SURGICAL ANATOMY OF THE UPPER EXTREMITY. 501 



FIG. 321. Fracture of the humerus 

 above the condyles. 



Care should be taken not to raise the elbow, but the forearm and hand may be supported 

 in a sling. 



Fracture of the humerus (Fig. 321) immediately above the condyles deserves very attentive 

 consideration, as the general appearances correspond somewhat with those produced by sep- 

 aration of the epiphysis of the humerus, and with those 

 of dislocation of the radius and ulna backward. If the 

 direction of the fracture is oblique from above, downward 

 and forward, the lower fragment is drawn upward and 

 backward by the Brachialis anticus and Biceps in front and 

 the Triceps behind. This injury may be diagnosed from dis- 

 location by the increased mobility in fracture, the existence 

 of crepitus, and the fact of the deformity being remedied by 

 extension, on the discontinuance of which it is reproduced. 

 The age of the patient is of importance in distinguishing this 

 form of injury from separation of the epiphysis. If frac- 

 ture occurs in the opposite direction to that shown in the 

 accompanying figure, the lower fragment is drawn upward 

 and forward, causing a considerable prominence in front, and 

 the upper fragment projects backward beneath the tendon 

 of the Triceps muscle. 



Fracture of the olecranon process (Fig. 322) is a frequent 

 accident. The detached fragment is displaced upward, by 

 the action of the Triceps muscle, from half an inch to two 

 inches ; the prominence of the elbow is consequently lost, 

 ami a deep hollow is felt at the back part of the joint, 

 which is much increased on flexing the limb. The patient 

 at the same time loses, more or less, the power of extending 

 the forearm. The treatment consists in relaxing the Triceps 

 by extending the limb, and retaining it in the extended posi- 

 tion by means of a long straight splint applied to the front 

 of the arm ; the fragments are thus brought into close apposition, and may be further approxi- 

 mated by drawing down the upper fragment. Union is generally ligamentous. 



Fracture of the neck of the radius is an exceedingly rare accident, and is generally caused 

 by direct violence. Its diagnosis is somewhat obscure, on account of the slight deformity visible, 

 the injured part being surrounded by a large number of muscles ; but the movements of prona- 

 tion anil supination are entirely lost, The upper fragment is drawn outward by the Supinator 

 brevis. its extent of displacement being limited by the attachment of the orbicular ligament. 

 The lower fragment is drawn forward and slightly 

 upward by the Biceps, and inward by the Pro- 

 nator radii teres, its displacement forward and 

 upward being counteracted in some degree by 

 the Supinator brevis. The treatment essentially 

 consists in relaxing the Biceps, Supinator brevis, 

 and Pronator radii teres muscles by flexing the 

 forearm, and placing it in a position midway 

 between pronation and supination, extension 

 having been previously made so as to bring the 

 parts in apposition. 



In fracture of the radius (Fig. 323) near 

 its centre, the upper fragment is drawn upward 

 by the Biceps and inward by the Pronator radii 

 teres. holding a position midway between pro- 

 nation and supination, and a degree of fulness 

 in the upper half of the forearm is thus pro- 

 duced : the lower fragment is drawn downward 

 and inward toward the ulna by the Pronator 

 quadratus. and thrown into a state of pronation FIG. 322. Fracture of the olecranon. 



by the same muscle : at the same time, the Su- 

 pinator longus, by elevating the styloid process, into which it is inserted, will serve to depress 

 the upper end of the lower fragment still more toward the ulna. In order to relax the opposing 

 muscles the forearm should be bent, and the limb placed in a position midway between prona- 

 tion and supination ; the fracture is then easily reduced by extension from the wrist and elbow : 

 well-padded splints should be applied on both sides of the forearm from the elbow to the wrist ; 

 the hand being allowed to fall, will, by its own weight, counteract the action of the Pronator 

 quadratus and Supinator longus. and elevate the lower fragment to the level of the upper one. 



In fracture of the shaft of the ulna the upper fragment retains its usual position, but the lower 

 fragment is drawn outward toward the radius by the Pronator quadratus, producing a well-marked 

 depression at the seat of fracture and some fulness on the dorsal and palmar surfaces of the 

 forearm. The fracture is easily reduced by extension from the wrist and forearm. The fore- 

 arm should be flexed, and placed in a position midway between pronation and supination, and 

 well-padded splints applied from the elbow to the ends of the fingers. 



