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Fractures of the Arm-Bone - Humerus.For convenience of description and discussion such fractures are divided into three classes: First-Fractures of the upper end of the bone, near the shoulder. Second-Fractures of the middle part of the bone, technically called the shaft. Third-Fractures of the lower end of the bone, near the elbow. Fractures of the Upper End of the Humerus.-These fractures are usually caused by a blow upon the arm, or by a fall of the individual. In some cases the end of the bone is at the same time driven tightly against and into the shoulder-blade at the joint, or the lower fragment is wedged firmly into the upper portion. Such fractures are called impacted. In most cases the two fragments remain separate and distinct; these, the usual ones, are called non-impacted. A non-impacted fracture of the arm near the shoulder can usually be recognized without much difficulty. The signs by which such recognition is effected are: First - Swelling and pain at a certain point. Second-Unnatural movement of the arm. Third-A grating sensation when the arm is moved by grasping the elbow, the shoulder, meanwhile, being held fast. Fourth - Loss of power in the arm. If the fracture be impacted, there will be no grating sensation perceptible, and the movements of which the arm is capable will not vary essentially from those of a healthy arm except that they are accompanied by great pain. Fractures of the arm near the shoulder-joint are sometimes confounded with dislocations of the shoulder. It is not a difficult matter to distinguish a dislocation from a fracture which is not complicated in any way; but in many cases a fracture at the upper part of the arm is accompanied by a dislocation of the upper fragment, so that both conditions are present at the same time. These are the cases in which errors are often made, and which, even when recognized, offer serious obstacles to successful treatment. A few points are given whereby an uncomplicated fracture of the arm can be, in most cases, distinguished from a simple dislocation of the shoulder : First, in case of fracture, the hand of the injured arm can be placed by the patient or by another person upon the shoulder of the opposite side, wrhile the elbow is at the same time kept in contact with the chest. In case of dislocation, the hand of the injured arm cannot be placed upon the opposite shoulder, either by the patient or by another person, unless the elbow is allowed to recede from the chest. Second, in case of fracture, the elbow of the injured arm usually lies against the body. If there be a dislocation on the other hand, the elbow almost invariably stands out from the body. Third, in case of fracture, the end or head of the arm-bone can be felt in its proper position under the prominence of the shoulder. If there be a dislocation, the shoulder of the affected side looks unnaturally flat and square. A sharp prominence can often be felt, constituting the point of the shoulder. By comparing it with the other side, the difference in shape strikes even the inexperienced eye. Fourth, in case of fracture, the grating sensation can usually be felt. In dislocations no such sensation can be detected. Fifth, in fractures the arm can be moved with unusual freedom. In dislocation the arm is fixed and almost immovable. Treatment. - The treatment of fracture of the arm in the vicinity of the shoulder-joint is a somewhat difficult procedure. It is important that we distinguish whether or not the fracture is impacted; that is, whether the two fragments are forced together, or remain loose and separate from each other. If the fracture be impacted, it is very important that we should not separate the fragments by rough manipulation or pulling upon the arm ; for the upper fragment is usually very short, and if we detach it from the lower, we are unable to grasp and place it in position again. Even if there should be a slight bend in the bone at the point of fracture, the result will certainly be much better than we can hope to attain if we separate the fragments and then attempt to set the bone again. If we find that the fracture is impacted, therefore, we should aim to keep the arm quiet in the position most favorable to healing. A sling suspended from the neck should be passed around the forearm and elbow, so that the arm is drawn well up toward the shoulder. We may then put a pad, consisting of a folded towel or a piece of lint, in the armpit, between the arm and the chest. A bandage is then applied several times around the body and the arm, so as to prevent any motion of the injured limb. If the fracture be not impacted, it is necessary to apply a splint. For this purpose various plans are employed. The best for domestic use consists in making a splint out of leather or stiff pasteboard. This should be cut of such size and shape as to extend from the elbow up on the shoulder, and to come about half way around the arm from front to back. In order to fit this nicely to the shoulder, it should be split up about three inches from the shoulder end, and the edges of this slit should be cut away so that the opening has the shape of a V. When this is applied to the outside of the arm, the sides of this V-shaped cut can be brought together and the splint thereby nicely fitted to the curve of the shoulder. A second splint, made of the same material, should extend along the inside of the arm from the elbow to the armpit. In this way the two fragments are brought between the two splints and can be held firmly in that position by a bandage. These splints should be carefully padded with cotton ; the edges, especially at the end of the inner splint which lies in the armpit, should be covered with several layers of cotton in order to prevent chafing of the skin. After these splints have been prepared, and several rolls of bandages two and a half inches wide are ready for use, the injured arm should be drawn forward from the body a little ; an assistant then grasps the arm at the elbow and draws it firmly downward, while another assistant holds the shoulder and prevents it from being drawn with the arm. While the member is thus held in position the padded splints are applied, one on the outside and the other on the inside of the arm. They are then bound firmly in position by means of the bandages. The arm is then slung in a handkerchief, which is then knotted around the neck and covers the forearm and elbow. If the patient be stout and muscular, it will be necessary to employ in addition to this bandage a pad made of a folded towel or napkin which is placed in the armpit. This dressing must be kept on the arm four or five weeks, at the end of which time we may expect that the broken ends have united. It will be well, however, not to permit the original dressing to remain the entire time ; for in many cases the arm is considerably swollen at the time of the injury, and hence a splint which fits it well at that time becomes loose a few days subsequently. If, therefore, there be much swelling when the first dressing is applied, this should be removed after four or five days and altered so as to fit the arm more closely. Five or six days later the dressing may be loosened so that the skin can be inspected at the points where the ends of the splints come in contact with it. It will often be found that the splints have chafed the skin somewhat, and if the dressing be not removed, severe ulceration may follow. If any chafing of the skin be discovered, pieces of lint spread with vaseline may be applied over the sore spot, and in re-applying the dressing, care should be taken to prevent pressure upon these chafed spots. In any case it will be well to renew the padding of the splints, especially at their edges and ends. If the patient do not complain of soreness after this first removal of the dressing, this may be allowed to remain till the end of the four or five weeks. If the patient's skin be especially delicate it will be necessary to remove the splint every five or six days, and to bathe the skin with a mixture of alcohol and water in equal parts. Every time that the dressing is removed, and the broken bone is thus left without support, extreme care should be taken that the arm is not moved either by an effort of the patient himself or by the careless handling of others. After the dressing is removed, the arm should still be carried in a sling for a week or ten days. It may be removed from the sling every day, and should be gently bent and extended by an assistant. This exercise may be performed for ten or fifteen minutes the first day the time being gradually extended as the arm becomes accustomed to it. At first the arm will be very stiff as well as weak ; but both motion and strength will be regained in the course of time. In unfavorable cases there occurs some impairment in the movements of the shoulder-joint, as a result of an extension of the fracture up to the end of the arm-bone. If this have occurred, some loss of motion is inevitable ; such a loss of power cannot therefore be attributed to lack of skill on the part of the surgeon. Fractures in the Middle of the Arm-bone.-These are the most favorable of all the fractures in the arm-bone, since they do not interfere with the movements of the joints, and they are readily .accessible for treatment. Such fractures are recognized by the usual signs : the arm is swollen, and very painful at some particular point ; there is a loss of power in the arm and hand, unnatural movement - such as might occur from the formation of a new joint. By gently moving the upper and lower parts of the arm we can distinguish a grating sensation. Treatment.-There are certain fractures near the middle of the humerus which require special dressings ; these we cannot describe in detail. For our purpose it will suffice to mention the dressing which is applicable to most cases of fracture in this situa'tion. A splint should be prepared which consists of two pieces united at their ends at a right angle. This splint is to be applied to the front of the arm and forearm, the right angle fitting into the front of the elbow joint when the arm is bent. The upper piece should be long enough to extend almost to the armpit, while the lower one reaches nearly to the wrist. A second splint is prepared long enough to reach from the elbow to the shoulder along the back of the arm. These splints are carefully padded with cotton in the manner already described. The arm should then be drawn downward by an assistant who grasps the limb at the elbow. While it is held in this position the splints are applied and bandages are wound firmly around the arm from the wrist to the shoulder. The arm is then rested in a sling. The object in including the forearm in the splints is simply to prevent movement at the elbow. This is an important part of the treatment, since such movement often results in delay, or even failure, of the fragments to unite. This dressing may be allowed to remain (if the patient do not complain of pain from the splints) about two weeks. At the end of this time the splints should be removed and others applied which extend only as far as the elbow. The object of this change is to permit movement of the elbow, which otherwise often becomes quite stiff. At the end of four or five weeks the splints may be removed entirely, if union have taken place between the fragments. The arm should be carried in a sling for another week or two until the new bone has become firm enough to endure ordinary movements without breaking. Fractures of the Arm-bone near the Elbow.-No fractures in the body tax the knowledge and the skill of the surgeon more severely than those involving the elbow-joint. The arrangement of the bones and ligaments is so delicate and intricate that an injury to this joint is usually followed by some loss in the movements natura to it. Fractures of the humerus in its lower portion frequently extend into the joint and cause serious impairment of the power and motion of the arm. They are often complicated with some dislocation of the bones forming the joint. There are, however, some fractures which break the bone of the arm almost transversely across just above the joint. It is of such fractifres, uncomplicated with dislocation of the bones, that we shall speak in this chapter. A fracture of the lower part of the humerus is indicated by the usual signs. First - There is pain at some point in the arm, increased upon pressure with the fingers. Second-By moving the forearm backward and forward while the arm is firmly held, we can often distinguish a grating sensation. Third-The lower end of the upper fragment of the bone can often be felt by placing the fingers over the front of the arm just above the elbow. Fourth - The movement of the arm at the elbow is not impaired. Fifth - There is often some shortening of the arm, which can be detected by measuring on the inside of the arm from the elbow to the shoulder, and by comparing this measurement with the corresponding distance on the sound side. , Sixth-If the arm be bent and allowed to rest naturally, there will be an unusual prominence of the elbow. This fracture is sometimes confounded with a dislocation of the bones of the forearm. The latter can, however, usually be recognized by the following signs : 1. The arm cannot be bent at the elbow. 2. There is no grating sensation to be felt when the injured member is moved. 3. There is an unusual prominence at the back of the elbow. 4. There is no sharp edge to be felt at the front of the arm ; the lower end of the arm-bone can be felt as a smooth, rounded and thick body, situated just in the bend of the elbow. 5. There is no shortening of the distance between the shoulder and the elbow. Treatment.-The chief danger to be apprehended from a fracture of the arm near the elbow is that stiffness of this joint will remain permanently. This is a point which is to be borne in mind in the application of a dressing ; for if the elbow be permanently stiff, it is highly important that the arm should be dressed in such a position as will give it the greatest possible usefulness when the elbow becomes stiff. It is therefore customary to apply splints to a fracture of this description in such a way that the arm is bent at the elbow almost at a right angle across the body, the thumb being turned upward. During the first few days there is so much swelling around the elbow that it is impossible to apply a splint with advantage or even to ascertain exactly what the injury is. This swelling should be treated by wrapping the arm in cloths saturated in hot water, and surrounding these with oiled silk or rubber sheeting. After the swelling has been reduced the splints may be applied. These should consist of two pieces. The outer splint should extend from the shoulder to the wrist on the outside of the arm, being bent at a right angle at the position of the elbow. The inner splint should also consist of two pieces with a similar angle at the elbow. Some surgeons use only the outer splint, and seem to secure good results. These splints must be very carefully padded, extra thicknesses of cotton being arranged to cover the bony prominences of the elbow. They are then applied in the way indicated, and are fastened in position with a firm bandage. The arm thus dressed should be supported in a sling. The splint should be worn from three to five weeks ; the older the patient the longer it becomes necessary to support the arm, since union occurs less promptly in advanced life than in childhood. At the end of this time the splint should be removed, and the elbow should be gently bent. In most cases it will be found that there is decided stiffness of the elbow-joint; in fact at first it may be impossible for the patient to bend the arm at all. By gently exercising it for a few minutes every day, however, there will be a gradual decrease in the stiffness of the joint. Sometimes motion is completely regained, while in other cases a certain amount of stiffness remains permanently. In order to obviate this stiffness of the elbow, surgeons have sometimes employed a single splint provided with a hinge at the elbow. This is applied to the back of the arm, and after the first ten days, the arm is gently bent at the elbow for a few minutes a day. This can often be done without disturbing the ends of the fractured bone. But first, if you want to come back to this web site again, just add it to your bookmarks or favorites now! Then you'll find it easy! Also, please consider sharing our helpful website with your online friends.
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