tachyardia In general, the following types of cardiac disease present the greatest threat to life during anesdvcsii severe lortic vilvulxt stenosis or insufRcvency, complete hcitt blocks and recent myocardial infarction If the patients condition or serial electrocardiograms reveal a recent myocardial infarction surgery should be postponed for at least 6 weeks if the surgical condition present does not immediately imperil the patients life If d«om pensation is not present, a patient who has mitral stenosis, arteriosclerotic heart disease. Of essential hypertension docs not constitute an unusually poor risk Most patients with congenital heart disease who live Jong enough to develop orthopedic conditions re quiring correction under general anesthesia usually tolerate the anesthesia well As a rule, conduction anesthesia is preferable to general anesthesia m the severe adult cardiac patient if the surgery can be done expeditiously Ptolonited procedures should probably bt performed under general anesthesia to avoid excessive fatigue ami discomfort m the patient A general endotnehcal technic is definitely indicated when the surgery requires the patient to be placed in the prone position and is probably indiatcd for all prolonged gentral anesthesias administei^ to this group of patients Tlic tndiv tracheal lube provides acrt-ss to the airway of the patient to remove obstructive secre- tions and allows the anesthetist to have better control of the level of oncstlicsia and tlic level of ventilation of the patient s lungs Vulmaiiarj Disease Whether patients lufftfing from acute upper respiratory infcc lions should have tieetnc l>one surgery depends upon die surgeons philosophy Some feel that the possibility of an assoaiteJ boctcremu rmkes such surgery unduly hazardous A ewnmotv cold m an adult does not significantly affect the risk of general anesthesia during operation Tlie risk of pulmonary OKnpIicttions during the postoperative pcrioil IS undoub*edly enhanced Endotracheal anesthesia unless it is absolutely indicated, should best be avoided beausc of the don^r of trauma to the inflamed pharyngeal and PRINOPLES OF FRACTURE TREATMENT 87 laryngeal mucosa Quldren present a different problem Unless it js absolutely indicated general anesthesia should be axoided if the pabent has a cold of recent origin The air passages of children are small, and any diminution in their caliber either from swelling of the mucosa or the presence of excess secretions might be critical The highest mci dence of death attributable to anesthesia oanirs m the first deade of life, and where possible, surgery should be deferred if the patient is not in opbmal phjsical condition Conduction anesthesia should be used when feasible, in cither age group, if the patient has an acute upper respiratory infection Although conduction anesthesia might be chosen for certain procedures in patients suffering from lung disease, general anesthesia is not contraindicated Pulmonary tuber culosis, unless there is widespread destruction of lung tissue, docs not significantly affect the anesthetic risk, and general anesthesia per se should not affect the course of the dis ease If copious bronchial seaetions or pus is present, either from tuberculosis or some other bronchopulmonary disease, endotracheal anesthesia should be used for all but ex tremely brief procedures done under general anesthesia Hie endotracheal tube pro\ides an avenue for removal of live secretions, allowing better ventilation during surgery and less risk of atelectasis postoperative!) !f time allows, the djspneic emphysematous patient should be treated with postural drainage and aerosolized bronchia] ddaters and wetting agents for several dajs to a week preopcrativel) to open the air passages and clear them of accumulated seactions Preoperativc preparation of such patients lessens the anesthetic risk during surgery and decreases the madence of postoperative pul monary complications Ether or nuotliane appear to be the best general anesthetic agents for use in the severe asthmatic patient Cyclopropane "ind Pentothal occasionally pre apitate asthmatic attacks during surgery because of their tendency to produce bronchiolar constriction Dter and Ktdney D:sease There is no good anesthetic agent to use in the presence of severe hepatic or renal disease The inhalation agents depress the functions of both organs The nonvolatile drugs used in anesthesia are detoxified by the liver and/or eliminated by the kidneys Conduction anesthesia is preferable, but the total dosage of a locally aaing drug used should be held to the absolute minimum If general anesthesia IS necessary, inhalation agents should be used since they are eliminated through the lungs A small dose of Pentothal might be used for induction of anesthesia, but large amounts should be avoided If pain is not present preanesthetic sedation should be omitted If pain relief is needed a very small dose of narcotic may be given If the dose IS ineffective, the amount of drug given can be cautiously increased DRUG HISTORY SHOULD BE OBTAINED Tfuc allergies to local anesthetic agents and the ultrashort acting barbiturates are very rare A careful history will usually reveal that o\erc!o5age or some other anesthetic mishap was at fault rather than the drug itself If there is a reasonable doubt as to the true nature of the previous difficulty, that drug and those closely related to it structurally should be avoided Adverse reactions to the narcotics are much more common Fortunately, there is a large group of analgesic drugs from which to choose, and a suitable substitute should not be difficult to locate Ap patently there are no true allergies to the accepted inhalation agents Some patients do tolerate certain anesthetic agenb better than others but the main consideration is the safety of the anesthesia Iiv other worvls a history of nausea and vomiting following an ether anesthesia does not contraindicate the later use of that agent if it is the best for the patient s condition and the procedure involved The narcotic addict should be piemedicated with the drug to which he is addicted and in the dosage to which he is accustomed If the patient has a history of addiction to a narcotic but is no longer addicted, his particular drug should be avoided and the use of any narcotic should be held to the lowrest levels compatible with humane treat ment The nonarrhotic alcoholic usually requires very heavy premedication to affect a 88 PRINaPtrS AND GENERAL ASI ECTS ^;ood sedati\e effect They also can be expected to rctjmte more ancsthcHc agent to in duce and maintain anesthesia "nits applies partioilarlj to Pentothal and ether Because of the large amount of anesthetic necessat) to induce anesthesia delayed emergence is not uncommon Emergence delirium is also Fig R4 Drawing jJlustraljns method of obtain qf local anesthesia fox reduction of traumai c dis location at shoulder (From Rice C O Minnesota Med 12 532 1929 ) Of PRIsaPLl-S /NO GINIRAr ASMCTS after the fracture j$ reduceduce tachjeardia tachypnea and hyper tension manifested by a headache 2 The patient should receive a barbiturate as preanesthetic medication 100 to 200 mg of Nembutal or Seconal for the adult % PRINOPLES AND CtNERAL ASPECTS 3 TIic minimum volume of {he most dilute solut tn c f ancsthtlit aj,tn{ capibic of pro lucin;, the dwired effect should be used A pnen cjiuntit} of drup is much less toxic m I dilute solution than in a concenlnletl one c j; 100 ml of 0 5 per cent solution has a ^rc Iter margin of sifety than 50 ml of 1 per eent Conccnlntcd solutions, sudi as 2 per cent procaine or 1 5 per cent Xjlocainc ire needed onlj for blocking Urge nerves or plexuses Dilute solutions such as 0 5 per cent procaine or o 25 to 0 5 p'-r cent \pIo- came should b“ used for skin inhltralions Between these extremes the surgeon sliould choose the concentration of the solution foe injection according to the sire of the area to be blocked le how mucli lolumc of the solution it will take and by the surgical conditions desired within the field S“nsQry blod. alone requires a lower concentration of the drug than dqes motor paraljsis The safe limits of dosage for adults on a milli gram per hour basis have been given ns 500 mg for Xjlocaine and 750 mg for pro came. On a weight bisis the dosage of procaine should not exceed 10 mg per kilogram O mg pet pound), or of Xjlocaine 7 mg pec kilogram (3 mg pet pound) For infants and children the same milligram p“r kilogram (or pound) per hour bisis may be used with dilute solutions 1 A local vasoconstrictor such as epinephrine should be added to the anesthetic solution to slow absorption The optimal concentration of epinephrine is 1/200 000 or 0 25 mL of 1/1000 solution of epmephtme added to 50 ml of anesthetic solution A higher concentration of epmephrint does not decrease the rate of absorption signifiantl) and IS accompanied faj a much greater incidence of sjilemic reactions and localiaed re active hyjsercmta 5 The needle should be aspirated by drawing back the plunger of the sjringe before injecting the anesthetic solution This is to decrease the inadence of intravascular injection or in the case of blocks near the vertebral column to prevent accidental sub- irichnoid injection Tlve most common minifcstalions of reactions to local anesthetic drugs arc thiy< related to their effects on the central nenous system In all reactions stimulation and de pression of the cortex and medulbiy centers occur The classical picture is cortical stimulation and medullary depression Signs of cortical stimulation ire usually early and maj be mild and transient such as talkativeness and nervousness and may be mistaken for excess anxiety or frank hystena This sort of response can often be prevented bj a barbiturate given prior to the anesthesia When these sjTnpfoms appear small infra venous doses of an ultrashort acting barbiturate should be given until ihej subside If the cortical stimulation results in convulsions the treatment is giving oxygen b) mask and an intravenous barbiturate to the point of controlling the convulsion Any excess of barbiturate bejond the minimal amount nexessary to control the convulsion is dangerous because it may add to the concumnl medullary depression which is always present and also the cortical stimulation phase ma> pass on into one of cortial depression which would be cnhanccil by the drug depression It is hkclj that about as many patients have dic«l as a result of the overcnlhusiaslic use of intravcncus barbiturates for local anesthetic reactions as have been uved A blood pressure cuff should be placed en the piticnls arm prior to anesthesia or at the latest at the first sign of an impending re action and hts blood pressure taken regularly If the blood pressure has fallen oxygen should be given by mask and a vasi^revior sliould be given intravenously before any birbiturate is used Tlie hypotension if untreated might progress rapidly to cardiac arrest The treatment of cardiac arrest is prinurily artificial ventilation of the lungs by intermittent inflation with oxygen or air and atliriciil circulation of live bliKnl by rhythmic squeezing of the heart until it resumes its spontaneous beat Convulsions result in deaths only wh-n there is suiricient spasm of the respiratory muscles to cause liypoxu Minor twitching which does not impair respiration especially in an imconscjonv pat ent should certamly not l>c treated with intravenous barbiturates It shouH be notfil that PRINCIPLES OF FRACTURE TREATMENT 97 although signs of cortical stimulation do occur sometimes during reactions to Xjlocaine, depressive signs such as drowsiness or coma are mote frequent Depression of the Mtal medullary centers occurs during all sesere reactions al though it may be masked earl) by the effects of cortical stimulation During the de presstve phase the respirator) center is depressed with the result of hypoventilation Some means of giving oxygen by positive pressure either to assist the weakened respira tion or to provide artificial respiration if necessac), should be immediately available If a crisis like this is allowed to develop when such equipment is not available the operator should apply expired ait (mouth to mouth) resuscitation An oxygen enriched itmos phere is preferable, however, since there will be a concurrent hypotension due to de prcssion of the vasomotor center and (he mytKardrum may be depressed from the direct action of the anesthetic The treatment of the hypotension is oxygen by mask a slight head dowTi tilt to the table and an intravenous Msopressor if the first two measures fail to raise the blood pressure Since the hypotension is the result of peripheral vascular collapse a peripherally acting vasopressor would stem to be the drug of clioire Vasoxyl 5 to 10 mg intravenously is a drug of this type If the patient has a severe bradycardia or if he has a history of heart disease, ephedrine or Methedrmc should be used instead, since they raise the blood pressure by increasing cardiac output If neither of these drugs is effective, Vasoxyl may then be tried Since the drugs used m combating local anesthetic reactions arc given intravenously, it is obvious that intra venous infusion equipment should be available so that a vein may be kept open for therapy as required In summary, no local anesthetic procedure should be attempted without means for resuscitating the patient immediately available TIic minimum requirements are a blood pressure cuff and manometer, oxygen with a bag and mask suction equipment for aspira tion of regurgitated stomach contents a scalpel to enter the chest an intravenous solu tion of a vasopressor, and an intravenous solution of a barbiturate Equipment for con tinuous intravenous infusion ;s desirable The patient should be asked about previous experiences with local anesthetic agents A barbiturate should be given 60 to 90 minutes before the anesthetic is in/ccted The dosage of local anesthetic agent should be calcu lated on a milligram per hour basis according to the patient s age, weight and physical condition Epinephrine, m a precisely measured 1/200 000 concentration should be used with the injected agent Test aspirations should be made frequently during injections of local anesthetic agents If a drug reaction should occur, one should be alert for the de vefopment of the depressive phase of the reaction which may lead to the death of the patient if not properly and promptly treatcvl methods or OBTAINING REDUCTION The methods used to obtain reduction can be divided into closed manipulation traction and open operation Other things being equal closed manipulation is to be preferred in cases rn which the fracture lies close to the end of a long bone such as fractures of the lower end of the radius and fractures about the ankle Reduction by closed manipulation is also preferable m instances m which the iracture is trans^erse and in which one may expect to obtain stable engagement of the bone ends after they have been placed in contact with one another, and in cases of bones which are quite super ficial, as m the fingers and in the tibia Treatment by traction is usually preferred in severe open fractures or m oblique and comminuted fractures of the shafts of long bones especially of the femur and of the humerus which are covered by a thick layer of muscles and in which it is dilficult or impossible to maintain reduction once it his I’fen obtained However (he choice between manipulation and traction treatment of i given fracture admits wide leeway depending upon the surgeons skill in minipuhling a limb or in using traction PRINQPLES or TRACTURC TREATMENT P<) It IS to be emphasized that the terra skill m using traction is used broadly and includes not only the ability to apply it properly but also the interest on the part of the surgeon which s\ill cause him to inspect it frequently and keep it efficient Traction is dynamic energy and must be guided and vaned from day to day as the positions of the fragments change in response to the forces exerted upon them Mampulalioti Methods of manipulation vary with the training and methods of different surgeons and with the position and type of fracture For instance in a fracture through the shaft of a long bone one surgeon will prefer to obtain engagement of the fragments by means of direct traction in the long axis of the bone traction being made in line with the position assumed by the upper fragment and being made while the joints at either end of the injured bone are in a neutral position that is semiflexed By this method the sleese of muscles and periosteum around the fragments may be de pended upon to cause the bone ends to fall in place and engage one another when suffioent traction is applied to the limb to pull them apart Reduction is satisfactory if with the traction relaxed the normal length of the limb is maintained and is cjuite stable to upward pressure on the distal fragment Various mechanical aids arc used to supply traction and counlertraction (Fig 86) Other surgeons depend upon angulation witli traction and countcrtraction for en gagement of the bone ends and place the joints in a neutral position that is semiflexed and bend the limb at the site of the fracture until the bone ends are engaged Then the limb IS straightened and normal length ts obtained In fractures around the wnst and ankle the manipulation used is a combination of traction and countertraction leverage and direct pressure on the fragments While manipulating a fracture the surgeon should envision not only the shape of the ends of the fragments and their positions m three 88 Spreader made of square wooden block v-ilh Iwlc in middle for use in appl>ine tract n to CTtremmcs with adhcsise tape planes but also the forces which are maintaining the abnormal position ind "Rh ch must be o\ercome during reduction as well as the structures, such as intact ligaments and periosteum which may be useful in obtaining and maintaining reduction Some surgeons prefer to manipulate all fractures under the fluoroscope howe\er this is a \ery dangerous practice not only to the patient but also to the surgeon and few who have engaged in this practice for very long still base their fingers Furthermore a fluoroscope is completely unnecessary and should never be used Traction Traction may be applied to the skin by means of adhesise tape (Fig 88) moleskin adhesive or various types of glue and muslin bandages or it may be applied to the bone by means of the Kirschner wire or pins which pass through the bone distal to tJie fracture (Figs 91 92) Certain fractures of the femur, especially supracondylar fractures and open fractures or m fractures in limbs m which the skin has been so damaged that it is impossible to apply adequate adhesive traction must be treated by skeletal traction The various methods of applying adhesive and skeletal traction are taken up under the bones for which they are indicated Skeletal traction has the advantages that it is more efficient more weight can be and it is more comfortable to the patient if it is applied correctly On the other 100 PRlSaPLES AND GENERAL ASPECTS hand it has the disadvantage that occasionallj, esen under the best of conditions, the bone will become infected from the pm «outid In many clinics skeletal traction has become a lost aft It is an art that onij a good surgeon can appreciate and it takes as good a surgeon to use skeletal traction success fullj as It does to do operative procedures lie 89 /t Cl CM ( f *nnr«t meflt to Cin'ell > aW Ction tfj r»r »t tn •fjn " It used lo uffw cstTHDity i? Apparatus fir it«e «Icn is sscU suited ftr use where vsjuipmcivt is twt plentiful an I it involves onIj a small area of skin surface so far Js its application is concerned h n ver) adaptable and is applicable where soft tissue damage is very extensive It enabled IK/NOfLIS OI FKACri/KC TRCATMLNT lOt \ one to dress and obsene open fractures ^\lthout ddBcuU) and without causing the patient too much pain, and it allows early mmements of joints Its use is not to be niinimized m pathologic fractures such as bone tumors with fractures and certain frac Tig 90 A Method of applying adhesive to lower extremity for traction B Adhesive his been covered by firm giujc bandage and leg is supported in Thomas spl nt Pig 91 Wire traction to femur 2immer clamp tures m osteom}elitis in which internal fixation is not possible It is useful when the general condition of the patient is 'critical and when any other form of treatment is not tolerated This is particularly true tn those patients in whom there is severe shock or 102 rRINCULI-S ANf) ( rNn?AL A^l'icrs severe texjuej to chat or head T^hidi Tvoqld prnent an open operati\c proadure, ocn thnu;;h it is indicated There arc disid\jnti^B to sLtlettl traction T!it chief objections to treatment of fiatturcs b) traction arc that (t) they require prolonged hospitalization and constant supervision to maintain the comfort of the ptticnt and the position of the fracture, (2) there is a danger of delajed or nonunion due to distraction, (3) there is a possibilitj of pin track infection ^\hich may, if it occurs, be quite anno)mg, (4) improper application of skeletal traction may damage vessels or nenes, (5) restoration of functions of tJic joints is delayed and in some cases may never be completely normal, and (6) pressure sores and decubitus ulcers may occur in poorlyr nursed cases rig 9t Nonunion due lo cloir^rtion It must be remembered that the application of skeletal traction n as important as any other surgical procedure Surgical tcchnic should be as meticulous as any open operative procedure Prevention of motion of the uirc or pm at the site of entrance 1 $ important the pulling up of the skin when applying the pm will prevent skin tension on the pin at the entrance or exit Sharp pms and a dry dressing, which must not be changed loo often, must be used frequent application of mtiseptics is not necessary No good surgeon would think of applying Menhiolalc or aknliol over an abdomind vvound dill) following a clean appendectomy clissure then apply antiseptics to the wound produced by the skeletal traction jnn’ When the general condition of the patient peniuii, some prefer a general anesthetic when applying skrittal traction Jl makes the patient more comfortable and the surgeon an more easily rctiuce the fracture without rreessive shock to the patient and unnccrs sary damage lo the fracture site PRINUPtES Ol FRACTURr TREATMENT lOB The ideal technic of appljmg skeletal traction m the treatment of a major long bone fracture is to ha\e general anesthesia with the patient m bed to which is attached the necessary equipment for balanced traction With the use of aseptic technic, a suitable pm IS placed m the desired bone The extremity is suspended and traction is applied using 5 to 10 pounds more weight than is usually required to counteract muscle pull With the patient still anesthetized x ray films in two planes are obtained If these re\eal that the fracture fragments ha\e been pulled past each other the weight is reduced and the position is rechecked wnth the x ray film In this way the fracture can be satisfactorily aligned and adjustment of the splint and weight can be made in one sitting to maintain this position fig Skeletal traction to arm for fractured humerus Kirschner wire m olecranon with Conwclls abduction frame being used Mechanical Traction Reduction and rtxalion Apparatus The work on leg length enmg by Abbott and Crego and others showed that by means of pins or taut wires through the fragments of a bone and the use of a screw traction apparatus, it is possible to lengthen a bone and to control the position of the fragments The same prinaple has now been applied to the treatment of fractures and seseral more or less complex and expensive reduction machines or automatic splints are now on the marl et These automatic splints or screw traction reduction maeJunes are successful, and we belieae relatnely safe, in the hands of those who are skilled in their use, but we beiieie that their use requires considerable skill It is a mistake to expect the splint to do the work unless it is used with intelligence and skill In using such machines it is necessary to follow the position of the fragments with x ray films and one should remember that It IS possible to pull and hold the bone ends too far apart and thus court delayed union After the fracture is reduced, the position is maintained by the speaal fixation apparatus which is attached to the pins or by mcorporating the pins in the plaster which encases the limb We feel that such method of treatment has only limited application We adapt the treatment to the fracture, not the fracture to the treatment Wf PRWQPLrS AND CENCRAL ASPECTS ImmobilizalioN Immobilization ts secured by rtcumbenc), bj bandigcs oc simp, b) traction, by splints, and by plaster of Pans casts The character of immohilirafion depends considerablj upon the type of fracture and the tendency to dispbccmtnl of the fragments either bj muscle pull or b) grasilj, and also upon the choice of the surgeon In fractures of the spine or pchis, for tnstance, without displacement, simply placing the patient recumbent on a firm bed and fracture boards \m 1! often afford adctjuite im mobilization In fractures of the clavicle or lower end of the humerus, sufficient immobilization may be obtained by bandages and adhesive tape Tlic same is Ime in certain fractures about the anUe without displacement In fractures with a tendency to displacement immobilization must be obtained by traction or splints, and in cases in which traction IS used, especiall) in the femur and bones of the leg. splints are necessary to support the limb and to prevent posterior angulation of the fragments The choice as to whether a gnen fracture should be immobilized in ft splint or plaster cast depends upon the availability of a suitable splint and upon the ability of the surgeon to use plaster of Pans We prefer plaster of Pans to the average Splint witli the exception of the Thomas splint for the lower extremity Other surgeons who do not use plaster of Pans and arc not adequately trained in its use will keep on hand a large supply of splints and use these in preference It is our expcnence that most fractures can be adequately trealcd by plaster of Parts casts, that the patients are more comfortable in casts tltm in splints, and that the casts require less attention after they have been applied ri>. Cast as applied for imnobiiiration of fneturrs of holh honn of leg iinmcStlinng both ankle and knee joint moderate flevion at knee This is nut a ualkingeaU The former objection to plaster of Pans (hat it could not be used with traction has been met by pins or a wire through the bone ami mcorporatcil m the cast which permits adequate traction while the lunb is encased in plaster (see Tigs 1058 and t06l) However, the best method of management will depend upon the specific injury, the general condition of the patient, the ctpencncc and training of the surgeon and the physical plant in which treatment is conduaed All things being ct|Uj! we do not like to use a method that ri-quires a long period of immobilization or hospitaliza lion External Skeletal Fixalioii Uy external skeletal fixation we mean the fixing of the fragments by one or mote pins or wires which ate inserted into the bone and extend out through the skin Tliere are three types in general list In Uic simplest type the fracture is reduced generally by open operation and the fragments arc fixed by one or more stainless steel wires drilled through the two frag ments and crossing the fracture site This ts a reasonably safe procedure, as the wire is thrust through intact skin and the only strain on Uic wire is at the fracture site Tlw wires are pulled out as soon as they are no longer needed, about 4 weeks) The second method is the reduction of the fracture by traction wiili from 1 to I pins or wires penetrating or transfixing the extremity and the Ixvne ^^’^n^e fraction n maintained, a plaster cut is applied, with the wires or pins incorporated in the caU and PRINCIPLES OF mACTURn TREATMENT 105 thus maintaining the position of tlie fragments Such methods demand good aseptic skin preparation and surgical technic Otherwise, infection of bone and soft parts is more likely to occur The third method is the use of multiple pins or half pins m one of the so called automatic splints (Stader, Roger Anderson, Zimmer, Hames, and others) On account of the difficult) in using the metliod successful!) and the dangers of dela)ed or nonunion and infection, we do not use this method (Tig 96) Tor oblique fractures the bcided w/rcs of Thomson and Terciot mai be useful Fig 96 Infection of pinholes after external skeletal hxalion Multiple nog sequestra and infection required muiliple saocemation and chemotherapj' Open OperaHott tn Treatment 0/ Closed Traclures There Mill aliva)s be a cer tain number of surgeons who will treat a large percentage of their recent fractures b) open operation This, however, we believe, should gradually decrease as surgeons in general become more skilled m the treatment of fractures by closed methods In other words the frequenej witii whidi open operation in closed fractures will be performed will %ary imersely with the skill of the surgeon m treating fractures b) dosed methods The advantages claimed for the open operative treatment are as follows (I) anatomic reduction can usually be secured, (2) internal splintage can be applied, (3) the period of hospitalization and the convalescent period are shortened, (1) it is usually pos sible to instigate early active motion, and (5) in certain instances it may be a lifesaving procedure nie disadvantages are as follows (1) the operation converts a closed into an open fracture and there is always danger of an infection, (2) after reduction has been obtained it must be in most instances, maintained by adequate external splintage, (3) as little nonabsorbable foreign milerial should be left m the wound as possible, (4) un ion IS slower, and ( 5 ) the incidence of nonunion is greater Postoperative chemotherapy has lessened the danger of infection The use of Vitalliuni and stainless steel has largely overcome the objection to leaving foreign mate- 106 PRtNQPLrs AND GENERAL ASPECTS rial in the vound Consequently, open opetahons for the treatment of fnchirts can now be done w ith greater sa/et) than at anj time «i the past The advantages claimed for the cl<»ed treatment arc that (1) there is practical!) no danger of infection and the patient $ life is less endangered than b> an operation (2) union is more certain and is obtained more quidJ) after an adequate dosed rcduc tion than after open operation and (3) no foreign nutcrial is left m die wound There are certain fractures however in which open operation is nccessarj if the nuximum restoration ol function is to be obtained These are largely fractures imolnng joints fractures in which small pieces of the ends of the bone are separated and in wluch it IS impossible to control these fragments by manipulation or by traction as well as fractures of the shafts of bones in which muscle or other tissue is caught between the fragments and in which it is found to be impossible to bring the fragments into direct contact or in which proper approximation has not been obtaincsl after a fair at tempt at the closed method has Ixcn tried (Tigs 97 98) We do not recommend re- peated violent attempts at dosed reduction To perform an open reduction is less traumatizing Fig 9" Clo5<\l iransiene fracture of humctiit R^'cileJ attenpls ii i impuht'e reilu ti >' were uniuccruful at mull of inicrrfltuton of tofe i «u« r»g 98 After open reduciion Emit »c»e bdd logeiher b) wire tuture and arm »at in mohilired in a hing ng oti I irm mtinn and st adiisablc for the operation !n closed fractures in which ipcraticm is dccmcil necessary the operation is K-vl pcrfi'imel as sixm as Uic patient s amdition willallowi TRtrARATlos fOR OPTRATJOS U the up«it««v Can be done immcdutely, the slirt should be shared, scrubbed with soap and water, then wished ihorougldy with alcohol 108 PRINOPLCS AST> CENERAL ASPWrTS and ether and punted uith iodine and alcohol Tlic incision should be made in such a manner as to approach the bone b) the shortest route possible ssithout damacmj; im porlint structures After the inrtsicm is made thrrni^h the skin the skin mij Iv protcctcvl b) skin tosvels applied with dtps with the hmh complcld) coicred so ihil no skm is exposed and so draped lint it can be free!) imnipulatcil and traction ipplied when necessjf) With another citm knife iht wound should then be carried down to the hone and the fracture exposed If the in|ur) imobes the joint, this should be opened freclj and any loose fragments of bone removed or replaced The fracture shoul 1 then be reduced bp traction iescrage, or direct pressure INTERNAL fixAHON After the fracture is reduced and the fragments are replaced It is necessary that they remain in position This brings up the question of interna! fixation VC'hen a fracture occurs a certain amount of the bone is deprned of its blood supply and therefore dies The extent of injury and (he amount of penost'-um and soft Tip lot The Luck eleclrc hone and ilrill Explosion proof with oscillating and rutai np features (Couites) Zinvner Manufacturing Co \tarsaw Ind ) tissue that is stripped from die bone determines the degree of bone necrosis It is im peratne therefore in doing open operations on fractures that as little additional bone Ise killed as possible There must nescr be wide stripping of the periosteum fhe in tctnal fixating dcxicc must be one which wiU ptoside maximum internal fixation but at the some lime its application must not materially increase bone death Where possible imernai fixation should be sufficiently strong to make external fixation unnecessary thus allowing early active use of the extremity The device must prevent rotational and angulation stresses and at the same lime allow the fragments to approximate each other should some absorption occur By and large intramedullary rods come clvsest to satisfy mg these demands as they provide firm fixation of the fracture control rtitalinnal an! angulation stresses if the proper size rod is used allow intermittent contort aimprcssion forces across the fracture surface do not hold the fracture m distraction as al«orpfi'ii takes place do not require extensive sttipping of the pcnv'vtcum. and lUhough they da AND crNFRAL ASICCTi PRINaPLtS or FBACTURC TREATMENT 111 r g 106 i Subtroc! inter c comn nuted closed fracture of ft r h d spheement and shorten ng B InUa cdulhry na 1 jppl td ll sta nlcss tcel V re bands to mainta n fxa on of comm n ted fragment* of up| er one fo th of temur C Malj us t on wl 1 de el p i no nonun on folio ng surg cal procedure a* shown in 3 n alpos t on and non n on ere due to mpr per t x t In e n i i t on st Id I a c b -cn -d ut by flanged 1 p na I nd fxat on w (h screws to femur v th ni 1 thrOugli neck inJ head 112 PRlNOPLtS AND CCNtRAl. ASPrCR interfere with medullary arcuJaton with resultant death of some of the bone along the medullary cavity they are tlie best hxatmg device in those s tuations in which they can be used It should noted however that infection following intramedullary fixation s considerably greater than that of an) other t)pe of fixation and should only be used by those capable of met culous technirjue Cons derable interest has recently been stimubted with the use of plastic materials designated as bone glue for the fixation of fractures One such substance Ostamer is a form of intramedullary fixation Its application rerjuires a wide exposure of the frac tuced bone i dry fie! 1 and meticulous techn c when mixing the mater al and applying r g 107 Intjan edulUiy na I wh ch 1 ad been appl ed n closed fraclure tfir u^h ro ddle of femur n an adolescent Nail was dr efl too far in and became lost m ih n the medullary canal and demanded cons derable surgcal procedure for remo at No lujolc or loop on upier end of na I tise of ntrameJullary na [ s seldon ind rated n fracture? n adolescen s it With the poss bit) of additional bone death both from the cx^ osure and from llic heat of the substance if it is improperlj handled For success a large medullary canal is demanded It should be reinforced with metal rods of the type for intern-il fixat on as well as external fixation If the material should fracture nonunion is likely to occur pRiNapLES or rRACTURt treatment US and It nuy cause a considerable problem should infection follow the operatne procedure It maj ha\e a use in \er) skilled hands m certain t)pes of pitholopic fractures and difficult nonunions other%\ise we do not adsise its use In spiral or obi que fractures of Ihe shafts of Irnj, Iwncs a iequalc fxafion may at times he obtained bj the insertion of two or more screws directetl at n^^ht angles to (he shaft of the bone for maximum strength If a plate is to be used it should be of the Eggets type Wire sutures and Parham bands may be used m certain circumstances Oc casionail) it is advisable to carrj out an open operation on an extensively comminuted fracture or m one that does not lend itself to the usual means of internal fixation Wire sutures or the spike operation of Mumford may be most useful In the forc^irm and in the leg the surgeon may at times be able to stabilize one relatively slightly damaged bone to maintain length and alignment of the comminuted opposite one In most instances internal fixation regardless of type must be supplemented by external fixation for the major portion of the healing period CHEMOTHERAPY After Open reduction of dosed fractures chemotherapy should never be used routinely It should be used both before and after operations in all circum stances where there is a history or other evidence (hat the bone may have been infected at some time in the past Qiemotherapy is a helpful adjunct following open reduction of closed fractures in those circurnstances where there has been extensive trauma to the soft tissues or a long and difficult operative procedure In other words if the surgeon has had to struggle unduly to obtain reduction and fixation of the fracture m all probability the patient should receive chemotherapy in the postoperative period We continue to feel that thorough irrigation of the wound with careful excision of all strands of damaged and devitalized tissue before closure are of the utmost importance For irrigation we use a sulfanilamide solution which has been used routinely in alt operative wrounds for over 15 years and we have found no cause to change or deviate from this technic physical therapy in treatment Oh INJURIES OF BONES AND JOINTS During and after World Wars I and II physical therapy was used very extensively in the treatment of the various disabil ties whicli followed wounds both v/ith and with out fractures and m the base hospitals of the different armies a large personnel and elaborate equipment were provided for this purpose Following this time a tremendous wave of physical therapy swept this country and has not only affected the medical pro- fession but also has impressed even (he laity The result has been the establishment of physical therapy departments in various hospitals and the purchase of various forms of apparatus by physicians and surgeons all over the country We believe that this has been carried to the extreme and wish to emphasize the fact that in physical therapy just as m most other forms of treatment the therapeutic value of the method is largely dependent upon the skill w ith which it is administer^ We further wish to emphasize the fact that in the average fracture if the bones are replaced in a good functional position and immobilized over a sufficient period of time normal union will occur and if the soft parts ace not extensively damaged normal function Will return This however is not true of jo nt fractures and the compl cations which arise jji these m/unes are mentioned under traumatic arthritis It is well how ever to say here that m a great many instances physical therapy has been used over periods of many months in futile efforts to restore normal function m joints the mechanics of which have been disorganized av a result of an injury We have not seen an adequate analysis of a scries of fractures in which it has been shown to our satisfaction that by the extensive use of physiothefap“utic methods the period of disability has been shortened and the permanent result improved to such an ®*tent that the result was worth the effort expended Until this has been shown we shall 114 PRINCIPLrS AND GCNrHAL ASPtCTS continue to adopt a middle ground position and shall particularly warn the average sur(>con aga nst the principles of early massage and mobiliration as practiced and a Ivocatetl by Liicis Championnierc His great d ctum was mo\ement is li/e We be litsc U^at \ better d ctum v.ould bt that the healing of a fracture occur? more rapidly an! more surely when inmohiliz.it i n is maintained According to his method a m Tg 108 A Conwell s riexD e*tfnsoni«er for detem n hr degrte of mot on of elbow wrsf knee nnd ankle (From Conwell H £ Sufg Gynec A Obst 40 710 19’5 PH and Co Phda lelr! a Pa ) m nimum of spl nlage is used and very gentle slow rhjthmic massage is begun on the day after the injury and is repeated and contnued one or more t mes a day thereafter He also began limited movements immcdatelj after the injury ind the range of mose ment was gradually increased In certa n fractures this mctliod when appi cd by one skilled m its use is undoubted!) a successful one and s capable of producing excellent results The aserage surgeon who treats fractures howescr is not a plijsal therapist, PRINOPLIS OI IlUCTURl TREATMJ NT J15 and larthcrmore we hd\c no accephbh etidcnce that the results iftet mtensne pb^sical therapy are any better than can be obtained bjr more consenative methods and we Inse also seen fractures m which after an excellent reduction displacement recurred as a result of too early and jn;udJCiou5 use of massage and movement We cndcasor to apply our immobilization so that the hrab can be exercised or esen used while the fracture IS healini; but this must be done without danger of mosing the fragments, and we do not bivahe our casts for heat, massage, and possne mosement of yomts until the frag ments are quite firmly united The first dictum of the physical therapist as well as the surgeon should be to do no harm Ph}sio(bfrapeiilic Agents The physioUierapcutic agents which ha^t been pro\cd to be of aalue in the treatments of fractures are fl) rest (2) movement (active and passive), (3) heat, (4) massage, and (5) procccssive resistance exercises REST Rest IS placed first in this list because we believe that it is the most important ^od should be used not only in the beginning of the treatment but also in joint frac hires from time to time during the convalescence whenever the joint becomes stiff and Sore during a regimen of active or passive movement We have seen immobilization for a brief period m a plaster of Pans cast or splint result m marked improvement in joints ^hich had been manipulated heated massaged, and exercised over a period of months 'Without improvement ACTIVE Movement Movement is most important in the restorabon not only of motion to a joint but also of tone and power to the muscles It is to be remembered, however, that union of the fractured bone in good position is even more important man moiement that union must not be jeopatdrzed by too early attempts to restore function, and that the rule should be to obtain union in good functional position first and restore function later 116 PRINOPLES AND CrNCTAL ASPECTS Tlie time at which actne and passive movements can safclj and profitably be begun depends largely upon the type and location of the fracture and the age and constitution of the pitient lor instance in children we seldom concerned about the restoration of normal movement in a joint onless there has been some irrq>anWe dimige to the articuhr surfaces or to the soft tissues Wt frequently see children ivhase joints have been inimobili/ed over periods of 6 months or a >cir without permanent limitation of motion On the other hand, in adults beyond middle life, and especially in those of the plethoric type or in those who are known to be afflicted with arthritic diathesis, im mc^ihzation over a period of a few weeks may result m long continued and occasionally permanent limitation of motion in certain joints for this reason, m adults we endeavor to have our patients voluntarily put all of the joints of the extremity through the full range of movement at least twice a day when this can be done without any detrimental effect upon the treatment of the fracture This is particularly true in fractures of the vipper extremity tn which stiffness of the hand is apt to follow immobilization In frac fures of the lower extremity, if the limb is immobilized in good position, permanent limitation of movement does not as a rule, occur The exercises should be begun as soon as possible after the injury, usually on the second or third day, and the patient should increase them gradually, but should not arry them to the point where they cause more than \cry sli^t pain After union has oc curred and between this period and the Irme when the limb is sufficientlj strong for weight bearing or other function, the active exercises should be encouraged ind increased in order that by the time the patient is ready for the resumption of function, not only considerable motion will have been restored to the joints but also considerable power to the muscles These exercises wdl, of course, vary with the patient and w ith the frac tures and they roiut be determined by the surgeon for the individual case and so arranged that they do not disturb the position of the fragments until union has oc curred fASSrVE MOVEMENT Passive movement is net, as a rule, of greit benefit in the restoration of motion to joints We wish here to distinguish passive movement from assisted active movements In certain instances in which the muscles are very wieak the patient is able to carry out active movement if the effects of gravity or friction are removed from the part In these movements, however no appreciable force m the direction of movement is exerted bj the phpical therapist By passive movement we mean a forcible attempt to flex or extend a limb Such attempts usually result not only in irritation of the involved joint but also in resistance by involuntary contraction of the muscles MANIPULATION UNDER ANESTHETIC Manipulation IS occasionally resorted to m an effort to break up adhesions around oc «i a joint and to increase the range of motion m certain cases in which apparently no other form of treatment can be expected to ob- tain the desired result Before resorting to this, it is necessary, first, that the fracture be suffiaently healed that refracture will not occur, second, Aat too great a degree of atrophy not be present in Uic bones, as odvetwise the bones may be fractured oc the articular surfaces may be crushed and permanently damaged, and third, that slow, steady traction combined with active movements and function have been tried out over a period of weeks, during which time careful observation of the joint has been maintained, and that these measures have failed to restore function We mention these precautions beouse we wish to emphasize the fact that brisctnent farce is a dangerous procedure, really more dangerous than an open operation, and the patient and the surgeon should realize this before the manipulation is undertaken If the precautions mentioned are obsmed manipulation under an anesthetic or brisement fored may be practiced with considerable benefit to the patient This is par tioilarly true of shoulders, elbows, and knees Stiff and contracted fingers, on the other PRINCIPLES OF FRACTURE TREAniEm 117 hand, are much more satisfactorily treated by gradual stretching or, m certain instances, by doing a capsulotomy and following later with traction, since manipulation of these small joints is likely to be followed b) an acute irritation with an increase m the dis ability Sometimes following the manipulation hydrocortisone (5 to 75 mg) is injected into the joint cavitj, the amount \arying with the size of the joint This treatment tends to lessen inflammation and adhesions and may be repeated within a fewr days if neces sary HEAT It 15 difficult to e\aluale the effect of heat m injuries To many patients heat IS gratifying They ate made more comfortable, consequently, they beliese that it is doing them much good and the psychic effect is beneficial So far as we know the prinapal effects of heat in fractures are (1) to cause dilatation of the blood vessels in the area and thus mcrease the arculation and (2) to reliese pain The mechanism by which heat reheses pain has not yet been determrned In regard to its effect upon circulation, local heat undoubtedly causes \a$cuht dilatation, and it is said that it has a sery marked decongestise action which tends to reduce the swelling in a part Of this w-e are by no means certain The common methods of applying heat are (1) application of dry or moist heat to the outside skin area such as with heat lamps, heating pads hot packs or whirlpool baths, (2) application of heat to the deeper tissues by means of electric currents, such as diathermy, and (3) appliation of deep heat by means of ultrasonic radiation In most cases moist heat seems to be more effiaent than dry heat It may be applied by means of hot soaks, poultices or stupes That stiffened joints and muscles tend to loosen temporarily and mo%c more freely when they are heated is fairly well established Consequently, exercises of hands or feet are often preceded by hot soaks or bakes CoiUrast Dalhs The alternate heating and cooling of a part tends to alternately dilate and contract the blood vessels, consequently, a sery \3luable form of physical therapy for restoring the sascular tone m stiffened hands and feet that are cold, swollen, and cyanotic is contrast baths The extremity is first plunged into water as hot as the patient can stand it and is held there 2 minutes, it is then plunged into cold water and held there 1 minute This procedure is usually done six to eight times at each setting and repeated three to four times or more daily MASSAGE Massage is of use pnnopally as a preparation for actne muscular exet cises and joint mo\ements It should be begun lightly, should not cause pain to the patient should be slow and rhythmic in character, and the stroking should be m the longitudinal direction of the limb from the distal end toward the body As the massage is continued, it can be more Mgorous Massage, if persisted in with sufficient Mgor and o%er long enough time, may be of distinct benefit m decreasing the swelling in a limb It IS also helpful m increasing the circulation in a part where this is impaired The chief benefits claimed from massage, howeser, are that it restores power in paralyaed or weakened muscles and that it increases the range of movement in stiffened joints This IS not true Power in weakened and paraly’zed muscles can be restored only by actne contractions of these muscles, and the exercises are most efficient when voluntarily performed by the patient The contractions however, can be brought about by stimulation of the given muscle by an eicctnc current It is doubtful whether electric stimulation is of much permanent value in the treatment of paralyzed muscles In the treatment of fractures we believe it is very important that the massage not be undertaken until quite firm union has been obtain^ Motion of the fragments may result m delayed or even prevention of union The chief value of massage in the treat ment of fractures is the stimulating effect as a preliminary to active exercise of the limb It is most efficient if the limb is first heated 118 IRINCIPLES AND GENERAL ASPECTS PROGRESSIVE KESCSTANCE EXERCISE As Stated m tlic discussloa of movement, xkc consider exercise and function the best and most important forms of ph)sial therap) At first the exerases are done against gravity or even with gravity lessened by water or b) supporting the extrermty on a smooth flat, powdered surface Later, as the union becomes more firm the exercises are done against resistance The amount of resistance is increased gradually as the strength of the muscles improves In restoring a quadriceps for instance, one may start the patient sitting on a table and lifting a 5 pound vseight fastened to the foot As the muscle strengthens the v.etght is gnduali) increased to 40 pounds or more It is important to lift a heavy weight a few times (5 to 10) several times a day rather than to straighten the knee a large number of times consecutively CHAPTER 4 COMPLICATIONS OF FRACTURES Tractufes are accompanieti b) more or less tnjurj to surrounding so/’t parts, and in addition there may be injuries or lesions in other parts of the bodj In the strict sense of the ■word, all of these injuries arc complications of the fracture but sve usually reserve the term complications for those conditions ^\hich are of sufficient gravity to demand treatment and to affect the prognosis in the given case In certain instances the complication may be of more importance than the fracture itself, and the diagnosis and treatment of a fracture should include the diagnosis and treatment of any complication that may exist at the time of the injury or that may arise during the treatment Many fractures arc caused by severe violence to the whole organism this is espe cially true of those injuries resulting from falls or auromobile acudents, and it is not un usual for more than one bone to be broken Vv'hen a patient comes under the physician s are for a fracture, a areful history and physial examination must always be atried out to facilitate an accurate assessment of the patients injuries, so ilut all injuries may be known and treated in their proper order In the unconscious patient, this of course is made more difficult, but a systematic examination should allow Ae surgeon to assess the extent of damage and to formulate a rational plan of treatment INJURIES TO OVERLYING SOFT PARTS W'l'rtfR skin ts ^coAeir avn/ oVixvr coiwnwrAartivar es estMfshsd f.'-vc ture and the skin surface, we are dealing with an open fracture, and injuries to the over lying soft parts are considered under that heading, but, in fractures due to direct violence, the overlying soft parts are always crushed and may be devitalized over a wide area Although the skin may not be broken at the time of the original injury, cinders dirt, or other contaminated foreign material may enter the skin and later the skm may slough over a wide area and either cause a closed fracture to become open or may con siderably complicate the treatment and prolong the convalescence In certain severe frac lures especially in those around the elbow and around the ankle joint, swelling may be so great as to be a dominant factor in the infuey This nuy result in the formstion of large blebs on the skin, thus rendering manipulation difficult and injudicious and greatly complicating the treatment At times swelling ts of such magnitude that it endangers the survival of tissue distal to if Immobilization, elevation, and compression bandages should be immediately applied If tiiesc measures do not soon restore satisfactory circula tion surgical decompression must be accomplished Too frequently the internal fixation enthusiasts especially tliose who advocate the use of the intram^uUary nail forget the trauma to the soft tissues and see only the fixation in the x ray film Further trauma is often brought about by applying the intra 119 120 PRINQPLES AND CrNERAI, ASPECTS medullar} nail later a considerable amount of sloughing of the soft parts takes places and in many instances necrosis of the bone occurs In most of these cases if skeletal traction had been applied and used for a 'nhile much better results would have been obtained in the final anal}sis VraclHre Blister Not infrequentlj a fracture bister complicates se\ere and mod erately severe fractures especially of the forearm leg ankle and wrist The lesion is the result of swelling and is always assoaated with an embarrassed circulation A blister may be noted clinically as early as 12 hours after the injury or as late as 3 weeks follow ng the initial trauma When they do oecuc they can be opened aseptically and the application of a compress on dressing for "’4 hours will usually bring about early re covery r g 109 Rupture of Achilles lendoti at )iiiKton of muscle and tendon due to muscular v olencc Treated bf operat »e tepa r INFrCTlON Infection m open fractures by gas baallus tetanus and the pyogen c organisms is d scussed in Chapter 6 Rarel) dosed fractures may becime nfcctcd cither from necrosis of the overlying soft parts or in \er} rate instances from hematogenous im plantat on of bacteria in the fractured area INJURIHS TO MUSCLES Muscles and tendons in tlic \ an ty of t fracture may be injured or even severed bj the fracturing force in fractures due to direct violence and by the d splacment of the fragments in those due to indirect violence In additon to the d rect injury suffered at the time of the accident musdes in the area are usually infiltrated with blood and their function IS disturbed over a considerable penod In cases wh di ate necessarily subjected. COMPLICATIONS OF FRACTURES 121 to prolonged immobilization the musdes undergo atrophj of disuse This atrophy tends to disappear with the restoration of function but in senile patients and m patients in whom motion of the affected joints is not restored the atroph) mi) be imiisuaJJ) pro longed Of maj be permanent Another t)pe of injury to a muscle is one m whidi a muscle or tendon is taught m the callus or scar tissue incident to the healing of a fracture or to the wounds in the soft parts These troublesome adhesions are mote frequent in open fractures than in dosed fractures but in closed fractures of the middle third of the femur the quadriceps may become adherent to the shaft and demand operative interference in order that motion in the knee maj be restored fig no Rupture of long head of right biceps brachii muscle Treated by suture of tendon to st ort head Volkmann s Ischemic CoulracUne This contracture is the most severe form of traumatic muscle contracture with whidi we have to deal This condition usually results from obstruction to the arterial supply, but under certain arcumstances it may occur as a result of obstruction of venous return as has been shown by the investigations of Brooks In either arcumstance muscle tissue is killed and, since musde has only a limited power of regeneration it is replaced with scar the contraction of which not only 122 PKINCIPLCS AND GrNLKAL ASILCTS intetfeces with the (unction o£ the teitummg Mible muscle tissue but also intetfetes with proper function of the surrounihng nenes Since, the great 4nnjoritj of the cases occur m fractures of the elbow this tonJiticm « discussed m detail m Chapter 13 Rupture of Muscles oiul Tetulous Occasionally tendons or muscles are ruptured by muscular violence (Iigs 109 HO) Such accidents ire not as a rule accompanied by a fracture and tlic lesion general!) demands repair by open operation Myostiis Ossificans Afyos tis ossificans is a condition in which the muscle becomes replaced by bone The ossification may be so extensive as to involve a large part of the muscle not onij interfering with the function of the given muscle or muscles but also 111 O n cal r ctme of rupiu/e of Ion? head of biceps brad iinrghtarni A Anter or view B Poster or v ew Open fxaton carrej out with transfix on of tendon lo bciptal griove with g( od results blocking motion m the neighboring joint Myositis ossificans complicating a fractuie occurs most frequently following fractures and dislocations at the elbow joint (Fig 112) In this relation it is also desaibed in that section Mjositis ossificans however more frequently occurs without fracture only about one half of the patients are able to recall an injury and it is not always dosel) assoovted with bone Ossi[)iug llenuitonia This cond tion is tfic laying down of bone in a hematoma in a muscle or beneath the periosteum (Fig llj) It is usually caused by a contusion With relative rest to the part die abnormal bone lends to be resorbed over a period of months If a troublesome mass persists it may be exased If it does not cause trouble some symptoms it should be left alone 124 PRINaPLES AND GENERAL ASPECTS INJURIES OF IMPORTANT BLOOD VESSELS Because the walls of the blood \essels ate unusually tough tliese structures can be subjected to considerable trauma without senous damage Occasionally in fractures how ever the large arteries or scms may be tom punctur^ or injured by pressure If such an injury occurs and is of such an extent that blood is perm tted to escape from the vessel into the surrounding tissues there is ^ rapid ntttasasabtm of blood in the area If the injured vessel is an artery a false aneurysm may be produced and this may pulsate Injury to major vessels of this type are rare m closed fractures but are not un common in open fractures particularly gunshot injuries Pulsations distal to the arterial lesion may not be lost and there mv} be little immediate change in the appearance or Tig 1\4 A Comm nuleJ ftactuie d sial one ih td of fenvut v- Ih tircuUloty wibiroissn'Wt of leg B Femoral arteriogram showing relaionshp of femoral artery and collaterals to fracture Adjustment of fracture improved c rcuUtwn d stally Artery was compressed, not tuptuted function of th" extrem ty so that careful examination for a pulsating swelling with an audble bruit must be nude to discover the lestoti At times the distal pulse will be absent and the extrera ty may be cold and become gangrenous Injuries to vessels asso ciated with supracondylar fractures of the humerus will be discussed with fractures of the elbow An important area of arterial injury in closed fractures is damage to the interior tibial artery ind/or vein as it passes through the fibrous canal between the tibia and fibula We have recently seen two cases of this con 1 1 on wh ch were not recognized early and resulted tn loss of the extrem ty Tlie pcssibility of vascular damage must be in mind constanlly with both oycn and closed fractures Major vascular damage assonated with fractures must lie tepuicd when poss blc and the fracture sitbilizcd vcith internal fixation as descnbeil under the ' section on the treatment of open, fradures OccasionaEy the artery is crushed and Fig 116 y1 014 neglected fiaaure of lower end of ulni 'Mlh marked displacement and non union of fta«ure tl rough lower one fourth of radius with angulation and o>crIapping of fragments produang total d sab I ty of hand and forearm B and C Anatomic position of same arm as in /I following surgical procedures carried out by rntemal fixat on of fractured radius being held m place "itli stainless steel bone plate and resect on of lower end of ulna Fairly good functional results with marked improsement of total preoperattve disability 126 PJlINai'LLS ANl) CCNIHAL ASP£CTS may become thrombosed without the deselopmwit of a false aneurysm In such cases there are loss of pulse and loss of arculation m the distal portion of the extremity Very rarel) i traumatic aneur)sm or an axterioseoous fistula or false aneurysm may desclop as a late complication of a fracture and requires surgical rnten ention When a large s’ein is injured there rs also an extravasation of blood into the tissues and an extensile hematoma is formed The rapidity with which the hematoma deselops depends upon the Size of the \ein Such hematomas do not pulsate, but they may become very extensive and threaten gangrene of the extremity, w-hidi is likely to be swollen cy’anotic, and cold A late complication occasionally seen, especially in frac tures of the pelvis and of the upper thigh, is thrombosis of the iliac or femoral veins with the dev elopmcnt of edema and swelling in the extremity BRAIN INJURY In automobile acadents brain injury is the most frequent cause of death. If the patient is unconsaous immediately after an accident, there is a brain injury "nus may be mild or severe and may or may not be accompinied by a fracture of the skaill If blood or cerebrospinal fluid escapes from the eat or nose, the injury is severe In any event the patient ^ould be placed on his side with the face down and transported to a hospital, and there he should be placed on a firm bed m the same position Morphine is contraindicated in every case of brain injury because it depresses the medulla with its respiratory and vasomotor centers If unconsaousness persists and there arc signs of increased intracranial pressure effort should be made to reduce inlracnnial pressure by either dehydration or spinal puncture Most of the attempts at dehydration have been discontinued, however, some people still use 50 per cent sucrose solution intravenously This does reduce the mtra cranial pressure, but this reduction is temporary The pressure soon recovers and may then become higher tlvsn it was prior to the instigation of treatment If dehydration is to be used, a much better method is to inject 200 ml of 30 per cent urea solution intravenously over a period of approximately 30 to 45 minutes This will reduce intracranial pressure and does not have the bad side effect of glucose or sucrose solution in having the pressure return to a higher lev el than it was prior to treatment Lumbar puncture is still used and also helps to remove blood from the subarachnoid space Tills method is similar to that of d^jdtation and should be repeated at to 12 hour intervals dependini; upon the condition of the patient Lumbir puncture may be very dangerous in that the removal of the pressure below may force the brain stem down into the foramen magnum and death toay result This procedure is made safer if a manometer is used and the pressure is gradually reduced to approximately the ooc mal level of ISO to 200 mm of water If the patient is in shock this should be combated by warmth and transfusion, if necessary The ear or nose should not be irrigated or packed tightly to prevent the escape of fluid but should be left alone and antibiotics ^vwi to combat tlie danger of meningitis or brain abscess The surgical complications of skull fractures and brain injunes are as follows Middle Memugeat Hemorrhage This ojmplication develops early in a matter of hours Typically there is a short period of unconsciousness (it may not occur) followed by a lucid interval which is followed 1^ a gradual onset of coma The important signs are dilation of the pupil on the side of the inju^, a slowing of the pulse and, more important, the presence of bradycardia with other signs of increase in the cranial pres sure There may be motor weakness on the opposite side, and there may be an elevation of blood pressure, whicli comes on a little later The treatment is immediate craniotomy with ligation of the bleeding artery ojMPUCAnoNS or rRAcruars 127 Depressed Fracture of Skull This complication is ifficult to determine by palpa tion through an extensive hematoma but can usually be seen in the x ray films If the depression, although not symptomatic, is over either the sensory motor, or the visual areas m the occipital pole, or over the left temple area of a right handed individual, the depressed fracture should be elevated In addition, there is frequently an mtercerebral hematoma beneath the depressed fracture whidi would not be found and evacuated unless surgical intervention was taken If the depression is over areas other than those named above, and is not causing symptoms, it need not be elevated in every case Subdural Hematoma Subdural hematoma may develop within a few hours or even after several months and cause symptoms of cortical compression If a diagnosis of sub dural hematoma is made relatively early after the injury, evacuation of the hematoma through the exploratory perforated openings will usually be adequate However, if some time has elapsed since the injury and the hematoma is old the walls of which then become organized, it can best be removed by a formal craniotomy Linear fractures of the skull without signs of one of Uie above surgical complica tions require no specific treatment Scalp wounds should be debnded carefully and the underlying skull examined for fracture Then they should be irrigated and closed by primary suture and antibiotic therapy should be instituted to prevent infection whether or not a linear or stellate frac turc of the skull is present In case of a large comminuted open fracture of the skull flaps should be retracted, the wound irrigated gently foreign material and m driven bone and damaged brain removed and the wound dosed and antibiotic therapy insli tuted VISCERAL INJURY Injuries to chest and pelvic viscera are discussed in Chapters 9 and 17 Intra abominal injuries (rupture of spleen liver stomach intestine or kidney, or extensive retroperitoneal hematoma) may also complicate fractures due to severe violence Such injuries are accompanied by shock and abdominal symptoms and may require an ex ploratory laparotomy and an attempt to repair the damage Gasinc Uemorrhagi roUouwg Trauma Friescn and others* hate shown that there is a definite connection between {.aslric hemorrhage and bleeding and erosions and ulcerations following severe trauma Their conclusions follow 1 Gastroduodenal ulcers and/or erosions, with resultant hemorrhage, are an occa sional complication of fracture and amputation of long bones in man 2 Gastroduodenal ulcers and/or erosions can be produced m experimental by operative fracture or curettage of the bone marrow, the madence of su^ Of ulcers is markedly increased when histamine administration accompanies the tracture specially in dogs Experimental fracture of long bones abets the ulcer diathesis 3 Gastroduodenal ulcers and/or erosions can be produced by e I«tion of small amounts of fat. this reproduction of the phenomenon of fat rnn aho increases the susceptibility of the laboratory animal to the histamine provoked 4 Emboh of fat can bo demonstrated m the submucosal and ^cosal the stomach and duodenum, not only m experimental ^imals subject^ to operat. e fracture, but also in patients dying early after fracture of long bones The appearance of the fat from the tissues is rapid , •Fr.eric S R, «.d othera Rrlmuush.p of Bone Trauma to DeseleP""' »' duodenalLesionsmExpenmental Animals and m Man Surgery 24 134 lyis 132 mNClPtrS and OINtRAL ASPECTS arthritis is most frequently seen m ttiose patients who are of the heavj or plithoric type and who are bejond middle life and in certain cases with gouty symptoms In considering the treatment of traiumtic arthritis the first thing to determine is why the arthritis has descloped If the arthritis is the result of a condition which can be corrected bj a surgical procedure (bis should be attempted If on the other hand the fracture has united with the fragments in good position and the contours of the in solved joint are practically normal surgery can do Jittle good Consequently no opera tion short of removing the joint and performing an arthrodesis or an arthroplasty should be considered The surgical treatment of the disability incident to fractures in \arious regions which result m chronic progressive arthritis in the invohed joint is considered m the special part of this book Fig 122 A M nor frarture of lower end of rad os B Heal ng of fracture but acute b ne atrophy of hand and wrist Atrophy developed with n J weeks following fracture coftimenc ng wi'h severe pain w hich became unbearabfe at r mes ACUTE TRAUMATIC BONE ATROPHY (SUDECK) When an extremity is immobilized there is a tendency for bone itfophy to occur Tins iS natural ind slu uid be expected in all fractures In occasional cases howocr the atrophy is profound in degree and occurs with great rapidity Th s curious condition 1$ sometimes called Sudeck s atrophy because it was first described by him or it mi) be called acute traumatic bone atrophy It is n rapidly progressing osteoporosis which in COMPLICATIONS OF TRACTURrS 135 \olves the bones of the extremity following an injury and is especially e\iclent in the bones distal to the injured area (Fig 122) It IS charactenzed chnically bj pun, usual!} out of proportion to that expected from the injury, whicli persists after immobilization, slight spelling dilatation of the super ficial ^essels, and purplish discoloration in a warm and moist extremity Although the etiology remains unknown, it appears to be a reflex sympathetic dj'Strophj We base recently decompressed the median ner\e in tlie carpal tunnel m tsso cases associated xvith Colies fractures Although both of these patients were seen some time after the fracture and did not present the picture of acute atrophy, operation was followed b) prompt relief of pain and improsement of function Further experience ts needed to clarify this problem In the cases that ha\c come under our care we base found restoration to normal is best accomplished by Nosocain, stellate ganglion blocks, immobilization of the involved extremitj, and sedation In many instances deep x raj therapy in doses of 75 to 100 r repeated two or three times will reverse the process Although this condition is self limiting with regard to pain if not diagnosed and treated promptly marked stiffness and flexion contracture develop, and these may be permanent When pain and swelling are controlled, exercises and active use are slatted very slowly at first and graduallj in creased according to the patient s tolerance FAT tMBOLISM Fat embolism of some degree occurs with every major injury or fracture as it ts possible to recover abnormal quantities of fat from the blood, sputum, and urine The clinical picture of fat embolism however is rather rare in our experience While the occurrence of fat embolism is gcneraflj accepted the mechanism has not been satisfac toril} explained The current belief is that m extensive fractures of long bones and m crushing m juries of cancellous bone such as sometimes occur when extremely atrophic bones are manipulated a variable amount of fat is forced out of the marrow cavity and enters the veins The difficulty with this theory is that one would expect an amount of pressure necessary to cause mobiljaation of the fat to result in the collapse of all open veins in the Vicinity However if the pressure is great enough to tear off the vein from its attach ment to the bony wail the mobilized fat could be forced into the canal m the bone and out into the vein at its point of exit Arandwy: KbAWf v«, Kbit 5-5A k/f lari d'iw.'ped. wA-i Ab/t blood stream in unusuallj large amounts The third explanation is that some chemical change occurs m the blo^ or in the fat which is normally present in the blood as an emulsion of chylomicrons and causes demulsification whidi the result that the chylo miaons form globules of fat which block, the capillaries m various organs and especially those of the lungs At autopsies the lungs arc likely to show large amounts of fat in the capillaries and occasionally the capillaries in the brain, kidney, and other Organs maj be blocked by fat Whether or not the fat found in these capillaries is the cause of death is still a moot question The symptoms arise only when a vital region of the brain is blocked or when many capillaries m the lungs arc blocked and thus throw a large portion of the organs out of function In the usual case the symptoms do not appear immediately after the injury but come on after a period of from several hours to three days The symptoms may be either pulmonary or cerebral m type depending upon whether the fat collects m the lungs or in the brain In the pulmonarj type there arc signs of pulmonary edema with coarse rales m the chest, but normal resonance on percussion There are also rapid breathing and rapid pulse With pallor which is later followed by cyanosis In the cerebral tjpe there may 13f JRINaPLES AND CrNLRAL ASPlCTi be deliijum with pupillary changes twitching and coma In either t)pe the temperature may be normal subnormal or ele\ated and there may be a combination of the two types both pulmonary and cerebral In addition to the abo\c signs there k an assooated petechial rash mote prom nent on the flexor surfaces of the body o\er the chest and imolvmg the conjunctna The chief conditions from wh ch fat embolism is to be differentiated ire surgical shock pulmonary embolism and pneumemia The time clement is an important fartor m the differentiation of the first two of these tliree cond tions In surgical shock the sjmptoms usually occur immediatel) after the accident while in fat embolism the symptoms usually do not occur btfott twelve or more hours after In pulmonar) em bohsm due to thrombosis the sjmptoms nsuallj appear between the tenth and the twentieth day following the accident whereas in fat embolism they usually appear during the first 3 days Pneumonia can usually be differentiated by the impaired resonance and signs of an acute infection The only treatment is rest and sedatives In a good many cases of the cerebral type the patient recovers after a period of delirium or e\en of coma which may last for several ^>s Just why there should be a clinical picture of fat embol sm produced in certain patients who have had major trauma or major bone operative procedures and for it not to appear m the vast majority of people all of whom have excessive added fat in their circulatory system is a subject for further investigation Once the clinical picture has developed treatment is fairly symptomatic The work of Caldwell and Huber* and of Peltiert would indicate that the number of cases developing fat embolism can be markedly decreased bj the proper use of a tourniquet when carrying out major bone surgery also by proper tmmob hzation and at times b> a judicious use of a tnurn quet after major injury It is a premise also that tended to clarify some of the problems of the etiology of fat embolism in that there is not an inacase m the amount of circulat mg fat until after the tourniquet has been releasetl It would appear therefore that the source of the fat is in the traumatised cxtremitj It is also interesting to note that Peltier found that the use of a tourniquet associated with major bone surgery and injury did decrease the amount of fat m the circulating Wool even after the tourniquet was re moved whereas when used for soft tissue work there was a sight increase m (he amount of fat which suj^ests some contraindic'itions for the use of a tourniquet when only soft tissue surgery is going to be performed PULMONARY COMPLICATIONS Pneumonia and embolism are the two common types of pulmonary complicat ons met with after fractures Embolism is relatively rare Uit may occur after fractures as after any dfner surgical procedure anil is huc 'iofne iiAobgmerfc di (m diiSt m a inranfutKcii vein and the passage of the clot through the rght side of the heart and into the lungs where it blocks the pulmonary artery to a vanable degree In cases with small emboh only branches of the artery are blocked and the result is a localized infarct in the lungs accompanied by pain in the chest and usually by a pleural friction rub With large emboli the entire artery may be blocked and the patient may die almost instantly Pneumonia after fractures occurs most frequently in aged and debilitated pat ents especially m those the nature of whose injury necessitates immobilization m bed in recumbency It is so frequent in fractures of the hip in elderly persons that it is the ch ef cause of death in this lojucy The mortality « about 15 per cent depend ng usually on •Caldwell J T and Hubcc H U Fat Embolrtm Followioi? Trauma to Bones an Expen mental Study of Its Product on and Prevent on VCith Particular Reference to tf e Albee Opewton Sufg Gynec BtObst 25 <>50 i9l7 tPcIter L r Fat Embolism the Pfophylart c Value of the 7 urnejuet } Bone A Jo nt Surg 38 A 835 1956 COMPUCATIONS Of FPACTURES 735 ihe age and debilitation of the patient The most frequent type of pneumonia is a bilateral hjpostatic congestion of the posterior portions of the lungs \ihich gradually increases and terminates m a v.idespread brondiopneumonia with moderate fever and progressne weakness The best prophylaxis against this type of pneumonia is treatment so that the patient can be turned If the fracture is treated by traction insist that the patient sit up in bed for a good part of the time In other aged patients there may result generalized bronchitis iMthout marked hypostatic congestion This may terminate m a widespread bronchopneumonia More rarely there may occur a rapid and sescre lobar pneumonia which progresses to a crisis and may terminate either fatally or in recoterj fust as does It bar pneumonia in p 2 ttcnts who have not had a fracture Fig 123 Deform ty foilov ng open ep physeal separat on of rad us w tl loss of substance Ho» eter note that grots th js progress og w th deform tjr (&)urtesy Dr Frank Kennedy ) DELIRIUM Alcoholic del ritivi is an occasonal complication of fractures m patients whose nersous systems base been damaged by the excessive use of alcohol When this occurs it takes on the characteristics of dehrium tremens Traumatic delirium occasionally occurs in eldwly patients or in those who have been under prolonged mental distress It is similar to delirium after other operative cond tions and IS characterized by a low muttering febrile state in which events of the past arc recalled and remain uppermost m the patient s mind MALUNION Alalunion of a fracture may be defined as a condition m which (he fragments be come united by bone but m which the fragments are distorted in alignment or position (Eigs 123 125) In fracture of a long bone malunion may be the result of shortening COMPLICATIONS OF FRACTURES 737 due to o%ettiding of the fragments or to loss of substance or it may be due to fault) alignment resulting in abnormal angulation of the bone or to union with the fragments in an abnormal position as regards rotetion In fractures of bones sihich are sub- cutaneous in position, a lateral displacement may result m union laith a visible deformity svhich might be regarded as a malunion In fractures into and in the Mcmity of joints union of the fragments ma) occur in such a manner that the motions of the joints arc either blocked by projecting pieces of bone or the joint surfaces may be deformed so that it IS no longer possible for the movements of the joint to be carried out in the nor mal manner In the forearm after fractures of one or of both bones the radius and ulna may be united to one another by callus (synostosis) or angulation may occur in one or both bones so that rotation of toe forearm is limited or entirely prcNcnted The various t)pes of malunion are taken up under the particular bones m which they are likely to occur A B c Fig 125 ^ Synostos s 6 years after fracture of rad us and ulna There is a recent fracture above the synostosis B Same case } months after reduction A new synostosis is form ng resulting in loss of rotation of fomrnt Open opent on done taler Cross union removed from both areas with good function resulting C Synostosis of tib a and 6bula following fracture The treatment of malunion depends constdcrably upon the amount of disability and deformity v,hich it causes If the disability is great enough to warrant surgical inter ference the bones can be separated by surgical operation or by manipulation and the malunion can in most instances be corrected In certain fractures involving joints as was stated elsewhere it is frequently impossible to obtain a normal joint, and sometimes It IS impossible to obtain a joint which is stable and free from pain In such instances either an arthroplasty or an arthrodesis is to be considered NONUNION Failure of union of a fracture is a serious complication following both open and closed fractures and indicates that the initial treatment of the fracture has failed 138 PRINOPLES AND GENERAL ASPECTS Causes lollowing are the causes of nonun on of fractures (1) The incidence of nonunion associated with open fractures whether from trauma or surgical intervention IS higher than with fractures which are managed by closed reduction The exact reason for this is not always cleir One theor) the loss of the hematoma has not impressed A Fp Vf A Snnnf Hov* np nftctnn n open Inclure’ Hwl n dean granulation tissue When this occurs the edges of the pressure sores should be protected either by strapping with adhesne or with some ointment, and, as a rule, if the patients general condition is good, the pressure sores will heal slowly In the case of large sores the sore and the underl)ing bone which caused it may be excised and the skin closed by primary suture chapter 5 PATHOLOGIC FRACTURES Pathologic fractures are those sxhich occur in bones that ha\c been weakened by some disease or abnormal condition They are frequently called spontaneous frActuces hut they are not really spontaneous since they are ali^ays the result of some form of force although this force may be far less than would be necessary to cause a simihr fracture in normal bone D^ending upon the cause of the deficiency in the bone pathologic fractures may be divided into two groups (1) those due to local bone changes and (2) those due to conditions which affect the entire skeleton All should be treated both for the comfort of the patient and to obtain union PATHOLOGIC FRACTURES DUE TO LOCAL BONE CHANGES Bone Atropb) of Disuse When the functional demands on a bone are di minished there is a corresponding amount of bone destruction In a growing child there is also a tendency for the bone to increase in size and in length less rapidly than is normal Consequently uc may haie a condition of eccentric or concentric atrophy m the bone of the extremity This is especially true after the extremities have been immobilized for a long peri^ m plaster of Pans casts and when such a patient gets up after a fracture he is more susceptible to other fractures than is the normal person In addition to the rather acute bone atrophy incident to treatment or immobilization after a fracture there is a chronic bone atrophy that is always present m limbs which are extensnely paralyzed and which as a result of the paralysis ha%e not been used for weight bearing Fractures in such limbs often take on the characteristics of pathologic fractures in that they may result from relatisely slight Molencc and may be accompanied by relatively Jittle pain Inflammatory Processes in Bone Any acute or chronic inflammation which results in the destruction of bone may cause sudi cxlensne sieakenmg of the bone that a pathologic fracture may occur In osteomyelitis the fracture may occur after the bone has been operated upon for the cure of the disease and in such a manner that a large portion of the shaft has been removed In sudi cases the limb should be handled with care and should be adequately splinted This is especially true in adults A fracture in such diseased bone may lead to nonunion Another type of fracture occurring in osteomyelitis is a fracture through the dense eburnated bone This bone is extremely hard and capable of sustaining great pressure, but It is brittle and as a result may be broken by relatnely slight force 141 142 PRINOPLES AND OrNPRAL ASPECTS ^ fj CD Fig 130. A, Metastatic cardnonu from breast. B, Prophylactic insertion of intramedullary rod Ftacturc at site of tumor and also of fmoial shaft belcw Icston C, Appearance following applica- tion of Parham bands to control distal fracture. D, Healing of both fractures i'/j months later fol- lowing roentgen and hormone therapy. PATHOLOGIC FRACTURES 14 ^ PATHOLOGIC FRACTURES 147 Neoplasms Benign or malignant tumors may arise in the bone» or metastatic malignant tumors ma) occur An) of these may result in a pathologic fracture In )oung persons the most frequent cause of pathologic fractures is benign bone c)St (figs 129 and 132), which may occur in the shaft of a long bone and by its gradual enlargement and expansion cause a progressne thinning of the cortex In fact, in about one Aird of the cases the first sign of the bone cyst is a fracture which results from some trnial injury Multiple and solitary bone cjsts are occasionally associated with parathyroid adenomas (Fig l 43 ) In older persons metastatic carcinoma is a relatively frequent cause of pathologic fractures When a pathologic fracture occurs in an older person the surgeon should suspect the possibility of such a tumor immediately and rule it out by appropn ate study, including biopsy when indicated Many such fractures unite when properly treated and for these a medullary nail is often an excellent method I.iX,emse, such a nail may be introduced into an involved bone in which a pathologic fracture is impending Fig IJ5 Patholog c fracture of femur through solitary hone cyst Treated by closed reduction and abduction plaster cast with good results Most cases of this type demand bone grafting before good results can be obtained In adults benign tumors of bone rarely cause pathologic fractures largely because most of these tumors are productive rather than destructive in character and result in considerable new bone formation Another reason is that they fend fo occur near the ends of long bones rather than in the shaft For instance a giant cell tumor occurring in the end of a Jong bone may result in marlLcd destruction of the bone and yet even in this lesion a pathologic fracture is rarely seen PRINOPLES AND GFNLRAL ASPECTS Tig 13^ Tracture ihroui,! bone qst n 1 umetus treated e1sc> ! ere by Jeep % ray tl crapy f 11 cd by 1 cal ng of cyst 1 ut Ut rhance of gro th ebumat on of bone as result of «] mage to ep pi >sm| plate (’ ncl « of si rttn ng) Fig 1$9 Pathologic fracture of iwf and then the other hip foUt>'»fing deep x ny therapy for caocet of uterus, fractures did not unite. (Cputtesy Dr- Ori E Dadgley.) PATHOLOGIC FRACTURES 151 Fig 140 Pathologic fractufe of neck of femur result ng from localized osteitis fibrosa with cyst c formation in femur Nonun on \X hitman reconstruction later Osteotomy to correct varus and s hone graft will usually result in hesling of fracture in ihs situation (Courtesy Dr J Edgar Stewart ) Fig 141 Cyst of phalanx before and after etasion of cyst and packing with bone chips J$2 PRINUPLZS AND ODNERAl. i«PECTS Primary malignant tumors of hone for the most part invade and destroy bone very rapidly, and it is not uncommon to find pathologic fractures associated with these lesions. It has been out experience that pathologic frictutes ate likely to occur foUow- log biopsies for lesions of bone and following treatment for infection in bone For this reason it is our recommendation that plaster immobilization t>e employed following biopsy In those malignant tumors submitted to radiation, there is again further weak- .1 B c Fig 142 yf, Pathologic fracture through large cfU of uj’t'cr half of nbia B, Aprl'C^uon bone graft from opposite tibia C, Ewellent union anj regeneration 1 year posiopcrali'ely ening of the bone, usually about the time the radiation therapy is completed. This is a particularly hazardous time, and one in whidi fracture should be guarded against Large amounts of deep x-ray therapy may so damage the bones that they may break spontaneously or as a result of slight violent. This is most frequently seen after deep PATHOIOGIC rRACTURCS 153 xra) treatment for cancer of the uterus Roent^^enolog sts should endea%or so to d rect the ra)s that the h p is spared (Fif, 139) Aseptic necros s of the head as v^eIl as the neck of the femur may result from the same cause r s Pjlholo^ c fracture of humerus due h> large bone cyst n pat ent w ih parathyro d adenoma and hypercalce n a. After paratl yro d tumor was remo ed fracture and cyst healed PATHOLOGIC FRACTURES DUE TO GENERAL CONDITIONS Osteogenesis Imperfecta or Osteopsathyrosis The general tenns osteogenesis im perfecta and osteopsathyros s are used to dcsgnale a cond t on in -which there is a generalized hypoplasia of the skeleton and in wh di the bones of the affected persons are not sufficiently strong to bear the wear and tear of normal existence In these persons fractures occur from trisial acodents and depend ng upon the degree of bypopJasa may be very numerous and occur at frequent intervals So far as has been determined the caloum and phosphorus metabolism of these patients js normal and the fragility of the bones is the result of a defect m develop ment rather than of the inab Jity of the patient to assim late calaum and phosphorus 154 PRINaPLES AND GENERAL ASPECTS and to form bone Key* his classified these osndittons into osteogenesis imperfecta idiopathic osteopsathjrosis and heceditarj hypoplasia of mesenchjme or brittle bones and blue sclera All of these three types are characterized by abnormal fragility of the bone Many of these patients also exhibit an abnormal transpatenc) of the white collagenous connectne tissue and the sclera hare a blue tint the depth of the blue \ar) ing in individuals In the cases classed as osteogenesis imperfecta the fractures are present at birth or are noted soon after birth and frequently in lifting the infant the arms or legs may be broken A Kondstd or mose ftactisits may occot in a single person and ptartieally all of these patients die in early infancy In the cases classed as idiopathic osteopsathyrosis the fractures do not as a rule occur until after the patient begins to walk and are usually the result of minor injuries These cases may also hare the blue sclera and their bones are abnormally slender and brittle Hereditary hypoplasia of the mesenchyme is identical with osteopsathyrosis except that It IS transmitted as a dominant hereditary factor and the affected persons haie a tendency to deielop deafness in eafly adult life It should be borne in mind that if a patient affected with brittle bones and blue sclera gnes birth to children, approximately half of the children will inherit the condition and they in turn will transmit it to their children but nonaffected children do not transmit the condition These fractures usually heal well and should be treated as though the bones were normal Rickets Rickets is a condition in which the individual is unable to calcify the bone formed and in severe cases there is also a progressive rarefaction of the bones which leads to softenint; and bending with the development of deformities Occasionally how ever in very severe cases the rarefaction may be so great that pathologic fractures occur fractures m even severely rachitic persons will heal but of course do so much better with proper treatment of the disease Osteomalacia Osteomalacia or rickets m adults is not uncommon in those people who have long been on starvation diets It is prevalent in many parts of the world but IS seldom seen in this country Oscs are more often seen m pregnant women who have been on a grossly inadequate diet In very severe cases pathologic fractures may occur Osteoporosis In women after the menopause either natural or artifically created and in very old men there may be a considerable decrease m the amount of bone present Since the calcium and phosphorus metabolism in these persons is not altered the condition is at present explained on the basis of alteration of protein metabolism which interferes with the laying down ot bone matrix The normal rebuilding of bone therefore cannot take place while the normal amount of bone destruction con tinues The net result is a decrease in the amount of total bone This is exhibited in the X ray film by bones that cast a very light shadow and is spoken of as osteoporosis The bones most frequently involved ate the vertebral bodies the upper end of the femur the upper end of the humerus and the lower end of the radius Fractures m these locations are likely to occur after itdatively slight trauma These fractmes if properly treated will at times heal quite readily Osteitis Deformans or Paget s Disease Osteitis deformans Paget s disease is a condition m bone of unknown etiology which is chiraaerized by a great increase in the circulation of the bone involved active bone destruction and new bone formation going on in the same area New bone formation is usually more marked than bone destruction so that there is an increase m the size of the bone yet orientation of the newly formed trabeculae is not in normal amngeinem in itlabcpn to vhe stresses icul ♦Kty J A Bnttle Bones anj Wne Hetediurv Hypo?lisi4 of KesencI ymc Affli Sufg J3 323 19’6 PATHOLOGIC FRACTURrS 155 strains put upon the bone Althoujjh there is a gre^ amount of bone mass, because of this disorganization it is considerably \ieaker than normal This allorvs bending of the bone and pathologic fractures, v.hich often show up as Looser s* lines A slight amount of extra nolence may cause a complete fradure In this condition the alkaline phosphatase is tremendously inaeased and there may be some increase m the scrum calcium In Paget s disease fractures usually heal but much more slowly than in a normal bone In those patients with cxtensixe disease bed rest must be asoided m the treat raent of the fracture for fear of a high serum calcium with resultant kidney and sascular damage Fjg I'll Compression fracture of spine Jue to osteoporosis m patient 85 years old Treated by high back brace with shoulder straps Vitamins H C and D with figh protein diet and estrogens brought about marled symptomatic improvement Sjphihs Since tertiary syphilis frequently altadcs the skeleton, it is popularly re garded as one of the principal causes of pathologic fractures and of delayed or nonunion after fractures As a matter of fact syphilis may almost be discsgitded as the cause of either of these It is, of course, possible that a large gumma may so weaken a bone that a fracture will occur with relatisely slight Molence, as in the cliMcle Congenital syphilis howeser, in infants may result in a spontaneous separation of the epiphyses the so called pscudoparalysis of Parrot These epiphyseal separations may occur spontaneously and wn be recognized by the typical syphilitic lesions of the epiphyseal line as seen in the x ray film Diseases of Nertous System Tabes dorsalis and syringomyelia may result in trophic changes in the bones, particularly in the articular surfaces w-hich lead to pro grcssivc erosion of these surfaces and a total destruction of the joint (Charcot s joint) •Looser E Ueber pathologiscbc Ponnen »on Infektionen und CuIIusbildungen bci Rachitis und Osstimalikie und anderea Knociertkeankaneta Zeotalbl Chte 47 1470 1920 156 PRINaPLES AND C ENLRAL ASPrCTi At the same lime there is as a nile more or less rarefaction of the bones of the m\ohed extremitj but s\e believe that is due to disuse rather than to the netxous disease We have seen fractures m limbs affected with Qiarcots joint heal in the usual way but we have also seen true extra articular pathologic fractures which we could trace to disease of the nersous system and which did not heal We base not seen a fractured ned^ of the femur unite m the presence of Charcot s disease of that hip Fi); l4S Pathologic subluxatioa be assumed to be pathogenic This contamination occurs at the time of the injury and persists until such time that the organisms begin to grow and locally invade the tissues from this time on the wound is infected Roughly wc may assume that an open fracture becomes infected witJiin from 6 to 12 hours after the injury Consequently injuries seen with n the first 6 hours may be con sidered contaminated and those seen after the first 12 hours should be considered in fected whereas those seen between 6 and 12 hours after the injury are borderline cases There are of course instances with virulent infections m which the infection starts witiiin 6 hours after the injury but these arc unusual Not only is the wound infected but also there is provided an ideal culture medium for the growth of pyogenic organisms because the injury causing the fracture also produces considerable damage and dcvitaliza tion of the soft tissues and interruption of the blood supply Other things being equal the danger of infection is proportional to the extent of the tissue damage and con tammation OPEN FRACTURES The treatment of open fractures includes the treatment of the patient at the scene of the accident the transportation of the patient to a hospital or to some other point at which the injury will receive definitive treatin«it and the treatment m the hospital The last includes the treatment of the wound the reduction and immobilization of the fragments in a position which will result m satisfactory function when and if union oTOirs, and whatever aftertreatment may be indicated Treatment at Scene of Accident Treatment at the scene of the accident will m OPEN FRACTURES AND XCAR BOUNDS 1^9 depend upon the t)pe of injury, the locality in \^hich the accident occurred, and the available facilities If the patient is not severely injured if the patient has to be trans ported only a relatnelj short distance before the injury can recene de/inifne treatment, and if this transportation can be earned out without further injury to the patient, no special treatment is necessary at the scene of the acadent Hosseser, an open fracture IS a surgical emergency, and the patient should be transported to a hospital as soon as possible so that treatment may be instituted If the patient is seriously injured, it is advisable that certain measures be taken at the scene of the accident to prec'ent further injury to the patient and the deteJopment of shock Other things being equal, it may be said that the more se%ere the injury, the less the patient should be handled In other words, the sesercly injured patient should be left on the side of the road and made as comfortable as possible until an ambulance arrises instead of being transported some distance and placed in bed until he can be lifted again from the bed into some conseyance and taken to a hospital Gisen a case of a man who has suffered a seiete open fracture of the leg or thigh in a highway acadent, for instance, it is better that he be handled aery little that the extremity simply be straightened, and that he be cosered and kept warm and made as comfortable as possible where he is and an ambulance sent foe, rather than that he be carried into the nearest house where he will appear to be more comfortable once he is placed in bed Handling of the patient necessarily causes pain, increases the amount of injury to the soft tissues and tends to increase the amount of shock If the patient is bleeding and the bleeding is considerable m amount, it is scry im portant that this bleeding be stopped as soon as possible by pressure or by an improvised tourniquet if this can be applied In an open fracture it is also important that the wound be exposed and a clean dressing applied to it at the earliest possible moment This dressing not only lessens the bleeding but also protects the wound from further contamination If possible this dressing should include chemotherapy in the wound sulfanilamide or sulfathiazole, or preferably a mixture of the two m powdered form should be sprinkled liberally in the wound Tor this reason these drugs should be made asaibble in emergency dressing stations in m dustrial plants and also should be earned in ambulances which are sent out for the specific purpose of picking up the injured person The placing of the chemical m the wound at this time can do no harm and wrill tend to decrease the rate of the develop menl of infection, and whereas it may not be necessa^ if the patient is going to be operated upon immediately, one can never be sure but that for some reason treatment Will be delayed several hours, in which event the presence of the sulfanilamide or sulfa thiazole will retard bacterial growth and thus make the surgeon s work much more likely to be successful The patient should also be given peniallin (400,000 to 600,000 units) as soon as possible after the injury It IS important that severely injured persons be kept warm and dry, and, unless transportation to a hospital is unusually delayed, the patient is to be given nothing by mouth Following an injury peristaltic acbvity either ceases or is greatly di minished It can be assumed that anything m the stomach at the time of injury will probably still be there several hours later This must be taken into consideration when the debridement of the wound is undertaken, and the stomach must be emptied before submitting the patient to general anesthesia If a phystaan happens to be present to render first aid and to splint the injured extremities and if there is no evidence of bram or mlra abdominal injury, drugs for relief of pain will tend to decrease the amount of shock However, a physioan is seldom present at the scene of an acadent, and so first aid and splinting must be carried out by the people responsible for transporting the patient to the nearest hospital and drug therapy omitted until it can be properly administered 160 PRINCIPLES AND CENIRAL ASPICTS Treatment tn Hospital As stat«l in Chapter 3, once the patient am\es at the cmer^enq' room of the hospital, he should be examined immediately by physicians siho will (1) see that an adecimte ainva) is established, (2) control hemorrhage and (3) instigate procedures to combat shock When these procedures luve been accomplished, he IS then ready to make a rapid but verj careful examination of the entire patient so that he may be in position to assess the extent of mjuiy and establish priority of treatment in cases of multiple injuries If the tiound was covered with a sterile dressing and an adei^uate splint ^was applied before the patient was mosed to the hospital, the wound should not be disturbed unless Jt is netessat) to do so to control hemorrhage If splinting and dressings hase not been carried out previously they should be done now When an adei^uate airw’ay has been established, hemorrhage controlled shock combated wounds dressed and all fractures adequately splinted the patient is ready for x ray examination A properly oriented emergency room will base an x ray facility adjacent to It \X^en open fractures arc dealt with time is important in that it is desirable to instigate treatment to the wound before lovastie infection has developed However the patient should not be exposed to the additional risk of anesthesia and treatment of the open fractures until he is adequately pr^ared CHEMOTHERAPY As Stated ^fore, at the cachest opportunity a liberal amount of sulfanilamide or sulfathiazole powder or microcrysfals should be sprinkled m the wound and a dressing applied This may be done at the time of the emergency dressing or the first hospital dressing if the wound is dressed before the patient ts taken to the operating room "nie local chemotherapy slows but may not prevent, the development of infection m the wound Penicillin, 400 000 or more units inlramuscularly, or one of the broad spectrum anti biotics should be administered as soon as possible after admission to the hospital and repeated every 2 or 3 hours for the first 24 to 48 hours Antibiotics alone will not pee vent wound infection and cannot be used as a substitute for wound surgery The effect of antibiotics on the contamiruted wound ts primarily in the first few hours after injury Surgery and the patients defense mechanisms must accomplish their role if serious in fection IS to be avoided TREATMENT OF SHOCK TfaurtutiC shock IS indicated by unusual pallor and sweat ing a cold clammy skin, pinched facies dilated pupils, shallow respiration a rapid thready pulse subnormal temperature, and a low blood pressure If the shock is chiefly due to hemoiihage restlessness and air hunger may be present Shock, on the other hand, should be differentiated from fainting which may superficially resemble it but from which the patient quickly recovers when placed m a recumbent position Jt IS a moot question as to wJjrther the surgiaJ shock or the wjuiy should recent the primary treatment in the case of a severely injured patient who enters the hospital in a condition of shock Some hold that immediate treatment of the injury is the most efficient method of treating the shock On the other hand we believe that if the shock is at all serious it should receive the first attention and that the delay of an hour or a few hours m treating the injury will not greall) enhance the danger of infection This u particularly true since wc have available antibiotic drugs which lengthen the time during which debridement may be successfully accomplished Treatment of shock coivsists of control of hemorrhage administration of fluids blood replacement, elevation of foot of stretcher, and administration of oxygen when indicated Sedation should be deferred until the patient is out of shock, or if necessary the drug should be given intravenously in minimal effective dosages The preservation of body heat by dry warm blankets, hot water bottles, or other forms of external heat should not be used particularly if the patient is unconscious ANTTTrrANIC SERUM AND CAS GANGRENE ANTITOXIN Any Opcn ftlCtUtC may be contaminated with tetanus or a gas producing organism of the clostridial group Infer OPEN IRACTURrS AND 'WAR WOUNDS ICI tion b) any of these is more easil) pre^e^tec^ than cured The best propliylaxis is good surgial management of the wound Since all wounds cannot be treated early and all cannot be thoroughlj cleaned immunization to provide protection against tetanus is ad visaWe It IS regrettable that everjonc has not been immunized with tc-(anus toxoid as they could be protected by a booster dose repeated in 7 to 10 dajs if nd rated AJ! pa tients with open fractures who are not immunized should receive at least 1 500 units of tetanus antitoxin on admission and at the same time should be started on active im munization with tetanus toxoid Patients with severely crushed and contaminated wounds probably should receive much larger doses These larger doses maj interfere with active immunization but both active and passive immunization should be practiced F g 147 Gas gangrene of forearm Rad ©graph showing gas bubbles in t ssucs following shot gun wound Trcalcd by free mcision and gas bac Hus serum v th good results (Courtfiy Dr Jama J Clark ) We would like to caution against the indiscnm nate use of tetanus antitoxin particularly in patients with trivial wounds as the risk of serum react on is real and often much more serious than the onginsl lOftuy The advisability of the administration of polyvalent gas gangrene antitoxin to patients with an open fracture as a prophylactic measure is open to serious question and wc advise against it Even in the case of an established gas gangrene infection the danger of scrum reaction outweighs the benefit to be derived Lindsey and associates* found that antigas gangrene serum injected into muscles of goats before the injury lengthened the survival time However when given following injury it was not effective The best prevention of gas gangrene is prompt *L ndscy D W ve Jr Knght and No>« H B Role of Clostt d a n Mortal ty Following M Experimental -Wound m ifie Goat Effect of Oosirdal Anf tox n n Prolong ng Survival Surgery 45 617 1959 164 PRINCIPinS AND CINIRAt ASPECTS remo\e all dead or devitalized soft tissue and aJl foreign matter and to prescne all health) and vital tissue This should be performed in such a way that the best possible function will be restored to the injured part In the average instance howeier after the patient has been adequately prepared he is taken to the operating room still on the same stretcher on which he was placed on admission to the hospital An appropriate anesthetic is administered Under certain arcunutanr^s th s can be a reg onal nene block but in most cases general anesthesia ts requ red Spinal anesthesia should not be used in an} patient who has been in shock or who is Iikcl) to return to a state of shock after the treatment is instigated during ancsthes a Hie splint and the dressing are removed from the injured extremity but the extremity is supported in such a uay that the wound does A Fig 150 A Open ftaciore of both bouts of Iq; /I X ray film of stme case before irMimenl C Wound treated by debr dement Large eo nn nuted bone fragn ents v. etc feta ned fracture was stab 1 led with a Loties na ! and w undwasclosed Res Its were pocki not come m contact with any unstenle surfaces Any bleeding vessels should be damped until the wound can be adequate!) prepared A tourniquet should never be used “Hic use of a tourniquet interferes with the ability to Ueterm ne Mjlile and nonviable tissue OPEN FRACTURES AND WAR WOUNDS 165 and also often prevents the surgeon from establishing complete hemostasis which is of the utmost importance TTie area about the w-ound is thorough^ cleaned with soap and water with care taken to present it from running into the wound After the surrounding area is thoroughly cleaned the wound edges are next wrashed with soap and water The area around the wound is then prepared wnth iodine and alcohol and sterile drapes applied The entire wound is flushed out with copious quantities of lactate Ttmger s solution I-ig 131 Open fracture of iba Treated immed aiely by debndement, internal £xat on ‘ th sta niess steel bone plate and local sulfan lamide n wound Lnevenr/ol reco ery Fig 152 Open fracture of leg seen 2 hours following injury Treated by debr dement and fixat on w tl plate Wound closed and cMreiti ty immob 1 zed in cast Pr mary 1 eal ng and un on With pat ent walk ng in 3 months care being used to irrigate the depth of the wound After thorough washing a thin area of damaged skin at the wound edge is resected These instruments are then discarded gowns and gIo\es ate changed and the opcntise area is redraped By stages the wound is carefully d ssected to remose foreign mater al and desitalized tissue throughout the entire extent of the wound We do not feci an excision (en bloc) is often indicated The question often arises as to what should be done w th fragments of bone Small ICC PRINaPLtS AND GENERAL ASPECTS detached and contaminated pieces should be removed, but large fragments, even if completel} separated from all soft tissue, should be retained in an effort to prevent a gap at the fracture site After the wound is thoroughly cleaned, the surgeon is faced with two problems ( 1 ) should the wound be pacl^ed open or could it be closed and (2) should the fracture be fixed by some internal fixation device’ It IS not always easy to decide whether or not a wound should be closed How ever m general we can say that m cerum favorable situations in which the time from injury to debridement is short, the extent of soft tissue damage is small, the surgeon ts satisfied that a complete and careful debridement has been performed, and it is possible to bring the wound together without tension, the wound may be closed All others should be loosely packed open Closure by delayed suture (5 to 7 daj’s) or secondar) closure (over 7 days) may be effected when the wound is clean It IS important to stress that leaving the wound open does no harm and is always the safest procedure The next question concerns the fracture Again hard and fast rules cannot be made, but in general addition of any internal fixation device increases bone trauma and bone death and increases the chances of infection and failure of wound management How ever, in those circumstances in which stabilization of the fracture is important in proper wound management, Uic fracture should have internal fixation This is particulitly important if ^ere has been damage to a major vessel which has been repaired The fracture should be stabilized prior to the arterial repair In those few instances m which internal fixation is deemed important in (he proper treatment of the wound, this fixation should be provided by intramedullary fixation whenever possible It should be re membered that, when a fracture occurs, a certain amount of the bone is deprived of its circulation and dies The quantity of dead bone is proportional to the amount of periosteum stripped from its bed If, in addition to this trauma, further stripping of the periosteum and soft tissues from the bone is done to apply plates and screws, more bone necrosis ensues This increases the hazard of infection with delayed or nonunion Intramedullary fixation also produces bone necrosis along the medullary cavity, but in human beings the periosteum and surrounding soft tissues are more important in fracture healing than is the endosteum MANAGEMENT OF SEVERED NERVES AND TENDONS AT TIME OP DEBRIDEMENT. Severed nerves should be brought together with a single suture and left m contact with Viable tissue The nerve should not be sutured under tension or left stretched across a large dead space In these arcumstances the nene should be identified but not brought Vogtthet sepivs of ^ nerve at thvs stage la cootvawvdicated, but vf the tietvcs are identified, they can be eaSiIy found after the wound is completely healed and rc paired later Additional length, if needed, may be secured through healthy tissue Whether a tendon should be repaired at the time of debridement depends upon the tendon involved and the area m which it has been severed Usually tendons should be identified and not repaired at this time IM MOBILIZATION When possible the fracture is reduced before the wound is closed and It must now be immobilized by external fixation This is true unless rigid and ade quite internal fixation was used and whether or not the wound was dosed The tm mobilization is necessary not only for the treatment of the fracture but also as one of the most important measures in combating the infection It can be immobilized in splints with or without traction or in a plaster of Pans cast whidv may or may not be puldri We use a plaster cast in most instances and usually use very little padding It is important that the cast be applied while satisfactory position of the fragments is maintained and that It include the joints above and below the fracture If iht fragments arc not stable when reduced, we do not hesitate to transfix each end of the bone with a stainless steel pm of OPEN FRACTURES AND WAR WOUNDS 167 Fig. 153. A, Open fracture of both bones of leg with dressing o\er wound and leg partialljr iminobnized in pillow splint B, Appearance of open fracture following removal of dressing and splint prcparatojy to debridement. C, Initial roentgenogram D, Roentgenogram following debride- ment and reduction of fracture and closure of ■wound E, Metliod of immobilization Go^ result. 170 PRINCIPLES AND GENERAL ASPECTS AFTERTREATMENT The iftefticatment includes chemothetapj, supportive treat ment, if indicated, leaving the wound and the fracture alone, watching the patient for evidence of infection, and opening the wound and treating the infection if it occurs Chemotherapy Antibiotics are started as soon as the patient reaches the hospital and are continued in appropriate doses for the first 48 hours After this time these agents should be discontinued unless there arc signs of infection SUPPORTIVE TREATAIENT The patient nuj need transfusions or intravenous fluids and these should be given as indicated Leattng Wound Atone Wounds that have been closed at the time of debridement should not be dressed until the seventh or eighth day unless signs of infection develop at which time a window can be cut in the cist and the sk.in sutures removed However, no attempt should be made to alter the position or the alignment of the fracture for at least 2 weeks after the time of debridement Open reduction or secondary repair of nerves and tendons should wiit until ail soft tissue reaction to injury has subsided Those wounds that have been packed open at the time of debridement should not be disturbed until after the fifth day unless the reaction of the patient demands m spection of the wound At that time, if all has gone well, the patient can be prepared and taken to the operating room, and with adequate facilities and a good light the dressing can be removed and the wound inspected If at this time it appears clean and the wound edges can be brought together without tension it can be dosed Tins is frequently termed a delayed primary dosurc Should the wound appear dean but closure of the above-mentioned type impossible because of soft tissue loss closure can frequently be accomplished by shifting skin flaps or a split thickness skin graft In most instances at this stage it is preferable to close the wound temporarily w'lth a split graft rather than to attempt a major full thickness transfer which has not previously been prepared After the wound has been completely exteriorized with a split thickness graft and his healed final repair can be accomplished at a later time Should the wound prove, m the judgment of the surgeon to be undean it should be thoroughly irrigated, repacked and reimmobiliied In many cases waiting for another week will rtveal a clean gtanulat ing wound which lends itself readily to closure with a split thickness skin graft It should be remembered that all granulating wounds arc contaminited and no open fracture should be left to heal by secondary intention if it is feasible to close the wound by any other method Zttdence of Infection As a rule, the first evidence of infection is pain, and witli the development of gas gangrene this may be cxcniaating The pam is accompanied by an elevation of the temperature and a disproportionate increase in the pulse rate The toes or fingers may become swollen and cyanotic The leukocyte count is elevated and the wounds are red, hot, and edematous Treatment of Infection If infection supervenes or is suspected, the wound should be exposed and, if necessary, opened wide if it has been sutured, or the petrolatum gauze should be removed if it has been treitcd by the open mclliod, and thorough drainage assured Immobilization and chemotherapy should be continued The wound should be cultured and the organisms tested for resistance to various antibiotics and if indicated, an appropriate drug should be used in place of peniaUm and sCrepto myan Also, supportive treatment should be intensified as indicatcvl If gas gangrene is present, it should be treated as indicated in the following discussion, and this treatment should dominate the picture INFECTED OPEN FRACTURFS WITH GAS GANGRENE Open fractures whidi are compounded from without and which arc seen 12 or mote hours after the injury may be considered infected ami consequently' the surgeon must attempt to evaluate the gravity of the infection and regulate his treatment ac OPEN FRACTURES AND WAR WOUNDS 171 «ner wound Healmi; followed Plate nmo\ed 1 >ear later 172 TR-tNUPLCS AND GENtRAL ASPFCTS cofdmgly The degree of infection vanes directl/ with the virulence of the infecting organisms, with the length of time that has elapsed since the acadent, and with the amount of damage to the soft tissues in the vianit^ of the wound The first consideration IS to determine whether gas gangrene is present or imminent and whether scsere pjogemc infection is present or imminent In cases in w'hich there is severe damage to the soft parts with relatneiy little drainage through the skin even without infection, there will be marked swelling of the limb and discoloration in the subcutaneous tissues A glance at the wound will usuall} disclose serum or even frank pus and a smear from this material when stained and examined usually reveals bacteria, either staphylococcus or streptococcus or a number of different organisms One should be particularly impressed by the presence of large short thick bacilli m the exudate from the wound as these are likely to be the organisms of gas gangrene On the other hand they may be relabvely harmless saprophytes Fig \i0 Jfoderately advanced gJ$ gangrene ifi open comm noted fracture of os calcii suth gangrenous areas around ankle and plaftUr surface of foot These hav** been incised Note bronring of skin above lociscons Treated by ampuUt on about 4 inches below knee Dakin s solution to Stump and antigas bacillus serum Patient recovered (Courtesy Dr J O Dietcrie ) Dtdgnostt The diagnosis of gas gangrene ts not a simple matter in its early stages as any infected wound in the presence of an open fracture wiUi saprophytic organisms and devitalized tissues may give rise to a foul or even fecal odor Likewise the severe pain rapid pulse, moderate elevation in temperature, and genera! appearance of an extremely ill patient may result from staphylococcal or streptococcal infection as well as from gas bacillus Gas gangrene should be suspected of course when the wound lus a foul odor when dark pus exudes from it, when the surrounding skin is tense or marbiclikc in appearance and copper colored when the patients pulse rises disproportionately to the increase m temperature and when the patient appears unusually sick and has an icteric color If smears from the pus show short thick bialli in large numbers the diagnosis should be considered sufficiently established to warrant surgical intervention for gas gangrene The crucial point, however, m the diagnosis is the presence of gas m the wound or tissues, or both, and if this t$ carefully sought, it can usually be detected It should be remembered, however, that gas may be present m the wxiund or (issues without gas gangrene Tins is due to the physical characteristics of the wound so that air is drawn in and pocketed there and may result from dead spaces between the fragments or in the OPEN rRACTURES AND WAR WOUNDS Hi Tigs Fig 160 ’'•S 160 and 161 Roentgenograms of case m Fig 159 sho^ms fracture and gas in (Courtesy Dr J O Dieterle ) tissues Fig 162 Advanced gas gangrene of lower arm forearm and hand following open fracture at elbow Line of demarcation can be seen in middle third of arm Treated bj ration and antigas bacillus serum Patient recovered (Courtesy Major General N T Kirk, Uni ed States Army (Retired] ) 174 PRINQPLES AND GENERAL ASPECTS (issues which communicate with the outside air Also, air in the tissues nu) be found occasionally in chest iniuries in whidi air has escaped from the lungs, as from i pneumothorax The presence of air or gas in the tissue may be determin^ by palpation if a fine crackling crepitus can be obtained fn large amounts between muscle planes it can aho be identified m the x fay film, but the diagnosis should be made long before the gas IS sufficient in amount to show in the film (Figs 159 162) Cultures should be made, but surgical intervention should not be dela)ed is it is important to operate be fore gangrene of the limb occurs if the limb is to be saved Treahnetit When a gas infection is first suspected, the patient should be taken to the operating room where good lighting and instruments are available Under anesthesia, with whole blood available, the wound should be completely opened and all tissue carefully inspected Involved muscle is readily identified, as it is swollen dark red, firm, and does not contract In the earlj stages resection of the entire muscle maj stop progression of the disease At times several muscles may be removed and the extremity preserved However, if the involvement is extensive with dissection of gas into all fasaal planes, an open amputation through healthy tissue may be required If partial resection has been possible, the wound js packed open, immobilization is secured and tlie patient is given large doses of intramuscular penicillin, seditives and blood The effiacj of deep x ray therapy has not been proved In like manner various medications which liberate oxygen are of questionable value Unless there is some benefit to local instillation into the infected area, antitoxin is of no value Therefore treatment consists of adequate surgery antibiotics, and blood replacement INFECTED OPEN FRACTURES WITHOUT GAS GANGRENE Infected open fractures without gas gangrene are wounds m which the bacteria have begun to invade the tissues when 6 to 24 hrnirs or more may have elapsed since the injury The infection is usually mixed nnd, in addition to staphylococci and strepto* COCCI various saprophytic bacteria may be present The infection may be relatively mild Of It may be a rapidly procressiog fulminating infection The patient may be in good general condition or he may be moribund If his general condition is not good this may be due to the sev erity of his injuries of to (he infection From the previous discussion it is evident that these patients present problems similar to those discussed in the section on the treatment of open fractures plus those problems directly due to the infection, and that clinical judgment is even more important than surgical skill in their treatment If shock from the injury dominates the picture, supportive treatment of the patient IS the first consideration This may include transfusion and rest If toxicity from the infection is the most important feature this demands intensive chemotherapy, adequate drainage, and immobilization of the infected tissues treatment is carried out along the lines previously discussed except that in the presence of an acute fulminating infection chemotherapj is started immediately and the operation of debridement is replaced by one for drainage Fven this may not be ncccs sary because the wound may be wide open and drainage may be adequate Local chemo- therapy is useful but IS not effective against bacteria which have deeply invaded the tissues Immobilization must not be neglected because this is one of the most effective meisurcs in combating the infection The limb and the patient should be moved as little as possible The wound is cultured before or at operation and the resistance of the organisms is tested against various antibiotics Wlun indicated, the drug to which the organism is most sensitive is substituted for penicdlm and streptomyan Operation If the wound is obviously infected, the operation is for drainage and is not a debndetnenL The wound is enUr^ to the long axis of the limb, and the deep OPEN FRACTURES AND \PAR WOUNDS 175 fascia IS cut trans\ersely if necessarj in order to expose the depth of the \\ound Bleeding vessels are clamped and ligated with fine catgut Foreign bodies loose pieces of bone or any plates or screws that base been applied are remo-ved However if an intramedullary nail has been inserted it is not removed Necrotic tissues are exased but no effort is made to excise the walls of the «ound The flound maj be flushed nith normal salt solution If the fracture has not been treated previously it may now be reduced if this can b- accomplished without disturbing any of the soft tissue about it but no internal fixation is applied No attempt is made to repair muscles tendons or nerses The v,ound is then cashed out with a saturated solution of sulfanilamide and IS packed loosely with petrolatum gauae The extremity is then immobilized in a plaster of Pans cast In a borderline cas** in which the wound is not obviously infected a debridement may be carried out as described earlier if the general condition of the patient permits but the wound is not closed but is packed open and immobilized m a cast Ajtertreatment Peniallin or a newer antibiotic in large doses is continued until the infection is well controlled Supportive treatment and rest are used as indicated With a /a\ora6/e postoperatisc response the wound is not inspected until the fifth or sixth day At this time the patient is taken to the operating room The cast is cut away to allow full inspection of the wound and with a good light the dressing is remoNed If it appears clean it may be loosely closed if the soft tissues can be brought together without tension If soft tissue loss presents this closure can often be obtained by a split thickness skm graft If the wound is not clean it should be redressed and the same procedure repeated 4 or 5 days later Should closure then prose impossible one must resort to the Orr treatment OLD INFECTED OPEN FRACTURES Old infected open fractures arc those in which osteomyelitis has occurred This osteomyelitis differs from the ordinary hematogenous osteomyelitis however in that the infection in the bone tends to be limited to the iicmity of the fracture The treatment of these cases is usually operatise and is preceded by a short period of chemotherapy Before operation it is wise to culture the wound and test the organisms for sensitivity to sarious antibiotics and to use the appropriate drug in large doses When union is present it is advisable not to interrupt the continuity of the bone if possible because the presence of a fresh fracture not only greatly complicates the aftertreatment but may result in nonunion For this reason we do not believe in subperiosteal resections in the treiimeni of fhese cases This is especiaWy true in aduUs in nhom the power of osteo genesis is considerably less than in children As a rule these patients arc ready for a definite operative attempt to eliminate the infected bone m from 3 to 6 days after the institution of appropriate therapy whether or not sequestration of dead bone has occurred In some instances the dead bone will be sequestrated and simple removal of the sequestra will result m permanent healing of the mfeaed wound In others and these ate the majority whether or not sequestra are present there will be a variable amount of infected and dead bone enclosed in the callus and It w-ill be necessary to perform an operation such as we ordinarily plan for the at tempt to cure osteomyelitis, that is we approach the bone by a long longitudinal inasion between muscle planes being careful to avoid important blood vessels and nerves expose the bone subpenosteally and excise a wide saucerized area beginning with what in the surgeons judgment will be suffiaent to remove all of the infected bone niis sauceriza tion process is continued upward and downward on the shaft until all of the infected area is removed In the operation we remove as little of the cortex as is consistent with an adequate saucenzation Since the mature bone of adults regenerates slowly or not at all, it is JSO PRfNCIPLrS AND CCNLRAL ASPrCTS Fractures from shrapnel, shell fragments, shotguns, and explosions are caused by projectiles irregular m sire and shape with low %eIocitie5 These wounds, often filled with contaminated debris, require early operation and debridement High selocify missiles, with their great expansile and bssue deforming forces, often produce massive tissue necrosis remote from the path of the bullet These wounds likewise require early opera tne debridement and stabilization of the fractures wlien associated with arterial repair Since complete removal of all injured tissue is often impossible, all these wounds should be treated by delajed or secondary closure Experience has shown that civilian gunshot wounds, when inflicted bj medium velocity bullets from small caliber rifles and pistols, may often be treated txpectantl) »n the absence of assoaated arterial or bowel injury A special type of injury m avil life is an open fracture due to a shotgun fired at close range Tlus injury produces a large gaping wound, shot is scattered widely through the tissues, there is considerable destruction of the soft tissues, and it is not unusual that some of the wadding from shotgun shells is carried into the wound and buried m the tissues This wadding may contain spores of tetanus or of organisms which produce gas gangrene Such wounds must be thoroughly debnded, and the patient should be given tetanus antitoxin and treated with chemotherapy just as m other open fractures OPEN FRACTURES AND WOUNDS IN WAR OR MAJOR DISASTER Open fractures that occur in warfare or perhaps in major avilian disasters require some modifiation in the principles of treatment from those outlined previously for the care of civilian accidents beause of the increase m soft tissue damage associated with high veloaty missiles and of alterations in the faalities for the care of the patient These alterations are (I) obtaining transportation, may present difficulties, which may increase the time between the inception of the wound and the surgial treatment, (2) large numbers of wounds may have to be handled by relatively few surgeons, (3) Surgical technic must be simplified and speeded up, and (4) the sutgeon wVio operates will not have an opportunity to follow the patient m the postoperative period Under these arcumstances tint aid and splinting of the injuries on the field of battle ate earned out m a manner similar to that in civiban life The pnnciples of transportation are the same, and the patient should be moved to a surgical team at the earliest possible time Once there, he should receive the same treatment, the prinaples being the same, le, to establish an airway, control hemorrhage, combat shock, splint the extremities, assess the total injury, and plan definitive treatment When the patient is adequately prepared, anesthesia and debridement are carried out The principles of immunization and the administration of antibiotics are the same as listed under avilian injuries At times in civilian life the medium vcloaty missic may be treated somewhat as a closed fracture without debridement being performed However, in wartime or in the treatment of mass casualties, debridement should be perfotrned in all gunshot wounds and all open fractures The principles of performing the debridement have been described However, since the patient visually cannot be followed by the surgeon who operates, and since he may be moved from one institution to another at fairly frequent intenals. It is imperative that none of these wounds be dosed primarily They should all be left open, the fracture placed in the best possible position, and adequate immobilization accomplished by plaster casts NNTien the patient his reacted from this procedure and is no longer m shock, he may be transported to a base area for completion of wound therapy When the soldier or the civilian injured in a mass casualty arrives at this so- called rear area hospital, the remainder of the blooil Joss is restored He is made com fortable and, unless there are signs of infection, the wound is not disturbed until the fifth or sixth day, at which time it is inspected under anesthesia. All dressings and packs OPEN FRACTURES AND W'AR WOUNDS 181 are remo%ed and the vvound is thorou^Iy jru^ted preferably tvjUj a sulfanila/nide solution If it appears clinicalJ) clean the «ounc! js dosed if this is possible without undue tension Internal fixation should not be used The severance of major blood vessels is more common m wartime than in peace time injuries In instances of major vessels having been sutured or repaired \iifh a graft It IS of the utmost impottance to the success of this suture or graft that the associated fracture be stabilized bj internal fixation This can best be done when possible b) an jfltra/nedullary rod If the wound cannot be dosed without tension e'en when aided by the shifting of a small flap it should be padded and allowed to wait until granula tions have formed sufficient to hold a skm graft The wound may then be closed by \ spilt thickness skin graft This works well even in through and through wounds When the graft has taken the wound is completel) exteciorized and the danger of serious m fection IS temporarilj removed Treatment of the fracture by skeletal traction or other appropriate methods is continued Closure of the wound with a split thickness skin graft is not a permanent covering Therefore, when the fracture is stable plans should be made for the removal of the graft and for final wound closure with healthy skin This can usually be accomplished m the first 6 months and may require flaps from the abdomen or opposite extremity the shifting of local flaps and at times full th)ckn“ss skin grafts This final coverage may be done when the fracture has healed In those frac hires that fail to heal permanent coverage should be accomplished before bone grafting for nonunion or if not feasible a pedicle flap should be m position to effect final coverage at the time of grafting "What has been said about the necessity of debridement or drainage of all wounds due to shell or bomb fragments must be modified because many of the modern air bombs break into small (tagments which ause vvounds similar to those of rifle or machine gun bullets and these need not be debrided In patients with multiple wounds the number of wounds may be so great that debridement or even superficial excision of all wounds is not practical This is especially tnic m Instances m which a patient has been sprayed with small fragments from a highly explosive bomb, leaving many small foreign bodies m the patient These foreign bodies Will probably do no harm, and no attempt should be made to remove those which ace buried in the tissues Common sense should b« the guide in treating patients with multiple injuries and the surgeon should consider th** patient as a whole nther than concentrste his attention on one or two specific injuries Treatment of IVouiids of fowls If the woiuid involves the joint this should be opened widely at the time of the incision of the skm and fascia and live joint should be thoroughly explored Loose fragments of bone and any foreign material present in the joint should be removed Any soiled bone exposed in the wound should be excised The joint may or may not be irrigated with salt solution depending upon the choice of the surgeon In most instances we advise thorough washing out of the joint cavity The ^ound should then be dried and the joint cavity sprinkled liberally with one of the sulfonamide drugs and the wound should be treated just as described previously in the case of fractures not involving joints If closure is impossible or inadvisable, the wound should remain open The gauze packing should extend down to but not mto the joint civiiy In some instances the synovial membrane an be closed with fine catgut Under these Circumstances as a rule no attcanpt should be made to suture the capsule or ligaments exposed in the wounds and severed Tlie joint should be immobilized in a plaster of Pans ast as described Treatment of IX'oiinds tn Which InfecUou Is Present Previously we considered 'bounds which were not definitely infected These wounds may be 5 or 6 hours old or ffiey may be 15, 20, or more hours old The prwence or absence of infection in such 182 PRtNaPLES AND CENFRAL ASPECTS wounds depends upon the genera! condition of the patient the nature and se\eritj of the wound, the type of organisms which were impbnted in the wound at the time of the injury, and whether one of the antibiotics was placed in the wound shortly after the injury as well as upon the elapsed time Whether the wound is infected can be determined b) the surgeon when he examines the wound after the dressing has been removed If the tissues are red hot and edematous and if pus is present in the wound there is no question but that infection is present In such instances and in instances where the wound is not relatively clean the operation is not one of debridement but the treatment is drainage followed bj chemo therapy and immobilization Unless they ate necrotic or burned the wound edges art not exased after the skin has been painted with a skm antiseptic as described earlier The wound is enlarged in the Jong axis of the limb b> incisions through the fascia the deep fascia is cut transversclj and the depths of the wound are gentlj explored All visible foreign material is removed Obviously necrotic tissue is excised but no attempt IS made to remove all damaged or infected tissue Deep pockets of the wound are opened The granulating margins or walls of the wtMind are not excised as these art natures attempt to form a barrier against the spread of the infection Loose particles of bone are removed and the wound is then washed out thoroughly with Ringers solution and sprinkled generously wnth one of the sulfonamide compounds and packed loosely with fine mesh gauze A rather voluminous pressure dressing is placed over the gauze packing and the limb vs then encased in a plaster of Pans cast Tlvis is usually a cast over padding Transfixion pins and fixation incorporated in the cast may or may not be used If the pins can be placed m the parts of the limb not involved in the infection they may be driven or drilled through the bone without danger of spreadini, the infec tion and the added immobilization which they afford more than compensates for the slight increase m this danger PART 2 DIAGNOSIS AND TREATMENT OF SPECIFIC INJURIES CHAPTER 7 FRACTURES OF JAWS AND RELATED BONES OF FACE- JAMES BARRETT BROWN, M D , AND MINOT P FRYER, M D FRACTURES OF LOWER JAW The lower jaw is m an exposed position, it is relati'ely poorly protected b> soft tissues, and m some cases it appears to be relatively brittle External violence applied directly to the jaw m fights sports, falls, and traffic accidents accounts for most fractures Fractures occur most frequently near the mental foramen or the angle, and if both sides ate broken, they usuallj occur near the mental foramen on one side and near the angle on the other Fractures tlirough the sjmphysis, ramus, and condyle occur less frequentij Tlie force that breaks a condyle is necessarily transmitted from another part of the jaw and the most frequent cause is a fall or a blow on the chm This type of /n/ury may also jam the condyle backward or upward and splinter the bony ear canal or even the floor of the middle fossa This is perhaps the only way in which a skull fracture may directly complr cate a lower jass fracture, whereas m upper jaw fractures brain injury is frequently present, and fracture of the crania! bones must be looked for carefully Fractures may occur in areas weakened by pathologic processes such as osteo myelitis, benign cysts and tumors, and malignant growths inherent in the jaw itself or from secondary in\ohements such as caranoma of the buccal mucosa They may also occur during the extraction of teeth most frequently m removing difficult third molars Displacement The immediate displacement of the fragments is dependent on the direction of the force but the attach^ muscles soon modify the deformity according to their direction of contraction A knowledge of the action of these muscles will help one to find where the fragments are and then to replace and maintain them correctly With this information and rather simple equipment, the surgeon may accomplish ex celJent results m most instances tijlhout resorting to a study of all the numerous forms of apparatus that have been recorded It IS uell to remember that the direction of the fracture line itself may govern the displacement and also that irregular lines or fra^ents may be a help or a hindrance m correctly aligning the fracture, for example, if the obliquity of the fracture line as shown m Fig 173 were from below upward and backward, the posterior fragment might •Many of the principles involved are included in Ihe legends of the illustrations and may be followed as part of the text 1S6 DUGNOSIS AND TREATMFNT OF SPEOFIC INJURIilS be held do^vn in position, whereas if t were in the opposite direction some d rcct aim would have to be made at hold ngthc fut^ment down In fractures of the condyle and its neck it is ffevjuently stated that the external pterygoid muscle pulls the small fragment forward s> that the remaining large fragment cannot be reduced on this small fragment This m turn alls for open reduction or excision of the small fragment if it undergoes necrosis or if ankjlos s occurs We have found however that the condyle is more often separated with a small part of the posterior border of the r-imus attached to it and fortunately this tends to hold the condyle in a position dose enough to naemot so that fixation of the jaw m correct occlusion usual!) suffices Fig 171 Open ng muscles of faw The m sole groups atiacJ cd to the front ^larl of l! e jaw are the depresvon and a cord or!) tend to pull frapncols ut of reach (From Spaltehoir \V ffand Adas of Human Anatomy ed 7 FI ladelph a 1937 J B L pp ncoil Co ) dis] laceinent Tlie teeth should be brought into occlusion as nearly as possible sup ported there and the bandage appi ed with a gauze or spt ngc pa 1 under the ch n A 2 inch clast c bandage is perhaps the most comfortable (I ig 176) If tlierc IS any ten lency to disy lacemcnt ban laging and cs cn the use of lo ig strips of adhesive plaster w lU only occasionally sulTcc to hold the (aws in oalusion during the TRACTURES OF JAWS AKO RFI-ATCD BONDS OF FACE ISp period of healing In some instances there is little tendency to displacement, and rest is all that is required This is usually the type in which credit is gnen for bandage fixation, and the bandage does give some sense of support FIXATION BY INTERDENTAL WIRING The objects of treatment are to align the frag ments to bring the entire lower ^aw into a position so that the occlusion of the upper and lower teeth is the same as it was before the acadcnt, and to hold the jaw m this position until it will maintain itself This does not necessarily mean normal correct occlusion but normal occlusion for the individual patient To try to improve on occlusion is not good practice and one may gam infomution from the patients own sensations as to what is his normal occlusion V I* a * Cotpu* ataaibulai* Tig 174 The internal pceiygotd efevales and pulls inward the posterior fragment The masseter and temporal together however usually pull the fragment upward and outs dc the anterior fragment (From SpaJfehoJz W Hand Atlas of Humaa Anatomy ed 7 Philadelphia Jp37 J B Lippincolt Co ) The best splint that can be employed by the surgeon is the upper jaw, and the best fixation is by means of wires fastened around appropriate teeth on both jaws and then fastened together There will be found in the literature an endless number of ideas for mechanically fixing the jaws, many of them advocating complicated dental splints but it is thought that even a discussion of them in a general text of this type is unnecessary If these devices are to be used they of course have to be applied by their own advocates The majority of uncomplicated fractures of the lower jaw will undoubted! j do best if fixed 190 DUGNOStS AND TREATilENT OF SPEOFtC INJURIES direcllj to the upper jaw, with the position of rest which is with the lower jaw open slightly being disregarded Method of ]Viring The patient should be able to cooperate free from the e/Iccts of alcohol and with the stomach empty A pieoperatne sedative is desirable but not necessary A gentle effort at reduction of the fracture should be made and if there is too much discomfort block anesthesia of the mandibuhr nerves local infiltratnn from the outside about the fracture or deep block anesthesu of the third dn ision of the fifth nerve should be done It is not a safe procedure to wire jaws closed under general Ttg 175 n c external pteryf,o d may pull the condyle forward but ns Haled n *be text it most frequeotiy breaks w Ih a wedge or proloneai on down de ramus so that it inay be held in fairly good pos t on (From Spaltchol/ W Hand Allas of Human Ariaiomy ed 7 PI ladelphia J957 J B Upp ofolt Co ) anesthesia unless some arrangement is made for separating them if there should be respiratory difficulty in waking from the ancsthes a Local anesthesu may be necessary for applying the upper wires (Figs 177 18’) At the lime of reduction a studed effort sliould be made to deterrnine what i» normal occlusion for the patient and h s ideas of sensation should be closely followed if there is any question VCith this accomplished the teeth on which to apply the wires are next determined If the bicusp ds are present, they arc Ihi. ideal ones to use Next FRACTURES OF JAWS AKD RELATED BONES OF FACE I9I in order of preference are the molars, the cuspids,- and the incisors last, as the) can hardly be counted on to retain wires because of their shape If the fracture is behind the bicuspids and tends to displace, it is well to use one of the molars, in other words, try to place one wire on the posterior fragment if possible Where there is marked abnormality of occlusion, there may be difficulty m getting an) set of w ires that w ill remain firm throughout the period of fixation Various t)-pes of wire ma) be found satisfactory No 24 or 26 plain iron wire cut in about 16 inch lengths and the strands kept straight. No 24 Angles brass ligature wire, nickeled silver wire, and stainless steel wire The iron wire discolors the teeth temporarily but is strong cheap, and easily a\ailable Plain sihcr wire is not strong enough Fig 176 Bandage for suppocting fractured jaw The is closed in as accurate occlusion as possible A small pad is put under (he chin and the bandage is applied so that the chin is literally sfung from the top of the head No turns go around in front of the chm Fig 177 Diagram of wire fixation The bicuspids are preferably used as they have good interdental spaces and good necks around which to lock the wires The ends of the wires are cut off cleanly and turned toward liie teeth to protect the mucosa No wax covering is needed »f this IS done smoothly Note retention of third molar in fracture line to prevent elevation of posterior fragment This is essentially the Gilmer method A separate wire is put around each tooth preferably on two teeth on each side, above and below The wire Icxip is made to drop firml) in place around the neck of the tooth by a final tug gently on one end It is tight«ied firmly in place with the hands The turns of all wires should be made the same wa) The long ends of the wires are brought outside the mouth, and the patients eyes ate protected by hanging a surgical clamp on each w irc When all eight wires are On, the jaw is reset into what has been determined the 192 DUCNO-itS AND TREATKftNT OF SPFanc INJURIES best position An assistant stands at the head and cups his hands under the chin, and. if possible, the patient flexes his head to rclicse the tension of the opening muscles Tlie wires are then fastened together firmly with the fingers (not twisted with forceps), bringing the wires directly from one bicuspid to its opposite This is about tlie only change from the original Gilmer method of wiiing m which the wires were crossed Fis 178 Retention of tooth in fracture line for support of posterior fragment A Fracture near angle through socket of thirJ moljr rracture definite^ opened into mouth and eafernal draiiuge was indicated for ilus reason This third molar should defirnfei) be retained during the period of fixation to hold in place the posterior fragment B fracture reduced and jaws wired in normal occlusion The third molar holds the posterior fragment in plate during the period of fixation It can be genlly lifted from its socket 7 to M day* after the wires arc removed and union is solid enough to witlistand the rrueipulation from before backward This docs not permit opening die mouth for inspection but in a long senes this Jias not been nc-ecssary and other method* gne less firm fixation Esen with this method the wares will stretch and loosen somewhat and give sonic play in a fcv\ days time so that they may have to be carefully tightened if too much play of the fragment develops rRACTURES or jaws and rllated bones or face 193 Fig 179 Ivy method of interdental wiring Eyelet twisted m strtnd of wire (From Blair V P, h 7 , R A and Bru^n J B Essentials of Oral Surgery St Louis The C V Mosby Co) Tig 180 Ends of eyelet svire inserted between ptcmobrs (From BUir VP Iiy R A and Brown J B Essentials of Oral Surgery St Louis TTbe C V Moshy 0> ) Fig ISI Eyelet wire passed iraund teeth with one end through eyelet ready to be twisted (From Blair VP Ivy R A and Drown J B Essentials of Oral Surgery St luiuis The C V Mosby Co ) Fig 182 A Ends < f upper and lower eyelet wires twisted and tie wire passed through eyelets B Upper md lower teeth drawn into occlusion and ends of tie wire twisted and cut off short (From Blair V P, Ivy R A, and Brown 1 B liisesitiais of Oral Morgen', Louis The C V Moshy Co ) 194 DIAGNOSIS AND TREATMENT OF SPECIEJC INJURIES If accurate reduction and firm fixation ate obtained the patient v,iU be comfortable within from 5 to 10 minutes and the long ends may be cut off The short sharp ends arc then turned in neatl) so that the buccal mucous membrane is protccteil and there IS no need /or a protectnd cosering of Tiax or cotton There nu} be minor adjustments necessary from lime to time for these ends but the use of a gum cosenng onij makes more pockets for debris For cutting the wire small pomted electricians wire cutters are far more satisfac tor) than is any surgical tool and are almost indispensable when finally removing the wires About the only other instruments necessary arc small clamps and a small re tractor for the cheek Fig 183 Loss of substance Iroro infect on Note srea of low n rh a lo# graJe infect on pers sled oser a long period of time w ibout catemal dr iwgc The th rd molar las fortunately been present to hold the posterior fragment down in plate DISPOSAL OF TEETH IN FRACTURE LINE If a jaw IS broken through aJongsiile a tooth or directly into its socket the fracture is considered open and csp*cully liable to infection because of contaminat on fnwn the mouth Tlus classifies all such fractures as open fractures Although frequently recommended there is one serious drawback to the routine remosal of teeth from fracture lines because these scry leetii may gte saluable aid in fixation and in the case of fractures through the molar region and angle, may be indispensable in holding down the posterior fragment (Figs 178 and 183) Even if one of these last teeth were quite loose in its socket great help may be had by retaining jt during the period of fixation Also near the symphysis the retention of teeth during the healing period is important berause if they are remosed the space tends to be filled by tilting of the fragments About 10 to 14 days after the wires arc irmosctl and it is seen that the jaw will maintain its continu ty these insolscd teeth may be carefully lifted from their sixkets m order that any local infeclH ft may ha\e a dunce to clear and the jaw may become solid m this region Of course care must be taken to present refracturmg the jaw FRAcroRrs or jaws asd rflated bones ot face 195 Patients who do not report /or these extractions almost invanablj have trouble from infection around these teeth later EXTERNAL DRAINAGE As mentioned before, we think that an) fracture that goes through the jaw in the region of a tooth should be considered an open fracture, and certainlj is this true of those with displacement sufficient to tear the gum fringes visibly If these fractures are seen and wired in the first 48 hours, the rule has been to establish external drainage through the skin all the way to the fracture line If a patient is seen after this period and no infection has developed and the wiring can be done without too much manipulation, external drainage may be omitted, but careful watch should be kept for any sign of its necessity The occurrence of small fngments between the mam ones IS further indication for drainage The external incision need be only I 5 cm long It is placed under the jaw, usually m the general direction of the inframandibulat branch of the seventh nerve, which crosses over the body at about the midpoint along with the facial artery, and so in cisions behind this point are especially likely to cut this nerve The knife should go just through the skin, and deep separation to the bone should be made with forceps or scissors These wounds usually heal with little scar and may prevent serious infection with prolonged or permanent swelling of the side of the face This is a surgical pro cedure that offers dependent drainage of an almost assuredly infected field (Tig 183) This rule is not as important if chemotherapy is employed REMOVAL OF UiREs AND GENERAL RESULTS Single fractures sbould be kept fixed 3 to 5 weeks At the end of this time there will usually be some play between the teeth, and the patient will have a good idea about the solidity of the fragments If infeaion is still present, fixation may be prolonged Double fractures are usually fixed from 6 to 8 weeks The wires are removed carefully after cutting them apart and cutting each loop around the teeth with sharp, strong wire cutters If a tooth in the fracture Ime has been saved for fixation, there will frequently be some springiness m the union, but this should become solid after the tooth is finally removed Only very infrequent cases will need to be resplinted Occlusion should be normal, but one of the involved teeth may be loose and cause a slight malocdusion, or it may be necessary to have an annoying cusp of some tooth cut down Persistent swelling of the face about the fracture line may occur, especially if abscess formation has occurred from lack of, or inadequate, drainage (Fig 183) PersistCTt infection and discharge, either internal or external, usually is an indica tion of a low grade osteomyelitis or the presence of \ small fragment that nature is trying to throw off Anesthesia of the lip and teeth may be permanent if the mandibular nerve has been cut across by the fragments X RAY FINDINGS X ray films should be taken toward the end of, or just after, the period of fixation If tlie teeth have maintained normal occlusion and function is good, the position of the fragments will necessarily be good though perhaps not perfect Valuable information is also given concerning the condition of the tooth roots close to fracture lines Persistence of Fracsiire Line on X raj Films An important point in late x ray find mgs m lower, and also upper, yaw fractures is that the fracture line may be solid obyec lively and subjectively and may still show plainly on the plate as though there were little or no union Tins has been frequently olwived, but as yet we have no satisfactory ex planation of the phenomenon (Fig 184) FIXATION WITH DENTAL SPLINTS AND WIRE ARCUES There ote many Sitisfactory dental appliances for splinting fractured jaws, but most of them require the skill of a 196 DIAGNOSIS AND TREATMCNT Or SPCaFlC INJURIES Fg 184 Pm sierice of fracture 1 nt on X ray film Fncture beg ns at Syn pl>j s and extenls ohr quely back to molar reg on Th s type may be slou m becom ng sol J tf 1 eld « 1 interdental w res because of rocking of the fragments on shallow ng and t may be netc n on from poor fixai on may be contr but ng cat scs but ih s lack of etic urn may be found at t mes in cases n wl ch heil ng I js ptogrtssed normally Tl s r an im portant med colegal po nt tig 185 Huccal anh feed to upper jaw Photo of buccal arch used In a »ety d fTnilt syn ’'I ys » fracture fompi cafeJ by muit pie fractures in upper |aw niACrUKES OI JA%S AND DELATED DOMES Of FACE JP7 dental surgeon, and it would be impossible to include here all the individual ideas that hive been recorded A simple procedure is to ligate a metal bar around the buccal surface of several teeth If this does not suffice, a similar bar cm be put on the upper teeth and the two fastened together Rjsdon has suggested that the arch be formed by using tegular fracture wires on the posterior teeth on both sides and then bringing them around in front and fastening them together Smaller individual wires then are used to fasten this arch to the teeth (fig 185) Fig t86 Simplest type of anterior splint with simple wires from posterior teeth fastened m front and to separate teeth and held to the upper denture with elastic bands Chm vertex bandage IS used for support ELASTIC TRACTION Although It IS found b) most surgeons that immediate firm fixation of jaw fractures gives the best results there are some instances in which elastic traction from one jaw to the o her may be indicated If a patient is seen some days or weeks after the injury and the fracture line is not solid but the jaw is out of position instead of breaking up what union has already been obtained, the orthodontic principle of elastic traction may be applied Treatment of ImUttdiMl and Complicated Cases When a fractured jaw is but a part of the injury, it can usually be supported with bandaging until full diagnosis and necessary treatment are afforded other parts Tull x ray studies of the skull and cervical spine may frequently be indicated, and the entire situation should be well in hand before attempts are made at fixation of the jaw FRACTURES COMPOUNDED EXTERNALLY The fragments are cared for as described previously if teeth are available for fixation Tlic soft parts should be approximated accurately, but external dependent drainage on be provided for through the wound if It IS situated properly Tliere is frequently a drawing in Of these scars to the bone, and secondary suturing may be necessary Ti^ 183 and 191 illustrate the result oca sionally seen of closing a wound of external opening without drasnsge or fixation of the fracture 198 DIAGNOSIS AND TREATMENT OI SPECIFIC INJURIES 187 0««p on of fifth nme branches Dooy landmarks rooRhljr I seated b> palpat < n are shown Th« lowor bordot of the lygonu tod then the c odyic ate detetmned by having the patient open or protrude the mandible The condyle ts almrst ai\a>s defniely felt as it slides forward on the art cular tubercle (eminecKe) The p< int of insertion of the needle u 2 to 2 S tm in front of tf e trai 5 u$ just below the lower border of the ty^oma Tri m I ere it passes brtwren the corono d process and the condyle of li e mand ble (sij. iokJ fossa) and |ust anter or to the art cular tubercle Occasionally jt may be necessiij to base the rnoilli held open s thsf tie spate between the zyRoma and the mand Me nay be increased (Fnm Drown J B ^turp Gjnee \ Obst 53 flJ2 1931 ) Fij: ISa Deep injection of fifth nerse branches Approzimafe relat on of needle and K ny landmarks Needle represented h> straw held in place *«ih modelmj: clay On lU course inward to the pferypo d plate tlie needle passes ibrtuph the pas td pland the nuiseier temptral and external pieopt'd miscles It may als » enctiuofer the irans'TtK facial internal nutillary miJJIe meningeal and masseteric arteries ^ far we base not seen any untoward results from flic pasupe of the needle through these iiruclutrs sbhovKh we base had several bfisk liemonhiRes throuRh the needle FRACTURES OF jAtTS AND RELATED BONES OF FACE JP9 FRACTURES WITH DEPRESSED FRAGMENTS AND NEED OF CIRCUMFERENTIAL WIRING In cases in which a block of ihe full thickness has been broken out and has been pulled down into the neck, it ma) be necessary to encircle this fragment with wire to pull It up in place and fix it Double strands of No 24 sihcr wire ate used and passed through the floor of the mouth on the inside of the fragment with a large needle This comes out through a wound, or stab wound, under the jaw and is passed back into the mouth on the outside of the jaw If teeth are present the loops arc tw isted together after one has been brought through an interdental space This gives a good hold on the fragment, and it may be manipulated into position and fastened to wires on upper teeth or to w hates er fixation is emplojed OPEN COMMINUTED FRACTURES These fcactures result from crushing injuries explosions and gunshot wounds 'Hiere may be badly fragmented and sloughed soft tissues containing dirt and foreign bodies Here again the mam object of treatment should be earned out the alignment of the lower jaw so that it o'cludes properly with the upper Widespread defandem^nt of bone fragments with little or no replacem'^nt or fixation followed b} a laborious debridement and closure of the soft parts cannot be too Fig 189 Deep injection of fifth nerve branches The deep course of the needle is shown After gently striking the pterygoid pUte by short withdrawals and reinsertions the point of the needle u carried up to Ihe undersurface of the great wmg of the sphenoid bone which is about at a tight angle to the pterygoid plate rrom now on this wndersurface of the gresfer wtng is equally as important as a landmark as is Ihe pterygoid plate To inject the third division the needle is earned backward by short withdrawals and rensertjons agaiast Ihe pterygoid plate and rs heU up against the sphenoid wrng When the posterior border of the plate is reached the needle slips off and the patient usually momentarily experiences severe pain The fluid is injeaed here It is not absolutely essential to get the pain of a direct hit of the nerve before injecting the fluid If it is not thought that a direct hit has been obtained an extra amount of fluid may be deposited, and a longer bme should be allowed for the development of ancsthesu Ten minutes may be necessary It is important to remember the rule of not going posteriorly or deep more than 0 $ to 1 cm from the edge of the plate Damage may be done to the internal carotid artery the middle meningeal artery or the eustachian tube The pharyngeal mucosa may even be punctured and fluid allowed into the throat This might also happen if enough were deposited in the ctutachiao tube It IS also possible to go enti/elj through Ihe foiamm ovale and inject the ganghoa duectly This has not been done so far nor have attempts been made to inject the first division because it IS thought that the probable paralysis of other nerves and the puncture of the dura mater might not justify Ihe procedure To inject the second division, the needle is canted forward to the sphenomaxillary fossa and the fluid IS deposited there Straws are placed to show the third division emerging from the foramen ovale and the second division coursing across the sphenomaxillary fossa (From Brown, J B Surg Gynec &Obst 53 852. 1931 ) 200 DIAGNOSIS AND TREATAIENT OF SPrOFIC INJOWrs sc\etely condemned It ^ould be bettet to sa\e detached bone frapments than to throu away viable ones and it would be bcUct to pack the soft tissues open than to fail to a) gn the bone fragments Periosteum if recognized shoul 1 never be sacrificed Each of these cases presents special problems but a general plan of are maj be outlincil Some type of anesthes a is necessary Deep block of the third division is ideal general anesthesia of any type including rectal is to be avoided unless tracheotoni) is arranged for (Figs 187 189) Ff; 190 Diect booe uinns nrctimfetcnt al wu Or«n fraclore $u«3 nrd In fall on plowbare rxterrul wound closed oo dca imsc nubJ shed and notl og done to repUee jaw Iras menu g ving good chince for doelopnienl of osteojnyel u* Marked duplaccment and comm njt on of fragroenu Open teducuoti w th direct and oraunfcmitii! wiring netessafy Qftomfemii j! » te also placed around jympbysii and anchored above to intcrdenu! wire FRACTURES OF JAWS AND RELATED BONES OF FACE 201 A careful search should be made of the wound and dirt foreign bodies and ac cessible bullets should be remo\ed Frank sloughs and completelj detached bone frag ments should be remo\ed and Mable bone fragments replaced It ma) be necessary to drill the fragments for fixation Mith silver wire or tendon of circumferential wires may be used When the veiy best possible plan for bone replacement is worked out th“ soft tissue replacement may be done Known points are searched for and closed and the remaining areas are closed with these key points as guides Dependent drainage up to the bone must be adecjuate If the floor of the mouth is torn open it is not closed tightly but preferably is packed with iodoform gauze (Figs 190 192) If fixat on to the upper jaw is impossible the metal band wired to the teeth may be used The jaws may closed as accurately as possble and supported with a well padded chin and elastic bandage F g I9l Cxtenial wound of patient m F g 190 It has been roughip but t ghtly do cd and Ihe jaw fragments left unfixed and not dra ned Wound opened to afford dra nage when w res were appi ed as shown n Fig 190 If the patent u edentulous and hs denture is available the fragments may be fitted into It and fastened to it with orcumferential v res around the plate and jaw This denture may m turn be fastened to the upper denture and a sling used under the ch n (Fig 195) The aftercare of these patients is tedious and discouraging especially when bone fragments keep separating Drainage must be kept up and some fixation maintained /requ«itly as long as 12 weeks These pat ents suffer sectional loss of bone with resultant narrowing of the jaw but if separation of the fragments can be maintained sepsis con trolled and any surrounding periosteum preserved regeneration and solidity may occur FRACTURES WITH LOSS OF SUBSTANCE In thcse cascs if any teeth rema n in any fragments wiring them m pos tion ^ould be done even (hough there may be 202 DIAGNOSIS AND TREATMtNT OF SPEaMC INJUXIES a. definite in the bone A dental splint speaally constructed should be used, but, if this is not available, a metal bar fastened around the buccal surface of the teeth may be used If an) siable slivers or periosteum has been left in the defect, ^ood regeneration may be the result, but the general result is a nairovvtng of the )aw that v.il! require bone grafting if function is impossible (Fig 193) FRArrURES OF JAWS AND RELATED DOMES OF FACE 203 Ttg 195 Loss of substance from infect on osteurnyelit s A V! idespread osteomyel t s follow •ng fracture durng extract on of an acutely infected tooth with full (h cluiess loss of substance External dependent drainage was ma nta ned for some weeks and the dead fragments were allowed to separate themselves after which they were removed from the area TTie jav, fended to collapse toward the rmdlinc but the large fragment with teeth n tt was wired to the upper jaw m its correct occlus on B Three months later New bone growing across gap no sequestra visible C Complete regenerat on of bone through area that gave normal funct on and occlusion m rest of jaw TRACTURES OF JAWS AND RELATED BONES OF FACE 205 FRACTURES OF EDENTULOUS JAWS TREATED BY INTERNAL WIRE PIN FIXATION These fractures are not considered open in the mouth unless there is definite evidence and external drainage is guided accordingly If there is little or no displacement rest may be sufScient If denhzres are asailable, to haie these in place and a supportive bandage under the chin may increase comfort If there is displacement and the frag ments can be fitted into the dentures fixation may be obtained in this uaj, or it may be necessary to put circumferential wires around the denture and jaw (Figs 192 and 195) Vig 196 Direct wiring of jaw Wires Ihroo^h anJ around edentulous f/ajiments Jf ingmenli are oblique as shos^n here it tnajr not be necessary to drill holes for wires Fir 197 Method of drilling and fixing fragments A wire loop has been passed through the hole in the posterior fragment to receive the s Ivcr wire If there is much obhrjuit^ of the fracture line one or two circumferential vires directl) around the bone plus a supportive bandage nuy suffice (fig 190) If displacement is marl.ed, open reduction, drilling and direct wiring of the frag ments may be necessarj It is frequently necessary to have some change made m the fitting of the denture after healing is complete (Fig 196) 206 DIACNOStS AND TREATMENT OF SPEOFIC INJURtCS Howevet the simplest means of fixing; the fractured endentulous mandible^ v,hen reduction has been eiTc-cted is with the use of internal une pins driien across the frac ture site As m other complicated fractures of the Jower jaw, this maj be used alone or in combination u ith other means of stabilization (Fig 191) FRACTURES OF RAMUS, CONDYLE, AND OTRONOiD PROCESS As mentioned prc viously fractures through the nech of the condyle are not as lilcl) to displace badlj as IS commonly bcliered and interdental wiring m occlusion will usuilly suffice The same thing applies to fractures of the ramus itself (figs 19S 200 and 201) If the condjie does tip entirely out of line necrosis or ankylosis may result and resection become neccs sary The advisability of immediate!) excising these displaced condyles is not clear be cause good function ma) result even m these cases following a period of fixation in occlusion Operative methods base been adso ated for pushini, condyles down into place with certain designed instruments both from within and from outside the mouth Trac tures with dislocation maj require onij fixaton but if there is complete displacement resection may be necessary Fi; I9ft Frariure of conJ)le the netk f lie uiHtflc has been fraitured anil pulleJ f (ward somcwhit by tie external plerysoi i miisrie Tic ijTipin,?e on Ibe audiKxy canal and ca *e Weed nfi from it Treatment by «irinA tl e jaws in notfital occlusion was successful *nJ the condyle apparently retained its siiality Opposite condyle was also broken but was n f displaced as rn fh The cotonoid process is only infrequently fiacturcd There may be a contplicatmg fracture of the zygomatic process that reijuircs clccalton or there may be a trismus that requires physical therapy dilating the jaws and blocking them open for from 10 to Id days There should be no effect on occlusion fnim this fracture The temporal muscle may pull the fragment high in the fossa (I ig 201 ) FRACTURES IN CHILDREN AND INFANTS fliiUrcn With teeth may luxe interdental wiring done using light wire or some form of dental splint may be applied Fractures m infants fortunately are mfreciucnt If there is unconirollablc disphccmcnt it may be necessary to do direct bone wiring but usually an niterni! vtre pin can be drixen across the fracture site bcloxx the tooth buds Very ocasionilly a second dentition uncrupleil toolJi may beci*me infected and cause persistent drainage until it is remoxed from the jaw FRACTURES OF /AWS AND RELATED BONES OF FACL 207 PATHOLOGIC FRACTURES If pathologic fractures result from benign processes fixation m occlusion should be done and an attempt made to remove the offending cjst or tumor without destro)ing the periosteum If such a growth is removed first and the danger of fracture is recogni2ed because of the reduced volume of bone interdental wiring IS frequently resorted to for protection against fracture if a malignant process accounts for the fracture the immediate treatment should be of the process, and in this instance little thought is given to the occlusion unless it is possible to w ire one side of the /aw m occlusion Fig 199 Position for ndiograin of condyle and associated region in ramus Kilovoltage 60 milljfljnperage 20 distance 28 inches tsme % second (Courtesy Dr Shemood Moore Malhn ckrodt Inst tute of Rad ology Waslungton University School of Medicine ) INFECTED FRACTURES — OSTEOMYELITIS If there IS communication with the mouth contamination about the fracture site is certain and frequently a mild infection develops If drainage is inadequate there ma) be widespread soft tissue infection with abscess formation and some loss of bone if the infection continues over a long penod This tj’pe of infection seldom proceeds to the wide block necrosis that may be associated with dental infection, but conversely those instances of widespread bone necrosis that are assoaated with extraction of acutelj infected teeth maj develop fractures These should be cared for as other fractures with speaal effort at maintaining soft tissue drainage preserving the periosteum and allowing necrosed bone to separate itself from surround ruACWRCS or javfs and RrLArro noNrs or facc 209 mg Jne bone before attempting to femo\e it This conservative treatment in regard to dead fragments gi\es the cjuickest md least complicated healing position may be the most accurately miintamed an and the tooth becomes solid it might be left in place but there js usuxll) trouble ot discomfort later that necessitates extraction Feeding Diinug Treatment It is neser neccssar} to retnose teeth to feed these patients The use of a stomach tube passed through the nose siould be preferable to the removal of sound front teeth hlan) patients ahead) have one or more teeth miss ing there is usually some space behind the last molars and occlusion is seldom so accurate that fluids cannot be got betiaecn the jaws Tlie diet will ncccssanl) have to be liquid or very soft After a few days an enter prising patient will be looking after his own diet satisfactnnly The following basic diet has a fairlyr normal balance of protein (71 grams) fit (102 grams), and carbohydrate (362 grains) and supplies about 2 600 calorics Calofio npisS ( <1511 It/i pt 180 Cream 20'/- pt 480 Stra ntd tomstDcv or othtr ' i T* SiRir Karoorgluase 10 tc l 200 I tcaspoinful 26V This diet may lx: mixed together and fcil through a tube or the ingredients may be made into any combinations desired Coffee lea ice cream fruit yuices and any flavoring may be added at w ill As other articles of diet arc bken such as ccrcils and ground meat, the total caloric V 110“ of the suggested basic diet may be cut down accordingly FRACTURES OF UPPER JAW General Consideratiom Tlie upper jaw presents a complicated problem for con sideracion when wc deal with injuries about the face for the following reasons 1 Both sides must be taken into account because of the transverse involvement in many instances (Figs 204 206 208 209 211) 2 Skull fracture and brain injury are such frequent complications that the possibility must always be considered (Figs 210 213) 3 All of the associated bones of the face may be involved which include the mxxilla zygoma, zygomatic arch of the temporal, nasal ethmoid and frontal bones palate and both the bony and cartilaginous nasal septumS (Fig 204 ) 4 The presence of (he sinuses and fracture lines through them enhances the chance of infection (Figs 204 210 213) 5 The nasal passages may be occluded and require early restoration (Iigs 207 210 211 213 215) 6 Displacement of the eyeball may occur with resultant diplopia (Iigs 20S 215) 7 Blindness may result from direct section of the nerve by one of the thin fragments of bone or by intraocular in;ur) Tlicrc may also be direct injury of the external ocular muscles or Ihcir nerves (Figs 20l 211 213) 8 Tlie lacrimal duct may be occluded (Figs 210 213 215) 9 Tbc associated injuries of the soft parts may be so great as to delay or hinder atfen tion to the bone displacement (Figs 210 215 215) 10 Bcausc of tlie possible permanent changing of the features both from soft tissue injury and from bony displacement it is necessary to include consideration of tins point in carrying out treatment in addition to the consideration of function (ligs 210 213, 215) FRACTURES OF JA\SS AND RELATED BONES OF FACE 215 lemporat bone is either crumpled inward by a sharp blow from the side or is coiiapscu by a blow from the front transmitted Ihrou^ the z>A^a comminuted Tb. may be » a.utoon ol the tranure enutcly amend the antrum The “be b«d to locate and hold in along the right side of the nose and such a fragment may t>e ry that eatend acro.a the tace a-e ».ua',y at the hi.heat le.e, (mhed m a. the glabella) but they may also be down lower just above the alveolus .y,. jaaimal bone tL aepamTionU eatytd into the ^STliVunTo he^^^^^ to occlude the lacrimal dutt deep in tl e orbit and Ihroosh the Kinea or tne t the separated Irom any toM mrdom m dclphia 1937 J D Lippincott Co ) 214 DtACNOSK AND TREATMENT OF SPEOttC INJURIES Heav") blunt crushing blosss arc usuall) the cause of fractures of the upper ;aw eg a heas-j jmpact of another s head or knee in sports the kick of a horse or a jam against a steering wheel or other part of a car in a traffic accident As stated an) other of the facial bones may be m\ohed and in fact man) fractures of the maxilla are from indirect violence which his been first received b) the ijgoma (milat oc >-oke bone) the prominent bone of the check Tlie extent of the fracture ma) vary from a simple alveolar avub on to a complete transverse separation of all the facial bones frim the skull so that they hang m a soft tissue slmg (Fig 210) The bon) orbit ma) be broken through and displaced so that the action of the extrinsic ocular muscles is interfered with and diplop a ma) result Blindn'^s may result from direct tnjut) to the globe intraocular hemorrhage or occasional!) b) direct injuf) to the optic nerve In one severe case the globe was nvt grossly in/ured but the nerve was found ait in two and the remaining distal end turnc 1 around and pointinq forward When the nasal sinuses are involved m the fracture line the question of infection and drainage arises This depends to a great extent upon the condition of the nose and sinuses before the accident and the un(!crl)mg principles of treatment are restoration of contour and maintenance of drainage If the lacrimal duct is torn or blocked a dacr)oc}Stiti$ ma) develop that fiiully may requ re excision of the sac This is never done primarily (Figs 210 and 213) Disp/10 Cntry t> tic antrum «as made (hroufth an icKis on in tie buccal fom * mucosa an i then (Irou;:h liic fracture of tlie antral wall The orbul border *js cart ed op into place and pacLrd *ilh 1 inch «od>fom» ginie The nxloform jtauzo is shown m place 17 days later just before it was renimed FRACTURES OF JAWS AND RELATED BONES OF FACE 219 If there is bulk displacement of the %hole side of the face and tendency for recur lence of the deformity open reduction and winn^ of the fragments maj be necessat) If diplopia does not occur and there is only sli^t external deformity about which the patient is not concerned, no special attempt need he made at delation Many methods ha\e been offered for clcsating a depressed zygomatic arch (1) towel dips and hooks to pull it in position from the outside (Fig 212), ( 2 ) heaiy soundhke instruments to ele\ate it from the inside of the mouth bj application high Fig 210 Comm nuted fracturw of facul and frontal bones X ray film shown in Fig 209 Til $ patient was seen soon after a 1 1 foot fall in which be was struck directly aaoss the face Immediate replacement of the markedly comminuted fragments was done rubber tubes were left in the frontal sinuses (these tubes were nut irrigated) and the fragments of the nose were held up and in place with through and (hrough wires as shown in Fig 207 The final results show good restoration of the nasal bridge and more impottanc good situation and direction of the infernal cant! I These patients should be watched lot evidence oi sinus blockage wh ch was suspected at one time later in this patient but he did not return for treatment 220 DIAGNOSIS AND TREATMENT OF SPraFIC INJURIES 211 X ray film of opfn njury to tSe fac al aoj fron al bones a few of ll e man) fracture 1 nej 1 a e b«n acra ched n ^mc pa ent as shown n Tg 207 I g ’P Draw ng on ph og aph of method of reduction of fraet rc of aygomat c attb n ol ng o Jer aitachmcn » of 7)gonta a» •HI Pot t on of hea^y hoi k hetieath flange of ogema after p cre ng of il n Re>en ng the d reef n th oueh which Ue rygoma has pj sod by pull ng on the hw k ft c surgeon gu do it in o mpacfoJ redu t on * h f ng«s of o her hand on upj'er bo Jer f b*ne T1 $ s tie melliod of cho e for the usual aygonat c arcl fra lu e a o d ng o ion obo c I a rl ne 11 weicr r\t ci e Ci e stu old he taken tn keep upward pull f h >c k c ntrollrJ at all I irei fa lu r f fragmen s to mpa t fy lbs netloJ or any other type of rrduci xi necess fates tlung ng to approach ll rough fracture I ne aho e can ne foi a wh h al ows for f xai xj by use of n emal spl nt n form of pack a antn m (rrom rryer M P S Cl n. N nl AtiKrca30 l}6l 19J0 ) niACTUKES OF JAWS AND JirLATTD BONES OF FACE 221 up outside the coronoid process (lig 206) and (3) open reduction by inserting a sound through the scalp of the temporal region, down along the temporal muscle to ward the coronoid and then ele\a(ing Che /ra^ent from here (Gil/ies) Simple de pressions of the zygomatic arch are, honoer rather infrequent To have this injury alone a blow is necessarj directlj from the side and applied directly to the arch itself If there is no trismus and no appreciable defocimt), little need be done except perhaps a simple external elevation with a hooL If this docs not suffice, the other procedures may be tried (Fig 212) COMPLICATED CASES OR FACIAL CRUSHES There maj be extreme laceration con tusion, comminution of bone and presence of {otei},n bodices Hemorrhage maj be severe and the airway obstructed The general and neurologic care of the patient may first re quire some hours Emphjsema is best controlled by cleaning out a free airway and if necessary pack mg (he nostrils Hemorrhage may require this pick plus one in the posterior nates Tracheotomy may be neccssur) although a simple rubber tube placed through the mouth may suffice and make the patient comfortable until the difficulties can be con trolled (Figs 191, 200 201 210) Pij, 215 A ENtemi’.c soft tissue leanoe. combined w«h comm n« on of ficial bones There IS wide separation of soft tis$u« and tone to a depth of 5 cm the inner canthus being badly displaced The patient was seen immediately Complete fijcati n and repair were done under biock anesthesia The most important features in this operation are to set in the inner canthus and mam ta n It lo hold the frontal process of the maxilla and the nasal bones in place and to close the soft tissues accurately B FimJ result with good posit on and direil on of the canthus and a Jinear scar on the nose the nostril is somewhat small due to an actual loss of tissue at the alar border Closure of this type of soft tissue lacerat on will out replacing and hold ng the bones would almost cetta niy necesiitate further operation For cleaning the individual case with torn soft tissues careful debridement removal of foreign bodies aligtun-nt and fixation of fragments and closure of soft parts should be amed out No considerable portKwi of bone should be sacrificed Fragments Will live with surprisingly little attachment and they should be replaced along with any known periosteum even if the contour is maintained by but a shell of bone As m the lower )aw this bone replacement should not be sacnfic^ in favor of soft tissue restora tion (Fig 215) The nasal airway should be restored if possible preferably by carefully choosing die through passage with normal lining piec^ out as accurately as possible and then inserting a large rubber tube through the infeaor meatus These injuries may show 224 DMGNOSrS AND TRHAT^trNT OF SPCOFIC >NJURir« Multiple internal v^ires can be used for multfple fractures or to gne the second plane of fixation if desirable (Fig 194) Ato/Haiice of the vertc canal is advisable even though the nerse inaj base been cut in hso b) displacement of the fragments The same is true of an) good teeth and this can usually be done by sta)ing below the canal When a second wire is placed abo\e the low er one there is more chance of damage of the nerve and teeth Fig ’IJ /I Severe fansl m/uiy Ijccral on* of pper eyet d anJ nose eoirwn outnl fraclure of nose jnd fra {ure-d siocat on of left rygonu B and C ricvaiion and (ixai on of fractumi nne with eatcmal spliQl repa r of lateraled iof( Issues and reduced left eygoma held n reduct n with internal w re p n us ng opposite aygoou » point of lol d ty D fold bony heal ng in re- du ed posit on One opera! on An clcctnc power drill is practicallj ncccssai) as the hand drill ma) not gne enough speed for easy penetration of tJic bone Regular Kirschncr wires may be used but stainless steel wires recommended b> Dr C H Crego m leg lengthening arc cheaper and cm be obtained in $u fable lengths of thickness from 05 inch to OS inch a threc-s ded point being put on them • »n i wire IS 111 8 sUinlrts iletJ The Msullat s « to g vp |Sp nfcpssjry siiTopit is prrf prable FRACTURES OF JA\tS AND RELATED BONES OF FACE 22} Local or deep block anesthesia is usually emplo)ed Tlie fragments are alined with the hands, or an open reduction may be necessary, an elevator being used between the fragments It is important that reduction be accurate, as onlj slight adjustment is possible after the wire is in ’ A puncture incision is made to get the wire in against the bone, and the wire and drill are lined up accurately Then, perhaps most important of all, the fragments have to be held in accurate position with the hands while the wire is drilled into place (Little mention need be made of the neccssiij of care with the drill and wire, and for a\oid ance of in/uiy to the hands that are hiding the fragments ) The wire usually is drilled on through the bone and a small opening is made to let it through the skin on the other side Secondarj internal wires may be needed occasionallj The anterior arch wire is applied by putting No 26 stainless steel wires on posterior teeth on each side twisting the strands li^tly for 2 inches, then tw isting them together in midline and holding them with individual No 28 wires around separate teeth Any other type of arch appliance may be used, but this one requires no added equipment and is usually satisfactor) ' This IS the wire that should suffice for the second and final plane of fixation and should impact the fragments together o\cr the internal w ire "Iiiterdenial fixtihon is done as mentioned if there is some final adjustment of occlusion to be secured or if the condyles also base been fractured The jaws may be fastened directly together or by any effectne method of elastic traction '7ii edeiiliilous pus when dental plates wired or bandaged in place with the mouth closed will not suffice, a single internal wire maj be effectne as the jaws are usually small from atroph) anj-way This plan for edentulous jaws seems mu.h less trouble for (he patient and surgeon than attempting any rigid fixation within the mouth with screws down into the bone and nenecanal 'Pressure dressings, of soft cotton mechanics waste, are applied to gi\e support to the soft tissues and present, as far as possible hematonus, hemorrhage, and swelling and also to lend further support to the bone fngments ' The /aw seems solid immediately and the patient experiences the usual comfort of a set fracture The ends of the wire are cohered and the patients do not object much to discomfort In some instances, (he wires may be cut short enough to be covered by tile skin, but it is probable that they all should be removed finallj Just one or two dajs ■ arc required in the hospital, and some patients can open the jaws and take soft foods almost unmcdkatel^ Tie remaial of the Hires can be done easily after 3 to 5 weeks, depending upon the progress There may be some irritation around the wires but no serious osteomyelitis should develop This plan was thought to be new, but arttclcs on the subject were found by Ipsen and Sobye in Denmark and Meade in Ireland, and these men seem to have been the only ones to have repotted it In the voluminous literature from the last war and since then there has been a multipliaty of dental splints, often with emphasis on some contnv’ance of little fundi mental bearing If this simple direct method of internal wire fixation by drilling a wire across the fragments will help avoid the use of complicated dental splints overhead plaster cap traction for elevated posterior fragments, and wide open reductions, it will be worthwhile TRACTURE OF NASAL BONES The nasal bones are broken oftener than any other bones of the face (perhaps oftener than any other bone m the body) Fiacture of the nasal bones themselves is not so frequent as is separation of thetr suture hoe from the frontal processes of the maxilla 226 PWGNOSIS AND TREATMENT OF SPCaFlC INJURIES or separation of the lateral cartilages from the nasal bones thcmsches Tlie frontal processes of the maxilla ma) also ^ separated from the bod) of the maxilla and be classed as a nasal fracture It is this t)pc that frequently accompanies extcnsnc fractures of the facial bones, and displacement inward ts almost sure to occlude the airwa) Dispiacemeul A blos^ direct from the front is likely to comminute and crush down the nasal bones themselves and perhaps break or deform the septum from the side the nasal bone or frontal process is broken in, or the lateral cartilage is separated from the bone This last displacement nu> almost cotrert itself, but other fractures usuall) sta) where the force has placed them Diagnosis following a blow on the nose if there has been hemorrhage from the inside some t)pc of fracture or separation has occurrctl that has been great enough to cut the nasal mucosa Tins is an important point because by the lime the patient is seen there may be so much external swelling that little can be dctennincd about external tig 216 Comininuted frativre of nasal bones (Couilwy Or ) deformity If there is not frank displacement careful palpation should be done, feeling for any slight clicks or grating of bone fragments 'Ilic nasal passages should be care full) cleaned out (cocainized if necessary), and careful inspection of the mucosa should be made Gross occlusion of the passages ma) be present and dilation b) the sjxtulum nuy elicit a click and some pain If this is not present but there has been bleeding the tear m the mucosa can nearly alw3)s be found Tins gives an idea of the site of the separation, and the septum and its mucosa should be carefull) examined If there is no tear, there may be a submucous hematoma, which should ht opened As much informa tion as possible should be obtained from the patient about the condition of the inside of his nose and the septum and also about the exttmil contour It should be rtmembered that ver) few noses arc perfectly straight, but unfortunately few patients seem to know this and until (he injur) have paid little attention to Uic exact contour of their ni»vc5, but just suppose it to be perfectly straight and in the midline FRACTURCS or JAVS AND RELATED BONES OF FACE 227 X RAY DIAGNOSIS X ray films may help somewhat for records and to determine the degree of comminution Their most accurate infomiation is given m rases of fracture of the frontal process of the maxilla, but this shows best on a posteroanterior or vertico submental view X ray films of childrens noses are usually worthless (Fsg 216) Treatment Fractures of the nasal bones may occur with or without complications UNCOMPLICATED CASES Most Simple fracturcs can be set (under local anesthesia) with a Kelly forceps inside the nostril to raise the fragment into position Frequentl) a distinct click will be heard and felt both bj the operator and the patient as the fragments approach their normal positions External molding with the fingers may help if there is wide displacement The replaced fragments frequently will remain m position without support, but narrow* iodoform gauze may be packed high up in the nostril to be retained as a splint This is changed in 48 hours or left out if fixation is firm A light metal splint (aluminum) is used over the nose, molding it into position, and is mam tamed 7 to 10 days Fig 217 Correction of old depressed nasal fracture with costal cartilage transplant Th s operation is thought to be necessary frequently because of the similarity of the deformity to that of a Joss of structure from syphilis COMPLICATED CASES Severe comminution and displacement witJi soft tissue laccra tion requires careful sorting and replacement of parts, packing should be light and if there is question of fracture higher up rubber tubing might be used through the meati, or the packing may be changed at least every 24 hours A simple method of restoring narrowness when the nose has been flattened is lo put a through and through fine wire stitch from side to side under the fragments and through the septum and tie them over perforated lead plates on the side of the nose, pulling them up carefully so that necrosis will not occur (Fig 207) Late complications There may be loss of substance that leaves a depressed bridge, and, if a natural appearance is desired, a transplant of costal cartilage may be necessary (Fig 217) There is occasionally a periostitis that proliferates along the bony dorsum so much as to make i definite humped deformity Tfes is removed with the chisel preferably in serted through an incision just inside the ala and up under the skin of the dorsum which has been raised (Figs 218 219) Continued bony displacement with deviation to one side may need complete freeing 228 DMCNOSIS AND TRLATJtCNl OF SllCiriC INJUBIE’J IRACTURrS OF JAWS AND RLLATCD BONCS OF FACE 229 of the bony nose and replacement in midl ne Tliis is done with saws or chisels ctrried along the maxilla at the point of fc/Jertton of the frontal processes beginning inside the nose It may also be necessary to free the septum from the palate and if one si Ic IS a great deal higher thin the other it may be necessary to rcmo^c a tr angle of bone from this side before the nose is mmed to the center (I ig '>20) F i. 22C Progress ve defor n f) as result of fra ture n ch IdhooJ Th s no e had des ated $ far to the t ght that ui the corcectioa t was oecessacy to ren o c a triangle of bone fron the left s de and then sv. ng t to the left after sect on ng the frontal process on the r ght TI c pos t OR ip^as ma nta ned by a w re and ored to a molar looih on the left $ de v tl the loop of lie w re caught around the lower angle of tl e loosened frontal p ociss n the r ght s de See F g 1 When the nose is mobi! zed it is swung into a si ght overcorrection and held there t iher with the external spl nt and pack ng as a broken nose or with a wire looped around the lower angle of the detached bone or through the septum w th a lead plate 230 DIAGNOSIS AND TOFATMENT OF SPEOHC INJURIFS to prevent cutting and brought on out into the bucal fornix and vvircil to a tooth (Fig 221) Sepitm Deualion Tlie nasal spine m old cases nu) be firmi) united on one side of the midline and carr) VMth it the septum so as to produce as)mmcfry and possibly inter ference with breathing The dispbeed nasal spine may be dctaclicd w ith a chisel and held over in position with a wire anchored to a tooth as is shown in big 221 If the cartilaginous septum itself is deviated at its tip into one nostril it nny be loosened along its lower attachment and sectioned from above downward where it bends over and then pushed over into the midime and held with mattress sutures through the columella and its own edge Some excess mucosi mty be excised from the promi nent side Resection of parts of the septum may be necessary later if brenlhing is im paired Whether these offending parts of the septum are the direct result of the trauma or whether they are old deviations mide more noticeable is not always clear (I ig ’2"’) rie D iphietnenl f nasal *pwK and septun F an iniuty the lowrr rn I of lie septum extended d rctlly into ll»e nchl nostnl It was repIareJ by 1 xisen ng it hclo* cult ng fhrou/jh It at lie bend and lien fxinc it in ils ne* tentral puMiion with mattress sui ires ibfouRh the septum and cniumella If the bon) nasal $p ne is also J tplaced t is fired with a ih set ami t eld over w Ih a wire I a leu th as the nuse is in Fi^s 2'0anl2'’l FRACTURES IN INFANTS AND CHILDREN Cfoss fractutts are lo be cared ft>r much the same as outlined ibovc Tlic instance difficult to deal with is that m which the child has fallen on the nose but ilocs not present any apparent deformity except swell ng Many of these injuctcs really are fractures with a pimhing in or a mashing down of the nasal septum It is possible that this condition if allowed to rcmiuj uncorrccted may acttiunt for some of the uncxpUincil bad deformities of the nose seen later in life (ligs 218 219) lor this reason if is perhaps good practice in all lases of fracture in infants or children to give an anesthetic and gently elesilc any possible depression with a forceps high up in the nostril Tins is a simple procedure and its application may seem a Inf cjuestionable, but it is not so much so as allowing a depression to remain and having the patient suffer extreme nasal deformity as he grows DISLOCATION 01 LOWER JAW The temporomandibular joint is cwnposcU of tiic condyle Ihe glenoid fosu an I the articular tubercle of the temporal bone, the meniscus, and the capsular and three FRACTURES or JAXCS AND RELATED DONES OF FACE 251 Other liysments There is a wjde range of motion in the joint, and the articular surface of the temporal bone is several times greater than that of the condyle General laxity of joint capsules chronic subluxalion and bad occlusion of the teeth are predisposing causes and most cases of dislocation occur in women In many cases of fracture of the condyle there is also dislocation Fortiard Dislocalioa Torward disloatton is the most frequent type and no fracture IS necessary for its production As the mouth opens ot the chin ts protruded the con dyle rides forward on the articular tubercle If it slips forward over the crest anterior dislocation results Giuscs are chronic subluxation blows on the jaw or chin with the mouth open and blows on the ramus Some spontaneous cases occur presumably from overactivity of the external pterygoid muscle which draws the condyle forward followed by contracture of the masseter (Fig 223) Fig 223 One side of a double anterior dislocation that had been unreduced 6 weeks and for which double open reduction was necessary DtSPLACEMENT AND SYMPTOAIS The /aw is held forward with the mouth open chewing is impossible and swallowing and talking are difficult at first The condyle may be felt and seen on the x ray film to be m front of the tubercle Tlie chin deviates to the opposite Side in unilateral dislocation This finding is the opposite m fracture and ankylosis when deviation is toward the affected side Hysterical opening of the mouth may be confusing but may be differentiated by x ray examination or under anesthesia (local or general) TREATMENT If the patient ts seen soon after the dislocation complete relaxation under anesthesia itself may effect reduction If not traction and manipulation may be employed by grasping the jaw with both hands thumbs inside the mouth on the molars (being ready to withdraw the thumbs if the jaw should snap shut) and the fingers out side on the body of the jaw Gentle depression of the molars followed by backward pressure on the whole jaw should carry the condyle down to the level of the articular eminence and allow it to drop into the joint Iirst one side and then the other may be done by pulling downward, outward, and backward on the /aw by holding it finniy in the molar area inside and out The tockward pull is not important because the condyle will slip m the fossa if the head »n be placed well up on the eminence General anesthesia is best, but block anesthesia of the third divisions has been satisfactory 2i2 DIAGNOStS ANB TREATMENT OF SPrOFlC INJURIES If this does not suffice as in cases that hasc been displaced for some bme, more traction may be secured by Gilmers mcthoil A stout flat stick 2 feet Ion;; is placed in the mouth the end resting on the postenor mthtn and the upper mohrs acting as a fulcrum Tlic teeth arc protected Mth rubber or g»ure, and a good amount of pressure can be exertcil to depress the cond)!e |ust below the eminence Obstacles to reduction are tenseness of the muscles and ligaments and infiltration of the surrounding tissues if displaced \er) long Bon) block of the coronoid process under the 2 )goma has been described but is lery infrequent Fif! 22-1 X ny films of temporomand bolar jo nts rhiuld be ulccii *ilh mouth 0{^c^J amt closed KiloiolUsrc 6C milliamperaer ’0 Jisiancr 28 inches time 5 seconds jn^le hoard 21* (Courtesy Dr Sher»f>oJ Mo re MallincLroJl tmtitu e of Radiology XCash ngtort t niiersity Sihfxs! of Medicine ) Open reduction nu) base to be done The joint is aj proached as outlined under ankylosis and llic condjle is elcsated back in place with a cursed clesator If both sides are done, tlie first wound should be left open until the other side is reduced Tlie jaw should be fixed shut m occlusion for fewn 2 to 3 weeks Bandage or plaster cap and sling may suffice but interdental wrnng as for fracture gives the safest retention Aftercare should be protection of the joint avoiding tcnigh food large biles of any kind, and subduing cons-ulsivc lauglimg or wi le yawning t/puwd Dtdocattan A sesete upward biro with the moutii open (most likely if many teeth are missing) might drive the condyle ihroui;h the thm roof of tlie glenoid FRACTURES OF JAWS AND RELATED BONES OF FACE 233 fossa into the middle cranial fossa Mosements arc impaired and the ramus apparently shortened Qosed reduction should be attempted under anesthesia or trephining abo\e might be necessary The usual case is not far out of position and wiring the ;aws in occlusion suffices Backtiard Dtslocattou A backward blow on the chm with the jaw closed might drive the condyle against the tjmpamc plate of the glenoid fossa and crush it into the auditory canal This might frerjiiently be complicated by fracture of the condyle itself Dislocation entirely under the bony aud tory canal has been reported Treatment should be dragging the jan foma/d into its coitsc^ occlusion and fixing It If the canal has been deformed its contour should be restored Otituard Disloealion Outward dislocation has been reported Jt is almost neces sanly complicated by fracture some place in the jaw The condyle should be freed from the zygoma and placed in the fossa and fixation in occlusion done along with whatever care is necessary for the fracture Medial Dislocation This type is almost always associated with fracture of the neck of the condyle or ramus it is extremely tare but may require open reduction Unreduced Dislocations These dislocations necessarily throw off occlusion but the patient may develop surprising function If open reduction fails it may be necessary to resect the condyle Chrome or Recurrent Dislocation Qironic dislocation may tend to occur if not guarded against in some instances The condyle slips o\et and m front of the eminence at any time the mouth is thrown open The first treatment should be voluntary rest and protection of the jaw and the use of a supportive chin bandage a great part of the time Next should be partial fixation of the jaw with dental bands and rubber or silk ligatures that may be removed at will Such an appliance may be worn a number of months There are many operative procedures described for shortening or excising joint capsule ligaments and intra articular cartilage Suhluxattou or Cracking }au ’ Because of some derangement of the joint mechanism and probably of the inlra art cular cartilage there may be a click on moving the jaw This may be a loud audible noise and even temporary locking open may occur The condition is mainly seen m persons with bad occlusion so that all their lives they have unconsciously had to make some effort to gel the jaws mto occlusion In addition there may be a nervous element m which the jaws are kept more or less constantly m motion There may be recurrent pain for a long period but many patients with loud aud ble cracks have no other discomfort Dental manipulation is apparently a frequent starting point of the trouble when the mouth has E>cen held open a long time or the joint traumatized during an extraction X ray studies of this condition arc somewhat disappointing Although patients with marked symptoms may show marked excursion of the condyle beyond the eminence of the glenoid fossa other patients without symptoms may show even more marked excursion Treatment is the same as for chronic dislocation and must be continued permanently in some cases In bad attacks firm fixation by interdental wiring may be done Many operative procedures have been recommended by Annandale Ashhurst Blake Brocken heimer Darcissac Dubecq Mi nro Morns Summa and others Tliey cannot all be referred to here Syndrome of Mandibular Aleniscus Dubecq*" has given a concise review of the subject and from his study thinks that all names sucli as snapping jaw cracking jaw X J Itecherches morphologiques pbys ologiques et cl oiques sut le mimsque manuibulaire luxation hab tucllf et craqoements t^nporo-maxinaim J meJ Bordeaux lt4 125 234 DlAGNOStS AND TREATMFNT OF SPFQFIC INJURIES etc should be discarded and the term [>amful fracking of the jaw substituted He states that the triad of sj-mptoms of pain ciackinp and esentualJ) blocKape should justify recognition of the syndrome of the mandibular meniscus TTus triad of symptoms is not alivajs present however as pirn is frtxjuentl) absent and there may be early blockage in rises due to trauma of orthodontic manipulation or tooth extraction Dubecq pointed out that the mandibular meniscus is an intra articular fibrocartilage that IS movable and that its mam function is to deaden the blo« of the condyle in the glenoid fossa and against the auditory canal It may be affected bj disease or trauma and maj be worn through when the teeth arc lost In the dog the meniscus may be removed with out producinr; symptoms and if (raumatiaed in situ blockage of movement develops This blockage finally disappears because of complete absorption Pa>» S)mf>loMalolog} of Alan^ibutar Join/ The joint is cjuite comphcalcJ in itself m Its anatomy and its movements and is m close assiKiation with other important anatomic structures Much investigation of its movement has been made and deafness has been reported from mterfcrerKe with the cartilaginous auditory canal and custachian tube Painful conditions about the ear and longue hive been traced to injury to the chorda tympani and auriculotemporal nenes by a condyle that has become misplaced or eroded or has not been held away from the glenoid fossa because of the lack of molar teeth Many such patients have been relieved of symptoms by increasing the s-paration of liic jaws m die molar region by the use of disks between the existini, teeth or by building up old dentures or supplying new incs Costen has summarized these investigations and added his own observations * ANKYLOSIS Bony ankylosis may result from a fnctorc of the con lylc with resultant necrosis dislocation unreduced fracture dislocation or from any type of infectious arthritis and may be a complication of mastoid disease Diagr/osis The jaw deviates to the ankylosed side This makes a flatness on the opposite side so tint it looks mote deformed thin the solid side Tliece is usually some swelling about the joint and the lack of movement ran usually be ntted on lare folly palpating both sides The preingular notch along the lower border of the jaw is deepened on the ankylos-d side The mouth can he opened little or hut very slighllj and there is further deviation to the affected side This is evidence against an anterior dislocation which throws the jaw toward th* opposite side It is also important to differentiate ankylosis due to scar bands inside the mouth In long standing cases no one in the patients family may remember which side was originally involved and aentrate determination of the fixed side must b- ma le Roentgenograms are helpful m determining the extent of bony fixation (Tig 225) Trealmetit Resection of the condyle with poss bly the coronoid priKcss and some of the ramus itself may l>e necessary for a cure Stretching or forcefully dilating the jaws apart will never suffice in real bony ankylosis and will usually do harm lascia transplanted into the space may be of help and also allow carl) movement and may cut down the amount of bone to be resected thereby preventing retraction of the jaw The skin incision is a flap from the temporal region down m frt nt of the crus of the helix o'er the tragus and diwn close to the hdic of llic car This gives an almost univoticwWc scat A fascial flap may be turned back but this never is large enough to cover the bony raw surfsce and it retract? into almost nc thing Tliese sup“rficial flaps •Costco J H <>loisoJ)nu Reflex Inuton Tit n ManJKjIar Jont as PiincijwJ In f pc Favi t Siutly of 10 Case* Ar»h Oi Uiyng 21 554 >955 Custen J It NeoraJgui and Har Xjmrioms A«ioeiatnl ^ ith D il theJ I onri on of Tcrrpimv maodhuljrj nt J A M A lo-» JS’ I9Vfi FRACTURhS OF JAWS AND RELATED BONES OP FACE 235 Fig 225 A Solid bony ankylosis of 6 yrjts duration At operation cortical bone appeared to be continuous from ramus to temporal bone B Same to nt -I months after operation Normal function of lower jaw except f< r somewlut lim ted opening C Scar from incision 2 weeks after operation The incision arches through the temporal region goes down just m front of the crus of the helix user the tragus and down immediately in front of the lobe The incision is practically unnoticeable later and may be used for ail approaches to the joint to replace those incisions placed farther out on the face Fig 22$ Bony ankylosis with reJ rf bf fomt nserticw A Only slight opening is possible several years after mastoid disease B Patient 15 ilajrs after operation wnh good opening and with some deviation to the resected side 236 DIAGNOSIS ANT) TREATMENT OF SPEOnC INJURIES are retracted forward but \\jthout loo much traction on the socnUi ncr^c fibers (Ii^ 225, 226) Tlic fascia and masseter ate cut and mused dottoward from the 2 )poma, and the joint IS exposed Rcmosal of bone ts done so that free n)o>aTitnt is obumcii Tlie operation is often a wide resection more than in arthroplastj Some autliocs recommend the removal of part of the zjgoma, but this does not appear necessary The bone is re mo\ed with rongeurs or duscis, and if desired a wide drill mij be used to start or to remove certain areas There should preferably be a free space of at least I cm from ramus to skull with the mouth dosed When suffiaent bone has been removed and movement obtained as free is possible the fascial flap is earned down in the empty space over tlic cut ramus and the super fiaal wound is closed with drainage, or free fascia lata ts used Hemorrluge from the internal maxillary artery may (Kcur and, if it docs, may hive to be controlled with an iodoform pack which may be removed through the lower part of the wound several days later The jaws are carefully dibted to full opening with a mouth gag between the molars and finally are blocked open with a wood block wired between the molars This may throw the jaw closer to the skull but the advantage of the soft tissue stretching is im portant The block is removed in from 7 to M slays If this block is omitted in children active motion of the jaw is encouraged as soon as possible Anesthesia must be guarded because of danger of blocked respiration before the ankylosis is relieved Bilateral A»k)louf liilatcrol ankylosis may occur, and the only hope of function is operation on both sides The worst joint should be treated first, and then, if the mouth cannot be opened, the other sule should be excised This is a radical procedure and may be extremely shocking to the patient The jitt ts forcefully dragged forward as far as possible, even past normal occlusion and wired firmly in position for from 10 to Id weeks Note that it is not to be blxkeil open because to do so may result m the patients inability to close the mouth later Good function usually results if enough bone has been cxcisctl In double resections the jaw may drop btek when the patient goes to sleep on his btek and cxxlude the air way Some suitable position in sleeping will he a matter of training Risdon of Toronto has proposed another procedure for ankylosis that he believes IS superior to joint resection The soft tissues arc elevated from the exicrnal surface from beneath the angle upward and the masseter is taken loose from the border of the jaw leaving a small pirt attached The ramus is drilled through in several places from before backward, about halfway up, or high enough to avoid tlic maxillary nerve and artery Complete section of the bone is then done, and the masseter is split in two from below upward so tlut a broad flap may be earned through the separated bone ends and sutured to the internal pterygoid muscle on the inner side of the jaw The remaining nusseter IS fcsutured to the stump on the bone, and the wound is closed Neither the seventh nerve nor the ankyloswl joint is disturbed A new false joint is produced and the advantages are an easier and less shocking operation and less subsequent retraction of the jaw Tills procedure should be a great improvement over double resection when there 1 $ ankylosis on both sides CIirMOTHERAPY IN COMPOUND TACIAL INjURltS AND )A\V IRACTURLS Wounds of the mouth jaws, and neck, with their marked tendency to infection make the use of antibiotics, peniallin, and the tetracyclines of great impoiUncr External drainage ts necessary, but prompt healing can he expected CHAPTER 8 FRACTURES AND DISLOCATIONS OF HYOID AND FRACTURE OF LARYNX AND TRACHEAL CARTILAGES FRACTURES OF HYOID Surgical Anatomy. The hyoid is a small U shaped bone which lies between the base of the tongue and the larynx and is not in contact with any other bone It con sjsts of a central body which is elongated transserseJy and has greater and lesser horns on each side It gi\es origin to much of the musculature of the tongue and, by virtue of Its suspension from the skull, supports this organ and the larynx Mechanism and Pathology fractures of the hyoid ate \er) rare but occasionally occur as a result of direct Molence— direct blows, throttling, or attempts at suicide by hanging They are frequently associated with fractures or in;unes of the larynx Tlie fracture of the hyoid usually occurs at the junction of one of the greater horns with the body, but it may imohe the body itself Diagnosis With the history of an injury m this region, followed by acute pain and swelling and accompanied by difficulty in swallowing and talking and the inability to protrude the tongue, a fracture of the hyoid should be suspected There may be attacks of suffocation or dyspnea, and the fracture may be complicated by a rupture of the larynx or trachea, with resulting subcutaneous emphysema TTie fracture may be Msible m the X ray him (Fig 227) DISLOCATION OF HYOID Instead of being broken, the bone may be dislocated by the same type of violence that results m fractures, or the disloation may result from attempts to swallow large bodies, such as a large piece of meat If the dislocating force is from the outside, the major horn is displaced inward If from the inside, as in swallowing, it is displaced downward against (he superior horn of the thyroid cartilage In patients with dislocation there is marked difficulty in swallowing but the voice and respiration need not be nfTccted It should be {xissiblc to delect the displacement by palpation Treatment With fracture the treatment is symptomatic; since displacement is as a rule, not important, and, if reduction is accomplish^, there is no means of maintaining It Dislocation should be reduced either by hypetextending the head and depressing the jaw or by direct pressure over the displaced greater horn In obstinate cases it may be necessary for the surgeon to insert his fingers into the mouth and make pressure down 237 23S DIAGNOSIS* AND TRLATMCNT Of SPLOilC INJURIfS rip 227 Fracture of l])oiJ whuh ItealcJ unJue lom^'ltcations Subcutanrout wpliyjcfiia folltnriniC ruf’lore of iraciica ft''m fall apairm of i*fp Tracheotom) «» nteo'wrjr FRACTURES OF mOID LARYNX AND TRACHEAL CARTILAGES 239 ward and forward against the displaced fca^ent In instances complicated by sesere injuries to the larynx or trachea there may be edema of the glottis and immediate tracheotomy may be necessary FRACTURE OF LARYNX AND TRACHEAL CARTILAGES The mechanism of these rare fractures is similar to that of fractures of the hyoid They are important because of the respiratory complications which may ensue and should be regarded as gra\e injuries which carry a guarded prognosis Diagnosis There is a history of dir^ rn/ury to the neck, follow ed bj acute pam and spasmodic coughing with cyanosis and the expectoration of frothy blood Swallow ing IS painful, and the \oice may be hoarse or it may be impossible for the patient to speak In cases in which there is a rupture extending from within the larynx or trachea into the adjacent tissues subcutaneous emphysema may be a prominent feature and may demand tracheotomy On palpation there is extreme tenderness over the injured area and a soft cartilaginous crepitus may be obtained With acute edema there may be marked respiratory difficulty, and immediate tracheotomy may be necessary The fracture may be visible in the x ray film (Figs 227 and 228) Treatment Treatment is in most cases symptomatic The most important point is that in severe cases tracheotomy may be necessary at any time and preparations should be made to perform this operation on short notice In uncomplicated cases the application of cold may sene to keep down swelling or a soft bandage or cotton pad reinforced by a bandage and of such volume that it makes a dressing about an inch thick extending from the base of the neck to the angles of the jaws may serve as a very comfortable splint (a mild Thomas collar) It tends not only to immobilize the neck but also to de crease the swelling and emphysema Attempts at reduction of the displacement are as a rule not advisable since they may result m increasing edema or hemorrhage into the trachea and lungs Such at tempts may be made however at the time a tracheotomy is performed if this should b“come necessary In some instances infection begins around the fracture and spreads into the soft tissues of the neck and demands incision and drainage In some patients who recover there may be a variable degree of disturbance in the voice due either to scar tissue formation around the vocal cords or to stenosis of the larynx CHAPTER 9 INJURIES OF THORAX SURGICAL ANATOMY The thorax is an expansile truncated cone which constitutes the upper part of the trunk and serses to contain and protect the lun^s, heart, and great scssels as well as the structures passing bchveen the neck and the abdomen It is bound posteriori) by the twehc thoracic sertebrae and the posterior portions of the ribs, lateral]} b) the middle portions of th« sibs, and antcnorly b) the stetnum, costal cartilages, and anterior portions of the ribs (Figs 229 and 2J0) Ribs A t)pial rib is a long slender, cursed, elastic bone which presents a head, neck, tubercle, and shaft There are twehe ribs on each side All are attacheil to the spine posteriori), and the upper sesen are attached to the sternum anteriorl) b) means of costal artilages, whereas the anterior ends of the eighth, ninth, and tenth are attached to (he cartilage of the sesenih rib The anterior ends of the last (wo ribs are not fixed, hence, (he) are called fioating ribs The head presents two articular facets for the bodies of the corresponding dorsal sertebrae and the tubercle presents an articular facet for the Iranssersc process of the corresponding sertebra The neck is the compressed portion of the rib between the head and the tubercle, an*! the sluft is the continuation of the nb around the bod) to its anterior extremity where it unites with the costal cartilage The shaft is flattened and smooth on its inner surface and roughened on its outer surface In direction it fint runs backward and outward and then twists downward and forward at the angle After it crosses the midaxillary line it curses inward toward the midliofi of the chest Slerimm The sternum or breastbone, is a broad flat plate of bone which lies m the mtdiine of the chest It is disided into an upper portion, the manubrium sterni. a middle portion or bod), the gladiolus, and an infcnor portion or tip, the ensiform cartilage ■Ihc manubrium is thickened and presents facets for articulation with the clasicles On its upper border there is a notch, the interdisicular notch Tlie body presents artioiti tions on either side for the costal cartilages of the second to the eighth ribs The ensiform cartilage is a small wedge shaped cartilapnous plate which pro/ccts downward from the lower end of the bod) of the sternum Tlie manuhrium is usuall) united to Uic boil) b)' a S)nchonJrosi$, but m adult life this |oml may oisif) The upper portion of tlie body IS marked by a prominent transseise ndge, the sternal angle, which is an important landmark as it is at the same lesel as the second costal chondral junction Costal CartHages The costal cartilages arc flat plates of hyaline cartilage whiJi sene as prolongations of the anterior ersds of the ribs and unite these bones to tlw sternum The first costal cartilage is continuous with the manubrium sterni, while the second to the eighth costal eartibges arc onitcd to the sternum by true /ointt 'ITie eighth. 240 INJURIES or THORAX 241 ninth and tenth costa! cartilages arc un led fo the costal cartilages of the seventh rib by fibrous tissue FRACTURES OF RIBS Fractures of the ribs ate relatively frequent injuries and tend to be multiple and are often bilateral One or more ribs may be broken in tvvo or more places Not only are these fractures frequent as isolated injuries but they are also relatively frequent compli cations of other severe fractures particularly those due to falls or crushing injuries or to automobile accidents Because of the great elasticity of the ribs in children fractures of these bones are relativelj rare bclo’a the age of puberty but thej may occur m severe crushing acadents bupenor thoftcle ■pettat« Mechanism and Causes Ribs maj be fractured b) e ther direct or indirect violence and occasionally by muscular action as from a cough or sneeze or from laughing Jn fractures which are the result of direct violence the fragments tend to be driven inward into the pleural cavit) and may not only rupture the par etal pleura but also penetrate the visceral pleura and damage the lung These fractures tend to occur at the point of impact of the fracturing force and in such instances the extent of the displacement and the number of ribs broken vary directly with the degree of the force and with the size of the area subjected to direct trauma (Frgs 231 and 232) 242 nWGNOStS AND TRrATMENT OF SPCOriC IVJlJRtES Ffacturts due to indirect \ olence arc usually the result of crushing; injuries to the chest or of seserc blows in wheb the fracturnj, force is distrbutci oier i considerable area so that the ribs arc bent inward at the po nt < f mpict an 1 ten I to break from be ng bent the break usuall) occurring just m front of the anck « f the r b (1 igs 2» and 234) In these ind rect fractures the ends of the fragments tend to be forc^ lut ward and the pleura is not ruptured unless there is cons dcrabic displa cment The median sm of a double fracture is usually a fruture from d rect violence at the po nt of impact and a fracture from ind rect violence near the angle < f the same r b I }. 2« ItKfix h«k » cw (Fom Mon » H II njn Aiw -w FI fj tlph j P tltalc t n> Vin A Cl ) Pathology Greenstick franuics nu) occur m children and si bpcri «tcal r o complete fractures maj iKCur in adults when the fracturing / rcc is not suHcicnt t cause d splacemcnt As a rule lowcvcr m st rb fractures meur in a lulls and the fractures arc complete and mij be comm nuted Tlie plane of the fracture may be transverse oblique or irregular and if complete I splafcmcnt occurs, a small amount of ovemdng is the rule In fractures m whch several ribs arc involve! cspcculb if these are double fractures the # Je of the clicst nuj be flattened if even caved in (Fig 235) Open fractures with U e exception of those due to gunshot w funds arc qu ic rare bit ma) occur and in such instances the correspond ng $ !e tf the ihest is usual!) opened b) the wound (Pig 236) TJie first (wo nbs are rare!) broken berause they ire protected by the shoulder anl cUvidc and the last two ate rarely broken because their INJUMCS OF THORAX Tij; 23S Multiple fractures of ribs m a child run over b) an automobile Chest was double strapped -48 hours after infuty when patient had recovered from shock Good results were obtained m 3 months 1 ig 236 Open multiple nb fractures treated by debridement and closure of chest F). J5’ Fc ■>« fig 2)7 Patient utth multiple {raitum nf ciht thuHing posture aisunieO hy piCienl in rRort (Cl relax and splint side of chest Fijt rximifution o( patient 'anh suspected (caccure u( ttb B> pressin;: (he Cau hatvls together the examiner sprin/;s side of cliett and pain is el iteJ at p<> nt i f /raciure Tif! 2)9 ral|ation to determine points of nuxiinum tenderness in patient 'tilh fracture of rib INJURIES or THORAX 247 disUl extremity is free and may be mo^cd widely in any direction before a fracture can occur The majority of fractures imoKc the fifth to the ninth nbs Diagnosis. 'Hiere is usuallj a history of an injury, either of a fall against the corner of a table or some other object or of a blo^t or crushing injur) to the chest, followed by a sharp pain in the side TTie pain persists and the patient is able to localize the pam very exactly If the fracture is at all $e\ere, the patient tends to lean to the affected side and support and immobilize the area of the fracture svjth the hands (Fig 237) The breathing is shallosv Deep breathing causes sharp pain m the chest, which is particularly aggravated b) coughing, sneezing, at laughing On ph)Stcal examination there may or may not be localized swelling and cMdences of contusions and lacerations of the sbn The patient should first be asked to localize with the fingers the points of greatest pam Then the surgeon should place one hand on the back of the chest well awaj from the painful area and the other hand on the front of the chest and gently compress the chest by springing the anterior extremit) of the ribs msiard (Fig 238) If there is a fracture, this maneuver will chat sharp pam at the site The surgeon should then palpate the nbs in Ihc painful area, beginning in the front and working backward on the chest until the point of fracture tenderness is reached (Fig 239) If displacement is present and the patient is not too fat, it may be possible to palpate the ends of one or more fragments Good roentgenograms taken m the anteroposterior, lateral, and oblique views will usually demonstrate the fracture However, not infrequently a patient who has had a contusion of the chest presents the usual signs assoaated with a fractured nb without displacement, but a fracture cannot be demonstrated on the roentgenogram These m juries may be just as painful as those m which (here is a fracture In either case the treatment will be the same, provided, of course, that the fracture is one without dis placement Comphcaltons of Chest Iu]uries In many instances the complications of fractures of the ribs are a great deal more important than is the fracture itself, since they concern injuries to the lung, pleura, and intercostal arteries In addition to the surgical shock which 1 $ present in all severe injuries and fractures of other bones which may be present, chest injuries are subject to the following compilations (1) pneumothorax, (2) interstitial or surgial emphysema, (3) hemothorax, (4) hemorrhage into the lung (5) empyema, (6) traumatic asphyxia or cyanosis, (7) paralytic ileus, and (8) contusion of the heart In severe injuries to the chest, in which several nbs are broken the patient is usually m a state of considerable shock, which may be the dominant feature of the picture whereas the injunes of the bone are of relatively little importance and may be ignored until the shock is combated PNEUMOTHORAX In pncumolhorax the pleural cavity is filled with air, which may have been drawn in through an opening m the chest wall or may have entered the pleural cavity through some injury of the lung As the air enters the pleural cavity, the lung on that side collapses unless it is fixed to the chest wall by adhesions The presence of a pneumothorax is suggested by tcspiraiory embarrassment and displacement of the mediastinum to the opposite side It is diagnosed by the presence of a tympanitic per cussion note over the area occupied by Ihe air If the air is under positive pressure, the pressure may be so great as to seriously impair respiration and cause respiratory em barrassment and cyanosis This may occur in cither a wound of the lung in which there may be a valve effect so that the air is forced out into the pleural Cavity on inspiration and cannot enter tlie lung on expiration, or a similar wound m the chest wall In instances m which the positive pressure in the pleural cavity is the cause of respiratory embarrassment, the symptoms may be relieved by aspirating the diest, and it may be advisable to suck out as mudi of Ae remaining air as possible Elkins inserts 248 DIAGNOSIS AND TREATMrNT OF SPEOFIC INJURIES a athrter into the pleural ci'ily and submerges the other end of the tube in a jar of water The positoc pressure m the chest forces the air out through the tube and the water pres enls air being drawn into the tube during inspiration iNTERsmiAt OR sURncAL EMPHYSEMA Not infretjuentlj m fractures of the r bs with pneumothorax the au is forced out into the tissues of the cliest wall through the rent m the parietal pleura, and interst tul «nph)-serm ma} occur As a rule this interstitial emphysema is not marked in degree or of much importance It can be r«og nized b) soft crepitus when the inxohed ara is palpated In occasional cases the degree of cmphjscma may be marked and the au may spread up and down the chest wall H'C Ti#: ■’ll Mils sc folljpsc of I«r*|t foII('« 14: conlus n if n 10 lays lun^ rlfirrJ eni rrly into the neck invyhc the faie an I esen the extrcimt rt a 1 1 sauve r >t s JcrablL pain an 1 discomfort In mslinccs in whid* it is maikcsl small inciMxis through tie skin may he nu le under antscftis. prtrautions in order t» relieie «Ie tens m As a rule the opening in ijic chest or in the lung heals and the air tn tl c Its'ues is gri luallj absorbed A \et) dangecous type of intcfstitul emphysema an I tne tlul u Jifraill to o mKif INJURIES or THORAX 249 Fig. 242 ^f«al lOft?s uscJ m <«um case* tiheie expansion of a compression of chest and ribs IS needed following sesere injures to chest Tong po nts ate set here for tib ttaaion (From Reynolds Walker, Jf J Bone & Joint Sutg 37 A 966 1955) Tig 24 < Collapse (pneumothoH* from with.ft) of U(t lung following confuston of chnt in '«hieh no fraciure was demonstratcJ Tliere »aJ >«> slight imnejiile JisahilitT and llie pjltcnt wal sent home, but a ph>SKiJn was callevi 21 boors later, »hm ihe patient was in a severe state of shock with air hunger, rapid pulse, and respiration Vig 2ti. Same case as in fiR 241 Panial eiraiwion of lung followiivs ospirati.m of sliest wilh sutli.in machine Air escaped llirocjsh needle wfwi it etWered pleural rants. atU patients condition was much improreJ later aspitation bjr HInl springe was followed bp complrte et- pinsion of lung. Fig 217 Bilateral collapse of lungs (pneumoU otax from w thin) following contusion of chest m automobile accident Patient recovered under conservative treatment no aspiration rest in bed With sedatives and oxygen tent Returned to woifc 2 months after in;ury DUCSOSIS AND THEATMf'NT OF SFfCIFIC IVjURirs IS one in a bronchus is tom or nipUired and in which dit air escapes into the tissue of the lung itself rather than into the chest wall and then trascis up the mcdi astinum and into the neck In this type expectant and supportive treatment are all that one can administer HEMOTHORAX Hcmothotax IS blood m the plcuial caMt} It may be due either In a tear or rupture of the lung or to an injury of an intercostal artery or vein In simple fractures of the ribs hemothorax is rarely a troublesome feature but it may occur in open fractures due to gunshot wounds it is practically always present The amount of blood, however, is usually small and need cause no concern, but in some instances the amount of blood may be considerable, or even fatal hemorrhage may occur when a large vessel IS m|ured Blood in the pleural asity behaves like blood in joints and does not readily clot or become organized but is slowly absorbed However, if there has been bleeding to any degree the blood should be removed whether or not there is respiratory embarrass ment In cases with evidence of severe hemorrhage, operative intervention should be undertaken to stop the hemorrhage Before the pleural cavity is explored, the chest wall should be investigated since the hemorrhage may be from an intercostal or infernal mammary artery It should be remembered that when air is present in tlie pleura! cavity some blood IS also present and that hemopneumothorar is more frecjuent than cither pneumolhorax or hemothorax iiEMORRHAOE INTO LUNG Hcmorriuge into the lung may occur as a result of a blow or compression of the chest even without a fracture of the nbv The symptoms ante immediately after the injury and consist of severe pain deep in the chest dyspnea, and a rapid weak pulse According to Sanfe* the x ray film re* veals a definite haziness of the involved arei with large irregular blotchy areas, of increased density EMPYEMA Empy cma or pus m the pleural cavity may result frum any open fractutc of the ribf one due to a bullet wound oc one tluc to direct v lolence or the mfcctfon may occur in a simple fracture of the nbs, the bacteria being transmitted tivrough a teat m ihe lungs fortunately the pleura has a high rcsivtance to infection, and infection in (czunutic hemothorax is rate The climcil findings are fever Icukocjtotts general toxemia, and the physical signs of fluid in the chest The treilmcnt is rib resection and drainage at the most dependent point and antibiotic tJierapy TRAUMATIC ASPHYXIA OR cntANOSis Traumatic asphyxia or cyanosis (Iig 3l8) occasionally follows severe compression of the abtlomcn or thorax or of both wiih cwmpktc oc pictvil cessatiQCv of cespvnAvoa foe a vaciible pcticwl of titcie U w cluuc terized by a vivid blood ml coloration of the conjunrtivae and a purple coloration of the face, upper chest and upper arms The color of the skin varies from violet or purple to black and is due tn minute pctechuc The coloration of the conjunctivae is the result of subconjunctival hemorrhages Apparently the condition is due to sii Iden backward pressure of the blood in the veins of the aflcctcil areas Unless the patient dies as a result of the injuries sustained at the lime of the accident, the discoloration gradually disappears m from 10 to 20 days The conjunctivae are the last tissues to clear up Permanent damage to the eyes an I even blindness ffv»m optic atniph) have been recorded as sesjudaem certain severe caves 1 »g 218 should be colotc«l Tlvc shoulders face, fiunt, an I back slwuitd a red disli violet, with a ring of normal skin around llie neck Tlic flesh on the rest manipulative reduction followed bj immobilization in recumbency with sandbag on chest Good result 258 DIAGNOSIS AND TREATMrNT OF SPEaflC INJURIES When displacement occurs, the lo«ef fragment is usually displaced forward, and its upper end overrides the looser end of the upper fragment (Tig 255) The periosteum on the posterior surface is reinforced by the mtrathoracic ligaments and is rarely torn Diagtiosts There is a history of in|ury to tlie chest with pain localized o\er the sternum A moderate amount of st^elling is present and, if displacement has occurred, the swelling may be considerable The patient tends to assume an attitude with the head and shoulders drooped forward, respiration is shallow, and deep respiration and coughing or sneezing are accompanied by intense pain at the site of the fracture On palpation it may be possible to feci the displaced fragments and to determine the displacement and mobility of the fragments may be observed during breathing In case a fracture of the sternum without displacement is suspected, the diagnosis can be confirmed by an x ray film, which should be taken m the lateral plane It will show any displacement as well as the line of fracture Tig 25”? Position of patient with pillow under sitouldets and sandbag strapped over sternum Fig 2S6 Adhcsue stcappiog across chest with thick felt pad over injury as applied in ambulatory dressings in fractures of sternum Iig 259 Old fraciucedislocation of sternuoi which united without reduction of displace ment Recovery w itli slight deforimt)’ and no disabiht) Treatment If there is no dispbcement of the fragments the patient should simply be placed in bed with a small pillow under the shoulders and a small sandbag on (he front of the chest over the sternum (Fig 257) The sandbag senes to immobilize the fragments more securely than does any fonn of adhesDc dressing yet devised It may be strapped on the chest with adhesive This position should be maintained for from 2 to 3 weeks at the end of which tune the patient may be allowed up with a cross strapping over a felt pad over the site of the fracture (Fig 258) and a posterior figure of eight bandage on the shoulders INJURIES or THORAX 259 REDUCTION In cases in which Uispbccfnent and o%erriding of the fragments are present an attempt should be made to reduce the displacement This is most satis factonly accomplished if tlie patient is placed in a position of hjperextension as illus trated in Pig 256 The hyperextcnsnwi should imohe particular]} the cenicai and upper thoraoc spine Likewise, the arms should be placed abose the head and the shoulders drawn backward If necessar), traction should be used witli countertrartion on the feet With the patient in this position the surgeon should attempt b) downward pressure on the upper end of the lower fragment to push jt backward into its normal position If this is very painful the fractured area ma) be anesthetized by infiltration Avith Novocain but a general anesthetic should not be given If to reduce the displacement bj the closed method is found to be impossible the fracture may be exposed preferably Under local anesthesia, and the depressed fragment can be levered up into place but this is not necessar) for a good functional result In certain instances the ensiform portion of the sternum becomes traumatized severely bruised, and chronically painful In some instances this will demand surgical removal if a fair chance at conservative treatment that is local heat and strapping has failed CHAPTER 10 INJURIES OF SPINE SURGICAL ANATOMY The spine is a flexible column composed of thirty three bones called \ertebne The upper tsvent) four of these arc mosiblc, or true, vertebrae and the lower nine, or false, ^e^teb^ae arc fused to form rwo bones, the sacrum and the coccyx The true sertebrae are diMded into seven cervical, twelve dorsal and fisc lumbar In this chapter we ate con cemed with the true vertebrae, the sacrum and the coccyx bein^ included m Chapter 17 on the pelvis (Tifl 260) ItidnuUial Vertibrae Each vertebra consists of a body, a neural arch, and a number of processes The bod) is a short thick section of cancellous bone covered by a thin sheath of cortical bone Its upper and lower surfaces ate flattened, whereas its borders ace slifihtl) conave from above downward The bodies are piled one upon another to sup- port the head and trunk The neural arch projects backward from the body as an osseous rm|! and in the articulated spine these arches form a flexible bony c>linder for the protection of the spinal cord Each neural arch consists of two pedicles and two laminae The pedicles are two short thick processes which project backward from the upper part of the postero- lateral portions of the bodies The laminae are broad, ihm plates of bone which project backward and inward from the pedicles and fuse to complete the neural arth They are joined to the pedicles by the isthmus Processes The spinous process projects backward from the junction of the laminae and serves for the attachment of muscles and ligaments The transverse processes project laterally from the junction of the pedicles and laminae and sene for the attachment of muscles and ligaments The articular processes are four m number and spring from the junction of the pedicles and laminae The superior articular processes face upward and backward, and the inferior articular processes face downward and forward FsrsC and Second Certtcal Vertebrae The two vertebrae differ radially from the other true vertebrae The first or atlas, has no body or spinous processes but consists of two lateral masses which are united by anterior and posterior arches The lateral masses support the ocaput and articulate below with the axis The arches form a large ring for the inclusion of the odontoid process of the ^xl$ and the spinal medulla The second, or axis IS remarkable in that its body is extended upward as the odontoid process which fits into the anterior portion of the ring of the atlas where it is held by the strong transverse ligament Embrjologially the odontoid process represents the body of the atlas Arlicidaltons and Ligaments of Spine The vertebral bodies are held together b) the annulus fibrosus and intervertebral disc These are reinforced by the strong anterior 260 INJURIES OF SPINE 261 Tig 260 The vertebra! column, right lateral riev (From Moms, H Human Aiutomjr phjJj delphu P Blaktston s Son & Co ) 2c 2 niACNCiii AND TTtrATMrNi oi siraiir iNjiiRjrs. and posterior longitudinal ligaments nhich extendi from the occiput to the sacrum and by the interspinous ligaments the Iigimenttim flasum and the facets with their Iiga mentous attachments Each disc consists of a central semi/lmd nucleus pulposus and a peripheral annulus fibiosus TTre semifluid center is maintained under pressure and the fibrous border is compressible Thus the discs act as sliocl*. absorbers and permit bend m; of the bodies on one another (1 ig 261) The articular processes possess a surface of artiaiUl cartilage and form true joints with the processes of sertebrte abo\e and below The ligamenta subilaia unite the laminae of adjacent vertebrae ind the interspinous supraspinous and mtertransverse 1 gaments unite tl»e spinous and transverse processes of adjacent vertebrae Fg 261 The interjpinous anti suprasp nous > ^amenu m the lumbar reg on (Froni Mon s H Human Anatomy PI Ijildpha P tons Son A Co) Physiologic Cun es Normal!) the sp ne is stra ght m the lateral plane and presents four curves m the anteroposterior plane These arc cervical dona! lumbar and sacro coccygeal curves Tlie dorsal and saccrococcygcal arc convex bacLwartl and are primary curves whereas the cervical and lunAar ire concave backward and arc secondary curves (Pjg 260) Motements of Spine The cervical region possesses the widest range of movement whereas the dorsal region is relatively fixed Nodding forwiird and backward of tlie head occurs primarily at the occipifo- atlantoid joints and rotation of the head occurs pnnuril) at the atlantoaxoid joint Lateral bending of the hea 1 occurs priocipill) in the m d portion of the cervial spme and flexion and extension of the head occur in the liwcr portion However when an) of these motions are full all vertebrae lakcpirt Relatively little motion in flexion extension or lalual bending is possble in the dorsal spine because it enters into the format on of the bony thorax but much of the rotation w hich occurs below the cervial region takes place in the dorsal spine The lumbar spine admits practially no rotation but allows a wide range of motion iNjcrRrrs or spwe 265 m flexion, extension, and lateral bendini; Much of the motion occurs at the dorsolumbir and lumbosacral regions Surface Landmarks The lips of the spinous processes can be palpated m the mid line of the back The bifid tip of the spinous process of the second cervical \ertebra IS the first one s^hich can be palpated belnsi th- occiput In the cervical and upper dorsal regions the tip of the spinous process iies opposite the body of the sertebra belov. The spinous process of the fourth lumbar vertebra lies at the level of the aest of the ilium The anterior surfaces of the bodies of the second and third cervical vertebrae can be palpated bj inserting the finger into the posterior pharynx Spinal Cord and Jis Membranes The spina! cord is much shorter than the spinal column, and in the adult its lo^er end lies at the level of the disc between the first and second lumbar vertebrae Anterior and posterior nerve roots spring from the sides of tlie Tig 262 Sensory distribution of spinal nerves (From Davis G G and Voris H C Arch Surg 20 l4> 1930) cord and pass outward and downward to emerge between the vertebrae as the spinal nerves Because of the relative shortness of the cord the centers for the spinal nerves he at a higher level than the vertebrae beneath which each emerges and by which it is designated and this disparity increases as the distance from the upper end of the cord increase s .Chipaplt v-ru U-for determining the relation of the segments to the spinous processes of the vertebrae is in the cenical region add one to the number of the verte- bra, and this will give the segment opposite it In the upper dorsal region add two, and from the sixth to the eleventh dorsal add three The lower part of the eleventh dorsal spinous process and the space below it are opposite the lower three lumbar segm^ms The twelfth dorsal spinous process and the space below it are opposite the sacral seg ments The spinal cord presents two enlargements — the cervial for the upper limbs, which comprises the lower four cervical and upper two dorsal segments and ends opposite the JNJURirS OF SPINE 265 seventh cervical spine, and the lumbir /or ihe lower limbs, s^hich lies opposite the three lower dorsal spines As the spinal nerves pass through the intervertebral /oramina, thej he close to the articular facets and are exposed to injury if th«e ate fractured or dislocated In the lumbar region of the carul the filum termmale of the cord and the roots of the lumbar and sacral nerves form a leashlike bundle oiled tfie cauda equina Injuries in this region cause lesions of the ncn e roots but not of the cord proper The cord is covered by three membranes dura, arachnoid, and pia mater The dura IS a dense fibrous sheath which forms the outer covering and sends prolongations to invest the nerve roots as they enter the intervertebral foramina It is attach^ to the ^alls of the vertebral canal at various points, but in most places it is separated from the bone bj a layer of fat and areolar tissue which contains the arteries to the cord and a rich plexus of veins The arachnoid is a delicate membrane which lines the dura and is attached to the cord by a multitude of thm weblike strands The space between the dura and the cord which js crossed by these strands is called the subarachnoid space It contains the cerebro- spinal fluid Tlie pia is a thin membrane which is close!) applied to the cord GENERAL CONSIDERATIONS To the lay mind and, unfortunately, to many medical minds as well, a broken back or neck is a broken back ot neck and as such is a dreadful accident which results in sudden death or complete and permanent panlysis below the level of the lesion This gloomy point of view ts the heritage of pre Roentgen days when only the severe frac hire dislocations of the spine with extensive damage to the spinal cord were recognized as fractures of the spine At the present time we know that more than half of the fractures of the spine are not accompanied by paralysis and that with adequate treat ment most of these patients may be expected to recover and return to their former occupations It should be emphasized that fractures of the spine are not dangerous because of the skeletal injury but are dangerous to life only when assooated with damage to the spinal cord or other visceral ot skeletal injuries On the other hand, it is also to be emphasized that the skeletal injury may cause prolonged disability if proper treat ment is neglected Jn this chapter we shall emphasize the treatment of the skeletal injury We believe that unstable fractures of the spine should be treated by rest and support or reduction and immobilization until the lesion has healed, but that stable fractures may be treated without immobilization so that the patient may start eariy active motion within the tolerance of pam In cases of fracture or fracture dislocation of the spine with spinal cord m/ury, early reduction and immobilization offers the best chance for recover) If the displacement is such that it does not lend itself to manipu latne reduction, open reduction of the fracture, and exploration of the spinal cord may be done if mdiated, followed by mtcraal fixation and spinal fusion If this is performed early, even though no nerve function returns managonent of the patient is materially facilitated Spinal injuries will be considered under the following headings Compression frac tures of spine, fracture dislocations without paralysis, rotary dislocation, hypercxtension fractures with elements of dislocation, posterior dislocation of lumbar vertebrae, isolated fractures of transverse processes, isobted fractures of spinous processes and laminae, isolated fractures of articular facets, Schmorls nodes, injuries of cervical vertebrae, de celeration injuries dislocations of (xrvical vertidjrae fracture dislocations of cervical vertebrae, injuries of spinal cord and nerve roots associated with injuries of spine, spondylolisthesis, and lesions of intervertebral discs in low back. 266 DlACNOStS AND TRtAT^^^^T OF SPFQdC INJURfFS COMPJirSSION FRACTURES OI SPINE Incidence and Came Tlie nujorit) of fnctures of the spine are of the compression tjpe, and most of these are due to automobile accidents or falls, usually from a height, in sihich the patient lands upon the feel or buttocks and in sshich the spine is hyperflexed or jackknifed by the supctinoimbcnt body weight. It is to be cmpliasircd, how-e\cr, that a compression fracture of the spine nuj result from an apparently trivial injury, such as occurs when a person slips and suddenly sits down upon the floor Otiiet cases art due to the same mechanism in which a wei^t falls upon a patients back, head or shoulders from above hyperflcxing and crushing the sj me Rarely a compression frac hire results from a fall or dive on the head or shoulders and m these cases the cervical or upper dorsal vertebrae arc usually imohed whereas in those due to falls upon the feet or buttocks or tt> crushing injuries the fracture usually occurs in the dorsolundnf region Piji 21 " t Antcr r cjmjtrsinn fr;icTutc of third lurnKir vcrttbfa htcral » r» hefort t an! afftr B roJutlK n r n I ipcmieorion frame Itodf carl wjlh rexjmbcnc) in hed fir ’ i nihi hotly cast friun axillae in hipj anl t>ul of bed for 8 weet-s and ihcn Taylor hatlc hme for 4 mimf/ix Ceoii (vsaia in a tnhi Over 70 per cent of the cases of compression fniaures occur at the drrsolumbar region that is at the junction between the relatively fixed thoracic and the movable lumbar spine In a senes of 125 fractured vertebral botlies Wallace found that the first lumbar vertebra was broken 35 times and tlie second lumbar vertebra was broken ly times The third fourth and fifth lumbar vertebrae were broken 7, 9, and 10 times respectively Tlie other dorsal and cervical vertebrae were bfokai ftom I to 6 times with the exception of the first and second cmical and the first dorsal in which fractures did not occur in luv senes In Wallaies veftev there were 125 ccmii rnSn ii fraitures if the vcflelrjl NkIics m 82 patients and in Coiiwcll s senes there were 126 frailtircs in IW) patients Not m frcvyucntly two adjacent vertebrae arc cnislied and occasionally difiiiitc fractures of two or mote vertebrae with one or more tiomul vertebrae IxSween them may occur from a Single accident One of us lus tccctUly treated a patient who had five distinct vertebra! iNjURtrs or SPINE 267 INJURIES OF SPINE 2(9 fractures from an automobile accident None of the sertebrac ^^as severely crushed or displaced and there were no neurologic disturtiances Pathology As the force in hyperflexion is applied the anterior portion of the bod) of one of th** sertebrac tends to gi\e way and is crushed by the bod) of the next \erte bra above (Figs 264 268 270 272 275) the two bodies being folded together on the articular facets and pedicles which act like a hinge and arc relatively stronger than the bodies of the vertebrae As the cancellous bone is crushed it maj be spread apart or broadened and loose fragments may be forced outward in any direction usuall) forward or to either side but occasional!) backward into th" spinal canal where they may impinge upon and compress the cord With the compression of the vertebral body the fragments m Fig 269 lateral compress on fracturo-d siocat oa of second lumbar »ertebra mth some sensory cord involvetnent which cleared up in 4 inontlis Treated with bed rest for 3 weeks followed by body cast from hips to axillae and Taylor back brace Only moderale d sability resulted (Courtesy Dr M F Crowell Veterans Adm oisirat on Hospital Tuscaloosa Ala) ma) be impacted quite Bcmiy so that considerable force is necessary to loosen the im partion and restore the normal height of the vertebral bod) In addition to the fixation in hyperflexion b) impaction of £tagments there is also a variable amount of fixation in this position as a result of muscle spasm incident to the fracture There may also be a variable amount of damage to the intervertebral discs in the vicinit) of the fracture The) may be torn and the contents of one or more of them ma) be forced out into the surrounding tismes and the disc flattened The strong anterior common ligament which is continuous across the discs and vertebral bodies usual]) remains intact although it may be stripped from the anterior surface of the body of the fractured vertebra The fact that this ligament remains intact enables us to correct the 70 PIAGNOSIS ANl* TRnATMtNT Of SPrariC iNJURiES INJURinS Ot SPINE 211 Ti^ 272 Unusual tompwssian fracture of tl ird lumMr 'ertfhn with anterior and posterior fxaiimentJ T'i, 273 Tncture dislocat cn of sp nc associated with transverse mye! tis below les on Closed reduc tion was unsuccessful and open reduction was performed, but paralysis remained 272 DIAGNOSIS AND TRrATAtCNT OF SPEOFIC INJURIES defonnty m these fracture by hyperwtension of the spine siilh 1 ttlc fear of damai;in£ the cord by pulling the \ertebrae apart Occasonallj in \erj severe injunes when the force continues to act the vertebra above is d splac^ forward or forward and to ones de on the vertebra below (Figs 275 ^ a c Tg 274 ji and B Antcroposier or and lateral v cw of franutc-d si xat on of frst I nhJ on second lunbar vertebra w th no Fanils s C lateral x ruy appctrance / llnw nf. cl ird reJu tJoa D slocat on rema ns Open rcduct on was rot cmJem on anj mJuci on of can press on fractures of sp ne for loss er dorsal and lumbar fractures ( Fro n VC atson Jones R J Bone A Jo nt Suig 11 $0 193 1 ) Fg 288 Same metJod as m Ftg 287 but for n dJonal fractures (From VCaisun Jones R J Done A Jo nt Surg 11 30 1934) 282 DIAGNOSIS AND TREATMrNT 01 SPEQIJC JNJORILS Because of the peculiar arrangement of the anterior longitudinal ligament hyper extension of the spine tightens this ligament, and the cortical shell of the injured serte bra IS restored to its original height Ho«e\er, then, remiins i defect in the center of the compressed area in which the cancellous trah-ciilac failed to follow the cortical shell, which is Ihvis depriaed of bony support The defect created by this maneuacr is slowly obliterated with callus and new bone To maintain the fracture in the corrected position hyperextension must be rigidly continued until complete healing has occurred This may take 6 to 8 months or longer Because of these facts most compression fractures that are treated by hyperextension or so called reduction and immobilizition in a plaster cast have an eaentual end result as shown by the x ray film that is essentially the same as that seen in the original film (Fig 285) Prolonged immobilization in hyperextcnsion not only adds to the period of temporary disability but also allows soft tissue contractures that may be quite difficult to overcome and may leaxe variable degrees of permanent impairment Since we discontinued reduction and immobilization of these compressed but stable fractures of the spine no patient has required a spinal fusion operation for a persistently painful back With conservative tceatment the period of disability is remarkably shortened and the amount of permanent impairment has been reduced to a very low level Stable compression fractures of the cervial spine seldom require redurtion, and immobilization in a neck brace or Thomas coUac is usually adequate Unstable or displaced fractures of the cccual spine demand more \igorous treatment as described on p 314 The majority of compression fractures occur in the lower dorsal and lumbar areas In these areas if reduction by hyperextension is desired, one may use the method of Watson Jones (bigs 286 288 ) or that described by Arthur Dans (Fig 28P) In the aaerage case we prefer these methods to that of using an apparatus such as Goldthwait irons (Fig 2S>0) However if there is much displacement, or if there is evidence of fracture of the posterior elements reduction and hyperextension over the Goldthwait irons is the safer method as there is much less danger of damvtiing the cord METHOD OF WATSON JONES * This method combines simplicity with efficiency (Figs 286 288) Before the patient i$ placed in hyperextension a double layer of stockinet IS pulled over the trunk and pmned over the shoulders and in the penneum and pads of felt are placed over the anterior iliac spines and over the kyphos Two tables are arranged end to end at a distance apart of about 1 2 inches greater than the length of the patients trunk The head table should be about 12 inches higher than that which supports the thighs The patient is then lifted into position with his lower extremities resting on the lower table and the chest and head supported on the upper table by the abducted arms The trunk must be allowed to sag and neither the chest nor the pelvis should rest on a table As soon as the patient is in position application of the plaster is started and com pleted as rapidly as possible As the piaster is niWied m on the back the reduction is completed There is no forcible manipulation The plaster jacket extends from the gluteal cleft to the scapulae behind and in front from the symphysis pubis and groins up to the clavicles It must rest on bone both above and below As soon as the plaster has set the patient is placed in bed face up with a large pillow beneath the arched back Later the cast i$ trimmed to permit movement of the arms and legs, but not enough to rob it of its bony support above and below, and a small window may be cut over the kyphos if he complains of pressure here Likewise, if abdominal distress develops, a large abdominal window should be cut m the cast, but •VTatson Jonev, R Treatment of tractates and rracture Dislocations of Spine J Bone A JoiolSurg 16 30, 1954 INJURIES OF SPINE 283 not Otherwise If distress continues, it may be necessary to remo%e the cast and place the patient flat m bed GRAVITY SUSPENSION METHOD OF DAVIS This method IS based upon the fact that the anterior common ligament practicallj alnap remains intact and that the strength of this ligament is such that hj'perextension may be applied to the spine without danger of pulling the fractured ^e^tebrae apart, thus causing further damage to the spinal cord The firm attachment and relative mvulnerabiliij of the intervertebral discs, together with the firm incorporation of the annulus fibrosus with the anterior common ligament and epiphyseal plates, ensure restoration of the orcumference and the general contour of the vertebral body b) the manipulation The method consists of actually restoring the contour of the body of the vertebra by obtaining the limit of hyperextemion and of maintaining this position with adequate fixation In cases in which the fragments are impacted, it maj be necessary to manipulate the region of the fracture while the spine is held in a position of hyperextension, thus causing disimpaction, with a general restoration of contour As the spine is hyper extended, leverage is exerted through the pedicles ind posterior arches which tend to act on the impacted body and pull the fragments apart to a point at which the anterior common ligament is taut and the width depth, and height of the body are restored Davis wished to correct an erroneous impression created by the use of the word niampulaitte correction or reduction The word manipulation was never intended to convey the necessity of the use of force The method from the beginning never used more force thin that involved in gravity suspension of the feet except in ases when X ray films afterward showed incomplete restoration of the anterior vertical height In such dses gentle pressure forward on both sides of the kyphos by measured thrusts was used to disimpact Davis stressed from the beginning that no more than geiille manipulation is ever necessary While foot suspension or any other type of hyperexten sion involves manipulation in the generic sense of the word, gravity suspension is a more specific and more accurately descriptive term Gravity suspension implies avoid ance of force The force involved is no more than that involved in the child s game of wheelbarrow Foot suspension apparatus does exactly what one does in this game and nothing more FRACTURES OF MiDTHORACic REGION Thesc fracturcs may be treated as described for fractures of the lower thoracic and lumbar region, but reduction is more difficult and less complete Fortunately deformity is less important here as an incomplete reduction or no attempt at reduction, and leaving the deformity alone is rarely the cause of trouble later In reducing these fractures with the face down an attempt is made to concentrate the force over the kyphos (Figs 287 and 288), and reduction is resisted not by the spine but by the thoraac cage ' HIGH THORACIC FRACTURES” Thc scctioo of the Spinal coIumn from the middle of the curve of thc thoracic region (prominence of the l»ck) upward presents unusual difficulties No completely satisfactory method of reduang these fractures exists Because this section is relatively rigid and does not enter into spinal movements except in a negli gible way, these are for the most part stable fractures which do not require reduction and external immobilization However, should it seem advisable to attempt reduction and immobilization, they can best be accomplished m thc following manner Reduction With Patient Lyng on His Back As stated thesc methods are not as efficient for fractures of the Tower thoracic and lumbar spine as are the Watson Jones and Divis methods, but they arc used in many clinics and satisfactory results are obtained lor (he application of a plaster jacket with the spine m hypcrextension while the •Davis, A G rractuxes of the Spine. J Bone A. Joint Surf 11 155, lp29 2B0 wACNOsis ANn nirAniLNr or siraiic iNjuRirs patient is lying on his back, it is to be emj^mized that the Hawley or any other type of fracture table with a pelvic rest and a support for the shoulders is not dhcient b^ust it IS necessar) to support the spine at the lesel of the fracture A popular method of doing this IS b} means of the Goldthwail irons Figs 291 and 292 lilastraU spc-cially arranged equipment for the immediate reduction and immcdiitc ipphcalion of the Minerva jacket These irons are two softly tempered steel bars which arc strong enough to maintain a part of the body viei^iit and are supported at each end by steel standards V7e have used these irons on the Hawle) table by resting one end on the pelvic support and the other end on the upper end of the table The irons are kept from turning by having the lower end fitted viith studs which project into the holes in the pelvic support and the upper ends fitted m notches in a flat steel bar The irons are bowed upward to obtain the desired hyperextension and the patient IS laid upon them After the plaster cast has set the irons are pulled out of the cast The Goldthwait irons have the advantage that the plaster can be molded well around the front of the dicst and pelvis They have the disadvantages that they cannot be accurately adjusted and that the hjperextension cannot be sharply localized The above disadvantages are met by the automobile jack fitted with a removable pad, as used by Ryetson anti O Donoghue or a long strip of flexible steel, as used by James Bost If a Bell table is available any desired amount of hyperextension can be obtained gradually by means of a canvas sling under the site of the fracture as illustrated m Fig 295 Tig 294 Plvatogtaph of pititnt on Con’«,ells modified Heraiiatl. BtidfocJ fnnie for gradual correction of compressed fractures of spinal ccrtelne Any amo nt of convexity of the frame can he accomplished with aid of tiirnbucl.le thereby bringing about any desired hyper exftnwwH o! ip Of can hr sewvevf utth say degree np/d/ty Cm>rxjty can he eas ly adjusted to area of compression Traction and countertraction arc applied lo I ead and pelvis and to lower extremities if necessary An ancstheUc can be given but is seldom ind cated Griultial CorreeHon of Deformity When there is some contraandication to im mediate correction of the deformity such as multiple rib fnctures fneture of the femur or an unconsaous patient one may attempt to correct the deformity of the body of the vertdara gradually by hypcrextension m bed Treatment is carried out on an adjustable frame (Fig 294) and should be started with the patient in a comfortable position that is as -i rule with frame slightly concave and with the site of the fracture opposite the hinge in the frame The hypcrextension may be made gradually, and usually at the end of 15 to 20 minutes full correction of the deformity is obtained This correction should be controlled by literal x ray films taken while the patient is on the frame m a position of hypcrextension At the limit of extension the patient feels tension in the abdominal muscles and physical examination iNjURirs or sptNr 2fi7 wiJI disdo5e a disappearance of the abiwcmal prominence of the spines at the site of the fracture In resistant cases v.c apply head and foot traction and combine the traction and hj'perextcnsion methods Narcotics are usuall) ncccssar) during the rapid correction or the patient may be left recumbent for i few dajs and the correction carried out serj gradually over a period of 3 to 4 days Instead of a frame a hospital bed with a knee lift maj used The head of the patient is placed at the foot of the bed and the knee support is clei ated until the desired amount of hyperextension is obtained In order to simplify the aftercare the patient may be shifted to the Goldthuait irons or a suspension hammock and a plaster /acket may be applied as soon as hyper extension is obtained It has been our experience that some patients do not tolerate the prolonged hyper extension on the frame and may suffer from abdominal distention and \omiting m addi tion to severe pain These symptoms can usually be telie\ed by placing the patient on a flat bed with feicture boards under the mattress However if the symptoms are severe continuous gastric suction and the administration of parenteral fluids may be reo in fr»mc for I’ weeks, then irohuli or? binty <*« (or K weeks anJ a Tiytor tu k hca e f k t r-onll < B Sine months folhwin^ intufj showing furtlwr tiirpcision or ulkirse C Ten roonrhs follow tiR tniuty Ulustcii or tcmleflcy of fracture i > return I or«R nal tion n Jescti*^ a I! Treated by Hbbs fuion afier ihe coiwwaine »neit(oJt Iiad fa led Good rtsulu OW Compression I raclurei of Spme Abcnit Ivilf of the cases of old fractures of the spine with pam show bonj fusion of the fractured sertebra with the one ahose or be low and man) of these show hypertrophic arthritis in the ncigiihoring scrtcbrac In the cases with bon) fusion the pam lends to be localized just abose or just l>clow the point of fracture and is prcbably due to the faulty mediinio of the spine and the resul inl abnc mill strain in this area Some surgeons l>clic\e that these cases with pain demand spinal fusion m c rdcr to eliminate motion in the painful area It should be remembered howeser that, if fusii n IS to effect relief i f the sj-mptotns it shoul I fix tlul pnrli in of die spine wluth is pa n ful Coinecjucntl) in cases of rlJ fracture with ankylosis of the fractured stftchral bodies the fusion shcwil 1 inclu Ic the /racturr I sertebra an 1 the ones alwnc an 1 bel w wh ch ate painful UTiether conscrsatisc treatment or fusioo m a given case n to be aJsiseJ will luve INJURIES 01 SPINE 29J to be deaded by the individual surgeon Also, it is to be noted that the sjmptoms may be caused by a disc lesion Khmmells Disease Theoretically the condition desaibed by Kummell is one m which after a compression in;urj a vertebral body which at the time of the injury was not fractured or compressed gradually gives way and collapses some months later, and the condition is supposed to be due to a rarefying osteitis which is caused by a disturb ance of the arculation at the time of the injury We believe that these cases are the re- sult of unrecognized compression fractures FRACTURE DISLOCATIONS WITHOUT PARALYSIS Fracture dislocations with or without paralysis present greater difficulty m regard to diagnosis, therapy, and end result than does the compression type ‘Iherapy is fraught with danger The greatest danger is that the surgeon may pro duce injury or paralysis m a case of fracture dislocation without paralysis Fracture dislocations constitute an exception to the rule of hyperextension so universal in the compression type Fortunately these cases are rare Fig 299 DetnonstnUion of factors entering iota diagnosis 0/ rotary dislocation Note UtasI tiUini, of second lumbar vertebra difTcrcot alignments of upper and lower seres of spinous processes literal angulation of two spinal segments and rotation localized (Courtesy Dr Arthur G Davis ) Diagnosis The history of the nature of the accident may be helpful in determining the degree of force Extreme hypcrficxions result from collisions at high velocity falls from a height, mine cave ms the falling of heavy tdijecls on the shoulders or falls from a height in which the patient strikes fool first fracturing one or both calcanei Pain, shock ileus bladder Jivturhano: internal organ rupture and associated frac tures obviously arc more likely m these cases The treatment of such complications may for the moment outrate m importance the diagnostic rtudy of the spinal lesion As soon, however, as appropriate measures have been outlined, a preliminary survey x ray examina iNjVRiLS OF spmr 293 hon IS in order Tlie anteroposterior film wdl show \ccy littie of significance unJcss there IS an element of twist entering the mechanics of the injury In the lateral view besides noting the immediately obMOus compression comparison of the posterior borders of the bodies IS the best criterion to show the d^ree of dislocation cnaoachment on the spinal canal and jackknifing Further x ray anatjses are contained under the different types of fracture dislocations Rotary Dislocation In this type of frachire dislocat on one articular facet is displaced upward and caught m an abnormal position It is thought that the mechanics producing this rarelj Ftg, 301 Aatcnoe d splarerncni ot fourth on fifth lumhar vertebra with incture on anteior upper border of fifth vertebra with no Cord mvoUcinent Treated with bed rest for 3 '^eeks no nanpuJaton and well fitted plaster cast (com pritu to axillae and later by Taylor baeJr brace Good results and no change in pos t on of d spUcement Fracture healed w th only n oderate disabil if Occurring clinical entity represent a spiral twist of the torso along with the usual flexion effect Fig 300 shosvs the nature of the roentgenographic findings m such cases A study of the anatomic specimen shown in Fig 299 helps more clearly to visualize the actual status of the piostenor arch Fig 300 shows an anteroposterior and a lateral roent 2^i DIAflNOSXS AND IIUIATMLNT OI SPIOI^IC IVJURttS ficnogram made m the case of a fracture dislocation of the third lumbar >eftebra Neuro- logic signs x\crc normal The fnlloning findings s^cre noted in the intcropostenor pro;ection 1 Lateral angulation with its apex at Uk. third mltispacc 2 A wide intenal between the spinous processes of the third and fourth lumbar vertebrae 3 A rotation of the entire upper section of the spine as indicated b) the defective alignment of the spinous proasses of the upper section of the spine with those of the lower section 4 An unerjual compression of the two halves of the body of the vertebra (The patient was a slender boy In a corpulent person such details would be sbll further obscured ) A lateral roentgenogram revealed the following additional findings 1 Gross enlargement of the intervertebral foramen 2 The appearance of one articular process being impaled on the one below 3 The two different levels appearing in the centrum Wherever this apparently double shadow of the vertebral bod) appears, the disloca tion of one articular process must be anticipated as the most logical cause of such asj-m meinc compression This type of injury is much more common in the cervical spine Treatment In the cervical spine skeletal traction will usually effect a reduction Occasionally this will fail to unlock the facet Open reduction is then required In the dorsal and lumbar spine, traction and manipulation are seldom successful, therefore, open reduction is the procedure of choice The operation may be performed as follows liie patient is placed prone on an operating table which breaks in the middle The posterior arch at the point of kyphos is exposH by the usual subperiosteal method as in fusion The laminae and articular processes arc exposed m detail One articular process will then be found to be mounted in front of its subjacent paitntr Evidence of fnetute of the articular processes must be sought for Ordinarily, however, the opposite joint Will be found luxated but ooc completely dislocated Provided the patient is being operated upon within a few weeks of injury the table is then broken to induce the necessary fiexion to disengage the jumped processes A bone forceps then grasps the spinous process of the dislocated vertebra, or a blunt elevator may be used to pry the process into proper position When the process has been cleared by thus eliminating the factor of rotation, the table is straightened The articular processes w ill then be seen to engage in normal relationship In case the articular processes have been fractured, fusion ordinarily restricted to the two vertebrae involved should be done with or without the accompaniment of hyper extension as indicated In the cervical spine, spinal fusion should always accompany the operation of open reduction and, in most cases, lower in the spine H) perextenshn Fractures With Elements of Dislocation This rare type constitutes another outstanding exception to the rule of hyperex tension reductions The fracture is caused by forabJe hyperextension, and the antenor longitudinal ligament and the body of the vertdirae are ruptured and separated Hyper extension obviously is not only loeffcrtive but positively dangerous The diagnosis of sudi hyperexlension fractures may be immediately apparent from the lateral x ray film in which an open space appears between the upper and lower fragments of the centrum and the vertical height of the body » increased. Ibis appearance should give the surgeon pause, and from this point on extreme caution must be brought to bear for fear of dire and immediate results of ill advised treataient Hyperextension in such cases may ausc INJURIES OE SPINE 295 immediate paralysis Evidence of a contusion o\ef a spinous process also ^\lU apprise the surgeon of the role of hyperexlension in the causation of the injury Tortunatelyr the chance of encountering a hy^erextension fracture is remote Trealnsetit When from the history and the nature of the acadent or by x ray cxziTuniUon or other diagnostic measure such hypTextension fractures are identified the first precaution is to avoid completely any attempt at hyperextension It will be re membered that the posterior ligamentous investiture of the area is probably intact so that if the patient is placed either supine or prone upon the canvas sling and a three point plaster jacket is applied with the spine approximately straight, such cases ordinarily promise to go throughout the usual convalescence without incident Qieck x rayr films taken with the Bucky diaphragm the next day after the plaster is dry will help to determine whether anything more needs to be done or whether immediate fusion should be considered POSTERIOR DISLOCATION OF LUMBAR VERTEBRAE Posterior dislocation is a rate injury but may occur occasionally in the lower lumbar spine usually at the level of the fourth or fifth lumbir vertebra It must be remembered that normally there ate considerable variations m the anatomy of this area In addition there is frequently some alteration of alignment secondary to degenerative changes in the disc and m the apophyseal joints To establish a diagnosis of posterior dislocation very dear and careful roentgenologic examination to include right and left oblique views anterior, posterior and lateral films as well as a detailed coned down film m the suspected area is required If the dislocation actually exists there must be disruption of the posterior spinal joints and this should be visible in these films In this type of injury prolonged immobilization in a well fitted plaster cast may result in sufficient healing to give a stable spine However if the fracture is definite and comminuted and the displacement is of any degree spinal fusion should be cart ed out ISOLATED FRACTURES OF TRANSVERSE PROCESSES These fractiues were practically never recognized before the advent of the use of the X ray but during recent years since it has been the custom to take x ray films of injured backs it has been found that they are not infrequent ZSiohg) Nearly all of the isolated fraoutes of the transverse processes occur in the lumbar region but they occasionally occur in the cervical region Tor the most part the injury is the result of direct trauma as a blow or a weight falling upon the lumbar region while the spine is flexed However even in these instances in which there is a direct blow it is the opinion of most physicians that the fracture of the transverse process IS an avulsion type fracture resulting from violent spasm of the quadralus lumborum muscle The fracture may also result from a pure muscular effort as in lifting and straining In addition to the fracture of the transverse process there is a rent in the deep fascia which is usually more extensive than one would suspect from the x ray film If there is much displacement the fracture usually fails to unite However, after the soft tissue has healed this nonunion does not produce disability The processes most fre quently^ broken are those of the second third and fourth lumbar vertebrae because these processes ate more exposed to injury, since the transverse processes of the first lumbar vertebra ate protected by the lower ribs and those of the fifth by wings of the ilia Frequently two or three or more processes are fractured and occasionally the trans verse processes on both sides are fractured (Tig 302) Diagnosis There is a history of direct trauma to the back of a fall from a height or of a sudden pain m the bick during violent muscular exertion followed by pain and disability in the low back- On physical examination the patient complains of pam in the low back, which is 29 (> DIAGNOSIS AND TRLATMLNT OF SPEOFIC INJURIES localized in the region of the fractured transverse process but may be n idely distributed in the lumbar region and there is tenderness uhirh is most marked directlj over the fracture or fractures AH movements of the bad^ are painful and are limited by muscle spasm When the patient is lying down rasing the leg on the affected side causes pain which is especially pronounced if he attempts to flex the thgh against resistance This IS due to the pull on the iliopsoas muscle Likewise if the hip is passively h)pet extended pam is produced at the site of the fracture Finall) the diagnosis must be made by x riy films taken m the anteroposterior plane This will show the fracture if it is present In interpreting an x ray film of the transverse processes it should be remembered that each of these normall) has an epiphysis Fig 30’ Fractures of traiwierse processes of all luirbar vertebrae on right side Treated w th short plaster jacket Un on d d not occur in vertebrae I 2 and 5 but functional result was good at the end which does not unite until after the twentieth year and also that occas onali> the transverse processes are asymmetncal and that one of them may point in an ab- normal direction A third factor to be considered is that the first lumbar vertebra may present an anomalous rib which resembles a fracture of the transverse process finally the shadow of the psoas muscle may cause a line across a transverse process which re sembles a fracture In a fresh fracture the line of the fcactiuc as seen in the film is usually irregular INJURtCS OF SPIN€ 297 and shaqply defined and m many instances there is more or less separation of the loose distal fragment As a matter of fact this fragment may be displaced se\eral centimeters The fracture usually occurs at about the middle of the shaft of the process Treatment There is no special reason why these fractures should cause prolonged disability The patient should not be told that he has a broken back but should be told that he has a fracture of a small process of one of the \ertebrae and that he will be all right again m a fes^ weeks This is urged because so many of these cases result in pro longed disability largely as a result of the mental attitude of the patient rather than of the fracture itself Many cases base been reported of fracture of the transverse processes in wb ch the patients have continued their active occupations not knowing they had suffered a frac turc until some weeks later As a rule however it is better to treat these patients in bed for the first few days and sometimes longer when multiple fractures are present During this period of rest m bed if the patient has cons derable pain it can be relieved by strapping with adhesive or by the application of a corset with stays which is well fitted and extends from the axillae to the pelvis The corset should get a firm grip upon the pelvis and the shoulder straps may or may not be included to prevent twisting of the body (Fig 337) F g 305 Fracture of Iratisvctse processes of the second and third lumbar vertebrae Treated w th rest in bed for 5 days and adhes estrapp ng to back w Ih good res It in 5 weeks The corset should be worn for from 2 to 5 wed^s depend ng upon the seventy of the fracture and the reaction of the patient During this tune the patient need not remain in bed unless he has cons derable pain wrhen sitting or walking At the end of this time the corset should be removed and the patient may go without support The surgeon should be cautioned against overtreatmg these patients otherwise they get the idea that they arc ser ously injured and are apprehensive of resuming normal occupations rracture of the transverse process in cervical vertebrae u an extremely uncommon injury and is usually associated with other trauma to the cerv cal spine In tliose unusual isolated fractures of transverse processes of the cervical vertebrae immobilization with a Thomas collar is usually adcquite 29b DIAGNOSIS AND TREATJ.ICNT Or SPCQIIC IVJURIFS Prognosis Most of these patients ^ould be able to resume ihcir normal occupa lions m from 8 to 10 \\eeks after the injury except those xnth multiple fractures with se\ere contusion of the soft parts or low bad. strain In these patients the disabiht) nuj extend to 4 months or longer Union usually occurs m cases with little or rclafnely slight separation and nonunion usually occurs m cases with wide separation, but we ha\e rarely seen nonunion result in disability and have never found it necessary to operate fot the removal of a transverse process which has failed to unite after a fracture ISOLATED FRACTURES OF SPINOUS PROCESSES AND LAMINAE Isolated fractures of the spinous processes an I laminae arc relativel) rare injuries and ace practically alv«ays due to direct violence although tsccasional cases have been Fig 301 Fracture of sp nous process of seventh cefv cal vertebra (clay shovelers fracture) Trcateil with Thomas collar for 3 weeks and wjih local heat afterward Goods results >n 2 months Fig 305 hfult pie fractures of spinous processes of lumbar vertebrae Treated b} tesl ° bed /or 2 weeks and body east for 3 weeks f llowed ty coiset with stays w th good reswlt. reported as the result of muscular violence Most of the cases occur m the cervical region and ate caused by blows or falls upon the bad. of the necL TJie spinous process may be broken off usual)} abi ut the ntidJIe of its shaft or one or both laminae maj be frac hired When i nl) t ne lamina i\ fractured there is usually no dispUctmenL When both laminae art broken the scparaleJ pi rtion if tlic arch if ihe vertebra maj^ be driven inward and cause pressure on the spinal cord Diagnosis There is usuallj a hisuiy of direct trauma to the back or neck, followed by pain and disability with limitation of motion in the involved region of the spine On INJURIES Ot SPINE 2PP physical examination there is acute lootlized tenderness over the fractured spinous processes and muscle spasm m the involved -irci It nny be possible by pilpation to de Icct abnormal mobility of the spinous processes TTie finil diagnosis depends upon the xtdy film which when taken in tlic lateral plant, will show the fracture (i ig 304) As a rule, there is little or no displacement, as the attached muscles and ligaments (end to present displacement or to pull the broken fragment back into position if it is displaced by the fracturing force Treatment Just as is the case with fractures of the transverse processes these frac tures of the spinous processes and laminae are not, as a rule, serious injuries and should not be overtreated Since there is little or no displacement union may be expected either With or without immobilization However in most instances it is advisable to immobilize the fractured area with a well fitting Thomas collar Rest m bed after the first day or two IS not necessary unless there are other injuries or unless the patient is very uncom fortable when up The immobilization should be continued for from 2 to 4 weeks depending upon the seventy of the lesion and the reaction of the patient It should be discontinued as soon as the patient is comfortable without it, and no disability as a rule need be ex pected Nondisplaced fractures of the laminae or pedicles may be treated with bed rest with or without a plaster jacket until the acute pun has subsided The area then should be immobilized in a plaster cast for a period of 3 to 4 months m an effort to obtain union of the fracture In fractures of the laminae m which the fragments are displaced m such a manner that they ausc pressure on the spinal cord associated with cord symptoms, immediate operation should be performed and the offending bone should be lifted off the cord As a rule this is a relatively simple procedure and it wnll not be found necessary to remove the spinous processes and laminae although the surgeon should not hesitate to do this if any difficdty is experienced in keeping fracture fragments away from the cord Post operative immobilization is not necessary in that particular instance unless there are other fractures involving the vertebrae ISOLATED TRACTURES OF ARTICULAR FACETS Isolated fractures of the articular facets arc rare injuries which occasionally vre found in patients who have received a severe low back strain Tlicy are not, as a rule diagnosed until the strain has been present for some time and has failed to respond to the usual forms of treatment Then the fracture of the articular facet may be seen in tlic anteroposterior x ray films, but if such an injury is suspected it is best demonstrated by oblicyue X ray films as Ghormley and Kirklan have shown The supine patient is rotated 32® or more to the right to show the tight articular facets and 32® or more to the left to show the left articular facets The tube is placed directly above the spme When these patients are seen relatively soon after the injury there is not too much dilficulty m estab lishing a diagnosis of an acute fiactvie of the articular process However, wjjen the patient is seen late, the diagnosis is very difficult as there may be a congenital failure of fusion of the articular process or an old nonunion If the surfaces of the bones are smooth, It is difficult to say whether this is an old ununited fracture or a congenital defect In the acute fracture, immobilization until the symptoms have subsided is usually all that is necessary, as it generally becomes asymptomatic whether or not the fracture unites Occasionally this injury is followed by a degra Other standard \ir«s were negal \c INJURIES or CERVICAL VERTmRAr Itieitletice Tlie cervical region of the spine differs from the tiioracic and lumbar regions in that the vertebrae art quite freci) movable upon one another and that pore dislocations without a fracture maj occur The mjuncs maj be dm led info minor an I serious groups The minor injuries include sprains an! strains Die severe injuries m dude subluxation acute disc rupture dislocations fractures and fracture-dislocations Minor Injuries Minor injuries ma) be termed sprains or strains of the cervical spine Dicy art rtla tivel) frequent and ma) follow sudden turns of the head falls and especially automoj ile accidents in which the cat in wKch the patient » sitting is struct from beh nd so that INJURIES OF SPINE 30i the body ts forced forward and the head is snapped backward (Fig 308) These m juries are of the deceleration type After such an injury the patient maj experience im med ate severe pain and soreness of the neck assoaated ^ ith headache or there may be relatnely little pain jmmedialel} after the acadent with the symptoms appearing later that day or in the next few days The symptoms may be mild moderately se\ere or very acute they may last for a few days or for many months or they may be intertnittent The pain varies in d stnbu tion It IS usually present in the back and more marked on one s de of the neck and may radiate down over the shoulder or upward into the ocapital region Occasionally m what IS generally considered frank intervertebral d sc les oos in the cervical spine r g 307 A Pos { on for lateral x ray film of cerMcal sp ne s It ng reJaxcd eyes honzonlal and sandbags m hands to depress shoulders B Ch o chest pos t on Flex on may be held voluntarily or with pass ve ass stance (Courtesy Dr Arthur G Davis) the pam may radiate down the arm to the hand in the distribution of the affected nerve root Tlie pain may or may not be rel eved by lying down It is usually aggravated by moving the head in certain directions On phys al examination the head may be held in the nocmil position but move ment IS usually limited m certain directions This is especially likely to be true of for ward bending or bending toward the painful side and usually rotation is limited and painful If the pam is severe all movements of the hcid may be limted and the head S02 DIACKOStS AND TREATMrST 01 SProriC INJURIES may be held in a guarded manner ThCTc is likely lo be tenderness o\er tlie nenc roots of the brachial plexus on the affected side, oser the scalenus anterior muscle on the affected side and oser the back and side of die neck There ma) also be tenderness o\er the superior angle of the bod} of the scapula The ordiruty roentgenograms nu) fail to sho% csidence of fracture or dislocation Howeicr, in seme injuries flexion and extension films of the cenical spine, particular!) in the lateral projection may sho’a instability between one nr more %crtebral bodies and there is frequently a loss of the normal cenicil lordosis It is thought that this straight enmg of the cenical spine is the result of muscle spasm The roentgenogram nuy res cal a considerable amount of degenerative dianc^ with narrowing of the intervertebral discs and sclerosis of the apophj’seal joints In individuals who recene deceleration type in juries and who haie had previous degenerative changes in the cervical spine the sjmp toms ITU) be more acute resist usual forms of treatmmt and list for a considerable period of time Intervertebral disc rupture may result from these injuries although they are rarely of suthcicnt sev erity to warrant surgical intervention Trealnient While we cal! these injuries minor injuries because the x ray cxamina tion reveals no evidence of fracture or dislocation the) may be the cause of prolonged pam and disability The treatment is largely symptomatic and is adjusted to the degree of pain the tolerance of the patient to the pain as well as to his economic condition If U« pam is so severe that the patient is more or less incapacitated wc believe that he should be put to bed with head traction This can be furnished by means of a halter and usually 3 or 6 pounds of weight are sufficient to relieve the pam Tlie traction can be removed at intervals It may be helpful if a folded towel or sheet is placed under the back of the reck In patients in whom the pam is not sufficiently severe to warrant hospitalization or rest m bed at home but is still quite troublesome relief may often be had by means of a Thomas collar We usually make this out of heavy cardboard (press board) the pattern cut to hold the head in the erect position Umbilical tape is then fastened fo the card boacd vyida adhesive This is padded with sheet cotton coveted by a bandage and then With stockinet and the umbilical tape is used to tie it in the back It should fit fairly snugly and not only limit the movement but also offer some support for the head The collar can be worn as much of the time as it ts useful hrequcntly it is worn only at night while the patient is m bed We sometimes have patients with chronic neck pvm use head traction at home They are supplied with a halter and are instructed lo fasten this to a rope which runs over a pulley to the other end of which is attached a d lo 6-pound weight They sit in a chair 10 to 15 minutes while traction up« ird is made on the head Tins can be done twice a day or more if indicated Wc sometimes apply head traction in the office and manipulate the neck The patient sits m a chair the head simg is adjusted and head traction is applied until the buttocks arc just lifted from the chair VCith the trunk im mobilized the head is rotated first to one side and then the other This may afford con siderable relief and we have not found that it is dangerous The patients arc also given salicylates and vitamin B is indicated If not rtliocd and if the symptoms art severe operation for removal of tlic offending cenical disemay lx? considered Occasionally wc sec patients usually children in whom after a minor accident or from an unknown cause tlic head is tilted to one side and the chm is rotated so that the appearance is that of a unibteral disloation of the cervical spine However the x rays fail to reveal any such lesion but may show obliteration of the normal cetvial lordosis These patients can usually Iw relieved by manual traction and manipulation without anesthesia The maneuver u>^ is that of Walton and this may be accompanied by a cruncli, but it is not, as a rule very painful After the mvnipulation the patient is fitted wiili a Thomas collar, which is worn for 2 weeks or longer INJURIES or SPINE 303 If the manipulation is not tolerated, we me head halter traction, 4 to 6 pounds or more, ^ith the patient in bed for a few hours at intervals, and apply a Thomas cervical felt collar when the traction is not being used In adults if the pain and disability resist prolonged consenative treatment, espe- cially if there is evidence of nerse root tmolvement, these cases should be referred to a neurologic surgeon for a cerMcal myelogram and possibl) for remo\al of a protruding cerv ical disc According to Gershon Cohen Budin and Glauser *■ fractures of the spinous processes in the cervicodorsal area may occur when a sudden hyperflexion of the necl. takes place The fracture resembles those described as clay sho\elets whiplash frac tures (Fig 304), which implicate the stretching of the interspinous supraspinous, and nuchal ligaments, and such paiholo^ has been duplicated m cadasecs by these authors They state that in a whiplash accident a sudden pull by the ligamentum nuchae and interspinous and supraspinous ligaments on the spinous processes to which thej are attached can result in an avulsion fracture The authors further state that when the ligamentum nuchae tears, espenally at or near its periosteal attachments, the resultant hemorrhage can be extensive and, m certain instances such hemorrhages may organize and lead to calcification of injury depends upon amount of force encountered A Patient in upright posiiion driving an automobile B Position of body when strifcini; force is from front C Position of body when farce producing injury is received from rear (From Gay, J R, and Abbott K H JAMA 152 1698, 1953 ) In personal correspondence (October, 1955) with Dr Kenneth H Abbott relative to his review of a senes of 160 deceleration injuries of the neck, he stated that he found that m over 90 pet cent of these cases in which the patient remembered which way tlie neck flipped (and over 50 pet cent of them did remember) they staled that, when the car was struck from behind the first movement of the head and neck was backward (Fig 308 C) If the deceleration occurred from a sudden stop or by striking an object in front, there was an acute flexion of the head and neck (Fig 308, B), but this oc curred uncommonly Abbott further stated that the other type of movement of the head was a lateral deceleration and that this brought about pain in the side of the head He concluded that he hid not seen i ruptured intervertebral disc from an acute deceleration •Gershon Cohen, Dudin P and Glauser F Whiplash Fractures of Cervicodorsal Spinous Processes Resemblance to SboveJersrxactiiJwJ A M A 155 560 1954 304 WAC^OSIS AND TRfATMFNT or SPtanC INJURIFS injury of the hyperextension t)pe and that this is to be expected in the h) petexiension mechanism because such force is not the mechanical method of produang a pos teriorlj ruptured intenertcbral disc Abbott conciuded that, in fact a rupture of an inter vertebral disc is more Iikelj to «cuf in x mechanism in which an acute flexion of the neck IS brought about Abel* states that close questioning of the patients indicated to him that more damage occurs to the neck when there is a side to-side component to the whiplash than when the snapping is directl) forward and backward Apparentl) the maximum injurj to those patients invohed in accidents occurred when the collison had been parti) or wholly from the side or the head had been turned to the side at the moment of impact In fact, in his own experience this oblique type of deceleration injury has been b) far the more common and cerlaml) the more likcl) to be disabling With forced h}-per extension and flexion from the anterolateral and posterocontralateral sides, the neck is much less flexible and the intervertebral discs appear to lose much of thcir cushioning action With hypercxtension m this manner, the apophyseal joints become weight bearing and on the reverse forced hyperflexion there i$ development of excessive torque and considerable ligamentous pull on the posterolateral elements of the vertebrae An attempt was made to reproduce th«% oblique type of deceleration injury on cadavers and to correlate the findings with known chntcal cases The necks were x rajed in routine and special projections before the procedure between the hypwrextension and hyperflexion, and again after the procedure Subsequently tlie neck stumps were dis sected out and x rayed again The soft (issues were then removed completely from the vertebrae, and the vertArae were subjected to careful anatomic study Three types of fractures of the smaller elements of (he cervical v'ertcbrac were pro* duced experimentally on the cadavers and apparently the roentgenographic evidence of these fractures was duplicated in patients Usually these fractures are not visualized m routine views of the cervical spine In Abels experience, two additional stereoscopic views are necessary preferably with direct magnification technique (1) a modified basilar view of the skull centered over the first cervical vertebra for adequate visualization of the first and second cervical vertebrae, and (2) an anteroposterior view angled about 50^ caudad for adequate visualization of the posterior elements of the lower cervical vertebrae Abel states that he and his associates have come to the conclavion that minor fractures of the neck must be quite common and rather frequently arc found as inadental findings on x ray films The high inadence of fractures in their cadavers tends to con firm this point Moreover, from close questioning of patients, these fractures apparently have a wfide range of seventy of symptoms and the symptoms may be quite nonspecific From a practical standpoint, m attempting to attribute a fracture to a recent injury, they tend to ignore minor asymmetries and, cvcqvt in the most obv lous cases, insist on comparison x ray films in about 2 months for confirmation Demonstrable changes arc slight and slow to appear as is true m otlier flat bones Additional rcchecking in 6 months or even longer may be necessary for compirte certainly, especially m the aged Our experience has been that in most of these injuries, even though they are severe in the beginning for the first few days or even tlie first few weeks m the extreme type of case, almost no case bwomes panunently disabling and that Uie psychologic reaction of prolonged treatment without thorough understanding and explanation to the patient not infrequently brings on a neurosis which is unnecessary and which the physician should not allow to occur ♦AJ>el M S MoJeraicly x^vete Whipljvli fniunes and TJieir Di4;rri>Mi* Present^ in parts at the Eighth Intenwtional Coogms of RjJiologr Mcxifo Cur Jalf 1956 and at the mcetins of die Amwian Medical Assocutioo (Orthopaedie Section), New York Oty June. 1957 INJOftlLS OF SPtNE 305 However, the patient suffering from such injurj should recene from the very be ginning a careful orthopedic and neurologic examination, and if there is an) evidence of severe nerve trunk irritation, the patient should in most ases, be treated immediately, probably v-nth bed rest, light cervical traction for a few days with physical therapy, and gentle stretching of the neck muscles If there is recurrence of nerve pam when the patient becomes ambulatory, the physical therapy should be continued, and, in some instances, the patient should be fitted with a cervical collar Gradual progressive neck exercises should be included m the treatment Proper treatment in the early period of these cases, with or without neck collar, will bring about complete recovery in the mifority of instances and will greatly mtnimiae the too often increasing inadence of chronic neck shoulder atm syndrome which IS always slow to respond to any type of therapy later DISLOCATIONS OF CERVICAL VERTEBRAE Incidence and Mechanism Vertebral dislocation without fracture is very unusual in the dorsal and lumbar regions of the spine However in the cervical spine this lesion though uncommon is not rare Langwordiy has reported 30 cases and Brookes has had 40 cases, and large centers have no dilficulty in compiling considerable series of cases One of the factors allowing dislocation in the cervical spine is that the articular processes he in a nearly horizontal plane and a sudden twist of the neck may rotate an articular process forward over the one below, whereas in the dorsal and lumbar areas the articular facets lie m a more nearly vertical plane and dislocation here without fracture is almost impossible “nte ma/orcty of the ascs of dislocation in the cervical spine are due to trauma in which the head is violently flexed and twisted to one side, many occurring in such an accident as a fall downstairs Occasionally, however cases are seen m which the disloation occurs as a result of muscular violence alone spontaneously during sleep or from infection or burns with ^efocmity Unilateral DUloealious Pathology The disloation occurs most frei. 317 A Waltons methoJ in reduction of dislocation of cervical vertebra on left side With moderate traction and flexion deformity is increased by routing head to right B Second maneuver ith deformity increased head is ^nt or flexed laterally sharply a^aay from dislocated Side C Third maneuver Chm is returned to middle and neck is liyperextended Langworthy, in performing the manipulation used the edge of his hand as a fulcrum on the opposite side of the neck and bent the head laterally against this hand to dis engage the facet He stated that in most of the older patients in whom the dislocation has been present for some time great force is required m this part of the manipulation and that the hand, acting as a fulcrum, presents a lateral pushing of the head and neck toward the shoulder, which is not an effecti\e maneuver in the reduction In some cases he had used practically his full strength in this maneuver without harm As soon as the dislocation v>as reduced, he threw the head hadk. into hy'perextension and kept it there INJURIES or SPINF 31! creased slightly This slight flexion and increase of the deformity should be accompanied by moderate traction on the head This tends to unlock the articular facet When this has been accomplished, the head should be forably inclined to the right and the dun rotated to the left or to the midline, the neck is then hyperextended Inclining the head to the right lifts the displaced facet up to the fc\el of the top of the one below, and the rotation to the left, performed ’ahile the head is indmed to the right and the facet lifted carries the facet back mto its normal position If this nio\ement can be performed freelj, the reduction may be regarded as complete but when possible it should be controlled by lateral x ray films taken before the cast ts applied Reduction is maintained by the position of hyperextension Tii, 317 A Waltons method in reduction of dislocation of cervical vertebra on left s de With moderate traction and flexion deformity is increased by rotating head to right B Second II Jneaver With deformity increased head is bent or flexed Jaterafly sharply a« ty fro n d slocated side C Third maneuver Chin is returned to middle and neck is hyperextended Langi\orthy, in performing the manipulation used the edge of his hand as a fulcrum on the opposite side of the neck and bCTt the head laterally against this hand to dis engage the facet He staled that in most of the older piticnts m whom the dislocation has been present for some time great force is required in this part of the manipulation and that the hand acting as a fulcrum presents a lateral pushing of the head and neck toward the shoulder, which is not an cfectise maneuver in the reduction In some cases he had used practically his full strength in this maneuver without harm As soon as tlie dislocation was reduced, he threw the head back into hyperextension and kept it there 312 DIAGNOSIS AND TRIATMINT OF SPCOriC INJURIES to pre%ent redislocation In old didocations on the left side he bent the head to the n^ht as far as it would go then applied tjuid. force to bend the head still farther to the right and at a point of maximum appUcahon of force rotated the head sharply to the left Taylor s Method of Redi/clioa In Taylor s method slow stead) traction combined with flexion and followed by hyperextenston is used to effect the reduction The prinaple consists of controlled traction exerted on the head with countertraction on the shoulders or lower extremities until the contracted cervical muscles have relaxed sufficiently to permit a successful manipulatne reduction on the part of the operator Fig 318 d Taylors method used m reduct on of dulocations and fracture dislocat ons of cervical lertebra Iraction is made br surgeons body with sJing aro nd patents head and chn wb le counlertnct on on shoulders is nude by assistant B Head is steaded by surgeons hand When neck is felt to elongate cervical spine is gently hyperextended Taylor recommended that traction be applied bj a suspension sling for the head which he fastened to a band of clothesline passed around the operators pelvic girdle and of such a length that the patient s vertex is onl) a short distance from the operator who faces the patient and grasps his neck m the damaged area supporting the head m the liands Wlien everything is read) fhe operator applies traction on the ned^ muscles graduall) and mcreasmgl) b) bad»ing the body avva)r while holding the neck with his two hands thus maintaining control of the whole procedure The traction is first exerted in the axis of that portion of the cervical spine above the injury so as to unlock the articular processes of the damaged vertebra After triction for a period varying with the degree of strength and muscle spasm (5 to 10 minutes) the neck is felt to elongate and the bones to unlock then the head and upper spine are allowed to sag downward while still under traction Reduction is indicated as follows (1) sometimes by the pahent who feels the bone slide into place with immediate relief of previous discomfort (2) by finding the spinous process m proper alignment and (3) by a film taken by a portable x ray machine and developed while the patient remains on the table After reduction is accomplished, a plaster cast INjURfCS OF SPINE 313 which extends from head to p^his is applied Ihe plaster cast should be left on 4 or 5 weeks m cases of dislocation without fradure At the end of this tune it should be temosed and the patient should be fitted with a leather or padded pasteboard Thomas collar which should beworn for 2 weeks or longer, as necessary In cases with small chip fractures or slight cnishmg fractures of the vertebra with no cord injury the plaster jacket must be worn longer, usually 2 months and can then be followed b) a brace or Thomas collar for several weeks the duration of the im mobilization depending upon the seventy of the fracture 314 DIAGNOSIS AND TREATMENT Oh SPEOFIC INJURIES TRACTURE DISLOCATION OF CERVICAL VERTEBRAE Fracture dislocations of the cemril certebrae resemble those of the di rsal and lumbar rej^ions of the spine hut are even more serious injuries because they arc usually accompanied by extensne lord and frequently result in immediate death from the accident or in K tal transverse lesions with later compilations and death That this IS not always true is evidenced in Iig 324 which shows an old fracture disloation which was unrecognized and which healed with the bones m their abnormal positions These are severe injuries in which the body of one or more cervical vertebrae is fractured or there has b«n a variable amount of displacement The patients are usually completely inapaatafed the head is unstable they arc unable to sit up or to move the head voluntarily and there is obviously a severe injury to the neck There may be a van able amount of paralysis from minor sensory or motor paralysis or reflex changes to complete loss of movement and sensation below the level of the lesion Fig 320 Simple type of head tract on used in tiwtment of fractare dislocai ons of cerv cal spine This liacCion is useful m cervical traumatic arthniis or mustle spasm or nonUuumat c dis locations of atlantoaxial toint Sandbags sub Iize head Lmergetjcy Trealment It is important that it be recognized that Uiese patients have a severe injury to the cervical spine and that any rough handling of the patient may be followed by additional iii]ucy to the spinal cord with an increase m the paralysis, con sequenlly they are handled very gently In transportation the head should be maintained in a position of moderate extension and is usually supported by an attendant who sits at the side or head of the litter and a folded sheet or large towel is placed beneath the back of the neck to maintain normal lordosis in this region A slight amount of traction on the head is helpful and sandbags may be placed on either side of the head to prevent rotation The same treatment is carried out when the patient reaches the hospital and no attempt should be made to get x ray films of the neck until traction has been apphevl INJURIES OF SPINE 315 to the head Temporary traction can be applied by hand or by a head sling ^ ith a u eight of from 5 to 10 pounds hanging over the head of the bed When the patient is turned he should be rolled like a log the head and shoulders being moied together The taking of x ray films can be postponed until the general condition of the patient ^^a^rants movement or they can be taken in bed with a portable machine Neurologic examination should be made as soon as possible after the injury and F S 521 Head halter {Courtesy Z mmer Manufaclut np Company Vt arsaw Ind ) Tig Fracture dislocal on through Umna of sxth cervical vertebra with compress on of Seventh cervical vertebra followed by un on and fus on There were no neurolog c symptoms 316 DIAGNOSIS AND TREATMI NT OI SPCQI-IC INJURIES F* 5*3 F* JN TiS 323 ^^Jld crushed friciurc of seventh cervical vertebra TTsesc fractures /nay accompany dislocations and demand prolonged tmmob I zation and freedom from motioa Fig 3M Old fracture dislocation of seventh cervical vertebra seen by Cooviell I year after injury with anterior un on No treatment following mjuiy except fcvv days rest and local heat Such treatment is not rec mmended Patient had moderate necL pa n at loterrals I year after injury Treated by local heat and support with improvement INJURIES or SPINE SV should be repeafed from time to time, as occasionally these injunes involve hemorrhage into the spinal cord which ma} cause progressise paralysis which may be relieved by laminectomy Following areful phjsical examination, appropriate x ray films are obtained to establish a diagnosis If the patient is handled carefully, and particularly if there is head halter traction, adequate exposures can be obtained without undue risk to the patient When a diagnosis of fracture dislocation of the cervical spine is thus established, skeletal traction is applied by the methods previously described As a rule it does not take as much weight to obtain a reduction as is true of cases of dislocation without fracture Again care must be exercised not to ovetpull the cemal spine and not to maintain this overpulled position during the healing phase Fi^ 325 Metal brace as vsed m minor infuftes of eenicaJ spine and ronvalesccAt treaiment of fractures lo tins region (Courtesy Zimmer bfaoufacturmg Company Warsaw Ind ) r racinres arid Dislocalwns of Alias and A x/s Fractures and dislocations of the atlas and axis deserve speaal attention, since, be cause of their location, they have a considecabl) higher mortality than do similar injuries of the lower cervial lertebrae However, they arc by no means necessarily fatal In addition to the cases which result from trauma, definite disloations of the atlas or the axis may occur without a preceding tnyury (Fig 328) Berkheiser* has reported five such cases, all occurring in children, and in each instance the dislocation occurred after an acute upper respiratory infection BerUieiser believed these to be pathologic dislocations caused by mfiammation m, and distention of, the joint capsule or of the bursa betw een the odontoid process and the atlas Rotary Dislocation of Atlas The most frequent lesion jn this region is a rotary dislocation of the atlas on the axis This injury is similar to that described above as a rotary dislocation of the cervical vertebra m that the articular process of the atlas slides forward on that of the axis below and gets caught in the intervcrtrfiral notch (Fig 328^ Symptoms and treatment are identical with those of dislocations of the cervical spine The only difference between these lesions and those m the other cervical vertebrae is that before manipulation is undertaken it should be determined whether or not the odontoid process is fractured, for if it is fractured, manipulation may result m sudden death because of the displacement and compression of the medulla •Bcrtheisef, E J, and Scidler, F Nontiauinatic Dislocations of Allantoasial Joint, J A M A 96 517, 1931 318 DIACNOStS AND TRl-ATMtNT OF SPCailC INJURirS In Bcrkheisecs senes of nontraomatic dislocations four of the five cases s\cre sue cessfully treated by traction 'Hie patients were immobilized on a Bradford frame and light traction was applied to the head In the beginning the fraction s'as applied m the horizontil plane after svhich the head was hyperextended bj placing a pad under the back, of the neck The period of traction \acied from 8 tlajt to 5 months After reduction the head was immobilized in a plaster cast Dislocation of Axis 11 ilh Fracture of Odoutonl Process This type of dislocation and fracture is as a rule fatal since it is only m cases with httle or no displacement that the medulla escapes Yet occasiomlly the patient survnes and may e\en escape paraljsts and live indefinitely Fs 327 Fg J 8 ^27 Old nOdCraumaCic anterior d slocat an at atiantoaxiil font N^iih ankylos s It was an acute n lOltaumafic d ilocaiicn when firsf seen Patient had parjlys s of rghl upper and lower extremit cs wlicn first seen but recovered motor and sensory power in C weeks following appl ” tinn of Iraetion to bead Treated bi Itjction for 3 months then by plaster cast and later by metal brace Good results in It months Dislocation followed lonsdlits with nfection about atlantoaxial foint Tig 328 Anterior d slocation of atlas Treated by mm pdatne reduction and immobiliaat n n plaster and later by metal brace Go< d results Diagnosis The etiology and symptoms are those of other cenical dislocations and fractures usually a fall upon the bead follcmed by pun and stiffness in the neck and fixation of the head in an abnormal attitude If the patient is not paraly’zcd he will tend to support the head with the hands and is unmiltng to relinquish this support to another person Sudden death may occur at any lime from a sudden displacement of the head With a pinching oil of the medulla It is of course, impossible to determine by physical examination whether or not the odontoid process is fractured m these upper conical lesions However such a fracture should be suspected if the patient has a marked sense of instability of the head on the neck The displacement can be determined in some cases by palpation since an unusual prominence of the spinous process of the axis indicates INJURIES or SPINC 3/9 a sLppmg forward of the atlas and of the bead Likewise, the transverse process of the itlas can be palpated about halfwaj between the angle of the ;aw and mastoid and rotatory displacement of this bone wjJI result in abnormilit} in the positions of these processes It IS unwjst, however, to attempt to nuke the dngnosis ot such t liisUicaUon b) physical examination for, when a dislocibon or fracture djsJocatron of the sths and axis IS suspected, great care should be taken not to subject the patient to injudicious mampu lations He should be placed on a bed or stretcher at the earliest possible moment with the head jn a position of hyperexicnsion and supported b> sandbags Then x raj films should be taken of the region both anteroposterior!) and latetall) Dislocation of the atlas on the axis with or without fracture of the odontoid process should be suspected when the patient has pain that radiates from the neck to both occipital areas, and con Fig 3’9 Transverse fracture of base of odontoid process tinues after the head and neck have been plated at rest As it is often difficult to be sure whether a fracture of the odontoid process is present, an apparent!) negative result m an X ray film taken immediately after the injury in such a circumstance should not be con sidered final, but the films should be repeated in 24 to 48 hours If at the end of this time there is still no evidence of fracture or displacement, it is then fairly safe to as sume that a fracture does not exist Treatment Patients m whom cviden e of a fracture of the odontoid process with out displacement has been obtained by xray film should have immediate immobihzation m a plaster of Pans jacket as prei lousljr described This cast should include tlie head and be Supported on the pehis If the patient survives after displacement of the atlas and 3X1$ associated with fracture of the odontoid proass he should be treated b) skeleton traction to obtain reduction and then should be placed m a plaster of Pans cast for 3 to 4 months Traction ma) fail to reduce the displacement, but it will maintain the position 320 DIAGNOSIS AND TRtAT>trNT OF SPtOFlC INJlJRItS and pte\'ent further difpkcement If the in/ured area appears particular/j' unsfab/e fusion of the cervical spine should be cirried out as soon as the patient s genera! condi tion warrants Fig J30 Nonun on of odonlo J process T rst ro«»tgenogram follow ng acciJent show ng quest enable invol ement m fracture B Two years later defn te nonuO on w Ih spasm and oc cip tat radial on C and £> Fns on of att» and ax s «s ng \»ite and osifnpsr osteal graft Result some IimiUUon of mot on m nodd og but otherwise pa n free Pat ent returned to his occupaf on as truck driver {Courtesy Dr Aril ur G Djvis) INJURIES OF SPINAL CORD AND NERVE ROOTS associated with injuries of spine As has been slated spinal injures present two distinct problems (I) the injury to the sertebral column and (2) (he injury to tfie spina! cord and nene roots We be INJURIES, or SPINE 321 lieve that the subject is siraplifietl by considering these two problems separately In the preceding pages we ha\e discussed the diagnosis and treatment of fractures of the verte bral column This section snll include the diagnosis and treatment of the injuries of the spinal cord and ner\ e roots Occurrence and Mechanism, The spinal cord is so well protected by its fluid bed and covering membranes and fits so loosely m its bonj canal that in the majority of fractures and dislocations of the vertebrae it escapes injury However, in severe crush fractures or fracture dislocations or in dislocations or fractures of the laminae the spinal cord IS frequently crushed or lacerated and may be completely se\ ered DAMAGE BV DiSPEACED BONE The most frequent mechanism is one in which with a fracture dislocation a vertebra is displaced forward upon the one below it and the spinal cord IS crushed betw een the posterior border of the body of the inferior vertebra and the posterior arch of the one above Occasionally the displacement is lateral and the same mechanism acts m the lateral plane 7/ // /a he noted that the displacement may be temporary and that after crushing the cord the lerlebra may snap back into approxwiately Its normal position, so that the x ray fdm may leteal no appaient cause for the exiensne cold lesion Occasionally the cord may be stretched tightly over the Lyphos, or it may be compressed or penetrated by fragments of the body or posterior arch of the fractured vertebra In the cervical spine Schneider* has shown that in the presence of bony spurs on the posterior vertebral margin, which arc usually present in older people, plus severe hyperextension, there may be marked narrowing of the spinal canal, and it »s possible to compress the cord between the lamina, the ligamentum flavum, and the bony spur with out there being evidence of fracture or dislocation In these patients, if tlie dentate ligament holds, there is contusion to the central portion of the spinal cord with sparing of the lateral or peripheral portions Tim was previously described by Taylor f In these patients the nerve fibers to the lower extremities will not be particularly involved, whereas the central portion of the cord which includes the anterior horn cells and the most medial portion of the pyramidal tracks ate damaged with a resultant paralysis of the upper extremity This syndrome is therefore characterised by paralysis of the hand, weakness of the arms, and alterations m sphincter muscle control, but is without paralysis of the lower extremities HEMORRHAGE In addition to actual mechanical damage by displaced bone the cord may be injured by hemorrhage All fractures are accompanied by hemorrhage, and m fractures of the spine this hemorrhage may be extradural, subarachnoid, or intra medullary Very rarely extradural hemorrhage from a large localized hematoma may cause pressure on the cord Due to the large size of the subarachnoid space, hemorrhage here practically never causes pressure on the cord as the blood usually settles below the level of the cord IntrameduIIaty hemorrhage or hematorayelia is bleeding into the substance of the cord Tills IS always accompanied by injury to the adjacent nerve cells and fibers The gray matter is much less resistant to damage by hemorrhage than is the white and con sequently suffers more The symptoms vary with the location and extent of the bleeding, and the bleeding varies from microscopic extravasations to relatively large hemorrhages involving several segments or multiple hemorrhagic areas may be present The symptoms may resemble those of syringomyelia and in the cervical region may result m diaphrag matic paralysis, whereas hemorrhage in the lumbar enlargement may result m paralysis of the bladder and rectum •SthneiJcr R C Syndromeof Acvitc AntMiorSpinalCord Injury J Neurosutg 12 95 , 1955 ITaylor A R The Magnitude of lojaiy to the Cervical Cord of the Neck Without Damage to the Spinal Column, J Bone & Joint Sorg 33 B 543,1951 324 DIAGNOSIS AND TRCATMCNT OF SPEOFIC INJURIES the conus meduHaus resulting m loss of sphincter control and the ankle reflexes with saddle anesthesia, and there may or may not be other sensory disturiaance in the losver extremities It should be pointed out that any back in;urj which is accompanied by complete paralysis of both motor and sensory dements to the lower extremities without invohement of the sphincter always of a hysterical nature BtADOER AND RECTAL DISTURBANCES Bladder and rectal disturbances occur not only m all complete cord lesions but also m incomplete lesions in which the centers con trolling the bladder and rectum are insoKed These centers lie m the third and fourth saaal segments which ate situated at the level of Use first and second lumbar vetlebiae Consequently in fractures imolving the first and second lumbar sertebrae or in fractures below this in which the third and fourth sacral oerre roots are injured there may be relaxation of the sphincters and incontinence of urme and feces In lesions situated abo\e these centers if the afferent fibers jn the posterior column or efferent fibers in the lateral columns are mvoU ed there is retention of urine and oanstipation LESIONS OF CAUDA EQUINA AND OP NERVE ROOTS The nerre roots emerging at the le\el of the fracture may be in\ohed in fractures at any le\el whereas in fractures below the second lumbar \crtebra the cord is not affected as it normally ends here but the lumbar and sacral nerve roots comprising the cauda equina may be injured either in the canal of at their points of exit In these lesions of the ciuda equina the lower the lesion the fewer the nerve roots that can be injured These lesions of the nerve roots and of the cauda take the form of a peripheral nerve injury in the distribution of the affectevJ root or roots with a complete severance There is flacad paralysis of the muscles loss of reflexes complete sensory paralysis and incontinence of the rectum and bladder These lesions are not necessarily symmetrical as it is not necessary that both roots at a given level be involved In addition to the paralysis these lesions of the nerve roots and of the cauda arc frequently accompanied by severe lancinating pains radiating along the course of the involved nerve roots These pains are due to mtation or contusion without complete severance of the given nerve roots Trealment of Fraelures of Spine W$tb FaraJjsis In patients with this type of fracture time is very important because the cord lesion may be due to pressure or edema and as stated previously the spinal medulla docs not tolerate long continued pressure and a lesion which is physiologic may become anatomic after 6 hours Consequentlj It IS imperative that the pressure if present be reduced immediately We believe that the most effective manner of lelievm? pressure and widening the spinal canal is to reduce the fracture or dislocation Reduction is best accomplished with skeletal traction either after the method of Crutchfield or some modification of the apparatus he used If closed reduction is not readily accomplished open reduction should be per formed If open reduction has been necessary regardless of whether the cord is ir reparably damaged the unstable segment or segments should be stabilized with a spinal fus on hielteaiions for Lamnieciomy la lajuries of Spine Probably the most difficult problem m the management of a fracture dislocation of the spine associated with spinal cord damage is the decision of whether an operative procedure should be undertaken and if so when Kahn* states that if paralysis occurs immediately and is complete for 24 hours following injury it will be pernuneot No form of treatment directed toward the spinal cord itself will aid m its amelioration (Tliis docs not apply to lesions of the cauda equina ) Time is therefore of the utmost importance This truth has been further decnonstrated by the work of Tatlov.f who compressed •Kahfl E A nal Cord Injuries f Bone A Jo or Sur^, 41 A f 1919 iTarlov r M SpmJl Cord Compress on SpnngfielJ HI, 1957 Cl arics C Tl omw PubI shcr INJURItS OF SPINC 325 the spinal cord of dogs and found that there was little reco\er) after 6 hours As has been stated previously, m an) ease of fractare dislocation, it is of the utmost importance to reduce the dislocation In this waj pressure upon the cord is removed more efficiently than b) anj other method If the dislocation lias been reduced and the paraljsis is com plete, laminectomy is indicated only in those ases in which there has been an associated fracture of the posterior elements and it appears that there may be bone fragments pressing upon the cord Most of the time under these circumstances, however, the paralysis will not be complete Another indication for laminectomy is a massive inter vertebral disc rupture, a possibility that should always be kept m mind The Quecken stedt test may show partial or complete lock, but operative intervention should not be undertaken until a myelogram has been performed Coleman and Dowman feel that the Queckenstedt test is adequate to distinguish the cases of paralysis with continued spinal cord pressure from those in which the cord has been damaged but is no longer com pressed However, in our experience this test is not reliable We have seen patients in whom the Queckenstedt test indicates the presence of a complete block even after open reduction and decompression when we were reasonably sure that all the pressure had been removed from the cord Jn the case of complete paralysis with fracture dislocation of the spine m which anatomic reposition of the dislocation has been accomplished, one may expect very little, if any, benefit from laminectomy However, if the patient and the relatives demand exploration, we do not think it should be denied Under these circumstances, following decompression, internal fixation and spinal fusion should be added to the operative pro cedure This will lessen the period of postoperative fraction and immobilization and may help decrease the pain associated with instability in those who survive In the syndrome of acute injury of the cenical cord as described by Schneider, in which there is no evidence of fracture dislocation, yet paralysis of the upper extremity IS present, laminectomy is contraindicated in the presence of function in the lower ex tremidcs In the early incomplete lesions of (he spinal cord m which reduction has been accomplished but in which there is no evidence of returning function, tlie surgeon may consider exploration This should, however, not be done until the patient s general con dition IS stable DELAYED CORD COMPRESSION In addition to the cases which show compression of the cord at the time of admission and in which early operation is indicated, there are certain cases m which a Queckenstedt test taken soon after the injury reveals no blocking of the subdural space, but in which, if this test be repeated 12 or 24 hours later, a gradually increasing occlusion of the space may be detftrtcd These are patients who enter the hospital with neurologic evidence of only a partial lesion of the cord, m whom pain continues or increases or a neurologic examination made 12 or 15 hours later reveals an increase in the motor and sensory paralysis In such cases the Queckenstedt test should be repeated at least every 12 hours, and, if the later tests show evidence of a partial or complete block, laminectomy should be resorted to Pressure on the cord may be due to hemorrhage outside the dura mater or into the cord or to progressive edema of the cord The question of edema of the cord without narrowing of the canal and without direct pressure on the cord is one of the most difficult problems presented by these patients Allen has shown experimentally that with a uniform trauma of the cord produced by dropping a weight upon it after the canal has been opened, a complete and perma nent paralysis may be produced, and that this paralysis is probably the result of edema in the cord itself because, if the dura is split and a longitudinal incision js made into the cord immediately after the compression the animal will recover He has further shown that this edema reaches its height in about 4 hours and that, if the release of the pressure is delayed longer than 6 hours after the injury, the operation does little or no 3J6 DrACNOilS AND IRTATAfLhTT Of SpcajIC INJURJfS good Tor this reason, surgetj, if it is to be of benefit m cases due to etUnia, must he done immcdntely, otherwise it emnot pre\cnt permanent paralysis Care of Patients \Y'itb Paralysis The care of patients with paralysis may be con sidered under the following headings (1) correction of deformitj, (2) prevention of bed sores, (3) general nutrition, (4) cire of bladder and rectum, and (5) prevention of contractures CORRECTION OF DEFORMITY Cottcction of the defociDity 1 c , dislocation, IS an im portant part of therapy for the cord injury as described previousJj and is best accoin plishcd in the cervical spine by skeletal traction In otlicr areas gentle manipulation and extension may cause reduction If these arc not successful open i^uction decompression (if indicated), internal fixation and spinal fusion should be done If for some reason operation is not advisable the best position possible is p cal deform ly Symptoms le I cved by tow bact brace •q Diagtiosis The presenting symptuns of patients with this condition usually fall into one of three categories They may have back pain only they maj haie back pain and sciatica radiation to either one or both legs oc they may ha\e sciatica only In our experience the most frequent history is that of a gradual onset of low back pain with some radiation of pain to one or both buttocks This pain is aggravate by activity and IS improved by rest Frequently the patient will be able to Cite one or two examples of phys cal activity that have definitely aggravated the condition and which may m the 330 DJAGKOSIS AND TRCATMFNT Or SPEOriC INJURIES patient s opinion be the cause of his pam In other words it may be difficult from history alone to differentiate between spondylolisthesis ruptured disc or other lesions producing nerve root irritation The phys cal examination may be helpful in a differential diagnosis particularly in the more severe cases On phjsicat examination the most striking feature is lordosis and in severe cases there is i shortening of the torso and a waddling gait Occas onally however this lordosis is not obv lous The next most striking feature is a depression of the spine of the fourth lumbar vertebra that is when palpated the spine of the fourth lumbar vertebra can be felt to be abnormally anterior to the spine 'itj k:-' Fig JJ4 ‘'ponJylol sihesis of fifth lunbtr vtjttbw on sacrum wh th became j^roRttss 'ds worse during adolescence Pit ent 1 id I d n mj rj treated by Jun h< wcral fus on w ih saiis factory result of the flftli lumbar vertebra Ihcre is usually Jiniitation i f m tu n in the lumbosacral region especially i n forward bending This mi) or ina) not bt icioinptnied b) muscle spasm an 1 pain Ncurokgn. examination of iIk Kv tr extremities will vary depending upon the amount of nerve root compression Iinall) the diagnosis must be n nf rmed b) a roentgenologic examination It is of the upmost importance that oblique views be taken INJURILS or SPINl 53/ fn order to discover thcic cases ^vith Jitllt or no dispJjcement of the \ertebril body At limes it may be necessity to take these obhque views m more than one plane When the oblique roentgenogram is examine! it is mted that the pars inlerart ailans and the articular processes form an outline that cither resc-mbles i Scotty y the development of small fissures or cracks which not only impair the nor mal function of the annulus fibrosus but also will allow the escape of some of the fiuid of the semiliquid nucleus pulposus Fissures and cracks in the cartilaginous plates of the vertebral bodies may act in the same way to allow the escape of fluid The nucleus pulposus then becomes less gelatinous and more fibrous in nature When the integrity of the annulus fibrosus is altered, the disc unit no longer functions normally, thus placing extra and unusual strain on the ajpophysea! joints and surrounding supporting ligaments This extra strain in itself may produce pain in the back or referred pain in the extremi ties without there being a disc rupture or nerve root compression Large rents m the ■innulus fibrosus show evidence of healing by the ingrowth of a vascular granulation tissue, and it is within the realm of possibility that small nerve endings may accom pany these vessels and in themselves would be a source of pam m certain instances On^ large tents occur m the annulus fibrosus and extend down to the nucleus pulposus, protrusion of the nuclear material through these rents may occur at any time even during the normal activities of the individual, or at times associated with falls or heavy lifting If the weakened spot is at the side or front the rupture may produce little or no symptoms except those associated with the abnormal function of the disc unit If there ace cracks m the cartilaginous plates, the rupture may occxu in the body of the vertebra This type of rupture is usually demonstrated in the ordinary x ray film and is commonly referred to as SchmorJ s nodes If, however, the rupture occurs posteriorly, It IS possible that the protruded mass of nuclear material may compress the spina! cord or one or more nen c roots and thus produce the clinical picture of nerve root compression An intervertebral disc involvement or a resultant nerve pressure usually is not present in the average compression frarture of the spine It has been our experience that most of the intervertebral disc ruptures occur following relatively minor strains or sprains in acadents and even with unknown etiology Diagnosis A tentative diagnosis of a rupture of the annulus fibrosus with retro- pulsion of the nucleus pulposus is made from the history and the physical examination and IS confirmed and localized by one of the various diagnostic procedures, such as the myelogram or the discogram However, none of these procedures can be relied upon to give lOo per cent accurate results Therefore the location and type of disc rupture can be accurately assessed only by careful exposure at the time of surgery In many instances the patients history and the phy'sical examination are so characteristic that a reasonable diagnosis of disc rupture at a specific level may be made However, it is our feeling that no patient should be submitted to surgery without having had one of the diagnostic ptex^ures not only to confirm the localization but also to be sure that the patient does not have nerve root compression from more than one disc or from some other lesion 334 DIAGNOSIS AND TREATMCNr OF SPCaFIC INJURIES A historj of im injury can be obtained in oier half of the cases m others the rupture occurs from the stress and strain of ordirury life This injurj may be a fall on the feet or buttocks or the pain maj arise during lifting or it may be caused by a sudden twist or awksvard mo\ement of the low back In over half of cases m which symptoms are associated with an injury the paui ‘follows the injury immediately In others the onset of symptoms is delayed for a variable period of time A not in freciuent history is that the patient while lifting feels a sudden pain and somebmes a snap in the low back This is followed bj moderate pam in the lumbosacral region which is not sharply localized but spreads outward on either side and down over the buttocks Tlie pam penists and increases in degree and in the extent of its radiation Fig 336 Typical scial c scol os s wiih pun down r ghl lei, in acute mierverttbral disc Ics on Sciatic pa n may develop immediately but more often it makes its appearance I or 2 days or even some weeks later In other patients and these arc usually the ones in tJie older age bracket the pam begins gradually and with no known cause and the patient can re all no known injury which may have accounted for the symptoms A characteristic feature in the histones of these patients is that the patient may have had several similar attacks (hat is (he symptoms tend to be intermittent and may disappear entirely for a period of months or years tmly to reappear again either with or wvthout a subsequent injury The pain ts aggravated by movement it is usually but not always relieved by tc^ U lends to be imiliteral and the distribution vanes am Sidttably It may lx aggravated by prolonged standing by bending or lifting by cougli mg or sneezing or even by sitting INJURIES or SPINE In approximately 90 per cent of patients with tnter\ertebral disc lesions the rupture and displacement occur at the levels of the fourth and fifth lumbar sertebrae The pain IS neatly aIsva)S present m the lumbosacral region of the low back and m the distrifau tton of the sciatic nene The back pain is usually unilateral but may be bilateral If bilateral it tends to be more se\efe on the side of the lesion It may be referred to the buttock but It IS usually referred down the back of the thiqh and to the lateral and posterior surface of tlie leg or it may imohe the foot and the patient may complain of numbness In some patients the back pain subsides and only' the sciatic pain persists In others the leg pain subsides and the back pain persists We now beiiese (hat m most of these cases the symptoms are caused by lesions of one Of more interiertebfal discs m the lumbosacral area We ha\e abandoned the old diagnoses of lumbosacral strain sacroiliac strain hypertrophic arthritis and facet syn drome to explain the symptoms in idiopathic low back pain sMth or without sciatica By idiopathic v,e mean pain due to some pathologic condition which cannot be excluded by physical or X ray examination such as spondylolisthesis neophsms either within the spina! canal or encroaching upon it or infectious diseases such is tuberculosis or 'inkyhsing arthritis Fig 337 A Camas belt wuh steel sl3>s ised iti ireaimetit of lumbosacral stnuns B Seen from front The patients may be roughly dnided into two groups In one group the pain has a sudden onset and usually follows a definite injury although the symptoms may begin gradually and result from some unknown cause In this type the pain is usually limited to one side and tends to begin in the low back and later to extend down into the buttocks posterior thigh leg and even tlio ankle and foot on the affected side It is aggravated by activity and is somewhat relieved by rest especially if the knee and thigh are flexed It frequently is accompaninl by neurologic disturbances, espcaally hypesthesia in the foot and leg and diminution of the ankle jerk on the affected side If severe the pain IS usually aggravated by coughing In severe cases the patient may be completely disabled and even confined to bed and require considerable sedation for relief In the second type the pain is usually limited to the m dime of the low back or is bilateral is no more marked on one side than on the other and is not referred to the buttocks or down either extremity It is not aggravated by toughing and is not accompanied by any neurologic disturbances It is likely to be aggravated by prolonged standing or by an unusual amount of work and to be more severe at the end of the day In some instances the pam is troublesome at night espeaally if the patient sleeps on a soft bed JVi DIACNOSI'! AND TRCATArJ NT OF SPruFIC iNJURft Fjf! 338 Antfrofostwior and oblique mws of normal subarachnoid space in lumbar rej;on filled w th Lipiodol Note uniform space opposite le\els of imervertebcal discs (Courtesy Dr W G Scott ) li^. 3J9 M>closram si iwiBi. defimte findmits of imiilifte tuplurcd (hrm ated} mienerttbral disc between fourth and fifth lumbar vertebrae Operation performed and disc found and removed No furtlier surgery req nred Eicctllent results INJURIES OI SPINE 3i7 JJff niACNOSIS AND TRLATMENT OI SI rOF C INJURIfS I g 31’ /t Mill ne protrusoi of nu If s pulp(« s h «w«n f nh jnd ffti lumbar ertebrae 0 Pouhle un htcrai p otruson n rght $lh knees to llii cliesi Straifthlen knees and lower slowly Ten times twneslaily Side Streiebiug Lie On the back Place hands on hips Flatten the back Retract the abdomen lohile slowlj, raising the nght side of the chest as high as possible and pressing down on the nghc INJURIES or SPINE 343 hip Do not eJevafe Ihe sboulde/ Eslule slorvJy anJ relax Repeat on the left Side Ten times alternately, twice daily Truni Extrcise Assume corrwt standing posibon with feet parallel and 6 inches apart Pull up the arch and curl toes supporting the wei^ on the outer borders of the feet Place hands directly over head with thumbs clasped and palms forward Bend slightly forward circle to the left slowly bending so that the hands while extended above the head describe a circle about 18 inches in diameter Twenty five times Then repeat circle to the nght Deep Breathing Assume correct standing position Oasp hands behind head fnhafe slowly and force the head and elbows back as far as possible Hold and exhale slowly bring elbows forward Repeat fifteen limes Career/ S/anJ/ag Back to wall Head shouldm hips and heels touching Chin in and chest up viith the weight resting on the balls of the feet and feet parallel Tlatten the back retract the abdomen, and stretch tall Hold this position and walk away Do at least ten times off and on during the day Correct Waikiitg Walk in the correct standing position with the toes turned slightly inward and the weight resting on the outer borders of the feet (Cultivate the habit of flexing the toes and pulling up the inner Side of the foot off and on during the day while either sitting or stand ing ) Also get the habit of pressing downw-ard with the toes while walking thus using the fore foot to propel the body forward Correct Silling Sit well back m the chair with the bead up chin m chest up and the ab- domen retracted In bending forward bend from the hips and avoid slumping at the waist These exercises should be c-trried out slowly once or twice a daj The nwtibef of times each is done is varied with the abilit) of the patient to do them MEDICATION Narcotics are avoided, especially m chronic cases The drugs which are most frequentlj used are asptrm and BufTerin. which may be combined with codeine when the patient is having a good deal of pain All patients arc given relatively large doses of vitamin B Muscle relaxing drugs ot all types have been of little benefit in our experience However, when these cltugs are combined with tranquilizers they have been found quite useful in certain patients Prognosis The sjTnptoms are relieved by conservative treatment in about 80 pet cent of the patients and most of them can return to their regular ^ork or state of activity Hoflcver, between 15 and 20 per cent of (he patients fail to obtain lasting relief With conservative treatment and require surgery The indications for operation are (1) a patient who remains disabled for a period of approximate!) 5 months despite good conservative treatment, (2) an individual with a typical picture of nerve root compression from an intervertebral disc with advancing neurologic signs, and (3) a patient with a picture of massive protrusion of an inter vertebral disc with, severe nerve root comptesaioo tUat does not show improvement after a short period of conservative therapy When a patient is considered tor surgery a myelogram or a discogram should be obtained If the result of either of these tests con firms the diagnosis, the surgeon will then have to deade whether to do a simple disc removal or combine the disc rcmovul with spinal fusion It is realized by aU that simple removal of the protruded portion of the mtervertebnil disc will relieve the nerve root compression but that it does not change the altered function of the damaged disc unit If spinal fusion is earned out and is successful, not only is there relief from the nerve root compression but also the damaged unit js sealed off and the patient should hav e a stronger spine with a better chance of permanent relief When satisfactory methods of obtaining spinal fusion without an increase in the morbidity and the period of disability are developed, we feel reasonably sure that (he combined operation will be carried out much more frequently Until that time we will continue to do simple disc removal and resetv e spinal fusion for those patients who have complications Technic for Myelography The pahent is placed on a tilting fluoroscopy fable and a lumbar puncture is done between the third and fourth lumbar vertebrae with the patient either sitting or lying on his side About 10 ml of spinal fluid is withdrawn and saved for laboratory examination Then 3 to ^ ml of Pantopaque is slowly injected into the TRCATMtNT OP SPCanC INJURIES INJURJES OR SPINE 345 spinal canal Tlie stylet is replaced m the needle this is cosered with a sterile sponge, and the patient is gently lowered to the table and placed m the prone position The table is tilted downward and the form of the Pantopaque is watched in a fluoro scope as it fills the lumbar cul de sac and defects art circfull) noted The table is leseled and again the course of the fluid is carefullf noted linall} the patient is turned ob lic^uely to the right and left and the procedure is repeated in each position He is then turned on one side and the column of fluid is examined m the lateral \iew Spot films ate made in all positions After the examination is completed the patient is again turned on his face the stylet IS remoiecl from the needle and the opaque medium is withdrawn It is usually possible to get neatly all of it out The spinal fluid is examined for protein A protein content of 40 or more mg is considered high for a young or middle aged adult and is suggestise of a disc lesion Very high protein which is xanthochromic is suggestixe of a tumor (We use the myelogram as a guide in our operative procedure but are not limited by it If its result is negative and we think that the patient should be operated upon we operate upon him If positive (f IS valuable corroborative evidence of our diagnosis Vf e find that it is accurate m about 80 pet cent of out cases and that a discrepancy between the myelogram and the operative findings occurs in about 20 per cent of our cases Usually these discrepancies are minor but in about 5 per cent of the cases major discrepancies have been noted ) fig 547 Pad to be placed on operating table for posit oning pat ent for removal of intervertebral dscs Operalite Treatment The technic usually employed for removal of a ruptured intervertebral disc m the lumbosacral region is as follows Postlion of Patient The patient is pbced prone on an operating table which can be broken m the middle and has a kidney rest which can be pushed upward thus flexing the lumbar spine In addition, sandbags are placed under the shoulders and iliac spines or the patient lies on v specially constructed pad Anesthesia Whether the surgeon uses endotracheal or local anesthesia will depend on his appraisal of the patient as well as upon the availability of a skilled anesthetist All things being equal we prefer local anesthesia Regardless of the anesthetic, the operative procedure is the same The patient is dra[^ and the skin is anesthetized in the midlme over the proposed length of the masion the incision to be 4 or 5 inches long and centered over the disc ihou^t to be causing the symptoms In orienting this disc we consid«- the fourth lumbar disc as being opposite the crests of the ilium One }4C niACNOSIS AND TRtATMCNT OF SPCUIIC INJUFIIi per cent No%ocim contninmt; 3 Jrops of e|«nephnnc to the ounce is mjecteJ into the skin then I/2 } Novociin rontiinin^ 3 drops r f epincphrmc to the ounce is injected into the subcutaneous tissue The skin tncismn is mule hemostasis is effected b) electric coaguKtton and skm toweU irc applied Then y» per tent No\oc\in is in jected into the muscle beneath the lumbar fascia and info the deeper lajcrs about 5 ml being placed against the periosteum of each lamina and mteraertebral articulation in the operatise field as well os against the dorsum of the sacrum Noscicatn ts also injected beneatli the fascia on the opposite side Exposure "With a knife the fasoa ligaments and muscle attachments on the affected side are cut from the tips of the spinous processes m the field Then with a broad sub periosteal elesator and gouge the muscles on the affected side are separated from the spinous processes lamina and interxening ligaments subpenosteallj and retracted out ward As near!) as possible the dissection IS subperiosteal and ss the tissues are separated from the bone gauze sponges are packed into the wound to control the bleeding Tendinous insertions ate cut with a knife and the dissection is earned up and down the spine deepening the wound each time to evposc the lamina and hgamenta flaia and then outward to expose the articular facets Tissue between the laminae and coiering the ligamenti fla\a is remosed with 4 large cutet or a gouge and self retaining retractors ire inserted in the wound We use a unilateral retractor which has three tines on the opposite side and these are pushed down through the fascia and into the muscle to afford counterfixation Exposure of Neiie Root With a 24 gauge needle and a 2 ml syringe 2 per cent Ncnocain which does not contain epinephrine 1$ injected through the ligimentum fiavuro into the nene root Only about 0 3 ml need be placed m the root jf this is punctured by the needle When this occurs the patient feels a sharp pain If the nene root is not punctured 2 m! is injected in the vicinity The ligamemum flas-um is then separated from the laminae abose and below by sharp dissection and 1$ excised care being taken to te moie the lateral portion between the facets and not to injure the underlying structures A button of bone is removed from the opposing surfaces of the two laminae or from the lamina of the fifth lumbar vertebra and the superior margin of the sacrum to provide a wider exposure This may be done with an osteotome a gouge or with rongeurs At the level of the fourth lumbar vertebra the button usually includes some of the articular facet When the bone is removed care is taken not to injure the dura mater or to rupture atvy of the extradural vessels With a small instrument the extradural fat is pushed aside to expose the nerve root This runs downward and outward from approximately the middle of the button above to the outer border of the button below and crosses the disc at approximately the lower margin of the lamina Normally it ts white shiny and firm and freely movable but it may be swollen and pink and may be adherent to the annulus fibtosus With a large extrusion directly under the nene (he nerve may be flattened and adherent to the domelike swelling beneath the posterior longitudinal ligament The nerve root is pushed mward to expose the disc and if necessary veins in the floor of the spinal canal are pushed to one side Sometimes if veins arc cju te large and are easily ruptured they may cause troublesome bleeding and obscure the operating field 'X^ctv the veins are ruptured the bleeding can be controlled by strips of Cottonoid wet with salt solution These strips are pacl^ into the comers of the wound above and below the disc in order to control the bleeding and permit inspection of the disc. With a special nerve retractor the nerve is pulled toward the midline The normal disc is flat and firm A pathologic disc may be (1) retracted soft and thin (rate), (2) wide domelike bulging into the canal and relatively soft and elastic (quite common) (3) extruded so that some of the disc material 1$ pushed out into the tissue of the floor of the canal and covered only by a thin membrane (this 1$ the usual INJURIES OF SPINE 547 type and here the nenc root is stretched across the top of the disc), (4) disc material extruded and free m the canal (rare), or (5) eroded through the dura mater The disc IS incised with a sharp knife or a window is cut out, and as much of the contents of the disc as can be taken out are remosed with pituitary forceps and a curet, care being taken not to push either instrument froward into the space but to insert it gentlj With the fingers and then pull outiaard sMth as much force as necessar) This is to at Old penetrating the annulus fibrosus «i front and damaging large %'essels in the abdominal cavity The wound, including the disc, is then washed out with sulfonamide solution, the kidney rest is lowered and the table straightened, the floor of the canal is inspected again for more disc material, and the wound is closed with the fascia and superficial muscles sutured to the interspinous ligament and the subcutaneous tissues and the skin sutured separately The patient is placed in bed with a fracture board under the mattress He may mo\e about m bed at will The next day the dressing is chan^^d No restrictions are placed on his sitting up or getting up as soon as he feels like doing so Generally the sutures are removed on the seventh day and the patient is permitted to go home As a rule, no post operatite support is worn but the patient is advised to avoid much lifting or stooping for about 2 months His activities are increased as tolerated If he continues to base difficulty after the operation, he is put back on the consenatne treatment for this condi tion RESULTS OF DISC OPERATION Careful longterm follow up examinations of 115 patients who had been submitted to surgery for the removal of intervertebral discs showed the following results 15 excellent, 40 good, 56 fair and 26 failure Irom this study we concluded that (1) better results were obtained m those patients with good historical, physical, and m)elographic evidence of nene root compression from a disc lesion, (2) better results were obtained m patients with completely extruded discs, (3) slightly more disc lesions were found at the fourth lumbar disc than at the fifth lumbar disc, (4) results m women were not as good as in men, (5) 14 patients had recurrences sufficiently severe to require reoperation. with 10 of these on the same side of the original laion and 4 on the opposite side, and (6) all patients requiring a second operation for removal of disc material should also have a spinal fusion CHAPTER 1 1 INJURIES IN REGION OF SHOULDER GIRDLE AND SHOULDER SUKGICAI. ANATOMT Shoulder Girdle The shouWer ^irdJe which sei\e$ to attach the upper limbs to the tmnk IS formed by the sapulac and clavicles It is open behind but it is dosed in front by the manubrium stecni with which the inner ends of the citvtcles articulate CLAMCtE The davicle is a lon^ doubly curved bone which is placed almost horizontally at the upper and anterior part of the thorax immediately above the Arst I b and serves as a prop to support the shoulder and hold it away from the chest wall (Fig J48) The inner two th rds are roughly cylindrical m shape and the outer third IS flattened from above downward The mesial half of the bone is convex forward and the lateral third is concave forward The enlarged mesial or sternal extremitj articulates with the manubrium sterni whereas the outer or acromial end articulates with the mesial border of the acromion The bone is subcutaneous th^ou^hout its length and lies in the plane between the sternomastoid and anterior part of the trapezius muscles above and the pectotahs major and anterior part of the deltoid muscles below SCAPULA- The scapula is a large irregular bone the chief funa on of which is to serve as a socket for the humerus and to furnish leverage for the attachment of muscles wh ch move the arm and the shoulder It is ait»ch“d to the trunk entirely bj muscles except for Its articulation with the clavicle It consists of a bodj head neck spine acromion and coracoid process The body is a large thin trianimlar plate of bone which is strengthened by a thicken ing of Its borders and is slightly convex backward to conform roughly to the contour of the thorax Its posterior surface is divided into infraspinous and suprasp nous fossae by the spine which is a triangular plate of bone projecting back-ward and upward from the posterior surface of the body and lying in the plane between the posterior portions of the trapezius and deltoid muscles It extends transversely across the upper third of the bone and its outer extrem tj is thickened flattened and curved forward to form the acromion which is the summit of the shoulder The mesul border of the acromion pre sents an elongated facet wh ch articulates with the clavicle The head of the scapula prc-senls a concave articular surface the glenoid cavity whidi IS directed outward and forms a shallow socket for the head of the humerus It IS situated directly beneath the acromion and attached to the upper portu n of the thickened inner border of the body by a short constricted neck The coran id is a thick bcaklike process which arises from the antenor pirt of tlic neck and curves upward forw ard and outward m front of the glenoid caeity 346 INJURIES IN REGION OF SHOULDER GIRDLE AND SHOULDER 549 Sternoclaticular Joint, This jomt is the onlj articulation between the shoulder girdle and the trunk It is formed the enlarged inner extremitj of the claMcle and a smaller facet at the posterolateral angle of the manubrium A fibrocartilage is interposed between the two bones The integnt) of this joint is maintained entirelj bj ligaments One group is the sternoclaMcular ligaments, which arc a thickening of the joint capsule and completely surround the joint They arc reinforced bj the interclaMcular ligaments, which stretch across the top of tlie sternum The strongest, and therefore the most important, are the costoclavicular and rhomboid ligaments, which bind the inner one fourth of the clavicle to the first nb This articubtion permits a limited amount of motion m practical!) every direction, including atcumduction, and forms the center from which all movements of the shoulder on the trunk originate Acromtoclaitcular Joint This is a simple gliding joint between the outer end of the clavicle and a flattened articular facet on the inner border of the acromion (Figs 349 and 330) It lies almost in a sagittal plane and is surrounded by a thin capsular ligament which is strengthened above and below by the acromtoclav icular ligaments The integrity of the joint is further strengthened by the strong coracoclavicular ligaments, the Fig 348 Diagrammatic drawing to illustrate that when clavicular prop is broken and support of clavicle is removed whole shoulder falls inward and forward and scapula tilts outward (From Scudder, C. L. Trwrment 0 / Fractures Philadelphia VT B Saunders Co after Davis PeoHi ) conoid and the trapeaoid, which bind the clavicle to the coracoid process In addition there is a strong coracoacromial ligament which stretches from the tip of the acromion to the coracoid process The joint permits backward and forward rotation of the scapula on the clavicle Upper End of Humerus The upper end of the humerus consists of a large round head which is joined to the shaft b) a slightly constricted surgical neck, and two processes — the greater and lesser tuberosities which are situated on the proximal portion of the shaft The convex head is directed upward, mward, and backward to articulate with the shallow glenoid cavity of the scapula Around its arcumference is a shallow groove, the anatomic neck to which the articular capsule is attached Lateral to this groove the upper end of the shaft is thickened to form the greater tuberosit) which faces direct!) outward and upward, and below and m front is the smaller, more prominent lesser tuberosity The bicepital groove which lies between the two tuberosities lodges the long tendon of the biceps muscle Below the tuberosities the shaft of the bone is slightl) constricted to form the surgical ned<. The upper end of the humerus is developed from three centers, one for the head. 350 DfACNOSIS AND TRLATMLNT OI SPrOHC INJURHS md one for each luberosity which unite about the fifth jear to form tlic raplike upper epiphysis which m turn unites to (he shift at about the twentieth year Shoulder Joint The shoulder joint (rif,s 549 351) is i bill and scKkct joint formed by the larpe hemispherical head of the humenis and the rehtnel) small and shallow glenoid cdMty It is entirely surrounded b) a rather loose capsular ligament which Tig 349 Norma! shoulder showing, ihe Ifamnitous #«ac!menu beivfcn acron on and loncnd processes of scapula and cUvtete (from Henry MO M nnesota Mtd 12 111 19’9 ) T/g 550 Nomul shoulder viewed from above sbowuig acrom oclav nilar jo nl and comtoacrotnial ligament (From Henry At O Al noesou Med 12 431 1929) IS strengthened by the coracohumeral ligament whidi extends from the coracoid process across the top of (he joint to the greater tuberosity The ligaments do not serve to mam tain the bones in apposition and the integrity of the joint is largely dependent upim iNjunirs rK rlcton or sHoacojR girdle and should! r 331 the surrounding muscles The tendon of the long head of the biceps traverses the upper part of the joint ciMtj and is iltachcil to the supenot margin of the glenoid casity The cavity IS slightly deepened by the glenoid ligament Vkhich is attached around its margin outside the capsule Between the capsule and the oaerlying structures are scaeral bursae, the most important of which is the large subdeltoid bursa which lies oser the greater tuberosity and is prolonged under the acrortuon The joint permits eiery vanetj of movement, including circumduction and rotabon Abduction is limited to 90° by the overhanging acromion, and the elevation of the arm above the head is accomplished by rotation of the scapula on the clavicle The muscles around the shoulder may be divided into a superficial group which arise from the chest and the shoulder girdle and arc attached to the shaft of the humerus below the surgical neck, and a deep group which arise from the scapula and are attached to the humerus above the surgical neck The superficial muscles are the deltoid pectoralis major, Jatissimus dorsi, and the teres major The deep muscles are the supraspinatus infraspinatus, subscapulans, and teres minor Fig 351 Section through shoulder |oinl (Morns, H Human Anatomy Phihdclphia, P Blakis ton s Son A Co ) DIFFERFNTIAL DIAGNOSIS OF INJURIES TO SHOULDER AND SHOULDER GIRDLE The history, symptoms, and location of the pain as stated by the patient may lead the surgeon to suspect some definite injury, but the differential diagnosis should be made by physical and x ray examinations A rough estimate of the injury may be determined from the amount of disability present If tlie patient with the elbow extended can raise the arm vertically over the head and lower it slowly, it is probable that there is no serious injury to the shoulder or shoulder girdle However, full movement may be present m subperiosteal or incomplete hdctuKS of the clavicle rn children If the arm can be raised to the horizontal position only with difficulty and if the patient then lets it drop suddenly and experiences a sharp pain over the clavicle, there IS probably a fracture of the clavicle without displacement The diagnosis is confirmed by point tenderness and a positive roentgenogram On inspection the surgeon first notes the posibon of the shoulder If the shoulder ii2 DIACNOMS AND TREATMENT OF SPEaPJC INJURIES IS displaced dos\nward inward and fomacd diere has been some disturbance m the supporting function of the claMcle This may be either a complete fracture with displace merit or a dislocation of its inner end As the bone is subcutaneous throughout its length the type and location of the lesion can be deteontned by palpation but in lesions around the sternocJa\iai!ar joint a roentgenogram may be necessary to determine the exact nature of the injury In examining a patient for displacement of an intact shoulder it must be remembered that in many normal persons one shoulder usually the right is slightly lower than the other and that the shoulders are always asymmetne in patients with cursature of the spine The contour of the shoulder as determined by inspection, and palpation is compared with that of the other side A slight depression of the acromion with an abnormal prominence of the acromial end of the clasicle indicates e ther an acromiocIaMCuIar dis location or a fracture \ery close to the joint Local tenderness and the ability to reduce the deformity temporarily by pressing upward on the elbow while the claiicie is im mobilized with the surgeon s other hand suggest acromioclavicular dislocation A flattening of the lateral surface of the deltoid muscle below the acromion sug gests a dislocation at the shoulder or a fracture of the surgical neck of the scapula with displacement or an epiphyseal separation or fracture of the upper end of the humerus wiith displacement If tltere ss a dislocation, the ftngets can be made to sink into the space beneath the acromion which is usually occupied by the upper end of the humerus It should be noted howeser that the presence of great swell ng may obliterate the flattening and esen make it difficult to deterinine whether ot not the upper end of the humerus is in its normal position Consec{uentIy the avis of the shaft of the humerus should be projected upward and it should be noted whether or not this axis tends to intersect the glenoid canty Jf the axis of the humerus does not intersect the glenoid canty and the arm is maintained m an abnormal position by muscle spasm there is a dislocation at the shoulder The type of dislocation can be determined by palpating the head of the humerous in its abnormal location If the humerus is intact and its head can be felt deep in the t ssues beneath the acromion and if the deformity an be reduced by upward pressure on the elbow and recurs w hen the pressure is released there is a fracture of the surgical neck of the scapula with displacement If the head of the humerus is in its normal position and if there is po nt tenderness of the upper «id of the humerus and the head of the bone does not moi e w ith the shaft tlieie is an epiphyseal separation or a fracture through the upper end of the humerus with displacement It is usually possible to palpate the upper end of the distal fragment m the anterior axillary region If the signs of a fracture through the uppr end of the humerus w-iih displacement arc present and the glendoid canty is felt to be empty there is a fracture d sloation at the shoulder and the head can usually be palpated in its abnormal position Marked swelling behind the shoulder suggests ether a posterior dislocation a fracture of the scapula or a fracture of the upper end of the humerus with posterior displacement In fractures of the spine or body of the sapuia with displacement it is usually possible to detect irregulanties m tlic aintouc of the spine < r vertebral border of the bone In obese patients or in those in whom the accident has occurred some hours or days prev ousiy the disturbances in contour mentioned may be obscured Tlie two shoulders should then be palpated systematically as described in tlve section on cxamina tion of the shoulder In fractures without demonstrable displacement, the surgeon has to depend upon point tcndern«s and local pain elrated by axial pressure torsion cross INJURIES IN REGION OF SHOULDER GIRDLE AND SHOULDER iJJ Strain or muscle pull on the suspected bone which can be produced by manipulating the extremit) These lesions are fractures of the clavicle fractures of the coracoid process acromion glenoid cavit) or neck of the scapula and fractures of the upper end of the humerus cspeciall) of the tuberosities In most instances an x ray examination is neces sary to determine the details of the lesion The diagnosis of sprain contusion or periarthritis should be made onl) after care ful physical and x ray examinations ha\e ruled out definite anatomic lesions Esen in the presence of negaltse roentgenograms and a history of recent injury if pain tenderness and limited motion are present the shoulder should be treated by rest and heat and protection unbi improsed EXAMINATION OF SHOULDER GIRDLE AND SHOULDER As accurate a history as possible should be obtained with emphasis on the mccha msm of the accident the manner in which it occurred \^hat injury the patient belie%es he suffered the exact location of pain and the extent of disability resulting from the accident The patient should then be stripped to the waist and if his general condition permits should b- seated upright upon a stool The surgeon should inspect both shoulders carefully nobng their relatixe positions and whether or not one shoulder is displaced downward forward or inward Any abnormality m the contour of the shoulder or shoulder girdle and any swelling in the region of the shoulder should be noted He 'fiR "fSi h Tj reft paipat on an'd tn^nipuiaiion dt cut cie ~b "Lompar son dt contour dt clav cie on injured aide with that on un nvolTod side should then ask the patient what mosements he can perform without pam and have the patient try to abduct adduct rotate and move the shoulder backward and forward to ascertiin the amount of function and disability Having learned what he can from the history inspection and amount of disability the surgeon should palpate the entire shoulder in a systematic manner It is well to begin with the clavicle Tliis bone is subcutaneous and should be palpated carefully with the fingers throughout its entire length the positions of its twx) extremities and regularity of its contour being noted and compared with that of the other side (Figs 352 A and E) In palpation point tenderness should be carefully noted wherever it occurs Having ascertained the condition of the clavicle the surgeon should palpate the acromial ends of the clavicles and the acromial processes in the manner shown in Fig 353 ‘Hie palpa tion should be continued over the scapula the operator making bimanual examination of the body and spine of this bone as m Fig JJ-l The head and upper end of the shaft of the humerus are then examined by grasping the outer portion of the two shoulders as m Fig 355 Tlie humerus is then palpat^ bimanually as shown in Fig 356 INJURIES IN RLCION OF SHOULDER GIRDLE AND SHOULDER and pul! Ihe two shoulders upiiard and badovard in order to determine whether the deformitj can be corrected If a fracture of the body of the scapula is suspected, he should grasp the lower angle of this bone with one hand and immobilize its upper portion With the other and slov-ly but strongly manipulate the body of the bone between his two hands, noting whether or not pam or afanormal mobility occurs He should then grasp the lower end of the humerus in the manner shown in Vig 355 so that the pa tient s forearm is supported on the surgeon s forearm With his other hand palpating the upper end of the humerus, he should execute gently motions of abduction, adduction, and rotation, taking particular note as to whether the upper end of the bone moses with the shaft The range of passive rotation, abdiKlion and adduction (Fig 357, A) and of flexion and extension should be determined Then by seizing the elbow with one hand and supporting the shoulder witlv the other, the effect of axial pressure on the humerus should be noted, and it should be determined whether there is any telescoping of the bone F/nallji, the length of the arm is measured from the tip of the acromion to the external condjle of the humerus is determined and compared with that on the other side (Fig 357, Z?) Fig 357 A Method of determining range of adduction at shoulder This is especially jm poriant m dislocations B, Method of mcasurinc length of arm from tip of acromion to external condyle of humerus Roetitgenographic Exapritialtott When a provisional diagnosis has been made, X ray films m several planes are obtained to conhrm the diagnosis and the extent of bony involvement FRACTURES OF CLAVICLE Etiology TJie clavicle is one of the most freijucntly broken bones in the body, and statistics show that it is involved in from 5 to 10 per cent of all fractures This is espeaally true m childhood when many of the fractures are incomplete and arc often not recognized The reason this bone is so frequently broken is that it senes as the only connection between the shoulder girdle and trunk and so must withstand any force tending to push the shoulder inward against the chest Usually the injury is a fall, cither from a height or on the outstretched hand, elbow, or shoulder, and the shoulder IS pushed violently inwardfj against the chest TTie divide may also be broken by crush mg injuries or by direct vioJena from in front and ibovt Very nrely the hone may be broken muscular action Pathology ami Displacement Tlic clavicle may be broken in any part, but in the lifcat majonty of cases the break occurs in the middle third just internal to the attach ment of the coracodavicular ligaments This is the vulnerable region of the bone because SS6 PIAGNOSIS AND TRrATMCNT Or SPCaHC INJURIES it contains the junction of the ts\o cunes, because it is unsupported bj ligaments, and because an elastic rod, broken by compression from its ends, tends to break near its middle In adults the fracture line is usually oblique, but it ma) \ary from transi'crse to almost longitudinal and may take almost any direction In older persons the bone is often comminuted Since the function of the clavicle is to hold the shoulder up and away from the Fi^ jjg Fraclure of n^ht divide with typical displacement Note downward forward and mward droop of shoulder and swellmu over clavicle Fig 359 Fracture of left divide Typical posture assumed by patient with this lesion Note downward forward and inward droop of shoulder There is also a fracture of left mandible INJURIES IN REGION OF SHOULDER GIRDLE AND SHOULDER 357 chest, complete fracture of the bone results m shortening with o%erfidmg of the frag ments, the shoulder drops downward, forward, and inward, and the outer fragment goes with the shoulder (figs 358 360) This displaament is due partly to graMtj when the patient is m the upright position and partly to the pull of the muscles which pass from the trunk to the shoulder, espeaally the pectoral and the trapezius, which pull the outer fragment inward and tend to rotate it m such a manner that its inner end is directed backward The sternocleidomastoid muscle tends to pull the inner fragment upward and back ward, but its displacement is limited by the costoclavicular ligament Howeier, even without much displacement, the end of the inner fragment may be quite prominent be- cause the displacement of the shoulder stretches the skin over it In children the fracture line tends to be roughly transverse and is often incomplete, when it may be of either the greenstick or infraction type In either case, the bone tends to be bowed forward at its middle third, thus exaggerating the normal anterior convexity and shortening the bone to a variable degree Fractures of the inner third are quite rare, and, if the costoclavicular ligament re mains intact and attached to the outer fragment, there is little or no displacement How ever, if this ligament is tom, the outer fragment may be pushed inward and pass m front of, behind, or above the inner fragment, which roaj be comminuted When the outer third of the clavicle is fractured, the lesion is usually a transverse break Since the outer fragment is fixed to the aaomion and the inner fragment is bound to the coracoid process, there is little displacement unless this ligament is ruptured, but the scapula may swmg forward and cause an angular deformity at the site of the fracture If the coracoclavicular ligaments ate ruptured, the outer fragment is displaced downward and inward, the scapula being carried with it, and the displacement is similar to that which occurs in an acromioclavicular dislocation with a tearing of the coracoclavicular ligament These fractures of the outer third ate often due to direct violence, and the bone may be comminuted Dmgtiosis In cases of complete fracture with overriding of the fragments, the diagnosis is relatively easy The patient assumes a characteristic attitude with the limb on the affected side supported by the other hand and the head is inclined to the affected side with the chin rotated to the opposite side to release the tension of the sternocleido mastoid muscle on the inner fragment On inspection the contour of the shoulder is normal, but it is found to be lower than the one on the other side, slightly closer to the midline of the body, and displaced slightly forward (Figs 358 and 359) The dis placement is espcciall) well seen from behind In a thin person the break in the contour of the bone may be visible, or it may be obscured by the swelling which occurs after the accident On palpation there is tenderness over the site of the fracture, and it is possible to feel the prominent outer end of the inner fragment beneath the skin The displacement of the shoulder can be reduced by pushing upward, outw^ard, and backward on the elbow or by pulling the shoulder m this direction but it tends to recur as soon as the pressure is released (Fig 361) With the patient lying on die back, the forward and downward displacement lends to be corrected by gravity, but the overriding of the fragments (in Ward displacement) persists In fractures without overriding or displacement a history of injur) followed by disability m the arm and the location of the pam and point tenderness ate usually sufficient for a diagnosis In children with incomplete fractures (Figs 363 and 364) there may be no dis placement and the history may be indefitute, the parents simply having noted that the child complained of pam or cried when lifted by the arm and did not use the arm normally On physical examination the shoulder may be normal to inspection, but usually S}8 PMONOSIS AND TRfATMrNT OF SPrOIlC INJURIES INJURIES JN RrCION OF SMOULDJ R GIRDLE AND SHOULDER 3SP iht chiltl Will fx. u/jjbJc to m;sc the iffectecl arm aboie the )e%tl of the sbouJilcr, ani) point tenderness may be eliciteil at the site of the fracture There may be slight swelling o>er tire fracture, and the dngnosis cm be confirmetl by ^ ray examination or some clap later, by a small amount of callus at the site of the fracture If there is increased anterior convexity of the middle third as compared with that of the outer side, the diagnosis is less difficult In fractures of the inner third of the claucle there may be relatnely little displace ment of the shoulder, and the diagnosis is made by point tenderness loss of function of the shoulder, and in some instances by palpation of the displaced fragments In fractures of the outer third there may be no deformity and the diagnosis is made by the history of the injury, loss of function, and point tenderness However if the coracodaviculat ligament is torn and the outer fragment is displaced there is a definite dropping down of the point of the shoulder with a prominence of the distal end of the proximal fragment and the deformity may be \isible and palpable resembling that of an acromioclavicular dislocation but slightly closer to the midhne of the body Tig 364 rraclure of clivule in a child without displacement Treated by Conwell type of adhesive strapping with got d result Roentgeiwgraphic Cxamiuaiiou In the great majority of instances an x ray film IS not necessary for a diagnosis of fracture of the clasicle but it is \er) useful in de termining the exact line of the fracture and the amount of displacement In fractures Without displacement the x ray film is useful in confinning a clinical impression or in ruling out a fracture This is especially true of injuries near either extremity of the bone In fractures of the outer third an x ray film is often necessary to differentiate the lesion from an acromioclavicular dislocation In lesions of the middle and outer third an anteroposterior view is all that is necessary, but m lesions of the inner third it is better to have the patient prone and make the exposure posteroanterior in such a manner that the shadow of the spine clears that of the sternoclavicular joint on the affected side Choice of Method of Treatment The object of treatment is to obtain a satisfactory functional and cosmetic result, to make the patient comfortable, and to restrict the pa tient s activity as little as necessary In deciding upon a method of treatment the character of the f racturc and of the patient must both be considered According to Lester* more than two hundred different methods ha\e bcwn described and recommended for the treatment of fractures of the clavicle This is of course evidence that we have no method whidi is sabsfactory to the majority of surgeons As •Lester C W Treatment of rractures of Clavicle Ann Surg 89 600 19i9 360 DIACNOSIS AMD TREATMENT Or SPEOFIC INJURIES w-as stated previously the displacement can be reduced by simply pulling the slioulder backward outward and upward but this reduction is almost impossible to miintain in an ambulant patient because any form of dressmi; or apparatus which maintains anatomic reduction will be intolerable to the patient In diildcen any bandage that relieves pain IS all that IS required The surgeon must be careful that his treatment does no harm Therefore the external fixation device used must not embarrass the circulation or damage the skin We shall describe the methods which we use and discuss the indications for their use POSTERIOR FIGURE OF EIGHT BANDAGE (ligs 365 and 366 ) Thin felt Of cotton pads of suitable siae are placed over the front of each shoulder and axilla One or more gauae or muslin bandages 3 or 4 inches wide ate then applied as a posterior figure of eight to the two shoulders The bandage must be applied tightly enough to hold the shoulder back and yet not so lightly ihiU it constri^s the axillary vessels Sufficient bandage must be used to make a firm dressing which should be reinforced by long strips of adhesive and the forearm supported by a sling Billington uses a posterior figure of eight plaster of Pans bandage and makes a plaster yoke providing a very efficient dressing ft J6V F« Cig 565 ?tijteiioi fijnite of eight handvge useful >n tVirtdjtn anA in aAu\n when ihtrt « nft diiplacemcnt or as convalescent dress ng Fg 5C6 Posterior figure of eght bindage seen from from Mole anieror cross snap W preient slipping AxiLiARY PAD, SWATHE AND stiNC A piece of absorb“nt cotton is folded to mike a pad about l6 by 8 inches and about 2 inches thick A strip of adhesive tape inch wide and 18 inches long is placed across one side of the pad and the opposite side is well powdered with talcum A pad of felt about 2 inches in diameter and Yi inch thick is placed over the site of the fracture The deform ty is then reduced by pushing the shoulder upward outward and backward using the slightly abducted arm as a han lie to control the shoulder A long stnp of adhesive 2 inches wide is then placed vertically over the pad over the fracture Tlie adhesive begins well down on the chest and is pulled tightly over the shoulder and down the back to the level of the angle of the scapula The cotton pad is then doubled with the powdered surface outside and pushed well up in the axilla and the ends of the strip of adhesive are crossed over the shoulder to hold the pad snugly The arm is then brought to the side with the elbow slightly fonvard and a strip of adhesive 3 inches wide is passed around the arm and chest The elbow and forearm ate then supported in a modified Velpeau bwidage (Itg 368) or in a triangular sling The slmg must be large enough to project beyond the elbow in order that its ends cm be folded and pitmed snugly about the elbow Tlvc sling may be tied or pmned at the back of the neck or tapes may be attached to its ends and crossed behind and brought around under the arms and tied over the chest, thus taking the weight on the shoulders rather than on the neck INJURIES IN BEGION OF SHOULDEa GIRDLE AND SHOULDER 3(1 CONXTEtL s* ADHESIVE DRESSING Hie material consists of (our pieces of ae (4 inches wide by 48 inches long) one pad of cotton and a small circular pad of felt (3 inches in diameter) For children these dimensions vatj according to the sue of the child Application of the dressing is made as follows After the chest has been shaved and cleansed with ether the patient is placed in a sitting position si ith the hand of the uninsohed side on top of the head The arm of the injured side is against the side of the chest with the forearm resting m the patients lap Adhesise strip 1 is then applied This strip [Fig 369] commences in front just at the point of fracture of the distal fragment With the aid of an assistant and with the patients cooperation the shoulders are pulled backward tension being made on adhesive strip I which is earned out and around the upper part of the arm on the injured side then in and diagonally across the back to the opposite axilla extending underneath the latter then around in front crossing both sides of the chest and terminating about 2 inches below the nipple line on the m jured side This strip pulls the injured shoulder baAward thcrebj tending to approxi mate the fragments by correcting any overlapping Flit 3<>7 F nt roll o( mod fifd Velpeau bandage useful for ch Wren nhen atlho ve s I kely to irntate $kin and for obese adults Fig 36S Complet on of modified Velpeau bandage Th s dress ng does nor ma nta n redurt on if there is tendency to d spbeement The felt pad is applied directl) over the fracture the pad being held in place iMth a small piece of adhesne tape [Fig 370] Adhesive strip 2 [Fig 370] commences m the medial 1 ne of the abdomen a few inches above the umbilicus and extends diagonally up the chest on the injured side and over the felt pad With the application of considerable tension the adhesive is then ex tended diagonally down the back to the medial 1 tie terminating usually at the lumbo sacral region This strip should be applied only after the patient has taken a deep expiration Adhesive strip 2 aids in preventing any tendency of an upward displace ment of the fragments this displacement usually being more marked m the proximal fragment as a result of the action of the sternocleidomastoid muscle A large cotton pad is now applied in the axilla [Fig 371] which aids in pulling the distal fragment outward and at the same time separating the skin surfaces of the arm and chest The forearm is ilexed nearly to an acute angle at the elbow and placed against the chest While the oppos le ends of stnp 3 arc held w idelj apart it is first applied [Fig 372] to the inferior surface of the elbow after a small piece of cotton has been applied to the latter With considerable tension the front and back halves of •Conwelt H E Fractures of Cb ide S mple FiKation Dc«s ng With Summary of Treat ment and Results Attained in p2 Cases J A M A 90 938 ip'^S 362 DIACNOSIS AND TRCATMlNT OF SPEQIIC INJUIUCS the adhesne strip are brou|;ht up the corresponding surfaces of the arm meeting and o\efIappmg Q\e: the shoulder near the middle third of the cliMcle |lig 375] This strip pulls the shoulder upward, thereb) aiding further approximation of the distal fragment which is usually displaced downward Strip 4 commences on the back, at the midaxiltar} line of the opposite side m the r« 57J Fe Fim t n <1I» JrWMiM. 19’8 ) lij. 30 Aiih^i n flrsiMip faJfeivi Tie 37(1 Anitsi n fsc* nturp r»g 371 ! tf 9vilbf> yiJ Tic 372 Appl cjtion of th rJ stnp i7l F" »?■> cs not prtnidt sufficient stibilily to avoid ni,id external fixation and shoiill be axoidcvl if possible Complications lortunatel) compliutions arc rare m fricturcs of the clavicle In tig 3S3 Comm/n frJCtun of clavicle Reduced under ^enecaf anesthesia and immobilized i adhesive diessins abducted an mcisjon of adequate fenglh is nude below and parallel to the clavicle, and the bleeding teasel is located and ligated or repaired As much of the clavicle is resected as IS necessary for exposure of the tcssel berause this bone maj be removed without much disablity or deformity If it is the subclavian artcr) and repair is impossible the vein should also be ligated The wound is then closed with a rubber tissue dram which IS remov'cd at the end of 48 hours and the fracture of (he clav ide is treated bj internal fixation 36S DIAGNOSIS AND THEATMENT OF SPEanC INJURIES Occasionally the brachial plexus is compcessed bj exuberant callus about a displaced fracture s^ith the late appearance of neurologic signs and sjmptoms Not infrequently howeser the cla\ide is comminuted (fig 383) or the fracture IS accompanied by a dislocat on of one exlrenuty or by some other lesion of the shoulder In a senes of 500 cases reported by Eliason* there were 13 associated fractures of the scapula 6 acromioclavicular dislocations 6 fractures of the humerus 9 fractures of one Of more ribs 3 d slocations at the shoulder and 3 fractures of the olecranon ProgHosij Fractures of the clavicle tend to un te qu ckly and firmly and nonunion IS rare unless there is marked loss of substance or interposition of soft parts or marked displacement and inefficient treatment However many of these fractures unite with more or Jess deform ty and th s is the rule in fractures w-ith displacement which are not treated in recumbency with lateral traction Fortunately a fracture of the clavicle which has un ted with cons derable deformity almost always gnes a good functional result STERNOCLAVICULAR DISLOCATION I arteUts and Meehamsni D slocatton of the sternoclavicular joint is a relatively uncommon injury It may result from a fall in wrheh the patient strikes the point of the shoulder but it is more commonly associated w th automobile accidents in which Tg oS4 I) literal siemoclav cular dslocatoo (chronc) vc^eJ from t de Note upward and anter or diilocat on of clavicles the force may be applied directly over the claiicle as well as at the point of the shoulder The dislocation may be anterior superior or posterior depending upon the direction of the forces wh ch are responsible for the dislocation as the final displacement is relatnelj 1 tile influenced by muscle pull If the d slocation is complete the costoclavicular liga ments are also ruptured The intra articular fibrocartilage tends to remain attached to the proximal end of the clavicle and to be dispbeed with it although the fibrocartilage may remain in the jo nt Diagnosis S nee the joint is subcutaneous and the sternal end of the clavicle is qu tc large the diagnosis is not d fHcult (Fig 384) Unless the sternal end of the clavicle has been forced backward it can be felt beneath the skin m its abnormal loca ton If It has been forced backward palpaton will reveal that it is absent from its normal location When it is forced backward beh nd the sternum it may cause pressure on the trachea or the med aslinal vessels Roentgcnographic examination of the sterno clavicular joint is not always easy but with anteroposterior stereoscopic films as well as the oblique films this jo nt can usually be adequately visualized Trealfuent If the patient is seen fairly soon after the injury reduction of antero super or d slocation is usually accomplished eas Ij by traction on the abducted arm and •Eliaion E L. Frarturcs of Oav de J A M A 91 1971 19 8 INJURIES IN REGION OF SHOULDER GIRDLE AND SHOULDER J()P by maDipulation of the proximal end of the clavicle If reduction is not readily accom plished by this method the patient is placed on hts bacf^ in bed and sLin traction is applied to the arm in a position of approximate!) 100® abduction of the shoulder Reduction of a posterior dislocation prticularly one in which the proximal end of the clavicle IS locked behind the sternum may be more difficult In this t)pe of dislocation the shoulder girdle is rotated anteriorlj and is fixed so that ^hcn the patient lies on his back his shoulder does not touch the table This is a relatively rare condition Stem * Fig 38S Lelt sternoclavicular chronic subluxat on Of^rative fixation vas necessary for relief Fig 3S6 A RelfOstcrnat dislocation of clav etc *t left sternwlavicular articulaton Treated by 5 pounds of skin traction to left upper extremity for 7 days with excellent results as sho%n in 8 B Two years later Good poritson followed this closed reduettoa by traction (rrom Stcia, A H Jr J Bone It Joint Surg 59 A 656 1957 ) in 1957 ^as able to find only 35 cases in the literature to which he added 3 cases of hts own Two of these cases were reduced by the method of traction with the shoulder in full abduction and some elevation (Fig 386 ), but the third case resisted reduction by manipulation and traction and required an open operation In this patient it was noted that the fibrocartilaginous disc remained with the sternum rather than with the proximal clavicle •Stem A Retrosternal D sfocalioo of the Ctaviefe J Bone & Joint Surg 35>-A 656 1957 370 DIAGNOSIS AND TREATMENT Of SPEOIIC INJURIES Wheieas reiluct on of these <1 slocaUons is muaU) relatnely ensil) obtaineil main tcnance of the reduction is considerablj more difficult With posterior dislocation rcduc t\on IS usually readily controlled by a figure of eight ban lage This can be constructe I either with muslin bandage alone rr it may be reinforced with j lister which then is the BilUngton type joke descnbed in the discussion of the treatment of fractures of the clasicle In anterior dislocations of the sternoclavicular joints the same method maj be Tig ?88 Latent trad on far right sieniocUsiCutu d ilocal on V. th satulbigs over E« on Treated by recumbenej for or 3 «eelij and ihen ambulatory adh« ve dress n^, for 2 weeks adequate to control the position of the sternal end of the daiicle If the clavicle tends to ride up the add tion of a pressure pad directly over the proximal end of the dai iclc will usually be sufficient At times the antenor and superior d slocations are quite un stable and even a plaster figure-of eight bandage will not ma nta n the reduction In these circumstances it may be necessary to maintain reduction with a shoulder spica cast With the shoulder and arm well forward Occasionally none of these methods is satisfac tory to maintain reduction and it is necessary to treat the pit ent in bed in traction A INJURIES IN REGION OF SHOULDER GIRDLE ASD SHOULDER 37 J sandbap may then be placed o\er the 5tcmoch\iaibr joint to auement the traction to maintain reduction of the joint as lUustnted in I ii; 38R At the end of 3 to 4 ^^eeks the soft tissues hast usually healed suflicienllj so that (he external fixating desices may be remosed and the patient may be started on guarded exercises If (he patient is seen relatnel) early after the accident and the reduction has been maintained until the soft tissues hasc healed a good result should be obtained in that the joint should be stable ixith little tendenc) for recurrence of the dislocation A posterior dislocation with locking of the proximal end of the clavicle beneath the sternum may resist all attempts of reduction of the dislocation and open reduction may be required If it is a relatael} recent case open reduction maj not be too <}t{ficuh but. if tbe dislocation has been present for seseral weeks there is considerable scarring and open reduction of a late retrosternal dislocation should not be attempted by the surgeon unless he is accustomed to w orktng within the chest At the time of open operation it will be noted that the capsule of the sterno- clavicular joint IS thin and that after dislocation it is usually stretched and attenuated so that simple repair of the capsule is inadequate to maintain reduction It is alwajs advisable, therefore to reconstitute the costoclavicular ligaments This is best done by fascial transplant It may be adxisable at times to reinforce this transplant with a braided wire suture passed around the clavicle and the first rib A similar procedure is used for a recurrent or chronic dislocation in the sternoclaMcuIar joint It has been our experience that this gnes a much better result than does resection of the proximal end of the clasicle ACROMIOCLAVICULAR DISLOCATION Varieites and Mechamrm As the joint is situated near the point of the shoulder it IS exposed to frequent trauma In/uries here are more frequent than at the sternal end of the clavicle The acromion may be dislocated either downward or upward on the clavicle A fall or blow on the point of the shoulder with the force directed downward and inward tends to tear the acromion loose from the clasicle and displace it downward and inward The weight of the upper extremity and the pull of the pectoralis major and latissimus dorsi tend to maintain the displacement If the force is not great the injury is limited to a teaming of the articular capsule and the coracoclavicular ligaments remain intact and pce\ent the dropping down of the acromion but a slight displacement results from the rotation of the scapula around the coracoid process With severe trauma the coracoclasicular ligaments are torn and the acromion is completely separated from (he clasicle and is displaced downward and in ward Not infrequently a small portion of the outer end of the cJaiicle Js torn off and displaced with the acromion Upward dislocation at this joint is a very rare injury but occasionally occurs from force transmitted upward through the humerus from falls or blows on the elbow or hand The acromion is pushed up over the end of the cla% icle and caught in this post tion As soon as it is loosened it tends to drop downward Diagnosis Since the joint is subcutaneous the diagnosis can usually be made by palpation and inspection (Tig 389) The history of an injury followed by pain tender ness and swelling over the acromioclavicular joint with inability actiselj to abduct the arm leads the surgeon to suspect either an injury to the outer third of the c!a\icle or an acromioclavicular dislocation Careful palpation of the line of point tenderness and the distance of this line from the outer Iwrder of the acromion will determine whether or not the location of the injury corresponds to that of the joint as determined by examina tion of the opposite shoulder In cases of slight displacement, palpation wnll reveal a slight sulcus at the site of (he joint With complete dislocation tbe outer end of tbe clavicle is unusually prominent. i72 DtAGNOSlS AND TRUATMENT OF SPEanC INJURIES A B Fig 389 A Right sfrom ocfav cular J slocat on « th Jd« nward d splacement of acromion note typ ca! tleformity B Posterior \iew of same case Poster or v ew of ih s type of case t generally of greater d agnust c mportance than antcr or sie« fg 390 AcroroioclaMcular dslocatoti * Ih fractures of clav cle and acrom on Treated w til lateral tract on for '* Mceks plaster spica « il arm aMucted for 3 urcks and strapp ng and si ng for •! weeks Good result Fiff 591 Acromioc/avicuUt separation with fractures freateJ b? pfaster spica with arm abducted 90 * for 3 weeks adhes ve sfrapp ng for 3 weeks and si ng for 3 weeks Tig 392 Mod fied Stimson hgure of eight aJhestse dress ne for Bcromioclavicotar d sfocat on Note that strap 2 is started internally to acromioclavicular joint about junction of outer and middle thirds of clavicle is brought around underneath dbov w th padding, and directly up and over middle third 0 / clavicular area thereby pushmg downward on distal end of clavicle and pulling arm up from below by tens on of strap 2 at elbow As can be seen strap 1 stead es arm to chest and body maintaining firmer fixation and aiding strap Z in hold ng dislocation m place 374 DIAGNOMS AND TRCATitLNT OF SPFaFIC JNJURIES Tii, 393 Modwatety severe scromiociaviailjr dislocation (left) Treated by traction 2 weeks plaster spica alxiucticn cast to si ouidcr for 2 we^s adhesise dressing for M days and with forearm in sling for 2 weeks Good result Tig 391 /i Position in cast StraeMse as in FiR 393 B Type of cast used m /f INJURIES IN RTCION OF SHOULDER GIRDLE AND SHOULDER 57^ whereas the point of the shoulder is displaced doT\nTiard and a definite sulcus is palpable and e\en Msible between the two The deformity can be reduced by pushing upward on the elbow while the outer end of the clasicle is pressed downward, but it tends to recur as soon as the pressure is released Whether or not a small bit of the clavicle has been torn off with the acrcmuon cannot, as a rule, be determined m the ab scnce of an x ray film If the injur) to the shoulder is not the only injury which the patient has recened, acromrodaiicular dislocation may be missed, partinilarly if the patient is examined in recumbency It is unportant, therefore, to have the patient sit up so that the w-eijihl of the arm will tend to cause a displacement and make the diagnosis more obvious For the same reason it is also advisable to take x ray films in a sitting position The rare upward dislocation can be diagnosed bj the presence of the unusuall) prominent inner border of the acromion riding up on the outer end of (he clavicle Since the contouix of the acromiodavicular /omt are such that its integrity depends entirely upon the ligaments, it is neccssar) not only to reduce the dislocation hut also to maintain the reduction until the ligaments have healed This is accomplished by any method which supports the shoulder against the outer end of the clavicle Although re duction of this dislocation is relatively cas), maintenance of the reduction until the ligaments have had a chance to heal, which usually takes from 5 to 6 weeks maj fcie a very difficult problem As a rule simple slings and dressings are ineffective and useless and are not recommended The abduction plaster shoulder spica alone, similar to that illustrated m Fig 394, B, is usually not satisfactory However, by the addition of a suspender strap of muslin or canvas, it will usually work quite well This method was employed satisfactorily with soldiers during the war and can be employed m young vigorous men without much difficulty The patient is required to wear the plaster cast for a period of 6 to 8 weeks It has been our experience that this method is not well tolerated by women and is useful only in those circumstances m which it is desirable to avoid a sar Even With the abduction plaster cast and a canvas sling it is difficult to maintain pressure upon the clavicle and the arm when the patient is lying down If this method IS used, it is important that the patient remain in a scmisitting position even at night Fortunately this is a reasonably uncommon injury m women In men with a complete acromioclavrculzf dislocation associated with a rupture of the coracoclavicular ligaments we recommend repair of the ligaments by operative means plus internal fixation Since kb/t tupsc,'* ^t< 4 'i.Vie WLitswiocliJiwrfiM \vgiT?rtTAi> trcA Vivw.g Va maintain the reduced position even after Uiey are repaired, it is mandatory that the clavicle be maintained m a reduced position until the coracoclavicular ligaments have healed Otherwise a recurrent dislocation may be expected Many operative procedures have been devis^ for the treatment of complete dis locations of the acromioclavicular joint One method is that described by Bosworth in which the dislocation is repaired by open operation, the acromioclavicular ligaments are Sutured, and the clavicle is held down to the coracoid process with a screw until the coracoclavicular ligaments have had an opportunity to heal Surgeons have been some what reluctant to fasten the clavicle to the coracoid process with a screw for fear that this would limit rotation of the clavicle and would impair the function of the shoulder However, late cases which we have examined whidi were treated by this method have not had restriction of shoulder motion This, in our opinion, is a satisfactory method of managing this problem although we seldom use it A much more common method is to reduce the dislocation and to fix it in this position bj one or two threaded pms driven across from the acromion into the distal end of the davtcle If these pins arc seated directly in the center of the acromion and are well seated m the clavicle, they will work satisfactorily and maintain the position until the coracoclavicular ligaments have healed 576 DIAGNOSIS AND TREATMENT OF SPCaFlC INJURIES Hoxse\er so often these threaded pins catdi a tfi n edge of bone in the acromion or in the claMcIe and later pull out or cut through and allow redislocation In addition if the pms are left sticking out through the skm there is a likelihood of infection We ha^e seen cases in which infection has traveled down along the pins and involved the joint necessitating removal of the pins and the results have b'^en poor A much more satisfactor) method m oor hands has been that descr bed bj Orofino and Stem * This method is very satisfactory in men but because the scar is d sfigurmg It IS seldom applicable to women and efforts should be made to treat them bj non operative means The technic of the operabon is as follow-s With the patient lying on his back under general anesthesia the invihed shoulder is elevated with a sandbig Tlr r g 395 /f Cofnptele acrom oclavicnlar d stocation w ih rupture of forac*cljv cular 1 Ran tnts B Follow nR repa r aoJ intenul (ixitioR w th bra deJ wire skin IS prepared with soap and water ixline and alcohol an 1 the arm is draped out Side so that it may be moved as necessary durmg the operat ve procedures The surgeon then makes an incision starting over the acromioclaviculir jo nt and curving mcthall) and distally so tlut it extends past the medal margin of the corac id process and distal to tt for a short distance Superficial hteedng ts controllcil and the incis on is then deepened through the soft t ssucs down to the deep fascia wh ch lies over the deltoid muscle at its acrom oclavicular insertion The deep fascia is incised and the fascia and a port on of the delto d muscle arc separated friwn the clavicle and retracted laterally 'Orofino C r anJ n A H Jr Operat e Ireatnent for Retcnt and Complete Tea s of Coraeoclav culax Ligammu Am J Surg 85 760 195J INJURIES IN REGION OF SHOVLbCS. CIRDIF AND SHOULDER J77 Blunt dissection is usuall) suRiaent to e^^ose the prominence of the coracoid process The periosteum is tlien elesated from the cUsicle exposing the distal one third of this bone and the acromioclasicular joint A drill hole is then made through the center of the claMcIe from the superior to the loferiot surface dircctlj oser the coracoid process A braided stainless steel wire is then passed around the coracoid process and through the drill hole m the cUsicle and the wire suture is firmly united bj twisting the free ends so that the clavicle is pulled down tightlj The coracoclavicular ligaments are repaired with silk, and the wound is closed m fajers with the deltoid fibers being reattadied to the fasaa o\er the claside The arm is then bound to the side with a Velpeau bandage (Tig 3P5) This bandage is retained for the first week at the end of which time the sutures are remosed and the patient is then given a sling and allowed to engage in gradually increasing exercises Results with this method of management have been excellent and there have been no recurrences The braided wire suture eventually will break and fragment and for this reason Stem recommended that the wire be removed at the end of 8 to 10 weeks However we have seen no difficult) result from the wiie breaking smee b) this time the costoclavicular ligaments have been well healed Also since it is sometimes difficult to remove the wire we are inclined to leave it alone Fig. 596 Complete acromioclavicular dislocation w th tearing of ligaments (From Henry if O itinnesotJ Med. 12 451 I?’? ) Trealmeut of Acute and Cbrotuc Cases A complete dislocation m w-hich the dis placement has been present for 2 weeks or mote may be considered chronic because the power of the ligaments to heal b) simple reduction and immobilization has ceased In these cases it is useless to attempt cure by consenative methods and if the disability is 'ery great an open operation is indicated Several such operations are described in the literature A very satisfying one is that devised hj Henry * Jt endeavors to reconstruct the coracoclavicular ligaments by means of hving fascia The operation is performed as that described by Orofino and Stem except that m addition to the wire suture a strip of fascia Jata is passed beneath the coracoid process and over the clavicle as well as through drill holes into the acromion to reconstruct not only the coracoclavicular ligaments but also the acromioclavicular ligament •H«ny if O AcTomtorlavicuJjf Dwiocations Minnesota iled 12 451 1929 INJURIES IN REGION OF SHOULDER GIRDLE AND SHOULDER J7i) Resection of Outer End of Claude In cases of old dislocation with a pam ful acromioclavioilac joint, associated with an incomplete tear of the coracoclavicular lipaments, the Mumford operation or resection of the outer one inch of the cla\icle gives excellent results and relief of pain The operation is simple and the convalescence IS short Howeser, if there has been a complete rupture of the coracoclavicular ligaments and thej ha\e failed to heal so that there is considerable displacement of the distal end of the clavicle, resection of the outer one indi does not give a good result because the clavicle tides up and there is a tender spot at the point where the clavicle has been resected This may interfere with carrying things on the shoulder or the wearing of straps across the shoulder In these persons repair of the tjpe described bj Henry should be carried out, or, if resection is indicated for some special reason the major portion of the clavicle should be removed FRACTURES OF SCAPULA One would expect this broad thin plate of bone which occupies such an exposed position on the shoulder and baef. to be one of the most frequent sites of fracture but compared (o the clavicle, it is relatively free from injuf), partly beausc its edges are thicl^ened thus reinforcing the plate of bone and partly because it is freely movable on the chest wall and lies between thicl pads of muscle Meebamsitt In some instances the body of the scapula is broken as a result of direct violence, and there is more or less damage to the overlying soft parts though the break is rarely open How'ever, most of the fractures of the scapula are the result of indirect violence su^ as falls upon the hand, elbow, or shoulder with force transmitted through the humerus while the scapula is pulled forward by the serratus anterior This results in a fracture of the surgical neck or glenoid cavity or a buckling and fracture of the body of the bone The t«ne may be broken in any of its parts, but the most fre quent fractures are those of the body, neck and glenoid cavity fracture of Body of Scapula There may be a single transverse or oblique break m the bone but mote frequently It 1 $ comminuted by fracture lines running in various directions The break is mote often m the region of the lower angle and very rarely near the upper angle of the body In extensive fractures there may be more or less overlapping or separation of the fragments but as a rule the muscles on either side bold the pieces in position and there is little or no displacement (Fig 399) Diagnosis Diagnosis is made from the history of an injury either directly over the bone or indirectly from force transmitted through the humerus followed by local pain, swelling tenderness, and usually an inability to raise the arm fully on the affected side Disability is due to the fact that pam occurs when the scapula is automatically fixed in the attempt to raise the arm On physical examination there is tenderness over the scapula, but this may be diffuse, and as the bone is quite deep seated it is usually im possible to elicit point tenderness If cither the vertebral or axillary borders are broken and the fragments are displaced it may be possible to detect the irregularity by palpa tjon along the border of the bone A frsetaK of the scapula may best be detected by fixing the bone by grasping the spine and upper border with one hand and gently manipulating the lower angle with the other hand (Fig 554) In this man ncr if the bone is broken definite pam can be eliated, and it may be possible to detect false motion and crepitus An x ray film is necessary to learn the details of the fratture Complications Not infrequently fractures of the body of the scapula arc part of ex Icnstve crushing injuries of the chest with multiple fractures of the ribs or spine or both and the fracture of the scapula may be overlooked or ignored because of the gravity of 380 DIAGNOSIS AND TREATMENT Of SPEaiTC INJURIES the Other mjunes and their accompanying shock, surgical emphysema, or pneumothorax In other instances the direct trauma \ihich causes the fracture may produce seiere injuries to the soft parts and the laceraticms may communicate with the fracture and render it open although usually they do not do so 'Treatment As there is little tendency for the fragments to be displaced, all that is necessary is to make the patient as comfortable as possible until the bone has healed This js accomplished by immobilizing the shoulder and the soft parts o\et the scapula A lery efficient and comfortable dressing is illustrated m Fig 405 A crisscross strapping with adhesive is applied oier the scapula as in the illustration care being taken to have the strips of adhesise long enough to reach from the front of the affected shoulder well down around the opposite side of the chest and to apply them tightly after the patient his exhaled completely After the crissaoss strapping has been applied over the scapula a pad of absorbent cotton IS placed in the axilla and the atm on the affected side is fastened to the chest by a single strip of adhesive 3 inches wide and long enough to reach around the arm and chest The wrist is then supported by a close hitch or a loop of bandage which passes around the neck This dressing is worn for a week or 10 days and Ihen reapplied of if the fracture is not sery painful at this time the crisscross stripping is applied and the arm is sup ported in a triangular sling The strapping is continued for ’ weeks or until the patient IS comfortable without it Function is gradually resumed about 4 weeks after the injury and complete recosery is to be expeaed In coses with lacerations over the scapula the crisscross strapping cannot be applied until the wounds ha\e healed and the surgeon will treat the wounds of the soft ports and pUcc a cotton pad in the axilla immobilize the shoulder by a circular bandage around the upper arm and chest and support the wnst with a close hitch or loop of bandage around the neck Usually these lacerations do not communicate with the fracture and they can be treated as simple wounds of the soft parts If diere is consideraWe displacement of the fragments the surgeon should attempt to reduce this by manipulation of the arm or shoulder and of the inferior angle of the scapula Usually adduction or abduction and traction of the arm will reduce the dis placement If the displacement recurs when the arm is lowered to the side it will be necessary to treat the fracture with the arm in abduction cither with an abduction splint or plaster jacket and shoulder spica or by recumbency with lateral traction as will be mentioned in the treatment of fractures of the surgical neck and glenoid casity of tJic scapula Fracture of Spme of Scapula Fracture of the spine of the scapula is practically always the result of direct violence and ts usually accompanied by a comminuted fracture of the body of the scapula An isolated fracture of the spine docs occasionally occur Diagnosis is made by the loal tenderness and swelling with a palpable diange tti contour and the ability to detect loose fragments or false motion There is little tendency to displacement but false motion and crepitus may be elicited Treatment In these injuries as in fractures of the body of the scapula there is little or no tendency to displacement of the fragments and they arc treated exactly as arc fractures of the body of the bone Fracture of Acromwtt Since the acromion forms the top of the shoulder it is exposed to direct violence and also to indirect force transmitted upward through the head of the humerus or by leserage action through the tuberosity in abduction injuries It is so strong howeser i82 DUGNOSIS AND TREATMENT OF SPEOnC INJURIES Ihat it IS rarel) broJ^en and injuries tending to fracture the jcromion usuilly result in fractures of the cla\icle or dislocation it iht shoulder or acromioclawcular joint riie process ma) he broken at its base oc in the rejtion literal to the acromiochiicular joint When the break is through the base the separated process is pulled downward and inward by the deltoid muscle and the weight of the shoulder On inspection the shoulder IS flattened and the patient is unable to raise or abduct the arm B) careful palpation along the outer portion of the spine the fracture line can be felt as an irregulant) in the bone or located by the presence of pomt tenderness and false motion may be obtained by manipulating the acromion or by pushing upward on the humerus while the scapula is fixed Tig 4(11 Obi q«c frirtuie llr ugl base of «CTwnoo ptoctss Treiie>i by itoscd leJucloti »tul adhesive sirapping pf slculJer and forearm to body Fiialon carrrti out for ( wevks w cr the process A comenient and effiaent method of treatment is to place a pad of saddlers felt 3 inches in diameter and lt/» inches thick over the fractured process This is held in pbee by a strip of adhesne 3 inches wide nhidi is started on the posterolaterti aspect of the shoulder and pulled forward and downward across the pad and fastened around the opposite side of the chest After padding the axilla and protecting the chest bj a circular bandage (he hand on the affected side is placed on the opposite shoulder and immobilized m the third and fourth strips of Conwclls adhesive dressing or in a Velpeau bandage This dressing is worn for about 3 weeks and then the arm is earned in a sling for 2 weeks longer Prognosis If the above method of treatment is used a normal shoulder is to be expected Even in instances where the process fa Is to unite there is usually a good functional result Tig 403 Con m nuted fracture of surjical neck of scapula wth upwarl J splacemeni of glenoid cavity Treated by recumbency wilh lateral wachon for 3 weeks with ambulatory plaster cast will arm at 90* abduction for ’ week* then arm al $ Je and foreann n jl ng for I week Good result Fracture of Surgical Neck anil Glenoid Cat it) These fractures maj result in iirecU) from force transmitted to the glenoid cavity through the humerus or from falls or biros on the shoulder The most common type is one in which the coracoid process and glenoid cavrtj are detached from the rest of the bone b) a fracture line which begins m the suprascapular notch and runs downward and outward to some point on the axillar) border beneath the glenoid (Tig 403) Ocasionally the line may begin lateral to the coracoid process or it may even involve the spine and include the acromion fractures of the gltnoid cavit} arc included m the description of fractures of the JNJOfiJtS JN RICION OF SHOULDER GIRDLE AND SHOULDrR 38^ neck of the scapula because they frequently occur as concomitant injuries w ith a typical neck fracture or m an atypical neck fracture the fracture line may imohe the glenoid cavity On the other hand the glenoid cavi^ alone maj be involved in the lesion The fractures of the glenoid cavity var) from small chip fractures of the margin to extensive comminutions m which the small fragments are widely separated (Tig 404) In fractures of the neck the weight of die extremitj and the pull of the muscles passing from the trunk to the humerus cause the separated articular fragment to be dis placed downw’ard and inward This displacement vanes with the amount of damage to the ligaments If the coracoclai loilar and coracoacromial l/gaments are not torn there IS little displacement even with the Epical complete fracture of the neck in which the coracoid process is included in the articular fragment On the other hand if these Iiga meats are torn or if the fracture line is lateral to the coracoid process the displacement may be considerable r g 404 Sevetely comminvted frstctaie of bod) of scapuia and gleno d cavity Ti-eatcd the same as case shown in F g 403 except recumbency was for 25 days and plaster sp ca cast for t8 days Only fa r result Diagnosis In a typical fracture of the neck of the scapula with tearing of the liga ments and marked displacement the lesion resembles somewhat that of a dislocation of the shoulder except that there is no fixation of the upper extremity The shoulder is flattened the acromion is prominent and the head of the humerus is felt to be absent from its usual position There is total inability to use the arm but passive motion is not restricted and by pushing upward upon Ae elbow the deformity can be reduced and crepitus may be obtained This maneuver is usually accompanied by severe pain and the deformity recurs promptly when the pressure is released The axilla is swollen and tender and it may be possible to palpate the sharp lower border of the articular fragment In fractures of the neck or glenod in which the ligaments remain intact and m 38C DWGNOSiS AND TREATMfNT OF SPEOnc INJU81CS ^hich there iS little or no displacement, the diagnosis is more difficult Swelling and tenderness are present about the shoulder especiall) in the axilla, and there may be slight flattening of the shoulder and prominence of the acromion In a fracture of the neck of the scapula if the inferior angle and bod) of the bone are grasped with one hand and the upper end of the humerus and coracoid process with the other, false motion and crepitus may be demonstrated b) imnipulating one part of the bone while the other IS immobilized Fractures of the glenoid ca\ity arc to be suspected when pain and crepitus occur on slight rotation of the humerus Chip fractures of the rim of the glenoid cavity arc frequent complications of dislocations of the shoulder hut may occur as isolated injuries In either instance the) are difficult to diagnose except by x ray examination An x raj film should alwa)’5 be taken in shoulder injuries when it is possible to do so Fi£ 40) Ambulatory adhesive dressme for fracture of body of scapula Simple cross strap* mg of scapula and axillary pad and adhesive swathe around arm Forearm sli uM he supported by sling Tig 4oA Ambulatory plaster of Pans spica lackel for fractures of surgeal neck of scapula or glenod cavity This dressing is excellent for moderate glenoid fractures fractures of neck of scapula or for follow up dressing m cases reqi ir ng recumbency Trtatmtiil The method of treatment depends upon the sevent) of the injury an I w-hether the glenoid cavit) is involved In simple fractures through the neck of llic scapula with reiativelj little damage to the ligaments and only slight downward displacement of the shoulder joint and no in vohement of the glenoid cavity a most satisfactory method of treatment is a slight modification of the acromioclavicular adhesive dressing A small pad is placed m the axilla and with the arm to the side a strip of adhesive ) inches wide is started in the opposite axillary line at the level of the angle of the scapula and brought across the back Then the patient is told to exhale deeply upwird pressure is made on the elbow bj an assistant to reduce the displacement completely and the adhesive is earned around the arm and chest and fasten^ tightly A second and occasional!) a third strip is placed above or below the first one thus immobilizing the scapula and the upper end of the humerus Wilhoul relaxing the upward pressua on the elbow a pad of cotton IS pliced over the upper third of the forearm and a long strip of adhesive 3 inches wide is placed under the viyspcr third of the futcaim and its ends are catned vertically upward and crossed oicr the shoulder to be pulletl lightly and fastened di wn the bvck m I chcsl Tlvc wrist is then suspendetl x clove lutcli ind a sling art un I llu neck This dressing is worn from I to 6 wc^s and is renewed as often as necessary It INJURIES IN REGION OF SHOULDER GIRDLE AND SHOULDER Jf>7 IS then replaced by a triangular sling, \ihich should be worn for 2 \seefvs, after which the patient gradually resumes function of the atm In fractures of the neck with considerable damage to the ligaments and downward displacement of the shoulder but no damage to the glenoid cavity, the above mentioned adhesive dressing should be tned but the resulte should be cirefuUy checked by an X tay film and if the position of the fragment rs not satisfactory, the patient should be treated in an abduction plaster /acket or in reoimbency with lateral traction as will be described below Fig ‘107 Lateral traction by Conwells upper estremity abduction frame in teambency for frartures of surgicat necL of scapula glenoid fossa ctavicfe or upper third of humerus or for acrorniDcJavicular dislocations !f the fracture line invoUes the glenoid ca\itj and there is comminution and separation of the fragments, the fracture must be treated with traction and with the arm m abduction and preferably with the patient recurrent if a stiff and painful shoulder is to be avoided The traction tends to pull the fragments of the glenoid back into position and to hold them there JSfl DIAGNOSIS AND TREATMrNT OF SPFOnC INJURIES ITie patient is placed on a firm mattress and a lateral traction apparatus is set up (Fig *107) The traction strips are applied to flie forearm ■which is suspended with the arm abducted 90® and externally rotated 90° Traction strips are then placed on the arm and from 6 to 12 pounds of traction is instituted A Thomas ring splint or thick support beneath the shoulder should be atoided because they not only are uncomfort able but also tend to displace the fragments The arm really needs no support but if immobilization is desired a small thm board may be placed under it In sesere fractures of the glenoid casity this treatment is continued for from 6 to 8 weeks and the patient is permitted to use the arm when such mosements do not cause pain At the end of this time the arm can be brought down gradually to the side and earned m a slinj^ but physical therapy and abduction and rotation exercises should be continued for some weeks longer In certain instances m which it is highly desirable to treat the patient in an ambulant apparatus the abduction splint with traction or the plaster jacket and shoulder spica may t« used In simple fractures through the glenoid casity with little or no displacement the fracture should be treated with an axillary pad swathe and sling for about 2 weeks after which only a sling is used and exercises are prescribed to restore function Prognosis In fractures of the neck which do not imohe the glenoid cavity a nor mal shoulder may be expected in 3 months unless there is severe damage to the soft parts and traumatic arthritis or periarthritis develops These may prolong the disability indefinitely In fractures of the glenoid cavity without displacwnent one usually obtains a prac tically normal shoulder If the bone is comramut^ there is likely to be more or less limitation of motion and occasional twinges of pain from time to time cspeciiJly with changes of weather f DISLOCATION OF SCAPULA etiology Disloation of the scapula is a very rare inyuij hut by outward fraction on the arm or by direct violence from behind the entire scapula may be dislocated out ward and rotated outw’ard so that ib lower angle or vertebral border becomes caught between the nbs and fixed in an abnotmal position The rhomboid muscles attached to the vertebral border are either stretched or torn Dfugnoiis The diagnosis is relatively easy as the axillary border of the scapula, especially m its lower portion is unusually prominent and the vertebral border is dis placed outward or cannot be palpated especially in its lower portion The bone is fixed in Its abnormal position and severe pain is produced by attempb to manipulate it or the shoulder Treatment To reduce the dislocation the lower portion of the vertebral border must be freed from between the ribs Usually this can be done by having an assistant make traction on the hypcrabducted arm white the surgeon grasps the axillary border of the scapula and rotates the bone forward at the same time tlial he pushes it directly backward As soon as it is released the scapula tends to slip back to its normal position After reduction is accomplishctl the scapula is pushed as far as possible toward the midline and strapped firmly m place by wide strips of adhesive which begin in front pass under the arm on the allettcd side and arc carried over the scapula and around the chest or over the opposite shoulder A pad is placet! in the axilla an I the arm 1 $ strapped to the side by a single wide band of adhesive whidi passes entirely around the chest The forearm and wrist should be supported by v clove hitch or sling This dressing is worn 2 wxxiks and the arm is carried m a sling 1 or 2 weeks longer lit very rare instances it may be necessary to perform an open reiluction and suture llie bone in place INJURIES IN REGION OF SHOULDER GIRDLE AND SHOULDER 389 DISLOCATION AT SHOULDER Trequenc) Dislocation occurs more frequently at the shoulder than at any other joint m the body, and statistics show that thts lesion comprises approximately 50 per cent of all dislocations Hone and Marble,* in analyzing 1,603 shoulder ^’irdle injuries found that 500 were dislocations of the shoulder Hie frequency of disloation was second only to fractures of the clavicle The great nujotity of the cases occur m robust adult men, but the accident may occur in patients of any age or sex, though it is ex tremely rare m children Predisposing Causes The relatixe frequency with which dislocation occurs at the shoulder may be explained by the following anatomic characteristics of the joint (1) the head of the humerus is relatnely much larger than the shallow glenoid avity m which It rests, (2) the capsule and ligaments are relatively loose and weaL and the integrity of the joint is largely dependent upon the muscles which may be easily stretched, (3) the joint has a very wide range of movement and leverage am be exerted upon it through the upper extremity, and (4) the joint occupies an exposed position upon the body Types According to the position of the humeral head in relation to tlie glenoid cavity, dislocations may be classified as anterior, posterior, inferior, or superior, and, depending upon the relationship of the head of the humerus to surrounding structures, these primary divisions may be further subdivided by such terms as subcoracoid sub clavicular, etc Anterior Dislocations at Shoulder Anterior dislocations of the shoulder constitute the bulk of shoulder disloacions Posterior dislocations are much less common, and inferior and superior dislocations are quite rare Eliolog) Although a number of dislocations of the shoulder have occurred m the same family and m twins, as reported by Gallic and Le Mesurier,t no known ptedis posing factors have ever been clearly defined It is interesting to note that m 1920 de roarmenstranx, in examining shoulders roentgenographically, found a defect in the posterosuperior portion of the head of 4 out of 80 normal shoulders and speculated as to whether or not this might represent a predisposition to dislocation All reported series of cases indicate that the vast majority of dislocations are the result of trauma although in 3 pec cent of thfjir oases JIopv aud M?/We d.»d myf .hst assoaafed jwib the shs locations Anterior dislocation of the shoulder may result from several different types of injuries (1) a fall on the outstretched arm or hand, (2) a blow from behind the shoulder, (3) hyperextension of the abducted arm, (4) external rotation and hyper extension of the elevated arm, (5) an anterior dislocation when the head of the humerus is levered out of the joint by forces applied to the fully abducted arm, (6) violent muscle contractions associated with epileptic seizures, sho^ therapy, or contact with a high voltage current Pathology Depending upon the force acting on the upper humerus, the glenoid labrum may be detached or destroyed and the capsule stripped up for a considerable distance on the anterior neck of the scapula Bankart| fdt that this type of trauma was the cause of recurrent dislocation of the shoulder and that those dislocations that healed •Rowe C and Marble H C Fractures aad Other lo/uncs Chicago 1959 Year Book Publishers. Inc IGallie W £, and Le ^f«lurler A D Recumng Dislocation of Shoulder J Bone A Joint Surg 50-B 9 19.18 iBankart A S D Recurrent or Habitual Distocatian of Shoulder Joint Bnt M J 2 113’ 1923 390 DIAGNOSIS AND TRCATKLNT OF SFCaHC INJCRtCS v.ithout tecurtcnce did not hi\c damige to the glenoid labrum or the capsule stripped /rom the bone It seems likely that there must be damage to this area of Uie joint :n all anterior dislocations although of course the degree varies from practical!) no disturbance to actual fractures or depressions on the interior lip of the glenoid civit) In addition to damage to the glenoid hbmm anterior npsule, and nm of the glenoid there is also damage to the head of the humerus Hus damage ts the creation of a groove or tie pression in tlic posterosupcrior aspect of the head and undoubted!) represents a com pression fracture How often this occurs in ordinary dislocation is dilHcuIt to sa), nor have we been able to hnd an analpis of uncomplicated dislocations in regard to (his element of the injury Adams* found that in recurrent dislocations there was a defect in the humeral head in 82 per cent of his cases Where the trauma of dislocation is violent, in addition to the anterior lip of the glenoid being depressed or fragmented there mi) be an associated fracture of the greater tuberosit) of the humerus As open reduction of acute dislocations is rarely necessary vit do not know how often there is damage to the rotator cuff or the extent in which the capsule ma) be torn in the severe injuries The deltoid and posterior scapular muscles are stretched over the glenoid Tib -lOS Subcoracoid dislocation at left shoulder Note flattening of shoulder ptominmce of aaomion and swelling in the subcoracoid region Fig -109 Same palioit seen from behind riailcnins of shoulder is even more evident Fig followed by pain and disability in the shoulder and the arm is fixed in a position of slight abduction (about 30®) Attempts to bring It to the side or to move it mote than a few degrees in any vlirection cause pun and ire resisteil by an clastic like force On inspection the arm appears to be lengthened, and its axis is displaced inward and downward and passes below and anterior to the glenoid The axilla ts bro.idened and the anterior axillir) fold is displaced downward The normal contour of the shoulder is disturbed in that the acromion is unusuallj prominent and the deltoid muscle ts flattened In an) except very flesh) persons an unusual fullness is visible in the region below the coracoid process (Tigs 408 110) On palpation the fingers sink into the space beneath the acromion, and the head ♦Adams } C- Ttecurimt Dislocation of Sloulder ) Done A } ini Sur^; JO-H 2fl 19 INJURIES IN REGION Of SHOUJJJUl GIRDLC AND SHOULDER 391 of the humerus rs feJt to be absent from its nomui position and can be palpated on the front of the shoulder near the coracojd process as a rounded mass which rotates with the shaft of the humerus There is practically no acti\e motion^ but passive rotation is fairly free although It may be painful Other motions are markedly limited Tins is especially true of adduc tion unless there has been extensive tearing of ligaments Another important finding is the presence of Dugas sign, i e , the inability to place the hand of the upper extremity uith the in/urecai on w th only si ght dtspUceroewt inw* d Rcdutt on under in oncstl ft c Immob I lat on w tJ adl c dress ne for I"* days afler wl h f rwrm was can rd m i »1 ng lot 10 days G )oJ result casit) and nu) c\cn effect rcductu n though it shoul 1 not be carried out w-jih great ft cc in the hope that it ma) do so It is far brttn surgetj to proceed genti) with the three stages of Kochcr s method as described in the following paragraphs IJCTIRNAL ROTAnoN (fig 4lJ ) The surgeon now grasps the patient $ elbow wiih one hand and hts wrist with the other and wh Ic pressing the patient s ami aga nst tl ~ INJURIES IN REGION OF SHOOLDFR GIRDLE AND SHOULDER 393 chest wall \er> slo^lj but firmly, rotates the arm and forearm outward until the fore arm points almost directly away from the side of the body (about 75°) Cotton recom mends that this external rotation be performed so slowly that from 2 to 5 minutes be consumed m its accomplishment ADDUCTION FORWARD (Tig 4l4 ) With the external rotation and slight traction maintained the patient s arm is now earned forward across the ch“st in such a manner ri/5 412 Anterior dislocation of shoulder before and after reduction Immob hied for I ecks m Velpeau bandage followed by lim ted abduct on of arm for 6 ^eeks wit! good result Tig 413 Kochers first maneuver for reduction of anterior disloeatmn at shoulder Arm is earned into full etternai rotat on white e{bo« is held against chest and moderate tract on is made on humerus Fig 4l4 Kochers second maneuver Wh le rotation and tract on are maintained humerus Is adducted across chest Fig 4I5 Kochers th rd maneuver Traction stiff mamtaneef while arm is rotated inward until hand »s placed on oppoiitt shoulder that the point of tho elbow tends to approach the ensiform cartilage or midline of the abdomen The mosement should be slow, firm and steadily progressive and the elbow should be kept as close to the chest as possible and the arm somewhat levered over the ribs m order to lift the head of the humerus and cause it to slip over the edge of the 59 i DIACjNO^tS AND TRHATMrNT OF >PEanC INJURIES glenoid In the nujorit) of instances the head slips into the glenoid asity during this second maneuver of forv^ard adduction and the reduction maj* be so gentlj ac complished that the surgeon does not know ?khen it happens INTERNAL ROTATION (Ftg 415 ) With the point of the elbow held as close to the midhne of the bodj as possible the arm is rotated wtemallj bj using the forearm as a leser and the hand is placed upon the opposite shoulder This maneuver completes the reduction and restores the head to its normal position If much resistance is encountered in performing the third maneuver, the attempt has probably failed and the surgeon should start again at the beginning lir: 416 I » ng fi« of aisjstanl n axiha a* aid »n rcduiing dislocati ni of iVk uldcr (CouUny Di Benismio Meyer J In the second attempt it is advisable to place some sort of fulcrum in th* patients axilla before Stirling ihc sea>nd maneuver A fist or forearm (Fig 4l6) of an assistant or a folded sheet or large towel is enouch and gives the surgeon a fulcrum over which he can lever the shaft of the humerus and lift the heal outward and into the glenoid cavuj If this seiond attempt with an axillary |ad or fulcrum fails, the surgeon should examine the shoulder carefully to make sure that his diagnosis is enrre-ct and that he i' m t dealing vvith a fracture-dislocation of the shoulder If no t>b$tacle other than muscle spasm or adhesions in the case of an old dislocation can be found Ihc surgeon should INJURirS IN REGION or SHOULD! R GIRDLE AND SllOULDfR s(art again, first pulling the head of the humerus down and out as close to the glenoid cavitj as possible If this third effort fails tn a fresh subcoracoid dislocation, we behe^e it is time to quit and either do an open reduction or let some other surgeon trj his hand at it, as 1 jolent manipulations may do more harm than good Tr/ict/on and Leierage Method This is one of the oldest and still one of the most elHaent methods of reduction Tlie surgeon s heel m the axilla is a satisfaclor) fulcrum for the lever When this method is used, the patient lies on his back, and the surgeon places his unbooted heel m the axilla and, grasping the patients wrist, makes traction on the arm m line with the humerus, at the same time adducting the arm slightly, thus levering the head of the humerus outward over the margin of the glenoid If reduction does not occur immediately, the arm is rotated outward to lift the head of the humerus o\er the margin of the glenoid The surgeons right heel is used for a dislocation of the right shoulder and the left heel is used for a dislocation of the left shoulder The traction should be slow and steady because Molent manipulation may damage the soft tissues Although this method of reduction works well, with some surgeons there is a greater likelihood of producing injury to the structures about the shoulder girdle than w ith other methods, and wc do not fas or its use Gradf/al Reduction by CraiHy and Traction This is a safe, gentle, and relatively painless method which we think should be used more often No anesthetic is needed, but patience and gentleness on the part of the surgeon are required The patient is placed prone near the edge of a table with a pillow under die chest, his head turned to the unaffected side, and the dislocated extremity hanging vertically downward over the side of the table, and is left in this position for a few minutes If spontaneous reduction does not occur during this procedure, the elbow is flexed and, with me hand supported, a sandbag weight 5 to 10 pounds is laid across the forearm close to the elbow, or a weight is hung across this area, or gentle longitudinal traction is made by the surgeon for a few minutes Then the atm is slowly and gently abducted and externally rotated If reduction has not occurred, the surgeon may give a final lift upward to get the head over the glenoid labrum This method was desaibed by Stimson Milch and Lacey, and Crawford A modification of this method is to have the patient sit on a revolving stool The dislocated extremity is grasped by the surgeon in a position of shaking hands and with the patient leaning slightly forward and to the side of the dislocation, the patient then slowly turns his stool away from (he surgeon causing the arm to go into external rota tion Very frequently the dislocation will be reduced without undue stress ot pain to the patient Operame Reduction of Recent Anterior Dislocation If the application of the methods described above fails to effect reduction and if there is no fracture of the humerus, there must be some obstacle to reduction which does not show in the roentgen ogram, and an open operation is justified In a rare instance m which open reduction of a recent dislocation is indicated, it is our opinion that, after the dislocation has been reduced, a repair of the anterior capsule should be performed after the method of Bankart For details of this operative pro cedure see p 410 TREATMENT AFTER REDUCTION After (hc shoulder dislocation has been reduced, the arm must be bound to (he side with the humerus rotated inward to guard against a recurrence of the dislocation and to permit die torn ligaments and capsule to heal For this purpose a Velpeau bandage or an adhesive dressing with a clove bitch for the forearm, as illustrated m Fig 4l7, is fairly comfortable and quite simple to apply A pad of absorbent cotton is placed m the axilla and a 3 inch strip of adhesive long enough to encircle the upper arm and chest is strapped tightly around the upper arm to 596 DJACNOSIS AND TREATMtNT OF SPEUnC INJURIFS enorcJe lh« chest )ust beneath the uppc^ite axilla A sifrnlar strip is passed around the loner arm and chest and a third strip around the loner arm fle\cJ forearm and chest and the wrist is suspended bj a close hitdi or crant slinc Tlie dressing sliould not he tight enough to obstruct the circulation in die arm The dressing should be worn for from J to 1 netks At the end of this time U maj be remosed the arm carried m a sliog and exercises begun in an effort to hasten the restoration of function Tlie sling should be continued for from 1 to 3 weeks or until the shoulder is stable fairly strong and not painful when the sling is omitted It has been showm by McLaughlin* and by Rowcf that primaiy dislocations m which no external support or a support onl) for a period of 7 to ZO daj-s was utilized following reduction had a considerably higher incidence of recurrence than did those in which the external support was present for approximately 3 weeks There seems to be %crj little adiantage of continuing the external support past this period of time Thi;sc supports pre\cnt ex temal rotation and abduction They do not completely immobilize the shoulder In Vig 117 Simiile dxalion Jrmifl^ to be used after reduct nn of distucated shoulder fig 418 AcrwnioclavicuUr adheswe dressing for use sfier icdurton of disSicaton at shoulder addiUon it was also noted by these authors that the age of the patient at the time of the first dislocation was of the utmost importance in determining whether there would be a recurrence Tlicy found that the >3St mayonty of the recurrent dislocations occurreil in the first 2 or 3 decades of hfc and thnt the percentage of tccutrincc decreased as the patient became older so that only a few occur in patients mer 50 ycais of age It would appear therefore that the age of the patient md the period of external fixation are both im portant in determining whether or not the dislocation will recur Likewise there is a dcfi mte correlation of the incident of rccurnnccs with llic sescrity of injury issociated with the initial dislocation After the bandages base been remosed, the patient is started on pendulum exercises and as a rule there is no difTiculcy in resfonng muscle power and range of motion "Hie patient IS cautioned not to get the arm into a position of delation and extension until full pow cr has been restored to the shouKler muscles Olhfr At!lettor Disfocu/ioiis Deperuling upon t{« final resting plicc of the head •Mrljuchlin H L. and Oxallaio ZJ Znmary Anierior D ilocal pni Am J Surp f‘* 6JS 1950 fRowe C R Pn snoi i in D rtocat on tf the St nliJer } It m X Jo nl pe of fixation is also useful in rerta n fractures about shoulder arm and elbow 400 DUCNO^lS AND TREATMFNT OF SPratfC INJURIES and arcumference of the axilla are increased the arm is fixed in an abnormal position and Dogas sign w present pist as in subconcoid dislocation The only differences hicen the two are that in the subglenoid dislocation the head of the Jiiunenis can palpated in the axilla, the axis of the humerus is displaced directly downward and arm tends to be maintained m a position of ^x>ut 45® abduction Tis 424 SuhilenoiJ daslovation t>t shoulder "Mlh ft3rtk.re ihtoojih luberoiit) and tliroush anatomic neck of liumenis Treated hy closed re loclioft and immobiliraiion m cwt at po* aWucI on 5ome permanent diiahilii)’ i'sr^ INJURICS IN RirClOM OF SHOULDCR GfRDLE AND SHOULDER 401 Lil'catio Zrecla Tins is a rare t)pe of inferior dislocation m which the arm is directed directI) up\'.ard and is fixed in this abnormal position and cannot be lowered Usually the humerus is rotated m such a manner lli« tlie forearm rests on tlic top of the head Jt is an exa^erated subglenoid dislocation produced b) hyperabduction with dossn ward pressure on the humerus There is extensile tearing of the capsule ligaments and muscles and the nerves especially the orcumficx may be m/ured Likewise one or both tuberosities may be torn off The diagnosis is obvious In addition to the erect deformity the head of the humerus can be felt m the axilla at some point on the axillary border of the scapula TREATMENT Treatment is reduction by traction upward and slightly outward After the head of the humerus slips into the glenoid canty the arm is gentlj lowered to the side and treated as a subcoracoid dislocation Tig 426 A Fostetior d sfocat on (dosed) of sEouIder B Cbsed reduct on of d slocation earned out alter wh ch rad ograph showed good reduct on with fracture U rough greater tuberos ty of humerus Good results Posterior Dislocations at Shoulder These are rare injuries m which the head of the humerus is forced directly back ward through the posterior capsule and comes to rest upon the posterior surface of the neck of the scapula beneath either the acromion or the spine Depending upon the position of the head these dislocations are classified as subacromial and subspinous the latter being the more extensile displacement In our experience posterior dislocation has been assoaated either with electric shock therapy or with accidental contact with a high \oltagc current The capsule is extensivelj torn in its posterior portion and the subscapuJans is torn or stretched across the glenoid fossa The postenor scapular muscles are torn off or stretched over the upper end of the humerus The diagnosis is not difficult, but the subacromial dislocation may be overlooked be cause the displaced head is shielded fay the acromion and masked by the swelling The shoulder is markedly swollen behind and flattened in front and the acromion is promi 402 DIACNOHS AND TRrATMFNT OF ^PFUFIC INJUUILS nent The arm js usually fixed in adduction »ilh the elbow acainst Ihc chest and attempts at abduction cause pain The position of the arm >afies considcrabl) m different cases In the subspinous t)pc it ma) be abducted and forward Tlie gleno d casity maj be parti) filled bj the shaft and the head » hfgcly responsible for (he swelling behind the shoulder and ma) be palpable here However the extensive swelling ma) mask the dis placed head of the humerus and it may be nccessat) to rotate ihi sivaft slightly to identify the head m its abnormal position X ray examination is most important and should include an axillar) view which is more revealing than a lateral view through the torso Trea/mefJt Reduction is by traction in the long axis of the humerus assisted b) pressure on the displaced head with Ihc thumbs When the head has reached the nm of the glenoid it may be assisted over this by gentle adduction of the arm thus lever ing the head outward and gentl) rotaivng it inward After reduction treatment is the same as for subcnracoid dislocation except tliat the arm should be immobiliaed directly downward against the chest and not brought forward Superior Dislocations at Shoulder These are extremely rare in;urics in which the head of the humerus ndcs upward in front of the acromion, wh ch may or may not be fractured All of the tccot led ascs are m the older literature and most of these were old unreduced dislocations In a recent case the diagnosis would be obvious and reduction would be accomplishctl by downward and outward traction assisted by pressure on the head with the thumbs Contpheattons of Dislocations Complications axe rather frev^uent m dislocations at the shoulder and may be very severe The most frequent types are those in which fractures of either the humerus or the scapula are produced at the time ot the original inyury or by strenuous attempts at reduction These fractures during reduction are particularly likely to occur when the disloation has been present for some time and scar tissue formation and bone atrophy have developed Associated rractutes Tlic fractures which have occurred with dislocations of the shoulder arc glenoid coracoid and acromiOn of the scapula anatomic or surgical neck or either tuberosity of the humerus The most frequent is fracture of the greater tuberosity FRACTURES OF CLENOID Onc of the most frequent complications is fracture of the glenoid which consists of a chip off the lower part of the anterior hp This injury cm be positively diagnosed only by x ray exam nation It is to be suspected if during reduction bony crepitus is felt at the point when the head slips into the cavnty or if the dislocation recurs very readily after reduction FRACTURES OF CORACOID PRCXESS AND ACROMION Tliesc injunes arc both rare and give rise to local tenderness and swelling over the site of the fracture In fracture of the acromion false mobility and ertp tus may bt ebtaned by manipulating the dc tjchcd fragment In the coraconl process the fracture is usually diagnosed only by means of the X ray film FRACTURES OF TUBEROSITY OF HUMERUS liactuie of ihc gicatct tubcfosit) IS a frecpjcnt complication and it may be possible to palpate the detached fragment m the tissues beneadi the acromion where it has been drawn by the supraspmalus muscles As a rule however the fragment remans attached to the humerus by the periosteum and there is little tendency for it to be widely separated The lesser tuberosity is rarely fractured ^t when it is torn off the biceps brachit tendon may slip out of its groove and interfere with reductir n Here t there is Iitlle tendency to displacement of the detached fragment The diagnosis of a fracture of tlic tuberosity is difiicult to make in the absence of a pos tive roentgenogram INJURIES IN REGION Ol SHOOU)ER GIRDLE AND SHOULDER 403 FRACTURE OP ANATOMIC NECK OP HUMERUS This IS a \ery rare Itsion in con nection sMth dislocation of the shoutder and can only be differentiated from fractures of the surgical neclv with dislocation by the x ray film FRACTURE OF SURGICAL NECK OF HUMERUS (FRACTURE DISLOCATION AT shoulder) This injury is a sesere and rather rare complication of dislocation of the shoulder The head of the humerus is absent from its normal position and can usually be Fig 427 /i Peiicriof duloeil on of shoulder «j|J) fracture d spUiewitni «/ greaifr luberos ty of humerus Treated by closed reduction with excellent results as sherwn la B B F xat on of forearm to chest and body with adhesne with repeated changes for 1 month after which actse and passive mot on was begi n Good results m $ months Fig 428 Paralysis of right deltoid muscle following traumat c d slocation of shoulder Note atrophy and inabil ty to abduct arm palpated in the tissues beneath the coracoid process The clinical picture resembles that of a fracture of the surgical neck of the humerus m that the arm is not fixed in abduction and false motion can be demonstrated but the glcnt id cavity is felt to be empty and the head of the humerus can be palpated in its abnormal position It is aery important to 404 DLAGNOStS AND TRrATMrNT OF SPCaFiC INJURIES recognize this compilation before attempting ictluction since energetic manipublion may ause considerable permanent damage to the soft tissues in the i lanitj Nefte Iti/t/ries Although uncommon ncncs may be damagw at the time of the dislocation and csidence of nerve inyuiy must always be searched for prior to the instigation of treatment According to Rowe and Marble the nerves most frcqucntlj injured arc the ulna radial circumSex and median in that order However in our experience the arcumflex has been more common The arcumflex nenc arises from the posterior cord of the brachial plexus anterior to the subsapularis and passes through the quadrilateral space and then divides into upper and lower brandies "nie upper branch is primarily motor and supplies the teres minor and deltoid muscles It may be imposs ble to determine loss of motor function prior to or immediately after reduction brause of the injury associated with the dii loation However, the lower or sensory branch which fciecomes the lateral brachial cutaneous supplies a large area over the laleraJ side of the shoulder and sensory disturbance in this area indicates danvigc to the arcumflex nerv e Vascular Injuries Fortunately vascular injuries arc very rare Ocasionallj however ihe axillary artery or vein may be torn at the time of the injury or by violent attempts at reduction When, the artery is torn the radial pulse is absent and a large hematoma which may pulsate appears rapidly in the front of the shoulder and axilla VC hen the vein is torn the hematoma appears more slowly and the extremity is swollen and cyanotic Open DtslocaUous at Shoulder Open tlislocations at the shoulder are very rare but may result from great violence The head of the humerus may be driven through the sV,in of the axilla into the pectoral region or even behind Ihe shoulder Because of the marked displacement associated with these injuries there may be both nerve and vascular complications Treatment of Computations Treatment of the various compilations is as fnllows FRACTURE OF GREATER TUBEROsrtY OF iiUMERUS Fractufe of the greater tuberosity of the huenems » a. (aisly cowkwmv accompaw nvent v\( dislocatvou of the shouUlec and suggests a certain amount of damage to the rotator cuff and joint apsule However the supraspinalus muscle usually remains attachcii to the greater tuberosity Following re* duction of the dislocation the greater an I the lesser tuberos ties if fnctured usually drop back into satisfactory position and require no special treatment other than to con tinue the period of immobil zation for an extra I or 2 weeks until the ftacture fragments have A chance to partially reattach themselves Then act vc cxcrase is commcnccil as prcvi ously described Occasionally the amount t f displacement of the greater tuberos ty result mg ftocn the pull of the short rotator muscles is great enough to indicate tlut good shoulder function will not result unless the fracture fragments arc rqxisitioncil Many times this reposition ng may be obtained by jiHluction of the arm and maintenance of this position of ab luction until the fragments have part ally united However in the elderly patient this method may interfere viilh restoraton of function of the joint and in the younger ind vidual it will probably be prone to increase the incidence of recurrent d»s location lor this reason wc seldom employ this method of conservative therapy and feel tlut in those cases in which the displaeimcnt of the fragments is sufficient to indicate im pjirment of joint function the j tocedurc of choice iv operative reposition an 1 internal fixation of the fracture fragments and rcprir of the damaged soft tissues FRACTURE Of SURGICAI NECK OF HUMERUS { FRACTURE PISIOCATION AT shoulder) This IS a very serious compliat on of disloation of the shoulder which fortunately docs not occur frequently however since its presence clungcv boih the eluvial picture and the treatment it is important that those who treat frictures be /am har with its diagnosis which has been discussed on p HI and with its treatment which follows INJURIES IN REGION OF SHOULDER CIRCLE AND SHOULDER 405 The indications ate to reduce the dislocation and fracture as soon after the injury as possible It is s’cry bad practice to permit the fragments to unite with the head out of its socket and to evpect to reduce the dislocation after union has been obtained because reduction will then probably be impossible without an e'rtensne and difficult operation and because the callus incident to iuikmi may seriously damage the brachial plexus Reduction may be accomplished bj manipulation or by open operation Reduction by Manipulation In a fresh case reduction by manipulation offers a fair chance of success but rei^uites considerable skill The fracture of the humerus eliminates the possibility of using that bone as a le%er, and consequently it is useless and even dangerous to attempt reduction by Kochers method or by any other method which uses the humerus as a lever Closed Reduction by Traction and Manipulation As this is a difficult procedure, general anesthesia is necessary Reduction can only be accomplished by a combination of traction and direct manipulation of the separated head of the humerus The object of traction is to pull the upper end of the shaft of the humerus so far away from the glenoid cavity that if does not mtcrfere with the passage of the head into the socket and this amount of traction must be maintained until the reduction is accomplished Because the traction must be slow, steady powerful, constant, and under the control of the surgeon, it should, if possible, be obtained by mechanical means Effiacnt methods of obtaining this traction are the screw traction apparatus of Boehler or the Soutter traction apparatus With the Boehler apparatus the traction is obtained by means of a pm passed through the olecranon and regulated by a long traaion screw while the frame makes counterptessure against the chest wall So efficient is this method that Boehler has reported 8 consecutive cases of fracture dislocations at the shoulder m 7 of which he was able to effect reduction Lacking such an apparatus the surgeon may apply countertraction with a sheet around the chest and obtain fraction on the arm by means of the screw footpiece on a fracture table, by a block and tackle, or by a husk 7 assistant In the case of mechanical traction, the traction may be applied to the arm by means of a pm through the olecranon or by a double clove hitch around the arm the elbow being protected with saddler s felt The direction of the traction should be directJj Outward (90® abduction) When the upper end of the shaft has been drawn well away from the glenoid cavity by a slow, steady pull, the head should be pushed outward and upward by direct pressure and forced over the nm and into the glenoid cavity Intact shreds of periosteum may cause the head to be drawn out with the shaft and then reduction by upward pressure in the axilla is relatively easy If the head does not follow the shaft, reduction is mote difficult and may fail entirely It is impossible to describe the method of getting the head into the glenoid cavity The surgeon must use his fingers and thumbs and gradually push it outward and upward and ov er the glenoid nm After reduction has been acojmphshed immobjJiaation of the fracture and of the dislocation must be maintained For this purpose Boehler uses an abduction atm splint with traction We prefer to treat these {xitienb in a plaster spica jacket or in recumbency with the lateral traction frame (Fig 406), alxlucting the arm about 60® and using just enough weight to maintain the position of the fracture (5 to 8 pounds) The shoulder is further immobilized by a large cotton pad m the axilla and a figure of eight elastic bandage over the shoulder At the end of 4 or 5 weeks union will be sufficiently firm to begin gentle active and passive motion and the arm can be lowered to the side and carried in a sitng In cases several days old, we believe that it is useless to attempt dosed reduction Open Reduction If dosed reduebon fails or is not deemed advisable, an open re duction IS indicated An inasion about 5 inches long is made over the sulcus txrtween 406 DIACNOSIS AND TREATMTNT OF SPEOFIC INJURIES the pcctoralis major and the deltoid muscles The muscles are retracted and the dis located head and upper end of the shaft are exposed The shift is pulled outn-ard and downward to expose the rent in the capsule and the glenoid cavity which is then cleared of debris In order to do this it may be necessary to diside the insertion of the pcctoralis major muscle After the glenoid casity ts cleared the head is lifted mto plicc with circ taken to preserve its muscular attachments if possible It may be necessary to diside the insertion of the subscapuUtis muscle In handling the head cate should be taken not to injure its articular surface It can usually be lifted into place with a pair of hon jawed bone forceps applied to its nonarticubr portion or a strong hook can be plactd in the medullary canty or cancellous tissue of its broken surface If this fails a small drill hole may be made in the cortex and a hook passed through this After the head is back in the glenoid easily in its normal position the fracture is reduced and the capsule and severed or tom muscles arc sutured Small holes are then drilled through adjacent portions of the two fragments and they arc tied together with wire or the fracture may be stab lijed with mult pic threaded pins or a Rush nail de- pending upon the amount of comminution and the type of fracture The wound is now closed m layers and dressed with the arm at the side and the hand on the opposite shoulder (Velpeau bandage) The wiring of the fragments will maintain reduction of the fracture At the end of 4 weeks actnc and passive motions should be begun cautiously and increased gndually These shoull be supplanted by local heat and massage to hasten the restoration of function Remoi li of Head of Humerut In instances in which the head of the humerus hts been found to be completely stripped of all soft tissue attachments it has been recom mended that the head be removed because of the hkcl hood of aseptic necrosis and nonunion of the fracture or if union should occur late degenerative changes in the shoulder joint (Iig 425) However vve have never been safisficil with the end results (Stained by removal of the head of the humerus and repair by insertion of the rotator cuff muscles into the proximal end of the shaft of the humerus Therefore on occasions we have replaced die head and have been very gratified with die result obtained If the head is severely comminuted the chances of having a good functioning shoulder are markedly deacased Under these circumstances wc recommend teplacccncnt with a prosthesis INJURIES TO Bioou vESSEts If a large blood vtfsscl is ruptured and a brgi- an I growing hematoma is present the region nnivl be explored immediately and Uie bleed mg vessel ligated or repaired NERVE INJURIES Nervc injuries should be watched carefully and if the injury involves the brachial plexus and there is no cv dence of recovery at the end of a few weeks the plexus should be exposed and an attempt made to repair the damage If the paralysis involves only the circumflex nerve an abtiuction splint should be worn as soon as It can be applied without danger of causing a recurrence of the dislocation In cither case the paralyTcd muscles must be supported and protecteil from stretching an I as power hegins to return helped by graded cxerasev If a cord of the plexus is sevcrc«l It should be sutured but the prognosis is poor Mwt of these nerve injuries arc due to contusion or stretching and recovery is spontaneous Old Dislocations at Shoulder Occasionally one secs a dislocation at the shoulder which has been present for a considerable time and such a caw offers a senous problem to the surgeon The patients usually have marked dcfomiity and disability in the shoulder and more or less pam and there may be definite evidence of pressme on the brachial plexus Consctjuenlly the surgeon should attempt relief of tlic symptoms and restoration of function and contour if the general condition of the patient ss satisfactory However if the condton has INJURIES IN RrCION OF SHOULDER GIRDLE AND SHOULDER 407 existed for 6 months or Jonger and there is Jitde or no pain and a fair function of the extremitj, it is usuallj ise to let v.'ell enough alone Obstacles to Jieduciton The obstacles to reduction consist of shortening and fibrosis of the muscles espeaally the pectoralis major and subscapulatis the formation of scar tissue around the head of the humerus whidi binds it firmly in its abnormal location and to the surrounding structures healing and contraction of the capsule filling of the glenoid cavitj ■with scat tissue or bone fragments atrophy of the humerus and over growth of the glenoid margin All of these obstacles tend to increase progressively with the duration of the dislocation Choice of Method of Reduction Old unreduced dislocations almost ln^arlabI> require open operative repositioning However we always make a practice of making one attempt at closed manipulative reduction This is done w the operating room after the patient is fully anesthetized and everything is prepared to proceed immediately vvith an open operation Occasionally we have been successful in performing a closed reduction Fig 429 d Anterior duJocation of shoulder which had been undiagnosed and unreduced Seen S’ weelj /ollowinfi tnjuty Careful tJosed redact on was atlempied without sucitss B Good reduct on of shoulder follov ing open operat procedure Pat ent developed about 70 per cent full functional resulo but as a rule this has failed and an operative procedure must be carried out In either instance after reduction it is advisable to fix the humeral head to the glenoid cavity With one or two threaded pins to prevent redislocation m the immediate postreduclion period The extremity is then immobilized m a Velpeau bandage Technic for Operalite Reduction An anterior inasion about 5 inches long is made over the sulcus between the deltoid and the pectoralis major muscles These muscles are separated and retracted to expose the upper end of the humerus and the region over the glenoid cavity If necessary the antenor margin of the deltoid muscle can be cut for a variable distance close to its origin from the clavicle and the pectoralis mayor tendon is divided dose to its insertion, leaving suflliaent attachment for repair The scat tissue and remains of the capsule ate then cleared from the anteromfenor margin of the glenoid cavity and an opening large enough to admit the head is made by sectioning the subscapulatis muscle. After the muscle has been cut reduction is comparabvely easy and the head of the humerus is either levered into the glenoid cavity with a bone skid or manipulated into position 40S DIAGNOSIS AND TREATMENT OE SPtanC JNJURIES A/ter reduction has been accomplished the capsule is repiired with svhato'cr tissue IS left around the margin of the opening the duideil subscjpularis and pecturahs major are sutured the anterior margin of the deltoid muscle is replaced and sutured to the clavicle, and the ^ound ts closed m hjers The stability of the shoulder is tested gently If there is a tendency for redislocation the humeral head is placed m good position and transfixed with a threaded pm which passes into the glenoid cavity Tliis pin is cut off below the skin and is removed m 3 to 4 weeks The arm is then immobilized with a Velpeau dressing and the aftertreatment is the same as for a fresh dislocation except that the physiotherapy must be contmucxl longer Pregnosis Kqsorts in the literature indicate that better results are obtained by the closed method of reduction but this is probably due to the fact that the closed method is usually applied to fairly fresh cases Other things being equal the longer the dislocation has existed before reduction the poorer the result will be In most casts the shoulder will be stable strong and free from pam but limited in jbviuction and rotation Recurrent Dislocation at Shouliler McLaughlin and Cavallaro* reviewed the records of 575 patients with dislocations of the shoulder and selected 101 for mote detailed study Of these 101 patients ’l or 20 7 per cent suffered recurrence of the dislocation Rowet studied 188 patients with dislocations of the shoulder, and of this number 102, or 20 J> per cent, Iml recurrence of the dislocation Recurrences of dislocation are more common in epileptics CflHsej Tlierc ate many factors involved in recurrint dislocation of the shoulder Bankart called attention to iniury to the glenoid labrum and or a detachment of the capsule from the neck of the glenoid and felt (hat these injuries vvere responsible for all recurrent disloations He urged repair of the capsule as a method of curing recurrent dislocation of the shoulder It ts interesting that Gerster ^ m 1B81 mavlt. somewhat similar observations and urged capsular repair in (he treatment of this condition Other workers have ailed attention to the defect in the head of the humerus which is usually on the posterolateral aspec t and have demonstrated how Out in abduction and external rotation this dfiFccTcomes m contact with the lower anterior cvlgc of the glenoid and could easily contribute to disloauon Volkmann Cramer Loebker and Ricbinccr Mueller and others hive discussed the defect m the humeral head It appears that the Bankart defect and the defect m the humeral head are the result of the trauma of dis loation Wlwlhcf the Bankart lesion exists in every anterior dislocation of the slioulder and whether its failure to heal allows recurrent dislocation are difficult to ascertain since this lesion may be produced only with repeated dislocations It would appear that the defect m the humeral head is a compression fracture and probably accompanies the original dislootion Either or both of these lesions do not appear to be adequate to explain the facts concerning recurrent dislocations because both McLauglilm an i Rowe found that dislocations of the shoulder occur just as commonly after the age of 45 as they do before but 90 per cent of recurrent dislocations occur before the age of 15 Therefore although the patient over 15 has the same lesions in the shoulder he is not so prone to develop recurrent Jisloation In addition to tiiesc facts the magnitude of trauma associated with the original dislocation is an impiirfant consideration as to whether a recuttente will develop Patients whose ptinury vtislocation is avsrxaatcd with considerable trauma have less likelihood of a recurrent dislocation Tins is furtlicr attested •M Lauehlin, M L and Cavailaro \IC V Pruiury Anienor PvIv3tK>ni Am J ^uis fl5 1950 1Ro»f C R PiofinoJis m Doiovstm of the Sle a reduced incidence of recurrence Besides the patients who de ^elop compJete recurrent dislocation, there is also a group of patients who ha\e sub- luxations, and, aJthough they usually can reduce this subluxation themselves, it is ac- companied with considerable pain and they have little trust in the use of the arm The pathologic findings in both the complete recurrent dislocations and in subluxations are the same. Trealmetti. The only effective repair or treatment for recurrent dislocation of the shoulder is surgical. Many different operative procedures have been devised and utilizetl m the treatment of this condition The operations usually fall into one of four categories (1) plication or reefing or repair of the /oint capsule, (2) bone block procedures, (3) muscle Of fascial slings, and (4) the tendon suspension operation, sudi as in the Nicola procedure Fig 4}0 Modified Nicola operation for recurrent dislocation of shoulder, showing the tunnel for Jong tendon of biceps brachii muscle through the humems under bfopital groove (From Hobart, M H J Bone a. Joini Surg 15 73% ) NICOLA^ OPERATION. This Operation, which in effect converts the tendon of the long head of the biceps bracbii into a Jigamentuni teres to the humeral head m an effort to maintain it within the glenoid cavity, has a very limited application and should be reserved for the elderly patient who does not expect to take part in strenuous physical activity It IS not sufficiently successful to be us^ m the younger age group A brief description of the operation follows The incision begins at the acromion just lateral to the coracoid process and passes downward for 3 inches The deltoid fibers are scj»tated, care being taken not to injure the atcumflex artery and nerve, which may appear beneath the muscle m the lower part of the incision ♦Nicola, T Recurrent Anlenor DislocatiOQ of Shoulder, New Operation^ J Bone & Joint Surg U 128, 1929 4/0 DIAGNOSIS AND TRl-ATMrNT OF SPEOnC INJUWrs The biopitil groo\c «s located by palpation and the tr 2 ns^'Cfse humeral ligament is divided This inasion is extended upvfard into the shoulder to expose the long tendon of the biceps brachu The elbow is now flexcti and the tendon of the long held of the biceps brachii is divided i/» inch above the tendon of the p'Ctonlis major By means of a quarter inch drill or ^ougc a tunnel is made from a point in the bicipital groove 1 inch distal from the lesser tuberosity to emerge on the articular surface of the head of the humerus in line with the groove and from to indi from the articular margin A flexible probe is then passed through llie tunnel and the proximal part of the cut tendon of the biceps brachii which has been denuded of its synovia! covering is drawn through the tunnel and sutured to its distal part The arm is then abducted to *> 0 ° the transverse humeral ligament is sutured to the tendon the wound is closed and the ann IS inunobilized in a Velpeau bandage for 2 weeivS after which it is placed in a shni; and exercises arc started to restore function (Fig 430) pum PLATT AND BANKART OPERATIONS Thcsc procedures aim at restoring the integrity of the anterior capsule or at reattaching the labrum or apsule to the glenoid nm Fither of these operative procedures seems to be quite successful Although wc have used both to a small series of cases, to date wc have not had a failure The Putti Platt procedure is attractive m that technicall) it is not quite so diflicult to perform as the BanXart operation Experiences at the blassachusctts General Hospital as reported bj Rowe* indicate that there is a recurrence rate of I to 5 per cent after the Bankart pro- cedure and of approximate!) 20 pec cent after the Putti Platt procetiure Technics of Operations The front of the shoulder is exposed by a Jong curved in cision which begins over the outer end of the clavicle curves vnwaril over the coracoid process and then downward and outnurd to the region of the deltoid insertion Tlic deltoid muscle is separated from the pcctoralis muscle and retracted outward its origin being severed from the clavicle for an inch or more The cephalic vein lies between the two muscles and if injured during the exposure should be ligated The coracobraciiialis and the short head of the biceps brach i are detached from the coraaiid process either by sharp dissection Icav ing the pectotalis tmnor attached or by division of the coracoid process and reflection of all three muscles As thc-se muscles arc turned down care must be taken to avoid injur) to the musculocutaneous nerve Blunt dissection then exposes the subscapularis muscle and tendon In the Bankart procedure the shoulder is rotatevl outward and the subscapularis tendon is divided after ligating the plexus of veins which identify its lower border and sejviraling it from the capsule with a blunt dissector The mesial portion of the tcndin IS secured with heavy silk sutures and permitted to retract The capsule i« incised about inch lateral to the glenoid nm The margin of the glenoid cavity is scanficvl and holes are made in the nm with a dental drill or heavy towel clip and the lateral segment of the capsule including the Jabnim which is usually drtached is sutured to the margin of the glenoid Then the capsule is rcpiired and the subsapulans is brought out to overlap its original insertion thus shortening this muscle The subscapularis and coracoid process are then repaired and tlie wcHind is closed and immobilized in a Velpeau bandvge fin 3 or 4 weeks after which exercises arc started in an clloit to restore function In the Putti Platt procedure the subscapularis tendon and capsule are incised vertically about an inch or more mesial to the attachment of the tendon to the humerus The lorn capsule or hbrum is then lifted forward to expose the glenoid nm and anterior surface of the neck of the sapuia and llicse are scarified The lateral portions of the subscapularis tendon and capsule are then sutured to the soft tissues in front of the •Rime C R Pmenosit in Didooiicmof the M>oulJff J IVncA Jo nf Surp vrA 9>’ l9iC INJURIES IN RIGION OF SHOULDER GIRDLE AND SHOULDER 4ll glenoid iim (the deep surface of the subscapulacis muscle), no attempt being made to suture them to the bone The mesial portion of the tendon -which has been secured with silk sutures is then pulled outward and sutured to the lateral portion near its insertion, thus shortening and thickening the antenor capsule and subscapularis tendon and stimulating the production of a heavy scar in this area When the operation is finished, abduction is quite limited, but within a fe^ months it is usually normal or almost normal if the patient has been faithful in exercising the ami PostopcratiNclj the extremity is immobilized m a Velpeau dressing for 4 vieeks and then a sling for 2 weeks, after which time exercises m abduction and external rotation ate started Accino and Lieberman, in personal correspondence and communications, report several cases of chronic disloations at the shoulder in which the patients fullj recovered after excision of the acromion process They stale that, accepting the facts of the primary traumatic etiology of the original dislocation and the patholog} found at surger), it was at the same time their thought that the old idea of the acromion acting as a lev er to throw the humerus out of joint might be valid They emphasize that in radiographs of the dog, in which dislocations of the front quarters ts a rare occurrence there is no evidence of an acromion process FRACTURrs or UPPER END OF HUMERUS Ciassificaiiou In surgical literature the upper end of the humerus is that part of the bone which is proximal to the insertions of the teres major and Jatissimus dorsi muscles It includes a constricted portion of the shaft (the surgical neck), the tuberosi ties, the anatomic neck, and the head It is usual to classify fractures which occur in this region as follows (I) fracture of the surgical neck, (2) fracture of the anatomic neck, (3) separation of the upper humeral epiphysis, (<1) fracture of the greater tuberosity, (5) fracture of the lesser tuberosity, and (6) fractures of the head In practice we are not able to make a sharp distinction between fractures of the anatomic and surgical necks but find that fractures through the cancellous region of the bone may involve the anatomic neck the surgical neck, and the tuberosities Furthermore, the treatment of fractures of the surgical neck and fractures of the anatomic neck is idential Whether the fracture is impacted does, however make considerable difference m the treatment Consequently we shall use the following classification (1) complete fractures of the upper end of the humerus, (2) impacted fractures of the upper end of the humerus, (3) fractures of the head of the humerus, (4) fractures of the greater tuberoJif)', 0) fesiXures of the lessee tubeeosity. and (6) sepseatioa of the upper epiphysis of the humerus Complete Fractures of Upper Eud of Humerus Occurrence and Cause Complete fractures through the upper end of the humerus include fractures of the surgical neck of the humerus They are rather unusual m chil dren, m whom the usual lesion m this area is an epiphyseal separation, but they are frequent m adults of all ages and of both sexes They may be produced by direct violence, such as a blow or fall on the shoulder or upper arm, but they are more often caused by indirect violence, such as a fall upon the outstretched hand Pathology The fracture line tends to be roughly transverse and rather irregular in character It may lie completely in the compact bone of the surgical neck or in the can cellous bone of the anatomic neck and tuberosities, or it may occupy the transition zone between the compact and cancellous bone Not infrequently the fracture line is deeply serrated or oblique and involves both regions, and m many cases the bone is com minuted, witlv the separation of one or more relatively large fragments In children the fracture may be subperiosteal or incomplete Displacement. Occasionally, even without definite impaction, the bone ends remain 412 DWGNOSJS AND "nirATMENT Of SPEOFIC INJURIES in contact and there is relatnelj little dispUiwnent, but in the majonfj of instances there is a characteristic displacement The proximal fragment is abducted and tends to lie externally rotated mth some fomard flexion (Fig 431 ) Abduction of the proximal fragment is due to the posterior scapular muscles, especially the supraspmatos Those muscles suhich ace attached to the greater tuberosity also tend to rotate the upper fragment outnard but this force is parti) neutralized by the subscapularis, nhich is a strong internal rotator, so that only moderate outward rotation of the upper fragment occurs The upward displacement of the distal fragment is due to the fiactuiinc force i^nd to the pull of the muscles which cross the fracture line (deltoid biceps brachu triceps brachii, and coracobrachialis) The inward displacement of the distal fragment is due to the pectorahs major latissimus dorsi and teres major The anterior displacement of this fragment is largely due to the pectoralis major, short head of the breps, and coraco' brachialis muscles Vig Forrw causing displacement in fractures of humerus abo»e iniertiim o( pectoralis mainf (From Griswold R A Goldberg It and Joplin R Am J Surg 43 31 t?39 ) The position of the lower fragment as regards rotation is independent of muscle pull and depends upon gravity Coosecyucntlj it w inconstant In tare instances a con tinuation of the fracturing force may displace the distal fragment baclvwwrd or even out ward and it may remain in the unusual location Diagtiosss rollowmg the injury there is complete disability of the extremit) and the arm, unless supported hangs useless at the side or may be twisted in an abnormal manner There is a variable amount of local pain and swelling The swelling tends to in crease rather rapidly and maj involve the entire arm and shoulder region Ecclijmosis usually appears on the front and inner side of the arm within 24 hours md nuy be very extensive, even involving the forearm On inspection the contour of the shoulder is normal, but the swollen upper arm appears to be shortened and displaced inward, and the outer surface of the deltoid muscle may bt flattened or even conovc m its middle and lower portion Tlic anterior axillary fold is deepened and distorted and there is a slight prominence on llic front of the shoulder which is most evident when vicwetl from the side TJic above signs arc not so prominent in the cases without displacement On palpation there is acute point tenderness over the ends of both fragments an I INJURIES IN REGION Of SHOUtOER GIRDLE AND SHOULDER 413 the rough proximal end of the distal fragment may be felt in the anterior axillarj region lateral to the coracoid process Deep palpation of the outer border of the deltoid muscle may reveal the end of the abducted proximal fragment Measurement of the distance from the tip of the acromion to the external epicondyle of the humerus sshen compared with that on the other side smU resell the amount of shortening or uprvard displacement of the loner fngmsnt On manipulation it will be found that the head of the humerus does not mose when the shaft is rotated, and there may or may not be crepitus Abnormal mobility can be demonstrated by grasping the upper end of the humerus mth one hand and gently mosing the loner end from side to side or telescoping it (alternately pushing it up and pulling it down) The diagnosis should be confirmed by x ray examination and m most instances lateral as we!! as anteroposterior views should be made The lateral new of the upper r»g *152 Methcxl of reduction under local anesthesia Palient sits upright on chair or stool A folded towel is placed o>cr flexed forearm at elbow Traction is secured on arm bj' stepping in muslin sling and gradually bearing more and more weight on fling Both hands of surgeon are left ft*e Ip xnaiijpuJate central end of distal fragment Assistant holds patients fonami fle»ed to 90* at elbow and at same time aids in maintaining patients upright position aijttnst traction being exerted on forearm If surgeon places toe of his foot beneath rung of stool and dorsiflexes foot v.hile gradually bearing more weight on sling the procedure is a steady well controlled pcogres sively increasing traction (From Howard N 3 su'd Eloesser L J tone &. Joint Surg 16 1 1934 ) end of the humerus can be obtained by abducting the arm, placing the cassette on top of the shoulder, and directing the lays upward through the axilla, or better through the chest wall with the arm at the side Complications Gjinplicahons associated with fractures in this region are (1) dis location of the head, (2) vascular injury, (J) nerve injury, and (4) open fracture Management of fractures of the upper end of the humerus assoaated with dislocations has been discussed previously llie brachial artery and/or sein may be damaged bj the fractate, depending upon the force applied and its duration at the time of injuf) U there is a laceration of the brachial artery, it should be repaired The fracture in such ofcumstances must almost always be stabilized intemalJ} Nerse injury assoaated with 412 DIACNOqS AND TBEATVtCNT or SPEOFIC INJUBIES in contact and thcfc i5 relatively little displacnnent, but in the nujofitj of instances there is a characteristic displacement The proximal fragment is abducted and tends to beexternaJIj rotated siith some forward flexion (Fig 431) Abduction of the proximal fragment is due to the posterior sapular muscles especially the supraspinatus Those muscles which are attached to the greater tuberosit) also tend to rotate the upper fragment outward but this force is partly neutralized b) the subscapularis which is a strong internal rotator so that only moderate outward rotation of the upper fragment occurs The upward displacement of the distal fragment is due to the fracturing force and to the pull of the muscles which cross the fracture 1 ne (deltoid beeps brachit triceps brachii and coracobrachiahs) The inward displacement of the distal fragment is due to the pectoralis major latissimus dorsi and teres major The anterior displacement of this fragment is largely due to the pectoralis major short head of the breps and coraco- brachialis muscles Fj? 431 Forces caul ng d jplaccinent in fiactum of hiunervi above uwert on of peaoral % major (From Gni»oId R. A Goldberg H and JopI n R Am J Suig 43 51 1939 ) The position of the lower fragment as regards rotation is independent of muscle pull and depends upon gravity Conseipientl) it is inconstant In rare instances a con tmuation of the fracturing force may displace the distal fragment backward or even out ward and it may remain in the unusual locition Diagnosis Following the injury there is complete disability of the octrem tj and the arm unless supported hangs useless at th“ side or maj be twisted in an abnormal manner There is a variable amount of local pain and swelling The swelling tends to m CTease rather rapidly and nuy involve the entire arm and shoulder region Ecchjmosis usually appears on the front and inner side of the arm within 24 hours and may be very extensive even involving the forearm On inspection the contour of the shoulder is normal but the swollen upper arm appears to be shortened and displaced inward and the outer surface of the deltoid muscle may be flattened or even concave m its middle and lower portion The anterior axillary fold is deepened and distorted, and there is a slight prominence on the front of the shoulder which is most evident wh“it viewed from the s de The above sgns arc not so prominent m the cases without displacement On palpation there is acute point tenderness over the ends 0 / both fragments and INJURirS IN RIGION OF SHOUttlLR CIRDLH AND SHOULDER 4i5 these fractures js reasonably unconunon but should always be carefully looked for prjor to the institution of therapy Nenc injuries assoaated with closed fractures should not be explored as long as the fracture can be treated closed since complete severance of the nerve m such circumstances is unusually rare Open fractures m this area are not common, and when the> do occur, the same pnnciples apply as m any other open fracture 'E'ipcntnce ruth the hanging cast as wtroduced by Caldwell* has con vmced us that Howard and Eloesserf are correct in their statement that the fracture should be reduced and immobilized with the ann at the side and contrary to the opinions expressed m former editions wc now rarely use the abduction plaster cast or treat these fractures by lateral traction Displaced fractures m this area are treated by closed reduction using either local or general anesthesia and by the method described by Howard and Elocsser, or a modification of this method applied with the patient lying on bis back and traction and manipulation carried out with th** arm at the side Tg Fracture of Surgical neck of humerus reduced by closed manipulaUcn and hanmng cast QfVijL After a satisfactory reduction has been obtained a hanging cast is applied Fractures in children are usually either epiphyseal separations or the fracture line is somewhat lower m the shaft than that in adults Because of the type of fracture and also of the lack of cooperation in children a banging cast docs not work as well as it does in adults Therefore after reduction these fractures are usually best managed in an abduction shoulder spica. In adults if reduction has been obtained with the arm at the side, it will usually be stable and thus allow early actisc exercise of a pendulous or arcumduction type in the shoulder We do not like to start excKise however, until after 7 to 10 days because m the early period there is too much pam We find that the free exerase of the shoulder which this method permits more than compensates for the possible loss m ab duction which we feared when we abandoned the abduction treatment of these fractures and the patients are much happier and regain the use of their arms sooner than with the •Caldwell J A Treatment of Fractures ui Ontinnati General Hospital Ann Surg f>7 151 1933 fHoward N and Elocsser L. Ticatineot of Fractures of Upper End of Humerus Ex penmental and Clinical Study J Cone & Jo nt Surg l6 I 193d INJURIES IN REGION OF SHOULDER GIROLF AND SHOULDER 415 these fractures is reasonabi) uncommon but diould always be carefully looked for prior to the institution of therapy Ner\e mjunes issoaated with closed fractures should not be explored as long as the fracture can be treated closed, since complete se\erance of the ner\e m such circumstances is unusually rare Open fractures m this area are not common, and, when they do occur the same principles apply as in any other open fracture Treatment Experience with the hanging cast as introduced by Caldwell* has con vmced us that Howard and Eloesserf are correct in their statement that the fracture should be reduced and immobilized with the arm at the side and, contrary to the opinions expressed m former editions we now rarely use the abduction plaster cast or treat these fractures by lateral traction Displaced fractures m this area are treated by closed reduction using either local or general anesthesia and by the method described by Howard and Eloesser, or a modification of this method applied with the patient lying on his back and traction and manipulation carried out with th" arm at the side Ttg 4}1 Fracture of jur^ica! neck of humerus reduced ty clewed mmipulalion and han^m^ cast Good functional result obtained After a satisfactory reduction has been obtained a hanging cast is applied fractures m children are usually either epiphyseal separations or the fracture line is somewhat lower in the shaft than that in adults Because of the type of fracture and also of the lack of cooperation in children a hanging cast does not work as well as it does m adults Therefore, after reduction these fractures are usually best managed in an abduction shoulder spica In adults if reduction has been obtained with the arm at the side, it will usually be stable and thus allow early active exercise of a pendulous or arcumduction type in the shoulder We do not like to start exerase, however, until after 7 to 10 days because m the early period there is too much pain We find that the free exerase of the shoulder which this method permits more than compensates for the possible loss in ab duction which we feared when wc abandoned the abduction treatment of these fractures, and the patients are much happier and regain the use of their arms sooner than with the •Caldwell J A Treatment of Fractures m Cincinnati Geoeral Hospital Ann Sure 97 161, 1933 tHoward N and Eloesser L Treatment of Fractures of Upper End of Humerus Ex pertmenial and Clinical Study J Bone Re Joint Suig 16 1 1934 INJUJUES IN ECGION OF SHOI/IJJCR GfRnLC AND SKOULDFR 417 older methods Occasionally a satisfactorj posibon cannot be obtained by the use of this method and open reduction and internal fixation will be required HANGiNO CAST METHOD After the fracture has been reduced the elbow is flexed to 90®, and with the forearm in mid position between pronation and supination a plaster of Pans cast is applied from the upper arm to the wnst or base of the fingers It Fig Fracture of proxiaiat |*o« on of shaft of humeros with mi ked d splacemeot Treated bj* closed rrunipulatit'e redoct a aad shoulder spea » ith arm n 45 abducton Good mult Fig 4J7 a Fracture through sutgeal neck of humerus with marked d srUcement Closed manpulative reduct on fa led B Open reduct on and internal hxat on hy intrameduirary na Is wh ch were cut off below the skin Excellent reduct on good union and noniial fun t on IS applied over a moderate amount of padduig and the weight of the cast cartes with the musculature of the patient that is light casts are used for weak muscles and heavy casts for patients w ith strong muscles After the plaster has set the forearm is supported across the lower chest by a sling which IS passed through the loop constructed m the cast at the wrist, thus 4iS DIAGNOSIS AND TREATMtNT OF SPtanC INJURIES (unclonai mutt SI ghl defonii ty shovkn n C Norn al /unc INJURIES IN RLCtON OF SHOULDER GIRDLE AND SHOULDER 419 permitting the weight of the cast and the extremity to maintain reduction of the frac ture In fractures with little or no displacement the hanging cast is applied without anesthesia REDUCTION If complete displacement is present and the fragments are not badij cormnmuted, reduction under loal or general anesthesia is adsisable If comminution IS present, the traction of the cast maj be depended upon to effect reduction When satisfactory anesthesia has been obtained, the elbow is flexed to 90®> and With the forearm supmaled slow stead) traction is made m line with the shaft of the humerus until the fragments have slipped b) one another During this maneu\er the long head of the biceps brachit tends to pull the distal end of the proximal fragment down to the side It may be necessary to make countcrtraction by means of a band in the axilla, and to abduct the arm and flex it forward When the distal iragm^nt has been pulled down beyond the proximal one, its proximal end can be pulled or levered outward and backward until it is in line with the proximal fragment, and when the traction is released the two will engage This manipulation may be performed by the method of Cotton and Morrison, who use the surgeon s forearm as a fulcrum as follows With the patient recumbent the surgeon places bis foiearm in the patients axiJJa with his hand resting on the table The assistant maintains the traction and swings the atm inward across the chest while the surgeon presses the proximal end of the distal fragment outward and backward with his forearm Another method is for the surgeon to grasp the patient s upper extremity with both hands so that his thumbs rest on the outer surface over the tuberosity and his fingers on the axillary surface As the traction pulls the distal fragment down the surgeon pulls or squeetes the proximal end outw'ard or backxvafd until it is I'n line with the proximal fragment As the traction is decreased, the fragments are engaged and their stability is tested by pushing upward on the elbow The hanging cast is then applied and suspended across the body by a slmg which supports it at the wrist Although in many instances a hanging cast not only will be adequate for immobilization but also may effect satisfactory reduction, we wish to emphasize that displaced fractures should ^ treated by closed reduction followed by the hanging cast for maintenance of position Aflerheaimeut The patient is instructed to remain upright as much as possible and to let the arm hang from the shoulder He is cautioned not to rest the elbow on the arm of the chair while sitting During the night he shoufd sfeep propped up in bed in a semirccJming position or, if he remains in bed, a weight of about 5 pounds should be fastened to the cast at the elbow and hung over the foot of the bed for traction The slmg IS so adjusted that the forearm is hoorontal ABDUCTION, TractUfcs of the upper end of the humerus m children and occasional long oblique or spiral fractures in adults are best immobilized in a plaster shoulder spica This may readily be applied after reduction without a speaal fracture table (Figs 439 and 440) LATERAL TRACTION Lateral traction is used for those fractures whidi cannot be satisfactorily reduced or in which the fragments tend to slip after adequate reduction Of m those patients with other injunes whidi prevent the patient from being ambulatory Either skeletal or skin traction may be used, d^ending upon the condition of the skin The amount of weight vanes directly with the musculature of the patient The arm is placed m about 45° of abduction, the angle being determined by the position of the upj>er iragment Traction is maintained for from 3 to 4 weeks Then the pati«it can usually be gotten up and the fracture treated in a hinging cast foe front 2 to 4 weeks or until union is firm The position of the fragmenls should be diecked at the end of 43 hours by means Fig (II /f Cloicd d splaceU epiplnjeaJ scpawtj n of upper homeml epiplivjis ^ R«ultj S’ fjr as union is concerned following, closed imoipulame mlucfion and fixation at sl» uMer \oittained When the fracture is treated with a hanging cast and the patient has exercised the shoulder daily there is little danger of stiffness in this joint unless the fracture tnvolxes the joint IvipactedTractures of Upper End of Humerus Impacted fractures through the uppei end of the humerus tend to occur m patients beyond middle life but thej may occur m adults of any age and are scry rare in chil dren Thej are largely the fractures w-hich are usually classified as those of the anatomic neck Most of them are the result of indirect violence caused bj a fall on the elbow- or outstretched hind the force being (ransm tted upward through the shaft of the humerus The fracture usually occurs in the transition zone between the compact and cancellous bone and a continuation of the force drives the end of the compact bone up into the cancellous portion The fracture line tends to be roughly transverse oc slightlj oblique beginning on the inner side near or m (he anatom c neck and passing outward through the tuberosity In rare instances the fracture may followr the ) ne of the anatomic neck Ordinarily w ith the impaction there is a slight adduction deformity Dugttous The diagnosis of these fractures is not so easily made as m those with out impaction and miy be impossible in the absence of a roentgenogram There is a history of an injury follow-ed by severe pain and disabil ty in the shoulder with local tenderness which is rather general over the upper end of the humerus The swelling is relatively slight and there may be a slight flattening of the deltoid muscle Fcchymosis app-ars withm a few days usually down the side of the atm over the biceps brachii and all motions of the shoulder are lim ted and painful especially abduction and rotation but there is little demonstrable shortening no perceptible deform ty and no false motion \XTien the shaft of the humerus is mov^ the head tends to move with it Pressure transmitted through the long axis of the humerus by pushing upward on the elbow- tends to cause pain in the region of the shoulder The diagnosis is made the presence of a raUier severe injury to the shoulder with the signs of a fracture and by excluding fractures of the clavicle scapula an 1 the com plete fractures through the upper end of the humerus without impaction \ ray Lxammatton Diagnosis should always be confirmed by an x ray cxamina tion and it is to be pointed out that even m a good roentgenogram the fracture line may not be obvious In fact, it may not be visible and it may be necessary to take a roentgenogrim of the opposite shoulder and make the d agnosis on the basis of a slight d stortion of the upper end of the humerus In add tion to the routine view in the anteroposterior plane a lateral view of the humerus should be mule as the lower frag ment is often displaced anteriorly This view is easily obtained by abducting the arm placing the cassette on top of the shoulder and directing the rays upward through the axilla or through the body with the arm at the side Ireatme/il Tlie treatment to be instituted depends to a considerable extent upon the age physique and temperament of the patient and the am >unt of deformity If the patent is a comparatively young or middle aged adult with the expectation of INJURIES IN REGION OF SMOULDER GIRDLE AND SHOULDER 425 many jeats of acti\e life and if there «s considerable deformity, the surgeon should break up the impaction and treat the fracture as described m the preceding section on complete fractures of the upper end of the humerus If the patient is aged and debilitated, eien in the presence of considerable deformttj, no attempt should be made to break, up the impaction, but the fracture should be treated by simple immobilization with a hanging cast If the patient is a joung or middle aged adult m apparently good health and there is little or no demonstrable deformity the fracture should be treated with a hanging cast and exercises Tig 443 >4, fracture through surgical neck of humerus m good rosiiion Treated hy hanging cast with good result as shovn in B Vractures of Head of Humerm Fractures of the head of the humenis alone and not associated with other fractures of the humerus are very rare m/uries because the head of the humerus is much denser than the surrounding bone Fractures may be cauwd by indirect violence, such as a fall on the hand or elbow, or the force may be transmitted through the tuberosity from a blow or fall on the shoulder Occasionally they occur in the presence of a dislocabon In the mam, the fractures of the head are of two types A small piece of the head may be chipped off and remain loose in the joint, or in extensi\e comminuted fractures of the upper end of the humerus the head may be split into two or more fragments If a small piece is broken off, the arm should simply be immobilued m a sling and active and passive motion should be begun early If the fragment giies trouble such as locking or pain m the joint, it should be removed by simple arthrotomy which can be performed through the anterior route Extensive comminuted fractures with fragmentation of the bead are serious injuries and offer a poor prognosis with regard to function These fractures arc usually best treated in a hanging cast However, if displacement of the fragments is great, open re duction may be advisable At operation, whidi is best done from 7 to 10 days after the injury, the fragments should be loosened, anatomic reduction obtained, and, if necessary, small drill holes made m their extra articular portions and they should be sutured or pegged together Separated fragments which cannot be immobilized m ap proximately their normal position should be excised Postoperative fixation will depend on the stability obtained If possible a hanging cast « preferred 424 DIAGNOSIS AND TRCATMCNT OF SPraFIC INJURILS Fractures of Greater Tuberosity fractures of the greater tuberosity may accompan) dislocation of the shoulder or may occur as isolated injuries from direct \iolence such as a blow upon the shoulder from compression by the acromion in hyperabduction injuries or rarely by muscular action The tuberosity maj be torn off broXen across mashed in or a small diip may be pulled off As a rule there is little tendency to displacement of the fragments Very rarely a large fragment may be torn off and pulled up under the acromion Fig 445 A Subglenoid d skKauon of shoulder 'Mth dispUtenent of greitec tuberosity of humerus B Encellent posit on follow ng closed reJoct on Ann strapped lo cJ est for 3 w eeks after which motion was started Cxcetlcni anatomic and functioiul results m 3 months Diagnosis There is a history of an injury with acute tenderness and swilling o\ct tlic Literal surface of the shoulder and especially around the greater tuberositj Passne moicments of the shoulder espccialty satemal totatiort aggraMtc the pain and there ts total inability to abduct or rotate the arm eatemaHy In some cases slight crepitus may INJURIES IN REGION Or SHOULDER GIRDLE AND SHOULDER 42S be obtained on passive abduction or rotation of the arm, and in rare instances a /arge fragment -fthich is completely separated may be palpable and movable Upward pressure on the elbow demonstrates the fact that the shaft of the humerus is intact The diagnosis should be confirmed by x ray examination (Fig 444) Treatmeut. Treatment depends upon the si 2 c of the fragment and the degree of displacement If the fragment is relatively large and so displaced that it interferes with movement of the shoulder, it is exposed through a short vertical anterolateral incision through the proximal portion of the deltoid muscle, reduced, and fastened with a screw Of nail Otherwise the fracture is reduced and the arm is immobilized in a position that affords stability to the fracture (Fig 445) fig 4i6 Closed fracture of greater tuberosity of liumerus Good position Treated ■with strapping at shoulder loint for 10 ia\s and active and ^sive motion and exercise daily there after Excellent functional results Fracture of Greater Tuberosity With Dislocation of Shoulder When the shoulder is dislocated anteriorly or down'^ard, it is imperative that the arm be immobilized m a position of adduction because recurrence of the dislocation tends to occur if a position of abduction is used for immobilization When fracture of the greater tuberosity accompanies dislocation, die fragment of the tuberosity will usually settle back into place and offer little obstruction to the restoration of function following reduction If it remains widely separated, it should be exposed and replaced by open opetahon and fixed w ith a screw or navi Fractures of Lesser Tuberosity Fracture of the lesser tuberosity is a rare injury as an isolated lesion but miy result from forcible external rotation of the arm or violent contraction of the subscapularis muscle The symptoms are inabihlj to rotate the arm internally and localized pain, which IS aggravated when active adduction or internal rotation arc attempted The patient tends to support the arm m a position of internal rotation and adduction, there is moderate 426 DIAGNOSIS AND TREATMENT OF SPEaFIC INJURIES s'Relling and tenderness o%er the anteiiot and inner portion of the upper end of the humerus and it ma) be possible to palpate the detached fragment in the subcoracoid region More frequently the injury occurs in connection with dislocation of the shoulder or extensive comminuted fractures of the upper end of the humerus Treatment As the subscapulans muscle is inserted into the lesser tuberosity and as the action of this muscle is to rotate internally and adduct the arm treatment should be immobilization of the arm in a position of adduction and internal rotation This is best accomplished by placing the hand on die affected side on the opposite shoulder and immobilizing the atm in this position Tvith adhesive and bandages for a period of about 3 weeks At the end of this time the arm can be carried in a sling for 2 weeks longer and then use can be gradually resumed No special exercises are necessary and a normal shoulder is to be expected When the injury occurs in connection with disloca tion of the shoulder or comminuted fmeture of the upper end of the humerus the fracture of the lesser tuberosity may be ignore! and the shoulder dislocation or humerus fracture treated as described m the section on dislocation of the shoulder It will be found that the fracture of the lesser tuberosity wdl not increase the disability inadent to the accompanying grave injury Separation oj XJpper Eptphysis of The upper end of the humerus develops from thtee centeis of ossification — one for each tuberos ty and one for the head These unite at about the seventh year to form a caplike mass of bone which surmounts the conical end of the diaphysis In its inner half the epiphyseal line follows the line of the anatomic neck to about the middle of the bone and then passes outward and downward to the lower border of the greater tuberosity Ossification is completed at about the twenty fifth year but epiphyseal separations of the upper end of the humerus have not been recorded after the twentieth year Occurrence and Cause Separation of the upper epiphysis is probably the most frequent injury to the upper end of the humerus in children espeaally between the ages of 4 and 14 years It may result from indirect violence such as a fall upon the elbow or outstretched hand the force being transmitted upward through the shaft of the humerus or it may result from direct violence such as a fall or blow on the outer surface of the shoulder Occasionally the injury results from forcible abduction or outward rota tion of the arm with traction Displacement The epiphysis may simply be loosened and practically no d splace ment may occur or the shaft may be completely sq^arated and displaced upward as in the complete fractures through the upper end of the humerus described previously When this occurs there tends to be abduction and external rotation of the upper frag ment, and the diiphysis tends to be drawn upward forward and inward just as occurs in fractures through tlie upper end of the humerus In other instances the displacement IS incomplete that is the diaphysts is only partly displaced Usually in cases with separation tJiere is more or less stripping of the periosteum of the shaft but this being unusually tough in children fends not to be completely ruptured and so binds the fragments together and may render nduction by traction relatively difficult In older children a portion of the upper end of the shaft is often split off with the epiphysis and occasionally the upper end of the shaft is dmen into the epiphysis and impacted Diagnosis In cases without displacement tht diagnosis rests upon the history of the injury the age of tht patient and the swilling IcnUrness disability and local pain In such instances the x ray film may show a slight displacement or may be completely negative Jn displacement the upper end of the shaft tends to project anteriorly and ause a prominence under the anterior portion of the deltoid muscle which is usiully INJURIES IN REGION OF SHOULDER GIRDLE AND SHOULDER 427 pilpable and may even be visible head of the bone can be pJpated in its normal position m the glenoid cavilj With complete displacement the diaphysis is pulled upward and inward and causes a prominence in the front of the axilla near the coracoid process whicli can be palpated and even seen The arm is shortened, the axis of the humerus is altered, the anterior axillary fold is distorted, false motion is demonstrable, and the head of the humerus Fig 447 Closed, complete separation of upper humeral epiphysis Closed manipulation and traction failed to obtain reduction Treated by open reduction and immobilization in plaster cast with arm m 45* abduction at shoulder with po^ result Fip 448 Fiucture through upper portion of humerus in a child Treated by closed reduction plaster jpica cast 5 weeks and siing 2 wedcs Good result in 3 months can be palpated in normal position In doubtful cases with slight displacement, diagnosis can be confirmed by x ni) films taken in both the anteroposterior and lateral directions Treaime»t As stated previous!), in children the hanging cast does not work as vvell following reduction as does immobilization m a shoulder spica In older children it maj 428 PIACNOSIS AND TREATMENT Of iPEaFIC INJURIES work quite well but m either group disphcement ts reduced b> manipulation under anesthesia which m children will usually ht\e to be general anesthesia After reduction has been obtained the upper extremity js immobilized in the degree of abduction that affords stability of the fracture by a plaster shoulder spica E\en with widely displaced fractures closed raanipuIatiNC reduction is usually successful and esen though the alignment mayxary somewhat growth can usually be relied upon to correct the position Very rarely in an older adolescent there may be an indication for an open reduction and internal ffication but this will seldom be required the surgeon •uniimtands the anatomy and the methamsms of injury and reduction BURSITIS AND PERIARTHRITIS OF SHOULDER In addition to fractures and dislocations m the region of the shoulder we are confronted with a large group of cases which we find impossible to diagnose accurately or classify satisfactorily All the industrial and insurance surgeons ace familiar with these cases, and most of them are quite wary of them because they may be lery discouraging from the standpoint of treatment These lesions are lanously classed as periarthritis of the shoulder subdeltoid bursitis subacromial bursitis sprain fractures of the acromion rupture of the supra spinatus tendon etc The patient usually 40 or more years of age suffers an injury to the shoulder This injury may be a direct contusion as from a blow or fall on the shoulder or it may be an indirect trauma from a fall on the hand or wrenching or strain of the shoulder In many cases the injury is apparently trivial but the shoulder remains sore stiff and pa nful and the pain may be referred down the arm even to the fingers In others and these are in the majority the pain and stiffness develop without any injury On physial exam nation there is little or no swelling and no disturbance of the bony landnucks In a chronic case there is atrophy of the muscles of the shoulder There is a variable amount of tenderness to de^ pressure which vanes greatly in loca tion The most frequent site of tenderness is below the anterior margin of the acrom on over the subacromial bursa and tuberosity of the humerus In some cases the tenderness IS posterior and below the margin of the auomton in others it is around or even on top of the acromion and again it may be over the coracoid process In cases in which there is a localized calcium deposit the tenderness is usually localized over this depos t and It may be v ery acute or only moderate in degree Motion of the shoulder m the anteroposterior plane is generally free and painless but abduction internal rotation and external rotation are limited and painful The roentgenogram should be taken in the anteroposterior plane with the humerus m internal and then m external rotation There may be a deposit of calcium Usually this is above the greater tuberosity but may be elsewhere because whereas it usually occurs in the supraspirutus tendon it may ocoit m any of the tendons around the joint If the condition is of long standing, there will be a variable amount of atrophy of the bones Treatment The most important factor in the treatment of these patients is for the surgeon to bear tn mind the fact that a great many patients who have had no injury to the shoulder develop a practially identical tram of symptoms Consequently in our treatment of a similar condition following an injury to the shoulder we must not I m t our efforts to the local condition but must treat the patient as a whole Locally «e put the shoulder at rest and apply local heat or cold Rest may be ob- tained by an axillary pvd swathe and sling Heal may be applied by means of hot fomentations a hot water bag an electric pad infrared lamp diathermy or any other convenient method In many patients heal aggravates the pain They are best treated with an ICC bag INJURIES IN REGION Of SHOULDER GIRDLE AND SMOVLDFR 429 After the acute pain has substc!ed the sling is continued as are the other measures but the swathe is remo\ed and abdui^oa and rotation exerases are gisen to restore moN'ement in the shoulder Those patients who fail to obtain satisfactory relief of pain and return of function of the shoulder in a reasonable period of time with the abo^e consersatne treatments will often benefit by the injection of one of the steroids into the tender area of the shoulder capsule In the acute cases in which there is x ray evidence of a calafied tendinitis, we ha%e found that breaking up a portion of the alcified deposit and wash mg out much of it with a Nmocain solution will frequently gne dramatic relief At times the surgeon docs not strike the calcium deposit with the needle These patients usually have an aoite exacerbation of sy-mptoms If we add to this procedure which was described by Patterson ♦ the injection of hydrocortisone or other steroids m and about the involved area relief is somewhat more assured In the acute and chronic cases with out calafication the steroids have not been very effective Many of these patients obtain benefit from deep x ray therapy both m the acute and the chronic states The dose that is usually given is from 75 to 100 r two or three times a week for four treatments and maximum benefit may be expected 1 week after the last treatment Operatiie Treatment Not infrequently before steroids were developed and very rarely at the present time a ptient will have so much pain from an acute calafied tendinitis that it cannot be controlled with either cortisone and/or x ray therapy Under these circumstances sufgtal intervention may be necessary If so it may be performed m the following manner An inasion 2 or 3 inches long is made downward from the anterolateral border of the acromion and the fibers of the deltoid muscle are separated to expose the anterior wall of the bursa This may or may not be thickened The muscle fibers are separated from It and as mudi of the anterior wall as can be exposed is excised Care is taken not to extend the masion far enough downward to cut the circumflex ner\e After the anterior wall is removed any calafied material in the bursa or in blisters m the floor of the bursa is evacuated Granulation ussue or necrotic tissue in the fibrous floor of the bursa is excised The humerus is rotated inward and outward and any adhesions are broken up The wound is sprinkled with sulfonamide powder and the skin and sub cutaneous tissue are dosed with silk Swinging exerases are started within a few days The procedure will usually relieve the pain It is not possible to remove all of the cal aum deposits without extensive damage to the rotator cuff and no effort should be made to do so In the subacute and dironic cases surgery has no place As an aftermath of the mfiammatory condition there may be a great deal of restriction of mot on of the shoulder and if this is associated with continued pain it may be advisable to attempt to speed up the pabents convalescence with a manipulation under anesthesia plus the injection of hydrocortisone following the manipulation Manipulation m these cases of so-called froaen shoulder should be undertaken with much caution The upper end of the humerus has been weakened by the inflammation and disuse In add bon many of the chronic cases with restriction of shoulder motion of sufficient severity to warrant a manipulation occur in the older age group usually m women and here again the bone may be very delicate Forceful manipulation in either group may result in fracture of the humerus If the manipulation is earned out gontly one will gradually stretch the adhe sions and cause them to give way and fear In the few cases in whiA we have bad an opportunity to observe a manipulabon for a frozen shoulder while the shoulder was exposed surgically the rotator cuff was tom dunng (he procedure How often this occurs •Patterson, R and Damcb W Tixaunnt of Acute Buisjtjs by Needle Imgatioo J Bone & Jo Qt Surg 19 993 1937 4i0 DIAGNOSIS AND TKCATMENT OF SPEOnC INJURIES Mith manipulatton for frozen shoulder or adhesne capsulitis is unl.nown but it must be common TECHNIC OF MANIPULATION With the full) anesthetized patient lying flat in bed the affected arm is held in a relaxed position by the surgeon and abduction is gradually increased while counterprcssmc on the shoulder is made w th the free hand As the adhesions gradually part ^e arm will go into full abduction Then with the use of the elbow as a lever gentle force is applied to restore rotation When this is accom plisbed the arm may be carried nto full elevation and circumdu-Tion In the patient who has a very tight shoulder it is often advisable to discontinue the manipulation before full motion is obtained In either case following manipulation cortisone is in jected into the glenohumeral joint and also into the rotator cuff The arm is then tied to the head of the bed in a position of full externa! rotation and elevation unhl the patient has recovered from the anesthesia This procedure is followed by a great deal of pain and hea \7 doses of narcotics are requited to maintain any degree of comfort It has been our observation that tf wc start cortisone b) mouth or intramuscular injection 2 or 3 days prior to the manipulation and continue it for 1 or 2 da}3 afterward that it is more effective than morphine in relieving pain It should be pointed out that a frozen shoulder regardless of its etioloiq which at the present time is not clearly understood is a self limited disease and will eventually become pain free with restoration of func tion Undoubtedly there must be some cases m whidi the pain and stiffness are perma nent but we have never had an opportunity to see such a case RUPTURE OF ROTATOR CUFF It IS our impression that damage to the rotator cuff is a reasonably frequent injury suffered m both athletics and industry Many m note and partial tears must undoubtedly heal and become asymptomatic We have had the opportunity of following a number of patients in whom wc nude a provisional diagnosis of a tear of a portion of the rotator cuff who made a complete and uneventful recovery with consenative treatment How ever if there is n massive tear of the rotator cuff which more commonly involves the supiaspinatus tendon the period of disability is prolonged and complete restoration of movement and power is not obtained Under these circumstances there is almost in variably a h story of recent injury followed by pan and Joss of function of the arm Examination will reveal some swelling about the shoulder there is usually tenderness over the greater tuberosity and there may be a palpable groove over the top of th* humerus so that when passive abduction is catcied out it may be felt to pass under the acromion This may be accompanied by a somewhat oigwhecllike action of the shoul fer when active abduction is performed Afore commonly however in a patient with heai) muscles nothing is palpable The patient as a rule does not have the ability to abduct the shoulder fully or to ma ntam the arm in abduction once it is passively placed there There is usually no Iim tat on to passive motion and the ordinary roentgenogram is normal One is therefore able to make a presumptive diagnosis of rotator cuff tear but before the cuff is explored the diagnosis should be proved by arthrography (Fig I’l?) TTve aithrogram is obtained by injecting a rad opaque material directly into the joint and noting by roentgen examination its extension beyond the ordinary confines of the rotator cuff Such an injury is best treated by operative repair In the young pvtient who is seen relatively soon after the accident the tendon can usually be sutured directly across the tear In patients m whom this is not possible Wilson s* melhwl of repair by the me of fascial strips interwoven within the tendon is qu tc useful McLaoghlinf mol fieJ this •Wilaort P D Comrlclc Ruplurv irf Supraip C13W* Tendon, I A M A Sf 1951 tMcLauRhlift It L L« ons of the Mosculotend twas Cuff of the Shoul Jer tl e E*r«iure Treatment of Tears With Rrtr«ct»on J Itooe & Jo nt Suij; 2i5 31 tpf-t INJURIES IN KZXilON OF SHOULDER GIRDLE AND SHOULDER 431 somewhat hy attaching the proximal end of the supraspinatus tendon of cuff directly to the humeral head wherever it would fft Operaltte Procedure The enUre shoulder joint may be adequately exposed bj a number of operatne procedures We prefer a modified Cubbins type of exposure which IS performed under general anesthesia in the folIovMng manner After endo- tracheal anesthesia, with the patient lying on his bach a large sandbag is placed behind the injured shoulder The shoulder and arm are then prepared and draped so that the arm is free A curved incision is begun just distal to the acromion at its posterior edge The incision tlien is carried forward around the acrcMnion along the anterior surface of the clavicle then inferiorly along the deltopectoral groove The deltoid muscle is then detached from the dasicle and from the acromion about Yg inch from th" bone Tig 449 Atthrogram of shoulder showing radiopaque material outside confines of rotator cuff and turned back This allows an excellent view of the rotator cuff enabling the surgeon to determine the extent of injury, and proMdes adequate room for repair Following repair, the coracoacromial ligament is sectioned and, if deemed necessary, the acromion may also be partially excised The wound is closed in layers and the shoulder is im mobilized m a piaster spica cast in a position of abduction of approximately 80° and With suffiaent forward flexion to bring the palm of the hand directly anterior to the chm After the plaster spica is worn for 6 weeks it is removed and actne exercise is slatted Although a normal or nearly normal range of motion frequently follows this proce dure rarely are normal power and function cAtained Maximum rehabilitation usually requires 9 to 12 months of physical therapy and effort on the part of the patient CHAPTER 1 2 FRACTURES OF SHAFT OF HUMERUS SURGICAL anatoms: Surf: tally the shaft of the humerus ma) be considered js eMendinj; from the upper border of the insertion of the pectoralis major muscle abo\c to the supracondylar rid«s below (Figs 450 and 451 ) It is roughly cylindrical when cross sectioned and practically strai£:ht in its long axis The anterior surface is cosered by the deltoid biceps brachii and brachiahs anticus muscles and the posterior surface ts covered by the deltoid artd triceps brachii muscles Consec^uently the bone is most successfully palpated on its lateral and mesial aspects where the intermuscular septa d p down between (he muscles to be attached to the bone The icitetmuscuUc septa divide the arm into anterior and posteciut compattmecits The anterior compartment contains the biceps brachit coracobrachialis and brachialis anticus muscles and the neurovascular bundle which has its course along the mesial border of the biceps and is sepaiatcd from the bone by the other muscles The posterior compart ment contains the triceps brachii muscle and the radial n^rve This nerve lies in a shallow groove in the posterior and lateral surfaces of the midd)*' and upper thirds of the shaft The direction of the groove and of the nerve iS from within outward dovvnward and forward and they he between the origins of the inner and outer heads of the triceps muscle FRACTURES OF SHAFT OF HUMERUS Occurrence and Cause f ractures of the shaft of the humerus are not as common as are those of the upper end of the bone but arc by no means rare In the majority of cases they are Oie result of direct violence such as falls on the arm at the side blows and crushing injuries and for this reason ate frequently open Occasionally the shaft of the humerus is broken by indirect violence such as a fall on the elbow ot hand It may also bt broken by muscubr action Tlie shaft of the humerus is said to be the most frequent site of fracture from this cause Pathology and Displacement Fnetures from dirca violence tend to be roughly transverse or comminuted whereas (hose from indirect violence or muscular action tend to be oblique or spiral In rare instances the ends of the fragments may remain in contact with some anguU tion but with little or no displacement Usually however the ends are displaced and slip by one another and the lower fragment is drawn upward by the contraction of the muscles of the arm The shortening is usually less than one inch but may be more than one inch The outward or inward displacement of the lower fragment depends largely upon whether the fracture line lies above or below the insertion of the deltoid muscle If the 432 raACTUKHS or shaft of humirus 433 sha/t IS broken above the deltoid insertion this muscle bein^ attached to the lower ingment, tends to draw it outward whereas the pectoralis major latissirous dorsi and teres major pull the upper /raiment inward (Fig 452) If the fracture line lies below the deltoid insertion this muscle and the coraaibrachialis tend to draw the upper fragment outward and forward whereas the lower fragment is simply drawn upward b) the arm Fig 450 Drawing of humerus anterior view showing muscle attachments (from hforrs H Human Anatomy PhilaJetphia P Blalcrston s Son & Co ) muscles Gravity and position also influence the displacement pirticularly in rotation as the forearm is usually carried across the chest and ^e lower fragment is thus rotated in ward while the upper fragment remains in the mid position These displacements from muscular action are by no means constant because a continuation of the fracturing force may cause the displacement and the distal fragment may move upward and m any direction around the proximal one 434 DIAGNOSIS AND TREATMENT OF SPrOFIC INJURIES Diagnosis In a complete fracture of Uie shaft of the humerus with displacement the diagnosis is usuall) obvious at a ghnce If there is any doubt the arm may be measured from the tip of the acromion to the external condyle to determine shortening and f:enll) manipulated to demonstrate abnormal mr^tltty or crepitvis The extensive swell ng may render it diihcult to determine the displacement Fig 451 Draw ng of luinorus poilrrtor v cw showing muscle •itachments (From Morr* H tinman Anicom> PhlidNpha P Ulakiston s Son A. Gs ) In incomplete fractures in children or fractures u about d spheement the dugnos s 1 $ more difficult and is made from the d sability po nt tenderness and angulation or abnomul mobility if present Complications As was stated since a large percentage of these fractures arc the result of direct violence, many of them arc r^ien FRACTURrS OF SHAFT Ot HUMERUS 435 Fi^ 452 Forces causing displacement n fractures of humerus belosi insertion of pectoral s ma) r (FromGnswold R A Goldberg H and Joplin R Am J Surg 45 51 1939) Fig 15J Fracture of humerus v. th rad al nerve paralys s At operation nerve fo nd partially severed It was tepa red and bones fixed with w re and cast runet onal recovery fbffowed 436 DIAGNOSIS AND TREATMENT OF SPEOFIC INJURIFS Other than open /ractures radial nerve paralysis is the most frer^ucnt and serious complication of fractures of the shaft of the humerous because of the intimate relation of the ner\e to the bone sphere it lies in the muscuJospiral 5 roo\e The nerve miy be injured at the time of the accident by the frattunng force it may be lorn by or crushed between the frajjinents or it may be injured secondaitly by mosements of the fragments or by being stretched over the displaced fragments The symptoms of radial nene injury are wnstdrop and loss of supination of the forearm and extension of the fingers and thumb There is also some sensory disturbance of the dorsum of the forearm hand and thumb The triceps brachii is not affected because the nerves to this muscle leave the radial nerve before it enters the musculospual groove Complete severance of the radial nerve assoaated with a dosed fracture of the shaft of the humerus is t very uncommon occurrence Therefore dosed fractures of the humeral shaft complicated by radial nerve paralysis should not be subjected to exploration of the F15 4i4 Fracture of humerus m th nonun on due to interpos t on of muscle between fr»P ments Successfully Ireated by open operation Muscle was remo eil from between bones medullary canal was drilled open and ends of bones were freshened and s tured together w lli metal bone plate Fixation in hang ng cast for J weeks molded plaster spl nt for 2 more weeks and si ng to forearm for 3 weeks Good results radial nerv'e unless it is decided that the fracture can best be treated by open reduction If the fracture can be adequate!) managed by closed methods the fracture should be so treated with the anticipation that the nerve function will probably return If however after 3 months there is no evidence of return the nerve should be explored Elcctromj'Ofjraphic studies arc important aids m estimating the degree of nerve damage and are also helpful in following the course of nerve regeneration B) giving due consideration to the injury the potliojuiy physical findings and electro myograph c studies the surgeon will often avoid an otherwise unnecessary exploratory operation. More rare!) the median or ufrur nerves may be injured With median nerve paralysis there is loss of pronaUon of the forearm the flexion of the wrist, fingers and thumb is impaired and there is inability to oppose the thumb and little finger There is also sensory disturbance on the volar surface of ttie hmd thumb and index and middle fingers VC'ith ulnar paral)sis there is impairment of flexion of the ring and little fingers inability to FRACTURES OF SHAFT OF HUMERUS 437 Spread the fingers or adduct the thunA and loss of sensation on the ulnar side of the \olar and dots-il surfaces of the hand and of the ring and little fingers In rare instances the brachial artery or vein may be torn or so injured that thrombosis occurs with resulting swelling loss of the radial pulse or e\en gangrene if untreated Nonunion is a frequent complication of fracture of the shaft of the humerus In many instances this is the result of inadequate tceatment However often as with non union in other bones the cause is not definitely known The following maj be important factors (1) interposition of soft tissue between the fragments (2) inadequate reduction (3) inefficient immobthration (4) open fracture and (5) extensne damage to soft tissue All these may contribute to this unfortunate result Another common complication is stiffness of the shoulder and elbow To aioid this actiie and passne exerases must be started as sed the arm support^ in a sling and active exetases start^ for the elbow and wrist Usually after 2 or 3 weeks the si ng may be removed and the patient may be allowed to resume active use of the arm As a rule physical therapy is not indicated but it may be helpful when imnu^ilization has been prolonged or if the fracture was associated with extensive soft tissue damage CHAPTER 1 3 FRACTURES IN REGION OF ELBOW SURGICAL ANATOMY houtr End of Ihtnierus fn its lower fourth the shaft of ihc humerus is broadened lateially and flattened anteropostenorly and lerminates in the internal and cxltinal condjies which are separated by the coronoid and olecranon fossae The articulat surface lies below and between the condyles and is directed downward and forward at an angle of about 43® It IS unecjually divided by a median ridge into a larger internal surface the trochlea, and a smaller lateral surface, the capilellum The trochlea w-hich articulates with the greater sigmoid fossa of the ulna, is concave from side to side and conveic antcro- posteriorly and is continued around the end of the bone onto the posterior surface where It terminates in the broad rather deep olecranon fossa The capitellum is rounded to articulate with the head of the radius and faces forward to such a degree that it is not Msible from behind On the anterior surface of the shaft just above the trochlea and capitellum arc shallow depressions for the coronoid process and the head of tJie radius These are super imposed on the olecranon fossa behind and cause the bone to be ver) thin in this area Surgically the lower end of the humerus may be divided into an external and internal condyle each of which is surmounted by an eminence the epicondyle The external condyle includes the rounded capitellum and the bone above it Its most prominent portion IS called the external cpicondjle The internal condyle includes the trochlea and the bone above it Its most prominent portion is called the internal epicondyle This is much more prominent than the external epicondyle and its posterior and inferior surfaces present a groove for the passage of the ulnar nerve fn anatomic literature the epicondjles are called condyles Upper End of Ulna The shaft of the ulna is thickened in its upper half and termi nates above m the coronoid and olecranon processes which arc separated by the sipmoid fossa This IS hollowed out of the adjacent anterior surface of the olecranon and superior surface of the coronoid process It is convex laterally and deeply concave in its longitudinal direction to articulate with the trochlear surface of the humerus The olecranon is a heavy process of bone which projects upward tn the line of the shaft and presents a broad proximal end for the insertion of the triceps brachii muscle Its posterior surface is subcutaneous and its anterior surface forms part of the floor of the greater sigmoid cavity The coronoid is a thick pyramidal process which projects from the anterior surface of the shaft of the ulna and is roughened for the insertion of the brachialis anticus muscle Its superior surface u articular and forms part of the fliw of the greater sigmoid cavity On its lateral side there is a small articular surface the lesser sigmoid cavity, for the border of the head of the radius 146 FRACTURES IN REGION OF ELBOV 447 Vpper Und of Rati/r/s The upper end of the radius consists of i disc shaped head and a short cylindrical neck which unites the head to the shaft of the bone The upper surface of the head is slighti) concave and articulates with the capitellum and the rounded border articulates with the lesser sigmoid cavity on the side of the coronoid process of the ulna The bicipital tuberosity is a prominent process on the mesial side of the shaft of the radius just below the neck of the bone for the insertion of the tendon of the biceps brachii muscle B Tig 4(r8 A Left elbow joint showing anterior and internal ligaments B Left e!bo» joint showing posterior and external ligaments (rrom Moms H Human Anatomy Philadelphia P BUkiston s Son A Co ) Ossification of Bones at Elbou At birth the lower end of the humerus is entirely cartilaginous and later this becomes ossified from four centers The largest of th“se is for the capitellum and the outer part of the trochlea ft appears at about two years and the ossification extends inward across the strip of cartilage to unite with the small center for the inner portion of the trochlea which appears about the eleventh year This entire strip FRACTURES IN REGION OF ELBOW 449 \^hIch forms the articular end of the bone fuses \iith the shaft about the sixteenth year The centers for the medial and lateral condyles (epicondjles) appear at about the fifth and twelfth years, respectively That for the lateral condole (epicondyle) rapidlj coalesces with those for the capiteJIum and trochlea to fonn the lower epiphysis, whereas the center for the medial cond)]e (epicondyle) forms a separate cpiphjsis which unites to the shaft about the eighteenth year Ulna and Kadtus The upper end of the ulna is practically all developed from the shaft of the bone except a small epiphysis for the tip of the olecranon v, hich appears about the tenth year and fuses with the shaft about the sixteenth year Tlie head of the radius IS developed from a single center which appears at the fifth to seventh years and fuses to the shaft at the eighteenth to twentieth years Eibow fotiit. The elbow joint is really composed of two separate joints, a mam hingelike joint between the humerus above and the head of the radius and the greater sigmoid cavity of the ulna below, and a smaller joint between the border of the head of the radius and the lesser sigmoid cavity of the ulna which permits rotation of the head of the radius in the orbicular ligament The stability of the elbow joint is largely dependent upon the contour of the articu lation between the trochlea of the humerus and the greater sigmoid cavity of the ulna This IS, however, reinforced by strong lateral ligaments winch bind the ulna to the condyles of the humerus (Fig 468) The medial hgome/it is considerably stronger than the lateral, which is not inserted into the radius but splits to blend with the orbicular ligament and ultimately to be attached to the upper end of the ulna The synovial cavities of the two joints communicate The capsule is relatively thin except where it is re inforced by the lateral ligaments The stability of the joint between the head of the radius and the ulna is almost entirely dependent upon the orbicular ligament, which encircles about three fourths of Che radial head and is attached at either end of the lesser sigmoid cavity, thus binding the radius firmly to the ulna Motemettls. Tlie axis of the elbow joint is obliquely transverse so that in the ex tended position the humerus and ulna form an angle of from 5 to 20* which is open outward and is known as the carrying angle, whereas m the flexed position the ulna swings inward toward the mouth (Figs 469 and 470) The carrying angle is most evi dent when the forearm is supinated because with pronation the radius swings inward around the ulna and apparently obliterates the angulation, but the line of the ulna and the humerus remains unchanged The joint between (he head of the radius and the ulna permits free rotation of the head of the radius in supination and pronation Structures w Region of Zlbou Just beneath the skin in the superficial fasaa over the front of the elbow are the median cephalic and basilic veins, which return a consider able portion of the blood from the forearm and consequently should not be compressed by dressings of damaged m surgical exposures At the bottom of the depression or cubital fossa m front of the joint is the biceps tendon which is inserted into the bicipital tuberosity of the radius The brachial artery lies mesial to (he tendon and divides into the radial and ulnar arteries m the lower portion of the cubital fossa The median nerve lies just medial to the artery The radial nerve courses downward between the brachioradialts and the braclvialis anticus and terminates by dividing into the deep and superficial radial nerves The ulnar nerve passes backward through the internal intermuscular septum a short distance above the elbow and lies m the groove on the posterior surface of the internal condyle where it is encased in a sheath of dense fibrous tissue After its emergence from this tunnellike sheath it enters the forearm between the heads of the flexor carpi ulnaris The muscles of the elbow are usually divided into flexor and extensor groups The flexors are the biceps brachit, brachialis anticus, brachioradialis, and the flexor carpi radialis These muscles flex the forearm, and the biceps btachii, by virtue of its attachment to the tubercle on the inner side of the shaft of the radius, acts as a powerful supinator 450 DlAOiOSlS AND TREATMENT OF SPEOFIC INJORJtS of the forearm The extensor group consists of the triceps bnchii and anconeus svhose action IS to extend the forearm on the arm The medial condjle and the ridge abo%e it give origin to the flexors of the xvnst and fingers and to the pronator teres while the lateral condjle and ridge give origin to the extensors of the wrist and fingers but the leverage of these muscles is so poor at their origin that they have little or no effect upon the movements of the elbow’ DIFFERENTIAL DIAGNOSIS OF FRACTURES AND DISLOCATIONS AT ELBOW It IS usually poss ble to decide from the history and the extent of the disabiht) whether there is a serious injury at the elbow If the patient can acxucately flex and extend the elbow and supinate and pronate the forearm fully there is probablj no fracture or dislocation Much can be learned about the extent and character of the injury from the location and amount of swelling and the degree of deformity present Of course the surgeon should learn all that he can from the history and inspection but the final d at nosis should be made by palpation and manipulation ind confirmed by x ray examination Palpation should be begun by identifying the three cardinal bony landmarks at the elbow “niese are the internal and external epicondyles of the humerus and the tip of ti'C olecranon After they have been definitely identified the surgeon should note whether they occupy their normal rclatonship to one another and whether they are displaced m relation to the shaft of the humerus The internal and external epicondyles of the humerus are at approximately the same level With the elbow extended the lip of the olecranon J es about the middle of the line joining the two condyles and with the elbow flexed to PO® the tip of the olecranon occupies a position directly d stal to the middle of the transverse interepicondjlar line and if lines are drawn between the epicondyles and from each epicondyle to the olecranon these three lines form an isosceles triangle The three cardinal bony landmitWs are so important in diagnosis that depen Img upon ihcif relations to one another and to the I ne of the shaft of the humerus the traumatic lesions at the elbow may be divided into three groups as follows 1 The three cardinal bony landmarks arc not norma) in their relat on to one another 2 The Utrec cardinal bony landmarks arc normal in their relation to one another but are not normal in their relation to the shaft of the humerus 3 The three cardinal landmarks are normal in their relation to one another and to the shaft of the humerus In deciding whether the cardinal bony bndmarks arc normal m their relations t» one another and to the shaft of the humerus it is often helpful to compare the injure I elbow wilh its normal fellow 1 If the three card nal bony landmarks arc not normal there is cither a dislocation at the elbow or a fracture of the lower end of the humerus or of the olecranon with dis placement If the tip of tlie olecranon is displaced backward or upward one of the following les ons IS present (a) Posterior dtslocalion of both bones at the elbow' (common) Tlie elbow IS fixed by muscle spasm and the head of the radius and the inner border of the sigmoid cavity can be palpated behind the condyles If the coronoid process is broken it may be possible to pull the forearm forward with relatively little force but the dislix’ation tends to recur when the traelion is released If the head of the radius is not palpable behind the external ton lyle there is pnbabty a fracture of the neck of the radius or very rarely a dislocation of live ulna atone (b) Intercondyloiv! fracture or epiphyseal scpari tion (uncommon) laisc motion is present and the sigmoid cavity can be felt to contain the internal condyle (c) Fracture of the olecranon (common) There are tenderness and FRACTURES IN REGION OF FLBO'X 4^1 Fis 47t Drawing to Jho\s bon) faivJtnirks at tibov «ith forearm extended Fig f72 Dnxving to show bony LindmatLs at elboti, with forearm flexed 452 DIACNOSI'; AND TRCATMENr OF SPCOFIC INJt^RlES Spelling over the olecranon with a paipble sulcus between the fragments and abnornul mobilit) of the detached fragment There js loss of power in extension If the tip of the olecranon is displaced Itterall) or raesiall) there is i rare external Of internal dislocation at the elbow If the tip of the olecranon is displaced forward in front of the humerus there is a vet) rare anterior dislocation at the elbow If the internal condyle and eptcond))c and the tip of the olc-cranon ate displaced up- ward and there is false motion at the elbow there is a rare fracture of the internal condyle If the internal cpicondylc is tender and dispitced (usually downward and forward) there is a rallier rare fracture of the internal epicondyie If the external condyle and epicondyie are displaced or abnormal m contour and false motion IS present there is a rather rare fracture of the external condyle If the external epicondyie is lender and displaced downward there is a nrc fracture of the external epicondyie If the elbow is broadened and the cpicondjies are abnormally far apart and cm be squeezed together or moved independently Uicre is in intercondylar or T fracture of the humerus In this nther common lesion the three cardinal bony landmarks may also be abnormal in their relation to the line of the shaft of the humerus 2 If the three bony landmarks are normal m their relations to one another but are abnormal in ihcir relations to the axis of the shaft of (he humerus there is a supracondylar fracture of the humerus In the common extension type Ihe cpicondyles and olecranon are displaced backward and in the rare flexion type they are displaced forward from the line of the shaft of the humerus The diagnosis cm be confirmed by demonstrating false motion of the lower fragment 3 If the three cardinal bony landmarks arc normal in iheir nlations to ont onolhet and to the shaft of the humerus any one or more of the fractures mentioned in the preceding section may be present without demonstrable displacement, and while the location of the tenderness and the disability may lead one to suspect the nature of the lesion the diagnosis should be confirmed by x ray examination The same is true of all of the following lesions except dislocation or subluxation of the head of the radius and fracture of the upper portion of the shaft of the olecranon with displacement m which the diatrnosis can usiuUy be made by palpation If the head of the radius can be palpated m its normal position and there is local swelling and tenderness witli pam on rotation of the forearm there is probably a fracture of the held or neck of the radius These lesions ire rather common If the head of the radius can he palpitcd in an abnormal position there is a disloca tion of the head of the radius and the character of the dislontion is determined by the location of the radiil head The anterior dislocation is ritlicr common Sharp limitation of supination with pain and tenderness iser the hcid of the radius in a small child points to subluxation of the head of the radius Deformity (usually anterior bowing) of the upper third of the shaft of the ulna denotes a rare fracture in tins region and the lesion is usually accompanied by an anterior dislocation of the head of the radius I racture of the coronoid process may be suspected if there is moderate swelling and acute tenderness over the front of the eibwand acute pain at this point on passive flexion or on attempts to flex the forearm against resistance Tins lesion is unciKvvmon A rare iiitra articular fracture of the capitcllum may be suspected m a patient pre- senting symptoms < f a foreign Iwdy in Ihe joml ind no demonstrable lesion on phvsical examination Sprain at the elbow is unusual but a history of a moderate in/ury with miMlcrafc swelling and disability and moderate tenderness and a negative roentgenogram may be diagnosed as a Sprain Tig 473 A, Lateral vJw of elbow jomt »n nomwl rase Only tJ>e fat ventral to Jmmenis n visible. B, Latetal vi xn) films Compirable mcws of the uninjured arm should also be obtained At limes the original film maj be inconclusnc or fail to show a fracture In these circumstances the presence of an area of translucencj just anterior or posterior to the humerus as seen m the lateral mcw may be helpful (Fig 473) NorcU* and more recently Kohnt bait described these findings indicating that the ap pearance is due to displacement of the fat pads assoaated with joint effusion EXAMINATION OF ELBOW Both elbows are exposed and the injured elbow is inspected from the front bick and sides and tompated with that on the other side to determine the amount of the swelling and the character of the deformitj if present Then the patient is asked to attempt to flex and extend tlie elbow and pronate and supinate the forearm to determine the amount and character of the disability The surgeon should palpate the elbow and definitely locate the three cardinal bonj landmarks (Hgs 471 and 172) These are die tip of die olecranon and the cpicondylcs of the humerus With the elbow flexed to 90* they should form an equilateral tnangle and With the elbow extended the lip of the olecranon should lie about the mid point of the line uniting the two epicondyles The integrity of the lower end of the humerus should be tested b) fixing the shaft and gently pulling the forearm and pushing it backward thus ikmonstrating false mol on if present Having located the three ardmal bony landmarks and tested the humerus the surgeon should carefully palpate the entire elbow and note any abnormalities in the bony contour or points of loal tenderness Finally he should test the lateral stability of the joint by fixing the humerus and moMng the extended forearm from side to side and should test the flexion and extension at the elbow and the supination of the forearm It IS of the utmost importance tlut a careful neurologic examination as well as a survey of the arculaiory status of the extremity be ditamed in every injury to the elbow COMPLETE FRACTURES OF LOWER END OF HUMERUS Classification Complete frarturcs of the lower end of the humerus fall naturally into three groups (1) extension type (2) flexion type and (3) intercondylar T orcom minuted fractures Tlic extension type of fracture is usually the result of backward thrust or hyperexlcnsion at the elbow and the distal fragment tends to be displaced backward Depend ng upon the loation of the line of fracture they are called supracondylar frac tures transverse dicondylar fractures and epiphyseal separations The flexion type is caused by falls or blows on the flexed elbow and the distal fragment tends to be displaced forward Tlic intercondylar or T fracture may result from cither hypctcxtcnsion injuries thrust injuries or direct trauma and may be comm nuted with no characteristic displace- ment of the fragments Lxictiston Type Occurrence and Meebamsm Extension fractures and epiphyseal sepml ons arc the most frequent traumatic Icsuns Ihic cxcur in the region of the elbow and arc especially common in children The injury usually results from falls on the hand with the elbow in extension and the lower end of the humerus u pushed backward by force transmitted upward through the bones of the forearm Occas onaily these fractures are due to forcible •Nofcll H G Roctiij^cfioIoKic Visuiluaiioa of Exifacaj'tular Fat lis Imronan e in the D aenoiK of Traumatic Iniur es to tite Elbow Acta Raj ol 42 ’05 J95 1 IKohn A M Soft Tissue Allcrat ons ID Elbow Trauma Am J Rottilxenol *2 1959 rRACrURIJ, IN RICtON OI tLnOW hj-perextension at the elbow, the lower end of the humerus being pulled off by the lateral ligaments, while the olecranon, locked in its fossa, acts as a fulcrum, as in a fall on the extended hand with the forearm pronated Pathology The pathology differs for each type of extension fracture SUPRACONDYLAR FRACTURES This injury IS much more common in childhood than It IS during adult life although it does occur in the aged The fracture line usuall) begins close to the articular surface on the front of the shaft and tends to be roughly transverse in the frontal plane but courses obliquely upward and backward m the sagittal plane The obliquity tends to be more marked m adults, whereas m children the fracture line is often practically transverse In tare instances the fracture line is spiral As a rule the frac ture is complete, although occasional greenstick fractures occur in this region Tlie displacement is characteristic m that the short distal fragment is displaced up ward and backward This is due partly to a continuation of the fracturing force and partly to the puH of the triceps bra^ii muscle which serves to maintain the displacement, while the end of the proximal fragrnent projects into the cubital space beneath the brachiahs anticus and biceps brachii tendons and may injure the brachial artery and vein or median nerve in this region Deltoid Tir 475 Supracondylar fracture of humerus of extension type showing charactenslic displaccmeni and pull of musdes In addition to the typical upward and backward displacement the distal fragment is often forced lateral!) or mesially (Figs 475 and 477) by the fracturing force, and as It IS controlled by the forearm it may be deviated outward (valgus) or inward (varus) by gravity or the pressure of splints Furthermore it is often rotated inward by custom of supporting the forearm across the chest The forearm muscles which are attached to the condyles tend to pull the short lower fragment forward, ilexing it on the forearm In addition to the fracture of the bones there is usually considerable damage to the soft parts, and this may be so severe that it dominates the picture The periosteum is stripped up from the posterior surface of die proximal fragment and from the anterior rRACTURES rN RICtON Ol- ELBOW 4^1 45S DIAGNOSIS AND TREATMFNT 01 SPTanC INJUWFS surface of the distal fragment the joint capsule ts usually torn and there is a satiable amount of hemorrhage into the joint and into the surrounding tissues The hemorrhage and resultant swelling may be so sesere that the \enOus return from the forearm and esen the radial pulse are interfered v.iih and immediate treatment maj be necessary to sase the cxtremitj This is discussed further under the headini; of Volkmanns ischemic con tracture (seep 492) TRANSN ERSE OR DICONDYLAR FRACTURE This type of cvtcnsion ffacture has been described as a separate cl meal entity by Kocher Ashurst, and Chutro The fracture line lies just abose the epiphj’seal line courses transserselj across the lower part of the bone passes through one or both condoles and is always partly mtra articular as it passes through the cotonotd and olectanoiv fossae (lig 479) The lower fragment includes all of the articular surface and usually the internal condyle (epicondylc) rii; iso separation of lower cpiirss of humerus of eatens on type w ih ptiler r anJ meJ al d splatemcnt Note reversal of nnyuig an|.le Ii^: 4si Rocnipenognm of pal ent in r c 4S0 Tp physis is fractured and J slocated haefc ward and inward In ll is case it was necessary to aspirate the elbow to tcl ese mtra art cular tern on and restore circulation D splaremeuf was then reduced under anesthesia and eslfcni I) was im mob 1 rod m moderately acute Rex on by meaos of a posterior plaster mold and a plaster swatlie around body forearm and hand placed forward for 3 weeks Molded poster or plaster shell to arm and forearm for H days Good result The mechanism of production displacements and soft part injuries are s milar to those in the typical supracondylar fracture except that m rare instances the dicondylar fractures arc impacted All gradations between the typical supracondylar and the typical dicondylar fractures occur and many authors do not distingu sh between the two types FPlPUYStAV SEPARATION Up to ihc age of 4 or 5 years the entire artilagc pUlc of •lie articular surface of the lower end of tlur humerus tends to be separated m one piece (1 igs 4Srt and 481) In older patientF with injuries at Uic epiphyseal line the externa! condyle is broken off from the shaft and the epiphyseal cartilage may be split leaimg the thin trochlear portion attached to tlic shaft As a rule esj>ccia11y in older children a portunof the shaft IS broken off and displaced with the epiphysis OjnsccjuenUy in older IRACTURCS fN RLGIQS 0^ ELBOW 4^9 children these epiphyseal injuries are reall) separations of the external condjle and are a nsidered under that heading The small center of ossification m the trochlear portion of the epiphjseaf cirtilagc IS prachcaJly never injured alone and rarely displaced with the capitellum The mechanism of production displacments, and soft part injuries in these epiphyseal injuries are similar to those of the supracondylar fractures described above but the epiphyseal lesions differ slightly in that they exhibit a greater tendency to stripping up of the periosteum from the posterior surface of the shaft of the humerus Dtagnoits The diagnosis of extension type fractures is described as follows sifpRACONnvLAR FRACTURES The appearance of the arm depends upon the degree of swelling and displacement With relatively little swelling and incomplete displacement the patient presents simply a swollen tender painful elbow w hich with the history of the injury followed by complete disability leads the surgeon to suspect a supracondylar fracture This suspiaon is strengthened if there is point tenderness above the condyles Tig hV- Sopracon&y^ar IraCtuie ’i umerus o'! ewens on type w t'li poster or iisp'uecment viewed from side to shew deformity Fig 483 Same pat ent viewed from front and if the three bony landmarks (the olecranon and the internal and external epicondyles) are in their normal relationship However a roentgenogram may be necessary to confirm the diagnosis With only moderate swelling and upward and backward displacement of the lower fragment the deformity is characteristic and resembles that of a posterior dislocation at the elbow (Fig 482) The forearm appears to be shortened and the region over the triceps brachii tendon on the posterior surface of the lower third of the arm is concave when viewed from the side IIjis concavity may be obliterated by the swelling and the patients tendency to support the forearm in a position of slight flexion with the unm jured hand Palpahon will reveal point tenderness above the condyles and it may be possible to feel the sharp lower border of the proximal fragment beneath the biceps brachii tendon and above the fold in the front of die elbow The epicondyles and olecranon are m their normal relationship to one another but posterior to the line of the shaft of the humerus and measurement (acrom on to external epicondyle) will reveal shortening of the 460 niAGNOilS AND TRCATAIENT Of SPrOUC INJURIES humerus finally manipulation will show false motion in escrj direction except Hexion which IS usual)} limited to 90® and this may be acrompanicd b) crepitus which is most easily obt lined by traction on the forearm thus bringing (he ends of the bones together The deformity can be reduced by pulling the moderately flexed forearm downward in 1 forward but it tends to recur when the elbow is extended A B F j; -tut /i SupraconJ)lar Iracturcof humefiM in an aJoInretit u ih marked and hark ward dspJ^5 and 496) or skeletal After 5 to 10 dajs the ssstlhng is usuallj su/Tioentl} corrected to allow maintenance of reiluction in reasonably acute flexion and at this lime the arm may be brought up into this position and held in plaster ITie patient who arnses in the hospital with considerable swelling but with good arcubtion and without midence of nerse msobanenl, should ha\e a closed reduction followed by traction as described aboxc The patient who has a con sidcrable amount of swelling interference with the radul pulse or with apillaty return difficulty m extending the fingers or ecidetiiCe of oerse involvement should have teduc tion of the fracture and traction If the circulatory embarrassment does not readily respond to this method of treatment the patient must be closely watched to determine whether it will be necessary to decompress the antccubiUl space and/or explore the brachial artery It is our strong conviction that every child with a displaced supracondylar fracture of the humerus should be admitt'-d to dve hospital for at least 24 hours of li;, 189 Manif lali'c reduction of vofrjci ndjrlar fnciure of liuii trus rnit nuncuirr slight bspctextersioiv with ira lion t n foreatn awl counterttavtion li> arm and bavkwani pressure on Eroximjl fragrnent to eoeage fmemcflis Second nuncuver wlile iractioo and pressure are man tamed forearm is si wly Aeced white (otwacj pressure is mads on distal fragment Note tliat forearm is prunatrd ibscrvation and if ihvrt is any suspicion of extreme swtlling or ciriulatiiry embarrass ment they shoul 1 Ik mnnlaincd in Iracti m in the hospital until all danger of circula tory impairment has dis-appeacvd This fracture should never l« reduced under local anesthesia Method of Reduction After the patient has been adetjiutcly prepared for a gcncnl anesthesia which demands a complcfc history and physical examination an empty stom-idi appropriate preoperatne medication and a competent anesthetist the surceon may then proceed with manipulative reduction as follows Wlicn muscular relaxation hvs been oblaincsl by the anesthetic an assistant fixes the arm and the surgeon grasps the forearm with one hand and slowly hyperextends the elbow and applies moderate traction to pull the lower fragment down As the lower fragment is pulled down th" FRACTURES IN REGION OF ELDOW 465 surgeon uses his other hand to raanipuhtc the fragments into position, first correcting any lateral or rotary displacement and getting the fragments in line Then be pushes the lower fragment fon.varcl and presses the lower end of the upper fragment backward and holds them in position While maintaining the traction he gently flexes the fort arm, which is held m proiution or in the neutral position as regards rotation (midway b-'tween pronatxon and supination) berause full supination tends to cause adduction of the lower fragment If the displacement has been reduced flexion will be free except as limited by the swelling (Tig 489) Some surgeons use a slightly different and quite as eflicicnt method of reduction With the patients elbow flex^ to about 90° the surgeon grasps the condyles of the humerus with one hand and pulls them downward while he presses the lower end of the upper fragment backward with the other hand (Tig 490) When reduction has been obtained, the elbow is flexed to the position of maximum flexion With safety It IS to be emphasized that these fractures arc not reduced by the movement of flexion They are reduced by extension, traction in the long axis of the humerus, and manipulation with the surgeon s thumb and fingers VC^ere more traction is needed Scott s meth od is useful After the fracture has been retluced, the forearm ts flexed to help maintain the reduction Tig 490 Reduction of supracondylar fracture by frasping distal fragment and puilini’ it dnwn and forward ^untertractiun to arm by an assistant is usually necessary Posilion of Maxunufii rie\toii Safely The degree of flexion in which to im mobilize the forearm vanes inversely with the swelling and must be determined by trial as too much flexion not only interferes with the senous return from the forearm but may even obliterate the radial pulse A safe plan is to flex the elbow until the radial pulse IS obliterated, to extend it until a bounding radial pulse returns (approximate!) normal), and then to extend it about 5® or more to allow for further swelling and to immobilize it m this position This will usually be a little less tlian a tight angle After the immobilization the hand must be inspected every few hours and if airulation is found to be impaired, the dressing roust be loosened A great deal of emphasis is pul on the position of acute flexion m the treatment of these fractures of the lower end of the humerus This is dangerous and may cause ischemic paraly’sis or csen gangrene The orculation must not be blocked fay the position The fracture is immobilized in as much flexion as can be maintained with safetj, and acute flexion is obtained later if deemed necessary after the swelling has decreased Acute flexion will not accomplish reduction and is not necessary to maintain reduction after it has been obtained In certain cases the distal fragment may slip back a little or lift back and these cases must ha\e another anesthetic and the defect must be corrected, but it is much better to do this than to risk an isdiemic paralpis or gangrene by jamming the ruACTUJirs ;n region of elrow 4C7 acutely swollen elbow up into a position of acute flexion and holding it there while the patient $ severe pain is ignored or relieved by opiates Itnmobihzttltnn After Reduction For complete fractures through the lower end of the humerus which have been reduced nothing is as eiflcient as a plaster of Pans dressing properly applied It is trae that m the great majority of instances the position of hj-per flexion, if it can be obtained with safety, and the adhesive dressing described previously, or Lund swathe, posterior angular splint, or posterior plaster mold will maintain posi tion after reduction, but occasional!) they permit rotation, lateral deviation, or eien total displacement of the lower fragment, and the careful surgeon should not take this chance The plaster of Parts dressing (Eliason*) is applied as follows After the fracture has been reduced and the position of maximum flexion with safety has been determined, the {oreatm is supported in this position in pronation or m the mid position between pronation and supination and pointing directly forward with the arm slightly abducted Sheet cotton is wound around the upper arm and chest and a plaster mold half again as long as the distance from the acromion to the wrist and wide enough to extend halfway around the arm and forearm is prepared and applied from (he base of the Angers along the ulnar surface of the forearm around the eJl»w, up the postero lateral surface of the arm, over the shoulder and obliquely down across the front of the chest F e -192 Fis 49> Tig 492 Excellent dressing for immobilization of severe supracondylir fractures which have been reduced Posterior plaster mold is incorporated m a Ight piaster cast which extends around body and involved arm shoulder and elbow fixing involved arm and elbow to chest with forearm placed forward and forearm and hand near mid pronation and supination No bandage has been used m order to show detail on forearm Tig 493 Same dressing viewed from hoat showing plaster swathe around chest We prefer a light plaster spica cast over the piaster mold The atm can be abducted to an angle of po® at the shoulder to reduce the swelling or it can be brought forward and outward about 30“ and rotated mward about 45“ to bring the fully pronated fore- arm across the cliest •Eliason E L Dressing for Supracondylar FractortS of Humerus J A, fif A 82 1934 1921 Fs 4 i F* F g *<95 ^me cnt m ci I g 49t » t! »oti «n susi'en.l n »n4 ifter t»el! ng h« l>«n rcJun upper tl r I of am to hue of finpen w ith forrann m n^l t angle Acs on C Good un on and ntellenl results 1 mnnil v Iaih rlexioft Type Occurrence auJ Mechanism Tlicse fractures arc as rare as the extension type arc avmmon The) are due to direct trauma on tlie elbow in which the force is appi ed to the oiccranc n or posterior surface of the ufna usuall) by falls upon the flexed elbow with the olecranon thrust upwarl and fotwarl an! curjing the lower fragment 0° The surgeon places his thumbs 474 WAONOSIS AND IREATMINT OI SPEOnC INJURIES m the cubital fossae and grasps the foreann and cond)Ies v.ith his fingers He makes tnction m the long axis of the heimctus to bang the lower fragment down be)Qnd the tnd of the upper fragment at the same lime correcting an) dcformitj in rolition or lateral displacement VXTaen this has been ACCompUshed, the lower fragment is pushwl directly backward and an attempt is made to aigJgt it upon the upper one Tlie traction and then the backward pressure are gradually released If the reduction is complete the fragments will be fairly stable with the elbow flexed PO^ A long posterior plaster mold reaching from the base of the fingers up the foteamr, o\<.c the shoulder and down the fr( nt of the chest is applied as in the treatment of supracondylar fractures of the ex tension type (hig 50J) with care taken not to displace the fragments Tlic foteatm and arm arc then encased m a plaster bandage to guard against the slipping forward of th- lower fragment and the plaster molds and upper arm arc fixed to the chest b) a arcular swathe or plaster of Pans bandage The front of the elbow region is left open This dressing is left on for 5 or 4 w^s after which it is temosed and a posterior plaster mold is applied for some 2 or 3 weeks longer depending upon the age of the patient and the scverit) of the fracture The plaster mold is then replaced by an ocdmity triangular sling and the patient js encouraged to begin actne exercises with the arm Intercondylar, T, or Commtnnted Fracinres Oce/irrence ainl Mechanism Intercondylar fractures arc quite rare m children but are not uncommon m adults Tliey arc usually the result of severe in;uries such as falls from a height on either the flexed or extended hand the mechanism being similar to that in the production of the fncturcs of the extension type or they may be produced b) direct trauma to the elbow « m fractures of the flexion type A severe type, the car window elbow* is illustrated in Tig 504 Palholog) Tlicse fractures are really supracondylar or dicondylar fractures of the lower end of the humerus in which the distal fragment is split cither by the ulnar or by the distal end of the upper fragment In the typical intercondylar fracture there is a transverse or oblique fracture through the lower end of the shaft of the humerus and a roughly vertical fraautc between the condyles In addition there may be more or less comminution especially of the distal fragment (lip 505 and 506) In the simplest type there may be little or no separation of the condyles and the distal portion of die bone may be displaced backward Tl»e picture is practically identical with that of the supracondylar frartuie of the extension tyjic In the severe type Uie condyles may be widely separated and the upper fragment may be dmen down between them or one of the condyles may be rotated or pushed fat out to one side These fractures are often open and arc often complicated by other fractures of the upper ends of the radius and ulna They arc always atcompanicd by great swell ng and damage to the soft tissues around the elbow Diagtinsfs In intercondylar fractures with little separation of the lower fragments the clinical picture is identical with that of a suprarondy lar fracture of the extension or flexion type depending upon the displacement, and the diagnosis can be nude only by X ray examination However a split bc^ecn the condyles may be suspected if, with the atm and foccatm carefully supported slow, steady lateral pressure on the condyles causes pain, especially if this pain occurs wHct the pressure is released without causing movement of the lower fragment In cases with considerable separation of the condyles the bfovdening of the elbow is marked and palpation even in the presence of extensive swelling will fcica! a definite broadening m the lower end of the bone Unless the upper fragment is jammed down between the condyles they can usually be squeezed together by lateral pressure of tlic fingers and thumb and inlepcn«lcnt mobility of the condyles may be obtained by manipulation The shortening of the arm and ihc deformity are similar to that in supracondylar fractures and false motit n is present m every direction FRACTURCS IN REGION OF ELBOU 475 stilT but painless and fuiut on of hand is fijt 505 Soere ) resect f»n < f the condyles and posfoperat \e immob I zation with a cimiUr cast to arm and forearm Kes ills were catly mot on w tSi 50 jxt cent fund on Anyone who his opciatcd upon these badly bioken and comminute I fractures of the lower end of the humerus must base been impressed by ihe extreme d fficulty of fixing the fragments in thetr proper positioos Consequently in most mstinces the best treatment is by suspension and traction In applying traction to Uic lowet end of the humerus a small pm or wire throuch FRACTURES IN REGION OF ELBOU 481 the Upper third of the ulna js the most eBioent method An anesthetic may be used from the beginning or after the traction has been applied Either local or general anes thesia should be used and an attempt should be made to reduce the fragments b) having an assistant fix the arm while the surgeon mali^s traction on the moderatelj flexed fore arm pushes the upper fragment bacbsiard pulls tlie lower fragments forward and squeezes them together Then the forearm should be suspended at an angle of apptoxi matel) 135® of extension at the elbow that is midway between full extension and a right angle flexion thus exerting traction on the lower fragments of the humerus The traction should be maintained for from 3 to 5 weeks depending upon the se^e^lt) of the fracture The position should be checked by a portable x raj machine and if it IS not found to be satisfactory a second or third reduction bj manipulation should be attempted after the swelling has decreased The sescrely comminuted frac tures of this region alwajs result in some permanent impairment At times traction will afford as good result as one may expect However tf the joint surface is not restored by this means open reduction with internal fixation is indicated When the fragments are quite firm!) united in good position the patient should be encouraged to begin active motion at the elbow and local heat may be used The exercises should be continued until full motion is obtained or despaired of FRACTUBES OF SINGLE CONDOLES AND EPJCONDYLES or LOWER END OF HUMERUS Tractures of luteriial Epicoti4)le Fractures of the internal epicondyle are also called epitrochlear fracture spra n fractures of the internal condyle or extra articular fractures of the internal condyle and before (he age of 18 years the lesion may be an epiphyseal separation rather than a fracture The prominent tip of the internal condyle may be torn off by the internal lateral ligament m forcible abduction of the extended arm or it may occur as a com pliation in dislocations of the elbow (Fig 513) Occasionally it may be knocked off by direct violence Pathology The small piece of bone which is torn off or knocked off is usually displaced downward and forward and more or less rotated by the pull of the superficial flexor muscles of the forearm which take their origin from it Not infrequently the amlsed fragment is displaced into Ihc elbow joint and may be locked between the coconoid process and the trochlear surface of the humerus Occasionally there may be ,ncu:ticaiy' .nn .d’^lvnitwn^ sprariC ISJURII s iround the ncd. Tliis is most eJlicientlj done b) a posterior plaster of Pins mold n tending from the upper arm to the bisc of the fingers The plaster should be si ell molded around the external condyle in order to keep it in place This should be worn until the fracture is solid and then be rqitaccd by a trianguhr sling and the pilient mi) begin actne motion to restore the function at the elbow Fic 519 >1 rpftufe of external corta^Ie of I ««r end of liuments xiith martfd d iplactn cut an^Iaijon, and rotation of condjlar fragmnit to an aJnlnccnt B Pi » prraiiir rnulis anJ union follow inR imetnal fixation by hotdioi; fnpnent in »ilh \o 5 rbrow c fatput ihfou>.l> dr II 1 oirs in bone Cood functional result* «rrr t bta nnl With displacement outsiarJ, dossnward, and backward or forward, an attempt should be nude to rciluce the ftacture under eilbcr local or general anesthesia Tlus IS best accomplished b) direct numpulation of the fragment with the forearm m a tRACTURCS IN REGION OF ELBOW position of almost complete supination and extension and strongly adducted m order to open up the outer side of the joint If there is much ssselling o\er the fracture the edema should be pushed aside b) slow, continuous pressure The problem is to push die displaced fragment back where it belongs When the reduction appears to be satisfactory, the condyle is held in place with the thumb while the supinated forearm is slowlj flexed to a moderatdj acute angle In this position the capitellum tenle to exert lateral pressure and hold it in position The position of the fragment should be checked bj postreduction x ray films and if reduction is not satisfactory, an open c Fij; 520 A Fracture of external condjrJe of elbow with anterior displacement B Oosed reduction C G(>od union 3 months iaier and excellent results followed reduction should be performed and the fragment accurately replaced and fixed by a screw Of a wire nail When the capitellum is rotated so that its fractured surface faces outward attempts to reduce the displacement by manipulation are rarely successful This fracture should be reduced by an open operation, otherwise seiere deformity of the elbow will result and the fracture may fail to unite The fracture is exposed through a lateral incision and, after reduction, is fixed in place with a nail or screw or w-ith a Ktrschner W'lre External fixation is then applied m the form of a arcular plaster cast f90 WACNO«;iS AND TRrATMFNT Ot SPFOFIC iNJURlfS FRACTURES OF CAPITELLUM Fracture of the capifeHum alone is a ver) rare in;ur) tn \ihich a piece of the articu lar surface of the capitcllum is broLen off and displaced anteriorlj in front of the lov^er end of the proximal fragment ot set free in U« joint casity 'i.hete it may zander either backward or fomard and block either flexion or extension It was first described b) Kocher as the fracture loruli humeri and is usiullj caused b) indirect violence the force being transmitted through the radius but it maj be caused bj direct crushing injuries In size the loose fragment saries from a thin shier of bone and cartilage to i large piece comprising most of the capiteUuin (Fig 521) Diagnosis Unless the fragment is large or complicated bj other injuries, the im mediate sj-mptoms arc not seiere and consist of pain and effusion into the joint with more ot less limitation of motion which is characteristic m that it is free to a certain point and then suddenlj blocked Tlie diagnosis is made bj (he absence of the signs of an) other fracture and b) x ra) examination 1 H S’l rracture of cjp tcllum with dspbcrmcot TfwteO hy rxcicn of loose fNi; r Mil with satisfacKiiy result Treatment If the fragment is large it nuj be pcssiblc b) dircil pressure to push it back into place while the pioiuted forearm is adducted and slightly flexed If this an be done the elbow should then he immob lized m mmlcratel) acute flexion for 3 weeks With the hope that the large loose fragment will unite ‘^mill loose fragments free in the joint probably have no blood supply and arc not likely to umie even when acruraicl) redact and immobilized Tlic signs of a loose bod) in the joint with Iiinitatun or blocking of motion will persist as long as the frag- ment remains m the joint and it should be rtmoveil by arthrotomy The site of the anhrotomy depends on the location of the loose fragment as determinciJ by a roentgeno- gram taken shortly before the operation. FRACTURES IN REGION OF ELBOW 4i^I MULTIPLF FRACTURES IN REGION OF ELBOW Occurrence and Mechanism Multiple fnctur« at the elhow are rare in children htcause the ends of Jheir bones are lar^ly cartilaginous ind the fractures in the region usuall) occur m the shaft of the bones near the joint and it is rare for more than one bone to be broken But m adults it is not rare to find two or even all three of the bones broken at the elbow as a result of se\erc injuries such as a fall from a height or an automobile accident, espcciallj the car window fracture which is usually open and severe!) comminuted Pathology "niere is no rule as to (he type of fractures or combination of fractures which one may rrvpect to find m these severdy injured elbows Almost any combination of the lesions described in the preceding pages nuj be present and the bones may be extensively comminuted so that the elbow, as Cotton aptly remarked may be converted into a veritable bag of bones Diagnosis Whereas it may be possible to determine the presence of one or more major fractures accurate diagnosis of the various lesions present can be made only by anteropostenor and lateral x ray films, and even then one is likely to overlook some of the fracture lines At least that has been our experience Treatment In general these severe injuries should be treated as described under the treatment of intercondylar or T fractures of the lower end of the humerus that is b) recumbency and with suspension and traction The surgeon should attempt manipulalive reduction under anesthesia with the patient m bed and the traction applied By this means it is often possible to mold the fragments into place If the olecranon is fractured and the fragments are separated the displacement should be reduced and the fragments fixed by open operation This should be done im mediately unless there is some definite contraindication After the olecranon has been repaired the elbow can be treated as described When extensive comminution is present we do not believe that it is advisable to try to reduce and suture or nail or screw m place the various fragments of the lower end of the humerus Out experience has been that it is very difficult to fix these frag ments by sutures or any other method and that conservative dosed treatment gives better results An exception is a fractured external or internal condyle which is rotated and which It 15 impossible to reduce by manipulation These should be reduced by open operation Fractures of the head and neck of the radius in these complex injuries are best treated conservatively and may be more or less ignored for the time being In other w-ords, the surgeon should treat the fracture of the humerus conserva tively, suture the olecranon if necessary, and ignore the fractures of the upper end of the radius All dislocations should of course be reduced After consohda tion has taken place in the humerus and olecranon, if it is found that disability is due to some lesion m the upper end of the radius, the head of this bone should be removed It must be said however, that results in these cases leave much to be desired Recently Bush and McClain* have advocated more vigorous attempts at reduction by operation and internal fixation In patients with healthy skin tins approach may provide better results However, only the most skilled surgeon should attempt open reduction and internal fixation in these cases *Bush E J and NfcQain Jr Operatne Treatment of Fractures of the Elbow m Adults Inslnictional Course Lectures The Ameticaij Aeadem/ of Orthopedic Surgeons voJ If St Louis 1959 The C V Mosby Co 494 I)WONO>IS AND TPFATMENT OF SPEOUC INJORltS On manipubtion it wiU be found dist, as the unst is flexed, the contracture of the fingers is lessened, and, as th- -Rrist is eartendcd, the contracture of the fingers is in creased As the flexed fingers or ttnst is stretched in attempting to extend them the flexor tendons stand out like hard cords under the skin of the forearm Palpation of the muscles in the forearm discloses the fact that they are smaller in size than normal but are unusually hard and boardiike m con5i«fenq Trtatment of Jlarl) Cases In cases of fracture with great swelling cyanosis, pain and numbness of the extremity and absence of the radial pulse, it should be recognized that Volkmann s ischemic contr-'ctme is impending, and immediate attention must be gnen the circulation in the exfrermty If splints or dressings have been applied they should be removed regardless of loss of position of the fracture and the arm elevated and placed in susp^mn traction If this results in a decrease in pain and swelling and reappearance of the radial puls* and the patient is able to move the fingers a!! is well If the circulation is not restored fay these measures and the fracture is displaced reduction of the fracture may improve the circulation if not operative intervention must be undertaken at once The area is best explored by an incision that starts on the arm on the medial side extending down to tb“ superior aease of the elbow, then curves laterally and then again curves down onto the forearm When subcutaneous tissues are inased great care « exerased to preserve all veins since the deep vessels may have been damaged by the fracture and it matters not whether arterial supply is re established to the arm tf there ts no method of venous retvim The superficial nerves are also protected The lacertus fibmsus is cut across, and the brachial artery is identified in the atm and arefully traced down to and beyond the fracture site If the artery is found to be in spasm but otherwise undamaged this spasm will frequently be relieved by the stnppmg up of the vessel If not, 1 per cent Novoam or Xyloaine an be injected with a fine needle around the vessel and in its wall This may effect relaxation of the spasm. Spasm may farther be relieved by the injection of a small amount of heparin into the artery above the area of spasm. If th* spasm is relieved and there is no tendency for it to recur With manipulation of the vessel or the arm this may be all that is required Since the fracture site will be opened by this exploration the hematoma i$ evacuated and the frac hire IS readily fixed by two or more small threaded pins across the fracture site It is our opinion that fixation of the fracture ensures a better chance that spasm will not recur after the wound has been closed because neither plaster fixation nor traction will prevent further contusion to the vessel by the bone In children after all these methods have been used and the vessel does not remain permanently open but shows a tendency for the spasm to fccuf with manipulation of the vessel or arm. the artery should be clamped in the area of the damage and both ends ^ould be hgated This will usually be effectoe in relieving the spasm in the collateral vessels We luve never seen h.vnn come from hga tion of the brachial artery in this area under these circumstances and in fact, it nuy be the one thing that will prevent th- development of an ischemic contracture The wound IS then closed in layers with great care being used to protect the remaining vessels and nerv es When the surgeon is faced with damage to the brachial artery in adults, an effort must be made to restore continuity of the vessel DeBakey and Simeone* found that division of flie bradiul artery above its bifurcation resulted in the loss of some portion of the extremity in 25 per cent of the cas-s The student is referred to the work of Shawrf for details of repair •D-BaLci M. F muI SjmcocK F A Bat^ tniutses ef the Atterwfv m VSTotlJ 'X'ar II Anjljrju of ^ i7l Cases, Ann, SuiS 1^3 33< tShaw R. 5- Reconstructive Artemi Suigeiy in Lpfvr Estremirj- lijuncs. / ifcsoe A Joint Surp 4l A 6^3 1939 IRACTURCS IN RiCION OF ELBOW 495 Treatment of Late Cases of Coniracit/re The limit for the reversal of the orcu latoiy changes that produce a Volkmann s isdtemic contracture appears to be somewhere between 12 and IS hours after the injur) and onset of circulator) embarrassment Any case after 24 hours is Jate Since, boweser, there is a chance that something may be saved ue still recommend exploration of the brachial arter) up to 36 hours Although an exact hour cannot be gnen m any particular case, we have not seen re\ersal after this period of time, and usually from 36 hours the muscle will be found dead In these relatively early cases, which however ate too late and it is obvious that the muscle is dead we agree with Seddon that much time can be saved by excising the dead muscles at the time of exploration of the artery This will prevent some of the contractures prevent or lessen the extent of nerve damage and will permit an earlier reconstruction of the hand In the very late cases nodung much can be done about the fibrosis of the muscles It is advisable m these cases to perform a neurolysis of the nerves so that their function may be restored to remove and lengthen the contracted muscles and tendons and to transfer those remaining active muscles, when possible, to improve the function of the hand Tjjj 524 Limitation of movement at elbow and paralfsis of met) art nerve following suprarondjflar fracture of humenu Nert e lu\iiries Injuries to the median nerve may occur along with or in the absence of injury to the brachial artery m severe supracondylar fractures Because of its position in front of the elbow tlie median nerve is injured more frequentJj in these fractures than is the radial or ulnar nerve The deep muscular branch of the radial nerve is occasionally stretched and may even be torn in dislocations at the elbow and the upper end of the radius and m fractures of the radial head or neii Most of these radial nerve injuries are temporary and clear up with rest An important nerve lesion m elbow injuries is a paralysis of the ulnar nerve, which is especially prone to be stretched in dislocations (either posterior, posterolateral, or directly lateral) It is also occasionally injured in fractures of the internal condyle or epicondyle Late ulnar neuritis or paralysis may occur after fractures of the internal condyle or epicondyle or after supracondylar fractures in which union has occurred with a de- formity of abduction at the elbow In the fractures around the condyle the ulnar nerve IS injured by the production of callus or by direct Irauim from misplaced fragments, whereas in late injuries following supracondylar frartures with abduction tieformit) at the elbow, that is exaggeration of the carrying angle the ulna is injured by being pulled around the epicondyle 496 DIAGNOSIS AND TBFATMrNT OI SPEOtJC INJOIUFS The treatment of these late ulnat nerve paralyses is to expose the nerve, remoTC it from its canal behind the internal epicondjlc and transplant it m the subcutaneous tissue or beneath the origins of the flexor muscles of the forearm in front of the internal cond)le thus shortening its course and freeing it from the irritation aused b) the bone r S W Sketch shon inj; mechan sm of niuiy of bnrh at artery anU median und raJ al nerves m supracondylar fractures of hunerus (rrom Lipscomb P R (ind Burleson R J J Bonf * Joint ^ur*. 37 A -168 19SJ ) Maluniou of Supracondylar Fractures The most frequent t)pe of malunion in these cases is one m tvhich the posterior displacement of the lower fngnient has not beert reduced and the lower end of the proximal fragment projects into the cubital fossa and blocks flexion at the elbow In children growth will remove this block In adults with micked limitation of flexion the simplest and most efficient operation is not to disturb the malunion but to remove the offending distil end of the proximal fragment This can be done through a literal incision and a little more than enough bone must be removed to permit full flexion S nee no fracture has been created no splinting is necessary and exercises can be begun a few dajs after the operation If in addition to the posterior displacement there is also some lateral displacement or angulation or deformitj in rotation of the lower fragment in nsteotomj should be performed and the deformities corrected Usually the osteotomy should be performed through the line of the old fracture After the operat on the arm must be immobilized and treated as a fresh supracondylar fracture of the extension type In the very rare cases of milunion with forward displacement of the lower frag ment the deformity should be corrected after an osteotomy through the line of the fne hire and the extremity should be treated as a fresh supracondylar fracture of the flexion type or the offending bone may be removed from behind the elbow Alalumoti of Fractures of Csierual Condyle Old fractures of the exterrul condyle with malunion in children should be corrected by an osteotomy s nee subsequent growth of the internal condyle may proilucc mvfked deformity In adults a wedge osteotomy and bone grift should restore alignmcnl If non union exists bone graft is usually successful However, in adults with degenerative jo nt changes it is usually better to remove the extenul condyle Smcc tlie external condyle articulates only with the head of the ndius it has relatively little to do with flexion and FRACTURLS IN REGION Ot ELBOW 497 extension at the elbow, and a faiHj serviceable and fairly stable joint may be obtained after it Ins been completely excised Old Fractures oj lutenud Condyle In ununited fractures of the internal condyle with displacement the problem is more difficult because flexion and extension of the elbow depend on the joint betv,een the trochlea and the ulna Consequently, in order that these motions may be restored, this condyle must be replaced in approximately its normal position Unless this is possible m the adult it will probably be necessary to disregard more or less the bony structures present and to perform an arthroplasty with ■whate\cr bone is left In children and frequently in adults restoration may be obtained by open reduction and bone graft In doing the arthroplasty the surgeon should not endea^o^ to restore the normal contours of the joint but should endeasof to construct a simple hinge joint betv.een the lower end of the humerus and the greater sigmoid caxitj of the ulna and should not hesitate to remoxe sufficient bone so that with traction on the forearm there is a gap of approximately one half inch between the bone ends and no limitation of motion m either flexion or extension Old Intercondylar orT Fractures In these fractures especially where the condyles ha\e been severely comminuted and there is ankylosis w-ith marked deformity, it will usually be necessary and advisable to perform an arthroplasty from the mass of fused bone which is left Old Fractures and Dislocations oj Head and Idcck oj Radius These injuries are discussed under treatment of the acute cases, but in old mal united complicated fractures at the elbow it is not infrequently found that fractures of the head of the radius are one of the chief causes of disability If this is true the head and neck should be excised in order to restore motion of the fote-atm This may be done at a separate operation or may be done simultaneous!) with the operation for the restoration of flexion and extension at the elbow When the head of the radius is dis located forward and has been our of position for some weeks, it does little or no good to reduce the dislocation by manipulation and attempt to maintain reduction Const quently an open reduction should be performed and the radius should be reduced and retained m its normal position by a loop of fascia which is passed around the neck of the radius Position oj Optimum Function in Ankylosis oj Elbott Whereas the surgeon should always endeavor to obtain the maximum amount of motion after injuries at the elbow, one occasionally encounters severe open fractures m which more or less infection is present and in which it is practically hopeless to obtain motion In such instances it is important that the elbow be immobilized m such a posi tion that the patient will have as useful an atm as possible after the joint has become stiff There is considerable difference of opinion among various surgeons as to what this position should be By many it is argued that the elbow should be immobilized with flexion slightly beyond a right angle and with the forearm supinated, since with this position it IS possible for the patient to get the hand to the face However, we feel that it is even more important that he be able to use the hand in some gainful occupation Consequently we advise immobilization with the elbow extended to about 130®, that IS, about 40° extension beyond a right angle, and with the forearm m the mid position between pronation and supination as illustrated m Tig 527 49S DIACNOSIS AND TRCATMCNT OF SPrOFIC INJURIJJ. F g 5 6 Mc>l od of 1 alpat i\g head »f rad os i^hilc fotcai » towtcd ^ t! other hand F g $27 Poa t on of opt mom fuoct on for ankjlos s at elbou lo a aork ng man FRACTURIS OF UPPER END OF ULNA Vracturci of Olecranon Occurrence anti hXechanunt Despite the fact that it is a vcfj heavy strong process of borte the oleeranon is rather ft€<|uen.tly fractured m adults llus is partly slue to its exposed position on the point of the elbow where it rece aes most of the direct injuries to the elbo^ and partlj to the tremendous cross strain which is put upon it in falls upon the flexed and supinated forearm The process is rarely broken in children because in early life it is shon and thick and relatively much stronger than the lower end of the humerus The most common mechanism is a fall on the semiflexed and supinated forearm As the hand strikes the ground, the muscles arc tensed to break the fall and the power ful triceps bcachii snaps the olecranon over the lower end of the humerus wh ch acts as a fulcrum The next most frei^uent cause is direct trauma as occurs from falls or blows on the point of the elbow More rarel) the olecranon may be fractured b) hyper extension injuries such as usually result m d slocai on of the elbow m adults or supra condylar fractures m children Very rarely it is broken by muscular Molencc as in throwing Pathology The usual fracture is a transicrsc or sightly oblique break near the base of the olecranon (Fig 529) In the obi que fractures (Fig 528) the fracture line tends to slope down and back and emerge on the posterior border of the ulna In other instances a small piece of bone is pulled off the proximal end of the olecranon and the injury resembles a sprain fracture The fractures from direct v olence are often open and may be comminuted The displacement is largely due to the puH of the triceps bracliii muscle wh ch tends to pull the separated fragment upward but it is resisted by the strong fibrous cosermg on the olecranon This is forraw by a blend ng of the fibers of the lateral Iiga ments and capsule of tlie elbow and of some of the fibers of the triceps bradiii tendon all of wihich blend with the periosteum If this fibrous sheath is not torn by the fiic hiring force there is 1 ttle or no tendency to dsplacement even in the presence of considerable comm nution and as a matter of fact a considerable percentage of fractures of the olecranon show 1 ttle or no displacement If the fibrous covering of the olecranon is lorn the upper fragment is forced up- ward bj the fracturing force and drawn upward by the triceps bra^u muscle which is inserted into it However in a fresh fracture the displacement rs rarely more than ^ inch Fractures of the olecranon tn whidi there is wide separation of the fracmimls arc usually old fractures associated with rttensne tearing of Uic fibrous sheath in which the 528 Oblique fract tre of olecran n in a ihild TrealtJ br nnnit>b 1 nation in i plaster cast with elbow in moderate extenr o SOQ DIAGNOSIS AND TREATMENT OP SPEaFIC INJURIES unopposed tnccps brachii has gradualt) contncted and drawn the separated fragment upward The amount of scpantion of the fragments is increased bj flexion and decreased b) extension of the elbow In addition to the displacement of the upper fragment there may be more or less anterior displacement of the bones of the forearm on the humerus In such cases the upper end of the radius moses with the upper end of th* ulna and there is an anterior subluxation or dislocation of both bones at the elbow which can be easily reduced but lends to recur when pressure is released as shown in Fig 537 Tig S’9 Transvetie fracture of olecranon Treated by open reduction (see Fig 530) Since these fractures arc practically all articular there is more or less effusion into the elbow, and there may also be effusion into the olecranon bursa In severe injuries the fracture may be accompanied by dislocation oc fracture ol the head of tlic radius and fracture of the lower end of llie humcnis In closed fractures of the olecranon there IS, as a rule, relatiiely little damage to tlie soft parts FRACTURES IN REGION OF ELBOW 501 Diagnosis The region of the dbow is moderateJ) swolien, espeaally o^er its posterior surface and the patient usiufl} su{^rts the forearm in a position of sJight flexion (about 135° extension) In most cases of complete fracture there is a character istic soft fluctuant, tender swelling o\er the olecranon from effusion into the bursa and surrounding tissues Fig 531 A Lateral x ray film of closed fracture of olecranon before irealmcnt Note com minution and translucent area both anteriot and posterior to distal humerus which apparently represents displaced fat pad B Postoperatve vie* rracturc immobilwed wiih a Leinbach screw Palpation reveals pa nt tenderness over the line of fracture and if there is separa tion of the fragments it is usually possible to feel the sulcus between the fragments If the upper fragment is grasped with the thumb and fingers false motion can be demonstrated and it cm be noted that the fragment does not move with the forearm when tire elbow is flexed and extended If the elbow is extended the separated fragment can be pushed down against its origiiul attachment and crepitus can be demonstrated Act»e extension is of course abolished in fnauzes with separation of the ftag-^^ I-RACrURtS IN RLCION Of ELBOW $03 ments and xs greatly weakened and accompanied by pain m fractures witliout displace ment This loss of active extension of the elbow and pain tenderness and swelling over the olecranon are sufficient for a diagnosis Before treatment is instituted, however, details of the fracture should be learned from x ray films Consertalfte Treatment In fractures without separation of the fragments all that js necessary is to immobiliie the elbow in a position of p0° of flexion over a period of 6 weeks This is most corafortably maintained by a light plaster of Pans cast teaching from the axilla to the wrist Comminuted fractures without dispbcemcnt or transverse or oblique fractures with no displacement are best treated m a position of about 135® extension (45® flexion) We do not like to immobilize the elbow in full extension if it can be prevented As a rule if the fracture is not stable in the position of partial flexion it will not be stable in complete extension Those fractures that appear stable m this position and in which the )omt surface has been restored may then be immobilized m plaster until the fracture has healed It is important to obtain checkup films I week after the cast has been applie 1 to make sure that the fracture has not b^ome displaced The unstable or unr^uced fractures require open reduction and internal fixation k Lag S$3 Tfacture of olecraaon in a child Treated hy immobiluation in a plaster cast uith lod eraic extension of forearm at elbow Good result Tractures with displacement should be operated on since conservative treatment often results in fibrous union because the fragments cannot be brought together and because shreds of the lorn fibrous ^eath tend to hang down between the fragments However, a firm fibrous union with relatively slight separation of the fr3f;menis may give a fairly good functional result m the aged person Operatne Treatment If closed reduction has failed to restore or maintain ex cellcnt position and alignment of the fracture open reduction and interna! fixation should be carried out In our experience closed reduction of displaced fractures of the olecranon have been d sappoiating and the vast are Jater subyected to operation 50f DIACNOSIS AND TREATMENT Or SPrOUC INJURIES With internal fixation The purpose of the operation is to restore the continuit) of the elbow joint and to restore the insertion of the tn^ps brachit tendon Operative treatment usuallj results in firm bony union and » good functional result if atutomic reposition is obtained and maintained but it may be folloned by a mild traumatic arthritis with resultant disturbance in function The surgeon must first decide whether the condition of the fragments will allow open reduction and internal fixation in such a way that a satisfactory joint will result If the proximal fragment is badly comminuted if it is a small fragment or if the frac ture occurs in an elderly person excsion of the proximal fragment and repair of the triceps brachii tendon as has been recommended by Watson Jones* and also by McKeever and Buckf may be the procedure of choice Tig 331 Oblique fracture of oleaanon Treated by f*at on w th a wire loop Good result Excision of the proximal fragment and triceps repair give an excellent functional result m persons who are not called upon to do heai-y manual labor or to engage in contact athletics Howcicr some weakness an i instability of the elbow remain There *'\ayon Jones R Exc s on of the Olccnatm 1 ngment and Tr ceps Repa r in Testbw It on rraclurcs and Other Bone and Jo irt Inptncs ed 2 Bah more 1911 V» lha ns ^ Wilkins Cts fMcKcever F M and Bocl. R. Af Fracturef of the Olecranon Process of the Ulna J A M A 133 1 1917 506 DIAONOSJS AND TRCATMLNT Or SPLQFIC INJURU S Tig 537 Se'cre fra turc of ottcranon with anieror displacement of hoth bones at elbow Treated by open reduction wire fxaioo of fracture and immob lualion with elbow extended to no* Pair result Tip 55S Comm tvuted feature of olecranoa treated b> esc sion of promraal fragment anJ of loose fragments and fixation of treeps tendon to distal fragment Flbow remj ned weak but had kxkI motion FRACTURES IN REGION Ot ELBOW ^07 fore, m cases m which there is an opportunity to restore anatomic position of the frac ture we prefer to carry out repositiontnf, and intemaJ fixation It is imperatis'e that the internal fixating device b“ suHicirnily strong to present displacement of the fracture Catgut or wire suture is seldom adequate TECHNIC The fracture is exposed through a posterior longitudinal inasion to the ulnar side of the midlinc The ulnar ner\e is identified and freed sufficiently to allow it to be remo\ed from the operati\e field by retraction The entire area of the fracture should be exposed on botli sides to facilitate accurate repositmg of the fragments as siell as repairing soft tissues The foint a then opened b) increasing the deformity It IS thoroughly cleansed of debris and blood clots are washed out The fracture is then reduced care being taken to see that this reduction is anatomic and that the joint surface IS restored to as near normal as possible If the fracture is repositioned so that a groove or ridge remains on the articular surface a degenerative arthritis may be expected r»g 539 Circular plaster cast with forearm flexed 90* and in mid position with regard to rotation Used m postoperative treatment of roost fractures of olecranon and of fractures of bones of forearm la certain sesere com/nmuteJ olecranon fractures '«ith or without intemal fixalio/i if is best to extend forearm a few degrees besemj a right angle of flexion at elbow When accurate reduction of the fracture and restoration of the joint surface have been obtained, the fracture is held in this position by firm internal fixation In certain instances this may be obtained by the me of a Rush pm m others it is necessary to put in a transfixing screw and in others some surgeons prefer a I-einbach screw The type of internal fixating device used is relatively unimportant so long as it can be relied upon to maintain the fracture surfaces in firm ointact until union has occurred None of these devices gives sufficient support to allow the discontinuance of external fixation After the fracture has been reduced and the soft tissue has been repaired the wound is closed in layers without drainage md a plaster cast is applied with the arm placed in 1 position of comfort which is usually approxunately 90° of flexion Although full extension would take the tension off the fracture surface by relaxing the triceps brachii muscle this js not a comfortable position, nor is it necessary when accurate reduction has been obtained On the other hand dierc is no particular need to flex the elbow Txterral fixation is continued until there is x ray evidence of sufficient union of the iOt> l)lAC^OsiS AND TRCATMLNT OF SPXaHC INJUIUIS fractute to allow the institution of motion Early actise or pissne motion accomplishes nothing except that it maj disloate or displace a beautifuJI) reduced fracture Separation of Epiphysis of Olecranon In early childhood the olecranon is entirely cartilaginous and the bony process is formed bj growth upward from the shaft so that the age of 10 )ears the process is all bone with the exception of a small mass of cartilage at the tip At about this time a small center of ossification appears in this cap of cartilage to form an epiph)sis which unites to the shaft about the sixteenth jear This epiph)Sis is small and is cosered by the insertion of the triceps brachii tendon and IS thus protected from injufj Occasionally howeser it is separated either by direct or indirect siolence as the result of accidents similar to those which cause fracture of the olecranon in adults As a rule the separation is slight because the mam attachment of the triceps brachii tendon is into the bone of the olecranon Diagnosis and Treatment Usually the symptoms arc relaliaely mild There are moderate swelling and tenderness around the tip of the olecranon with loss of power m extension and pain on flexion of the elbow Closed reduction followed by plaster fixation IS usually successful Tig 540 Closed fracture of cor iwid process Trcjied by plaster cast in acute flexion No reduct on was nccessatj Good result Fracture of CoronotH Process Tracture of the coionoid process is a relalnely tare injury wh ch usually occurs as a complication of posterior dislocation of the elbow but it may occur as an isolated injury The mechanism is hyperextens on at the elbow the coronotd process being pulled off b) the brachial s anticus or knocked off by the lower end of the humerus In a personal case the injury resulted from a fall backward on the icc The hand was thrown out and back and slapped the ground with the elbow extended and the forearm pronated The elbow was defin tely felt to hyperextend and then snap back into place Doth lateral ligaments were ruptured and the toentgenogtam showed an oblu^ue fracture including about 3 third of the process with slight separation of the aiulsed fragment The fracture may also be caused being forced up against the humtnis as occurs in falls upon the flexed forearm The tip may be broken off or the fracture may be transsersc or oblicjue in any part of the process and the separated fragment may be dis j laced info the joint and lead to bi ny block at the elbow Diagnosis Tlic cardinal points in the d agnosis arc pam on pressure over the front of the elbow directly oier the coronoid process and pam at the same location on forcible flexion of the elbow or on attempts to flex the elbow against resistance There is a moderate amount of effusion into the joint, and, if the lateral ligaments are torn pain rRACTURCs IN Rfrios or rrnow 5f)9 swelling and tenderness arc present o\er the tom ligaments The diagnosis should be confirmed by X ray examination (Figs M0aod54t) Treatvient In fractures svith only slight separation no anesthetic is necessary The elbow should be immobilized in a posterior plaster mold or cast m as much flexion as is permitted (usually an angle of 45°) At the end of a week or so after the swelling and tenderness ha\e disappeared the elbow can be placed in acute flexion and immobilized for 3 or 4 ss-ed.s longer After this time it can be carried in a triangular sling until the patient is comfortable without it and use may be resameJ gradually In fractures nith moderate or considerable separation local or general anesthesia should be administered and the elbon fort^ into acute flex on while the surqeon s thumb makes pressure o\er the coronoid process and endeavors to force the detadie) Kg >4l Fracture ol eotono d prweess ompicaiog pi/stet or dslocston at elbrw Jrnted by reduci on and irnmob 1 rat on in a ixtsierior pJasiw nold to arm and forearm w th as mu ! flex on as could be ma ntained w th safety (70*) for -1 veeks Good result F g ^42 Trauma! c bun ( s of olecran n bursa Treated b) asp rat on and pressure bandage fragment back into pos tion The forearm should then be immob lized for 4 weeks in as acute flexion as can be ma ntained without endanger ng the circulat on of the hand Should closed reduction fail open reduction should be performed If bony block from a loose fragment excess callus or mjositis ossificans results the fragment or excess bone should be removed after the process has ceased to progress When the coronoid process is fractured in connection with a dislocation at the elbow the d slocation should be treated in acute flexion Traumatic Bursttis of Olecranon Traumatic bursitis of the olecranon is not rare and may be confused with a fracture of the olecranon It is usually due to a blow received on the elbow which is followed by 510 DIAGNOSIS AND TKCATMrNT OF SPrOFIC INJURIES immediate swelling over t!ic posterior surface of the olecranon process with relatnclj little disability at the elbow (Fig 542) On phj-sical examination the patient presents a soft tissue swelling over the olecranon which is not especially tender and there is no tendejness on palpation along the lateral bordets the bone Active extension of the elbosi 1 $ as a riile very Lttle disturbed and ih s and the lack of tenderness along the lateral borders of the bone are the chief points of differentiation between the burs tis and a fracture of the oleaanon without separation of the fragments If the blood in the bursa has clotted since the injury palpation elicits soft crepitus The condition must howesef be differentiated from an infectious burSitis and this is usually poss ble from the history In the traumatic cases aspiration yields bloody flu d In infectious cases the fluid is usually purulent but may be bloody and it maj be neces sary to culture the material in order to rule out infection Trealntenl The bursa is aspirated and "*5 mg of Hydrocortone is injected into the bursa and a compression dressing is applied If the effusion reappears the aspiration should be repeated A chronic thickened bursa should be excised and it is important that all of the sac be remoied FRACTURES OF HEAD AND NECK OF RADIUS Occurrence ami Mechantitn Fractures of the head and neck of the radius were formerly regarded as rare injuries but with increasing use of x ray films it is found that they occur tathcc fce<^uen operation C Normal growth and function as shown by x ray 8 years later CONSERVATIVE TREATMENT Conservative treatment is indicated in all simple fissures of the head of the radius m nondisplaced fractures of the head which involve less than one third of the circumference As a matter of fact this class will be found to include a considerable percentage of the fractures of the upper end of the radius and most fractures in children (Figs 543 and 544) If there is much swelling or pain the yomt should be aspirated to remove the blood One will seldom obtain more than 10 ml but this is a large quantity for this joint, and aspiration plus immobilization are effective in relieving the pain We prefer to immobilize these fractures m a position of neutral rotation and a 90® position of the elbow, by using a plastet cast that extends from the palm to just below the axilla This cast is left on from 7 to 10 days but not longer, after whidi time it is removed and the patient is started on active exercise while carrying the atm m a slmg most of the time With this regimen an essentially normal range of motion is usually obtained although occasionally a few degrees lirnitation of extension will remain If the arm is immobilized until the fracture is healed there will be marked restriction of motion which tends to be permanent OPERA'nvE TREATMENT When the head of the radius is comminuted or when a piece including as much as a third of the bead is bitten off and displaced or when the neck is fractured and the head is displaced or tilted in such a manner that its surface no longer fits the capitcllum and the lesser siynoid cavity of the ulna the fracture should be operated on unless it is possible to aimpletely reduce the displacement by manipulation Operative treatment is necessary because the continued displacement not only results in limitation of motion of the elbow and of the forearm but also is likely ^16 DIAGNOSIS AND TREATMENT OF SPrariC INJURIES to cause a traumatic aithtilis, ss hich roa) be the cause of considerable pam and permanent disability Unless tliere is some definite contraindicalion, such as shock from other injuries, loal infected abrasions or lacerations or otticr fractures in tlie MCinit), the operation should be petfoctned as soon aftcc the injury as possible In other nords when the lesion IS such that the surgeon knows immeciiitely tliat conservatne treatment will gne a poor result, he should adsise earlj operation Technic of Remotal of HevI of Rotims The operatise approach is by an oblique posterolateral incision which begins o\er die cpicondjle of the humerus and extends downward and bickward along tlie anterior border of the anconeus This incision may be earned to the ulna and then extended downward along the subcutaneous border of this bone Tlie muscles are separated tti Ime with the incision and the capsule of the joint is inased to expose the head of the radius The posterior interosseous branch of the radial nerve is not exposed or injured If the separated fragment is small, it may be removed and the remainder of the head may be left in place In nn adult if the bead is comminuted of if it is impacted upon the neck with displacement, the entire head should be removed and with il should be included enough of the neii to assure free rotation and free flexion and extension at the elbow joint Th'* stump of the neck should be rounded off by rongeur forceps and may be covered by' a purse string suture m the sur rounding soft tissue but vve prefer to have the smooth bare bone end in the wound The periosteum should not be stripped up and care should be taken to leave no tigs of periosteum attached to the stump of the neck When cnoui,h of the stump of the neck has been removed to assure free motion the joint capsule is sutured and the wound is closed in layers without drainage After the opention a posterior plaster mold or plaster cast IS Applied with the forearm flexed and supinaled and the fracture is treitcd as described previously under conservative treitment In diildrcn with fractures of the neck of the radius in whidi the intict radial head IS displaced it is usually possible to replace the head m its normal position by minipula tive reduction The head of the radius should not be tenvsvcd m growing chddtcn If manipulation fails to restore angulation below 45® in a young child or less than 15® m an older child the fracture should be reduced by open operation No internal fixation is required Immobilization until the fracture has united is obtained in A plaster cast After removal of the fractured radial head m the adult «e expect a painless elbow With almost normal motion and strength Sutro* has reported four cises with siiflicicnt regeneration of bone after the excision to cause disability and so have others Tins has not occurred in our experience but his report stimulates us to make the excision clean cut and smooth and free from pcnoslca) tags BORDERLINE CASES In those fractures in which a small portion of the bone is bmken olf or m which the displacement is slight the surgeon is justified in using conservative treatment until it has been determined whether or not marked limitation of^motion will result but he should not wait until traumatic arthritis has developed in the elbow joint Occasionally small detached fragments of the head of the radius become free in the elbow joint and act as loose bodies (joint mice) whicli blodv motion from time to time TIicsc should be removed not only because they blodv the motion but also because their continued presence in the joint causes irritation and may cause definite traumatic atlhntis DISLOCATIONS AT ELBOW Dislocations occur more frequently at tlie elbow than at any other joint in llic body except the shoulder This is probably due to tlic cxposc-d position of the joint and to the faa that it is subjected to tremendous leverage in hypcrextension injuries ft »s •Sutro C J Itegrottth of Bone at f^mioul ToJ of Radius lolIoAin^ Rewfion in TJi>» BrS on. } Bone fi Joint Sum R67 1955 rRACWRTS IN REGION OF ELBOW ^27 furtlier to be noted that in children and adolescents dislocations occur at the elbow much more /requently than they do at the shoulder This is due to the /act that the coxonoid and olecranon processes on s^hich much of the stability of the ;oint depends are poorly de\ eloped in early life T) pes. Posterior dislocation of both bones of the forearm upon the humerus is by far the most frequent type of dislocation nhtch occurs at the dbow The next most frequent type is a lateral dislocation of the head of the radius alone All other forms of dislocation at this joint are rare injuries They include posterior or outward dis locations of the head of the radius alone, posterior or inward dislocations of the upper end of the ulna alone, and forsvard, lateral, or dnergent dislocations of both bones of the forearm upon the humerus Posterior Dislocation Occurrence Posterior dislocation occurs more frequently than all other types at the elbow for six mam reasons (1) both bones ate usually dislocated because the radius IS firmly bound (o the ulna by the annular ligament and interosseous membrane, whereas It articulates rather loosely with the humerus, (2) the lov^er end of the humems is very wide m the lateral plane and rather rutrow m the anteroposterior plane, consequently the bones of the forearm can be dislocated posteriorly much more easily than they can laterally, (3) tlie antiirioc and posterior portions of the capsule of the joint are relatively weak, whereas the lateral ligaments are relatively strong, (4) the normal motions of the joint occur in the anteroposterior plane and there is practically no motion in the lateral plane, (3) the injuries which cause disloation are usually forces which tend to force the forearm upward and backward, and (6) posterior dislocation is resisted by the coronoid process, which is relatnely small in children AUehanisvi This lesion is m most instances the result of a hyperextension jojuiy at the elbow such as is incurred m a fall upon the outstretched hand with the elbow ex tended and the forearm supmated The force is transmitted through the ulna, and as the olecranon is levered against the lower end of the humerus the upper end of the shaft of the ulna is forced backward and the lateral ligaments are stretched or ruptured Tlie upper end of the radius moves with the ulna, and, when it and the coronoid process have been displaced backward to a point where they no longer rest upon the lower surface of the humerus, the bones of the forearm slip upward behind the humerus and become locked in their new position by the coronoid process whicJj comes to rest m the olecranon fossa It is also to be noted that force m abduction as well as in hypcrextension favors this tjpe of disIocslioQ, and that MiJgaigne found that the internal lateral ligament could be torn and the ulna forced backward by forcible internal rotation of the semiSexed forearm Pathology Tlie dislocation may be complete or incomplete In the incomplete form the tip of the coronoid process rests upon the trochlea, and in the complete form it has traveled upward and rests in the olecranon fossa Not infrequently there is a variable degree of displacement of the forearm in the Uteral plane, with either an abduction or adduction deformity present, and the upper ends of tfie forearm bones are displaced in the opposite direction on the humerus The most frequent ^pe is a dislocation back ward and outward m which the internal latoal ligament and anterior capsule are torn or detached from the humerus, and the external lateral ligament may or may not be torn With complete tearing of all the ligaimuts the lateral displacement of the forearm IS largely dependent upon gravity, since there is considerable lateral instability at the elbow joint The orbicular ligament usually teoiiins intact, and the upper end of the radius IS firmly attached to the ulna and is displaced with it The lower end of the humerus projects into the cubital fossa, and the tendons of the biceps and brachialis 5JR UlACNOSJS AND TREATMENT Oi SPrOFlC INJUWtS antiois are stretched over it and may be lacerated 'There may be considerable stripping up of the periosteum on the posterior surface and lateral borders of the loiter end of the humerus In severe injuries due to great force there may be sside displacement with injur) to the ulna, radial and median nerves or brachial vessels and the flexor muscles of the 1859 T e 5J4 Tfp nl pmimor d slontion ef Jett elbow forearm ma) be extensively lacerated and tom from their attachments Tlic dislocation may be complicated b) fractures of the upper end of the radius the coronoid process of the ulna, the external cond) le of the humerus or the internal epicondyle of the humcrui Diagnosis In a recent case the forearm is usually carried m a position of moderate flexion (about 135® extension), but there is no duractensUe position- It m-t> be full) TRACTUarS IN RCCION Ol rLBOW 519 extended or even hypercxtended may be m any position with regard to rotation and a laJgus or \arus de/onnity may be present (Figs 555 and 556) On inspection the anteroposterior diameter of the elbow is increased but the lateral diameter is normal except for the swelling which varies in different cases When viewed from the side the forearm appears to be shortened the olecranon is usuallj prominent and higher than normal and the low'cr end of the arm appears to be faow^ forward that is, it tends to be concave behind and convex m front There is a definite fullness in the cubital fossa over the front of the elbow, and if the extremity is viewed from the front the shortening appears to be in the forearm whereas if it is viewed from behind the shortening appears to be I n the arm As a rule extensive swelling occurs rather rapid}} after the jn;iiry and may involve the entire elbow region and obscure ih“ characteristic picture described above However, the diagnosis can be made bj palpation since it is alwajs possible to identify the fig 535 Pojttff or disloeat on at elbow wkS\ard aod upper end of ulna forward and sfou fy Hexes forearm over h s thumb Fig 360 Another method for nun pulative redact on of postenor d siocatioa at eihow \Vhen forearm is maiotamed in pos t on of flexion, co attempt should be made to hyperextend elbow since this ma) cause damage to soft parts but tract on can be made on flexed forearm and d slocaiion can be reduced in th s manner and then forearm flexed as show n tn Fig 339 patient he face dov,n on a fracture or regular operating table with the injured arm hang mg off the side After a few minutes considerable muscle relaxation occurs at which time rery gentle traction by the surgeon will complete the reduction Afterlrcalment Reduction basing been acxomplished the elbow should be im mobilized m as much flexion as it ts safe to use in the presence of whatever swelling maj have occurred This will vary from slightly less than a right angle to acute flexion 522 DIACNOSJS ANO TREATMTHT OP SPEOFIC ISJURjrS Roentgenograms should alp-uj-s be obtained immediately after reduction to be sure that a satisfactory reduction has been accomplished and again at the end of 1 week to be sure that some displacement has not occurred because s\e ha^e had an opportunit) to obsersc a few patients v,ho had complete tedislocation csen m a circular plaster cast Immobilization should be continued from 4 to d weeks, at the end of whidi time the cast IS remosed and the patient is started on active exercise This may be accompanied by local heat and massage but passive motion either by tlie patient or by a therapist should never be used, and under no arcomstances should the patient be advised to carry a weight or attempt to force motion of the elbow because this will only retard the return of function and may even result in permanent sti/Iness If tenderness and marked limitation of motion are present 7 or 8 weeks after the injury roentgenograms should be taken to determine wlicther or not mjositis ossi/ians IS developing If the x ray films show abnormal caloum shadows around the joint, the elbow should be immobilized and treated as described under mjositis ossificans If there IS no calcium deposit around the joint and the {Inion persists, the elbow should be ex tended by traaion or a wedging plaster or by operation as described under the treatment of supracondj hr fractures of the humerus III. 5<>l Postrror dilocation cl elbow in a child complicated hj fracture ot external nn dylc Treated by manipulatiii; tcduction and immobiliaation lo position of moderately acute fiexion with a posterior plaster splint to ann and forearm for 6 weeks Good result Trei/imem of Posterior Dishfatsoa CoPiplscateit by fracture A large percentage of the dislocations at the elbow arc complicated bj fractures Tliose most frecjuently seen arc fractures of the head or neck of the radius, fractures of one or both condyles of the humerus fractures of the coronoid prooiss or olecranon of the ulna, fractures of both bones of Uic foteatm, or a combination of two or mote of these In most instances tlic presence of these fractures can be excluded only by x ray examination In tlic presence of any of these fraclutes the dislocation should be reduced by nunipulation just as though the fracture did not exist Tlien the surgeon should treat the fracture m most Instances just as iltough there were no dislocation In other words, if the dislocation u compliotrd by a fractuir of the head of the ndius the disloation FRACTURES IN REGION OF ELBOV5' should be reduced bj manipulation and then the fracture of the head of the radius should be treated by simple immobilization in acute flexion or open operation as mdi cated according to the principles laid down in the section on fractures of the head and neck of the radius The period of iramob fization is somewhat longer in dislocations vihich are ac companiec! by fractures Production oj New Bone Around Elhou (Myosilts Ossificans, Osstjytiig Hematoma, and Exuberant Callus) (Fig %?) When a muscle has been sufficient!) damaged that part of it is killed the tissue is altered and as a rule fibrosis lakes place Under certain arcumstances this fibrous tissue reaction may be rather exuberant so that a fibrous tissue mass is formed scinch may be confused with a malignant change /ssoaaled with this reaction and at times without it new bone is laid down as a result of the histochemical changes which take place convert ing the damaged muscle hematoma anl reactive connective tissue to an ossifiibie medium Fig Myositis oss ficans following old fracture of lower end of humetus and d slocat on of head of radius Treated by removal of excess bone and redurt on and fjratioa of hnd of rad us with a strip of fasc a Good result Strauss* collected 124 cases of new bone formation m muscle, the so called m)ositis ossificans and found that 64 of them were m die flexor muscles of the arm with the brachialis antiow the most frequently involved Forty three ^ere in the quadriceps femons 13 in the posterior muscles of the thigh 2 in the gluteal area I m the thumb and 1 m the temporal muscles Ackerman t m reporting 26 cases found that they occurred as follows 2 m the forearm 6 in the buttocks 1 in the hand 2 m the abdomen 8 m the thigh 1 m the region of the pelvis 1 in the knee 1 m the neck 2 in the upper arm 1 m the elbow and 1 in the ankle It would seem that although this condition is a frequent complication of fractures and dislocations partirtilarJy dislocations at Ihe elbow joint it occurs more commonly in other sites in the body and it is not always eminently associated with bone or bone and joint, injury In fact many patients do not give a history of an injury •Gted by Lew s Dean Mjo lUsOssfcans J A M A 80 1281 IS’S t Ackerman L V Lxtraosseous Local zed Non Neoplast c Bone and Cart lage Formation (So called Sfyosits Oss ficans) J Gone & Joint Stug 4o-A 279 1958 526 DIAGNOSIS AND TBrATJIENT OF SPronC MJURItS Zone 1 Zone 2 Zone 3 Peripheral Zone Fig 56fi A Zone phenomenon of AAwmti^ «le»nonslrJting chjoge jn m cruifop f 4pp«f *nfr M3 one goes from center to pertpi eqr of Mte* of mjot t« «» ( cant B Pltoiotn ewgwph of active cefllral area. Thu u the p ctore thu map be cwtfused w ih osteosareoma C bfore matute bone at penplrwy (Froti Ackerman. L \ J Sone&Jont Snrg ^0-A 279 1938 FRACTURES IN REGION OF ELBOW 527 As stated before myositis ossi6cans is a process of bone formation within muscle tissue According to Ackerman m esety instance there is the presence of dead or dying muscle and early in the process there may be no bone formation discernible In Aose cases assoaated with injury he was able to find some evidence of bone formation as early as the nineteenth day and felt that this new bone formation should be Msible m the x ray film within one month of the onset of the process whether or not it is assoaated with injury Microscopically there is an area of damaged dead or djing muscle surrounded by a fibroblastic proliferation wttli progressive diange in appearance of the lesion from the center to the per phety This change is one from completelj undifferentiated tissue to that of quite well differentiated and mature bone at the periphery This has been define ated by Ackerman as a zone phenomenon and is of utmost importance m arming at a diagnosis and m distinguish ng myositis ossificans from a sarcoma (Fig 566) As the lesion becomes older Aere is a gradual process of ossific^ton until all activity has ceased After this follows a regressive stage in wh ch the size of the les on tends to decrease and if it happens to be in an area m which muscles and tendons are running over this lesion with motion of the jont there may develop a cartlaginous covering The lesion represents a condition which has been termed traumatic osteo- chondroma by Lent Johnson * Dtagnosis New bone formation around the elbow is to be suspected if the area te mams tender for an unusually long time if the restoration of motion is abnormally slow and if active or pass ve motion causes an abnormal amount of pam The early diagnosis an be made only by x cay exam nation and if a simple d slocation is not free from tenderness and pain and quite freely movable 6 weeks after the acadent an x ray film should be taken to determine whether abnormal bone formation is occurring TrtaUntnt The ideal treatment would be prevent on but we know of no way m r g 566 (continued) C More nuluce bone at periphery (From Ackerman L V J Bone A. Jo nt Surg 40 A 279 1958 ) •Cited by Ackerman L V Fxtraosseous Local zed NonNeoplastc Bone and On !age Formation (So Oiled Myositis Ossi£cans) J Bone & Joint Surg 40-A 279 1958 $28 DIAGNOSIS AND TRCATNfNT OF SPEanC INJURIES ssbidi ihe condihon an be prevenled It eitfier happens or it does not regardless of the treatment We belicsc ho’we%ef that rn certain cases carl> or too strenuous adisc and passive motion aggca\atcs the condition Once the process has begun the treatment is rest of tlie inioivcd joint This rest should be complete conlinuoos and of Jong duration The reason for rest js that attempts to restore motion irritate the invoiced tissues and the irritation stimulates new bone formation Consetjuentlp as soon as mjositis ossifians is diagnosed the elbon should be placed in the best functional position for the patient (usuallj at an angle of about tSS" and occasionally at an angle of about 70® depending upon his occupition vith the fore arm in the mid position mth regard to prooation and supination) and a nelj fitting plaster cast should be applied from the upper arm to the base of the fingers Tins im mobilization should be continued for 6 weeks or more if necessary until the loal tender ness has disappeared and tlie ne^ bone formation his ceased as can be determined by the fretyuent taking of x ray films Bush and JfcQain* state that they inject the area of early ossifiation nith tefneame and hydrocortisone and continue actne exercises and (hat they haic obtained gratifying resolution of the process We haic had no experience « ith this therapy After the tendency to new bone formation has ceased guarded attempts to restore motion should be made These should consist of graded actice exercises gentle massage and loat heat But passive motion should not be used and above all the elbow should not be manipulated When the entire process has completely quieted liown if there is a pernnnent bone block at the elbow the offending bone should be removed by operation Hie dissection should be sharp and dean and special care should be taken not to damage tissues or strip up the periosteum The type of operation will depend upon the location of the bone and It should not be attempted by any except a skillful surgeon Auterwr DtsJocaiiot: Occurreuce and Mechatusm Anterior disloat in at the elbow without fracture is a very rate lesion and in about a third of the rworded cases the dislocation has been contpliatcd by a fracture of the olecranon The probable ause is a fall or blow on the point of the flexed elbow PalboJogy TJiere is extensive tearing of ligimcnts the olecranon rests on the an tenor surface of the lower end of (he humerus and the head of the radius is anterior to and above the external condyle Dirfgiiosis Tlie elbow is supported m a position of 'ilmost complete extension and is immobilized in tius position by muscle spasm. On palpation the rounded condyles of the humerus an be palpated beneath the skm it Uie jxiint of the elbow the olecranon will be found to be absent from its normal position and the axis of tlie shaft of the ulna crosses tlie humerus abov c the condyles TrtatMtnt The treatment is immehatc reduction under adequate loal or general anesthesia VC'lien muscular rclaication has been obtained the arm should be fixed by an assistant while the surgeon grasps the tniurcd foreann with both hands and makes traction in the line of the arm While the traction « maintained with one hind the other push« the upper end of the forearm bickward and downward causing the olecranon to si p back around tlie lower end of the humerus W'hcn llic reduction is complete tlie elbow should be immobilized for 3 or 4 weeks at an angle of about 135® »n a plaster cast or posterior mold At Ihe end of this tunc active motion should be stirted and the arm earned m a sling *D <1 L r «nd McCIa n. ¥ J Jr Operative TfMlrrent of Fractures of tJ e Flbcu fn Adults, Instruct caul Course Lecturn The Artencan Aadeiry of Oftlioped c Surgeons xoJ t6, Louis 1959 The C V ^^osby Co FRACTURES IN REGION OF ELBOW’ 32P Lateral Dislocalton of Both Bojjes of Torearin Tliesc are rare jnyuries in Tvhich the /orcarm bones may be displaced either outward or inward on the humerus They may result from direct \iolence wrenching of the fore arm or falls upon the hand >30 DIAGNOSIS AND TREATMrNT OV SPrOHC INJURIES behind it In other instances the oHiicuIar ligament is tom and the head of the radius renuins in contact svith the capitellum The lateral ligaments are tom Diagnosis Unless it is limited bj great swelling motion of the forearm is fairly free in all directions but is \er) painful On inspection the elbow is broidened anl the axis of the forearm is shifted inssard The diagnosis ts made bj the abnornulities in the bonj landmarks The external condyle is unusually prominent and the sigmotj a\it) lies medial to the internal condyle and usually embraces it The triceps tendon can he traced upward and outward from Ihe prominent olecranon which lies behind the internal condyle Treatment When muscular eelaxatton his been secured by the anesthetic, the atm IS immobilized by an assistant The surgeon then grasps the wrist with one hand and makes moderate traction on the almost completely extended forearm S multaneously with the traction he manipulates the region of the elbow with his other hand pushing the upper end of the ulna downward and outward In most instances reduction i> not difficult Occasionally hovstscr the manipuhtion may result m the amvcrsion of an inward into a posterior dislocation If this occurs the postenor dislocation should then be reduced as described preiiously After reduction, the elbow is immobilized in a posterior plaster mold or plaster cast m as much flexion as the swelling pennits and supported with a sling The immobiliza tion should be continued for i weeks At the end of this time the plaster can be remo'cd and the forearm supported m a Jones sling The sling should be lengthened dailj and active motion begun fn order not to lose fl-xion the patient must flex the forearm folly each day The sling can be discarded as soon as the patient is comfortable without it Outtiarfi Dislncatton Pathology Tlic dislocation may be mcompletc tr complete In the incomplete type the sigmoid cavity rests upon the lateral part of the trochlea or capitellum the coroiHud prce been stretched o\er it Diagnosis Tlicre may or may not be a history of forable traction as described aboie, but this is not necessary, since the physical findings are characteristic A child, usually between the ages of 2 and 4 years complains of pain at the elbow and caitics the forearm pronated and refuses to use it riexion and extension of the forearm are free but supination is sharply iimitcvi Palpition is usually negative except for slight tender ness over the head of the radius, but there may be slight prominence of the liead The characteristic feature is the limitation of supination combined with free flexion and cx tension at the elbow The roentgenogram is negatiic or shows slightly increased separa tion IxAwecn the head of the radius and die capitcllum Treatment The treatment is reduction by manipulation as follows The surgeon grasps the aflccted elbow wiili one hand, with his tiiumb resting on the head of the radius With the other hand he grasps the wnsl, and, holding the forearm in almost «>mplele extension, supmates it As the child s forearm is forably supinated, the surgeon makes moderate pressure on the head or neck of the radius wiUi his thumb and pushes upward on the forearm As a rule the nunipulition requires relatively slight force and causes relatively little pain rrcquently no anesthetic is necessary As the child s forearm is supinated a shglit dick can often be felt and tiie pam and limitation of movement disappear immediately So easy is the reduction that frequently it occurs spontaneously or is accomplished accidentally by the parent or nurse Afiertreatmeat. The forearm should be earned in flexion for a few days niis can FRACTUSES IV REGION OF rLBOVP 535 be accomplished by a Jones sling or bandage and adhesive dressing The parent should be instruded to avoid hy’perextension of the child s elbow or traction on the child s fore arm for a fess weeks j In; 57 J D slocat o V'' '**' of head of rad us in a tl Id produced by sv before and after reduct on by nun pulat on ng ng child b) forearm Posterior Dtslocatwu of Ulna Alone Occttrrettce artti Mechatitsitt TTiis is a serj ntre injury because the upper end of Che radius is so firmly bound to the ulna that it almost always trasels with it Occasionally howetcr forable hyperextension ctmbined with adduction at the elbow may cause posterior dislocation of the ulna alone PatJjofog) The ulna is dislocated backward and adducted (gunstock deformity) while the radius remains m situ The internal lateral ligament is torn, and the erterrul one js probably intact The coronoid process may be fractured DIAGNOSIS AND TREATMCNT OF SPtanC INJURIES Diagnosis The forearm is usually held in almost complete extension and a moderate adduction deformity is present Hexion is markedl) limited but supination and pronalion are free The olecranon xs prominent behind the elbosv and its tip is displaced upward and outward Tire condition icsemWes a posterior dislocation of both bones but the head of the radius cm be palpated in its normal position Treatment Treatment is reduction manipulation and immobilization in flexion Reduction is accomplished by hypefcxtension and abduction As the hjperextended fore atm IS forced to the radial side the gunstock deformity is corrected and the ulna slips back into place with relatncly little dithculty The elbou is immobilized m flexion pref erably in a posterior plaster mold or cast and the aftertreatment i$ the same as that described previously for posterior dislocation of both bones of the forearm Anterior Dis^ocufioi/ of Ulna Alons This IS an extremely rare m|ur) which may result from a fall on the point of the flexed elbow as in Stimsons case The tip of the olecranon lies in front of the trochlea and the head of the radius is in its normal position In the recorded cases reduction was easily accomplished by adduction and forcible pronation thus pushing tlic ulna back into position Tlie aftcrtrcatmeni would be immobilization at about 90® flexion as described in anterior luxation of both bones of (he forearm REPAIR or OLD MALUNITED FRACTURES AND UNREDUerD DISLOCATIONS AT rLBOW Poor results with permanent impairment of function arc frerjuently seen followint; fractures and disloations at the elbow Many of these poor results are due to poor treat ment but in some instances with marked displacement and scsere comminution of the joint surfaces it is practically impossible to obtain a satisfactory result Not mfreejuent!) a patient with an old elbow myury with peiinancnt impairment of function demands relief As a role relief can be obtained only by operatne intencntion and this should not be undertaken lightly Operatne procedure will, of course \ary with the reijuiTcments of each mdiMiJual case and must be deoded upon after catefui study of complete roentgenograms and analysis of the functional disability Campbell* laid down the following principles for the guidance of the surgeon in the reconstruction of these elbows with old traumas 1 Reconstruction of the normal contour and alignment of tlie elbow joint with especial reference to the carrying angle 2 An increased or normal motion This is desirable, but stability and cfliaenl func tion should not be sacrificed foi the mere restoration of motion 3 Preservation of the condyles with lhar articular surfaces wlicn possible and flic securing of union between the detached condyles and the shaft m as nearly the normal relationship as possible d Union and proper alignment m T fractures between the condyles Ihcmschcs » and between the condyles and the shaft 5 Excision of bony blocks or bridges that retard or prevent full motion When the disability is due to an excess formation of callus or to a myositis ossificans, no operation should be attempted until ossification isccmplcte In considering the reconstruction of these elbows with oil traumas the sufgcof* should not Ignore the factor of growth awd as a general rule m cluldren every effort should be made to replace the bones in such a manner that norm.iI growtli will proceed •Campbell W C Majumted rractotes and Unreduced Dislocstiotj About the Elbow J A bLA 93 122 1929 FRACTURES IN REGION OF ELBOW 537 whereas in adults he may freely remove E>one and bend his efforts toward the establish ment of normal function Arthroplasties should not be performed until growth has been completed Old Posterior Dislocations of Both Bones If the dislocation has existed longer than 10 days the surgeon should be \cty careful in attempting to reduce it by manipulation because such attempts maj result la crushing fractures of the condyles of the humerus or irreparable damage to the soft tissues around the joint If the dislocation has existed more than 3 weeks, it is usually unsafe to attempt reduction by mampulation, and an open operation should be performed The fonow-ing operation desised by J S Speed offers the expectation of a useful elbow unless the bones have been out of place so Jong that the cartilage coiermg tlie articular surface has undergone fibrosis This usually does not occur until 2 months or longer after the injury Speeds Method for the Reduction of Old Dislocation at Elbow* The masion is made over the posterior surface of the elbow beginning m the midhne about 4 inches above the tip of the olecranon and extending down to just above the tip of the olecranon where it turns outward over the external condyle of the head of the humerus and the head of the radius for about 2 inches down the forearm The skin flaps are dis sected back, completely exposing the tendinous insertion of the triceps muscle and the posterior surface of the elbow joint The ulnar nerve is next looted dissected up from Its bed along the groove of the internal condyle and retracted out of danger The tendon of the triceps muscle is dissected out from its upper end and turned down and left attached to the olecranon An inosion is next made directly m the midhne through the fibers of the triceps muscle down to the humerus extending from 3 inches up the shaft down to the reflexion of the joint apsule around the arti^ar surfaces Subperiosteally all of the muscular attachments over the lower end of the humerus are stripped free When the attachment of the joint capsule is reached it is necessary to divide this with a knife or scissors Some difficulty may be encountered m freeing the tissues around the internal condyle and along the anterior surface of the humerus just above the joint but It IS essential that they all be loosened and that the lower end of the humerus be com pletcly mobilized This difficulty will be greatly lessened if the mcision has previously been extended down over the radius exposing the head and a small portion of the shaft Considerable callus is often formed over the posterior surface of the humerus around the olecranon fossa as a result of the stripping up of the periosteum at the original in jury This callus with the scat tissue in the olecranon fossa and inasura semilunaris is next thoroughly removed When the lower end of the humerus has been completely mobilized and the capi tellum and the head of the radius have been exposed, one is ready to mriy out the first step in the reduction Simply twisting the forearm with gentle pressure over the capitellum causes the head of the radius to glide forward over the capitellum into the normal po sition If this IS not easily accomplished further dissection will render the maneuver possible without unnecessary force The surgeon should avoid injury to the cartilage by levering or skidding the head of the radius forward After the radius is reduced the coronoid is slipped forward over the trochlea to complete the reduction The joint is then carried through the full range of motion to ascertain that there is no obstruction The periosteum and muscles arc next closed along the posterior surface of the humerus, fascia IS closed over the head of the cadias and the tendon of the triceps is sutured back into Its nornul position The arm is placed in apostenor splint and the elbow flexed at a right angle •Speed J S Operation for Unreduced Posterior Dislocation of EJbow Southern M. J is 193. 1925 538 MAGNWS AND TRl^TMPNT OF SPCOFIC INJlRir'i r B I f 2 F K 571 Trs ure of upr«t ll tJ of « cu ««l am« or *1 ^locat on of uppff eoJ of rad u< Trwfed by nun pulal e rcducr on and mn ob I x*t on n an er r and poster or plas rr molJr » fl forearm a flex on si gl tly beyond t t>l t af»gle ar elbow C ood csuU r g 373 R >enfi.en c an of pat ent n F g 5 I tRACrURLS IN REGION OF CLBO^ ^39 rRACTURES OF UPPER THIRD OF SHAFT OF ULNA WITH OR WITHOUT DISLOCATION OF HEAD OF RADIUS Occurrence and Isiechantstn Fractote of the upper third of the shaft of the ulna IS a rather uncommon lesion which ma) result from direct % lolence to the posterior sur face of the forearm just below the elbow and may be open The fracture line is usually roughly transierse, and the upper third of the shaft of the ulna tends to be bowed for ward, thus rendering the posterior subcutaneous surface concave In some instances there is complete separation of the fragments the distal fragment being displaced anteriorly and slightly upward These severe cases with anterior displacement are usually accompanied by anterior dislocation of the head of the radius (Monteggia fractures) A F s 577 A MonieRgia closed Intcture of elbow and forearm Closed reduct on carried out with excellent reapposition of fragments of fracture of ulna with good reduction of head of radios B Circular cast was applied, and patient developed normal function Evans* lus demonstrated both clinically and cxpenmentall} that fracture of the sluft of the ulna, with or witliout an assoaat^ fracture of the upper radius or a disloca tion of the radial head may be produced by forceful promotion of the forearm Reduction of these fractures by traction and supinatton usually was stable and allowed healing with normal function Diagnosti If there is no displacemeot the diagnosis depends upon llie presence of •Evans E Pronalion Jn/uries of the Eoreano, J Bone te Joint Surg 31 B 378 1949 $40 DIAGNOSIS AND TRtATMENT OF SPCOnC INJURIES point tenderness ind sucllmg ow the fracture hnc and pain in the same location v,}icn cross or axial strain is put upon the shaft of the bone Diagnosis should be confirmed bj X ray examination V7ith displacement the dorsal concasity »s MSible despite the swelling and tlic defoimity can be detected by palpation along Uk. subcutaneous border of the bone (figs Tig 578 Mmiegg a fracture of shaft of ulna »iili anterior liislocaiion of heaJ of radius Reduced fay open opcwlion anj ulna fi«ed hy a wire loop ^aiufactnry result 573 and 571) Rniatiun of the forearm or axial or cross sfrain on the ulna causes pJ'n at die site of the fracture and ma) demonstrate false motion and crepitus If theft. 1 $ oserridint* of the fraL,incnt< or even nurked anterior bowing of ihe ulna the head of the radius is practically alnajs duliKatcd (I igs 374 578), and tlie surgeon iliould alssaja examine Ihc bead of the radius in fractures of Uie upper third of th'- ulna FRACTURES IN REGION OF ELBOW" HI Conservative Treatment If these fractures are not accompanied by dislocation or fractures of the head of the radius they should be treated just as is desaibed in the con sideration of dosed fractures of the shaft of the ulna but when the head of the radius IS disloated this dislocation must be reduced and th“ fracture must be immobilized in a position of supination and mid flexion Consequently the surgeon should first reduce the fracture of the ulna by direct pressure and traction and then press the head of the radius bacL into its normal position and suptnate and Bex the forearm until the head of Iig 579 A Fracture of proxiinat th rd of shaft of ulna with disfcKation of lead before and after closed reduct oo. D Failure of maiupulab e reduction C Operative reduct on and fixa tion of ulna and remoial of head of rad as 542 HAGNOSIS ANli TRLATMFNT OC APIOnC INJtlWLS 1 g S80 Monfc^ i (nstMtc « il ms LeJ «Icfom t) TmtrJ hy trati rutjt t reJuct on 4n4 We have seen several such fractures (.Fig 580 ) Operatne Ireatment In fractures of the Monteggia type with severe deformity }44 DIAGNOSIS AND TREATifENT OF SPEOnC INJURIES of the ulna and complete displacement of Uic head of the ndius, open leduction and inltmal fixation maj be neccssarj m adults TTic fracture of llic u!ni is exposed throuch a posterior incision and reduced b) manipulation or Icxerace 1 ollowinq this in attempt IS made to reduce the hud of the radius hf traction on the flexed forearm and direct pressure on die radial head Then the clbon is fiexed and the anatomical!) reduced ulna IS fixed w itli an intramcduilarj rod This may be cut off flush mth the bone and counter sunk and left in permanent!), or it may be left protruding beneath the skin to be rc- moNcd m 8 weeks The x.ound is closed and tlie exltcmit) i$ immobiliicikl until tl« fracture is solid in a long posterior plaster mold or x cylinder cast maintaining the posi iion of flocion at the elbow and supination TENNIS ELBOW This condition is tariously known as tennis elbow, radiohumcral bursitis epi condjhtis and epicondylalgia It is rather common and is often resistant to treatment It IS cliaractenacd by pain originating in and around the lateral cpicondyle of the humerus It is quite ^aractcristic that the condition occurs after unusual ii«e of the ami as in tennis play-crs, painters, and occasionally in housewiics Pathologf The pathology prohabl) tanes in different uses In Osgood s* personal case there was a small bursa between the tendons of the extensor muscles and the tip of the condyle It is probable that m other cases there may be localized periostitis or tears of the muscle origins Diagtioiti The symptoms usually begin after unusual exertion and gradually m crease in seventy, often to a point at which the localized pain may be very arulc, and then tend to assume a chronic state m which the pain and weakness arc. felt only with certain movements, especially tn lifting objects with the pronaied forearm extended ot carrying a bag for a considerable time The pain may radiate down tlic forearm, or it may remain localized On physical examination the elbow presents a unable amount of loal tenderness over the up of or just below the external epicondyle and in certain cases thece may be a slight bulge or fullness tn this region Passive motions ate free, but the pam can usually be elicited by luting the patient make a fist and flex tJie wrist or attempt to lift an object with the elbow extended and tlic forearm pronated Tlie roent genogram is usually negative Trealnietii In mild acute cases rcLef and cure vre obtained by cross strapping witli adhesive applied over the bursa or by a posterior plaster mold or shni; applied to the arm elbow, and forewrm Wc have tried local injections of I per cent Novocain vvilh indifferent success We are now injecting 25 eng of Hjdrocortone in and around the sensitive area along with the Novocain and believe (hat this treatment is more successful In chronic cases in which there is considerable disability and whith have resisted con servativc UcitmciU the region should be explored and the small mflimcd bursa, if present should be removed If no bursa is found and this is the rule m our experience, the incision is earned down to tlK tender point on the bone and a small area of perios tcum 15 cxciscvl This also includes a thin shvet of the undtrlymc bone and a small amount of tlie surrounding musclt attachments Most patients are given a course of detp x ray therapy before they are Subjected to operative treatment and in a considenWe pcrccntige of these the pain subsides In others the pain subsides s(>ontancousIy •Ose«oJ, R II RjJiuIiufrcral Dimtis rptamdrl in, LfironJ) hlfcu (Tcnmi Flhow), Arth Sirg 4 i20. 1932 CHAPTER 14 FRACTURES OF FOREARM SURGICAL ANATOMY Sbafl of Vina The ulna may be considered the direct continuation of the humerus and Its shaft uhich ts practically straiftht is thick and strong in its upper portion and gradually diminishes in size in lU lower portion The posterior border of the ulna is sub cutaneous throughout its entire length and is easily palpated The shaft is roughly triangular on cross section and presents an interosseous crest for the attachment of the interosseous membrane The anterior and posterior surfaces are roughened for the attach ment of the flexor and extensor muscles of the forearm The shaft is narrowed in its upper third by the bicipital fossa which lies opposite the bicipital tuberosity on the radius Shaft of Radius Tlic radius may be considered a continuation upward of the hand !c is thicker below and graduall) decreases in diameter and becomes more cylindrical m contour in its upper half The shaft is bowed laterally to enable it to rotate around the ulna and is coNcred bj the muscles of the forearm in its upper half but it is practically subcutaneous on its dorsal and lateral aspects in its lower half The bicipital tuberosity which serves as a point of attachment for the biceps tendon is an o%al prominence which is looted on (he medial surface about 2 cm below the head of the radius Interosseous Membrane This is a strong fibrous membrane which stretches from the inner border of the radius to the outer border of the ulna and completely closes the space between th“ two bones which the exception of a small triangular area at the upper end which serves for the passage of the posterior interosseous \cssels It divides the fore arm into anterior and postenor compartments The great majority of the fibers of the interosseous membrane pass upward and outward from the outer border of the ulna to the inner border of the radius and are so arranged that they remain tense m all positions of rotation of the forearm It is thus seen that the slop" of the fibers is such that force received on the hand and transmitted upward through the shaft of the radius is gradually distributed through the interosseous membrane to the shaft of the ulna At Its upper border the interosseous membrane is reinforced by the oblique hga ment The fibers of this ligament lie at n^t angles to those of the interosseous mem brane passing downward and outward from the ulna to the radius and tend to resist traction forces which would otherwise pull the radius downward The oblique ligament also resists extreme supination of the foreann Moiements of Bones of Torearm Mosement of tlic forearm on the arm is largely controlled by Uie ulna and movement of the hand on the forearm is largely controlled by the radius whereas supination and pronation of the forearm are accomplished by 24 ^ 546 DIACNOStS AND TREATMtNT OF SPCaFIC JNJURICS rotation of the radius around the ulna fiotation ocoics at the superior and inferior radio ulnar articulations, and the normal range of morement is about 160® The axis on svhich the forearm and hand rotate passes through the center of the head of the radius abosc and through llie stj loid process of the ulna and the ring finger below In full supination the shafts of the bones arc widel) separated and are approxi matel) parallel whereas m pronation the cursed shaft of the radius crosses that of the ulna at the junction of the middle and upper tliirds and the bones are closely approxi mated at this point The interosseous space is widest when the forearm is m the mid position and narrowest when the forearm is fully pronated (Tigs 583 and 5S4 ) A a c Fig 533 Skrtches sbowine hones of ihe foreaffo and carnal and metAcarpal hones Skiicf’es made from nKni^enogram si own m Fig 5Sl MeJ or nntral ro*iUon donal *ic» w'lh e^how at fight angle D Full proiul on. dorsal > cw with elbow at iprrmnmately a r ght angle C Full iupinatjon, central siew with elbow at arpnwimately a nght angle itlurcfes The muscles of the fottann nuy be di\ i led into the flexors and prorulots which lie on the anterior and medial aspects and the txtensdn and supinators, which lie on the posterior and lateral aspects Tlic flexors of the fingers and wrist may be divided into superficial and d«p groujvs Tlie superficial flexors arise mainly from the intcrrul condyle of the Iiunwrus an 1 pass downward and outward to the wjist atvd fund The deep flexors arise from the anterior surface of the ndius and ulna and from the interosseous membrane and faJs riUCTORCS OF FOREARM J547 directly downward The median ner\e supplies all of the flexors of the forearm except the flexor carpi ulnaris and the ulnar half of the flexor digitorum profundus which are supplied by the ulnar nene The extensors of the wrist and fingers arise from the ex temal condyle of the hiunenis and from the upper half of the posterior surface of the radius and ulna and interosseous membrane and pass downward to the wrist and hand The pronators are two in number (1) The pronator teres takes its origin with that of the superficial flexor group from the inner condyle of the humerus and from the coronoid process of the ulna and passes downward and outward to end m a flat tendon which winds around the shaft of the radius to be inserted into the middle of its outer ABC Fig 584 Roentgenograms shoeing bones of noimal forearm /t Mi