FRACTURES OF THE LOWER END OF THE HUMERUS AND IN THE ELBOW-JOINT These are very important as to treatment, because mistakes will leave conditions which it will be hard to correct.
The fractura supracondylica demands the most careful replacing of the lower end, which is bent backward; this will be especially difficult when it is twisted sideways as well (narcosis) (Fig. 135, Plate 15).
Fixation of the upper arm and traction upon the forearm, which is flexed to a right angle, may correct the deformity (control with the skiagram).
After preliminary treatment with extension, lasting about two weeks, a rectangular pasteboard splint according to v. Dummreieher will suffice, which will keep the arm in supination and to which extension by means of elastic traction may be added (Fig. 171).
Motion in the elbow should be started as soon as possible, even after the first week.
The fractures in the elbow (Figs. 15G, 157, 15S, Plate 16) are adapted as well as possible with a skiagram as control; the elbow is fixed for a few days upon a rectangular flanged splint according to v. llumm reicher (Fig. 171). After a week we attempt extension and take another skiagram to look for any possible dislocation of pieces of bone. Should extension be possible without any such dislocations, we then keep the arm for one day in this extended position, and flex it the next day again to a rectangular position, later to an acute-angular one; we change with these "extreme positions" daily from now on (Figs. 172a, 172b, Fig. 170). After about three weeks, the parts will be united well enough to permit taking off the splint. The child must be able to touch the head, nose, mouth, and ears freely, and also to extend the arm almost fully before being dismissed from treatment. To obtain still further motion,
we put the sound arm out of commission (bandage, tying together of end of sleeve beyond the finger-tips). The use to which the arm is now put, in eating and playing, will provide further improvement of function; passive motions are also of help.
We were obliged to use silver wire in a few obstinate cases only. Small pieces of bone may be removed without any harm. In absolute ankylosis Bardenheuer's resection will offer the best results.
In fractures of the forearm (Fig. 151a, Plate 16) setting the frequent infraction flexions is of the greatest importance. This must be done fully even to over-correction, no matter if we thus produce a complete fracture or not. Splints have to be applied in such a way that the fore arm is in supination (the patient must be able to look into his palm with the arm in rectangular flexion in the elbow).
When there is only slight dislocation of the fractured ends, then a dorsal plaster splint or the above-mentioned flanged splint of v. Dumm reicher will suffice (Fig. 171). We are able to retain the correction by pieces of bandage or rolls of cotton. We should examine the patient frequently, at least once a week, because the faulty position is quite liable to return and the callus, which is at first as soft as wax, will still permit correction.
Union takes place in two to three weeks, during which time we must prevent the action of the biologically stronger pronators by enforcing supination; otherwise they will renew the deformity as long as the callus is soft, and when this hardens the angular bend will diminish the motion of supination.