Fracture of Surgical Neck 261 



inner side of the scapular end of the bone, which, perchance, is hitched 

 outwards by the upper end of the shaft. The pectoralis major and 

 deltoid may have something to do with the displacement. This frac- 

 ture resembles somewhat a dislocation, but the presence of the head 

 in the arm-pit at once negatives it. 



For treatment, a pad must be placed in the axilla, to thrust out the 

 lower fragment, and, as in the former case, the arm must be bandaged 

 against the side, and the shoulder protected by a stiff leather or gutta- 

 percha cap. An inside splint is of no possible value for steadying the 

 fragments, for the seat of fracture is high up in the axilla and out of 

 reach. When the upper end of the shaft-fragment is drawn inwards 

 the displacement may be recognised by thrusting the fingers up into 

 the arm-pit, and a biggish pad may be needed to keep the bone in 

 position. As this shaft-fragment is apt to be drawn upwards on the 

 inner side of the head-fragment, the elbow will require no support, for 

 that might be to still further elevate the shaft-fragment. Indeed, 

 when the overlapping is marked, it may be necessary to hang a shot- 

 bag upon the elbow, the wrist only being supported in the sling, so as 

 to bring down the end of the shaft-fragment. 



In fracture of the upper end of the humerus the presence of the 

 head of the bone beneath the acromion process centra-indicates dis- 

 location, which the inward displacement of the shaft might at first sight 

 suggest ; and the fact of the head not moving when the elbow-end of 

 the bone is rotated is clear evidence of fracture. 



Fractures of the lower end are specially liable to occur up to 

 puberty, a common form being that in which the epiphysis is carried 

 backwards from -the shaft together with the upper ends of the radius 

 and ulna. The appearance is much like that of dislocation of the 

 radius and ulna backwards, but in the latter injury the bones are 

 rigidly fixed, whilst in separation of the epiphysis pronation and supina- 

 tion are still possible, and flexion and extension also, if, by a little 

 gentle force, the epiphysis be brought into position. Such slight force 

 could not bring the dislocated bones into position. As soon as the 

 force is removed the elbow-end of the broken humerus slips back 

 again. If the sound fore-arm be extended the top of the olecranon 

 process is on a level with the condyles of the humerus ; the relative 

 position of these three pieces of bone is not disturbed in the case of the 

 fracture, but it is in dislocation, for the upper ends of the radius and 

 ulna are carried backwards and upwards behind the lower end of the 

 humerus. 



A condyle may be detached without the joint being implicated, 

 but usually such a fracture extends obliquely into the articulation. The 

 internal cojidyle may be detached by violent action of the group of 

 pronators, or by a fall upon the elbow. The accident is most likely to 

 happen before the eighteenth year, when ossification on to the shaft 

 takes place ; this fracture does not extend into the joint. It should be 



