SURGICAL ANATOMY OF THE UPPER EXTREMITY. 413 



ing to the direction of the fracture. Simple extension reduces the deformity, and the 

 application of a shoulder cap and splints to the arm will retain the fragments in apposition. 

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

 sling. 



Fracture of the kumerm (Fig. 248) 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 by the Brachialis anticus and Biceps in front and the Triceps' 

 behind ; and at the same time is drawn backward behind the upper fragment of the Triceps. 

 This injury may be diagnosed from dislocation by the increased mobility in fracture, the exist- 

 ence of crepitus, and the fact of the deformity being remedied by extension, on the discontin- 

 uance 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 fracture occurs in the opposite direction to 

 that shown in Fig. 248, the lower fragment is drawn upward and forward, causing a consider- 

 able prominence in front, and the upper fragment projects backward beneath the tendon of the 

 Triceps muscle. 



Fracture of the olecranon process (Fig. 249) 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 



FIG. 248. Fracture of the humerus above 

 the condyles. 



FIG. 249. Fracture of the olecranon. 



prominence of the elbow is consequently lost, and 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 position 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 approximated by drawing down the upper fragment. Union is generally liga- 

 mentous. 



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 and 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 

 Pronator 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 mid- 

 way between pronation and supination, extension having been previously made so as to bring 

 the parts in apposition. 



In fracture of the radius below the insertion of the Biceps, but above the insertion of the 

 Pronator radii teres, the upper fragment is strongly supinated by the Biceps and Supinator 

 brevis, and at the same time drawn forward and flexed Dy the Biceps ; the lower fragment is 

 pronated and drawn inward toward the ulna by the pronators. Thus there is extreme dis- 

 placement with very little deformity. In treating such a fracture the arm must be put up in 



