In oblique and spiral fractures it is often necessary to control the shoulder and elbow-joints to prevent re-displacement. This can be done by means of a plaster of Paris case enclosing the upper part of the thorax, together with the upper arm, abducted, and the elbow, at right angles.

It is sometimes necessary to apply continuous extension to the lower fragment to prevent overriding. For this purpose a Thomas' arm splint is employed, the extension tapes being attached to its lower end, but care must be taken that the traction is not sufficient to separate the fragments and leave a gap between them. The elbow should not be retained in the extended position for more than three weeks.

In rare cases it is necessary to have recourse to operative treatment.

When there is evidence that the radial nerve has been injured, and no sign of improvement appears within three or four days of the accident, operative interference is indicated. An incision is made on the lateral side of the arm, and the nerve exposed and freed from pressure, or stitched, as may be necessary; the opportunity should also be taken of dealing with the fracture. The limb is put up in a “cock-up” splint, with the hand in the attitude of marked dorsiflexion ([Fig. 31]).

Satisfactory results have been obtained without the use of splints, by relying upon massage to overcome the spasm of muscles, and allowing the weight of the arm to act as an extending force (J. W. Dowden and A. Pirie Watson).

In cases of un-united fracture, a vertical or semilunar incision is made over the lateral aspect of the bone, and the muscles separated from one another till the fracture is exposed, care being taken to avoid injuring the radial nerve. The fibrous tissue is removed from the ends of the bone, and the rawed surfaces fixed in apposition; the wound is then closed, and appropriate retentive apparatus applied. As soon as the wound has healed, massage and movement are employed.

CHAPTER IV
INJURIES IN THE REGION OF THE ELBOW AND FOREARM

The injuries met with in the region of the elbow-joint include the various fractures of the lower end of the humerus, and upper ends of the bones of the forearm, including the olecranon; and dislocations and sprains of the elbow-joint. The differential diagnosis is often exceedingly difficult on account of the swelling and tension which rapidly supervene on most of these injuries, the pain caused by manipulating the parts, and the difficulty of determining whether movement is taking place at the joint or near it.

Surgical Anatomy.—The medial epicondyle of the humerus is more readily felt through the skin than the lateral. The two epicondyles are practically on the same level, and a line joining them behind passes just above the tip of the olecranon when the arm is fully extended. On flexing the joint, the tip of the olecranon gradually passes to the distal side of this line, and when the joint is fully flexed the tip of the olecranon is found to have passed through half a circle. The head of the radius can be felt to rotate in the dimple on the back of the elbow just below the lateral epicondyle. The coronoid process may be detected on making deep pressure in the hollow in front of the joint. As the line of the radio-humeral joint is horizontal, while that of the ulno-humeral joint slopes obliquely downwards, the arm forms with the fully extended and supinated forearm an obtuse angle, opening laterally—the “carrying angle.” This angle is usually more marked in women, in harmony with the greater width of the female pelvis. The ulnar nerve lies in the hollow between the olecranon and the medial condyle, and the median nerve passes over the front of the joint, with the brachial artery and biceps tendon to its lateral side. The radial nerve divides into its superficial and deep (posterior interosseous) branches at the level of the lateral condyle.