In cases of old fracture and dislocation the head of the bone should be exsected, the functional result thus obtained being excellent.
Epiphyseal separation has been too often mistaken for dislocation. [Fig. 287], from Moore, shows how the periosteum is not necessarily entirely detached, but is stripped up to form a hinge, the fragment displaced forward, and its outer aspect often turned upward. This makes traction in an outward direction an essential feature of the replacement of the fractured surfaces, the manipulation being combined with fixation of the fragment so far as it can be seized through the axilla. If the epiphysis is properly slipped over upon the end of the humerus the case assumes ordinary features, and is to be dressed as usual.
Fig. 286
Fracture of the surgical neck of humerus. (Hoffa.)
Fig. 287
Separation of the upper epiphysis of the humerus; displacement forward of the lower fragment. (Moore.)
The shaft of the bone is frequently broken, lines of fracture running in all directions and occurring at all levels. A variety of displacement may take place. The evidences of fracture are usually recognizable and diagnosis is not difficult. The brachial artery and the musculospiral nerve are occasionally involved, either in callus or by primary injury from a spicule of bone. These fractures are more liable to delay in union or even to non-union than almost any others. These occur often without evident cause, while more or less absorption of bone has been known, by which complications are produced.
In the treatment of fractures of the shaft posture is necessary to observe, the fragments not only being held in position, but the axis of the bone being maintained. An external splint, extending up to and rounded over the shoulder, and an internal splint molded to the inner side of the arm, taking in the elbow and forearm, and placed at a right angle, and then the immobilization of the entire arm by its fixation to the body will give the best result. The writer prefers to make these of plaster of Paris, by molding strips of surgeons’ lint sopped in plaster cream, and maintaining the limb in the desired position while they harden. Should comminution be extreme, or shortening difficult to overcome, a few days’ confinement in bed, with traction upon the forearm, either extended or included in the above dressing, by the usual method, with weight and pulley, will give the best result. So soon as callus has bound the ends of the bone together the patient may be released from bed and the arm left in the right-angle position, in plaster, as above. Or over such a splint as has been described, made of molded plaster, may be hung by a bandage at the elbow sufficient weight (a bag containing shot) to maintain constant traction upon the lower fragment, while the patient is in the upright position, and to influence for good any overlapping or displacement of any kind during the critical period when the bone ends are being united by callus.