Fracture of olecranon with fibrous union. (Park.)
Treatment.
—The difficulty here, in treatment, consists in the necessity for counteracting the pull of the triceps. The arm first of all should be dressed in the extended position. Sometimes it is possible, by partly encircling the posterior surface of the arm just above the fragment with a strong piece of adhesive plaster, to which is attached some rubber tubing, to make a constant elastic pull upon the fragment, the tubes being brought down and attached to the sides of the anterior splint below the elbow. In the absence of swelling this can often be made quite effective. So long as much fluid is present no means will be efficient. It may, therefore, be well to wait two or three days until the fluid has disappeared, aspirating the joint if necessary. In young and otherwise healthy subjects there is strong reason for advising operation, as only by absolutely approximating the fragment to the main bone and maintaining it in position can bony union be secured. In properly selected cases, and when performed with every precaution, this measure frequently gives ideal results. A short ligamentous union is represented in [Fig. 299]. At other times the fibrous band will stretch out to an inch or more, not completely disabling the arm but weakening it. The extended position may be relaxed within a week after operation, but not for at least two weeks after other treatment. Passive motion should not be begun too early in the latter cases.
Fracture of the coracoid process is often combined with backward dislocation of the forearm, which is no doubt an incident of the injury or may occur later by mere muscle pull. The brachialis anticus, which is inserted into it, will pull the fragment up against the anterior surface of the humerus. This fracture should be dressed in the right-angle position, in order to relax the muscle, taking care to prevent backward displacement, while ligamentous union is ordinarily all that can be hoped for.
The ulnar shaft may be broken at almost any point, usually as a result of direct violence. As it is weaker in its lower half the greater number of fractures occur here. Fracture of the shaft is easily recognized, crepitus being always obtained, unless muscle tissue has intervened, this being a condition which will occasionally prevent bony union. If it can be established by x-rays that bony surfaces are not in contact and cannot be so placed, it is advisable to cut down upon the site of the fracture, remove the obstacle, and fasten the fragments together. So long as one bone is broken in the forearm the other may be relied on to act as a more or less efficient splint. There is but one position in which any of these fractures can be dressed with safety, that is midway between pronation and supination, i. e., with the thumb pointing toward the patient’s face. Splints used for this purpose should always be wider than the forearm itself, lest by pressure the ends be forced toward the other bone. Some hold that by gentle pressure along the line between the bones, as by a narrow pad or splint, the muscles may be made to press the injured bone away from the other; nevertheless only moderate pressure can be tolerated for this uncertain purpose. It has been generally customary to use two light wooden splints, one along the palmar, the other along the dorsal surface of the forearm, padding them properly and securing them in position by strips of adhesive plaster and suitable bandages. The same plaster-molded splints mentioned above can, however, be made just as effective for this purpose, if properly applied.
When either bone is broken near the wrist, and especially when both are broken, we have to combat the tendency of the pronator quadratus, which tends to pull the lower fragments together.
The styloid process is occasionally detached, as in violent sprains, or broken off in connection with other injuries. Inasmuch as it carries the upper end of the internal lateral ligament its detachment can be quickly recognized by the abnormal freedom of motion which such an injury would permit.
Fig. 300
