Treatment.—This fracture requires no set ting because, as already explained, the muscles prevent any displacement. Put a thick pad of wool over the shoulder-blade, or mould a gutta percha shield over it, retain by a firm bandage, and put the arm in a sling.
Fracture of the Point of the Shoulder (A cronzion process).—This fracture is usually caused by a blow from above. The deformity consists in the absence of the usual roundness of the shoulder. Compare both, sides, and note that on the affected side there is a sudden sink ing of the extremity of the shoulder. The pro cess can be felt floating in the hollow. When the arm is raised the fragments may be brought into apposition, and grating is felt, the round ness of the shoulder being restored. The per son is unable to raise his arm to any extent.
Treatment.—The acromion cannot be accu rately adjusted to the shoulder-blade, and, be sides, unites only by ligament. The sole treat ment, therefore, consists in keeping the arm well supported by a sling for about four weeks. The patient will never be able comfortably to place his hand on the top of his head.
Other fractures of processes of the shoulder blade are too rare to be noted here.
Fracturesof the (Humerus).— The humerus is liable to fracture of the upper end, or head and neck of the bone, of the shaft, and of the condyles or lower end.
Fractures of the Upper End of the Arm bone are generally produced by a fall on the upper part of the arm, when the shoulder comes into violent contact with the ground.
Signs.—The lower fragment is drawn by muscles inwards towards the arm - pit, and slightly upwards, so producing some degree of shortening, the upper fragment being tilted slightly outwards. The hand placed in the arm pit will be able to detect the sharp edge of the lower piece. The roundness of the shoulder is maintained, but the finger passed over the shoulder comes down the arm only a little way before it reaches a break or hollow. There is pain and loss of function, and the man keeps his arm close to his side. When the lower frag ment has been pulled down, the two ends will come into contact, and grating will be felt. Unnatural mobility also exists, but this is not so easily proved, because the person keeps the muscles strained to prevent movement.
This fracture is often confounded with dislo cation at the shoulders and it is of extreme im portance to distinguish them, since the force required to reduce a dislocation might, if prac tised on a fracture, lead to very serious results. The following table shows the differences:- In children this fracture sometimes takes the form of separation of the epiphyses—the ends of the bone which have not yet become united to the shaft. It is very necessary to restore the proper position of the parts, otherwise develop ment of the arm will cease. It occurs in chil dren under ten only. Its signs are the same as those already described.
Treatment.—Bend the elbow, fold the arm across the chest, so that the thumb is directed upwards. Grasp the elbow and pull gently and
steadily downwards, extension being made by fixing the shoulder. This reduces the fracture, the deformity pears, and the normal length of the limb is restored. To retain the limb in position two splints are necessary, one, long and right-angled or L-shaped (Fig. 36), so as to fit the position of the forearm across the chest, being placed on the inside, the other, a short moulded splint, being applied over the shoulder and seat of fracture. The inside splint is made of wood, and should be long enough to reach up into the arm-pit. To prevent pressure on the blood-vessels in the arm-pit, the top of the splint ought to be scooped out. One limb should ex tend down to the elbow, from which point the other limb comes off at an angle to pass along the forearm and hand. Before applying this splint, the hand and forearm should be bandaged. The splint is next to be carefully padded with cotton-wool, especially at places like the elbow where there are prominences of bone, and held in position, till the other splint is ready, by a few turns of a roller bandage. The outer short splint is made of gutta-percha, pasteboard, of other pliable substance. It is well softened in hot water, and is then placed, also padded, over the seat of fracture, to prevent the tilting out wards of the upper fragment. It should be long enough to project over the shoulder, round which it is to be moulded, and should pass downwards past the fracture to about the middle of the arm. This is immediately secured by one or two straps which bind both inner and outer splints. A roller bandage is then applied from the hand right up to the shoulder in the manner described under BANDAGES; and the forearm is then supported by a sling. It adds greatly to the comfort of the patient if, before the bandages and splints are applied, the arm is washed with soap and water, carefully dried, and then dusted with dusting powder. After not less than three weeks and not more than five, the splints should be removed in order to permit movement of the elbow and shoulder joints to prevent stiffening. The movement is not to be effected by the patient himself, for that would set muscles in action, and that is not desired; but some person must work the joints for a few minutes several times a day. To permit of this, and at the same time support the limb, small gutta-percha splints should be applied over the seat of frac ture inside and out. After five or six weeks the patient may be permitted to swing his arm gently backwards and forwards, and gradu ally to bring it into use. In spite of the utmost care some permanent deformity is not unlikely to occur. The arrangements for this fracture are similar to those shown in Fig. 37, with this exception, that the outer splint should in this case be moulded round the top of the shoulder.