SURGERY. 
necks, which they drew back at the period, when it is de¬ 
sired to keep well up the superior portion of the humerus. 
When a dislocation is accompanied with a fracture of the 
humerus, the reduction is generally impracticable, especially 
when the solution of continuity in the bone happens to be 
very near the shoulder joint. 
Fractures of the os humeri, are distinguished into three 
kinds; first, those which happen above the insertion of the 
deltoid muscle; second, those which occur below that point; 
and, thirdly such as take place towards the lower end of the 
bone. 
In the first example, the pectoralis major, latissimus dorsi, 
and teres major, draw the upper fragment inwards; while the 
deltoid pulls the lower one outwards. 
In the second instance, the displacement happens in the 
inverse of the former manner. 
In the third, if the fracture be not situated in the broadest 
portion of the humerus, but where the bone is covered by the 
triceps and brachialis, without their being attached to it, the 
ends of the fracture may be displaced in any direction by 
external force. On the contrary, if the injury be very near 
the elbow joint, the displacement can only happen backwards 
or forwards, on account of the considerable transverse extent 
of the bone at this point, and the resistance of the muscles 
of the forearm, which almost all arise from the external and 
internal condyles, and of course are connected with both the 
fragments. The lower one is mostly found drawn forwards 
and rotated outwards. 
A fracture of the head of the bone can only be distinguished 
by a very careful examination ; but, when any other part of 
the os brachii is broken, the case is in general plainly indi¬ 
cated by the grating of the surfaces of the fracture against 
each other, the inabdity to use the arm, and the manifest 
change in its figure. The ends of the broken part may be in 
contact with each other; or they may be drawn asunder,and 
the limb be more or less shortened. When the lower end of 
the fracture is retracted, the biceps muscle, brachialis inter¬ 
ims, and coraco-brachialis, are to be relaxed, and moderate 
extension made; but, in consequence of the extension of the 
forearm, it is sometimes drawn forwards and rotated out¬ 
wards. When the external, or internal, condyle is frac¬ 
tured, the muscles, arising from the part, should be relaxed ; 
a piece of soap-plaster, a figure-of-eight bandage, and a splint, 
to the side of the arm, on which the injury is situated, should 
be applied and the fore arm placed in a sling. The external 
condyle cannot be broken, without the fracture communi¬ 
cating with the joint, and, in every instance in which there 
is reason to suspect this event, it is necessary, after all risk 
of inflammation is past, to move the joint occasionally, in 
order to prevent the formation of adhesions within the 
capsular ligament, and an irremediable stiffness of the articu¬ 
lation. 
In ordinary fractures of the arm it is usual to apply two 
pieces of soap-plaster, which together surround the limb, at 
the situation where the accident has happened. Extension, 
if necessary, being now made by an assistant, who at once 
draws the lower portion of the bone downward, and bends 
the elbow, the surgeon is to apply a roller round the limb. 
The external splint is to extend from the acromion to the 
outer condyle, and being lined with a soft pad, the wood can¬ 
not hurt the limb by pressure. The internal splint is to reach 
from the margin of the axilla to a little below the inner con¬ 
dyle, and is to be well guarded with a pad, filled with tow, or 
any other soft materials. 
When the humerus is fractured near or above its tuberosi¬ 
ties, the only useful measures are to keep the arm well sup¬ 
ported, and perfectly quiet in a sling, to confine the member 
close to the side, and make the patient avoid moving 
about. 
When the fracture is oblique, and situated precisely at the 
part of the bone where the pectoralis major, latissimus dorsi, 
and teres major are inserted, such failure is observed to be 
most disposed to happen, and the circumstance is accounted 
for by the fragments being drawn away from each other for¬ 
759 
wards and backwards by the action of the foregoing muscles, 
combined perhaps with that of the deltoid. 
The dislocation of the elbow forwardscannot take place unless 
the olecranon be broken. The kind of dislocation most frequent¬ 
ly occurring at the elbow, is that in which the upper heads of 
the radius and ulna are displaced backward. This accident is 
facilitated by the small size of the coronoid process, which 
slips behind the os humeri into the lower portion of the 
cavity, naturally destined for the reception, of the olecranon 
in the extended state of the forearm. However, in some 
instances, the coronoid process is fractured; a complication, 
which is said not to admit of the ulna being preserved in 
its natural situation. The lower end of the humerus is 
situated upon the anterior surface of the radius and ulna, 
between the coronoid process and the insertion of the ten¬ 
don of the biceps muscle; and the lateral ligaments are 
torn. The fibres of the anconaeus and brachialis also pro¬ 
bably suffer the same fate. The olecranon and part of the 
biceps project backward to an unusual distance, causing an 
appearance, as if the arm were broken above its lower third. 
The biceps, pronator teres, supinator brevis, and triceps, are 
all in a state of tension; and, in consequence of the forearm 
being thus drawn in opposite directions by the antagonist 
muscles, it remains in a half-bent position. There are parti¬ 
cular instances of this kind of dislocation, where the displace¬ 
ment is much more extensive, and the injury of the soft parts 
far more considerable, than what is above described. Thus, 
the lower end of the humerus may be thrown further from 
the elbow, along the anterior surface of the radius and ulna, 
which displacement cannot happen without the laceration of 
several of the preceding muscles. In cases of this description, 
the humerus has sometimes been driven through the integu¬ 
ments, and even the brachial artery has been ruptured, which 
last injury one would expect to be more frequent than expe¬ 
rience proves it to be, considering the relative situation of the 
vessel to the elbow-joint. 
The next most frequent dislocation at the elbow consists 
in the ulna being pushed into the place of the radius upon 
the lower end of the humerus. In this case, the olecranon 
is brought nearer to the external condyle, the distance be¬ 
tween tire olecranon and internal condyle being of course 
much greater than natural; and, as these projecting points 
of bone can hardly ever be obscured by any degree of 
swelling of the soft parts, they are, in accidental injuries of 
the elbow-joint, important sources of information to every 
surgeon. 
In the lateral luxation of the head of the ulna outwards, 
the radius is invariably pushed off the lesser articular surface 
of the humerus; this surface and the outer side of the arti¬ 
cular pulley being now in contact with the sigmoid cavity of 
the ulna. The internal portion of the trochlea of the hume¬ 
rus is no longer applied to the ulna, and forms a prominence 
at the inner side of the elbow, while the olecranon and co¬ 
ronoid process, being propelled outwards, do not correspond 
to the cavities in the humerus naturally intended for their 
reception; and hence, they seriously limit the flexion and 
extension of the forearm. As the point of the olecranon 
constantly touches the back of the humerus, the forearm re¬ 
mains slightly bent; and the brachialis, biceps, and triceps, 
are in a state of tension, drawn outwards. A similar de¬ 
rangement of the pronator teres, and of nearly all the mus¬ 
cles situated on the palmar side of the forearm, will also 
explain the fixed pronation of the hand, and the bent state 
of the fingers. 
The lateral dislocation of the heads of the ulna and radius 
inwards, is more uncommon and generally incomplete. 
Lateral dislocations of the upper heads of the radius and 
ulna are always attended with rupture of the lateral liga¬ 
ments, and generally also with a laceration of the annular 
ligament of the radius, which is so intimately connected 
with the externa! lateral ligament, so as to be as it were a part 
or production of it. That it is frequently torn, is proved by 
the fact, that after a lateral dislocation of the elbow has been 
reduced, it is not at all uncommon for the surgeon to per¬ 
ceive 
