FRACTURE OF THE HUMERUS WITH MARKED Ppresented a boy who, ten days previous to his admission to the hospital, had fallen, striking with great force upon his left shoulder. Examination at the end of ten days re vealed a fracture of the upper extremity of the humerus just below the greater tuberosity, with displacement of the lower frag ment forward, producing a marked deformity. Under an anws thetic the slight adhesions which existed were broken up, and an attempt was made to reduce the deformity, but it was found impossible to bring the two fragments into apposition, notwith standing the extreme traction employed. An incision was there upon made along the anterior aspect of the bone, and upon ex posing the fragments an overriding of three-quarters of an inch was noticed. After loosening the adhesions, another attempt was made by extension and counterextension to bring the fragments together, but in spite of the employment of a great deal of force it proved unsuccessful. Within two weeks the muscles had con tracted to such a degree that the overriding of the fragments could not be overcome by strong extension and councerextension. Therefore, three-quarters of an inch of the lower fragment was removed subperiosteally, and the two fragments were brought together with heavy chromic gut sutures. Primary union re sulted, and the bone united very nicely. There is still a shortening of about half an inch.
Called attention to the value of pre liminary manual traction for the purpose of overcoming the resistance of the soft parts in cases like the one just reported by Dr. Eliot. This is also a valuable measure in the reduction of congenital displacements of the hip.
Asked Dr. Whitman how long after the occurrence of such an injury should these manipulations be undertaken, and also how long they should be continued? In the case under dis cussion the accident occurred ten days previous to his admission to the hospital. On two occasions the boy was placed under an . anaesthetic, and manual traction was employed for at least ten minutes ; but, notwithstanding this preliminary manipulation, it was found impossible to reduce the fragments at the time of operation.
Replied that he thought it advisable to resort to manual traction as soon as the conditions indicated it, and continue it as long as might be necessary to reduce the deformity. He had in mind more particularly congenital displacements in which there is marked accommodation shortening of the tissues. The manual force should be intermittently applied, relaxing and pulling alternately for from ten minutes to half an hour. It should be done under the influence of an anaesthetic.
DR. Eliot rejoined, saying that sometimes there seems to be a limit to the length of time during which this traction can be continued. He referred to a case of fracture of the femur which came under his observation last summer. There was very faulty union, and two inches of overriding at the end of the sixth week, although the fracture had previously been treated by extension. Traction of ten pounds and more was continued for two weeks longer without producing any change in the length of the limb, the slight amount of union having previously been broken up under ether. The fracture was then exposed, when it was found that the fragments were separated by muscular tissue. The frag ments were enucleated from this muscle bed, the amount of venous oozing necessitating the packing of the wound and the postpone ment of the reduction of the fragments until three days later, eight weeks after the original accident. An energetic attempt was now made to reduce the displacement, strong extension and coun terextension being applied from above and below ; and in addition to this traction was made upon the lower fragment by introducing a hook into the medullary cavity. By this method the deformity was finally reduced and the fragments were then sutured with silver wire.
This Dr. Eliot said, showed that even long continued preliminary traction is not always successful in accomplishing the reduction of a fracture, when overriding has taken place.