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Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.
by Thomson, Alexis; Miles, Alexander
Language: en18,652 downloads on Project Gutenberg
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Public-domain ebook sourced from Project Gutenberg #28428.
About this book
The Manual of Surgery, Volume II, is a comprehensive surgical textbook that opens with a detailed discussion of severe forearm injuries, describing the spectrum from a simple chip to a completely pulverised bone, the formation of sequestra, and the challenges of infection‑induced callus overgrowth. It proceeds to examine epiphyseal separations in growing patients, noting the influence of conditions such as rickets and syphilis, and outlines the anatomical, clinical, and radiographic features that distinguish these lesions from dislocations. The text then moves on to joint anatomy and injury, covering contusions, wounds, sprains and dislocations, and emphasizes the role of ligaments, muscles and bone shape in joint stability. Throughout, the authors interweave operative considerations, irrigation techniques, reduction methods, and the importance of precise epiphyseal realignment, providing a systematic, anatomy‑driven approach to extremity trauma.
Written in the formal, didactic prose of early‑20th‑century surgical literature, the work reflects the period’s emphasis on meticulous description and a strong reliance on emerging X‑ray diagnostics. Its voice is authoritative yet methodical, aimed at physicians and surgeons who require a thorough grounding in the pathology and management of complex fractures and joint injuries. Readers with a background in medicine, orthopaedics, or the history of surgery will appreciate its exhaustive detail and the way it captures the evolving understanding of trauma care at the time.
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The fracture is usually transverse in children and in cases in which it is due to muscular action. In adults, when due to external violence, it is usually oblique, the fragments overriding one another and causing shortening of the limb. The displacement depends largely on the direction of the force and the line of fracture, but to a certain extent also on the action of muscles attached to the fragments. Thus, in fractures above the insertion of the deltoid the upper fragment is usually dragged towards the middle line by the muscles inserted into the inter-tubercular groove, while the lower is tilted laterally by the deltoid. When the break is below the deltoid insertion the displacement of the fragments is reversed. The signs of fracture--undue mobility, deformity, shortening, and crepitus--are at once evident, and the patient himself usually recognises that the bone is broken.
The nerve-trunks in the arm--the median, ulnar, and radial (musculo-spiral)--are apt to be damaged in these injuries; in fractures of the lower part of the shaft the radial nerve is specially liable to be implicated. This may occur at the time of the injury, the nerve being contused by the force causing the fracture, or pressed upon by one or other of the fragments, or its fibres may be partly or completely torn across. When there is evidence of nerve injury, the practitioner should draw the attention of the patient to it then and there, and so guard himself against actions for malpraxis should paralysis of the muscles ensue. Later, the nerve may become involved in callus, or be damaged by the pressure of ill-fitting splints. Weakness or paralysis of the extensors of the wrist and hand results, giving rise to the characteristic "wrist-drop." The actions of the muscles should always be tested before applying splints, and each time the apparatus is removed or readjusted, to assure that no undue pressure is being exerted on the nerves.
Union takes place in from four to six weeks in adults, and in from three to four weeks in children. Delayed union, or want of union and the formation of a false joint, is more common in fractures of the middle of the shaft of the humerus than in any other long bone--a point to be borne in mind in treatment. Arrest of growth in the bone from injury to the nutrient artery is also said to have occurred.
_Treatment._--To restore the alignment of the bone, extension is made on the lower fragment and the ends are manipulated into position. This may necessitate the use of a general anaesthetic, and care must be taken that no soft tissue intervenes between the fragments, as is evidenced radiographically by the persistence of a clear space between the ends even when they appear to be in apposition.
In transverse fractures the position may be maintained by a simple ferrule of poroplastic or Gooch-splinting. The elbow is flexed at a right angle, and the forearm supported in a sling midway between pronation and supination. For a few days the limb may be bound to the chest by a broad roller bandage.
The splints are removed daily to admit of massage and movement being carried out, and while the splints are off, the patient is allowed to exercise the fingers and wrist. If at the end of four or five weeks, osseous union has not occurred, the reparative process may be hastened by inducing venous congestion by Bier's method.
In oblique and spiral fractures it is often necessary to control the shoulder and elbow-joints to prevent re-displacement. This can be done by means of a plaster of Paris case enclosing the upper part of the thorax, together with the upper arm, abducted, and the elbow, at right angles.
It is sometimes necessary to apply continuous extension to the lower fragment to prevent overriding. For this purpose a Thomas' arm splint is employed, the extension tapes being attached to its lower end, but care must be taken that the traction is not sufficient to separate the fragments and leave a gap between them. The elbow should not be retained in the extended position for more than three weeks.
In rare cases it is necessary to have recourse to operative treatment.
When there is evidence that the radial nerve has been injured, and no sign of improvement appears within three or four days of the accident, operative interference is indicated. An incision is made on the lateral side of the arm, and the nerve exposed and freed from pressure, or stitched, as may be necessary; the opportunity should also be taken of dealing with the fracture. The limb is put up in a "cock-up" splint, with the hand in the attitude of marked dorsiflexion (Fig. 31).
Satisfactory results have been obtained without the use of splints, by relying upon massage to overcome the spasm of muscles, and allowing the weight of the arm to act as an extending force (J. W. Dowden and A. Pirie Watson).
In cases of un-united fracture, a vertical or semilunar incision is made over the lateral aspect of the bone, and the muscles separated from one another till the fracture is exposed, care being taken to avoid injuring the radial nerve. The fibrous tissue is removed from the ends of the bone, and the rawed surfaces fixed in apposition; the wound is then closed, and appropriate retentive apparatus applied. As soon as the wound has healed, massage and movement are employed.
Injuries in the Region of the Elbow and Forearm
Surgical Anatomy--Examination of injured elbow--FRACTURE OF LOWER END OF HUMERUS: Supra-condylar; Inter-condylar; Separation of epiphysis; Fracture of either condyle alone; _Fracture of either epicondyle alone_--FRACTURE OF UPPER END OF ULNA: Olecranon; _Coronoid_--FRACTURE OF UPPER END OF RADIUS: Head; Neck; _Separation of epiphysis_--DISLOCATION OF ELBOW: Both bones; Ulna alone; _Radius alone_--FRACTURE OF FOREARM: Both bones; Radius alone; Ulna alone.
The injuries met with in the region of the elbow-joint include the various fractures of the lower end of the humerus, and upper ends of the bones of the forearm, including the olecranon; and dislocations and sprains of the elbow-joint. The differential diagnosis is often exceedingly difficult on account of the swelling and tension which rapidly supervene on most of these injuries, the pain caused by manipulating the parts, and the difficulty of determining whether movement is taking place at the joint or near it.
#Surgical Anatomy.#--The medial epicondyle of the humerus is more readily felt through the skin than the lateral. The two epicondyles are practically on the same level, and a line joining them behind passes just above the tip of the olecranon when the arm is fully extended. On flexing the joint, the tip of the olecranon gradually passes to the distal side of this line, and when the joint is fully flexed the tip of the olecranon is found to have passed through half a circle. The head of the radius can be felt to rotate in the dimple on the back of the elbow just below the lateral epicondyle. The coronoid process may be detected on making deep pressure in the hollow in front of the joint. As the line of the radio-humeral joint is horizontal, while that of the ulno-humeral joint slopes obliquely downwards, the arm forms with the fully extended and supinated forearm an obtuse angle, opening laterally--the "carrying angle." This angle is usually more marked in women, in harmony with the greater width of the female pelvis. The ulnar nerve lies in the hollow between the olecranon and the medial condyle, and the median nerve passes over the front of the joint, with the brachial artery and biceps tendon to its lateral side. The radial nerve divides into its superficial and deep (posterior interosseous) branches at the level of the lateral condyle.
In examining an injured elbow, the thumb and middle finger are placed respectively on the two epicondyles, while the index locates the olecranon and traces its movements on flexion and extension of the joint. The movements of the head of the radius are best detected by pressing the thumb of one hand into the depression below the lateral epicondyle, while movements of pronation and supination are carried out by the other hand. The uninjured limb should always be examined for purposes of comparison.
In injuries about the elbow much aid in diagnosis is usually obtained by the use of the X-rays; but in young children it is sometimes impossible, even with excellent pictures, to make an accurate diagnosis by means of radiograms alone. In cases of suspected fracture, a radiogram should be taken with the back of the limb resting on the plate, the forearm being extended and supinated. If a dislocation is suspected and a lateral view is desired, the arm should be placed on its medial side. In obscure cases it is useful to take radiograms of the healthy limb in the same position.
FRACTURES OF THE LOWER END OF THE HUMERUS
The following fractures occur at the lower end of the humerus: (1) supra-condylar fracture; (2) inter-condylar fracture; (3) separation of epiphyses; (4) fracture of either condyle alone; and (5) fracture of either epicondyle alone.
All these injuries are common in children, and result from a direct fall or blow upon the elbow, or from a fall on the outstretched hand, especially when at the same time the joints are forcibly moved beyond their physiological limits, more particularly in the direction of pronation or abduction. While it is generally easy to diagnose the existence of a fracture, it is often exceedingly difficult to determine its exact nature. Although the ulnar and median nerves are liable to be injured in almost any of these fractures, they suffer much less frequently than might be expected.
Ankylosis, or, more frequently, locking of the joint, is a common sequel to many of these injuries. This is explained by the difficulty of effecting complete reduction, and by the wide separation of periosteum which often occurs, favouring the production of an excessive amount of new bone, particularly in young subjects.
The #supra-condylar# fracture usually results from a fall on the outstretched hand with the forearm partly flexed, from a direct blow, or from a twisting form of violence. The line of fracture is generally transverse, or but slightly oblique from behind downwards and forwards, so that the lower fragment is forced backward together with the bones of the forearm, simulating backward dislocation of the elbow; the lower end of the upper fragment lies in front (Fig. 33).
_Clinical Features._--The elbow is flexed at an angle of 120 deg. or 130 deg., and the forearm, held semi-pronated, is supported by the other hand. Around the seat of fracture great swelling rapidly ensues. The olecranon projects behind, but the mutual relations of the bony points of the elbow are unaltered. The lower end of the upper fragment may be felt in front above the level of the joint, as a rough and sharp projection, and this sometimes pierces the soft parts and renders the fracture compound. Movement at the joint is possible, but unnatural mobility may be detected above the level of the joint. Crepitus and localised tenderness may be elicited. The displacement is readily reduced by manipulation, but usually returns when the support is withdrawn. The arm is shortened to the extent of about half an inch.
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