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second band, corresponding to B in the figure, passes along the patient's chest and is made to form a loop supporting the lower arm. tice readily gives the surgeon an adequate technic. A pair of irons, as shown in Fig. 8, are of assistance in bending the metal. Each of the iron bands is now wound with a gauze bandage so as to insure more intimate union with the plaster-of-Paris. The patient's body and the shoulder of the injured side are well padded with cotton wool, as is also

Humerus.

Humerus

Ulna

Ulna

a

b Fig. 9.—Tracing of roentgenograms of compound comminuted fracture of the humerus just above the elbow joint, associated with extensive laceration of the soft parts. a, One week after injury. b, Eight weeks later. Treatment by the fenestrated plaster dressing shown in Fig. 6.

the forearm. The padding is bound firmly in place by gauze bandages and then everything is ready for applying the plaster-of-Paris. Sufficient turns are applied to give a layer approximately 18 inch thick, and then the two iron bands, which have already been bent, are laid in place and fastened by further turns of the plaster-of-Paris bandages. Within a few minutes the splint is hardened. To hold the arm in the desired position a traction bandage is applied to the forearm just below the elbow (see Fig. 7). The fixation is excellent, and at the same time allows access to the most extensive type of wound. Figs. 9a and 9b are tracings of roentgenograms of a gunshot injury just above the elbow at the time of application of the splint and after healing has occurred. In Figs. 10a and 106, the patient is seen, illustrating the range of flexion and extension secured by this method.

Injuries in the Neighborhood of the Elbow.—As in the case of the shoulder, the surgeon must always consider the danger of ankylosis and immobilize in the position most convenient

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Fig. 10.—Photographs of the patient whose roentgenograms are shown in Fig. 9, illustrating the range of flexion and extension three months after injury. The primary immobilization was followed by treatment with the Schede splint, by means of which almost the normal motion was secured.

to the patient were ankylosis to occur. This is one of flexion of about 70° with the forearm midway between pro- and supination, that is, with the thumb pointing up, the little finger toward the ground. The splints already described for fracture of the lower end of the shaft of the humerus are also applicable to these fractures and joint injuries.

The Bones of the Lower Arm.—The problem is much more difficult when both bones have been fractured than when one is still intact to act as a splint for the other. In the latter case (that is, when only one bone is fractured) many methods can be applied with equally good results. The surgeon must merely appreciate the pathological condition involved. As a rule, the fragments of the fractured

Fig. 11.—Diagram illustrating the type of deformity frequently seen in gunshot injuries to a single bone of the forearm. The arrows indicate the lines of force which the surgeon should apply in reducing the fracture. The object of the reduction is the prevention of a bridge of callus between bones, which would prevent pro- and supination.

bone bend in toward the non-injured bone in such a way as to form a distinct angle. The danger in these cases is that a bridge of callus will form between the two bones of the lower arm, thus preventing pro- and supination. The object of the splint is to apply pressure in such a way as to force the extremities of the fragments outward. This can be accomplished: (1) by a fenestrated plaster splint; (2) by a moulded plaster splint; (3) by metal splints; (4) by padded wooden splints. They should hold the arm supinated, since in this position there is least danger of union between the ulna and radius.

The fenestrated plaster is applied by first padding the arm suitably and holding the padding firmly in place with a gauze bandage. The wounds can be marked either by indicating the corresponding positions on the patient's sound arm or, better still, by inserting two little wooden markers. These are discs of wood about 2 inches in diameter with a straight rod 2 or 3 inches long projecting from their centre. The plasterof-Paris is then applied, covering the lower arm and the lower half of the upper arm. As the plaster is hardening, the surgeon grasps the fractured bone above and below the site of the lesion, exerting force in the direction of the arrows as shown in Fig. 11. This tends, in the great majority of cases, to lever the fragments from the intact bone. The wounds are exposed for dressing by cutting windows in the plaster at the points designated.

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Fig. 12.-Fenestrated plaster dressing applicable to severe gunshot injuries

of both bones of the forearm.

The moulded splint is prepared by folding a plaster-of-Paris bandage backward and forward on a table until sufficient thickness has been secured to form a firm dressing. This is then applied to the side of the arm and held in place with several turns of gauze bandage. While it is hardening, the surgeon corrects the position of the bones as in applying the fenestrated plaster.

The application of the metal splints and of the padded wooden splints is made according to the same principles.

If both bones are broken, I know of no splint which gives perfect functional results in the very severe cases. A good method is the fenestrated plaster dressing reinforced by iron bands, as shown in Fig. 12. The technic of application is much the same as in the case of fractures near the elbow.

A single iron band is used, bent as indicated in the photograph. The arm is padded above and below the site of the lesion. Plaster-of-Paris is first applied over the padding, then the iron band is inserted and held

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Fig. 13.

FIG. 14. Fig. 13.—Tracing of roentgenogram of severe shell injury to both bones of the forearm, ten days subsequent to injury. Treatment by means of the fenestrated plaster shown in Fig. 12, which permitted the five incisions necessary for adequate drainage of the wound.

Fig. 14.-Three months later. The gap between the two ends of the radius was bridged later by a bone graft.

in place with a final series of plaster turns. Care must be taken to give the fingers plenty of room so that as soon as the muscles have recovered from the effect of the extensive traumatism they will be given fair chance to functionate. In Figs. 13 and 14 are shown tracings of roentgenograms of such an injury at the time the splint was applied, and twelve weeks later. The gap between the fragments of the radius was subsequently bridged by a bone graft.

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