of the arm, with direct pressure ; yet they will not generally prove
completely successful, nor will it be found easy to retain them when
Mr. Mayo treated a fracture of this character, which occurred in a
man of sixty years of age, with a figure-of-8 bandage, and a sling, with
a lathe splint on the outer side of the humerus, the upper part of
which was made to bear on the fragments, by uniting the upper part
of the circular arm roller to the figure-of-8 bandage. " The fracture
united favorably," he says, but we presume that he does not mean to
afiirm that it united without any degree of displacement ; a result
which, probably, ought never to be expected. Mr. Mayo adds, how-
ever, that "for a long time the patient had some difficulty in carrying
the arm backward."*
IVeatment of Fracttvrea of the Surgical Neck, including SeparcUions at
the Epiphysis. — I see no reason to suppose that the indications of treat-
ment can essentially vary in separations at the epiphysis, from those
in true fractures through any part of the surgical neck, since the rela-
tive action of the muscles remains the same, and the direction of the
displacement is generally the same. My remarks, therefore, upon this
point may be considered as equally applicable to fractures and epiphy-
In a considerable proportion of these cases not much displacement
of either fragment takes place, and consequently we have only to apply
such moderate retentive means as will insure quiet. Indeed, under
such circumstances we might not hesitate to adopt the posture treat-
ment practised by Dupuytren in two cases, both of which terminated
favorably. The treatment consisted in placing the arm, semi-flexed,
on a pillow, the pillow being arranged so as to form a pyramid, the
summit of which was lodged in the axilla, while the elbow was se-
cured to the side of the body by a bandage.'
Unhappily, however, as we have seen, this condition is not always
present; the most frequent form of displacement being that in which
the lower fragment is drawn upwards and inwards, or towards the
In such cases it will require, often, no little perseverance and skill
to effect reduction, if it is not found to be actually impossible, and
still more to retain the bones in place when once reduced. Indeed,
it is proper to say that a complete reduction is seldom accomplished
and permanently maintained, owing, probably, to the advantageous
action of the muscles which tend to produce the displacement, and in
part also to the difficulty of applying any apparatus or dressing which
shall act efficiently upon the fragments.
Sir Astley Cooper recommends for this accident a couple of splints,
* B. Cooper's edition of Sir A. Cooper on DislocationB, &c., American edition,
^ < Dupuytren on Bones, Sydenham edition, p. 99.
FRACTURES THROUGH THE SURGICAL NECK.
to "be placed one in front of and one behind the shoulder, an axillary
pad, a clavicular bandage, and a sling; the sling being made to sus-
pend only the wrist and not the elbow, since he bad observed that
when the elbow was lifted the upper end of the shaft was inclined to
Mr. Tyrrell informed Mr. Cooper that in a similar case he had found
the bone best maintained in its natural position by its being raised
and supported at right angles with the side, by a rectangular splint, a
part of which rested against the side, while the arm reposed upon the
other part; and until he had made use of this plan, he could not
succeed in removing the deformity^ or in keeping the bone in its
Mr. Erichsen has found a very convenient apparatus to consist of
" a leather splint about two feet long by six inches broad, bent upon
itself in the middle, so that one-half of it may be applied lengthwise
to the chest, and the other half to the inside of the injured arm, the
angle formed by the bend, which should be somewhat obtuse, being
well pressed up into the axilla."
The foUpwing is the plan which I would, however, generally re-
commend : —
The fragments having been reduced as completely as possible, a
broad and firm gutta-percha splint should be moulded to the outside
of the arm and shoulder. When it has become sufficiently hard and
Welch's arm splint.
Plan of author's leather
Leather splint closed at top,
firm, it may be secured in place by a roller carried from the elbow to
the axilla. If the splint covers well the top of the shoulder, and is
sufficiently wide, it is not apt to become displaced ; and by resting
against the point of the acromion process, it enables the upper turns
of the bandage to draw the broken end of the lower fragments out-
wards ; at least, as efiectually as any other dressing is capable of doing,
and renders an axillary pad unnecessary. The sling may then be
234 FBACTUBES OF THE HUMERUS.
applied as recommended by Sir Astley Cooper, or the arm may be
permitted to hang perpendicularly beside the body. The clavicular
bandage, also recommended by Sir Astley, complicates the dressing
very much, and does not seem to me to answer any very useful pur-
pose ; while the axillary pad exposes the brachial plexus to painful
if not injurious pressure.
As a substitute for gutta-percha, a firm sheet of felt may be em-
ployed, a piece of sole-leather or a carved wooden splint, or the very
complete shoulder and arm splint of Welch ; but in either case the
upper portion of the splint ought always to rest upon the shoulder, so
as to prevent its sliding downwards.
§ 5. Shaft, below the Surgical Neck and above the Base of the
Causes. — In a record of nineteen cases in which the cause of the frac-
ture is stated, I find this portion of the shaft broken from direct violence
twelve times ; from indirect blows, the concussion being received upon
the elbow, twice; once it was a consequence of tertiary lues, once it
occurred during birth, and three times in the same patient it has been
broken from muscular action alone, each consecutive fracture occur-
ring at a different point. The records of surgery furnish many ex-
amples of fracture of the shaft of the humerus from muscular action,
as in throwing a stone or snowball ; but the most singular examples
are those in which the bone has been broken in a trial of strength
between two persons, by grasping the hands palm to palm, with the
elbows resting upon a table, and twisting, when the humerus has sud-
denly given way a little above the condyles. This practice is called
by the French " toumer poignet,^^ the game of turning wrists. I have
seen one case of this kind, which was under the care of Dr. Winne,
and Malgaigne has collected five other similar cases, two of which
were reported by Lonsdale. In L* Union MedicaU is reported an ex-
ample in which the fracture occurred on a level with the insertion of
the deltoid, a little below the insertion of the pectoralis major and
latissimus dorsi. The fracture seemed to be nearly transverse.^
The example of fracture during birth, to which I have referred,
occurred in a healthy female child, whose parents were also healthy.
The mother was in labor six or eight hours, but the labor was not
severe. She was attended by a midwife, and does not know whether
violence was employed or not. Dr. Lockwood, of Buffalo, was called
on the third day, and found the arm broken a little below its middle,
and moving as freely as it did at the elbow-joint; he applied lateral
splints with bandages, &c. I saw the child with Dr. Lockwood on
the seventeenth day after its birth. There was then a perfect ferule
of ensheathing callus surrounding the fragments, and which, owing to
the softness of the fiesh, could be easily detected and defined. The
fragments had been firm at least three or four days. Nearly a year
» Amer. Med. Times, vol. iv. p. 168.
SHAFT BELOW THE SURGICAL NECK. 285
after, I again examined the arm, and could not discover any traces of
Dr. Ldwenhardt has also reported a case in which the evidence was
conclusive that the fracture was caused solely by the contractions of
the uterus, which forced the arm against the pubes ; the arm being
heard distinctly to snap when it was passing this point and while the
hands of the accoucheur were not aiding in the delivery. In this case
the humerus was broken in its upper third.^
Dr. N. Fanning, of Catskill, N. Y. has reported to me the following
as having occurred in his own practice : —
'' Mrs. H., of Catskill, was delivered June 8, 1865, after a short and
not severe labor, of a full-grown and healthy male child. The mother
was well formed, with ample pelvis. The labor was natural, and the
presentation the most favorable, the occiput corresponding to the left
acetabulum ; but immediately after the delivery of the head, a hand and
a portion of the forearm of the child were felt above the pubes. The
shoulders and body were delivered very quickly after the head, and
daring a single pain. Just as the right shoulder of the child was pass-
ing under the arch of the pubes, I heard a snap, not unlike that caused
by the breaking of a pipe-stem, which I soon found, as I suspected,
to be caused by the fracture of the right os humeri of the child in its
upper third." The bone united with some deformity.
Dr. Fanning is of the opinion that, in this case, the contraction of
the uterus, occurring while the arm of the child occupied some un-
usual position, was the cause of the fracture. It was certainly not
due to any force applied by Dr. Fanning himself.
Seat and Direction of ths Fracture. — The seat of the fracture is more
often below than above the middle of the bone ; thus, I have found the
fracture fourteen times^near the middle, and the same number of times
below the middle third, but only seven times above the middle third.
The observations of Norris, who found four fractures of the shaft
above the middle, and nine below, correspond with my own ;' but
M. Ghi^retin, in the same number of fractures, found nine above the
middle and four below.*
The line of fracture is generally oblique, but more often transverse
than in fractures of the clavicle, femur, or tibia.
Displacement. — ^The direction of the displacement depends, no doubt,
sometimes upon the precise point of the fracture and upon the action
of the muscles operating upon the two fragments ; thus, if the fracture
takes place just above the insertion of the deltoid, the lower fragment
is liable to be drawn upwards and outwards, in the direction of its
fibres, while the upper fragment is carried toward the origin of the
pectoralis major, &c. ; but, in a great majority of cases, the influence
of these muscles is more than counterbalanced by the direction of the
force, and by the direction of the fracture. Practically, therefore, it is
seldom of much importance to determine the exact point of fracture,
^ Lowenhardt, American Journal of the Medical Sciences, January, 1S41, p. 250,
from Medidn. Zeit, Mai 6, 1840.
s Norris, Am. Joam. of Med. 8ci., January, 1842, vol. xix. p. 28.
* Gu^retin, Presse M^dicale, vol. i. p. 45.
288 FRACTURES OF THE HUMERUS.
as to whether it is juRt above or below the insertion of a particolar
muscle ; nor, indeed, is it generally very easy to ascertain this point
with much precision.
The amount of displacement varies considerably in different persons,
and in fractures at different points, but it will average about three-
quarters of an inch. When the fracture is product by muscular
action alone, it is generally transverse, and displacement seldom occurs.
Such was the fact in every instance where my own patient broke the
arm three times consecutiv.ely at different points; and union was
speedily accomplished, and with no deformity. Dupuytren, however,
saw a case which constituted an exception to this general rule. The
fragments became completely separated, and were so movable tbat
union could not be effected, and he was compelled, after three months,
to resort to resection.
Results. — In twenty-three examples, the average shortening is about
one-quarter of an inch ; but of these, thirteen are not shortened at all,
so that the average of shortening in the remaining ten is three-quar-
ters of an inch ; the amount of overlapping varying from one-quarter
of an inch to one inch and a quarter.
In forty-five examples, not including gunshot fractures, I have three
times seen the humerus refuse to unite by bone ; once when the fracture
was in the lower third of the shaft. This was an oblique, compound
fracture, and no union had taken place at the end of five months. The
man was intemperate, but in pretty good health.^ In the second case,
the fracture had occurred a little below the middle of the bone, and
it was simple. Five months after the accident this patient cousulted
me, when I found the elbow anchylosed, the forearm being fixed at
right angles with the arm.' Neither of these patients had been under
my care previously, but I learned that an intelligent Canadian surgeon
had treated one of them, and the other had been seen and treated by
In the third case, a lad, five years of age, received a fracture
about three or four inches above the elbow-joint, by the passage across
the limb of a heavy army wagon. The arm was dressed with splints,
and in about five weeks several fragments of necrosed bone were
removed by Dr. Pope, of St. Louis, and the splints were again applied,
^ren months from the date of the injury. Dr. Brinton, of Philadelphia,
operated by perforation, and reapplied splints. When the splints were
removed, the limb was straight atid apparently firm, but the bond of
union gradually gave way, and when be came under my charge in
Nov. 1864, more than two years after the accident, the arm was bent
at an angle of 45°, and the union was fibrous only. Under my advice
all restraint and dressings were removed,- and he was sent into the
country to improve his general health, with the understanding that
I would operate at some future day. Subsequently, on the 14th of
April, 1867, I resected the bone at the seat of fracture, securing the
fragments with wire, and supporting the arm with a gutta-percha
splint. The result was a perfect bony union, and a very useful arm.
1 Report on Deformities, &c., Case 88. ' Ibid., Case 21.
SHAFT BELOW THE SURGICAL NECK.
In two other cases, the elbow remained somewhat stiff a long time
after the splints were removed; in one case, complete freedom of
motion was not restored at the end of fifteen years.
Generally, however, the motions of the elbow-joint have been very
soon restored after the removal of the splints and sling.
I ought to mention that, not unfrequently, fractures of the shaft of
the humerus, and especially where they are occasioned by direct blows,
are followed by great swelling, and sometimes by abscesses. In one
instance, the fracture having taken place within the insertion of the
deltoid muscle, the sharp extremity of the lower fragment was made
to penetrate the flesh, causing an abscess, and finally tetanus, of which
my patient soon died.
The following remarks of Malgaigne are too pertinent to be omitted
in this connection: "When there is great obliquity, with overlapping,
or a fracture with splintering, or a multiple frac-
ture, a certain amount of deformity is inevitable,
and the formation of callus demands one or two
weeks more. With the inflammation comes also
the danger of suppuration, and later, a rigidity of
the articulations difficult to dissipate. In short,
we must not forget that of all fractures, those of the
humerus are most liable to fail of consolidation."
On the other hand, we shall find, in the case of
this bone, as in all others, some remarkable excep*
tions, where, although the fracture may be com-
pound, and badly comminuted, yet the limb has
been saved and made useful.
Treatment. — In the treatment of fractures of that
portion of the shaft of the humerus now under
consideration, I have preferred generally a broad
and thick splint of sole-leather — felt, or gutta-percha,
may answer as well — sufficiently long to extend
from the top of the shoulder to the elbow-joint,
moulded accurately, and applied to the outside of
the shoulder and arm, while the limb is flexed to
a right angle, and while extension is being made
upon the humerus. This being properly padded,
and secured in place by rollers, I place the arm in
a sling beside the body. The sling must, however,
be so arranged, by being looped under the wrists, and not under the
elbow, as that the weight of the elbow and lower part of the arm may
aid in making extension.
Other surgeons have sought to make permanent extension in these
and certain other fractures of the humerus, by various contrivances.
Mr. Lonsdale constructed' an instrument which might be lengthened
or shortened to suit the case ; it was made of steel, and was worked
with a screw operating upon cogs in a sliding bar; resembling, in
some respects, the arm portion of Jarvis' adjuster. In the second
London edition of a series of plates illustrating the action of the
B. Shaft. C. Elbow rest.
B. Hook for attachment
of banda^, opposite
which is a crossbar for
the same purpose.
238 FRACTURES OP THE HUMERUS.
muscles in producing displacement in fractures, by S. W. Hind, is a
drawing of an apparatus invented by the author for the same purpose,
which is very simple, and in some respects more complete than Lons-
dale's, and which may be easily adapted to almost any form of arm-
splint. Indeed, nothing more is necessary than to attach to the ordi-
nary long splint a movable crutch.
Dr. Henry A. Martin, of Boston, has invented a splint, also for the
purpose of making extension in fractures of the humerus, the counter-
extension being made, by adhesive plasters, from the side of the chest.
H. A. Martin's exteasion in fraotares of tlie hameras.
The apparatus is elongated by a ratchet operating upon two steel bars,
which are thus made to move upon each other. I have never been
able to make reliable counter-extension from the walls of the chest
for any purpose whatever ; but this method is at least not likely to
do any harm, as there is no pressure upon the axillary nerves. The
plan may therefore deserve a trial.
Dr. E. A. Clark, of the St. Louis City Hospital, has proposed to
accomplish the extension, in fractures of the head and surgical neck,
by suspending a weight from the elbow. He reports one case suc-
cessfully treated by this method. When the patient is in the recum-
bent posture, the weight must be suspended over a pulley. Ko
SHAFT BELOW THE SURGICAL NECK. 239
donbt this is the only method by which Fig. 69.
really effective extension can ever be
made in fractures of the humerus, and
there may be perhaps examples of frac-
tures of the neck of the humerus in
which the fragments overlap persistent-
ly, where it will be proper to resort to
this novel expedient. When fractures
occur above the deltoid, the overlapping
is often excessive, and there is not much
danger of their being forcibly separa-
ted by the extension; but in fractures
below this, Dr. Clark's method would
expose to the danger of separation and
non-union of the fragments. As em-
ployed for fractures of the neck, no
splints are used by Dr. Clark ; yet as a
means of holding the lower fragment
out, a single outside splint might be
I believe that all these contrivances
may prove occasionally useful, but the
common experience of surgeons has
shown how difficult it is to accomplish
much extension bv means of pressure in
the axilla; a mode, too, which I think curks eztenslon in fractarei of the
must be wholly inadmissible when the necicoftiiehamerttB.
fracture approaches the upper end, since
the. pressure by the crutch-head upon the pectoralis major and latis-v
simos dorsi, which constitute the margins of the axilla, must tend to
displace the fragments upon which they act, inwardly, and which
seldom can be applied with much force to fractures near the con-
dyles, on account of the probable existence of inflammation and swell-
ing about the joint.
Malgaigne, when speaking of the apparatus of Lonsdale, remarks :
*' But the surgeon should never lose sight of the fact that permanent
extension is a resource always dangerous, often useless, and which
demands in its application much caution and watchfulness.''
The following example will illustrate the practical difficulty of em-
ploying permanent extension in fractures of the humerus : —
A laborer, aged thirty, was. admitted into the Buffalo Hospital of the
Sisters of Charity, on the second day of October, 1853, with a simple
oblique fracture of the humerus, which had occurred three days before.
The fracture was situated within the insertion of the deltoid, and hav-
ing been produced by the rolling of a log upon the arm, the whole
limb was much swollen. The ni^^bt following his admission, in a fit
of delirium tremens, he removed all of the dressings. When I visited
the wards in the morning, I found the fragments displaced and the
muscles contracting violently. The ordinary dressings were applied,
and continued until the fiflhday, when, as the delirium had not ceased.
240 FRACTURES OF THE HUMERUS.
iand the muscles continued to contract with great violence, it was de-
termined to attempt permanent extension. For this purpose we lifted
the elbow upwards and outwards, to relax the deltoid, and then.
having made extension with the forearm placed at a right angle with
the arm, we fitted carefully a large gutta-percha splint to the forearm,
arm, axilla, and side, in such a manner that wnen the splint was
secured to these several parts, the arm could not fall to the side of the
body completely, and in proportion as it did fall downward, it would
make extension upon the arm. This splint was well padded, and
secured in place by rollers.
On the sixth day the delirium had ceased, and never returned.
The dressings were well in place, and seemed to accomplish the indi-
cation we had in view ; but, on the seventh day, although he had kept
very quiet, everything was disarranged, and the whole had to be re-
adjusted. On the eighth and ninth the same thing occurred. During
this time we had varied the dressings, position, &c., each day, to meet,
if possible, the di£5culties; but it was at length deemed unwise to
pursue the attempt any farther, and we returned to the use of the
ordinary splints, laying the arm against the side of the body. The
union was finally completed without either overlapping or angular
Something may always be accomplished, when the patient is walking
about, by allowing the elbow to escape from the sling, so that its
weight shall make constant traction upon the lower fragment; and the
plan which I suggested some years since, of treating certain cases of
delayed union of the humerus, namely, extending the arm at full
length by the side of the body, so that the lower fragment shall re-
ceive the whole weight of the forearm and hand, might occasionally
prove valuable in recent fractures where the tendency to override
was very great. In three instances, I have already put this plaa
sufficiently to the test to determine its safety and utility.
The precise plan, and my reasons for its adoption in certain cases
of delayed union, were set forth in the following paper, read before
the Buffalo City Medical Association, and published in the Buffalo
Medical Journal for August, 1854.
" I have observed that non-union results more frequently after frac-
tures of the shaft of the humerus, than after fractures of the shaft of
any other bone.
" Comparing the humerus with the femur, between which, above all
others, the circumstances of form, situation, &;c., are most nearly
parallel, and in both of which non-union is said to be relatively fre-
quent, I find that of forty-nine fractures of the humerus, four occurred
through the surgical neck, twelve through the condyles, and twenty-
nine through the shaft. In one of the twenty-nine the patient survived
the accident only a few days. In four of the remaining twenty-eight
union bad not occurred after the lapse of six months, and in many
more it was delayed beyond the usual time. Two of the four were