Fig. 66.-Torsion-fracture of the humerus. Skiagraph. Hellmund, thirty-three years of age, sustained a fracture of the humerus by falling on the arm in a wrestling bout. In addition to the fracture, there was paralysis of the musculospiral nerve (compare Fig. 79). As the paralysis was not improved by an extension bandage, such as shown in figure 60, the nerve was exposed by an incision over the seat of fracture, twelve days after the injury; no injury of the nerve could, however, be detected. The wound was therefore closed, after interposing a soft pad, consisting of a layer of muscular tissue, between the nerve and the fragments, which were found in good position. The paralysis gradually disappeared, and the patient recovered with good functional result. [This observation of paralysis following a contusion of the nerve is a very interesting one, and the possibility should be borne in mind. Nevertheless it seems a safer plan to expose the nerve by incision if function is not restored in a few days.-ED.]

the fingers. By this means a bad error in prognosis may be avoided. Injuries to the vessels are less frequent.

With appropriate treatment good union takes place. Nevertheless the formation of a false joint is relatively more frequent after fractures of the humerus than after fractures of the other bones of the extremity, partly because of the greater difficulty of immobilizing the part, and partly on account of the displacement, which is often considerable, and may be complicated by the interposition of soft parts between the ends of the frag

ments.

Treatment. By incasing the upper arm, including the shoulder- and elbow-joints, in a circular bandage, the axillary space is protected against dangerous pressure. We may use plaster-of-Paris, wire, or padded tin splints. If the latter are used, a long splint should be applied to the outer side of the entire arm and a shorter one to the inner side

of the upper arm. The wire splints may readily be applied in such a way as to exert permanent traction in the long axis of the humerus. The splint is simply bent at the proper angle and firmly bandaged to the forearm flexed at a right angle. The upper extremity is bent over in such a way as to leave a space above the shoulder. Then a short loop, well padded with cotton, is passed around the axilla and attached to the projecting end of the splint with moderate tension, so as to produce permanent traction. The tension may be regulated by occasionally changing the length of the axillary loop. This dressing may be used in fractures of the upper, as well as of the lower, end of the humerus. A very ser

PLATE 35.

Fractures of the Humerus.-Fig. 1.—Anatomic preparation of the humeral region. Lateral view, showing the relation of the musculospiral nerve to the bone. The nerve lies directly upon the bone at the site of an artificial fracture. In front of it are recognized the brachialis anticus and the biceps; behind, the triceps; and above, the deltoid. The point where the nerve comes in contact with the bone corresponds approximately to the junction between the middle and lower thirds of the arm.

Fig. 2.-United fracture of the shaft of the humerus, with moderate deformity. In this case the musculospiral might have been injured. Fig. 3.-Fracture of the lower end of the humerus above the condyles (supracondylar fracture), with typical deformity simulating a posterior dislocation of the forearm. (See Plate 38.)

viceable appliance for all fractures of the humerus is the so-called collar-splint made of plaster-of-Paris strips, devised by Albers. The splint covers the entire outer and posterior side of the arm, which is flexed at the elbow with the forearm in supination, from the wrist to the shoulder, and extends up over the lateral and posterior region of the neck as far as the line of the hair. The plaster-ofParis strips are applied directly to the skin, which has previously been well oiled. The plaster dressing is then covered with a soft roller bandage, and a well-fitting gutter is obtained, which assures complete fixation of the arm and shoulder region (Fig. 68). While the bandage is being applied, one assistant should hold the head while a second. applies extension to the elbow.

If there is much tendency to secondary displacement after the fracture has been correctly reduced, good permanent extension becomes necessary. The counterextension in that case may not be applied in the axilla; or, when the fracture is to be treated with splints without rest in bed, the arm must be brought into greater abduction, so that the entire lateral surface of the thorax may be utilized for counterextension.